Treatment Outcomes and Adverse Events Following In-Office Angiolytic Laser With or Without Concurrent Polypectomy for Vocal Fold Polyps

Office-Based Blue Laser Therapy vs Thulium Laser Therapy for Reinke's Edema

OBJECTIVE

To compare the treatment outcomes of patients with Reinke's edema (RE) who were treated in-office using the blue laser vs those treated in-office using the thulium laser.

STUDY DESIGN

Retrospective case-control study.

METHODS

The medical records and video recordings of patients who underwent office-based thulium laser therapy for RE between November 2018 and July 2019, and office-based blue laser therapy for RE between November 2023 and March 2024 in a tertiary referral center were reviewed. The primary outcome measures used in this study were the Voice Handicap Index-10 (VHI-10) score and disease regression based on the laryngeal examination performed before and after therapy.

RESULTS

Twenty-two patients were included in this study. They were divided into 2 subgroups, 12 patients with 22 lesions who underwent office-based thulium therapy and 10 patients with 17 lesions who underwent office-based blue laser therapy. There was no significant difference in the decrease in the mean VHI-10 score following surgery between those treated with the thulium laser vs those treated with the blue laser (10.5 ± 13.15 vs 8.2 ± 5.98, P = 0.657). Nine out of 22 lesions (40.9%) treated with thulium laser regressed completely compared to 9 out of 17 lesions (52.9%) treated with a blue laser. The difference in disease regression between the two subgroups was not statistically significant (P = 0.455).

CONCLUSIONS

Blue laser and thulium laser can be used interchangeably in-office for the treatment of RE with no significant difference in patient self-perceived improvement in voice quality and disease regression. A larger study using objective measures is warranted.

Photoangiolytic Lasers for Treatment of Benign Laryngeal Lesions: A Systematic Review and Meta-Analysis

OBJECTIVES

To compare the efficacy of the 445-nm blue laser to the 585-nm pulsed dye laser (PDL) and 532-nm potassium-titanyl-phosphate (KTP) laser in the treatment of benign laryngeal lesions.

DATA SOURCES

Cochrane Library, PubMed, Scopus, and CINAHL.

REVIEW METHODS

Following PRISMA guidelines, databases were searched from inception through January 29, 2024, for studies reporting the use of photoangiolytic lasers for treatment of benign laryngeal lesions, including the 585-nm PDL, 532-nm KTP laser, and 445-nm blue laser. Outcome measures included lesion resolution (%), mean differences (Δ) in Voice Handicap Index (VHI-10), and summed dysphonia grade, roughness, and breathiness (GRB) scale.

RESULTS

A total of 45 studies were included for meta-analysis, consisting of 348 patients treated with PDL, 550 patients with KTP laser, and 338 patients with blue laser. Treatment with blue laser resulted in the greatest lesion resolution (94.0%; 95% confidence interval [CI]: 90.2%-96.7%), followed by KTP laser (90.4%; 95% CI: 84.1%-95.2%), and PDL (86.9%; 95% CI: 62.9%-99.2%). VHI-10 improved significantly in patients following treatment with blue laser (Δ13.3; 95% CI: 10.7-16.0; p < 0.0001), KTP laser (Δ10.3; 95% CI: 7.4-13.3; p < 0.0001), and PDL (Δ7.4; 95% CI: 4.8-10.1; p < 0.0001). GRB improved significantly in patients following treatment with blue laser (Δ4.1; 95% CI: 2.9-5.2; p < 0.0001), KTP laser (Δ3.0; 95% CI: 2.0-4.0; p < 0.0001), and PDL (Δ2.5; 95% CI: 0.8-4.2; p = 0.005).

CONCLUSIONS

Photoangiolytic lasers are effective in treating benign laryngeal lesions. Blue lasers are promising for laryngeal laser surgery. Laryngoscope, 2024.

Randomized Controlled Trial of Awake Transnasal Laser-Assisted Surgery for Benign Laryngeal Lesions

OBJECTIVE

To compare functional and cost-effectiveness of awake transnasal laser assisted-surgery versus microlaryngeal surgery for benign laryngeal lesions.

METHODS

This was a prospective non-inferiority randomized controlled trial conducted from May 2021 to December 2022 at two tertiary referral hospitals in Hong Kong. Patients were block-randomized to receive either awake transnasal laser-assisted surgery or microlaryngeal surgery, with post-operative follow-up in a multidisciplinary voice clinic for 1-year. Primary outcome was Voice Handicap Index (VHI-30). Secondary outcomes included operation time, complications, length of stay, peri-operative discomfort, recurrence, and medical costs.

RESULTS

Sixty-one patients were randomized to either awake transnasal laser-assisted surgery (n = 30) and microlaryngeal surgery (n = 31). Both groups had comparable demographics and laryngeal pathologies. Both groups showed significant improvement of VHI-30 score over time and had comparable post-operative VHI-30. Awake transnasal laser-assisted surgery group had a significantly shorter length of stay (0.5 vs. 1 day) and less throat discomfort (2 vs. 4) compared to microlaryngeal surgery group. Intraoperative complications were more common in microlaryngeal surgery group (14.3% vs. 0%). Otherwise, both groups had similar operative time and recurrence rate. Cost-analysis showed a significantly lower hospital cost for awake transnasal laser-assisted surgery (USD 3090) compared to microlaryngeal surgery group (USD 5120).

CONCLUSION

Awake transnasal laser-assisted surgery was safe, functionally non-inferior, as measured by VHI-30, to microlaryngeal surgery in managing benign laryngeal lesions, while superior to microlaryngeal surgery in peri-operative discomfort and medical costs.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:3732-3740, 2024.

Laser-Induced Blood Coagulation for Surgical Application: A Scoping Review

There is a lack of evidence-based reviews on the effects of laser irradiation on blood coagulation in the literature, despite a large number of clinical trials. We therefore evaluated the available evidence on laser irradiation parameters used in coagulation of blood to optimize physical parameters. We performed a literature search for recent scientific studies indexed between 2017 and 2023 using the databases of PubMed and ScienceDirect. Articles were selected based on defined inclusion and exclusion criteria, and 78 publications in total were eventually included in this scoping review. The following were found to produce significant benefits in blood coagulation for surgical application: (1) dentistry and oral surgeries: 980 nm, 27 s, 2 W, 1502.7 W/cm2, 26.5 J, 622 J/cm2, 400 μm; (2) urogenital disorders: 532 nm, 4 s, 40 W, 10600 W/cm2, 1.3 J, 424 J/cm2, 600 μm; (3) ophthalmic disorders: 810 nm, 1 s, 1 W, 3540 W/cm2, 0.75 J, 1326 J/cm2, 100 μm; (4) embryological surgeries: 1064 nm, 10 s, 25 W, 35400 W/cm2, 262.5 J, 371000 J/cm2, 332.5 μm; (5) dermatological disorders: 1064 nm, 20 W, 2440 W/cm2, 0.1 J, 24 J/cm2, 670 μm; (6) gastrointestinal disorders: 532 nm, 3 s, 20 W, 1051 W/cm2, 120 J, 26500 J/cm2, 760 μm; (7) neurological surgeries: 2.5 s, 1.5 W, 1035 W/cm2, 2 J, 1584 J/cm2, 385 μm; (8) pulmonary disorders: 1320 nm, 5s, 35 W, 12450 W/cm2, 250 J, 65000 J/cm2, 700 μm (9) cardiovascular disorders: 1064 nm, 16.5 s, 5 W, 1980.5 W/cm2, 900 J, 760 J/cm2, 400 μm. In conclusion, our scoping review identifies that combining data from all clinically heterogeneous studies suggests that laser irradiation reflects an effective method for inducing blood coagulation in several medical fields.

Surgical management of broad-based sessile vocal cord polyps: Transnasal vocal fold polypectomy versus microlaryngoscopic surgery: Our experience in 159 cases

OBJECTIVES

In this study, we retrospectively reviewed and compared the treatment outcomes and complications of office transnasal vocal fold polypectomy (TVFP) with those of microplarygoscopic surgery (MLS) for different clinical and histopathological features of broad-based sessile vocal fold polyps.

METHODS

We retrospectively reviewed the records of 159 consecutive patients with broad-based sessile vocal fold polyps treated by TVFP or MLS. The differences in efficacy and complication between these two surgical techniques were compared according to the different types of vocal fold polyps.

RESULTS

Satisfactory outcomes of both TVFP and MLS treatments were reported in patients with oedematous, gelatinous and vascular types of vocal fold polyps (p > .05). The efficacy of TVFP was slightly worse than MLS in fibrous polyps group (p < .05). The TVFP-treated patients did not exhibit obvious complications, whereas several MLS-treated patients had suffered different complications.

CONCLUSION

The therapeutic effects of both TVFP and MLS on the treatment of broad-based sessile vocal cord polyps are related to their clinical characteristics and histological types. Satisfactory outcomes are achieved in oedematous, gelatinous, and vascular types of polyps after either surgical procedure. TVFP has fewer surgical complications than MLS which can be a preferred option for the treatment of broad-based sessile vocal cord polyps at outpatient setting. TVFP also can be an alternative surgery option for patients who could not tolerate general anaesthesia or laryngeal suspension. In contrast, MLS has proven to be a particularly advantageous treatment in patients who have fibrous type of polyps.

Pre and Post-operative Voice Therapy Intervention for Benign Vocal Fold Lesions: A Systematic Review

Benign vocal fold lesions cause dysphonia by preventing vocal fold closure, causing irregular vibration and increasing compensatory muscle tension. Voice therapy delivered in addition to phonosurgery may improve voice and quality of life outcomes but the evidence base is lacking and what constitutes voice therapy for this population is not defined. The purpose of this systematic review is to critically evaluate the evidence for pre and post-operative voice therapy to inform the development of an evidence based intervention.

STUDY DESIGN

Systematic Review.

METHODS

Electronic databases were searched using key terms including dysphonia, phonosurgery, voice therapy and outcomes. Eligible articles were extracted and reviewed by the authors for risk of bias and for information regarding the content, timing and intensity of any pre and post-operative voice therapy intervention.

RESULTS

Of the 432 articles identified, 35 met the inclusion criteria and were included in the review. 5 were RCTs, 2 were individual cohort studies, 1 was a case control study and 26 were case series. There was considerable heterogeneity in participant characteristics. Information was frequently lacking regarding the content timing and intensity of the reported voice therapy intervention, and where present, interventions were highly variable.

CONCLUSION

Reporting in relevant literature is limited in all aspects of content, timing and intensity of intervention. Further intervention development work is required to develop a robust voice therapy treatment intervention for this population, before effectiveness work can commence.

Vocal Fold Polyps: A Scoping Review

OBJECTIVE

This review aims to summarize the current understanding of vocal fold polyp etiology, pathophysiology, and prognosis, as well as recent developments in management.

STUDY DESIGN

Scoping literature review.

REVIEW METHODS

OVID Medline, PubMed, Google Scholar, Conference Papers Index, and Cochrane Library were searched for publications within the last 5 years using terms including "vocal," "cord," "fold," and "polyp." All abstracts were screened. Relevant studies pertaining to the etiology, pathophysiology, diagnosis, management, and prognosis of vocal fold polyps (VFPs) were included for review.

RESULTS

Eight-hundred and sixty-five citations resulted from database review. Seven-hundred and thirty citations remained after the exclusion of duplicates. One hundred and ninety-three papers underwent abstract review, with 73 citations undergoing full-text review. Fifty-nine papers were included in the review.

CONCLUSIONS

VFPs are one of the most common subtypes of benign vocal fold lesions. Phonotrauma contributes significantly to the development of these lesions, with laryngopharyngeal reflux and smoking also contributing. Correct diagnosis relies on a careful history, stroboscopy, response to voice therapy, and, in some cases, intraoperative findings. Phonosurgery is a definitive means of treatment, though more recently, in-office procedures have demonstrated efficacy and are potentially less costly and less invasive treatment options. Treatment modalities can be tailored based on the type and size of the lesion, the patient's vocal needs, medical comorbidities, and initial response to voice therapy. Voice specialists can anticipate greater emphasis placed on minimally invasive office-based procedures for the management of vocal pathology.

The Efficacy of Different Voice Treatments for Vocal Fold Polyps: A Systematic Review and Meta-Analysis

BACKGROUND

Vocal fold polyps (VFP) are a common cause of voice disorders and laryngeal discomfort. They are usually treated by behavioral voice therapy (VT) or phonosurgery, or a combination (CT) of both. However, the superiority of either of these treatments has not been clearly established.

METHODS

Three databases were searched from inception to October 2022 and a manual search was performed. All clinical trials of VFP treatment were included that reported at least auditory-perceptual judgment, aerodynamics, acoustics, and the patient-perceived handicap.

RESULTS

We identified 31 eligible studies (VT: n = 47-194; phonosurgery: n = 404-1039; CT: n = 237-350). All treatment approaches were highly effective, with large effect sizes (d > 0.8) and significant improvements in almost all voice parameters (p-values < 0.05). Phonosurgery reduced roughness and NHR, and the emotional and functional subscales of the VHI-30 were the most compared to behavioral voice therapy and combined treatment (p-values < 0.001). Combined treatment improved hoarseness, jitter, shimmer, MPT, and the physical subscale of the VHI-30 more than phonosurgery and behavioral voice therapy (p-values < 0.001).

CONCLUSIONS

All three treatment approaches were effective in eliminating vocal fold polyps or their negative sequelae, with phonosurgery and combined treatment providing the greatest improvement. These results may inform future treatment decisions for patients with vocal fold polyps.

Office-Based Laser Therapy in Vocal Fold Polyps: A Systematic Review and Meta-Analysis

OBJECTIVES

To analyze voice outcomes and lesion regression in patients with vocal fold polyps treated in-office using lasers.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The search was performed in the Medline, Embase, and Cochrane databases using the preferred reporting items for systematic review and meta-analyses framework. There were no limitations to the year of publication and the search included studies looking at voice outcomes and lesion evolution of in-office laser treatment for vocal fold polyps measured through voice-handicap index, GRB, acoustic analysis or aerodynamics measures. Risk of bias was assessed using Cochrane's ROBINS-I tool for observational studies. Data analysis was performed SPSS software with a significance level of 5%.

RESULTS

We identified 167 articles, 10 of which met the inclusion criteria and were analyzed. The total number of participants was 242. Meta-analysis showed significant improvement in voice handicap index-10 scores (95% CI, [0.86; 1.45]) and decrease in GRB score (95% CI, [1.09; 4.13]) after in-office laser therapy. It also showed significant improvement in percent shimmer (95% CI, [0.26; 1.01]), and significant increase in maximum phonation time (95% CI, [-0.92; -0.18]).

CONCLUSIONS

Laser therapy an outpatient office setting is a reliable alternative to classical phono-microsurgery. Results show Office-based laser therapy of vocal fold polyps results in a significant improvement in subjective voice outcomes measures. This subjective improvement in voice quality is associated with partial or complete disease regression on laryngeal examination and an increase in maximum phonation time. Ovlaryngeal examination in patients with polyps treated with in-office laser.

Longitudinal Voice Outcomes Following Serial Potassium Titanyl Phosphate Laser Procedures for Recurrent Respiratory Papillomatosis

OBJECTIVE

Repeated surgical interventions are usually required to control recurrent respiratory papillomatosis (RRP), but at considerable risk of worsened postoperative voice quality. Potassium titanyl phosphate (KTP) laser has been reported to effectively manage RRP; however, voice quality after repeated procedures has not been investigated.

METHODS

This study recruited 16 patients with RRP treated using KTP laser between 2013 and 2019. KTP laser procedures were performed under general anesthesia via direct suspension laryngoscope or under local anesthesia via flexible endoscope, depending on the need for pathological proof, patient tolerance, and lesion size and location. Disease control was investigated by videolaryngostroboscopy. Voice outcome was evaluated using a 10-item voice handicap index (VHI-10), acoustic and perceptual analyzes.

RESULTS

We reviewed the medical records of 11 male and 5 female patients with RRP (age range: 23-73 years). Five patients received KTP laser once, six patients received it 2 to 5 times, and five patients received 6 to 15 procedures. Median VHI-10 decreased from 28.3 to 12.0 points after the initial procedure and were maintained at 10.1 to 11.0 points following subsequent procedures (P < .01, generalized estimating equation). Acoustic and perceptual analysis of voice quality also revealed significant improvements (P < .01), which remained stable even after 6 to 10 KTP laser procedures. Minor adverse events included slight fibrotic change of vocal folds and glottic web, but these did not significantly alter postoperative voice quality.

CONCLUSION

This longitudinal follow-up study revealed that serial KTP laser procedures can effectively control RRP while preserving phonatory function and maintaining adequate voice quality.

LEVEL OF EVIDENCE

4.

A 532-nm KTP Laser for Vocal Fold Polyps: Efficacy and Relative Factors

OBJECTIVE

We retrospectively analyzed the laryngoscopy results and voice outcomes of patients with vocal polyps who received potassium titanyl phosphate (KTP) laser treatments in a clinician's office, in order to establish the effectiveness and relative factors affecting the efficacy of this treatment.

MATERIAL AND METHODS

We enrolled 25 patients with vocal polyps who had undergone KTP laser treatment in the Department of Otorhinolaryngology at our hospital between July 2017 and November 2019. Pre- and postoperative evaluations were measured using laryngovideostroboscopy (LVS), the Voice Handicap Index questionnaire (VHI-30), the GRBAS scale (G hoarseness, R roughness, B breathiness, A asthenia, S strain), and objective acoustic parameters. The reduction rate of lesions was calculated and relative factors affecting efficacy (size, side, location, the position of lesions, type, gender, and occupation) were tested.

RESULTS

Areas of lesions decreased from 101.95 ± 70.16 before surgery to 30.49 ± 35.80 after surgery (Z = 5.234, P < .001). The LVS data showed that the postoperative proportions of normal to mild conditions were the same or higher than the preoperative data in 3 instances: glottal closure (100% vs 100%), amplitude (90.91% vs 63.64%), and mucosal wave (81.82% vs 54.55%). A significant improvement was observed in VHI-30 scores, GRBAS scores, and acoustic parameters (P < .05). The size of lesions had an effect on the GRBAS scores (P < .001) but not on VHI-30 scores and objective acoustic parameters (P > .05). Other factors we tested did not affect voice outcomes.

CONCLUSION

Potassium titanyl phosphate laser treatment can effectively reduce the lesion area of vocal polyps and improve the voice quality. The presence of small lesions seems to predict good subjective assessments of voice quality, but it remains to be seen whether this correlates with true voice quality.