Laryngoscopy

Laryngoscopy is the medical term for any examination in which the larynx (voice box) is visualized. Laryngoscopy may be performed in the office or in the operating room.

Laryngoscopy in the office is usually performed by passing a flexible endoscope (a camera) through the nose into the throat to visualize the throat (pharynx) and voice box (larynx). Therefore, this procedure is often called Flexible Nasopharyngolaryngoscopy. The examination is recorded for review by the doctor and the person being examined. Laryngoscopy in the office may also be performed by passing a rigid endoscope through the mouth.

Laryngoscopy in the operating room is performed by passing a rigid surgical instrument called a laryngoscope through a person’s mouth to visualize the throat (pharynx) and voice box (larynx) under general anaesthesia. This procedure is called direct laryngoscopy, or microlaryngoscopy.

This examination is crucial in the evaluation of people with voice or throat problems.

Videostroboscopy/Stroboscopy

Videostroboscopy (or stroboscopy) is a specialized examination of the vocal folds using an endoscope placed through the nose or mouth to examine the larynx (voice box) and the vocal folds, using both a normal light source and a strobe light source.

The strobe light source allows detailed assessment of the function of the vocal folds and gives valuable information about the vibration of the vocal folds and about how the vocal folds close against one another.  

The examination is recorded, and then reviewed straight after, so that the Laryngologist can describe the results of the videostroboscopy to the person undergoing the examination to enhance their understanding of both the diagnosis and the treatment of their condition. These video examinations are stored and can be used to follow a person’s progress.

David undertakes videostroboscopy at his main office in Remuera to assess the function of the vocal folds in detail and has extensive experience in the interpretation of this examination.

Transnasal Tracheoscopy

Transnasal Tracheoscopy (TNT) is a procedure to examine the airway (the breathing passages) from the nose to the lungs, including the trachea (the airway between the voice box and the lungs) using a flexible endoscope that is passed through the nose.

This examination is undertaken to evaluate people who have stridor (noisy breathing) or unexplained shortness of breath.

This examination has traditionally been performed under general anaesthetic (rigid tracheoscopy or bronchoscopy) or under intravenous sedation (bronchoscopy). With modern channelled videoendoscopes this procedure can now be performed using local anaesthetic only, without the need for a general anesthetic or sedation, making the procedure fast and simple. There is no prolonged recovery time.

David undertakes TNT at his main office in Remuera.

Transnasal Oesophagoscopy

Transnasal oesophagoscopy (TNO) is a procedure to examine the lining of the oesophagus (the part of the digestive tract between the throat and the stomach) using a flexible endoscope that is passed through the nose and then the throat, before entering the oesophagus. A flexible endoscope is a thin tube-like instrument, about 5mm thick, that has a miniature video camera in its tip.

This examination has traditionally been performed under general anaesthetic (rigid oesophagoscopy) or under intravenous sedation (gastroscopy). New ultrathin endoscopes allow us to perform this procedure using local anaesthetic only.

Why is TNO performed?
TNO is performed to determine if there are any abnormalities of the lining of the oesophagus of people with:

  • Dysphagia (difficulty swallowing)
  • Globus (the sensation of a lump in the throat)
  • Chronic cough
  • Reflux
  • Head and Neck Cancer

Advantages of TNO

  • TNO is a safe and simple technique to examine the oesophagus.
  • TNO does not require a general anesthetic or intravenous sedation.
  • TNO can be performed in the office, eliminating the need for admission to a day-stay facility or a hospital.
  • TNO is a quick and convenient procedure with no prolonged recovery time afterwards.

David undertakes TNO at his main office in Remuera.

Vocal Fold Augmentation

Vocal Fold Augmentation refers to procedures and operations that are carried out to augment (or bulk up) the vocal folds (also called the vocal cords) to improve the voice, and sometimes swallowing as well. In some people only one vocal fold is augmented (a unilateral procedure), while in others both vocal folds are augmented (a bilateral procedure).

Vocal Fold Augmentation is used to treat glottic insufficiency. Glottic insufficiency is the name given to the situation when the vocal folds do not close fully, or do not close strongly, resulting in problems such as a weak or quiet voice, a breathy voice, or vocal fatigue. Several conditions may cause glottic insufficiency, including:

Vocal fold paralysis: One of the vocal folds does not move, usually resulting in a weak and breathy voice.

Vocal fold paresis: Weakness of one or both of the vocal folds.

Vocal fold atrophy (also known as vocal fold bowing): The vocal folds lose their bulk and become thin, either due to ageing, or in some cases due to medications (such as steroid inhalers for asthma).

Vocal fold scar: Scar tissue on the vocal fold may respond to augmentation, however scarring can also lead to other problems affecting how the vocal folds work, requiring additional treatments.

Vocal fold sulcus: A sulcus is a depression or pit in the lining of the vocal fold. A sulcus may respond to augmentation, however a sulcus can also lead to other problems affecting how the vocal folds work, requiring additional treatments.

How is Vocal Fold Augmentation Performed?

There are two types of augmentation procedures: injection laryngoplasty, which is injection of the vocal folds with a filler, and medialisation thyroplasty, which is the surgical placement of implants into the vocal folds.  Each treatment may be performed on one vocal fold (a unilateral procedure) or both vocal folds (a bilateral procedure).

Injection laryngoplasty is usually a temporary treatment, and medialisation thyroplasty is a permanent treatment. 

Often a temporary treatment may be recommended first either to confirm the diagnosis (for example, for suspected weakness); to confirm that augmentation will be helpful; and/or to determine how much augmentation improves the voice, to allow someone to try augmentation before they decide to undergo a permanent procedure.  Sometimes a temporary treatment may be all that is required if recovery is expected and occurs – for example, in some cases of paralysis of the vocal fold.

Vocal Fold Injection Laryngoplasty

Injection laryngoplasty (IL) is one of the vocal fold augmentation procedures. The vocal fold is injected with a gel or paste that bulks up (augments) the vocal fold. This material is known as a “filler”, and so injection laryngoplasty is injection of the vocal fold with a filler.

Injection laryngoplasty is usually a temporary form of vocal fold augmentation. Often a temporary treatment may be recommended first either to confirm the diagnosis (for example, for suspected weakness); to confirm that augmentation will be helpful; and/or to determine how much augmentation improves the voice, to allow someone to try augmentation before they decide to undergo a permanent procedure.  Sometimes a temporary treatment may be all that is required if recovery is expected and occurs – for example, in some cases of paralysis of the vocal fold.

What substances are injected into the vocal folds to augment them?

The laryngeal injectables David prefers to use are temporary injectables. These are:

Hyaluronic acid (eg. Restylane or Restylane Lyft)

Hyaluronic acid is a synthetic material made from bacterial fermentation. This is a clear gel that is very safe to inject into the vocal folds. It is used for temporary augmentation. Hyaluronic acid lasts for 1-6 months (average duration of around 3 months) before it is resorbed by the body, and then loses its effect.

Calcium hydroxylapatite (eg. Renu or Radiesse)

Calcium hydroxylapatite (CaHa) is a synthetic material composed of tiny calcium-based microspheres suspended in a water-based gel. This is a white paste that is also safe to inject into the vocal folds. CaHa lasts for 6-12 months before it is resorbed by the body, and then loses its effect. However, it may persist for longer than this on some occasions.

Permanent injectable fillers, such a Teflon or Silicone, are best avoided in the vocal folds, because of the risk of adverse reactions to these fillers.

How is Injection Laryngoplasty performed?

Injection laryngoplasty may be performed in the office with local anaesthetic (LA), in which case the person receiving the injection is awake, or in the operating room where the person receiving the injection is asleep under general anaesthetic (GA).

How is Injection Laryngoplasty performed in the Office (with LA)? 

When injection laryngoplasty (IL) is performed in the office with local anaesthetic (LA) the injection is carried out with you sitting upright. The nose is prepared with a combination anaesthetic and decongestant spray. A small amount of local anaesthetic is injected through the skin into the windpipe. This will make you cough for a brief time.

A flexible endoscope is placed through the nose by an assistant to allow me to see the vocal folds on a video monitor.  A fine needle is placed through the skin of the neck. A small needle prick is felt when the needle enters the skin.  The needle is passed either under the cartilage of the larynx (the thyroid cartilage) to enter the vocal fold from below, or the needle is passed over the top of the cartilage of the larynx to enter the vocal fold from above.  There is a mild amount of discomfort as the needle is moved into position.

After the needle enters the vocal fold the filler is injected into one (unilateral injection) or both vocal folds (bilateral injection). The amount injected is determined by the appearance of the vocal fold and by the quality of the voice.

After the procedure, you should not eat or drink for one hour. You may drive home immediately after the procedure. Voice rest (no whispering, talking, or shouting) may be required for 2 days after the procedure.  Sometimes there is a mild amount of discomfort after the procedure, but this usually settles after 2 days.  A simple pain reliever such as Paracetamol may be taken as required.

What are the risks of Injection Laryngoplasty?

IL is a very safe procedure. Complications after IL are not common, however the following complications may occur: pain, poor voice quality, injection of too much or too little filler, early resorption of the filler, bruising of the neck, bleeding into the vocal fold, shortness of breath or infection.

Laryngeal Botox Injection

Botulinum Toxin (BTX) is a medicine used to treat some neurological disorders of the larynx (voice box), including Spasmodic Dysphonia (SD) (also known as Laryngeal Dystonia (LD)) and Vocal Tremor (VT). SD/LD and VT affect the control of the voice, causing voice problems such as a strained voice, a voice that breaks, or a tremulous voice.

Botulinum Toxin is also used to treat other disorders of the larynx including muscle tension dysphonia (that has not responded to voice therapy) and arytenoid granuloma.

How does BTX work?

  • BTX weakens muscles. In SD/LD, BTX alters the feedback loop between the muscles of the larynx and the brain, leading to an improvement in the control of the muscles of the larynx by the brain. The BTX only affects the vocal cords – it does not spread throughout the body.

How is BTX given?

  • BTX is a medicine that must be injected into the larynx. There are different techniques and approaches that may be used to undertake the injection. Sometimes, it may take several injections before the best technique for injecting a person is decided on.
  • The injection is usually done in the clinic, and the person receiving the injection is awake. They may have the injection in an upright seated position or lying flat on their back.
  • The BTX is usually injected by inserting a needle through the skin of the neck. The needle is usually passed through the skin of the neck either below or above the thyroid cartilage. The vocal folds are the most common part of the larynx injected with BTX, however, some people respond better to injections of BTX into their false vocal cords (structures that are located just above the vocal folds).
  • Sometimes both sides of the larynx are injected (a bilateral injection), but sometimes only one side of the larynx is injected (a unilateral injection).
  • Local anaesthetic may be injected into the airway before the BTX is injected, but many people do not require this, and avoid this, as it is an additional injection.
  • Rarely, the BTX may need to be injected when the person is asleep (under a general anaesthetic) by inserting a very long needle through the mouth.
  • To ensure that the injection is given to the correct part of the larynx, a special needle with an electrode connected to an EMG machine (a machine that detects the electrical activity of muscles) may be used. Flexible laryngoscopy (looking at the larynx with an endoscope or camera placed through the nose) may be used instead of the EMG, or with the EMG.
  • The procedure is usually of short duration, taking less than 10 minutes.

Laryngeal Laser Procedure

Some disorders of the larynx are treated with a medical Laser, which is a tool that delivers energy to the larynx to remove and/or modify abnormal tissue in the larynx. Laser treatment of the larynx may be carried out under general anaesthetic in the operating room, or it may be carried out in the office using local anaesthesia, as an in-office procedure.

In-office procedures are procedures undertaken to treat disorders of the larynx (and also pharynx, oeosphagus and trachea) for a person who is not sedated, using an endoscope passed through the nose to visualize the area being treated. Instead of sedation, local anaesthetic is used in the nose and in the larynx and trachea to numb the area being treated.

The advantages of undertaking such procedures in the office are:

  • the avoidance of general anaesthesia,
  • increased safety (compared to a GA procedure),
  • a shorter procedure time, and
  • the convenience of not having to be admitted to hospital.

The medical Laser that Dr Vokes uses in the office is the TruBlue Laser

The laryngeal conditions treated with a Laser in the office include:

  • RRP (Recurrent respiratory papillomatosis)/Laryngeal papillomatosis
  • Laryngeal dysplasia (precancerous/premalignant lesions)
  • Abnormal blood vessels in the larynx (varices or ectasias)
  • Reinke’s oedema
  • Vocal fold polyps (haemorrhagic polyps)
  • Laryngeal (arytenoid) granulomas

Salivary Gland Botox Injection

Botulinum Toxin (Botox, BTX) is a medicine that is sometimes used to help people who have problems with control of their saliva, resulting in drooling (or sialorrhoea). In adults, drooling is usually caused by either neurological disorders (such as Motor Neurone Disease) or as a side effect of the treatment of cancers of the mouth or throat, resulting in difficulty managing normal volume of saliva, rather than an absolute excess in the volume of saliva produced.

The Botox is injected into the main salivary glands: the submandibular glands and/or the parotid glands to reduce the amount of saliva produced by the saliva glands. It does not result in complete cessation of salivary production by the body as the effect on these glands is not complete, and because there are also hundreds of minor salivary glands that also contribute to saliva production. However, the saliva that is produced after such an injection may be thicker in consistency than before the injection.

The effect of Botox is usually temporary, lasting 3-4 months. Salivary gland Botox injections can be repeated as often as required.

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