Development of Procedures and Techniques for the Office

Transnasal Flexible Laryngoscopy Using Different Topical Preparations and Methods of Application-A Randomized Study

BACKGROUND

The field of laryngology has grown exponentially since the advent of the transnasal flexible laryngoscopy. Flexible laryngoscopy when performed skillfully using the proper technique, facilitates a good view of the hidden areas of the larynx.

OBJECTIVE

To compare the effectiveness of the topical agents in providing a more comfortable experience for the patient, allowing the practitioner to advance the endoscope with less friction, pain and discomfort for the patient using 10% lidocaine spray, 2% lidocaine gel, 4% lidocaine with xylometazoline (1:1) soaked pledgets, or aqueous gel.

MATERIALS AND METHODS

A prospective randomized single-blinded clinical trial was conducted in a tertiary care teaching hospital in South India where 376 patients were recruited and allocated into four groups based on the topical preparation used. Following endoscopy, each subject filled a questionnaire grading their experience on a visual analogue scale. The clinician also then answered a questionnaire on aspects of the endoscopy performed.

RESULTS

The pain score and the ease of performing the procedure among the different groups were comparable. Those in the 10% lidocaine arm experienced significant burning sensation (P = 0.0001). The other variables such as throat pain (P = 0.783), gag reflex (P = 0.318), unpleasant taste (P = 0.092), globus (P = 0.190), swallowing difficulty after the procedure (P = 0.273), difficulty in breathing (P = 0.744) and willingness to have a repeat procedure (P = 0.883) were also comparable.

CONCLUSION

Aqueous gel can be used topically during a flexible nasopharyngolaryngoscopy instead of an anesthetic agent alone or one combined with a nasal decongestant.

Feasibility of transnasal flexible carbon dioxide laser surgery for laryngopharyngeal lesions

OBJECTIVE

The fiber-guided carbon dioxide (CO₂) laser is a useful device for laryngopharyngeal surgery. The flexible CO₂ wave-guide laser has been developed and commercially available for several years. However, the transnasal use of CO₂ flexible wave-guided laser surgery through the instrument channel of a flexible endoscope (CO₂ TNFLS) is not permitted in Japan. This feasibility study aimed to assess the value and the safety of an in-office CO₂ TNFLS procedure.

METHODS

Patients with small laryngopharyngeal diseases were enrolled from June 2015. Eligible patients had indications with lesions generally localized superficial lesions such as the benign tumor, leukoplakia, and premalignant lesion-like carcinoma in situ (CIS). Patients were locally well anesthetized using xylocaine. After removing as much of the lesion(s) as possible with flexible forceps, the remainder of the lesions were evaporated using CO₂ TNFLS through the instrument channel of a flexible endoscope under local anesthesia.

RESULTS

Eighteen surgeries involving 13 patients, including 9 papilloma (7 recurrent respiratory papilloma [RRP]), 2 carcinoma in situ, 1 leukoplakia, and 1 large epiglottic cyst), were performed. Four patients with RRP required multiple surgeries. Except for 3 patients with RRP, all patients achieved disease control without additional intervention. All procedures were completed with no severe adverse events.

CONCLUSION

Office-based CO₂ TNFLS is safe and feasible for patients with laryngopharyngeal pathologies. It is especially valuable for RRP patients with small lesions to avoid surgery under general anesthesia.

In-Office Endoscopic Laryngeal Laser Procedures: A Patient Safety Initiative

Objective

To review complications of in-office endoscopic laryngeal laser procedures after implementation of standardized safety protocol.

Methods

A retrospective review was conducted of the first 2 years of in-office laser procedures at St Michaels Hospital after the introduction of a standardized safety protocol. The protocol included patient screening, procedure checklist with standardized reporting of processes, medications, and complications. Primary outcomes measured were complication rates of in-office laryngeal laser procedures. Secondary outcomes included hemodynamic changes, local anesthetic dose, laser settings, total laser/procedure time, and incidence of sedation.

Results

A total of 145 in-office KTP procedures performed on 65 patients were reviewed. In 98% of cases, the safety protocol was fully implemented. The overall complication rate was 4.8%. No major complications were encountered. Minor complications included vasovagal episodes and patient intolerance. The rate of patient intolerance resulting early termination of anticipated procedure was 13.1%. Total local anesthetic dose averaged 172.9 mg lidocaine per procedure. The mean amount of laser energy dispersed was 261.2 J, with mean total procedure time of 48.3 minutes. Sixteen percent of patients had preprocedure sedation. Vital signs were found to vary modestly. Systolic blood pressure was lower postprocedure in 13.8% and symptomatic in 4.1%.

Discussion

The review of our standardized safety protocol has revealed that in-office laser treatment for laryngeal pathology has extremely low complication rates with safe patient outcomes.

Implications for Practice

The trend of shifting procedures out of the operating room into the office/clinic setting requires new processes designed to promote patient safety.

A Novel Approach to the Challenging Injection Laryngoplasty

Introduction:

Injection laryngoplasty (IL) is typically performed either awake or under general anesthesia with paralysis. There is a subgroup of patients, however, for whom neither of these is a good option. For such patients, we report a hybrid technique that allows for a percutaneous injection without paralysis but with sedation to increase patient tolerance. Supraglottic airway laryngotracheal intervention (SALTI) brings the benefits of injection laryngoplasty to a group of patients previously underserved.

Methods:

Injection laryngoplasty cases using SALTI technique from July 1, 2013, to October 21, 2014, were reviewed. Data were collected regarding the indication, success of injection, comorbidities, and outcomes.

Results:

Seventeen subjects were reviewed. All were successfully injected without complications. Follow-up data were available for 15 subjects. The majority of patients experienced improved symptoms of dysphonia and/or dysphagia after the procedure.

Discussion and Conclusions:

This study demonstrates the feasibility of the SALTI technique for IL. The technique may also be useful for other procedures. Advantages include maintenance of spontaneous ventilation without paralysis, no neck extension, improved patient tolerance, and accommodation of difficult anatomy. Disadvantages are increased time and cost related to the operating room and the need for an assistant. Overall, SALTI permits IL in previously ineligible patients.