Quantifying Bevacizumab Efficacy in Recurrent Respiratory Papillomatosis

OBJECTIVES

To develop and validate a novel method for quantifying the efficacy of Bevacizumab (Bev) in treating Recurrent Respiratory Papillomatosis (RRP), and to evaluate the clinical outcomes of a three-dose Bev induction therapy followed by surgical intervention.

METHODS

Twenty-one RRP patients treated with a three-dose Bev regimen were included. A novel efficacy evaluation method using ImageJ software was developed to calculate the standardized lesion volume from laryngoscopic images. This was compared with the Derkay score. Clinical outcomes, including reduction rate, cumulative reduction rate, efficacy grading, recurrence, and adverse reactions, were analyzed.

RESULTS

In the study cohort, the reduction rate was significantly higher after the first treatment compared with subsequent treatments. The overall response rate increased from 75% after the first treatment to 100% after the third. Among patients with localized lesions who underwent surgery, 76% experienced recurrence with a mean recurrence time of 114.23 days. Most recurrent lesions were smaller than at baseline. Adverse reactions included increased blood pressure in seven patients, which resolved without intervention. The new method showed a significant positive correlation with the Derkay score.

CONCLUSION

In conclusion, based on the above findings, systemic Bev treatment for RRP is a safe and effective therapeutic approach, though further research is needed. Moreover, the new efficacy evaluation method we developed can significantly aid in studying the effectiveness of Bev treatment for RRP.

LEVEL OF EVIDENCE

2 Laryngoscope, 2024.

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.

Prospective Outcomes of Microlaryngoscopy Versus Office Laser Photoangiolysis for Vocal Fold Polyps

OBJECTIVE(S)

The objective of this study is to compare treatment outcomes for vocal fold polyps (VFPs) between operating room microlaryngoscopy and office-based photoangiolysis with the potassium titanyl phosphate (KTP) laser.

METHODS

Prospective nonrandomized cohort study of patients with VFPs undergoing microlaryngoscopy ("OR group") or KTP laser photoangiolysis ("KTP group"). Voice outcomes (patient-reported outcome measures [Voice Handicap Index-10 (VHI-10) and Singing VHI-10 (SVHI-10)], auditory-perceptual measures [Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)], videostroboscopic characteristics [Voice-Vibratory Assessment of Laryngeal Imaging (VALI)], and acoustic and aerodynamic measures) were performed at baseline and regular intervals after intervention.

RESULTS

Forty-four subjects (17 OR group, 27 KTP group) with VFPs were enrolled. Mean VHI-10 significantly improved from baseline to each follow-up interval in both groups, except for the 1-2-week interval in the OR group. Mean SVHI-10 improved for both groups at some intervals. Growth curve models and time-to-event analyses for patient-reported outcomes did not differ between groups. There were significant improvements in all categories of auditory-perceptual voice quality and some categories of videostroboscopic characteristics in both groups. No significant trends were identified in acoustic and aerodynamic measures. Improvements in most outcomes did not significantly differ between groups or based on polyp size. There were no major complications.

CONCLUSIONS

Significant improvements in patient-reported voice outcomes measures, auditory-perceptual voice evaluation, and videostroboscopic characteristics occur following surgical treatment of vocal fold polyps with either microlaryngoscopy or office-based KTP laser. Long-term voice outcomes do not significantly differ between treatment modalities.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:S1-S20, 2024.

Office-based Blue Laser Therapy of Vocal Fold Polyps: A Cohort of 18 Patients: Blue Laser Therapy of Vocal Fold Polyps

OBJECTIVE

To investigate the effect of office-based blue laser therapy of vocal fold polyps on voice.

METHODS

The medical records and video recordings of patients who underwent office-based laser therapy in a tertiary referral center between February 2020 and May 2020, and May 2021 and October 2022 was conducted. Only patients with vocal fold polyps who had undergone office-based blue laser therapy were included. The voice was evaluated before and after surgery using the Voice Handicap Index-10 (VHI-10), GRB perceptual evaluation, acoustic analysis, and maximum phonation time.

RESULTS

A total of 18 patients were included. The mean age of the study group was 52.5 ± 11.94 years. The male-to-female ratio was 2:1. Ten patients of the total group (53.6%) had hemorrhagic polyps and the most common site was the mid-third of the vocal fold. All patients who presented for follow-up (n = 15) had partial or complete regression of the lesion (4 and 11, respectively). There was a significant decrease in the mean score of VHI-10 (17.6 ± 9.97 vs. 4.27 ± 5.76, p < 0.001) and in the means of grade of dysphonia (2.0 ± 0.73 to 0.5 ± 0.63, p < 0.001), roughness (1.88 ± 0.81 to 0.44 ± 0.51, p < 0.001) and breathiness (0.81 ± 0.75 to 0.13 ± 0.34 p < 0.001). There was also a marked decrease in the perturbation parameters (jitter and shimmer) and a significant increase in the MPT from 10.66 ± 4.22 s to 14.26 ± 6.26 s (p = 0.028).

CONCLUSION

Office-based blue laser therapy is an effective treatment modality in patients with vocal fold polyps.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2712-2718, 2023.

Treatment of Vocal Fold Nodules: Transnasal Steroid Injection Versus Microlaryngoscopic Phonomicrosurgery

OBJECTIVES

Vocal fold nodules (VFNs) are bilateral, mid-membranous, swellings of the vocal folds. Intralesional steroid injection was successfully tried in the management of benign vocal fold lesions including nodules. The aim of the present study was to compare treatment outcomes of vocal fold steroid injection (VFSI) and surgery in patients with VFNs in terms of lesion regression, subjective, and objective voice parameters.

STUDY DESIGN

Nonrandomized controlled clinical trial.

METHODS

This bicenter interventional study was conducted on 32 patients with VFNs, in the age range of 16-63 years. Sixteen patients underwent transnasal VFSI under local anesthesia (the injection group), and 16 underwent surgical excision of the nodules under general anesthesia (the surgery group). Prior to intervention and at the follow-up visit, participants were subjected to videolaryngoscopic examination with evaluation of nodules' sizes as well as subjective voice assessment by auditory perceptual assessment (APA) of voice and the international nine-item Voice Handicap Index (VHI-9i). Objective voice assessments including the measurements of cepstral peak prominence, jitter, shimmer, harmonic to noise ratio, and maximum phonation time were also administered.

RESULTS

The size of vocal fold nodules was significantly decreased postintervention in both studied groups. There was a decrease in the VHI-9i score, a decrease in the values of jitter and shimmer, together with an increase in the values of cepstral peak prominence and maximum phonation time after interventions indicating improvement of subjective and objective voice outcomes in both groups.

CONCLUSION

Office-based transnasal VFSI is a safe and tolerable therapy option for VFNs. Voice outcomes of VFSI were comparable to surgery, hereby VFSI can be considered a promising therapy for VFNs and could be used as an alternative to surgery in selected cases.

Office-based Laser Therapy in Reinke's Edema: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze voice outcomes and lesion regression in patients with Reinke's edema treated in the office with lasers.

STUDY DESIGN

Systematic review and meta-analysis METHODS: The search was performed in the Medline, Embase, Medline, Cochrane, and Google Scholar databases using the PRISMA 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 Reinke's edema measured through voice-handicap index, 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

The initial search identified 650 articles, 6 of which met the inclusion criteria and were analyzed. The total number of participants was 58. Meta-analysis showed significant improvement in VHI-10 scores after in-office laser therapy (95% CI, [-1.46; -0.75]). It also showed significant improvement in jitter, significant increase in fundamental frequency (95% CI, [0.52; 1.71]) and significant decrease in lesion size (95% CI, [-2.03; -0.35]).

CONCLUSION

Office-based laser therapy is a reliable alternative to the traditional phono-microsurgery performed in the operating room. Patients show significant improvement in voice outcomes and laryngeal examination.

Comparison of the Effects of Botulinum Toxin A Injection and Local Glucocorticoid Injection for Treating Laryngeal Contact Granuloma

OBJECTIVES

To compare the effects of botulinum toxin A injection and local glucocorticoid injection for treating laryngeal contact granuloma and to discuss the indications for both regimens.

METHODS

The case data of 50 patients with laryngeal contact granuloma in the outpatient clinic of the Sixth Medical Center of the PLA General Hospital from January 2020 to December 2021 were reviewed, and the patients were divided into the following two groups according to the different treatments received: botulinum toxin A injection or local glucocorticoid injection. Quantitative assessment of the lesion size was performed using Image J software to compare the efficacy in the two groups.

RESULTS

On comparing the cure rate between the two groups at 3 months after treatment, 72% of patients in the botulinum toxin A group were cured compared to 40% of patients in the glucocorticoid group (P = 0.023). On comparing the cure rate between the two groups at 6 months after treatment, 88% of patients in the botulinum toxin A group were cured compared to 64% of patients in the glucocorticoid group (P = 0.047).

CONCLUSIONS

Botulinum toxin A injection is superior to local glucocorticoid injection, and local glucocorticoid injection is more appropriate for patients who cannot tolerate the adverse effects of botulinum toxin A.

Unsedated Office-Based Blue Laser Therapy in Female Patients With Reinke's Edema: A Retrospective Review of 8 Cases

OBJECTIVES

To report on the outcomes of unsedated blue laser therapy in female patients with Reinke's edema.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review of female patients undergoing unsedated office-based blue laser treatment of Reinke's edema between February 2020 and March 2022 at the Hamdan Voice and Swallowing Unit at the American University of Beirut Medical Center in Beirut, was conducted. Patients were assessed before and after the procedure with a follow-up interval of 3-6 weeks. Demographic data included age, history of smoking and grade of Reinke's edema. Voice outcome measures included the Voice Handicap Index-10 questionnaire, perceptual evaluation (GRBAS scale), acoustic analysis and maximum phonation time. Vocal fold lesions were evaluated using indirect laryngeal endoscopy.

RESULTS

A total of eight patients were reviewed. The mean age was 59.63 ± 7.98 years. One patient was lost to follow-up. We report on a total of 10 Reinke's edema lesions treated with the blue laser. There was a significant decrease in the mean VHI-10 score (14.86 ± 5.84-6.71 ± 7.32; P < 0.01) as well as in the means of three perceptual evaluation parameters (G, R, B; P < 0.05). There was also a nonstatistically significant increase in the mean fundamental frequency and habitual pitch. Laryngeal examination showed complete regression in 50% of the lesions, and partial regression in the remaining 50%.

CONCLUSIONS

Office-based blue laser treatment of Reinke's edema under local anesthesia can be considered an effective treatment modality as evidenced by improvement in post-procedure voice outcome measures.

Phonosurgery of Reinke's edema with microdebrider

PURPOSE

To present our experience with a new microsurgical approach for treatment of the Reinke's edema in suspension laryngoscopy-microdebridement. After a short review of existing literature we introduce speech therapy before and after the surgery into the protocol.

METHODS

 The authors compare the phonatory outcome, laryngostroboscopical results and subjective improvement of the voice of 30 patients with Reinke's edema that were operated with either microdebridement or cold steel surgery techniques. "Sandwich" speech therapy strategy was applied for the vocal rehabilitation before and after surgery in both patient groups.

RESULTS

After the microdebridement and the speech therapy the mucosal wave was regular, symmetric and periodic in all patients. No signs of abnormal scar tissue or anterior adhesions were observed. Significant improvement of vocal parameters was found after the surgery in both groups of patients: operated with the microdebridement technique and the cold steel technique. The subjective voice evaluated by Voice Handicap Index (VHI-10) was improved for both patient groups in a homogenous way.

CONCLUSIONS

Based on the similarity of the vocal outcome in the two groups, microdebridement of the vocal folds is an excellent method for removing the edema of the Reinke's space. Careful suction at a low voltage protects the lamina propria during the microdebridement. The authors discuss the indication to this innovating procedure in patients with difficult laryngeal exposure and small operating field.

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.

Unsedated Office-Based Thulium Laser Therapy in Patients With Reinke's Edema

OBJECTIVE

To report the outcome of unsedated office based Thulium laser therapy for Reinke's edema.

MATERIALS AND METHODS

A retrospective chart review of patients operated between March 2017 and November 2018 was conducted. Twelve patients were included, two of whom had two procedures performed. Demographic data included age, gender, smoking status, and grade of Reinke's edema. Outcome measures included Voice Handicap Index-10 (VHI), perceptual evaluation, extent of disease regression, acoustic analysis, and maximal phonation time.

RESULTS

Twelve patients were enrolled in this study, one of whom was lost for follow-up. There were eight females and three males. The mean age was 51.27 ± 9.12 years. Endoscopic evaluation 6-12 weeks after surgery revealed complete and partial regression of disease in three and eight patients, respectively. There was a significant improvement in the mean score of VHI-10 (15.00 ± 9.45 vs 3.07 ± 3.81) and the mean score of GRABS parameters following surgery (P < 0.05). The mean habitual pitch increased from 125.11 ± 28.48 Hz to 155.86 ± 55.14 Hz (P = 0.070). There was improvement in the mean jitter and shimmer but none reached a statistical significance. There was no significant change in the mean Maximum phonation time (MPT) scores before and after surgery.

CONCLUSION

Unsedated office-based Thulium laser therapy can be considered as an alternative therapy to patients with Reinke's edema who are not willing to undergo conventional microlaryngeal surgery.

Treatment of Vocal Fold Polyps with In-Office Potassium Titanyl Phosphate (KTP) Laser Ablation in Professional Singers

Vocal fold polyp (VFP) is an exophytic gelatinous lesion with an atrophic epithelium. After behavioral and conservative management, phonomicrosurgery is the treatment of choice for VFPs with excellent outcomes in terms of lesion resolution and postoperative vocal function. Office-based potassium titanyl phosphate (KTP) laser ablation is a new treatment modality for VFPs but its efficacy for professional singers has yet to be validated. Reported is a consecutive series of six professional singers (with seven episodes of VFP) who, based on patient and provider preference, underwent in-office KTP laser ablation of VFP. Two polyps required two ablation procedures; otherwise, a single treatment was successful in resolution of VFP at a mean resolution time of 44 days. Singing voice handicap index 10 improved from a mean of 30.8 (range 4-40) to 6.0 (range 0-22). All patients resumed their professional singing careers without vocal limitations. Posttreatment videos were reviewed by three blinded fellowship trained laryngologists, who were not able to accurately predict the laterality of the polyp (52% correct, p = 0.99).

The Use of 532-Nanometer-Pulsed Potassium-Titanyl-Phosphate (KTP) Laser in Laryngology: A Systematic Review of Current Indications, Safety, and Voice Outcomes

OBJECTIVE

To investigate the indications, efficacy, safety, and outcomes of potassium-titanyl-phosphate (KTP) laser procedures for treatment of laryngeal disease.

METHODS

PubMed, Cochrane Library, and Scopus were searched for studies providing information about the indications, efficacy, and safety of both in-office and operative suspension microlaryngoscopy KTP laser procedure in treatment of laryngeal disease. Diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

RESULTS

Of the initial screened 140 papers, 17 met our inclusion criteria. Six papers involved KTP laser procedures for benign and malignant vocal fold lesions in suspension microlaryngoscopy only, 10 papers focused on only in-office KTP laser procedures for benign vocal fold lesions, and 1 paper included both in-office and suspension microlaryngoscopy procedures. The following lesions may be considered as indications for KTP laser procedures: Reinke's edema, sulcus vocalis, vocal fold hemorrhage, polyp, granuloma, cyst, scar, papillomatosis, dysplasia, leukoplakia, and early vocal fold malignancies. Irrespective of the types of procedure (in-office vs suspension microlaryngoscopy), the KTP laser is associated with a low complication rate and overall good vocal fold vibration recovery. There is an important heterogeneity among studies concerning laser settings, indications, and outcomes used for the assessment of treatment effectiveness. There are no controlled studies directly comparing KTP laser with other lasers (ie, carbon dioxide laser).

CONCLUSION

The use of KTP laser procedures for treatment of laryngeal disease has increased over the past decade, especially for office-based management of vocal fold lesions. Future controlled studies are needed to compare the safety and outcomes of the KTP laser to other techniques.

Surgical and Nonsurgical Lines of Treatment of Reinke's Edema: A Systematic Literature Review

OBJECTIVES

The aim of this study was to carry out a systematic review of different surgical and nonsurgical lines of treatment of Reinke's edema to identify the effectiveness and the guidelines described to use each of them.

METHODS

We searched PubMed and Coherence for randomized controlled trials and case reports studies did on adult humans aged from 18 to 80 years, from January 1997 to December 2018. We included studies that treated patients with Reinke's edema by one and/or combinations of the following interventions: cold steel microlaryngeal phonosurgery, microdebrider, CO₂ laser, photoangiolytic laser, voice therapy, Steroid and Hyaluronidase injection. We selected studies that assessed patients pre- and post-treatment by at least one of the following measures: subjective assessment of the patient's voice by the voice handicap index, perceptual analysis of the voice by GRBAS scale, video laryngeoscopic examination of the VFs and the lesion, aerodynamic measures, and acoustic analysis of the voice by the computerized speech lab. We assessed quality of the included studies with the Cochrane risk of bias assessment Tool.

RESULTS

After removal of duplicates, research yielded 262 studies. Of 217 abstracts and titles, 36 full-text articles were read, and one study was added through hand search, resulting in 10 included studies.

CONCLUSIONS

Most of literature analyzed were deficient to address the effectiveness of any of the six lines included in this study. This is mainly due to the small number of the included articles and the small sample size in most of these studies. We found only 10 articles that reported the effectiveness based on comparing the results of before and after treatment. In addition, the variability of outcome measures used and the lack of the comprehensive assessment of the patient's voice, vocal image in most of the included studies made it hard to us to compare the results of any of the included studies. More researches with larger sample size and accurate randomization are needed for further accurate assessment of the effectiveness of the surgical and nonsurgical lines of treatment of Reinke's edema. The future researches should take in their consideration the use of an agreed comprehensive assessment protocol for assessing and comparing the outcome measures before and after treatment.

Implication and Management of Incidental Oropharyngeal Papillomas-A Retrospective Case Series Review

INTRODUCTION

Incidental papillomas of the pharynx can be found while examining the nasopharynx, oropharynx, and hypopharynx for other disorders of the head and neck. Purpose of the study is to explore the location, biopsy protocol, and decision to perform office-based versus operative management via potassium titanyl phosphate (KTP) laser when an oropharyngeal papilloma is discovered incidentally.

METHODS

A retrospective review of the senior author's patient population was performed using Current Procedural Terminology and/or International Classification of Diseases codes to identify patients who had KTP laser removal of incidental oropharyngeal papillomas. Patients were included based on the incidental nature of the papilloma and confirmed pathology report of squamous papilloma. Demographics, presenting complaint, lesion location, pathological analysis, type of intervention, and outcomes were recorded. When available, human papillomavirus (HPV) subtype was noted.

RESULTS

A total of 26 cases were identified, 13 females and 13 males. The median age at time of surgery was 58 years (range: 21-77). The most common presenting symptoms were difficulty swallowing and throat pain. The most common locations were the base of tongue, uvula, tonsils, and the soft palate. Of the 26 patients, 23 patients received KTP laser ablation therapy as an office-based procedure, while the remaining 3 were performed under general anesthesia in the operating room. Only 5 patients had a recorded recurrence that required reoperation. There were no operative or postoperative complications. There were 16 biopsy samples tested for HPV, where 12 were negative for HPV and 4 were positive for HPV.

CONCLUSION

Oropharyngeal papillomas, when present, can be found incidentally during examination of the oropharynx for other symptoms. Office-based biopsy and KTP laser is a safe and efficient means of identifying and removing most oropharyngeal papillomas.

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

Importance

In-office angiolytic laser procedures have been used successfully as an alternative treatment for vocal fold polyps; little is known in detail about the treatment outcomes and adverse events.

Objective

To examine the outcomes and incidence rates of adverse events associated with in-office angiolytic laser procedures with or without concurrent polypectomy as an alternative treatment for vocal fold polyps.

Design, Setting, and Participants

Retrospective cohort study at a tertiary medical center. We identified 114 consecutive patients with vocal polyps who underwent in-office angiolytic laser treatments between January 1, 2014, and August 31, 2016. After the exclusion of 17 with missing or incomplete data, 97 were enrolled.

Interventions

In-office 532-nm laser procedures with or without concurrent polypectomy.

Main Outcomes and Measures

Between 1 and 2 months after the surgical procedures, we collected the following outcome data: videolaryngostroboscopy, perceptual rating of voice quality, acoustic analysis, maximal phonation time, and subjective rating of voice quality using a visual analogue scale and 10-item voice handicap index.

Results

This study enrolled 97 patients (mean [SD] age, 45.6 [11.3] years; 48 [49%] male). The mean duration of symptoms was 10.1 months (range, 1-60 months). Twenty-nine patients (30%) had angiolytic laser procedures only, while 68 (70%) received laser with concurrent polypectomy. Both treatment modalities offered significant improvements. Only 1 patient (1%) receiving angiolytic laser with concurrent polypectomy underwent another treatment session, so this group had significantly less need for multiple treatments than those receiving laser treatment alone (6 [21%]; effect size, -1.57; 95% CI, -2.77 to -0.36). We identified 8 adverse events (8% of the cases): vocal fold edema (n = 5), vocal hematoma (n = 2), and vocal ulceration (n = 1). Patients treated with laser plus concurrent polypectomy had significantly fewer adverse events than those treated with angiolytic laser alone (2 [3%] vs 6 [21%]; effect size, 1.20; 95% CI, 0.26 to 2.13).

Conclusions and Relevance

In-office angiolytic laser procedures can be an effective alternative treatment for vocal polyps, although with possible need for multiple treatment sessions and occasional occurrence of minor postoperative adverse events. Concurrent polypectomy following laser coagulation allows less laser energy delivery and reduces the risk of postoperative adverse events and the need for additional treatment sessions.

Unsedated Office-Based Thulium Laser Therapy in Patients With Vocal Fold Cysts

The objective is to report 3 cases of vocal fold cysts treated with thulium laser in an office setting under local anesthesia. The surgical technique, which consists of surgical marsupialization, is described in detail with emphasis on the laser setting. All 3 patients had complete regression of the lesion and marked improvement in voice quality and good closure of the vocal folds during phonation. The authors review the literature on the application of laser therapy in an office setting and advocate this as an alternative treatment option for patients with vocal fold cysts who are at high risk for general anesthesia or unwilling to undergo the conventional microsurgery.

Updated Medical and Surgical Treatment for Common Benign Laryngeal Lesions

Benign laryngeal lesions are often the result of phonotraumatic forces on the vocal folds and thus classically are treated with a combination of voice therapy and phonomicrosurgical techniques to minimize inadvertent additional trauma. Newer management strategies expand on these techniques with the use of the pKTP laser as well as intralesional injections, both in the operating room and in the awake outpatient setting.

Laser Partial Arytenoidectomy as an Office Procedure

Bilateral vocal fold paralysis is a disabling condition that results in airway symptoms, dysphonia, and sometimes difficulty swallowing. Various types of glottal widening procedures have been described in the literature, all of which are performed in the operating room under general anesthesia. The aim is to report laser partial arytenoidectomy as an office-based treatment modality in a patient with bilateral vocal fold paralysis. Using Thulium laser fiber introduced through the working channel of fiberoptic nasopharyngoscope, a posterior cordectomy followed by resection of the vocal process of the right arytenoid was performed. The laser was used in a pulsed mode, power range 3.5 to 4.5 W, duration 70 to 300 milliseconds, repetition 2 to 4 Hz, and aiming beam 65%. The procedure was well tolerated and the patient was successfully decannulated 3 weeks later. Unsedated office-based laser arytenoidectomy might be considered a safe alternative to the commonly practiced glottal widening procedures in patients with a preexisting tracheotomy.

Histologic effect of the potassium-titanyl phosphorous laser on laryngeal papilloma

Objectives

Tissue effects occurring with potassium‐titanyl phosphorous (KTP) laser treatment are difficult to quantify due to the multiple variables that affect not only the fluence (energy delivered) but also the laser–tissue interaction. This histopathologic analysis of recurrent respiratory papilloma (RRP) removed after treatment with KTP laser therapy permits correlation of histologic effect with method of laser treatment.

Methods

The histopathology of RRP resected specimens in a single patient was compared following treatment with KTP laser in contact and non‐contact modes as documented with intraoperative photography and video imaging.

Results

Epithelial‐sparing injury selective to the microvasculature was identified on histopathologic assessment of a specimen treated with noncontact angiolysis. Highly cauterized papillomatous epithelium without identifiable vascular structures was identified on tissue removed after treatment with the KTP laser in contact mode.

Conclusion

The histopathologic assessment of acute KTP laser effect on papilloma permits correlation between technique of application and tissue effect. Similar assessments may be helpful to modify dosimetry for individual patients requiring repeated treatment and may also assist in refining the development of existing KTP laser treatment classification systems.

Level of Evidence

4

Vocal Fold Polyps: Literature Review

Introduction  Vocal fold polyps are one of the most frequent benign laryngeal lesions, impacting the quality of life of those affected by them, primarily the vocal production. Despite being a well-established therapy in conjunction with surgery, speech therapy alone may also be effective in treating these lesions. As such, otolaryngologists and speech therapists need updated bibliographic knowledge on the issue. Objective  To describe the literature findings on vocal fold polyps that discuss prevalence, etiology, histology, physiopathology, vocal characteristics or treatment. Data Synthesis  The present study is a review article based on a bibliographic search using platforms, databases and search engines, with no restrictions on means of publication, methodological quality or language. All the articles on vocal fold polyps pertaining to the object of study published in the past 15 years were included. Among the characteristics investigated, the most discussed were prevalence of men, smoking as an etiological cofactor, the possibility of histological differentiation from vocal nodules, the relationship with cover minor structural alterations, and the indication and effectiveness of different treatment options. Conclusion  Despite the discrepancies found in the present literature review on vocal fold polyps, there has been a notable scientific progress in the otolaryngologic techniques and in the effectiveness of speech therapy as initial treatment, with direct and indirect techniques, corroborating the need for scientific investigation of the issue.

Office-based laryngology: Technical and visual optimization by patient-positioning maneuvers

OBJECTIVE/HYPOTHESIS

To qualitatively and quantitatively assess the effect of discrete head postures/maneuvers during flexible laryngoscopy on visualization of specific anatomical structures within the laryngopharynx.

STUDY DESIGN

Prospective, observational study.

METHODS

Flexible laryngoscopy was performed on 18 sequential patients. Videos of the laryngopharynx were captured during the neutral head position and five discrete maneuvers: maximal sniffing, head extension, right turn, left turn, and chin down. Images were analyzed using ImageJ, and differences in the (normalized) anatomical areas of interest were examined with each maneuver (paired t test]. Covariates for surgeon, nostril, and gender were evaluated.

RESULTS

There was a significantly increased (P = 0.009) area of view of the anterior space (petiole of epiglottis/anterior laryngeal vestibule) with head extension. Right head turn led to a significantly increased view of the left pyriform sinus (P = 0.00001), whereas left head turn yielded an increased view of the right pyriform sinus (P = 0.0001). The right and left vocal fold/ventricle were better visualized during right head turn (with the scope traversing the right nostril) and left head turn (with the scope traversing the left nostril), respectively. Chin-down posture achieved a more distal view of the airway more frequently than the other maneuvers.

CONCLUSION

The anterior space (supraglottic larynx) may be best visualized and accessed with head extension. Right and left head turn improve visualization of the contralateral piriform sinus. Chin down provides improved airway visualization in a plurality of patients. Future studies examining maneuvers are warranted to create a catalog of validated techniques to optimize the efficacy of the office-based proceduralist.

LEVEL OF EVIDENCE

2 Laryngoscope, 129:330-334, 2019.

Office-Based Photoangiolytic Laser Treatment of Reinke’s Edema

Objective

To evaluate the safety, tolerability, and voice outcomes of office-based photoangiolytic laser treatment of Reinke’s edema.

Study Design

Case series with chart review.

Setting

Academic medical center.

Subjects and Methods

We performed a retrospective analysis of patients undergoing office-based laser treatment of endoscopy-proven Reinke’s edema. Safety and tolerability were evaluated by reviewing complications. Voice outcomes were analyzed by comparing pre- and postprocedural acoustic, aerodynamic, and Voice Handicap Index measurements. Complete data sets were not available for all subjects; sample size for each parameter is reported with the corresponding result.

Results

Nineteen patients met inclusion criteria. There were no minor or major complications. Five procedures were truncated due to patient intolerance. Phonatory frequency range increased (n = 12, P = .003), while percent jitter decreased (n = 12, P = .004). Phonation threshold pressure decreased after treatment (n = 4, P = .049). Voice Handicap Index also decreased (n = 14, P < .001).

Conclusion

This study represents the largest series of patients undergoing office-based photoangiolytic laser treatment specifically for Reinke’s edema. Our data suggest that this is a safe and effective modality to treat dysphonia associated with Reinke’s edema, although patient intolerance of the procedure may represent a barrier.

Comparison of treatment outcomes of transnasal vocal fold polypectomy versus microlaryngoscopic surgery

OBJECTIVES/HYPOTHESIS

Office-based procedures have been proposed for the treatment of vocal polyps, including indirect laryngoscopic surgery and angiolytic laser photocoagulation. Our previous report documented good treatment outcomes by combining the two aforementioned procedures. This study was intended to further compare the treatment outcomes of office transnasal vocal fold polypectomy (VFP) with those of microlaryngoscopic surgery (MLS).

STUDY DESIGN

A matched cohort study.

METHODS

This study retrospectively enrolled 50 age-, gender-, and size-matched patients with vocal polyps treated by VFP or MLS at a tertiary teaching hospital from January 2012 to October 2013. Treatment outcomes were evaluated before, 2 weeks, and 6 weeks after the procedures via perceptual rating of voice quality, acoustic measurement of the speech signal, 10-item voice-handicap index, maximal phonation time, subjective rating of voice quality, and videolaryngostroboscopic evaluation.

RESULTS

Both VFP and MLS resulted in significant clinical improvements 2 and 6 weeks postoperatively. Study results exhibited similar objective outcomes between VFP and MLS, whereas patients who received VFP reported higher subjective voice quality than those receiving MLS 2 weeks postoperatively. Six weeks after the procedures, the objective and subjective treatment outcomes were not significantly different between the two treatment groups.

CONCLUSION

This study shows that transnasal VFP may be used as an effective alternative treatment for small vocal polyps. Patients who received office VFP experienced rapid symptomatic relief with a higher degree of subjective effectiveness than MLS 2 weeks postoperatively, whereas the overall treatment outcomes showed a comparable level of effectiveness for both modalities.

LEVEL OF EVIDENCE

3B.

Analysis of Potassium Titanyl Phosphate Laser Settings and Voice Outcomes in the Treatment of Reinke’s Edema

Objective:

Despite increased clinical utility of the 532-nm potassium titanyl phosphate (KTP) laser, no studies have examined outcomes for Reinke’s edema (RE) as a function of laser parameters and initial treatment effects. Variability in delivery parameters, fiber-to-tissue distance, and immediate end-tissue effects limits universal application of existing study outcomes. We examine voice outcomes using standardized treatment classification, providing justification for laser parameter selection and immediate tissue effect in clinical use.

Methods:

Retrospective review of 9 patients who underwent KTP laser treatment for RE. Demographics, RE severity, laser settings, total laser energy, and immediate tissue effects were correlated with quantified voice outcomes.

Results:

An average of 157 joules (6-640 J) was delivered over a 0.369-second exposure time (0.1-0.9 seconds). Immediate tissue effects varied from nonablative treatment (type I and type II) to ablation without tissue removal (type III). Overall, Voice Handicap Index-10 (VHI-10) decreased by 8.23; improvement was most pronounced with type II treatments (delta VHI-10 = 12). No complications were encountered.

Conclusion:

Potassium titanyl phosphate laser can be safely and effectively used to improve voice in RE patients regardless of severity. This is the first study to provide detailed information on laser settings, energy delivery, and treatment effect in RE management; these results may guide clinical use of this modality, especially for novice laser surgeons.

Vocal process granulomas: a systematic review of treatment

OBJECTIVES

Vocal process granulomas (VPGs) are benign laryngeal lesions with controversial treatment and a tendency to recur. There are several treatment options with unpredictable results, high recurrence rates, and disappointing long-term outcome. The aims of this article are to focus on evidence-based current treatment strategies for primary lesions and recurrences.

DATA SOURCES

The data came from a systematic review of the literature.

METHODS

Main outcome measures were recurrence rate, reduction, and/or complete resolution. Inclusion criteria included English literature, randomized and nonrandomized trials, prospective and retrospective studies, and primary and recurrent cases. Exclusion criteria included case reports, teaching reviews, and papers not focusing on treatment.

RESULTS

The time frame of the included studies was from 1997 to 2012. There are 6 different treatment options (single or combined) for VPG. Antireflux medication is the mainstay treatment and when combined with lifestyle changes and voice therapy results in the lowest recurrence rate. "Bloodless" in-office or in-theater laser techniques appear to have lower recurrence rates when compared to traditional cold steel microlaryngoscopy techniques, especially for recurrences.

CONCLUSIONS

There is level 2A evidence that antireflux treatment is the main treatment strategy for vocal process granulomas with surgery reserved only for failures of medical treatment or airway obstruction or when diagnosis is in doubt.

The utility of the potassium titanyl phosphate laser in modulating vocal fold scar in a rat model

OBJECTIVES/HYPOTHESIS

We hypothesize that the KTP laser has the potential to augment wound healing in a rat model, and this modality may serve as a therapeutic tool for the management of vocal fold fibrosis.

STUDY DESIGN

Prospective, laboratory animal study.

METHODS

Rats were subjected to either vocal fold injury ± KTP laser treatment at low energy to simulate clinically relevant endpoints. In addition, cohorts were subjected to therapeutic KTP laser alone. Endpoints included the analyses of gene expression data related to the acute inflammatory response and extracellular matrix deposition and organization.

RESULTS

Therapeutic KTP treatment was associated with an additive effect on inflammatory gene expression in the context of the injured rat vocal fold mucosa. A similar additive effect was observed for matrix metalloproteinase gene expression, similar to data previously reported in the dermatology literature. However, histologically, the KTP had little effect on established vocal fold fibrosis.

CONCLUSIONS

These data are the first to attempt to provide mechanistic insight into the clinical utility of angiolytic lasers for vocal fold scar. Similar to previous data obtained in the skin, it appears that these effects are mediated by MMPs.

KTP 532 nm laser for laryngeal lesions. a systematic review

OBJECTIVE

To evaluate the effectiveness and safety of the 532 nm potassium titanyl phosphate (KTP) laser for vocal fold surgery.

STUDY DESIGN

Systematic literature review.

METHODS

Our systematic review was conducted using the meta-analysis of observational studies in epidemiology guidelines. We applied the criteria of the Oxford Centre for Evidence-based Medicine to assess the level of evidence.

RESULTS

We identified seven observational studies of eight case series, which reported a total of 243 KTP procedures carried out for vocal fold lesions: two series each concerning ectasias and varices, early glottic cancer, and recurrent papillomatosis, and one series each for keratosis with dysplasia and various benign laryngeal pathologies. There was also a retrospective review of the use of KTP laser in 387 endoscopic laryngeal surgeries. No studies compared the use of KTP laser with that of other technologies. Thus, according to the Oxford criteria, there is only level 4 evidence of KTP's efficacy and safety. In selected cases, the KTP instrument can be used without general anesthesia in the clinic setting.

CONCLUSIONS

The use of KTP laser for laryngeal surgery is still relatively innovative. Several surgeons have found KTP laser to be the equivalent of, or superior to, the CO2 or pulsed dye lasers, and none have reported inferiority. However, there are currently no published data to support these conclusions. To establish equality/superiority, it is desirable that further evidence of efficacy and safety be obtained, either through randomized controlled trials or at least through well-documented prospective observational studies with reporting of all relevant input and outcome data.