Transoral flexible laryngoscope biopsy: Safety and accuracy

Malakoplakia of Larynx: A Case Report and Literature Review of Localized Malakoplakia of Larynx

BACKGROUND

Malakoplakia is a very rare benign granulomatous disease, which can invade multiple organ systems, and is often related to bacterial infection and weak immunity. It is rarely occurred in the larynx, once this happens, the patient would complain of cough, hoarseness, dysphagia, and even dyspnea.

METHODS

We reported a case of malakoplakia of larynx. The patient complained of hoarseness and cough. Her lesion was located in the right false vocal cord. six case reports of malacoplakia in larynx were compiled from the literature and integrated with this case report.

RESULTS

After excising the tumor, the symptoms of the patient with cough, hoarseness and dysphagia were improved, and there was no recurrence during 1-year follow-up. The postoperative pathological diagnosis is malakoplakia. We found that malacoplakia is more commonly located in the supraglottic region, and we speculate that there may be a relationship between larynx-associated lymphoid tissue (LALT) and laryngeal malakoplakia. The effect of surgical treatment for laryngeal malacoplakia is satisfactory.

CONCLUSION

Malakoplakia of the larynx is rare. Bacterial infection, immune deficiency, and the distribution of LALT may be related to the pathogenesis and supraglottic localization of malakoplakia. The symptoms are related to the location and size of the mass and may be serious and fatal. Surgery is an important treatment for preserving laryngeal function and low recurrence rate.

Office-based flexible endoscopic guided biopsy: single-center feasibility analysis

BACKGROUND

Direct laryngoscopy and biopsy have been the standard of care for biopsy of lesions arising from the upper aerodigestive tract (UADT). The requirement of general anesthesia is often a prerequisite. Procedures performed under the laryngeal block and local anesthesia are not viewed as appropriate from the point of view of patient comfort. Office-based flexible guided biopsy offers a less invasive alternative for obtaining biopsies from UADT.

OBJECTIVE

To evaluate the yield, accuracy, feasibility, and safety of office-based flexible fiber-optic endoscope-directed biopsy (FEB) for laryngeal & pharyngeal lesions.

METHODS

Setting- Tertiary care referral center.Retrospective cohort of FEB procedures undertaken in the period from June-December 2022.

RESULTS

The study sample included 181 consecutive patients (median age 59 years) with lesions in supraglottis-25.4%, glottis-20.4%, nasopharynx-6%, oropharynx (base tongue/vallecula)-24.8%, and hypopharynx(pyriform fossa)-23.2%. The median time from outpatient visit to FEB was 1.9 days (1-4 days). Malignancy was confirmed in 166/181 patients, with 8 pre-malignant and 7 benign lesions. FEB confirmed the appropriate diagnosis in 159/181 (88.1%), and a repeat FEB in the 22 non-diagnostic situations yielded a diagnosis in another 8 (92.8% overall). The remaining 14 patients were appropriately diagnosed by a subsequent operating room endoscopy. The rate of conversion to direct laryngoscopy biopsy was approximately 7.73%. FEB demonstrated sensitivity (86.8%), specificity (100%), Positive Predictive Value (100%), Negative Predictive Value (23.3%), and overall Accuracy (87.29%). Univariate analysis indicated poor diagnostic yield for nasopharynx subsite (OR - 0.15; p = 0.003) and post-radiation/chemoradiation cases(OR - 7.04; p = 0.05). Multivariate analysis of the impact of patient characteristics, lesion subsite/morphology, and prior tracheostomy did not reveal a statistically significant association with histological yield. Mean biopsy time was 8 min with minor complications (pain/ minor bleeding) in 29/203 FEB procedures (14.28%), and major complications in 12(5.9%) (significant bleeding-2, airway compromise-9; death-1).

CONCLUSION

Office-based FFB is a viable alternative to direct laryngoscopic guided biopsy with acceptable sensitivity and specificity. Appropriate utilization of FFB will reduce the need for direct laryngoscopy.

Prospective cohort study assessing patient satisfaction and diagnostic accuracy in channeled endoscope local anesthetic biopsy in the investigation of head and neck cancer

BACKGROUND

There are delays in the head and neck Urgent Suspicion of Cancer (USOC) pathway. Local anesthetic (LA) biopsy with channeled endoscopes in outpatients can reduce time to diagnosis.

METHODS

Questionnaire-based prospective study of LA or general anesthetic (GA) biopsy for investigation of cancer from September 2021 to July 2022.

RESULTS

100% (n = 48) were very satisfied or satisfied with their overall experience. 71% (n = 20) of LA patients reported they would prefer to have a biopsy under LA. LA biopsy was 68% sensitive and 100% specific for cancer diagnosis. 28.6% (8) and 10% (2) of LA and GA patients had palliative MDT outcomes. Median time to diagnosis was 44.5 and 49.0 days for LA and GA biopsy, respectively.

CONCLUSION

LA biopsy had a high satisfaction rate and is sensitive for diagnosing cancer. LA biopsy can expedite treatment pathways. LA biopsy should be considered as an option for first line investigation.

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.

Diagnostic Yield of Office-Based Laryngeal Biopsy in Patients With Leukoplakia; A Case Study With Review of the Literature

OBJECTIVE

To review the authors experience in un-sedated office-based biopsies of patients with vocal fold leukoplakia and to review the literature.

MATERIAL AND METHOD

A retrospective review of 29 patients was conducted.

RESULTS

A total of 41 office-based procedures were performed (eight patients had bilateral vocal fold lesions and four patients had the procedure performed twice). In 26 out of the 41 biopsies, the pathology revealed benign lesion. In eight cases, the pathology showed dysplasia (four high-grade and four low-grade). Seven biopsies revealed squamous cell carcinoma. Five patients underwent suspension micro-laryngoscopy for definitive diagnosis. Four of whom had a change in their diagnosis.

CONCLUSION

Un-sedated office-based biopsy of vocal fold leukoplakia is an alternative to suspension microlaryngoscopy in case of carcinoma or nonmalignant lesions.

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.

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.

Diagnostic Accuracy Outcomes of Office-Based (Outpatient) Biopsies in patients with Laryngopharyngeal Lesions: A Systematic Review

Background

In‐office biopsies (IOB) using local anaesthetic for laryngopharyngeal tumours has become an increasingly popular approach since the advent of distal chip endoscopes. Although a wide range of studies advocate use in clinical practice, the widespread application of the procedure is hampered by concerns regarding diagnostic accuracy.

Objective

To assess the diagnostic accuracy of IOB performed via flexible endoscopy. In addition, to analyse modifiable factors that may affect diagnostic accuracy of IOB.

Design

A systematic review following the PRISMA guidelines was conducted. PubMed, EMBASE, the Cochrane Library, Web of Science and CINAHL were used in the literature database search. Quality assessment of included studies was perfomed using the Newcastle‐Ottawa Scale.

Results

A total of 875 studies were identified, 16 of which were included into the systematic review; 1572 successful biopsies were performed using flexible endoscopy; 1283 cases were accurately diagnosed in the outpatient setting (81.6%) and 289 samples did not provide an accurate diagnosis (18.4%). The median sensitivity of IOB was 73%, and the specificity was 96.7%. Analysis of variable factors did not show any significant differences in method of approach, size of equipment (forceps) and additional lighting system or learning curve.

Conclusion

IOB are a viable tool for diagnostic workup of laryngopharyngeal tumours. Clinicians should be wary of reported limitations of IOB when benign or pre‐malignant diagnoses are made. In cases suspicious of malignancy, confirmatory investigation should be conducted.

Pain Experience and Tolerance of Awake In-Office Upper Airway Procedures: Influencing Factors

OBJECTIVES/HYPOTHESIS

Awake, unsedated in-office upper airway procedures are performed frequently and have high completion rates, yet less is known about the patients' pain experience and potentially influencing factors. It is also unclear if patients' pain experiences become worse with repeated procedures. We identified procedure- and patient-related factors that might influence procedural completion and pain scores.

STUDY DESIGN

Retrospective chart review.

METHODS

Pre-, intra-, and post-procedure pain scores were collected prospectively for awake unsedated upper airway procedures performed at a single institution over a 5-year period. Patient factors reviewed were demographics, body mass index, psychiatric and/or pain diagnosis, and related medications. Procedure factors reviewed were procedure type, route, side, and performance of the same procedure multiple times. Patients reported their pain level before, during, and after the procedure using a standard 0 to 10 scale. Maximum pain score change (PΔmax), or the difference between highest and lowest reported pain levels, was calculated. Descriptive and multivariate analyses were performed.

RESULTS

Procedure completion was 98.7% for 609 first time patients and 99.0% in 60 patients undergoing 292 repeat procedures. PΔmax did not covary with age, gender, or BMI. PΔmax covaried with pain and psychiatric conditions and associated medications. PΔmax was highest for injection medialization and lowest for tracheoscopy. PΔmax decreased over time for those undergoing multiple identical procedures.

CONCLUSIONS

Procedures were performed with a very high completion rate and low pain scores. Age, sex, and BMI did not affect pain experience. A combination of pain and psychiatric conditions did. Injection medialization had the highest PΔmax and tracheoscopy the lowest.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1580-E1588, 2021.