Office-based pulsed dye laser treatment for hemorrhagic telangiectasias and epistaxis

Laser-Assisted Control of Epistaxis in Hereditary Hemorrhagic Telangiectasia: A Systematic Review

BACKGROUND AND OBJECTIVES

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease, causes recurrent mucous membrane hemorrhage, especially epistaxis. In this systematic review, we discuss the efficacies of the three most common laser photocoagulation treatments for HHT-related epistaxis.

STUDY DESIGN/MATERIALS AND METHODS

A systematic literature search was conducted in PubMed and MEDLINE from database inception to March 2019. Studies reporting epistaxis outcomes following argon, neodymium-doped yttrium aluminum garnet (Nd:YAG), and diode laser photocoagulation for HHT were included. χ² and Barnard's exact tests were utilized to detect differences in reduced epistaxis frequency and intensity rates.

RESULTS

Fifteen out of 157 published studies met our eligibility criteria, spanning a collective 362 patients. Argon, Nd:YAG, and diode laser therapy reduced epistaxis frequency in 90.4%, 88.9%, and 71.1% of patients, respectively, and reduced epistaxis intensity in 87.8%, 87.2%, and 71.1% of patients, respectively. Diode laser photocoagulation significantly underperformed in both outcome measurements when compared with argon (frequency: P = 0.005; intensity: P = 0.034) and Nd:YAG (frequency: P = 0.012; intensity: P = 0.041). There was no significant difference between argon and Nd:YAG in reducing HHT epistaxis frequency (P = 0.434) or intensity (P = 0.969). Categorizing HHT patients by clinical severity demonstrated a higher rate of improvement in the mild-moderate group compared with the severe group in both argon (P < 0.001) and Nd:YAG (P < 0.001) therapeutic methods. While no significant differences were found in rates of improved epistaxis outcomes between argon and Nd:YAG in mild-moderate HHT patients (frequency: P = 0.061; intensity: P = 0.061), Nd:YAG demonstrated greater rates of reduction in epistaxis frequency (P = 0.040) and intensity (P = 0.028) than argon among severe HHT patients.

CONCLUSIONS

HHT is a lifelong disease, plaguing patients with debilitating epistaxis. Intranasal laser photocoagulation of telangiectasias using argon or Nd:YAG laser therapy can yield improved epistaxis outcomes compared with diode laser photocoagulation. In severe cases of HHT, Nd:YAG laser therapy provides greater improvements in epistaxis outcomes than argon photocoagulation. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Angiolytic laser stripping versus CO2 laser microflap excision for vocal fold leukoplakia: Long-term disease control and voice outcomes

BACKGROUND AND PURPOSE

Vocal fold leukoplakia, white plaque on the epithelium, has the potential for malignant transformation regardless of dysplasia grade. It is treated with different laser types (CO2 or angiolytic) and various techniques (vaporization, stripping, or excision); however, only a few studies exist regarding comparative laser surgery results. This study was conducted to investigate clinical outcomes of CO2 versus angiolytic laser microdissection with regard to long-term disease control and voice preservation in vocal fold leukoplakia.

MATERIALS AND METHODS

Seventy patients with vocal fold leukoplakia treated by CO2 or angiolytic laser (pulsed dye laser or potassium titanyl phosphate) were identified retrospectively. Data regarding patient characteristics, treatment details, treatment outcomes including disease control (recurrence and progression) and the Voice Handicap Index, GRBAS scale, and acoustics were evaluated. The mean follow-up duration after initial treatment was 32 ± 26 months.

RESULTS

The study group comprised 14 patients who underwent CO2 laser microflap excision and 56 who underwent angiolytic laser stripping. Of the patients treated with CO2 laser, 11 (79%) had no recurrence and three (21%) showed recurrent leukoplakia, of which one patient (7%) showed histologic grade progression. Of patients who underwent angiolytic laser stripping, 12 had disease recurrence (21%), among whom three (5%) showed disease progression. Laser surgery type, disease extent, and histologic grade showed no significant differences in recurrence or progression rates. The postoperative Voice Handicap Index significantly improved (P = .03) and the G score significantly decreased (P < .001) in the angiolytic laser treatment group. In contrast, the Voice Handicap Index increased postoperatively in the CO2 laser group (P = .046).

CONCLUSIONS

The long-term recurrence or progression rates were not significantly different between angiolytic and CO2 laser treatment. The angiolytic laser stripping group showed better voice preservation compared with the CO2 laser group. Angiolytic laser stripping is suggested as an effective treatment option for vocal fold leukoplakia with comparable disease control and better voice preservation.

New Classification of Nasal Vasculature Patterns in Hereditary Hemorrhagic Telangiectasia

Background

Hereditary hemorrhagic telangiectasia (HHT) is a disorder characterized by the triad of recurrent epistaxis, telangiectasia, and a family history of the disease. Management of recalcitrant epistaxis in HHT remains a challenging problem for otolaryngologists. The precise coagulation of telangiectasias with the Nd-YAG laser has shown efficacy in the treatment of HHT-associated epistaxis, but results can be variable and patient selection is critical in ensuring a successful outcome. We propose a new classification of nasal vasculature patterns in HHT as a means for selecting the Nd-YAG laser for photocoagulation treatment.

Methods

The records of 40 patients who underwent Nd-YAG laser photocoagulation for HHT were reviewed retrospectively. Outcomes after Nd-YAG laser treatment were correlated with three observed nasal vasculature patterns: (I) isolated punctate telangiectasias or individual small arteriovenous malformation; (II) diffuse interconnecting vasculature with “feeder” vessels; and (III) large solitary arteriovenous malformation, which may be associated with scattered telangiectasia.

Results

Types I and II were the most common vasculature patterns seen in this patient population. Patients with patterns I and III showed greater improvement in epistaxis after Nd-YAG laser photocoagulation. Patients with pattern II fared better with septodermoplasty.

Conclusion

These findings suggest that analysis of nasal vasculature patterns can improve therapeutic stratification of patients with HHT. Proper patient selection using this new classification scheme may improve the management of epistaxis in patients with HHT.

Evidence-based management of epistaxis in hereditary haemorrhagic telangiectasia

BACKGROUND

There are currently no guidelines in the UK for the specific management of hereditary haemorrhagic telangiectasia related epistaxis. The authors aimed to review the literature and provide an algorithm for the management of hereditary haemorrhagic telangiectasia related epistaxis.

METHOD

The Medline and Embase databases were interrogated on 15 November 2013 using the search items 'hereditary haemorrhagic telangiectasia' (title), 'epistaxis' (title) and 'treatment' (title and abstract), and limiting the search to articles published in English.

RESULTS

A total of 46 publications were identified, comprising 1 systematic review, 2 randomised, controlled trials, 27 case series, 9 case reports, 4 questionnaire studies and 3 in vitro studies.

CONCLUSION

There is a lack of high-level evidence for the use of many of the available treatments for the specific management of epistaxis in hereditary haemorrhagic telangiectasia. Current management should be based on a multidisciplinary team approach involving both a hereditary haemorrhagic telangiectasia physician and an ENT surgeon, especially when systemic therapy is being considered. The suggested treatment algorithm considers that the severity of epistaxis merits intervention at different levels of the treatment ladder. The patient should be assessed using a reproducible validated assessment tool, for example an epistaxis severity score, to guide treatment. More research is required, particularly in the investigation of topical agents targeting the development and fragility of telangiectasiae in hereditary haemorrhagic telangiectasia.

Management of severe epistaxis after Young's procedure: a case report

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder affecting multiple organ systems, with epistaxis being the most common manifestation. Multiple procedures have been used for the management of epistaxis in the setting of HHT, including closure of the anterior nares via a Young's procedure. While this procedure results in loss of smell and permanent nasal obstruction, proponents note significant improvement in patient symptomatology.

METHODS

Case report.

RESULTS

A 70-year-old female with a history of HHT presented to an outside hospital with bleeding into the nasopharynx 2 months after undergoing a modified Young's procedure at an unaffiliated institution. She was transfused with 2 units of packed red blood cells (PRBCs) and transferred to our facility. Due to persistent epistaxis and need for airway protection, the patient was intubated and her throat was packed. She also developed aspiration pneumonia and hypotensive shock requiring vasopressors. Twenty-four hours following bilateral internal maxillary and sphenopalatine artery embolization, she developed significant epistaxis requiring reversal of the Young's procedure on the left and placement of an anterior-posterior pack at the bedside. Upon packing removal several days later in the operating room, she was noted to have significant bleeding that necessitated reversal of the Young's procedure on the right side to obtain adequate exposure and hemostasis.

CONCLUSION

We report a case of significant, life-threatening epistaxis following a modified Young's procedure that requiring multiple transfusions, bilateral embolization, and ultimately reversal of the Young's procedure for control of epistaxis. Although recognized as a potential complication, to our knowledge this is the first report in the English literature of such a case.

The use of the pulse dye laser in the treatment of vocal fold scar: a preliminary study

OBJECTIVES/HYPOTHESIS

Dysphonia due to vocal fold scarring is a challenging problem to the laryngologist. Vocal fold scarring after radiation, phonosurgery, and laser cordectomy causes moderate to severe dysphonia. Surgical attempts at scar removal and voice restoration have limited success. Pulsed dye laser (PDL) treatment has been shown to be effective in softening scarred skin by serial office treatments. The objective of this preliminary study was to evaluate the use of the PDL in the management of patients with established vocal fold scar.

STUDY DESIGN

This is an Institutional Review Board-approved prospective study involving 11 patients. The causes of scarring were phonosurgery (n = 7), radiation (n = 2), and partial laryngectomy (n = 2). The subjects were evaluated pre- and postprocedure using the voice handicap index (VHI), laryngeal stroboscopy rating, voice recordings with acoustic and aerodynamic analysis, and self-evaluation.

METHODS

The PDL was applied with the fiberoptic delivery system by three treatments at 1-month intervals in the office setting. Each treatment endpoint was blanching of the treatment site.

RESULTS

: There were three women and eight men in our study group. Ten of 11 patients subjectively improved by self-rating. No patients were worse. VHI improved from 48.44 pretreatment to 35.55 at 6 months posttreatment (P < .05). The jitter at 6 months improved from 2.230% to 1.654% (P = NS) and shimmer improved from 3.679% to 3.196% (P = NS). The noise to harmonic ration improved from 0.1428 to 0.1316 (P = NS). The mean phonotory flow went from 0.177 to 0.254 L/S (P < .05). Three raters blinded to treatment sequence rated the posttreatment stroboscopy findings as better than pretreatment in a forced choice comparison, kappa score 0.903.

CONCLUSION

PDL is a safe and potentially promising treatment for established vocal fold scar. Subjectively, no patients were worse and 10 of 11 patients reported improved voice. There was improvement in the VHI, acoustic measures of shimmer and jitter, and stroboscopy findings. Further study using this approach in a larger cohort seems to be warranted.