Safety of flexible endoscopic biopsy of the pharynx and larynx under topical anesthesia

Diagnosis of laryngopharyngeal carcinoma through office-based flexible laryngoscopy as a reliable alternative for biopsies under general anesthesia: Faster diagnostics with equal oncological outcome

PURPOSE

Diagnostic endoscopy with biopsy under general anesthesia (DE-GA) is still considered as the established standard to assess laryngopharyngeal cancer patients. Office-based flexible laryngoscopic biopsy (FLB) offers an alternative, but the effect on oncological outcome remains uncertain. Therefore, the diagnostic process and survival of patients undergoing FLB, compared to those undergoing DE-GA were evaluated.

METHODS

Patients suspected of laryngopharyngeal cancer who underwent FLB were evaluated. Patients with FLB-confirmed squamous cell carcinoma (SCC) were matched with DE-GA patients based on tumor site, T-classification, N-classification, age, and p16 overexpression. Time from first visit to diagnosis (FVD), time to treatment interval (TTI), disease-specific survival (DSS) and overall survival (OS) were analyzed.

RESULTS

FLB yielded a definitive diagnosis in 155/164 (95 %) patients. No complications were observed. Ninety-eight of the 124 patients in which FLB revealed a SCC received curative treatment and were compared with 98 matched patients who underwent DE-GA. Median FVD interval was 6 days after FLB and 15 days after DE-GA (p < 0.001). Median TTI interval (FLB: 28 days, DE-GA: 28 days) was equal (p = 0.91). Oncological outcomes were comparable (p > 0.05) between FLB (OS: 2-yr: 76 %, 5-yr: 42 %; DSS: 2-yr: 86 %, 5-yr: 85 %) and DE-GA groups (OS: 2-yr: 76 %, 5-yr: 50 %; DSS: 2-yr: 81 %, 5-yr: 79 %).

CONCLUSION

FLB in the outpatient setting demonstrates a high diagnostic accuracy, is safe, accelerates the diagnostic process and has no negative effects on clinical outcome compared to DE-GA. Therefore, FLB should be considered as the standard diagnostic procedure in patients suspected of laryngopharyngeal cancer.

Detection of laryngeal carcinoma during endoscopy using artificial intelligence

BACKGROUND

The objective of this study was to assess the performance and application of a self-developed deep learning (DL) algorithm for the real-time localization and classification of both vocal cord carcinoma and benign vocal cord lesions.

METHODS

The algorithm was trained and validated upon a dataset of videos and photos collected from our own department, as well as an open-access dataset named "Laryngoscope8".

RESULTS

The algorithm correctly localizes and classifies vocal cord carcinoma on still images with a sensitivity between 71% and 78% and benign vocal cord lesions with a sensitivity between 70% and 82%. Furthermore, the best algorithm had an average frame per second rate of 63, thus making it suitable to use in an outpatient clinic setting for real-time detection of laryngeal pathology.

CONCLUSION

We have demonstrated that our developed DL algorithm is able to localize and classify benign and malignant laryngeal pathology during endoscopy.

A systematic review on efficacy, safety and cost-effectiveness of office-based laryngeal biopsy

OBJECTIVE

Laryngeal cancer is the second most prevalent head and neck malignancy in the USA. With recent advances in technology, this procedure is increasingly performed under local anaesthesia. This study aimed to identify the efficacy, safety and cost-effectiveness of laryngeal biopsy in out-patients by conducting a systematic review.

METHOD

A literature search was conducted using PubMed, Medline, Google Scholar and Embase over a 20-year period. Inclusion criteria were: studies performed on out-patient diagnostic biopsy procedures of the larynx. Exclusion criteria included all therapeutic procedures. The outcome measures were sensitivity and specificity, complication rate and cost-savings.

RESULTS

Thirty-five studies were included in the analysis. The sensitivity and specificity varied from 60 to 100 per cent with a low complication rate and cost savings.

CONCLUSION

Office-based laryngeal biopsies are increasingly used in the diagnosis of laryngeal cancers, resulting in earlier diagnosis and commencement of treatment. The barrier to undertaking this procedure is low sensitivity.

The effect of local anaesthetic biopsy in head and neck cancer on cancer pathway waiting times

INTRODUCTION

The 31-day target in urgent suspicion of cancer (USOC) referrals fast-tracks patients through the cancer pathway. Local anaesthetic (LA) biopsy can be performed during an outpatient clinic and may improve pathway times. The aim of this study was to compare LA biopsy in head and neck USOC referrals with the traditional general anaesthetic (GA) pathway.

METHODS

This was a retrospective cohort study of USOC referrals to the NHS Greater Glasgow and Clyde head and neck multidisciplinary team between 1 June 2018 and 28 December 2020, and compared pathway times in LA and GA biopsies.

RESULTS

The mean number of days from clinic to biopsy was 4.4 in the LA group and 28.0 in the GA group. This was significantly faster in the LA biopsy group (p < 0.05). The overall pathway time in the LA and GA biopsy groups was 35.7 and 61.5 days, respectively, and was significantly faster in LA biopsy group (p < 0.05).

CONCLUSIONS

The LA cohort had significantly faster pathway times compared with GA biopsy. LA biopsy requires careful patient selection, but is an effective alternative to GA biopsy in the appropriate patient group.

Sentinel node identification in laryngeal and pharyngeal carcinoma after flexible endoscopy-guided tracer injection under topical anesthesia: A feasibility study

BACKGROUND

The aim of this study was to investigate the feasibility of flexible endoscopy-guided tracer injection for sentinel lymph node (SLN) identification in patients with laryngeal and pharyngeal carcinoma.

METHODS

Sixteen cT1-4N0-2M0 patients with laryngeal or pharyngeal carcinoma underwent intra- and peritumoral [^99m Tc]Tc-nanocolloid injections after topical anesthesia under endoscopic guidance. SPECT-CT scans were performed at two time points.

RESULTS

Tracer injection and visualization of SLNs was successful in 15/16 (94%) patients. Median number of tracer injections was 1 intratumoral and 3 peritumoral. The median duration of the endoscopic procedure including tracer injection after biopsy taking was 7 min (range 4-16 min). A total of 28 SLNs were identified which were all visualized on the early and late SPECT-CT. Most SLNs were visualized in neck levels II and III.

CONCLUSIONS

Flexible endoscopy-guided tracer injection for SLN identification is a feasible and fast procedure in laryngeal and pharyngeal carcinoma patients.

Safety of office-based flexible endoscopic procedures of the pharynx and larynx under topical anesthesia

INTRODUCTION

Flexible endoscopic procedures (FEP) using a working channel allowed otolaryngologists to perform more procedures on the pharynx and the larynx under local anesthesia. The purpose of this work is to demonstrate the feasibility and safety of this technique by studying the adverse effects of this practice in an office-based setting.

METHODS

This is a monocentric retrospective cohort study. We searched the database using the French procedural code for FEP performed in an outpatient setting between January 2005 and December 2020. Data regarding the patient's characteristics, indications, and periprocedural complications were extracted.

RESULTS

In total, we included 231 patients with a total of 308 FEP: 36% biopsy, 20% hyaluronic acid injection (including 3.5% at the level of the cavum), 20% injection of other substances (in descending order: botulinum toxin, cidofovir, physiological serum, cortisone), 20% exploration for an occult tumor, 3% samples for microbiological analysis, 1% other procedures. Of the 308 FEP included in this study, 24 patients (10.3%) had complications corresponding to 7.8% of the procedures performed. During the procedures, reported complications include minor laryngeal bleeding (n = 5), vasovagal syncope (n = 5), laryngospasm (n = 1) or nausea (n = 3), dysphagia (n = 3), and voice disorders (n = 3). Post-procedural complications were hypertensive crisis (n = 1), asthma attack (n = 1), pneumonia (n = 1), laryngitis (n = 1). Using the Clavien-Dindo classification system, these complications could be defined as grade I (laryngeal bleeding, vasovagal syncope, laryngospasm, dysphagia, nausea, voice disorders, and laryngitis) and grade II (hypertensive crisis, asthma attack, pneumonia) in 9.1% and 1.2% of cases, respectively. Most of these complications were self-limiting, while asthma attacks, pneumonia, laryngitis, and voice disorders required a medical intervention. All complications were managed without sequelae. There was no serious complication grade (no grade III, IV or V).

CONCLUSIONS

FEP, which is now well standardized in our institution, makes it possible to carry out a wide range of interventions with little morbidity. These results are in line with those of literature but this technique remains out of nomenclature in France. Our experience led to the development of an evidence-based standard of care that can serve as a framework for practitioners on a nationwide level, while the work to establish official guidelines by the French society of phoniatrics and laryngology is in progress.

Diagnostic Usefulness of Flexible Fibroscopy Biopsy in Suspected Lesions of the Otolaryngological Area

The efficiency in the management of patients with suspected malignant lesions represents the main objective of the oncology of head and neck. Flexible nasopahyngolaryngoscopy with working channel allows to quickly and safely assess and obtain histological samples of this type of lesion. Our objective is to describe the usefulness of this technique in lesions suggestive of malignancy in terms of efficiency, sensitivity and specificity. A retrospective study was carried out over a period of time from December 2014 to December 2019, including patients biopsied with flexible fibroscopy of lesions of debut suspected of malignancy. Here we assess the location of the lesion, the histological results, the diagnostic time and the epidemiological variables. 104 patients were included in the study. More than half of the lesions, 55.2% (57), were located in the larynx; 57.7% (60) resulted positive for malignancy in the flexible fiberscope biopsy; 19.2% (20) were taken to the operating room to get biopsied under general anesthesia resulting in 7.4% (14) positive for malignancy, which shows a sensitivity of the test of 81%. In our sample, a diagnostic time of 15 days was obtained. Considering our results, the few complications and the revised literature, flexible fiberscope biopsy with working channel is an efficient procedure for the management of oncological patients of head and neck.

A systematic review: impact of in-office biopsy on safety and waiting times in head and neck cancer

Objective

This study aimed to assess the current literature on the safety and impact of in-office biopsy on cancer waiting times as well as review evidence regarding cost-efficacy and patient satisfaction.

Method

A search of Cinahl, Cochrane Library, Embase, Medline, Prospero, PubMed and Web of Science was conducted for papers relevant to this study. Included articles were quality assessed and critically appraised.

Results

Of 19 741 identified studies, 22 articles were included. Lower costs were consistently reported for in-office biopsy compared with operating room biopsy. Four complications requiring intervention were documented. In-office biopsy is highly tolerated, with a procedure abandonment rate of less than 1 per cent. When compared with operating room biopsy, it is associated with significantly reduced time-to-diagnosis and time-to-treatment initiation. It is linked to improved overall three-year survival.

Conclusion

In-office biopsy is a safe procedure that may help certain patients avoid general anaesthetic. It was shown to significantly reduce time-to-diagnosis and time-to-treatment initiation when compared with operating room biopsy. This may have important implications for oncological outcomes. In-office biopsy requires fewer resources and is likely to be cost-saving five-years following introduction. With high rates of sensitivity and specificity, in-office biopsy should be considered as the first-line procedure to achieve tissue diagnosis.

Transoral Versus Transnasal Approaches in Office-Based Laryngeal Biopsy: A Cohort-Selection Cross-Sectional Diagnostic Accuracy Study

OBJECTIVE

The aim of this study is to explore the accuracy of two different approaches: transoral versus transnasal office-based laryngeal biopsy.

DESIGN

Cohort-selection cross-sectional study.

SETTING

Outpatient clinic of Phoniatrics in El Demerdash Hospital, faculty of medicine, Ain Sham University, Cairo, Egypt).

PARTICIPANTS

The study included all patients aged 18 years or more with suspicious lesions of the larynx or the oropharynx who are eligible for biopsy who came to the outpatient clinic due to different reasons during the period of March 2017 and March 2020.

MAIN OUTCOME MEASURES

Patients with suspicious lesions were referred for office-based-based biopsy-either transnasal biopsy or transoral biopsy. All patients were referred for subsequent direct laryngoscopy for definitive diagnosis.

RESULTS

The overall sample was 60 cases with 30 in each group. The majority of both groups were smokers. The most frequent cause of referral for biopsy was suspicious laryngeal mass. The number of biopsies obtained was significantly higher in the transoral group. Both approaches were tolerated by all patients with few limited aspiration or epistaxis. The sensitivity of the transoral approach was compared with that of direct laryngoscopy and was 95.8% with a specificity of 83.3%. The sensitivity of the transnasal approach was compared with that of direct laryngoscopy and was 26.3%; the specificity was 90.9%.

CONCLUSION

The transoral approach to obtaining a biopsy from the upper aero-digestive tract has better diagnostic accuracy than the transnasal approach when combined with transnasal visualization and transcricothyroid anesthesia.

Flexible endoscopy in the visualization of 3D-printed maxillary sinus and clinical application

Background

During postoperative follow-up, the visible range of maxillary sinus (MS) is limited, even combining 0° and 70° rigid endoscopes together. Flexible endoscope has been used in larynx examinations for a long time, but rarely in nasal cavity and sinus. We aimed to evaluate the application values of rigid and flexible endoscopes for visualization of MS.

Methods

We followed up 70 patients with lesions in MS via both rigid and flexible endoscopes. In addition, we used thin-slice CT image of the sinus to create a MS model and divided it into two parts for 3D printing. The inner surface of the 3D-printed sinus was marked with grid papers of the same size (5 mm × 5 mm), then the visual range under rigid endoscopes with different angle and flexible endoscopes was calculated and analyzed.

Results

In clinical follow-up, we found that flexible endoscopy can reach where rigid endoscopy cannot, which is more sensitive than medical imaging. Endoscopes showed the largest observation range of the posterolateral wall, more than half of which can be visualized by 0° endoscope. Almost all of the posterolateral wall can be revealed under 45° endoscope, 70° endoscope and flexible endoscope. The visual range of each wall under flexible endoscope is generally greater than that under rigid endoscopes, especially of the anterior wall, medial wall and inferior wall.

Conclusion

There was obviously overall advantage of using flexible endoscope in postoperative follow-up of MS lesions. Flexible endoscopy can expand the range of observation, and improve the early detection of the recurrent lesion. We recommend flexible endoscope as a routine application.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09410-8.

Techniques in Otolaryngology: Ultrasound-Guided Transcervical Fine-Needle Aspiration of Laryngeal Masses

Traditionally, laryngeal masses are diagnosed with direct laryngoscopy with biopsy under general anesthesia. The use of transcervical ultrasound–guided fine-needle aspiration for the diagnosis of base of tongue lesions, thyroid nodules, and cervical lymph node metastases has been well documented, and its use in the diagnosis of laryngeal masses has increased in recent years. We report a technique for office-based transcervical ultrasound–guided fine-needle aspiration for laryngeal masses without cervical metastasis (N0), with outcomes from 6 patients. Benefits of this approach included limited side effects, rapid in-office diagnosis, avoidance of aerosolizing procedures during the COVID-19 pandemic, and avoidance of tracheostomy.

PET/CT versus triple endoscopy in initial workup of HPV+ oropharyngeal squamous cell carcinoma

BACKGROUND

Synchronous primary tumors (SPTs) are detected via triple endoscopy or positron emission tomography/computed tomography (PET/CT). Patients with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV+ OPSCC) lack risk factors for SPTs.

METHODS

We performed a single institution retrospective review of the efficacy of triple endoscopy and PET/CT in HPV+ OPSCC patients.

RESULTS

Sixty-five HPV+ OPSCC patients underwent triple endoscopy and PET/CT. Patients were white (n = 48, 72.7%), male (n = 53, 81.5%), mean 58.7 ± 8.1 years old. SPT was detected in 1 (1.5%) patient via PET/CT. No SPTs were detected on triple endoscopy. PET/CT had 100% and 95.3% sensitivity and specificity, respectively. PET/CT positive predictive value (PPV) and negative predictive value (NPV) were 25.0% and 100%, respectively. Triple endoscopy specificity and NPV was 90.2% and 93.2%, respectively.

CONCLUSIONS

PET/CT is superior to triple endoscopy in ruling out SPTs. With negative PET/CT, only direct laryngoscopy with biopsy may be necessary.

Vocal cord biopsy under local anesthesia, with flexible bronchoscope as an outpatient procedure, by "inside-out" technique

Background

Pulmonologists commonly need to take biopsies of laryngeal lesions, either found incidentally while doing bronchoscopy for other indications or while investigating patients for hoarseness of voice and cough. Biopsy of laryngeal lesions has been conventionally done under general anesthesia to provide adequate samples and minimize risks and patient discomfort. Of late, these biopsies have been done as outpatient procedures, by flexible endoscopes, under local anesthesia. However, vocal cord biopsies are often challenging due to poor patient compliance. We have tested an innovative method, which we have called the "inside-out" method, to circumvent this problem.

Objectives

We aimed to analyze the feasibility, yield, and the safety of the "inside-out" technique for taking vocal cord biopsies as an outpatient procedure in awake patients.

Material and Methods

This was a prospective observational study. Data of 38 patients with vocal cord lesions in whom the above technique was employed were analyzed.

Results

The procedure had a diagnostic yield of 78.9% with a sensitivity of 96.7% and a specificity of 100% for detecting malignancy or dysplasia. There were no major complications.

Conclusions

The "inside-out" technique was found to be feasible and safe and with a high yield.

Novel Diagnostic Approaches for Assessment of the Clinically Negative Neck in Head and Neck Cancer Patients

In head and neck cancer, the presence of nodal disease is a strong determinant of prognosis and treatment. Despite the use of modern multimodality diagnostic imaging, the prevalence of occult nodal metastases is relatively high. This is why in clinically node negative head and neck cancer the lymphatics are treated “electively” to eradicate subclinical tumor deposits. As a consequence, many true node negative patients undergo surgery or irradiation of the neck and suffer from the associated and unnecessary early and long-term morbidity. Safely tailoring head and neck cancer treatment to individual patients requires a more accurate pre-treatment assessment of nodal status. In this review, we discuss the potential of several innovative diagnostic approaches to guide customized management of the clinically negative neck in head and neck cancer patients.

Evaluating Laryngopharyngeal Tumor Extension Using Narrow Band Imaging Versus Conventional White Light Imaging

OBJECTIVE/HYPOTHESIS

Comparing detection and extension of malignant tumors by flexible laryngoscopy in the outpatient setting with laryngoscopy under general anesthesia using both White Light Imaging (WLI) and Narrow Band Imaging (NBI).

STUDY DESIGN

Prospective study.

METHODS

Two hundred and thirty-three patients with laryngeal and pharyngeal lesions underwent flexible and rigid laryngoscopy, with both WLI and NBI. Extension of malignant lesions (n = 132) was compared between both techniques in detail.

RESULTS

Sensitivity of NBI during flexible endoscopy (92%), was comparable with that of WLI during rigid endoscopy (91%). The correlation of tumor extension between flexible and rigid laryngoscopy was high (r_s  = 0.852-0.893). The observed tumor extension was significantly larger when using NBI in both settings. The use of NBI during flexible laryngoscopy leads to upstaging (12%) and downstaging (2%) of the T classification.

CONCLUSIONS

NBI during flexible laryngoscopy could be an alternative to WLI rigid endoscopy. NBI improves visualization of tumor extension and accuracy of T staging.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2222-E2231, 2021.

Dual-energy CT for differentiating early glottic squamous cell carcinoma from chronic inflammation and leucoplakia of vocal cord: comparison with simulated conventional 120 kVp CT

AIM

To evaluate the value of dual-energy (DE) computed tomography (CT) in discriminating early glottic squamous cell carcinoma (eGSCC) from chronic inflammation and leucoplakia of the vocal cord, and to compare the diagnostic efficiency of DECT with that of simulated conventional 120 kVp CT.

MATERIALS AND METHODS

Seventy patients with glottic lesions confirmed by histopathology (38 cases with eGSCC, 11 cases with chronic inflammation, 21 cases with leucoplakia) were enrolled in this prospective study. The DECT-derived parameters were measured and compared using independent sample t-test. Receiver operating characteristic (ROC) curve was performed to evaluate the diagnostic performance, and comparison of the area under the ROC curve (AUC) was made using the Z test to further select the best diagnostic parameters.

RESULTS

Significantly higher iodine concentration (IC), normalised IC (NIC), effective atomic number (Z_eff), 40-100 keV (20 keV-interval), slope(k), and Mix-0.3 values were found in eGSCC than those in chronic inflammation, leucoplakia, and inflammation + leucoplakia (all p<0.05). Compared with attenuation measurement of simulated conventional 120 kVp CT, the NIC, 60 keV values derived from DECT showed significantly higher AUC in discriminating these glottic lesions (p<0.05).

CONCLUSIONS

DECT is more accurate for differentiating eGSCC from chronic inflammation and leucoplakia when compared with simulated conventional 120 kVp CT.

Office-Based Laryngeal Biopsy in Patients Ineligible for General Anesthesia

INTRODUCTION

Office-based laryngeal biopsy (OBLB) may provide a histological examination of laryngeal lesions in patients who cannot undergo a direct laryngoscopy. Nonetheless, only scarce information regarding its clinical applicability in these patients are available. The study's aim is to report the feasibility of OBLB in patients ineligible for direct laryngoscopy.

MATERIALS AND METHODS

A total of 55 patients presenting with laryngeal lesions requiring biopsy but ineligible for direct laryngoscopy because at risk for general anesthesia were consecutively enrolled. OBLB was performed using a flexible endoscope with a 2 mm instrument channel under local anesthesia on an outpatient basis. The biopsied lesions were categorized according to their location, morphology, and histology (benign, premalignant, and malignant). In case of malignancy the patients started non-surgical treatment; otherwise, the patients were scheduled for a close follow-up.

RESULTS

OBLB was well tolerated and no complications occurred. Laryngeal lesions were more frequently located in the glottic region (28 out of 55 patients), while the most frequent morphology was ulcerative (35 out of 55 patients). The histological examination revealed 34 cases of malignancy, 9 cases of premalignancy, and 12 cases of benign lesions. In none of the patients without malignancy the laryngeal lesion showed significant changes during the follow-up period and a re-biopsy was not performed.

CONCLUSION

In patients ineligible for direct laryngoscopy under general anesthesia OBLB could be considered as a sound-alternative method to assess the histology of suspected laryngeal lesions.

Impact of optimizing diagnostic workup and reducing the time to treatment in head and neck cancer

Background

Timely and efficient diagnostic workup of patients with head and neck cancer (HNC) is challenging. This observational study describes the implementation of an optimized multidisciplinary oncological diagnostic workup for patients with HNC and its impact on diagnostic and treatment intervals, survival, costs, and patient satisfaction.

Methods

All patients with newly diagnosed HNC who underwent staging and treatment at the Radboud University Medical Center were included. Conventional workup (CW) in 2009 was compared with the fast‐track, multidisciplinary, integrated care program, that is, optimized workup (OW), as implemented in 2014.

Results

The study included 486 patients with HNC (218 with CW and 268 with OW). The time‐to‐treatment interval was significantly lower in the OW cohort than the CW cohort (21 vs 34 days; P < .0001). The 3‐year overall survival rate was 12% higher after OW (72% in the CW cohort vs 84% in the OW cohort; P = .002). After correction for confounders, the 3‐year risk of death remained significantly lower in the OW cohort (hazard ratio, 1.73; 95% confidence interval, 1.14‐2.63; P = .010). Total diagnostic costs were comparable in the 2 cohorts. The general satisfaction score, as measured with the Consumer Quality Index for Oncological Care, was significantly better in a matched OW group than the CW group (9.1 vs 8.5; P = .007).

Conclusions

After the implementation of a fast‐track, multidisciplinary, integrated care program, the time‐to‐treatment interval was significantly reduced. Overall survival and patient satisfaction increased significantly, whereas costs did not change. This demonstrates the impact and improved quality of care achieved by efficiently organizing the diagnostic phase of HNC management.

After the implementation of a fast‐track, multidisciplinary, integrated care program for patients with head and neck cancer, this study shows a significant reduction in the time‐to‐diagnosis and time‐to‐treatment intervals, a significant increase in 3‐year overall survival, and an increase in patient satisfaction without increased diagnostic costs. This demonstrates the impact and improved quality of care achieved by efficiently organizing the diagnostic phase of head and neck cancer management.

Flexible Endoscopic Biopsy: Identifying Factors to Increase Accuracy in Diagnosing Benign and Malignant Laryngopharyngeal Pathology

OBJECTIVES

To assess the influence that several factors, such as the amount of obtained biopsies, difficult procedures, biopsy site and the experience of the attending physician, have on accuracy of flexible endoscopic biopsy (FEB).

MATERIALS AND METHODS

203 FEB procedures for benign or malignant laryngopharyngeal lesions were prospectively included. During the procedure, three representative biopsies (macroscopically containing vital tumor tissue and not only necrosis or healthy tissue) were obtained. The accuracy of each biopsy was separately analyzed. Difficulties during the procedures leading to failure of acquiring three representative biopsies were recorded and classified into tumor, patient and procedural factors. Histological results of FEB were defined correct when consistent with clinical context, additional biopsies or Positron emission tomography-computed tomography (PET-CT) revealed equivalent pathology, or the lesion was stable or resolved in >6 months follow-up.

RESULTS

The first representative biopsy yielded a correct diagnosis in 65% of the cases. After the second representative biopsy, 78% was correctly diagnosed. The contribution of the third and fourth representative biopsies to accuracy was 3%. The overall accuracy of FEB was 85%. Difficult procedures were more likely to result in misdiagnosis, whereas biopsy site or experience of the attending physician did not influence results.

CONCLUSIONS

FEB was accurate in diagnosing laryngopharyngeal lesions when at least two representative biopsies were obtained. Accuracy of FEB could be further improved by limiting possible constraints during the procedures, for example by selecting, informing, and anesthetizing patients carefully.

Safety of in-office laryngology procedures

PURPOSE OF REVIEW

A wide range of diagnostic and therapeutic laryngology procedures are currently performed in an office setting. In-office laryngology procedures (IOLP) are increasingly seen as standard-of-care, and while generally considered safe, high-quality evidence supporting the latter statement is lacking. This review aims to summarize recent literature regarding the safety of IOLP.

RECENT FINDINGS

There is a paucity of guidelines and standardized protocols for IOLP. To date, there is one available safety protocol specific to in-office laser procedures. Haemodynamic changes during IOLP have been documented and the significance of these changes continues to be unclear. Therefore, monitoring of vital signs is recommended. Continuing antithrombotic therapy during IOLP also appears safe, and this decision may be left to surgeon discretion. A protocol for management of antithrombotic therapy prior to in-office laser procedures is available. Actual serum lidocaine levels following topical application of mixed lidocaine preparations falls well below reported toxic levels but persists for longer than previously reported.

SUMMARY

IOLP are safer that suspension laryngoscopy under general anaesthetic. Although complication rates of IOLP are low, patient characteristics and potential complications of both the procedure and of topical anaesthetic use must be considered. One must be prepared and equipped to deal with these potential complications.

Laryngeal cytology: A cytological, histological, P16 and human papillomavirus study

BACKGROUND

Invasive diagnostic methods, such as punch biopsies, have a potential to produce undesirable side effects in the larynx, such as scarring and vocal dysfunction. This study is an attempt to assess the diagnostic potential of cytology to efficiently diagnose premalignant and malignant laryngeal lesions, while sparing patients the risk of complications of punch biopsies.

METHODS

Laryngeal smears, using endocervical-type brushes, and punch biopsies were procured from each patient. Smears were prepared and the brush was cut and put in Surepath preservative solution for cytological analysis and human papillomavirus (HPV) DNA testing. A Real-TM Quant kit that detects 14 HPV types was used for genotyping. Immunohistochemical staining for p16 was performed on cytological and histological specimens.

RESULTS

Cytological diagnosis was correct in 84.6%, 100% and 100% of cases with a histological diagnosis of squamous cell carcinomas, high-grade squamous intraepithelial lesions and benign lesions, respectively. However, cytological interpretation was correct only in 25% of low-grade squamous intraepithelial lesions. HPV DNA test was positive in only one case, which was a laryngeal polyp. Testing for p16 was negative in all the cytological and histological material.

CONCLUSION

Laryngeal cytology is a useful diagnostic tool in establishing the diagnosis of high-grade squamous epithelial cell abnormalities. Recognition of low-grade lesions, however, is challenging. HPV genotyping and p16 staining do not seem to be helpful ancillary techniques in cytological material procured from the larynx.

Office-based CO2 laser surgery for benign and premalignant laryngeal lesions

Objective

Patients with laryngeal pathology are often treated with CO₂ laser surgery, usually in the operating room under general anesthesia. Although office‐based laser surgery using several other laser types has been investigated, prospective studies on office‐based CO₂ laser surgery are scarce. Our goal was to investigate the feasibility of office‐based CO₂ laser surgery for benign and premalignant laryngeal pathology by analyzing completion rate, safety, effect on voice quality, and success rate (i.e., no residual or recurrent disease).

Methods

A prospective cohort study was performed of 30 consecutive procedures. Inclusion started in June 2016 and was completed in August 2018. Adult patients with clinically benign or premalignant laryngeal lesions who could not undergo transoral laser microsurgery in the operating room under general anesthesia were included. Reasons were either contraindications for general anesthesia, previously failed therapeutic laryngoscopy under general anesthesia, and preference of a procedure under topical anesthesia by the patient. The mean follow‐up was 9 months.

Results

Thirty procedures were performed in 27 patients (24 males) with an average age of 62 years. Twenty‐nine (97%) procedures were fully completed without complications. The mean preoperative Voice Handicap Index (VHI) score (VHI 44) significantly decreased 2 months (VHI 28, P = 0.032) and 6 months (VHI 14, P < 0.001) after the procedure. Almost two‐thirds of patients showed no residual or recurrent disease at their follow‐up visits.

Conclusion

Office‐based CO₂ laser surgery is a feasible and safe procedure that results in significant voice‐quality improvement. Almost two‐thirds of patients did not require further treatment.

Level of Evidence

2 Laryngoscope, 130:1503–1507, 2020

Digital Video Laryngoscopy and Flexible Endoscopic Biopsies as an Alternative Diagnostic Workup in Laryngopharyngeal Cancer: A Prospective Clinical Study

Objectives:

An office-based workup strategy for patients with laryngopharyngeal lesions suspicious for carcinoma is analyzed. The feasibility of office-based transnasal flexible endoscopic biopsies under local anesthesia and the impact on the diagnostic workup are evaluated.

Methods:

This study is a prospective analysis of patients with laryngeal, oropharyngeal, and hypopharyngeal lesions suspicious for carcinoma. One hundred eighty-eight participants were divided into 2 groups. The first group underwent an office-based biopsy procedure under local anesthesia using a flexible digital video laryngoscope with instrument channel (n = 53), and the second group underwent a biopsy procedure under general anesthesia using rigid laryngopharyngoscopy (n = 135).

Results:

Office-based flexible endoscopic biopsies were tolerated well, and there were no complications. These biopsies were 92.5% successful in acquiring a definitive diagnosis. Costs were reduced. Diagnostic workup time and time until start of therapy were reduced to 2 days and 27 days, respectively.

Conclusion:

Office-based biopsy under local anesthesia using flexible digital video laryngoscopy is safe, cost-effective, and successful in providing a histopathological diagnosis. It reduces the diagnostic workup time significantly in patients with laryngeal, oropharyngeal, and hypopharyngeal cancer, while also reducing the necessity to subsequently perform a rigid laryngopharyngoscopy under general anesthesia.

Topical Anesthesia for Endoscopic Office-based Procedures of the Upper Aerodigestive Tract

OBJECTIVE

Over the last two decades, an increase in office-based procedures under topical anesthesia in laryngology and head and neck oncology has occurred. Adequate anesthesia in the nasal cavity, pharynx, and larynx is essential for successful performance of these procedures. Our goal is to provide an objective summary on the available local anesthetics, methods of application, local secondary effects, efficacy, and complications.

MATERIAL AND METHODS

A descriptive review of literature on topical anesthesia for office-based procedures in laryngology and head and neck oncology was performed.

RESULTS

Lidocaine is the most applied and investigated topical anesthetic. Topical anesthesia results in decreased sensory function without impairing motor function of the pharynx and larynx. For the nasal cavity, cotton pledgets soaked in anesthetic spray and decongestant, or anesthetic gel, are effective. For the pharynx, anesthetic spray is the most frequently used and effective method. For the larynx, applying local anesthesia through a catheter through the working channel of the endoscope or anesthetic injection through the cricothyroid membrane is effective. Studies comparing the most effective application methods for each anatomical site are lacking. Complications of topical lidocaine administration are rare.

CONCLUSIONS

By properly applying topical anesthesia to the upper aerodigestive tract, several surgical procedures in laryngology and head and neck oncology can be performed in the outpatient clinic under topical anesthesia instead of the operating room under general anesthesia. Lidocaine is the most investigated anesthetic, with adequate efficacy and few complications. Studies that determine the most effective application methods are still wanting.