Pulsed Angiolytic Laser Treatment of Ectasias and Varices in Singers

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.

Photoangiolysis with the 445-nm Blue Laser and the Potassium-Titanyl-Phosphate Laser: A Comparison

OBJECTIVES

Photoangiolytic lasers have yielded significant innovation in laryngeal surgery in the last 25 years. After the discontinuation of the potassium titanyl phosphate (KTP) laser, a novel 445-nm blue laser was developed. The optimal balance between a laser's desired tissue effects and collateral tissue damage is a major determinant of laser selection in microlaryngeal surgery. The shell-less incubation system for the chick chorioallantoic membrane (CAM) simulates the microvasculature of the human vocal fold and is useful for testing effects of laser settings and in simulated surgery. The aim of this study is to compare the tissue effects of the KTP and blue lasers using the shell-less CAM model.

METHODS

The shell-less incubation system contains: polymethylpentene film (used as a culture vessel), calcium lactate and distilled water supplementations. By using this system, the chick chorioallantoic membrane (CAM) can be fully exposed with a good field for surgery simulation. The effects of the 2 lasers (532 nm KTP and 445 nm blue) were quantified at clinically relevant energy settings and laser distances from target. Measures included imaging real-time vascular reactions in the CAM model, post-procedure histologic analysis of CAM tissue and temperature changes.

RESULTS

Vessel coagulation and rupture rates were less common with the blue laser compared with the KTP laser. Histologic analysis demonstrated less tissue disruption with the blue laser. Temperature changes were less with the blue laser.

CONCLUSION

In this CAM model with specific conditions, the blue laser reveals less tissue damage than the KTP laser. Suitable working distance and power setting of the laser are necessary for desired tissue effects.Level of Evidence: Level 3.

Thermal Effects of CO2, KTP, and Blue Lasers with a Flexible Fiber Delivery System on Vocal Folds

OBJECTIVE

To determine the differences in thermal effects on vocal folds between four fiber-routed lasers.

METHODS

In this experimental laboratory study the thermal effects of an AcuPulse Duo CO2 (CO2 AP), UltraPulse Duo CO2 (CO2 UP), KTP, and Blue laser were analyzed using a Schlieren technique on a human tissue mimicking gel model. Power, laser duration, laser fiber distance to tissue and mode (continuous wave [CW] vs pulsed [P] modes) were evaluated in varying combinations in order to compare the effects of the tested lasers and to explore the individual effect on thermal expansion and incision depth of each setting. The model was validated by comparing the results from the Schlieren model with histology of ex vivo fresh human vocal folds after laser irradiation using a selection of the same laser settings, and calculating the intraclass correlation coefficient (ICC).

RESULTS

One thousand ninety-eight Schlieren experiments and 56 vocal cord experiments were conducted. In comparison with CW mode, less thermal expansion occurred in P mode in all lasers, while incisions were deeper in the CO2 and more superficial in the KTP and Blue lasers. The mean thermal expansion was found to be minimally smaller, whereas incision depth was pronouncedly smaller in the KTP and Blue compared to the CO2 lasers. Duration of laser irradiation was the most important factor of influence on thermal expansion and incision depth for all lasers in both CW and P modes. The ICC for consistency between the results of the Schlieren model and the vocal cord histology was classified from fair to excellent, except for the thermal expansion of the Blue laser, which was classified as poor.

CONCLUSION

This study demonstrates important differences in thermal effects between CO2, KTP, and Blue lasers which can be explained by the different physical characteristics of the P modes and divergence of the fiber delivery system. The Schlieren imaging model is a good predictor of the relative thermal effects in vocal fold tissue. Our results can be used as a guidance for ENT surgeons using fiber-routed lasers, in order to achieve effective treatment of vocal fold lesions and prevention of functional impairment of vocal folds.

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.

Comparative Efficacy of the KTP Laser and Cold Steel in Office-Based Surgery for Oropharyngeal Papilloma

Objective: This study aims to compare the efficacy of the potassium-titanyl-phosphate (KTP) laser and cold steel surgery in treating oropharyngeal papilloma. Methods: Between 2017 and 2020, we enrolled 242 patients with oropharyngeal papilloma who were treated with either the KTP laser (n = 160) or cold steel surgery (n = 82). Patient charts were reviewed for demographic data (age and gender), pathology, anatomical location of lesions, operative duration, pain rating, residual disease, and recurrence. Results: The oropharyngeal papillomas were successfully removed in all patients, except one with a significant pharyngeal reflex. There was no significant difference in the average time for lesion resection between KTP laser and cold steel group (18.11 ± 13.96 s vs 19.43 ± 16.91 s, P > .05). However, all patients who underwent cold steel surgery experienced bleeding during the operation and required postoperative observation (about 20 min), making the total procedure time longer than that of the KTP laser procedure, which did not cause any intraoperative bleeding or require postoperative observation. After KTP laser treatment, the pain rating was .49 ± .98, whereas after cold steel surgery, it was .74 ± 1.12 (P = .058). Twenty-five samples were sent for human papillomavirus (HPV) testing, and one tested positive for both HPV 6 and 11 strains, while another tested positive for HPV 16. No residual disease or recurrence was observed at the treatment sites after a long period of follow-up (M = 15.35 ± 10.79 mo; range = 6-39 mo). Conclusion: The KTP laser provided a better hemostasis effect and a good surgical field of vision during the operation, allowing the surgeon to complete the procedure in less time. No significant difference in terms of pain rating, incision recovery, and postoperative recurrence between the KTP laser treatment and cold steel surgery.

Return to Vocal Performance Following Microlaryngoscopy in Singers

INTRODUCTION

Although microlaryngoscopy has been recognized to be effective in addressing lesions in vocal performers, no detailed information regarding return to performance (RTP) following surgery exists. We describe our experience and offer proposals to establish standardized criteria for RTP among vocal performers.

METHODS

Records for adult vocalists who underwent microlaryngoscopy for benign vocal fold (VF) lesions and had a clearly documented RTP date between 2006 and 2022 were reviewed. Patient demographics, diagnoses, interventions, and postsurgical care before and after RTP were described. The need for medical and procedural interventions and rate of reinjury were used to determine the success of RTP.

RESULTS

Sixty-nine vocal performers (average age: 32.8 years, 41 [59.4%] female, 61 [88.4%] musical theater) underwent surgery for 37 (53.6%) pseudocysts, 25 (36.2%) polyps, 5 (7.2%) cysts, 1 (1.4%) varix, and 1 (1.4%) mucosal bridge. Fifty-seven (82.6%) underwent voice therapy. The average time to RTP was 65.0 ± 29.8 days. Prior to RTP, six (8.7%) experienced VF edema requiring oral steroids and one (1.4%) underwent a VF steroid injection. Within 6 months following RTP, eight (11.6%) received oral steroids for edema and three underwent procedural interventions (two steroid injections for edema/stiffness, one injection augmentation for paresis). One patient experienced pseudocyst recurrence.

CONCLUSIONS

Return to vocal performance at an average of 2 months following microlaryngoscopy for benign lesions appears overwhelmingly successful, with low rates of need for additional intervention. There is a need for validated instruments to better measure performance fitness to refine and possibly accelerate RTP.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:329-334, 2024.

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.

Indications, Efficacy, Safety, and Clinical Outcomes of 585 nm Pulsed Dye Laser in Non-Malignant Laryngeal Lesions: A Systematic Review

The objective of this manuscript was to review the indications, efficacy, and safety of a 585 nm pulsed dye laser (PDL) in non-malignant laryngeal lesions. Following the PRISMA statement recommendations, three independent authors searched for articles published in PubMed/MEDLINE, the Cochrane Library, Google Scholar, Scielo, and Web of Science. A bias analysis was performed following NICE guidance tools. From the 506 identified publications, 19 observational studies met the inclusion criteria. The PDL improves vocal quality objectively and subjectively in vascular lesions (p < 0.005) and improves vocal quality in patients with dysplasia/leukoplasia without changing the natural history of the disease compared to other treatments. Reinke's edema and granulomas require an average of 1.5 PDL sessions for resolution. Treatment of recurrent respiratory papillomatosis requires multiple sessions, with complete remission achieved in 50-70% of patients. Regardless of the lesion, the tolerance of the procedure under local anesthesia is exceptional (84-97%), and the results in terms of regression and vocal quality are promising. The complication rate is minimal, and the procedure does not interfere with other treatment alternatives. There is no consensus on laser settings. The lack of consistent use in evaluating vocal outcomes, whether objective or subjective, prevents the comparability between studies. The 585 nm pulsed dye laser appears to be an effective and safe therapeutic option in patients with non-malignant laryngeal pathology. Future controlled studies are needed to compare the 585 nm pulsed dye laser with other lasers or cold instrument procedures.

Surgical Outcome of Potassium-Titanyl-Phosphate (KTP) Laser Photocoagulation for Vocal Fold Vascular Lesions

INTRODUCTION

Laser technology is used in microscopic direct laryngeal surgery for a variety of indications. Lasers are categorized broadly as photoangiolytic or cutting/ablating lasers, based on the chromophores that absorb their energy. Photoangiolytic lasers such as the 532 nm Potassium-Titanyl-Phosphate (KTP) laser are absorbed selectively by the chromophore hemoglobin, facilitating controlled intravascular coagulation, with preservation of the overlying epithelium and adjacent tissue. Efficacy of the KTP laser has been demonstrated for incision, coagulation, and ablation in vocal fold (VF) surgery.

OBJECTIVE

The purpose of the present study was to examine surgical outcomes following KTP laser photocoagulation for the management of VF vascular lesions.

METHODS

Adult patients with sufficient data who had undergone KTP laser photocoagulation in the operating room for the treatment of VF vascular lesions were included in this retrospective study. Strobovideolaryngoscopy (SVL) video footage from all preoperative visits and all available postoperative visits was compiled and de-identified. Patients were followed up at days 1-7, 8-14, 30-60, and greater than 60 days after surgery. Three blinded physician evaluators reviewed and evaluated the SVL footage independently for postoperative outcome parameters. Postoperative SVL video footage was evaluated on a 5-point scale for surgical success (surgical objective score; 1 = failure and 5 = complete success). The average surgical objective score was 4.36, 4.04, 4.25, and 4.46 (out of 5) at postoperative visits 1-4, respectively.

RESULTS

There were 60 cases (19 male and 41 female) included in the retrospective cohort. The average age was 42.42 ± 15.51 (range = 18-74). Fifty-one-point six seven percent of subjects were professional voice users (singers, teachers, public speakers, and others). All subjects were diagnosed preoperatively with VF vascular malformations and had undergone pulsed KTP laser photocoagulation. There were 40 bilateral cases and 20 unilateral cases, for a total of 100 VFs included in the study. Vascular malformation recurrence was identified in 3.00% and 10.00% of subjects at the third and fourth postoperative visits, retrospectively. The formation of new vascular malformations was identified in 0.00%, 1.00%, 6.00%, and 7.00% of subjects at postoperative visits 1-4, respectively.

CONCLUSION

KTP laser photocoagulation is highly effective for the management of vocal fold vascular lesions. Presence of hemorrhage or edema does not affect the long-term surgical outcome. In relatively few cases, vascular lesion recurrence or formation of new vascular lesions may occur.

Office-based 532-nm KTP laser as a therapeutic modality for recurrent laryngeal papillomatosis: efficacy and relative factors

This study aims to investigate the efficacy of office-based potassium-titanyl-phosphate (KTP) 532-nm laser in the management of recurrent laryngeal papillomatosis (RLP) following other treatments. A retrospective assessment was performed on 55 patients in 259 cases of RLP between 2012 and 2019. Derkay scores were obtained for all patients who underwent 532-nm KTP laser procedure (6 W of power with a continuous output mode) prior to treatment and after treatment. Analysis of parameters is based on the distribution characteristics of data. An ordinal logistic regression was also performed. Patients received a median of 3 (range 1-24) office-based KTP laser treatments. Among them, 96.36% (53 patients) were previously on cold steel equipment, CO₂ laser, or microdebrider treatment under general anesthesia, and all previous treatments on them had failed. One patient progressed to invasive cancer, so he was excluded from the following analyses. After final KTP treatment, 36 patients (66.67%) received complete resolution with follow-up time ranging from 12.9 to 80.53 months (median 55.54 months). Results of subjective voice-quality indicators such as VHI-30 and GRBAS all improved greatly at the last follow-up. The initial Derkay scores and treatment intervals were found to be predictive of complete lesion remission. Arytenoid involvement may also correlate with lesion resolution. Serial office-based KTP treatment is an effective option for RLP patients, with ideal disease control and voice quality preservation. KTP laser therapy should be repeated with an interval of 1 month from the beginning of treatment until the lesion has been evaluated and subsided. Non-bulk or scattered laryngeal papilloma is an appropriate indication for KTP laser treatment.

Transoral flexible laser surgery of the upper aerodigestive tract with blue laser

PURPOSE

The introduction of fiber-guided lasers was a breakthrough in laryngology practice, opening the path for treating different pathologies with minimally invasive procedures, both in the operating room and in the office. The most recent technology in the area is the blue laser, which combines photoangiolytic and cutting properties, characteristics that make this equipment suitable for its use in upper aerodigestive tract surgery. However, there is not enough experience in this area. The authors present a case series of patients with different pharyngeal, laryngeal, and tracheal pathologies who were treated by means of transoral procedures using fiber-guided blue laser.

METHODS

The surgical records of patients with different upper aerodigestive tract pathologies who were treated with fiber-guided blue laser in the operating room, under general anesthesia with jet ventilation or supraglottic ventilation using suspension laryngotracheoscopy techniques between February 2018 and March 2022 were reviewed.

RESULTS

A total of 80 surgical interventions in a group of 38 patients were performed. A wide variety of procedures was executed, either using the laser alone or in combination with other techniques to treat different pathologies of the aero-digestive tract safely and effectively, with adequate functional results.

CONCLUSIONS

Following all necessary precautions, blue laser is a reliable tool to perform minimally invasive surgeries in the operating room using TOFLS techniques. It can be used alone or in combination with other devices to achieve the desired goals.

Surgery and Adjuvant Therapy Improve Derkay Scores in Adult and Pediatric Respiratory Papillomatosis

OBJECTIVES/HYPOTHESIS

Comparing Derkay anatomical score at time of procedure, disease characteristics, and mean treatment interval among adult and pediatric patients with recurrent respiratory papillomatosis (RRP).

STUDY DESIGN

Restrospective study.

METHODS

Retrospective review of juvenile-onset (JO) and adult-onset (AO) RRP patients treated longitudinally at pediatric and adult institutions from 1999 to 2019. Patients were included if they had a tissue diagnosis of papilloma and had at least a 12-month follow-up.

RESULTS

One hundred and twelve patients met inclusion criteria (68 JO-RRP and 44 AO-RRP). All patients were stratified into either potassium titanyl phosphate (KTP) (n = 42), CO₂ (n = 21), or microdebrider (n = 49) treatment groups. The Derkay score improved between first and last procedure in the KTP group (mean difference, 3.5; P < .001), CO₂ group (mean difference, 4.4; P < .001), and microdebrider group (mean difference, 4.1; P < .001), but overall improvement did not differ across groups (P = .73). Baseline mean to last mean Derkay score improved for nine patients during bevacizumab treatments (mean difference, 3.0; P = .01) but did not improve for these same patients during an interval prior to receiving bevacizumab treatments. Baseline mean to last mean Derkay score improved for 19 patients during cidofovir treatments (mean difference, 3.84; P < .001) but did not improve for these same patients during the interval prior to receiving cidofovir treatments. The AO-RRP population had more patients with dysplasia (50%) compared to JO-RRP population (10%) (P < .001).

CONCLUSION

Various surgical modalities appear to be equally effective treatments for RRP. Adult and pediatric patients have decreased recurrent disease burden when receiving bevacizumab or cidofovir. AO-RRP patients have more concomitant dysplasia.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2420-2426, 2022.

Use of 532 nm Potassium Titanyl Phosphate Laser on Vocal Fold Scars Under Topical Anesthesia: A Pilot Study

OBJECTIVE

This pilot study aims to evaluate the efficacy of 532 nm potassium titanyl phosphate (KTP) laser under topical anesthesia in patients with vocal fold scars.

METHODS

A series of 18 patients with vocal fold scars of varying degrees were treated. The KTP laser was used under local anesthesia in the outpatient clinic. It was set to deliver 6 W of power using a continuous output mode. Close-to-contact mode was used for laser irradiation, and contact mode was used for ablation and excision of the lesions. Some of the patients received laser scar ablation on both vocal folds; the scarred vocal fold on one side and the hypertrophic vocal fold on the other. Parameters include glottic closure, amplitude, and mucosal wave pattern were measured using laryngeal stroboscopic examination. Aerodynamic and voice evaluations were carried out using maximum phonation time (MPT), jitter, shimmer, Voice Handicap Index questionnaire (VHI-30), and GRBAS scale.

RESULTS

In total, 21 surgeries were performed on 18 patients. Glottic closure, amplitude, and mucosal wave pattern showed improvement 2 months postoperatively (P < .05). There was significant improvement in the postoperative scores for VHI-30, VHI-emotional sub-scale, VHI-physical sub-scale, and GRBAS (P < .05). There was no significant difference in the MPT and VHI-functional sub-scale before and after the operation (P > .05). Re-adhesion of the anterior commissure was observed in 2 patients with Type III scars.

CONCLUSION

The 532 nm KTP laser is an effective tool for the treatment of vocal fold scars. Further research is required to determine if serial laser applications could improve outcomes for this challenging condition.

LEVEL OF EVIDENCE

Level IV.

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.

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

Unsedated Office-Based Thulium Laser Therapy in Patients With Reinke's Edema

OBJECTIVE

To report the outcome of unsedated office based Thulium laser therapy for Reinke's edema.

MATERIALS AND METHODS

A retrospective chart review of patients operated between March 2017 and November 2018 was conducted. Twelve patients were included, two of whom had two procedures performed. Demographic data included age, gender, smoking status, and grade of Reinke's edema. Outcome measures included Voice Handicap Index-10 (VHI), perceptual evaluation, extent of disease regression, acoustic analysis, and maximal phonation time.

RESULTS

Twelve patients were enrolled in this study, one of whom was lost for follow-up. There were eight females and three males. The mean age was 51.27 ± 9.12 years. Endoscopic evaluation 6-12 weeks after surgery revealed complete and partial regression of disease in three and eight patients, respectively. There was a significant improvement in the mean score of VHI-10 (15.00 ± 9.45 vs 3.07 ± 3.81) and the mean score of GRABS parameters following surgery (P < 0.05). The mean habitual pitch increased from 125.11 ± 28.48 Hz to 155.86 ± 55.14 Hz (P = 0.070). There was improvement in the mean jitter and shimmer but none reached a statistical significance. There was no significant change in the mean Maximum phonation time (MPT) scores before and after surgery.

CONCLUSION

Unsedated office-based Thulium laser therapy can be considered as an alternative therapy to patients with Reinke's edema who are not willing to undergo conventional microlaryngeal surgery.

Doppler optical coherence tomography for energy seal evaluation and comparison to visual evaluation

Laser energy sealing systems have attracted much attention over the past decade given the general shift in surgical paradigm toward less invasive surgical approaches. Given this, it is paramount to have an objective method with which the quality of energy seals can be evaluated. Current methodologies used for this purpose can be problematic in the evaluation of small vessel seals. A methodology employing Doppler optical coherence tomography (DOCT) for the evaluation of energy seals is introduced. Avian chorioallantoic membrane vessels were subjected to thulium laser irradiation and were then scanned via OCT. Outcomes were classified based on several markers, predominantly the presence or absence of flow postirradiation. Vessel diameter and general morphology were also taken into consideration. Vessels were classified into four groups: seal (29%), rupture (30%), partial seal (19%), and unaffected (22%). All vessels were also evaluated visually by a trained neurovascular surgeon, and these visually classified outcomes were compared with DOCT evaluated outcomes. It was found that whether the vessel was considered sealed or not sealed was dependent on the evaluation method (p  =  0.01) where visual classification resulted in 18% more seals than DOCT classification. Further, the specificity of visual classification was found to be strongly dependent on the number of partial seals (p  <  0.0001). DOCT has shown to be an indispensable method for the evaluation of energy seals not only solely due to its high velocity resolution but also due to valuable microscopic morphological insight regarding the biological mechanisms responsible for energy sealing.

The Use of 532-Nanometer-Pulsed Potassium-Titanyl-Phosphate (KTP) Laser in Laryngology: A Systematic Review of Current Indications, Safety, and Voice Outcomes

OBJECTIVE

To investigate the indications, efficacy, safety, and outcomes of potassium-titanyl-phosphate (KTP) laser procedures for treatment of laryngeal disease.

METHODS

PubMed, Cochrane Library, and Scopus were searched for studies providing information about the indications, efficacy, and safety of both in-office and operative suspension microlaryngoscopy KTP laser procedure in treatment of laryngeal disease. Diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

RESULTS

Of the initial screened 140 papers, 17 met our inclusion criteria. Six papers involved KTP laser procedures for benign and malignant vocal fold lesions in suspension microlaryngoscopy only, 10 papers focused on only in-office KTP laser procedures for benign vocal fold lesions, and 1 paper included both in-office and suspension microlaryngoscopy procedures. The following lesions may be considered as indications for KTP laser procedures: Reinke's edema, sulcus vocalis, vocal fold hemorrhage, polyp, granuloma, cyst, scar, papillomatosis, dysplasia, leukoplakia, and early vocal fold malignancies. Irrespective of the types of procedure (in-office vs suspension microlaryngoscopy), the KTP laser is associated with a low complication rate and overall good vocal fold vibration recovery. There is an important heterogeneity among studies concerning laser settings, indications, and outcomes used for the assessment of treatment effectiveness. There are no controlled studies directly comparing KTP laser with other lasers (ie, carbon dioxide laser).

CONCLUSION

The use of KTP laser procedures for treatment of laryngeal disease has increased over the past decade, especially for office-based management of vocal fold lesions. Future controlled studies are needed to compare the safety and outcomes of the KTP laser to other techniques.

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.

Treatment Outcomes and Adverse Events Following In-Office Angiolytic Laser With or Without Concurrent Polypectomy for Vocal Fold Polyps

Importance

In-office angiolytic laser procedures have been used successfully as an alternative treatment for vocal fold polyps; little is known in detail about the treatment outcomes and adverse events.

Objective

To examine the outcomes and incidence rates of adverse events associated with in-office angiolytic laser procedures with or without concurrent polypectomy as an alternative treatment for vocal fold polyps.

Design, Setting, and Participants

Retrospective cohort study at a tertiary medical center. We identified 114 consecutive patients with vocal polyps who underwent in-office angiolytic laser treatments between January 1, 2014, and August 31, 2016. After the exclusion of 17 with missing or incomplete data, 97 were enrolled.

Interventions

In-office 532-nm laser procedures with or without concurrent polypectomy.

Main Outcomes and Measures

Between 1 and 2 months after the surgical procedures, we collected the following outcome data: videolaryngostroboscopy, perceptual rating of voice quality, acoustic analysis, maximal phonation time, and subjective rating of voice quality using a visual analogue scale and 10-item voice handicap index.

Results

This study enrolled 97 patients (mean [SD] age, 45.6 [11.3] years; 48 [49%] male). The mean duration of symptoms was 10.1 months (range, 1-60 months). Twenty-nine patients (30%) had angiolytic laser procedures only, while 68 (70%) received laser with concurrent polypectomy. Both treatment modalities offered significant improvements. Only 1 patient (1%) receiving angiolytic laser with concurrent polypectomy underwent another treatment session, so this group had significantly less need for multiple treatments than those receiving laser treatment alone (6 [21%]; effect size, -1.57; 95% CI, -2.77 to -0.36). We identified 8 adverse events (8% of the cases): vocal fold edema (n = 5), vocal hematoma (n = 2), and vocal ulceration (n = 1). Patients treated with laser plus concurrent polypectomy had significantly fewer adverse events than those treated with angiolytic laser alone (2 [3%] vs 6 [21%]; effect size, 1.20; 95% CI, 0.26 to 2.13).

Conclusions and Relevance

In-office angiolytic laser procedures can be an effective alternative treatment for vocal polyps, although with possible need for multiple treatment sessions and occasional occurrence of minor postoperative adverse events. Concurrent polypectomy following laser coagulation allows less laser energy delivery and reduces the risk of postoperative adverse events and the need for additional treatment sessions.

Office-Based 532-Nanometer Pulsed Potassium-Titanyl-Phosphate Laser Procedures in Laryngology

With fiber-based lasers that may be passed via the working channel of a flexible laryngoscope, in-office laser laryngeal surgery has become possible. The potassium-titanyl-phosphate laser has several features that make it ideal for laryngeal surgery, and it is now the laser of choice for in-office management of a variety of laryngeal lesions. Its applications have expanded significantly since its introduction, with reports of new indications continuing to appear in the literature. This article provides a comprehensive review of the indications and technical details of in-office potassium-titanyl-phosphate laser laryngeal surgery, and a summary of the existing literature regarding outcomes of these procedures.

Carbon debris and fiber cleaving: Effects on potassium-titanyl-phosphate laser energy and chorioallantoic membrane model vessel coagulation

OBJECTIVES/HYPOTHESIS

Photoangiolytic precision afforded by the 532-nm potassium-titanyl-phosphate (KTP) laser relies on predictable energy delivery. Inadequate energy output can cause vessel rupture, and excessive energy can cause thermal damage. The quality of the cleaved surface and carbon deposits from ablated tissue are two factors that could negatively impact fiber performance. The effects of these on energy output and blood vessel coagulation were assessed using a chorioallantoic membrane (CAM) model.

STUDY DESIGN

Comparative analysis.

METHODS

Laser fibers with carbon debris, optimal fiber cleaving, and suboptimal cleaving were inspected at three times magnification, and the light dispersion pattern of each fiber was rated. The average energy output from consecutive pulses through each fiber configuration was recorded. The effect of these fiber conditions on clinical efficacy was estimated by measuring vessel coagulation versus rupture in the CAM model. Repeated measures analysis of variance compared results.

RESULTS

Carbon debris and suboptimal cleaving resulted in decreased energy output in comparison to optimal cleaving ([-Δ244 mJ, d = 4.31, P < .001] and [-Δ195 mJ, d = 6.04, P < .001]). Optimal cleaving resulted in immediate coagulation of vessels. Fibers with suboptimal cleaving and carbon debris had unpredictable outcomes, requiring multiple pulses for coagulation or causing vessel rupture.

CONCLUSIONS

KTP laser fiber function is significantly affected by fiber tip condition. Carbon debris and suboptimal cleaving create significant attenuation of energy, which results in an unpredictable angiolytic effect, as demonstrated by increased vessel rupture in the CAM model. Optimal recleaving of KTP laser fibers restores prior energy output and predictable coagulation. Care should be taken to avoid carbon debris on laser-fiber tips and to cleave fibers properly.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2244-2248, 2019.

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.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Objective

This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia.

Purpose

The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology–head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology.

Action Statements

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia.

Disclaimer

This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia

Chick Chorioallantoic Membrane as a Model for Simulating Human True Vocal Folds

Objectives:

Evolving photoangiolytic laser techniques for treating vocal fold lesions motivated the development of a model for research and surgical training. The chick chorioallantoic membrane (CAM), which is composed of a microvasculature suspended within the egg albumen, simulates the vocal fold microcirculation within the superficial lamina propria (SLP). To characterize this model, we compared measurements of vessel diameters to superficial vessels in human vocal folds.

Methods:

The diameters of first-, second-, and third-order CAM vessels were measured in fertilized chicken eggs. The superficial blood vessels of the human vocal fold were measured from intraoperative images.

Results:

According to the branching pattern, vessel segments were identified as first-, second-, or third-order, with average diameters of 0.035 mm (0.02 to 0.1 mm), 0.18 mm (0.12 to 0.41 mm), and 0.8 mm (0.6 to 0.98 mm), respectively. The total vessels measured included 362 first-order, 119 second-order, and 82 third-order vessels. In 10 adult human vocal folds, an average vessel diameter of 0.04 mm (0.015 to 0.1 mm) was observed in 50 vessels.

Conclusions:

The CAM microvasculature suspended in albumen provides a useful surgical model simulating the microcirculation within the SLP of the human vocal fold. Although first-order CAM vessels best approximate the size of normal vocal fold subepithelial vessels seen at surgery, second- and third-order vessels resemble the vascular abnormalities frequently encountered during microsurgery for phonotraumatic lesions.

Foresight in Laryngology and Laryngeal Surgery: A 2020 Vision

Laryngology and laryngeal surgery have been in the vanguard of minimally invasive human procedural interventions for approximately 150 years. The natural passages through the oral cavity, nose, and pharynx have provided an accessible gateway to the larynx that has allowed for rapid translation of a variety of diagnostic and therapeutic technologies. Transoral and transcervical laryngeal surgery have been further facilitated by progressive advancements in local, topical, intravenous, and general anesthesia. With rapid developments in engineering disciplines (ie, tissue, chemical, mechanical) and voice science, there are a variety of current and near-term opportunities to advance our field. This report represents a panel at the 2005 American Broncho-Esophagological Association meeting that sought to use present perspectives, combined with cutting-edge research insights, to provide foresight into key aspects of laryngology that we believe will be developed by the year 2020. We hope that aspiring laryngeal surgeons will find elements of this discussion valuable for devising a strategic roadmap for research initiatives in laryngology and laryngeal surgery.

Office-Based 532-nm Pulsed KTP Laser Treatment of Glottal Papillomatosis and Dysplasia

Objectives:

Treatment of glottal papillomatosis and dysplasia was mirror-guided and done in surgeons' offices in the 19th century. It migrated to the operating room in the 20th century to accommodate direct laryngoscopic surgery, which required assistants to administer anesthesia and procedural support. The primary treatment goals, which are disease regression and voice restoration and/or maintenance, are tempered by the morbidity of general anesthesia and potential treatment-induced vocal deterioration. To obviate general anesthesia, office-based laser laryngeal surgery was first done in 2001 with the 585-nm pulsed dye laser (PDL), because it employs a fiber delivery system and its energy is selectively absorbed by oxyhemoglobin. Since then, this new angiolytic laser treatment paradigm has become a mainstay of management for many surgeons; however, there are a number of shortcomings of the PDL. To further develop this concept and address the limitations of the PDL, we used a 532-nm pulsed potassium titanyl phosphate (KTP) laser.

Methods:

A prospective assessment was performed on 48 patients in 72 cases of recurrent glottal dysplasia (36) or papillomatosis (36). All individuals had previously undergone microlaryngoscopic management with histopathologic evaluation.

Results:

Two dysplasia patients did not tolerate the procedure. Of the treatable dysplasia cases, there was follow-up in 29 of 34. Disease regression was at least 75% in 18 of 29 cases (62%), 50% to 75% in 7 of 29 (24%), and 25% to 50% in the remaining 4 of 29 (14%). Papilloma patients returned for treatment when symptoms recurred, so disease regression could not be assessed accurately. Similar to data obtained with the PDL, these data confirmed that dysplastic mucosa could normalize without resection.

Conclusions:

Our observations revealed that the 532-nm pulsed KTP laser provided enhanced performance over the PDL laser in a number of ways. The ability to use smaller glass fibers precluded mechanical trauma to the channels of the flexible laryngoscopes and allowed for improved suctioning of secretions. Oxyhemoglobin absorbs energy better at 532 nm than at 585 nm, and the KTP laser can be delivered through a longer pulse width. These factors provide enhanced hemostasis and improved intralesional energy absorbance. Finally, unlike the PDL, the KTP laser is a solid-state laser and is not prone to mechanical failure.

In-Office Laryngeal Surgery with the 585nm Pulsed Dye Laser (PDL)

OBJECTIVES: The 585nm pulsed dye laser (PDL) is a promising tool for in-office laryngeal surgery. Data with respect to the safety and efficacy of the PDL for office laryngeal use is sparse. The purpose of this study is to review our experience with unsedated office PDL surgery.

METHODS: Records of individuals undergoing in-office PDL between September 1, 2004, and September 1, 2006 were abstracted from a clinical database.

RESULTS: Forty-seven patients underwent 117 treatments. The most common indications were recurrent respiratory papillomatosis (RRP), Reinke's edema, and vocal fold polyps. One hundred and four of 117 procedures were felt to be a success ablating all disease. Thirteen treatments requred early termination. The most common factor responsible for termination was an inability to achieve a comfortable level of anesthesia. One patient with Reinke's edema developed postprocedure stridor that required a 3-day hospital admission for observation and corticosteroids. There was no incidence of any vocal fold scarring, web formation, or other complications.

CONCLUSIONS: The 585nm PDL is a promising tool for in-office treatment of various laryngeal disorders. Complications are rare.

Office-based Management of Recurrent Respiratory Papilloma

This review will highlight the indications and benefits of office-based therapy for recurrent respiratory papillomatosis (RRP) and discuss the utilization of photo-dynamic lasers and adjuvant medical therapy in office-based settings. Office-based management of RRP allows for more timely interventions, is preferred by the majority of patients, and negates the risk of general anesthesia. Current literature argues for the utilization of KTP laser over CO₂ laser for office-based treatment of RRP. Medical therapies for RRP are limited, but agents such as bevacizumab are promising and have been shown to reduce disease burden. Medical therapies that can induce disease remission are still needed. Office-based procedures save time and healthcare expenses compared to like procedures in the operating room. However, the increased frequency for office-based procedures predicts similar overall healthcare costs for office-based and OR laser excision of RRP. Office-based management of RRP is a feasible and well-tolerated strategy in appropriately selected patients with adequate local anesthesia.

Treatment of Hemorrhagic Vocal Polyps by Pulsed Dye Laser-Assisted Laryngomicrosurgery

Objective. Conventional surgical techniques of laryngomicrosurgery (LMS) on hemorrhagic vocal polyps are often difficult due to obscuration of the surgical field by inadvertent bleeding from the lesion, and there are often significant amounts of mucosal epithelium loss. Here, we introduce our surgical technique using pulsed dye laser (PDL), which can effectively resect the polyp with vocal fold mucosa preservation. Methods. Patients who were diagnosed with hemorrhagic vocal polyp and who were surgically managed using PDL from March 2013 to October 2014 were retrospectively reviewed. Preoperative and postoperative clinical outcomes and surgical findings were evaluated. Results. A total of 39 patients were treated with PDL-assisted enucleation LMS. The average age was 43.7 years (range 20–73), and there were 20 males and 19 females (17 professional voice users). In all cases, the hemorrhagic polyp was successfully enucleated after application of PDL, thereby preserving the overlying epithelium. Postoperative voice outcomes were favorable with clear preservation of the vocal fold mucosal wave. Conclusion. PDL-assisted enucleation LMS for the treatment of hemorrhagic vocal polyps can be a safe and effective surgical technique. It can be considered a promising treatment option for hemorrhagic vocal polyps.

Comparison of vocal outcomes after angiolytic laser surgery and microflap surgery for vocal polyps

OBJECTIVE

The microflap technique is a standard procedure for the treatment of vocal fold polyps. Angiolytic laser surgery carried out under topical anesthesia is an alternative method for vocal polyp removal. However, it is not clear whether angiolytic laser surgery has the same effects on vocal outcomes as the microflap technique because of a lack of studies comparing both procedures. In the current study, vocal outcomes after both procedures were compared to clarify the effects of angiolytic laser surgery for vocal polyp removal.

METHODS

Vocal outcomes were reviewed for patients who underwent angiolytic laser surgery (n=20, laser group) or microflap surgery (n=34, microflap group) for vocal polyp removal. The data analyzed included patient and lesion characteristics, number of surgeries required for complete resolution, and aerodynamic and acoustic examinations before and after surgery.

RESULTS

In the laser surgery group, complete resolution of the lesion was achieved with a single procedure in 17 cases (85%) and with two procedures in 3 cases (15%). Postoperative aerodynamic and acoustic parameters demonstrated significant improvement compared to preoperative parameters in both the laser surgery group and the microflap surgery group. There were no significant differences in any postoperative aerodynamic and acoustic parameters between the two groups.

CONCLUSION

The current retrospective study demonstrated that angiolytic laser surgery achieved complete resolution of vocal polyps within two procedures. Postoperative effects on aerodynamic and acoustic functions were similar to those after microflap surgery.

Comparison of treatment outcomes of transnasal vocal fold polypectomy versus microlaryngoscopic surgery

OBJECTIVES/HYPOTHESIS

Office-based procedures have been proposed for the treatment of vocal polyps, including indirect laryngoscopic surgery and angiolytic laser photocoagulation. Our previous report documented good treatment outcomes by combining the two aforementioned procedures. This study was intended to further compare the treatment outcomes of office transnasal vocal fold polypectomy (VFP) with those of microlaryngoscopic surgery (MLS).

STUDY DESIGN

A matched cohort study.

METHODS

This study retrospectively enrolled 50 age-, gender-, and size-matched patients with vocal polyps treated by VFP or MLS at a tertiary teaching hospital from January 2012 to October 2013. Treatment outcomes were evaluated before, 2 weeks, and 6 weeks after the procedures via perceptual rating of voice quality, acoustic measurement of the speech signal, 10-item voice-handicap index, maximal phonation time, subjective rating of voice quality, and videolaryngostroboscopic evaluation.

RESULTS

Both VFP and MLS resulted in significant clinical improvements 2 and 6 weeks postoperatively. Study results exhibited similar objective outcomes between VFP and MLS, whereas patients who received VFP reported higher subjective voice quality than those receiving MLS 2 weeks postoperatively. Six weeks after the procedures, the objective and subjective treatment outcomes were not significantly different between the two treatment groups.

CONCLUSION

This study shows that transnasal VFP may be used as an effective alternative treatment for small vocal polyps. Patients who received office VFP experienced rapid symptomatic relief with a higher degree of subjective effectiveness than MLS 2 weeks postoperatively, whereas the overall treatment outcomes showed a comparable level of effectiveness for both modalities.

LEVEL OF EVIDENCE

3B.

The effect of different angiolytic lasers on resolution of subepithelial mucosal hematoma in an animal model

OBJECTIVE

Vocal fold hematoma is traditionally managed with a period of voice rest, in the order of weeks, to allow natural resolution. This study is designed to examine the efficacy and safety of a number of hemoglobin-avid (vascular) lasers when used in the setting of acute vocal fold hematoma.

METHODS

Venous blood drawn from 4 white rabbits was used to create an array of subepithelial hematomas in the buccal cavities of each animal. Laser energy from I of 3 different lasers (532-nm pulsed potassium titanyl phosphate [KTP], 532-nm diode KTP, and 940-nm diode laser) was applied to each of the test hematomas at varying energy levels. Hematoma sites were photographed at days 0, 1, 5, 7, 9, and 12. Two animals were sacrificed on day 7 and the remainder on day 12. Histological evaluation of collateral tissue damage and residual hematoma was performed on biopsy specimens.

RESULTS

Macroscopic and microscopic ulceration at laser-treated sites was mostly resolved by day 7. Inflammatory cell infiltrate was present in laser-treated and hematoma-only sites. Laser-treated samples showed alterations in vascularity.

CONCLUSION

Hemoglobin-avid lasers may be beneficial in accelerating subepithelial hematoma resolution with a favorable tissue damage profile.

Analysis of Potassium Titanyl Phosphate Laser Settings and Voice Outcomes in the Treatment of Reinke’s Edema

Objective:

Despite increased clinical utility of the 532-nm potassium titanyl phosphate (KTP) laser, no studies have examined outcomes for Reinke’s edema (RE) as a function of laser parameters and initial treatment effects. Variability in delivery parameters, fiber-to-tissue distance, and immediate end-tissue effects limits universal application of existing study outcomes. We examine voice outcomes using standardized treatment classification, providing justification for laser parameter selection and immediate tissue effect in clinical use.

Methods:

Retrospective review of 9 patients who underwent KTP laser treatment for RE. Demographics, RE severity, laser settings, total laser energy, and immediate tissue effects were correlated with quantified voice outcomes.

Results:

An average of 157 joules (6-640 J) was delivered over a 0.369-second exposure time (0.1-0.9 seconds). Immediate tissue effects varied from nonablative treatment (type I and type II) to ablation without tissue removal (type III). Overall, Voice Handicap Index-10 (VHI-10) decreased by 8.23; improvement was most pronounced with type II treatments (delta VHI-10 = 12). No complications were encountered.

Conclusion:

Potassium titanyl phosphate laser can be safely and effectively used to improve voice in RE patients regardless of severity. This is the first study to provide detailed information on laser settings, energy delivery, and treatment effect in RE management; these results may guide clinical use of this modality, especially for novice laser surgeons.

The utility of the potassium titanyl phosphate laser in modulating vocal fold scar in a rat model

OBJECTIVES/HYPOTHESIS

We hypothesize that the KTP laser has the potential to augment wound healing in a rat model, and this modality may serve as a therapeutic tool for the management of vocal fold fibrosis.

STUDY DESIGN

Prospective, laboratory animal study.

METHODS

Rats were subjected to either vocal fold injury ± KTP laser treatment at low energy to simulate clinically relevant endpoints. In addition, cohorts were subjected to therapeutic KTP laser alone. Endpoints included the analyses of gene expression data related to the acute inflammatory response and extracellular matrix deposition and organization.

RESULTS

Therapeutic KTP treatment was associated with an additive effect on inflammatory gene expression in the context of the injured rat vocal fold mucosa. A similar additive effect was observed for matrix metalloproteinase gene expression, similar to data previously reported in the dermatology literature. However, histologically, the KTP had little effect on established vocal fold fibrosis.

CONCLUSIONS

These data are the first to attempt to provide mechanistic insight into the clinical utility of angiolytic lasers for vocal fold scar. Similar to previous data obtained in the skin, it appears that these effects are mediated by MMPs.

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.