Office-based laryngeal laser surgery with the 532-nm pulsed-potassium-titanyl-phosphate laser

Comparison of Angiolytic Effects Between the 445-nm Blue Laser and 532-nm Pulsed KTP Laser

OBJECTIVE

This study aimed to compare the selective absorption of the 445-nm Blue laser (BL) and the 532-nm pulsed potassium-titanyl-phosphate (KTP) laser by blood vessels.

METHODS

Thirty-six chicken eggs at day 14 of incubation were dissected to expose the chick chorioallantoic membrane (CAM). Third-order vessels of the CAM were identified and irradiated using BL and KTP lasers using various settings at a laser-to-vessel distance of 3 mm using 0.4 mm fiber size. In total, 494 vessels segments were irradiated. Mean (standard deviation) number of irradiations for each setting was 26.0 (4.6), range from 15 to 39. Outcome measures included ablation rate (AR) and rupture rate (RR).

RESULTS

The two lasers were compared for AR and RR at long and medium pulse width (PW) associated with different power levels. At long PW (above 100 ms), BL showed significantly higher AR than KTP at high energy (600 mJ/pulse) and low energy (400 mJ/pulse); they did not show different AR and RR at medium energy levels (500 mJ/pulse). Using medium PW settings plus high and medium energy levels, BL and KTP showed relatively high AR and did not significantly differ in performance. However, at medium PW plus low energy (400-450 mJ/pulse), KTP showed significantly higher AR compared to BL.

CONCLUSION

At long PW, BL appeared to show higher AR than KTP at high or low energy levels, but they showed equivalent performance at medium energy. At medium PW, both performed similarly from high to medium energy, but KTP appeared to perform better than BL at lower energy settings.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:3220-3225, 2024.

Laryngeal office-based procedures: A safe approach

PURPOSE

Laryngeal surgeries using a flexible nasopharyngoscope equipped with an operative channel has gained popularity, with gradual increase in the variety of interventional office-based procedures, under local anesthesia. The purpose of this study is to analyze the tolerance of such procedures.

MATERIALS AND METHODS

Retrospective cohort study. 337 cases were performed during 2 years. We collected the following data: type of pathology, type of procedure and modalities of anesthesia, adverse events.

RESULTS

19 % of the visits were for the purpose of Biopsy, 65 % for an injection, and Trublue Laser was utilized in 12 % of the procedures. Regarding the pathologies, 27 % were vocal fold paralysis, 18 % leukoplakia or another suspicious lesion, 15 % recurrent respiratory papillomatosis, 13 % neuromuscular disorder, 9 % vocal fold scarring, 7 % vocal cord atrophy and 6 % had an inflammatory presentation. Side effects were documented in 26 visits (7.7 %) and were minor in almost all the encounters: they included strong reflexive cough, deep throat pain, discomfort, gag reflex, anxiety, vagal discomfort, malaise, hypersalivation, nose pain, labile hypertension. More severe side effects were very rare and included septal wound and epistaxis, erythematous rash, dyspnea, and transient dysarthria. 13 procedures were either aborted, or canceled at initial steps, due to inability of the patient to tolerate the procedure and were rescheduled for general anesthesia. 97 % of the cases were released home after 1 h of surveillance.

CONCLUSION

Office-based flexible interventional laryngoscopy under local anesthesia is a safe and well-tolerated procedure, with abundance of various interventions feasible on ambulatory, office-based setup.

Endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis using radiofrequency versus coblation

PURPOSE

To assess the outcomes of endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis (BAVFP) using radiofrequency versus coblation.

METHODS

This was a randomized prospective cohort study that carried out on 40 patients with BAVFP who were subjected to endoscopic/assisted microscopic posterior cordotomy. The patients were randomly allocated into two groups: group (A) patients were operated with radiofrequency, and group (B) patients were operated with coblation. Glottic chink, grade of dyspnea, voice handicap index 10 (VHI10), and aspiration were evaluated pre-operatively and 2 weeks and 3 months post-operatively.

RESULTS

There was a significant improvement in the glottic chink and VHI10 scores postoperatively with a non-significant difference between both groups regarding the degree of improvement. In addition, there was a significant improvement of the grade of dyspnea with a non-significant impact on the degree of aspiration in both groups post operatively. There was a lower incidence of oedema and granulation formation in the coblation group but without a statistical significance.

CONCLUSION

Both techniques are effective alternatives for performing posterior transverse cordotomy in cases of BAVFP.

The Safety and Efficacy of the 445-nm Blue Laser for Operative Management of Benign Nonvascular Laryngeal Lesions

The 445-nm blue laser combines the features of photocoagulative vascular lasers and cutting lasers in one device. The purpose of the present study was to evaluate the safety and efficacy of the 445-nm blue laser for the treatment of benign laryngeal pathologies, other than vascular lesions. Outcomes were compared to those when already-established therapies were used.

METHODS

Adult voice center patients who underwent surgical intervention for vocal fold (VF) mass, VF scar, laryngeal stenosis, laryngeal web, or Reinke's edema were included in this retrospective study. Outcomes were compared to those achieved when traditional treatment modalities were used, including cold steel, CO2 laser, potassium-titanyl-phosphate (KTP) laser, and coblator. Strobovideolaryngoscopy footage was evaluated using a previously described model at four time points: postoperative visit #1: 1-14 days, postoperative visit #2: 30-60 days, postoperative visit #3: 61-365 days, postoperative visit #4: >365 days.

RESULTS

Eighty cases using the blue laser and 153 controls (n = 78 cold steel, n = 51 KTP laser, n = 22 CO2 laser, n = 2 coblator) were included in this study. Procedures performed using blue laser included VF mass excision (n = 45), VF scar reduction (n = 16), laryngeal stenosis resection/repair (n = 25), laryngeal web excision (n = 7), and reduction of Reinke's edema (n = 1). On postoperative strobovideolaryngoscopy examination, the surgical objective score did not differ significantly between the blue laser cohort and all controls at any postoperative visit. VF edema did not differ significantly between the blue laser cohort and all controls at any postoperative visit. VF hemorrhage scores were significantly lower in the blue laser cohort compared to all controls at the first postoperative visit, but hemorrhage had resolved almost entirely by the second postoperative visit in all groups. Postoperative VF stiffness was worse in the blue laser group at the third postoperative visit compared to controls, but both groups had improved to similar levels by the fourth postoperative visit. The rate of lesion recurrence (24.29% versus 17.19%) did not differ significantly between the blue laser cohort and controls on multivariate analysis (Odds ratio [OR] = 1.081 [0.461-2.536]). The complication rate (12.50% versus 10.46%) did not differ significantly between the blue laser cohort and all controls on multivariate analysis (OR = 0.992 [0.375-2.624]). The blue laser was associated with a lower rate of revision surgery (30.00% versus 34.64%) on multivariate analysis (OR = 0.380 [0.168-0.859]).

CONCLUSION

The 445-nm blue laser is safe and effective for the management of benign laryngeal lesions. It has efficacy and safety similar to those of traditional treatment modalities (including cold steel, CO2 laser, and KTP laser). Use of the blue laser may lead to lower rates of early postoperative hemorrhage and revision surgery. No adverse effects attributed directly to the use of the blue laser were observed in this study. Further research is encouraged to confirm or refute these findings.

Office-Based Treatment of Vocal Fold Polyps and Reinke's Edema: A Rational Comparison With Suspension Laryngoscopy

OBJECTIVE

Benign laryngeal lesions have traditionally been treated through suspension laryngoscopy under general anesthesia (GA). Recently, the development of operative videoendoscopes coupled with photoangiolytic lasers has allowed clinicians to treat these conditions in the outpatient clinic. We report our experience in the office-based (OB) setting for the treatment of patients affected by vocal fold polyps (VFPs) and Reinke's edema (RE), comparing it to patients treated under GA.

METHODS

A retrospective analysis was conducted on patients affected by VFP or RE. A 445 nm diode blue laser was used through the operative channel of a flexible video-endoscope for OB procedures, while GA surgeries were carried out with cold steel instrumentation. The Voice Handicap Index-10 (VHI-10) represented the primary outcome. Endoscopic outcomes, duration, and morbidity of the procedures were investigated as secondary outcomes.

RESULTS

A total of 153 patients were retrospectively enrolled. 52 were treated in an OB setting, while 91 underwent GA. Regarding patients with RE, both the OB and GA cohorts showed a significant improvement in VHI-10 (from 12.7 to 2.6 and 19.5 to 5.1, respectively; p < 0.001), as did those with VFPs (from 11.8 to 2.3 and 15.9 to 2.9 respectively; p < 0.001). No differences were found when comparing VHI-10 in the OB and GA cohorts. The mean procedural time of OB treatment (4.9 min) was significantly shorter than GA (37.1 min). No adverse events were reported.

CONCLUSION

Our data demonstrate the efficacy and safety of the OB setting. For selected patients, OB treatments offer comparable vocal outcomes, favorable morbidity, and reduced operation times, making them an appealing alternative to the traditional approach.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2665-2672, 2023.

Un-sedated Office-Based Application of Blue Laser in Vocal Fold Lesions

INTRODUCTION

Office-based laser procedures in laryngology have gained a lot of popularity in the last decade with the use of the KTP, PDL and Thulium lasers. Preliminary investigations currently report on the use of the 445 nm wavelength Blue laser for the treatment of various laryngeal pathologies, given its dual photoangiolytic and cutting properties.

OBJECTIVE

We aim to investigate the safety and efficacy of the Blue laser for the treatment of vocal fold lesions.

METHODS

This is a retrospective chart review of eleven patients with a variety of vocal fold lesions (polyps, Reinke's edema, papilloma, and leukoplakia), that underwent un-sedated office-based treatment using the 445 nm blue laser. The primary outcome was to compare preoperative to postoperative Voice Handicap Index (VHI-10) score and self-reported voice improvement using a visual analog scale (VAS). We also compared fiberoptic laryngeal examination before and after treatment.

RESULTS

Eleven un-sedated office-based procedures using the blue laser were performed. There was improvement in the mean VHI-10 score (n = 8) with a decrease from 15.13 ± 8.77 to 3.50 ± 3.46 (P= 0.015). Similarly, the mean VAS score (n = 7) decreased from 6.14 ± 1.21 to 1.71 ± 1.60 (P< 0.003). All patients had a complete or partial regression of the vocal fold lesions on fiberoptic laryngeal examination. None of the patients had complications after the procedure.

CONCLUSION

Blue laser therapy can be suggested as a safe and effective alternative treatment modality in office-based laryngology procedures for a variety of vocal fold lesions. A larger series is needed to better validate the efficacy of this laser as a new treatment modality.

Transoral Flexible Laser Surgery of the Larynx with Blue Laser

INTRODUCTION

Laser surgery of the larynx is currently the standard of clinical practice in a multitude of procedures. Lasers with photoangiolytic properties have a wide application in endolaryngeal lesions. One of their most prominent features is the ability to coagulate blood vessels, reducing unwanted tissue damage. Our objective is to expose the uses of the blue laser (445 nm) in the larynx.

MATERIAL AND METHODS

A retrospective study was carried out including 47 patients treated with blue photoangiolytic laser from October 2021 to January 2023 at a university hospital. Demographic data, type of lesion presented, date of intervention and scope of the procedure, as well as the parameters of the laser used, were recorded. The number of sessions received per patient, the result and complications were also collected.

RESULTS

A total of 47 patients with laryngeal lesions were treated, including vascular angiomas, laryngeal sulcus vocali, vocal cord polyps, Reinke's edemas, laryngeal papillomatoses, subglottic stenosis, laryngeal synechiae, subglottic granulomas, glottic scars, vocal fold leukoplakias, laryngeal dysplasias and tracheostomal granulomas. The mean age was 52.5 years, and 64.3% of the patients were women. The range of power used in the resective surgeries was 2-10 Watts with a 20-millisecond window. The average number of sessions received was 2.1 (range 1-4). A satisfactory situation was obtained in 45 of the 47 patients treated (95.75%), and an evident decrease in lesions was seen in the remaining two. There was no evidence of any complications directly derived from the use of the blue laser. Twenty-seven cases (54%) were treated exclusively in-office.

CONCLUSIONS

The blue laser is safe and effective in the treatment of a wide range of laryngeal pathologies. Its advantages include its portability, its photoangiolytic qualities as well as its ability to vaporize tissue in contact mode, which can treat subepithelial vessels or resect lesions.

Voice Outcomes Following Serial Office-Based Steroid Injections and Voice Therapy for Vocal Fold Scar

OBJECTIVE

Previous studies indicate that certain voice outcomes can improve following a single office-based steroid injection with voice therapy for vocal fold scar. We evaluated voice outcomes after a series of three timed office-based steroid injections with voice therapy.

STUDY DESIGN

Retrospective case series with chart review.

SETTING

Academic medical center.

METHODS

We evaluated pre-and postprocedural patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. We evaluated 23 patients who underwent three office-based dexamethasone injections into the superficial lamina propria one month apart. All patients pursued voice therapy.

RESULTS

Voice Handicap Index (n = 19; P= .030) decreased after injection series. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 23; P = 0.001). Dysphonia severity index score improved (n = 20; P = 0.041). Phonation threshold pressure did not decrease significantly (n = 22; P = 0.536). Videostroboscopic parameters of vocal fold edge (P = 0.023), right mucosal wave (P = 0.023) improved or normalized after injection series. Glottic closure (P = 0.134) did not improve.

CONCLUSIONS

Series of three office-based steroid injections combined with voice therapy for vocal fold scar does not appear to provide further benefit than one injection. Despite lack of improvements of PTP and other parameters, injection series is likewise unlikely to worsen dysphonia. A partially negative study provides value in investigation of less invasive treatment alternatives for a disorder that is challenging to treat. Future studies exploring effects of voice therapy alone without other intervention and consideration of sham injection versus steroid injection are warranted.

Comparative Results of Vocal Fold Injury According to the Fiber-Based Laser in a Rabbit Vocal Fold Model

OBJECTIVES

We assessed the safety of flexible fiber-based lasers including the potassium-titanyl-phosphate (KTP), CO2, and Holmium lasers using a rabbit vocal fold model and provided the safety evidence of laser before human clinical trial.

METHODS

In all, 120 male New Zealand white rabbits were used. Each laser was used to induce acute and chronic vocal fold injuries in 40 rabbits. The same laser energy with the same intensity and frequency were used in all cases, and we evaluated outcomes via surface scanning electron microscopy (SEM) and histological examination 1 day after injury. Histological and high-speed vocal fold vibration examinations were evaluated 1 month after injury. Surface injury roughness grading was done via SEM, and the Acute injury ratio and lamina propria (LP) ratio were also calculated. The dynamic glottal gap was measured through functional analyses based on recordings from a high-speed digital camera.

RESULTS

The Holmium laser caused significantly more vocal fold damage than did the KTP and CO2 lasers as revealed by SEM and evaluation of acute and chronic injuries. Functional analysis with high-speed digital camera indicated that the holmium laser reduced dynamic glottal gap compared with the normal vocal fold, where the other lasers did not.

CONCLUSIONS

The histological and functional analyses of rabbit vocal fold experiments indicated that fiber-based laryngeal laser surgery for vocal fold lesions could be performed relatively safely using a KTP or CO2 laser.

[Vocal fold polyps: modern possibilities of laser surgery in comparison with the use of cold microinstruments]

OBJECTIVE

To perform a comparative analysis of phonosurgical interventions, which were made using a 445 nm semiconductor laser or cold microinstrumentation in patients with «vocal fold polyp» diagnosis.

MATERIAL AND METHODS

The number of surgical interventions equal 30 regarding vocal fold polyp was done in otorhinolaryngology clinic of Pavlov First State Medical University of St. Petersburg in the period from September 2021 yr. to September 2022 yr. The phonosurgical intervention was performed under the conditions of direct suspension microlaryngoscopy by Kleinsasser under general anesthesia using high frequency ventilation through an endotracheal catheter. Surgical interventions were carried out using a 445-nm semiconductor laser in pulsed mode for patients of the 1st group (n=15) and using microsurgical instruments for patients of the 2nd group (n=15). The comparative analysis was conducted based on the results of an objective vocal function assessment by acoustic analysis, as well as on the data of a subjective assessment of the voice using the questionnaire VHI-10rus. The severity of reactive inflammatory phenomena in the postoperative period has been compared and the oscillating movements of vocal folds have been evaluated according to the videolaryngoscopy data. The severity of pain syndrome in the postoperative period was assessed by visual analogue scale.

RESULTS

There were no statistically significant differences in the results between two groups. Similarly, there were no statistically significant differences in parameter recovery degree, evaluated by videolaryngoscopy data. Moreover, a full recovery of mucosal wave was found in 93% of patients operated with laser on 7th day, while 47% of patients had the same result after use of cold microinstrumentation.

CONCLUSION

The use of 445-nm semiconductor laser for phonosurgical interventions in vocal folds' polyps can be recommended for predicted successful recovery of vocal function, minimization of reactive inflammatory phenomena in postoperative period and early patients' rehabilitation.

Comparison Between Coblation and Microflap Resection of Leukoplakia of the Vocal Fold

OBJECTIVES

The objective of this study was to compare the recurrence rate and voice improvement of vocal fold leukoplakia (VFL) between microflap resection alone or radiofrequency (RF) Coblation alone.

METHODS

Patients with VFL intraoperatively treated via microflap resection alone or Coblation alone were enrolled. The recurrence rate, voice assessment, and Videostroboscopic images were compared between the two groups.

RESULTS

The recurrence rate at postoperative 12 months was 37.7% (26/69) in the microflap resection group and 7.7% (4/52) in the Coblation group; the difference was significant (P < 0.05). The preoperative and postoperative subjective detection data from the two groups showed significant differences, but the Coblation group recovered better compared to the microflap resection group. No Coblation-related complications were found, including postoperative granulation tissue hyperplasia or anterior commissure adhesion.

CONCLUSIONS

In patients with vocal cord leukoplakia, RF Coblation had a lower recurrence rate and better voice improvement compared with microflap resection.

Surgical Outcome of Low-Power-Density Blue Laser for Vascular Lesions of the Vocal Fold

Photoangiolytic lasers such as the 532-nm potassium-titanyl-phosphate (KTP) and the novel 445-nm blue laser (introduced into the United States in 2020) are absorbed selectively by hemoglobin, permitting targeted ablation of vascular structures such as vascular malformations of the vocal fold (VF). Previously, we reported the high rate of success of KTP laser photocoagulation for VF vascular lesions. Compared with other photoangiolytic lasers, blue laser has the highest absorption in hemoglobin, and therefore it can be operated at lower power densities to minimize thermal injury to adjacent tissue.

OBJECTIVE

The purpose of this study was to determine the efficacy and safety of blue laser for treatment of VF vascular lesions using low power densities, and to compare outcomes of blue laser with those of KTP laser.

METHODS

Adult voice patients who underwent blue laser treatment of VF vascular lesions in the operating room at the lowest power densities that appeared clinically to cause the effect desired were included in this retrospective study. Baseline lesion characteristics and postoperative outcomes were assessed with a model that we had described previously. Postoperative outcomes were compared to those of previously reported KTP laser.

RESULTS

Thirty-one subjects (54 VFs treated) underwent blue laser vaporization of VF vascular lesions (average age was 40.63 ± 17.51). Data were compared to those of 66 subjects (100 VFs) who had undergone KTP laser vaporization of VF vascular lesions. There were no significant differences in subject demographics, past medical or surgical history, or preoperative location or severity of vascular lesions. Surgical success for blue laser at the low power densities used was 3.74 ± 0.50, 3.55 ± 0.94, 3.90 ± 0.94, and 3.70 ± 1.11 (out of 5) at postoperative visits 1-4, respectively. Surgical objective score was significantly greater following KTP laser at every postoperative visit. Treatment with KTP laser resulted in significantly greater generalized postoperative edema, and blue laser resulted in significantly greater localized edema at postoperative visits one and two. At visit three and four, there are no significant differences. VF stiffness following blue laser was 2.41 ± 0.67, 1.91 ± 0.69, 1.33 ± 0.47, and 1.10 ± 0.18 (out of 4) at postoperative visits 1-4, respectively. Postoperative VF stiffness did not differ significantly from KTP laser. Postoperative hemorrhage severity after blue laser was 1.79 ± 0.54, 1.59 ± 0.48, 1.15 ± 0.25, and 1.14 ± 0.26 (out of 4) at postoperative visits 1-4, respectively. Blue laser resulted in significantly less VF hemorrhage than KTP laser at the first (1.79 ± 0.54 versus 2.26 ± 0.83) and second (1.59 ± 0.48 versus 1.98 ± 0.72) postoperative visits. Vascular lesions treated with low-power-density blue laser were significantly more likely to recur than those treated with KTP laser (40.74% versus 10.00%). New vascular malformations were significantly more likely to form after blue laser than KTP (24.07% versus 6.00%). Subjects treated with low-power-density blue laser were significantly more likely to undergo repeat surgery than those treated with KTP (31.48% versus 14.00%). Significant predictors for the need for repeat blue laser included lesion recurrence, a lower surgical objective score at the third or fourth postoperative visit and a higher baseline lesion severity grade.

CONCLUSION

Blue laser is an effective tool for the surgical management of VF vascular lesions. Although overall surgical success ratings were inferior to KTP laser at the power densities used, the severity of postoperative edema and VF hemorrhage were significantly less with blue laser. Re-evaluation of blue laser using higher power densities is in progress.

Endoscopic coblation-assisted and partial arytenoidectomy for infants with idiopathic bilateral vocal cord paralysis

To review our experience with endoscopic coblation-assisted and partial arytenoidectomy (ECPA) in treating idiopathic bilateral vocal cord paralysis (BVCP).A retrospective analysis of thirty-three infants (19 boys and 14 girls, aged 1-10 months) with idiopathic BVCP undergoing ECPA was performed. The therapeutic process and outcomes (surgical success, swallowing function, and voice) were reviewed. The follow-up period was >33 months.Among the thirty-three infants with idiopathic BVCP, surgery was successful in twenty-nine cases but failed in four cases. Twenty-one, nine, and three patients underwent right, left, and bilateral ECPA, with surgical success rates of 90.5%, 100.0%, and 33.3%, respectively. In addition, four and six cases were combined with subglottic stenosis (SGS) and laryngomalacia, respectively. The surgical success rates of BVCP alone and BVCP+ other airway abnormalities were 95.6% and 70.0%, respectively. During the follow-up, five infants had slight difficulty swallowing, 12 infants had partial or complete recovery movement of at least one vocal cord with satisfactory voice outcome, and five infants had early granuloma formation, which disappeared spontaneously.ECPA appears to be a promising alternative to tracheostomy and initial management in infants with idiopathic BVCP who are free of other airway abnormalities.

Long-term outcomes of aminolevulinic acid photodynamic therapy for treatment of recalcitrant laryngeal premalignant lesions

OBJECTIVE

To assess long-term outcomes of ALA-PDT in treating recalcitrant laryngeal leukoplakia.

STUDY DESIGN

Retrospective Case-Control.

METHODS

We reviewed all laryngeal leukoplakia patients treated with ALA-PDT compared with angiolytic laser treatment alone (585 nm PDL or 532 nm KTP laser) from 2000 to 2019. Patients with laryngeal cancer (or a history of laryngeal cancer), leukoplakia previously treated with radiation and no pathologic report were excluded. Patient demographics, procedure details and outcomes were examined including histopathologic diagnosis, procedures performed, ALA usage, recurrence of leukoplakia and the development of cancer.

RESULTS

We identified 132 patients with laryngeal leukoplakia: 42 were treated with ALA-PDT and 90 were treated with an angiolytic laser alone (Laser group). The proportion of cases of high-grade dysplasia was 57.1% in the ALA-PDT group compared to 32.2% in the Laser group. In high-grade dysplasia cases, there was a statistically significant better recurrence-free survival (RFS) at 12 months and 60 months in those who underwent ALA-PDT 71.4% and 7.1% vs Laser 25% and 0% (p = .01). However, for overall groups, there was no difference in RFS (p = .25). Voice outcomes (patient subjective report) improved or were stable in 75% of subjects with no serious side effects reported.

CONCLUSION

ALA-PDT for recalcitrant and high-grade dysplasia is highly effective with improved recurrence-free survival compared to laser alone. ALA-PDT may be an appropriate therapy in patients who have failed prior angiolytic laser alone.

Blue Light Laser Results in Less Vocal Fold Scarring Compared to KTP Laser in Normal Rat Vocal Folds

OBJECTIVES

Preliminary investigations suggest that a novel blue light (BL) laser with a wavelength of 445 nm is comparable to the commonly utilized potassium titanyl phosphate (KTP) laser (532 nm) for treatment of various laryngeal pathologies. The objective of the current study is to make a direct histological comparison of the degree of vocal fold scarring after either BL or KTP laser treatment in an animal model.

STUDY DESIGN

This was a randomized controlled study using rats.

METHODS

Twenty-four Sprague-Dawley rats were randomized to BL or KTP laser treatment. Laser was delivered in non-overlapping pulses to normal rat vocal folds. Larynges in each group were harvested at three time points: post-operative day 1, 30, and 90. Three animals served as negative controls. The excised whole larynges were sectioned transversely and stained with hematoxylin/eosin and trichrome. Presence of subepithelial inflammation and protein deposition/fibrosis indicative of scarring were scored semi-quantitatively (from grade 1-3) by two pathologists blinded to treatment groups.

RESULTS

Between-group comparison showed that both laser treatments resulted in significantly elevated subepithelial protein deposition/fibrosis 90 days after treatment compared to negative controls (BL: 2 ± 0; KTP: 2.67 ± 0.29; control: 1.17 ± 0.29; P < .05). However, the degree of protein deposition/fibrosis was significantly higher in the KTP group compared to the BL group (P = .016). Within-group comparison showed that the KTP group showed evidence of fibrosis as early as 30 days after treatment, which was not observed in the BL group.

CONCLUSIONS

The current study suggests that the degree of scarring is significantly less after BL laser treatment compared to KTP in normal rat vocal fold tissue.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:853-858, 2021.

Spontaneous Vocal Fold Polyps Remission after Lockdown for Covid-19 Pandemic: Does Vocal Load Matter?

Objective

During the Italian lockdown for Covid-19 emergency, due to stay-at-home orders, many people experienced an unusual period of voice rest. The present case series aims at reporting the spontaneous regression of some vocal fold polyps during the Italian lockdown for SARS-CoV2 pandemic.

Methods

Five patients with voice complaints presenting to a tertiary referral center and diagnosed with vocal fold polyps before the lockdown were included. Because of the lockdown restrictive measures, planned elective surgical procedures were suspended. The patients were re-assessed immediately after lockdown. Multidimensional voice assessments were conducted before and after the lockdown period through laryngostroboscopies, perceptual voice evaluations, electroacoustic analysis and self assessments.

Results

The patients included in the present case series experienced a complete or nearly complete remission of symptoms. Videolaryngostroboscopies documented a complete or nearly complete regression of the polyps. Voices considerably improved both perceptually and electroacoustically. Self assessments showed a reduction of voice-related complaints.

Conclusions

The present study suggests that daily vocal load reduction may play a critical role in the conservative management of vocal fold polyps.

Effects of 445-nm Laser on Vessels of Chick Chorioallantoic Membrane with Implications to Microlaryngeal Laser Surgery

Objective

Previous research has shown that effective application of angiolytic lasers in microlaryngeal surgery is determined by wavelength, pulse width (PW), and fluence. Recently, a 445‐nm (blue) laser (BL) has been developed with a potentially greater hemoglobin absorption than previous lasers. The chick chorioallantoic membrane (CAM) represents a suitable model for testing various settings to find out the most optimal settings of this laser. This study used the CAM model to examine whether successful photoangiolytic effects could be obtained using BL.

Methods

Seven hundred and ninety three third‐order vascular segments of viable CAM were irradiated using BL via 400‐μm diameter fiber, 1 pulse/second, with PW and power varied systematically at standardized fiber‐to‐vessel distances of 1 and 3 mm. Outcome measures including vessel ablation rate (AR), rupture rate (RR), and visible tissue effects were analyzed using Chi‐square test.

Results

Energy levels of 400, 540, and 600 mJ (per pulse) were most effective for vessel ablation. A working distance of 3 mm resulted in higher ablation and less vessel rupture compared with 1 mm at these optimal energy levels. At 3 mm, a longer PW resulted in higher AR. At 1 mm, AR increased with shorter PW and higher power. The 1‐mm working distance resulted in lower tissue effects than 3 mm.

Conclusion

Findings in this study showed that BL was effective in vessel ablation using relevant combination of working distance, PW, and energy levels. To obtain high AR, longer working distance plus longer PW was required and if working distance was reduced, shorter PW should be set.

Level of Evidence

NA Laryngoscope, 131:E1950–E1956, 2021

[Photoangiolytic Lasers in Laryngology]

With photoangiolytic lasers like KTP (Potassium-Titanyl-Phosphate, 532 nm) lasers or the new "blue" laser (445 nm), even the smallest vessels and capillaries within the vocal fold can be treated without destroying the covering epithelium. This enables effective treatment of benign and malignant sub- and intraepithelial lesions of the vocal folds such as papilloma, edema, polyps, leukoplakia, dysplasia and capillary vessels while preserving the vibratory properties of the different layers of the lamina propria. Because photoangiolytic laser light can be routed through tiny glass fibers, office-based surgery with channelled flexible endoscopes are feasible as well as phonomicrosurgical operations under general anesthesia. Furthermore, the so called "blue" laser can cut tissues and thus broadens the technical armamentarium of the phonosurgeon.

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.

Outcomes Following Cordotomy by Coblation for Bilateral Vocal Fold Immobility

Importance

Bilateral vocal fold immobility (BVFI) can result in considerable voice and airway impairment. Although the carbon dioxide (CO2) laser is commonly used in transverse cordotomy, the coblator, a minimally invasive, low-thermal technology, has been increasingly used in otolaryngology.

Objective

To investigate outcomes associated with coblation to treat BVFI.

Design, Setting, and Participants

A retrospective case series was conducted between January 2012 and June 2017 including 19 patients with BVFI who underwent cordotomy by coblation in a single tertiary care institution.

Main Outcomes and Measures

Clinical, operative, and health status data for all patients were reviewed. Quality of life was measured by the EuroQol 5-Dimensions (EQ-5D), and the Voice Handicap Index (VHI) was used to measure vocal cord function.

Results

Nineteen patients were eligible for inclusion, 15 of which underwent cordotomy by coblation for BVFI without stenosis. Mean age was 57 years with 13 (68%) women. The etiology of BVFI included thyroidectomy in 8 (42%) patients and prolonged intubation in 7 (37%). Mean length of surgery for BVFI without stenosis was 17 minutes; mean operating room (OR) time was 63 minutes compared with 88 scheduled OR minutes (effect size, 25 minutes; 95% CI, 9 to 40 minutes). During follow-up, 4 (27%) of these patients developed granulation tissue postoperatively. Following surgery, patient-reported shortness of breath significantly improved, with 10 of 14 (71%; 95% CI, 45% to 88%) patients with some level of preoperative breathing difficulty experiencing improvement in their breathing. Stridor also significantly improved, with 10 of 12 (83%; 95% CI, 55% to 95%) patients with some level of preoperative stridor improved after surgery. The EQ-5D results trended toward improvement postoperatively (0.67 to 0.80; effect size, 0.13; 95% CI, -0.10 to 0.34). The functional (22 to 12; effect size, -10; 95% CI, -19 to -2), emotional (23 to 11; effect size, -12; 95% CI, -23 to -3), and total VHI all significantly improved (68 to 39; effect size, -29; 95% CI, -49 to -8).

Conclusions and Relevance

Initial outcomes of cordotomy by coblation revealed that this technique was a safe and efficient approach to treating BVFI. Coblation was associated with significant reduction in OR time compared with scheduled time, and patients experienced significant improvement in shortness of breath, stridor, and vocal cord function.

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.

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.

The Art and Craft of Phonomicrosurgery in Grammy Award–Winning Elite Performers

Background:

Since the renowned opera maestro Manuel Garcia presented “Observations on the Human Voice” using mirror laryngoscopy in 1855, there has been an inextricable link between performing vocalists and laryngologists. Today, specialized laryngeal surgeons continue the tradition of integrating medical and surgical management of performers with those skilled in vocal arts, voice science, and voice therapy. With advances in surgical instrumentation and techniques, increasing opportunities have evolved to surgically restore lost performing voices. However, it is especially challenging because of a range of factors, including the need for optimal technical precision, management of expectations, complexity of informed consent, public visibility of these patients, and the economics related to the success and failure of surgery. A number of these key issues apply to phonomicrosurgical procedures in nonsingers as well. Consequently, reviewing the art and craft of phonomicrosurgery in elite performers provides valuable insights into the optimal management of any patient.

Methods:

A retrospective review was done of microlaryngeal procedures for the past 20 years, and 18 elite performers were identified who were Grammy Award winners. Microsurgical methods for different lesions are illustrated. Composite analyses of the group along with their associated pathology was done to provide insights into key issues.

Results:

The 18 patients in this cohort have won 80 Grammy Awards, which were garnered from 242 nominations. All 18 had substantial deterioration in voice quality and could retain more than 1 pathology. Significant loss of superficial lamina propria (SLP) pliability was present in 15 of 18, varices and/or ectasias leading to vocal hemorrhage in 6, vocal polyps in 9, fibrovascular nodules in 6, arytenoid granuloma in 1, sulcus from prior microlaryngeal surgery leading to vocal fold SLP scarring in 4, sulcus from long-term phonotrauma leading to vocal fold SLP scarring in 4, benign cyst in 1, precancerous dysplasia in 2, and invasive carcinoma in 2. Subsequent to phonomicrosurgery, all reported improvement in their performance.

Conclusions:

Laryngologists and laryngeal surgeons have shouldered a burden of responsibility for elite performing vocalists since the origin of our specialty. Most lesions and diagnoses that are encountered result from phonotrauma. Optimizing singers’ care provides surgeons with extremely complex technical, emotional, social, and financial challenges. Focused analysis of managing elite performing vocalists effectively integrates a range of essential issues, which provide key insights to assist clinicians treating nonperforming patients requiring phonomicrosurgery.

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.

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.

Feasibility and Associated Limitations of Office-Based Laryngeal Surgery Using Carbon Dioxide Lasers

Importance

There are few reports evaluating awake, office-based carbon dioxide (CO2) laser surgery for laryngeal lesions. To date, this study was the largest reported case series of office-based laryngeal surgery by fiber delivery CO2 laser. Office-based laryngeal surgical procedures have become increasingly popular. Technical problems and treatment outcomes associated with the use of a CO2 laser for office-based laryngeal surgery have yet to be fully addressed.

Objectives

To discuss a single institution's clinical experience with office-based CO2 laser laryngeal surgery and the feasibility and limitations associated with this procedure.

Design, Setting, and Participants

This retrospective study evaluated 49 laryngeal surgical procedures performed using a CO2 laser in 40 consecutive adult patients at a single institution in Taiwan from July 1, 2014, through September 30, 2015. Laryngeal lesions treated included vocal fold leukoplakia (n = 13), benign vocal fold lesions (n = 10), Reinke edema (n = 4), recurrent respiratory papillomatosis (n = 6), and lesions outside the vocal folds (n = 7).

Interventions

Office-based laryngeal surgery performed using a CO2 laser under topical anesthesia.

Main Outcomes and Measures

Videolaryngoscopy was performed on all patients at each follow-up point. Among patients with benign vocal lesions and Reinke edema, videolaryngostroboscopy, voice laboratory measurements, perceptual measurements of vocal quality, and subjective evaluations were conducted before and after surgery.

Results

Among the 40 patients included in this study (28 men [70%] and 12 women [30%]; median [range] age, 56 [29-83] years), median follow-up time was 6.5 months (range, 1-21 months). Among the 49 procedures, 2 (4%) could not be tolerated by patients owing to severe gag reflex and laryngeal hypersensitivity, 6 (12%) could not completely evaporate lesions owing to an inadequate surgical field or laryngeal instability, and 1 (2%) led to a complication (ie, mild vocal fold wound stiffness). In addition, 2 patients with premalignant vocal fold leukoplakia showed lesion recurrence in the subglottic area. Among patients with benign vocal lesions and Reinke edema, postoperative phonatory function showed large improvements in jitter (effect size, 0.61; median difference, -0.98%; 95% CI, -1.57% to -0.11%), noise to harmonic ratio (effect size, 0.63; median difference, -0.02; 95% CI, -0.07 to -0.01), maximal phonation time (effect size, 0.61; median difference, 3.6 seconds; 95% CI, 1.9 to 8.8 seconds), and Voice Handicap Index-10 score (effect size, 0.60; median difference, -7; 95% CI, -12 to -2).

Conclusions and Relevance

Office-based laryngeal surgery performed using a CO2 laser was shown to be a feasible treatment option for various types of vocal lesions. However, patients should not undergo this procedure if they have multiple bulky lesions or lesions involving the subglottic area, the laryngeal ventricle, or (in cases of inadequate laryngeal stability) the free edge of a vocal fold.

Voice Outcomes following a Single Office-Based Steroid Injection for Vocal Fold Scar

OBJECTIVE

Persistent dysphonia from vocal fold scar remains a clinical challenge, with current therapies providing inconsistent outcomes. We evaluated voice outcomes after a single office-based steroid injection.

STUDY DESIGN

Case series with chart review.

SETTING

Academic medical center.

SUBJECTS AND METHODS

This study was based on pre- and postoperative analysis of patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. The sample comprised 25 patients undergoing office-based dexamethasone injection into the superficial lamina propria for mild/moderate vocal fold scar. Average follow-up was 13.7 ± 4.4 weeks; patients completed 3.5 ± 2.3 sessions of voice therapy between assessments. Complete data sets were not available for each parameter; sample size is noted with results.

RESULTS

Voice handicap index (n = 24; P < .001) and glottal function index (n = 22; P < .001) decreased after injection. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 25; P < .001). Fundamental frequency range increased (n = 24; P = .024). Phonation threshold pressure decreased (n = 14; P = .017). Videostroboscopic parameters of vocal fold edge (P = .004), glottic closure (P = .003), and right mucosal wave (P = .016) improved after injection.

CONCLUSIONS

Office-based steroid injection combined with voice therapy for mild/moderate vocal fold scar is associated with improved patient-reported and functional voice measures. These findings provide preliminary support for this approach. Importantly, the procedure is low risk and can be performed in the office, thus offering a simple treatment alternative to patients with a disorder that has traditionally been difficult to manage. Prospective studies evaluating the effects of multiple injections are warranted.

Laryngeal cryptococcosis: Literature review and guidelines for laser ablation of fungal lesions

OBJECTIVES/HYPOTHESIS

To describe the demographics, clinical manifestations, diagnosis, treatment, and outcomes of laryngeal cryptococcosis. Antifungal therapy guidelines are provided and the use of laser ablation is discussed.

DATA SOURCES

PubMed, OVID MEDLINE, and Embase databases and one patient who presented to our institution's otolaryngology department.

REVIEW METHODS

A review of the English-language international medical literature was conducted using the terms ("larynx" or "laryngeal diseases") and ("Cryptococcus" or "cryptococcosis") to identify reported cases of laryngeal cryptococcosis. Databases were searched from inception through January 2015.

RESULTS

Eighteen cases were identified and reviewed, including the first reported case of potassium-titanyl-phosphate laser ablation. All patients presented with hoarseness, and two (11%) presented with acute airway obstruction that required tracheotomy. Six patients (33%) were immunocompromised, including three (17%) who had an underlying human immunodeficiency virus infection. Seven cases (39%) described an exophytic mass. Histopathology indicated pseudoepitheliomatous hyperplasia in seven of the 17 reported results (41%). Methenamine silver stain was used in 12 of the 15 described cases (80%) to identify the fungus. Lumbar puncture results were reported for seven patients, none of whom had meningitis. Antifungal therapy was used in 15 cases (83%), and two (11%) received additional laser ablation treatment. Eleven patients (61%) had complete resolution.

CONCLUSIONS

Laryngeal cryptococcosis is a rare cause of persistent hoarseness. Most patients have complete resolution after treatment. For complex and obstructive cases, laser ablation coupled with antifungal therapy can successfully manage laryngeal cryptococcosis in select patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:1625-1629, 2016.

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.

Oncologic Efficacy of Angiolytic KTP Laser Treatment of Early Glottic Cancer

Objective:

Angiolytic laser removal of early glottic cancer with ultra-narrow margins was reported in a pilot study 5 years ago as an innovative surgical treatment strategy to better preserve vocal function. Subsequently, in a cohort of > 90 patients, enhanced voice outcomes were achieved and there was diminished need for post-treatment phonosurgical reconstruction. However, the initial pilot study examining oncologic efficacy had a limited number of patients and most did not have 3-year follow-up. Consequently, further analysis of the oncologic efficacy is valuable.

Method:

Retrospective review.

Results:

One hundred seventeen patients (T1a-71, T1b-11, T2a-10, T2b-25) underwent potassium-titanyl-phosphate (KTP) laser treatment of early glottic cancer with a minimum 3-year follow-up (average = 53 months). The “b” designation delineated bilateral disease. Disease control for T1 and T2 lesions was 96% (79/82) and 80% (28/35), respectively. All 10 recurrences were treated with radiotherapy. Fifty percent (5/10) were controlled with radiotherapy, and the other 5 died of disease. Larynx preservation and survival were achieved in 99% (81/82) with T1 disease and 89% (31/35) with T2 disease.

Conclusion:

This investigation provides further evidence that angiolytic KTP laser removal of early glottic cancer with ultra-narrow margins is an effective oncologic treatment strategy. Radiotherapy was preserved for future use in more than 90% of patients. Since a majority of patients are referred by an otolaryngologist to undergo treatment of early glottic cancer with radiotherapy, this investigation provides compelling information to reappraise this paradigm.

Vocal fold scars: current concepts and future directions. Consensus report of the Phonosurgery Committee of the European Laryngological Society

Scarring of the vocal folds leads to a deterioration of the highly complex micro-structure with consecutively impaired vibratory pattern and glottic insufficiency. The resulting dysphonia is predominantly characterized by a reduced vocal capacity. Despite the considerable progress in understanding of the underlying pathophysiology, the treatment of scarred vocal folds is still an unresolved chapter in laryngology and phonosurgery. Essential for a successful treatment is an individual, multi-dimensional concept that comprises the whole armamentarium of surgical and non-surgical (i.p. voice therapy) modalities. An ideal approach would be to soften the scar, because the reduced pliability and consequently the increased vibratory rigidity impede the easiness of vibration. The chosen phonosurgical method is determined by the main clinical feature: Medialization techniques for the treatment of glottic gap, or epithelium freeing techniques for improvement of vibration characteristics often combined with injection augmentation or implantation. In severe cases, buccal mucosa grafting can be an option. New developments, include treatment with anxiolytic lasers, laser technology with ultrafine excision/ablation properties avoiding coagulation (Picosecond infrared laser, PIRL), or techniques of tissue engineering. However, despite the promising results by in vitro experiments, animal studies and first clinical trials, the step into clinical routine application has yet to be taken.

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.

[Vocal fold scars: pathogenesis, diagnosis, therapy]

Scarring of the vocal folds leads to a deterioration of the highly complex microstructure with consecutively impaired vibratory pattern and glottic insufficiency. The resulting dysphonia is predominantly characterized by a reduced vocal capacity. Despite considerable progress in the understanding of the underlying pathophysiology, treatment of scarred vocal folds is still an unresolved chapter in laryngology and phonosurgery. Decisive for successful treatment is an individual, multidimensional concept that comprises the whole armamentarium of surgical and nonsurgical (e.g. voice therapy) modalities. The chosen phonosurgical method is determined by the main clinical feature: medialization techniques for treatment of glottic insufficiency, or epithelium-freeing techniques for improvement of vibration characteristics often combined with injection augmentation or implantation. In severe cases, buccal mucosa grafting can be an option. New developments include treatment with angiolytic lasers [pulse dye laser, PDL; potassium titanyl phosphate (KTP) laser], or techniques of tissue engineering. However, despite promising results with in vitro experiments, animal studies and first clinical trials, application in clinical routine has not yet been achieved.

Morbidity and Patient Perception of Flexible Laryngoscopy

Objectives:

The recently published Clinical Practice Guideline: Hoarseness (Dysphonia) revealed major deficits in the literature regarding relatively routine clinical decision-making. One of the more controversial points in the Guideline regarded the utility and timing of laryngeal visualization via flexible laryngoscopy, potentially because of sparse literature regarding the risks and potential morbidity. We sought to prospectively address this issue in order to optimize evaluation protocols.

Methods:

Two-hundred fifty consecutive patients with a variety of complaints completed a survey after undergoing flexible laryngoscopy. The survey queried 1) demographics; 2) discomfort of pretreatment anesthesia and scope placement in the nose and pharynx; 3) fear of future examinations; and 4) patient perception and past experience. Concurrently, the laryngoscopist reported the complications and anatomic variations encountered.

Results:

The discomfort and pain ratings from both the anesthetic spray and the scope placement were low. No statistically significant differences were observed with regard to sex; however, women reported greater fear associated with examinations (p = 0.0001). Anatomic abnormalities were observed in 14.4% of patients, and these patients reported greater discomfort, pain, and fear regarding the examination. No adverse events were observed.

Conclusions:

Flexible laryngoscopy was well tolerated, with little to no risk. The presence of nasal anatomic abnormalities predicted increased discomfort.

Local injection of bevacizumab (Avastin) and angiolytic KTP laser treatment of recurrent respiratory papillomatosis of the vocal folds: a prospective study

OBJECTIVES

Photoangiolytic laser treatment of recurrent respiratory papillomatosis (RRP) is effective, but does not reliably prevent recurrence. Therefore, sublesional injections of the antiangiogenic agent bevacizumab (Avastin) were given to assess the adjunctive effect on disease recurrence. Since bevacizumab is a new therapeutic modality for RRP, there were also primary safety objectives to determine whether there was a pegative impact on the voice and whether there were local or systemic complications.

METHODS

A prospective open-label investigation was conducted in 20 adult patients with bilateral vocal fold RRP. The patients underwent planned 532-nm pulsed KTP laser photoangiolysis of bilateral glottal disease 4 times with an approximately 6-week interval between procedures. At each planned laser procedure, the vocal fold that on initial presentation had a greater volume of disease also underwent 4 serial sublesional bevacizumab injections (7.5 to 12.5 mg in 0.3 to 0.5 mL). A sham injection with saline solution was administered to the other vocal fold as a control. Disease resolution was compared between subjects' vocal folds, and objective measures of vocal function (acoustic, aerodynamic), as well as patients' self-assessments of vocal function (Voice-Related Quality of Life survey), were obtained.

RESULTS

All 20 patients completed the study, and there were no local or systemic complications. After 4 injections, 3 of the 20 patients had no discernible disease in either vocal fold. Of the remaining 17 subjects, 16 had less disease in the bevacizumab-treated vocal fold despite starting with more disease. Only 1 of the 17 had more disease in the bevacizumab-treated vocal fold after 4 injections. Moreover, 7 of the 20 patients (35%) did not require a laser procedure in the vocal fold that had received 4 bevacizumab injections, as compared with 3 of the 20 vocal folds (15%) that were treated with laser alone. All of the vocal function measures displayed statistically significant posttreatment improvements, except for average fundamental frequency in the 3 female patients, in whom it fell below the normal range.

CONCLUSIONS

This prospective investigation provided evidence that bevacizumab injections enhanced KTP laser treatment of glottal papillomatosis without systemic or local complications. Coupling the antiangiogenesis agent bevacizumab with KTP laser photoangiolysis is conceptually synergistic and scientifically promising since the mechanisms of action are complementary.

Pulse dye and other laser treatments for vocal scar

PURPOSE OF REVIEW

Vocal fold scar is a challenging clinical problem, resulting in a spectrum of voice-related complaints. While there are a variety of treatment options available, it is rare to obtain outcomes similar to the perfectly normal voice. The pulsed dye and other lasers are an emerging treatment option for cutaneous scar and have shown promise for the treatment of vocal fold scarring. The purpose of this review is to summarize the theory, and describe clinical outcomes from both cutaneous and vocal fold scarring treated with lasers.

RECENT FINDINGS

There are a growing number of papers in the literature substantiating the use of pulsed dye and other lasers used to treat cutaneous scars. Some experimental models describe potential mechanisms of laser effect, which include the development of a sub-basement membrane cleavage plane, as well as up-regulation of proteins which may actively modulate continued fibrosis. One prospective pilot study of 11 patients with vocal fold scarring treated with the pulsed dye laser has also shown statistically significant improvement in subjective and objective voice measures, as well as laryngeal stroboscopy findings after treatment.

SUMMARY

The pulsed dye and other lasers have shown effectiveness and potential in treating cutaneous and vocal scarring.

Severe laryngeal dysplasia in a 20-year-old nonsmoker treated with CO2 laser excision: a case report and review of the literature

OBJECTIVE

We present the unusual case of a 20-year-old female nonsmoker with severe laryngeal dysplasia managed with endoscopic CO(2) laser resection with frozen-section analysis. We use her case as a platform for discussion of the current evidence surrounding laryngeal dysplasia, particularly etiology and the use of lasers in management.

BACKGROUND DATA

Laryngeal dysplasia represents a series of progressive epithelial changes that can eventually lead to invasive laryngeal carcinoma. Typically, most patients are male, in their 50s or 60s, and are smokers; to our knowledge our patient represents the youngest reported case of this condition in a woman with no established risk factors. We discuss the implications of this on her subsequent management with the CO(2) laser.

METHODS

With the help of intraoperative photographs, we describe our excisional technique with the CO(2) laser, model 315M Superpulse class 4 (Irradia AB, Stockholm, Sweden) at a 6-W continuous power setting.

RESULTS

At 6 months after surgery, our patient remains disease free with good voice quality.

CONCLUSIONS

Our patient appears to defy all the usual etiologic stereotypes that usually govern the development of laryngeal dysplasia. CO(2) laser excision plus intraoperative frozen-section analysis remains a safe and reliable method for the treatment of laryngeal dysplasia; the reassurance of histologically clear margins minimizes the extent of radical laser excision necessary and provides good functional results. We provide a comprehensive overview of the current literature on laryngeal dysplasia etiology and treatment, particularly the use of lasers in management.

Office based--is my anesthetic care any different? Assessment and management

Office-based anesthesia (OBA) is a unique and challenging venue, and, although the clinical outcomes have not been evaluated extensively, existing data indicate a need for increased regulation and additional education. Outcomes in OBA can be improved by education not only of anesthesiologists but also of surgeons, proceduralists, and nursing staff. Legislators must be educated so that appropriate regulations are instituted governing the practice of office-based surgery and the lay public must be educated to make wise, informed decisions about choice of surgery location. The leadership of societies, along with support from the membership, must play a key role in this educational process; only then can OBA become as safe as the anesthesia care in traditional venues.

Effects of Gold laser on the avian chorioallantoic membrane

OBJECTIVES

Office-based lasers have revolutionized the treatment of laryngeal disease. The 980-nm Gold laser is a device that may offer some practical advantages over other office lasers. The chick chorioallantoic membrane has been proposed as a model for predicting the effects of photoangiolytic lasers on vocal fold microvasculature. We sought to evaluate the effects of the Gold laser in this model.

METHODS

Vascular reactions in first-order vessels were determined for the Gold laser with both 0 degree straight and 30 degrees angled laser fibers. Vessels were treated at 15 W and a 500-ms pulse interval, with a 1-mm working distance. Pulse widths of 300 ms and 500 ms were evaluated. All vessels were treated until selective coagulation or vessel rupture.

RESULTS

We performed 60 trials on 30 embryos. The mean energy delivered was 33.7 J for the straight fiber and 51.2 J for the angled fiber. The laser achieved selective vessel coagulation without rupture in 100% (30 of 30) of straight fiber trials and in 100% (30 of 30) of angled fiber trials. In 6.7% (2 of 30) of straight fiber and 10% (3 of 30) of angled fiber trials, it caused minor injury to the surrounding albumin as indicated by white coagulum outside the vessel.

CONCLUSIONS

The Gold laser effectively coagulates small vessels without rupture at a working distance of 1 mm and settings of 15 W, 500-ms pulse interval, and 300- to 500-ms pulse width.

Microlaryngoscopic and office-based injection of bevacizumab (Avastin) to enhance 532-nm pulsed KTP laser treatment of glottal papillomatosis

OBJECTIVES

Photoangiolytic lasers effectively treat glottal papillomatosis, but do not reliably prevent recurrence. Therefore, sublesional injections of the antiangiogenic agent bevacizumab (Avastin) were given to assess the effect on disease recurrence and phonatory function.

METHODS

A retrospective investigation was done in a pilot group of 10 adult patients with bilateral glottal papillomatosis who had prior angiolytic laser treatment with established patterns of recurrence. The patients underwent 5 bevacizumab injections (5 to 10 mg) into the diseased vocal folds along with 532-nm pulsed KTP laser photoangiolysis treatments 4 to 6 weeks apart. Their disease resolution was compared to findings from prior laser treatment alone, and objective measures of vocal function (acoustic, aerodynamic, Voice-Related Quality of Life survey) were obtained.

RESULTS

All 10 patients had a greater than 90% reduction in recurrence. Four of the 10 had resolution. Four of the 10 have limited recurrent or persistent disease, receive injections of bevacizumab at 8- to 12-week intervals, and have not required laser treatment. Two of the 10 have ongoing periodic office-based KTP laser treatment along with bevacizumab injections. No patient has required microlaryngeal surgery with general anesthesia, and all 10 have had substantial improvement in vocal function.

CONCLUSIONS

This pilot investigation provides preliminary evidence that bevacizumab injections enhance photoangiolytic laser treatment of glottal papillomatosis while enhancing phonatory function. Coupling an antiangiogenesis agent with pulsed KTP laser photoangiolysis is conceptually promising, since the mechanisms of action are complementary.

Value and utility of 532 nanometre pulsed potassium-titanyl-phosphate laser in endoscopic laryngeal surgery

Objectives:

Recently, the 532 nm pulsed potassium-titanyl-phosphate laser has emerged as an effective angiolytic laser for treating mucosal lesions of the larynx in the operating theatre and clinic. We sought to assess the current impact of potassium-titanyl-phosphate laser on our laryngeal surgery practice.

Study design:

Retrospective review of 710 patients undergoing endoscopic laryngeal surgery over a one-year period.

Methods:

Medical records of the endoscopic laryngeal procedures were reviewed; 386/710 had been performed in the clinic and 324/710 in the operating theatre under general anaesthesia. Indications for the procedures were classified by pathology.

Results:

Pulsed potassium-titanyl-phosphate laser was used in 209/386 clinic procedures. The indications for these procedures were: dysplasia (114/209 procedures), papillomatosis (89/209), varices or ectasia (three of 209), and ‘other’ (three of 209). Pulsed potassium-titanyl-phosphate laser was used in 178/324 operating theatre endoscopic laryngeal procedures. The indications for these procedures were: cancer (54/178 procedures), dysplasia (52/178), papillomatosis (38/178), varices or ectasia (13/178), polyps (six of 178), nodules (six of 178), stenosis (five of 178), granulation (three of 178), and amyloid (one of 178).

Conclusions:

Due to its versatility, the 532 nm pulsed potassium-titanyl-phosphate laser is our most commonly utilised instrument for performing endoscopic laryngeal surgery.