Device Failure

Nicole Molin MD, Mursalin M. Anis, MD PhD, Ahmed M.S. Soliman, MD

Injection medialization laryngoplasty is a commonly performed procedure for the management of glottic insufficiency. Since first described by Brunings in 1911, both the technique and materials used have evolved greatly.2 Complications of this procedure are uncommon but include migration of the injection material, bleeding/ hematoma at the injection site, patient intolerance, suboptimal voice outcome, vasovagal response, and rarely airway compromise.2-4 Among the rarer complications is device failure for which literature is scarce.

On a recent survey of active members of The American Bronchoesophagological Association (ABEA) by our group, nearly all 24 respondents experienced needle failures during injection laryngoplasty, and 1/6th of them experienced needle failures more than 10 times.5 The most common reason for needle failure was clogging (59%), followed by twisting (22%), and needle tip fracture (19%). Most device failures occurred when the procedure was being done on an awake patient. Fifty four percent of respondents reported needle failure while using a percutaneous approach. CAHA was the injection material being used during nearly half of needle failures. Twenty percent of survey respondents reported aborting a procedure due to needle failure. Familiarity with managing these complications is essential. The most common reason for needle failure was clogging and twisting which can be managed by replacing the needle. Nearly a fifth of respondents, however, experienced needle tip fracture, a complication that has the potential for significant patient morbidity from the presence of a sharp foreign body in the aerodigestive tract and requires immediate intervention. All airway foreign bodies require urgent retrieval which has been traditionally performed using rigid bronchoscopy under general anesthesia.6 When the foreign body is not visible upon flexible laryngoscopy, radiography of the neck and chest is necessary to help locate it. Suspected foreign bodies in the airway will require prompt retrieval whereas those in the digestive tract have several management options based on the size of the needle.7

While device failure during injection laryngoplasty is rarely reported in the literature, it was experienced by almost all respondents in our survey, most of whom were fellowship trained laryngologists and perform these procedures regularly. Awareness of this complication is important to allow otolaryngologists to appropriately provide informed consent to patients and proceed cautiously.

An understanding of appropriate management is critical particularly for needle fractures that result in an aerodigestive tract foreign body which require prompt attention.

References

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Laryngol. 1911;18:525–30. 2. Bock JM, Lee JH, Robinson RA, Hoffman

HT. Migration of Cymetra after vocal fold injection for laryngeal paralysis.

Laryngoscope. 2007;117(12):2251–4. 3. Carroll TL, Rosen CA. Long‐term results of calcium hydroxylapatite for vocal fold augmentation. Laryngoscope. 2011;121(2):313–9. 4. DeFatta RA, Chowdhury FR, Sataloff RT.

Complications of injection laryngoplasty using calcium hydroxylapatite. J Voice. 2012;26(5):614–8. 5. Molin N, Anis M, Soliman, AMS.

Device failure during injection medialization laryngoplasty. J.

Voice. In Press.

6. Aydoğan LB, Tuncer U, Soylu L, Kiroğlu

M, Ozsahinoglu C. Rigid bronchoscopy for the suspicion of foreign body in the airway. Int J Pediatr Otorhinolaryngol. 2006;70(5):823–8. 7. Ambe P, Weber SA, Schauer M,

Knoefel WT. Swallowed foreign bodies in adults. Dtsch Arztebl Int. 2012;109(50):869.