Injection Laryngoplasty Is Effective for Laryngeal Dysfunction in Cancer Patients

New data suggest that office-based injection laryngoplasty (IL) appears to be a safe and effective treatment for laryngeal dysfunction in cancer patients. The results show that the minimally invasive intervention was associated with significant improvements in both subjective and objective measures of laryngeal function that were both immediate and sustained.

“These findings support the use of this approach more broadly to improve quality of life among patients with cancer,” said Michael E. Kupferman, MD, with MD Anderson Cancer Center in Houston, Texas.

The group reviewed results in a series of 61 cancer patients with vocal cord paralysis who were referred to a head and neck surgical service for vocal fold augmentation to treat their laryngeal dysfunction.

Laryngeal dysfunction was defined as dysphonia, weak cough, poor airway protection, or aspiration as a result of vocal fold paralysis. Laryngeal dysfunction is common in cancer patients and may severely compromise quality of life because of vocal restriction, decreased exercise tolerance, and aspiration. For decades, cancer patients with true vocal cord paralysis and aspiration underwent a permanent tracheostomy with or without enteric feeding tubes and with resulting poor vocal quality. Restoration was performed solely in patients thought to be “cured” of their cancer.

Office-based IL without the need for general anesthesia has been reported to be effective for vocal cord rehabilitation. But except for thyroid cancer, most studies have been performed in patients who do not have cancer.

“The indications for use, functional benefits, and improved quality of life have been overshadowed by the number of challenges [that] this unique population presents as a result of ongoing treatments, anticoagulation, general deconditioning, and end-of-life foci,” said Kupferman and colleagues.

All patients in this series underwent vocal fold augmentation using the transthyroidal IL technique, after which they were assigned to complete voice rest for 24 to 48 hours. Overall, 39.3% of patients had lung cancer, which was the most common cancer diagnosis, followed by head and neck cancer. Fifty-two percent of patients had thoracic malignancies. The study found that all patients reported an improvement in their voice and/or airway protection with a single injection, and 55 (90%) patients said that the improvement persisted at a mean follow-up of 3 months.

Of the 33 patients who had pre- and postoperative voice analysis, maximum phonation time nearly doubled, from 5.0 to 10.5 seconds in duration. Ten (71.4%) of 14 patients who had aspiration symptoms before their injection no longer needed a modified diet. The study determined the IL procedure to be safe. Two patients developed dyspnea that readily resolved with treatment.

Kupferman and associates said that it is important that oncology patients with laryngeal dysfunction be identified and referred to an otolaryngologist and speech pathologist for diagnosis and treatment. Regrettably, symptoms of limited communication are only infrequently solicited by oncologists and are not picked up on most quality-oflife assessments. The authors added that while all patients with glottic insufficiency will not need an intervention, the results show that IL is valuable in carefully selected patients who wish to improve glottic efficiency.

Finally, while providers are frequently hesitant to perform procedures in terminally ill patients, there is currently a growing interest in palliative care and end-of-life issues, such as the role of definitive interventions in cancer patients at all stages of their disease. Overall, patients in the series had poor oncological outcomes, and treatment can improve their overall vocal function in the last few months of life. The researchers emphasized that longer-term follow-up of surviving patients is needed to determine how long the results last.

Kupferman ME, Acevedo J, Hutcheson KA, Lewin JS. Addressing an unmet need in oncology patients: rehabilitation of upper aerodigestive tract function. Ann Oncol. February 14, 2011 [Epub ahead of print].