Early injection laryngoplasty improves swallowing outcomes in inpatients with acute vocal fold motion impairment

Objectives: The early evaluation and management of patients with acute iatrogenic vocal fold motion impairment (VFMI) lacks a standardized approach to identify those inpatients with dysphagia and risk of aspiration. The aims of the current study include (1) prospectively identifying patients with acute VFMI and swallowing dysfunction and (2) assessing changes in swallowing function before and after early injection laryngoplasty (IL). Methods: Clinical research, prospective interventional study. Inpatients who had undergone thoracic or cardiothoracic surgery were postoperatively assessed by a speech-language pathologist (SLP) using bedside swallow evaluation (BSE) and fiberoptic endoscopic evaluation of swallowing (FEES). Patients with abnormal FEES and VFMI were also assessed by an Otolaryngology consultant. Patients with a diagnosis of VFMI were candidates for IL if there was evidence of swallowing dysfunction and risk of aspiration on the SLP-performed FEES.If IL was indicated and performed, the patients were prospectively recruited for the study. Patients were evaluated by SLP for cough strength (peakcough flow, L/min), swallowing function, and diet advancement, before and after IL, using the National Outcomes Measure Swallowing Scale (NOMS) and Penetration-Aspiration Scale (PAS). The Voice Handicap Index-10 (VHI-10) and Eating Assessment Tool-10 (EAT-10) patient-reported quality-of-life questionnaires were also administered before and after the IL intervention. Results: Nineteen inpatients were included in this study (10 females, nine males). On average, initial FEES was performed 4.05 ± 3.87 (range 1-14) days following extubation. When indicated, IL was performed 6.47 ± 6.32(range 0-28) days after extubation and 1.95 ± 2.37 (range 0-11) days after the initial FEES. A post-IL FEES was performed on average 1.74 ± 2.07 (range 0-7) days after the injection. All patients after IL could take a diet by mouth, and 15/19 patients had their diet advanced. When compared to pre-IL scores, there was significant improvement in both NOMS score (+2.5; CI+2.00 to +3.00; P<0.001) and PAS (-5.00; CI -6.00 to-3.50; P<0.001) as assessed by SLP after IL. Significant improvement was also noted in the patient-reported VHI-10 (-16.5; CI -20.5 to -12.0; P<0.001) and EAT-10 (-11.0; CI -15.0 to -7.0; P<0.001) scores after injection. The mean peak flow before intervention was 108 L/min, increasing to 192 L/min after IL. On average, there was a significant increase in mean peak flow volume of 84.7L/min (CI 95%: 52.6-116.9 L/min; P< 0.001) from pre- to post-IL. No complications were reported, and all patients could tolerate the bedside IL Conclusions: Our study underscores the importance of early screening for VFMI and dysphagia in patients undergoing high-risk procedures, particularly thoracic or cardiothoracic surgeries. Early injection medialization of the acutely paretic/paralyzed vocal fold emerges as a promising therapeutic option. The close collaboration between the SLP and Otolaryngologist is crucial for early identification and bedside treatment of symptomatic VFMI, leading to improved voice, cough strength, and swallowing, and allowing fora more rapid return to a safe oral diet.