Cost Savings of Unsedated Office-Based Laser Surgery for Laryngeal Papillomas

Quality of Office-based Procedure Training During Laryngology Fellowship

OBJECTIVES

The primary objective was to assess the perspectives of recent laryngology fellowship graduates on office-based procedure training, with a secondary objective to compare this with previous research on perspectives of fellowship directors.

METHODS

Recent laryngology fellowship graduates were surveyed via an online survey platform regarding post-fellowship practice and various aspects of office-based procedure training, including perceived competence, mentorship, and barriers.

RESULTS

There were 51 respondents. Seventy-six percent of respondents felt they "definitely" received adequate office procedure training. Number of procedures as primary surgeon was significantly associated with perception of adequate training (OR 1.54, 95% CI: 1.08-2.19, p = 0.018) and high post-fellowship office procedure volume (OR 1.56, 95% CI: 1.02-2.39, p = 0.040). Fellows reported a lower percentage of procedures as primary surgeons compared with program directors (46.8% vs. 61.9%, p = 0.028). Fellows and directors agreed that informal debriefs were more commonly employed than more structured training elements such as checklists and simulators. Of nine office procedures, laryngeal electromyography, KTP laser, and transnasal esophagoscopy had the greatest decreases in practice after training.

CONCLUSION

Although most recent laryngology fellowship graduates endorse adequate office-based procedure training, a range of individual experiences exists, and office procedure volume, both overall and across individual procedures, may decrease after fellowship. Fellows performing office procedures as primary surgeons may be linked to perceived quality of training and post-fellowship volume.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1802-1806, 2024.

Serial In-Office Steroid Injections for Airway Stenosis: Long-Term Benefit and Cost Analysis

OBJECTIVES

To evaluate the long-term benefit of serial in-office steroid injections (SISI) in the treatment of subglottic and proximal tracheal stenosis (SG/PTS). Evaluate cost of SISI compared to endoscopic dilation (ED).

STUDY DESIGN

Retrospective study and cost analysis.

METHODS

All patients with SGS/PTS with at least two consecutive in-office steroid injections between 2013 and 2021 were evaluated. Patients with less than 2 years of follow-up data after the initial SISI series were excluded. Demographics, etiology of stenosis, total injections performed, time between steroid series, surgery-free interval (SFI) and adverse events were collected. For patients with known surgical history before SISI, pre-SISI SFI was compared. Institutional billing records and the national CMS average reimbursement were evaluated. Total charges for three treatment strategies (ED alone, ED with post-operative SISI and primary intervention with SISI) were also compared.

RESULTS

Forty-nine patients were included; 29 (59%) idiopathic, 11 (22%) traumatic and 9 (18%) rheumatologic. Mean (SD) follow-up time after the first SISI was 3.41 years (1.5), range (2.08-7.25 years). 79% (39/49) did not require additional surgery during the entire follow-up period. The SFI improved from a mean 13.5 months (SD 12.6; range 2-42 months) pre-SISI to a mean (SD) of 42 months (SD 20.2; range 10-87 months) (p < 0.0001) after SISI. Annual average charges for ED alone in our cohort was $15,383.28, compared to $7,070.04 for SISI.

CONCLUSIONS

SISI are an effective treatment for patients with SG/PTS. In-office steroid injections could offer cost savings for the patient.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2673-2679, 2023.

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.

Laryngeal Papillomatosis: A Non-traditional Flexible Endoscopic Approach

OBJECTIVE

To evaluate the efficacy of flexible endoscopic laryngeal surgery (FELS) using unconventional tools in the treatment of laryngeal papillomatosis (LP).

METHODS

We applied FELS using forceps, diathermy snare, and Nd:YAG laser for 47 patients with LP. In 38 cases (81%), surgeries were performed under topical anesthesia with spontaneous respiration and in seven cases we used general anesthesia with superimposed high-frequency jet ventilation. In two cases, both types of anesthesia were used in different sessions. In 22 cases (46.8%), the interventions were performed as outpatient procedures. The Nd:YAG laser was used in the majority (89.4%) of cases.

RESULTS

The expected result (complete eradication of the visible lesion) was obtained in all treated patients without procedure complications. Disease recurrence was established in 16 cases (34%) that led to repeated surgeries.

CONCLUSIONS

FELS, using Nd:YAG laser as a main tool, is a safe and effective approach that can be a feasible alternative to the conventional approach in the treatment of LP due to possibility to avoid repeated general anesthesia with its associated risks; applicability for the patients, who have contraindications for general anesthesia and transoral microsurgery; possibility to perform the intervention in an outpatient setting that leads to essential reduction of medical costs; economy of time. Nd:YAG laser ablation, preceded by diathermy snare resection, allows reducing the time of the intervention and thermal injury of the adjacent tissues, compared to using laser alone, and can be used in bulky and obstructive lesions that present a limitation for nonablative techniques.

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.

Equipping your facial plastic clinic for office-based procedures

Office-based procedures can be a fulfilling part of the facial plastic practice with the right tools, personnel, and preparation. Equipping the clinic for office-based procedures has several unique considerations that ultimately impact its success. It is important to strategize preemptively regarding what treatments will be offered and the respective equipment that will allow the safe, cost-effective, and high-quality delivery of those treatments. Most procedures in the office-based setting are cosmetic in nature and there are often overlapping treatment modalities that target similar outcomes. Patient selection and counseling is a crucial step in preparing for office-based procedures in the effort to maximize patient satisfaction. Nearly all the most common facial plastic procedures can be delivered in the office-based based setting under local anesthesia and moderate sedation, depending on the expertise of the surgeon. To enable these and other categories of treatments, there are certain expensive pieces of technology that one might consider for their office-based practice and other fundamental supplies that are necessary for almost all practices. Though the initial investment in equipment can be costly, this article also discusses more affordable alternatives or third-party sales of devices and equipment. The field of facial plastic surgery is very dynamic and having both peer and mentorship networks is invaluable in navigating some of the financial decisions discussed herein. This article also briefly covers personnel, training, and accreditation considerations.

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.

On the Merits of Using Angled Fiber Tips in Office-based Laser Surgery of the Vocal Folds

Office-based endoscopic laser surgery is an increasingly popular option for the treatment of many benign and pre-malignant tumors of the vocal folds. While these procedures have been shown to be generally safe and effective, recent clinical studies have revealed that there are a number of challenging locations inside the larynx where laser light cannot be easily delivered due to line-of-sight limitations. In this paper, we explore whether these challenges can be overcome through the use of side-firing laser fibers. Our study is conducted in simulation, using three-dimensional models of the human larynx generated from X-ray microtomography scans. Using computer graphics techniques (ray-casting), we simulate the application of laser pulses with different types of laser fibers and compare the total anatomical coverage attained by each fiber. We consider four fiber types: a traditional "forward-looking" fiber - not unlike the ones currently used in clinical practice - and three side-firing fibers that emit light at an angle of 45, 70, and 90 degrees, respectively. Results show that side-firing fibers enable a ~70% increase in accessible anatomy compared to forward-looking fibers.

Factors Associated With Tolerance for In-Office Laryngeal Laser Procedures

OBJECTIVES/HYPOTHESIS

A variety of laryngeal pathologies are increasingly being managed with in-office KTP laser (IOKTP) endoscopic procedures. The primary goal of this study was to identify patient characteristics and disease-related features that correlated with tolerance for IOKTP.

STUDY DESIGN

Retrospective chart review.

METHODS

The study was a retrospective review of adult patients undergoing office-based laryngeal laser procedures between November 2016 and December 2019 at a tertiary care center. Two blinded otolaryngologist reviewers scored videotaped recordings of IOKTP procedures and assessed severity and distribution of disease using a modified Derkay score, and evaluated procedure tolerance using a visual analog scale.

RESULTS

A total of 56 patients who received IOKTP procedures for laryngeal pathology were reviewed, 42 male and 14 female, with a mean age of 61 years. Gender, age, and BMI were not correlated with tolerance. There was a moderate, negative correlation between tolerance and total number of pathological anatomic laryngeal subsites (rs(56) = -0.35, P = .01). There was a weak, negative correlation between tolerance and total modified Derkay score (rs(56) = -0.29, P = .03). The median tolerance score was lower for patients with posterior lesions (Mdn = 6.4) compared with patients with non-posterior lesions (Mdn = 7.4), P = .04, and lower for current or former smokers (Mdn = 6.5) compared with never smokers (Mdn = 7.3), P = .04.

CONCLUSION

Patients with large disease burden or posterior lesions and patients with smoking history may exhibit poorer tolerance of IOKTP procedures, factors which can help guide pre-procedural counseling and management decisions.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E2292-E2297, 2021.

First-line treatment of exudative vocal fold-lesions by in-office local corticosteroid injection: A literature review

OBJECTIVES

There are emerging reports of the effectiveness of in-office awake vocal-fold corticosteroid injection in the treatment of exudative vocal-fold lesions. The aim of this study was to review this therapy and specify indications, practical modalities and outcomes.

STUDY DESIGN

Systematic review of the literature without meta-analysis.

METHODS

A systematic review by PubMed search for the period January 2000 to December 2018 was carried out.

RESULTS

Nine articles were included, for a total of 502 lesions: nodules (46.4%), polyps (31.7%), and Reinke's edema (21.9%). Submucosal injection of low-dose triamcinolone acetonide (0.1 to 0.3mL) was transoral, transcutaneous or transnasal via flexible endoscope with operating channel. Lesion volume was significantly reduced in more than 90% of cases, with significant vocal improvement in all studies. Relapse rates ranged between 4% and 31%, with time to relapse of 1 to 40 months.

CONCLUSIONS

First-line treatment of exudative glottic lesions by submucosal corticosteroid injection provides at least transient significant reduction in lesion volume and vocal improvement. It is consensually reserved to moderate-sized mainly exudative lesions without fibrosis. In-office injection provides an immediate therapeutic response in case of vocal impairment, enabling surgery under general anesthesia to be postponed.

Office-Based Procedure Training in Laryngology Fellowship Programs

OBJECTIVE

To assess the current practices and challenges of training office-based procedures to laryngology fellows in the United States.

METHODS

An anonymous web-based survey study was distributed to laryngology fellowship program directors, as listed by the American Laryngological Association. The survey was a 19-item questionnaire with free-text, Likert scale, and multiple-choice answers.

RESULTS

Twenty-two of 27 program directors (81.4%) replied to the survey. Many programs (8/16) have three or more laryngologists and do more than 10 procedures each week (10/16). Sixty-nine percent (11/16) of directors had not been trained for office procedures in their fellowship. The fellows are allowed to be primary surgeon on 68.75% and 75% of vocal fold augmentation and laser procedures, respectively. The expected competencies for these procedures on graduation are average-moderate and moderate. When program directors asked about the methods used for training, a minority of them use simulators (2/16), procedural checklists (2/16), or structured debriefing (2/16). The most commonly used methods were case-based troubleshooting (13/16) and unstructured debriefing (13/16). Patients being awake and patients' expectations are seen as the most important obstacles. Most of the directors thought office-based procedure training could be improved (14/16). The most common suggestions were using step-wise checklists, simulator-labs, and formal debriefings.

CONCLUSION

This is the first study evaluating the training of office-based laryngeal procedures during laryngology fellowship. Given the increasing importance of these procedures in practice and the herein identified barriers and need for improvement, fellowships should investigate the use of systematic training tools to improve fellow competency with office-based procedures. Laryngoscope, 131:2054-2058, 2021.

The safety of in-office laryngologic procedures during active antithrombotic therapy

OBJECTIVES

To determine whether patients undergoing in-office laryngologic procedures on antithrombotic therapy are at increased risk for treatment-related complications.

METHODS

Patients were those who underwent at least one in-office laryngologic procedure with any of three fellowship-trained laryngologists. Procedures were identified by current procedural terminology (CPT) code and included biopsies, excisions, laser ablations, and injections (therapeutic and augmentative). Patients were divided into two groups based on the use of antithrombotic therapy at the time of their procedure. Retrospective chart review was performed to identify any complications, with an average follow-up of 186 days.

RESULTS

Five hundred-sixty-four unique individuals were identified with ages ranging from 18 to 93 years old and with a relatively even distribution between females (45%) and males (55%). They underwent 647 procedures in total, 310 of which were performed while on some form of antithrombotic therapy. Sixteen procedures were associated with complications either during or after the procedure. In comparing overall complication rates, there was no significant difference between non-antithrombotic (2.4%) and antithrombotic (3.3%) cohorts (OR 1.09, 95% CI [0.46-2.60], P = .8454).

CONCLUSIONS

In spite of known risks in other settings, antithrombotic agents do not appear to confer increased risk of treatment-related complications during in-office laryngologic procedures, obviating the need for cessation of therapy prior to these interventions.

LEVEL OF EVIDENCE

4.

Applications of Office-Based 445 nm Blue Laser Transnasal Flexible Laser Surgery: A Case Series and Review of Practice

BACKGROUND

The recent introduction of 445 nm blue laser to office-based laryngology presents potential advantages. These include a desirable combination of cutting and photoangiolytic qualities and a lightweight, shock-resistant design. Despite its increasing use, current evidence is limited to experimental data and case reports.

OBJECTIVES

The authors present a case series and overview of office blue laser transnasal flexible laser surgery (TNFLS), considering indications, patient selection, safety, technique, and surgical outcomes. We also review the safety and relevance of TNFLS to the ongoing coronavirus pandemic.

METHODS

Retrospective case series and narrative review. Our primary outcome measure was preoperative and postoperative Voice Handicap Index (VHI-10) score. Complications were documented by nature and severity.

RESULTS

Thirty-six cases of office blue laser TNFLS were performed. A statistically significant improvement in VHI-10 score was demonstrated in cases of recurrent respiratory papillomatosis (RRP) and benign laryngeal lesions causing dysphonia (P < 0.01 and 0.045). Blue laser also proved effective in assisting office biopsy procedures. A minor and self-limiting complication was reported.

CONCLUSIONS

Office blue laser TNFLS is safe and effective in the treatment of RRP and a range of benign laryngeal lesions. Future research should compare the efficacy and safety of blue laser with potassium titanyl phosphate laser in office-based treatment of these conditions. Further assessment of the cutting qualities of blue laser, initially in the theater environment, is necessary to refine our understanding of future applications.

Longitudinal Voice Outcomes Following Serial Potassium Titanyl Phosphate Laser Procedures for Recurrent Respiratory Papillomatosis

OBJECTIVE

Repeated surgical interventions are usually required to control recurrent respiratory papillomatosis (RRP), but at considerable risk of worsened postoperative voice quality. Potassium titanyl phosphate (KTP) laser has been reported to effectively manage RRP; however, voice quality after repeated procedures has not been investigated.

METHODS

This study recruited 16 patients with RRP treated using KTP laser between 2013 and 2019. KTP laser procedures were performed under general anesthesia via direct suspension laryngoscope or under local anesthesia via flexible endoscope, depending on the need for pathological proof, patient tolerance, and lesion size and location. Disease control was investigated by videolaryngostroboscopy. Voice outcome was evaluated using a 10-item voice handicap index (VHI-10), acoustic and perceptual analyzes.

RESULTS

We reviewed the medical records of 11 male and 5 female patients with RRP (age range: 23-73 years). Five patients received KTP laser once, six patients received it 2 to 5 times, and five patients received 6 to 15 procedures. Median VHI-10 decreased from 28.3 to 12.0 points after the initial procedure and were maintained at 10.1 to 11.0 points following subsequent procedures (P < .01, generalized estimating equation). Acoustic and perceptual analysis of voice quality also revealed significant improvements (P < .01), which remained stable even after 6 to 10 KTP laser procedures. Minor adverse events included slight fibrotic change of vocal folds and glottic web, but these did not significantly alter postoperative voice quality.

CONCLUSION

This longitudinal follow-up study revealed that serial KTP laser procedures can effectively control RRP while preserving phonatory function and maintaining adequate voice quality.

LEVEL OF EVIDENCE

4.

Recurrent Respiratory Papillomatosis Office versus Operating Room: Systematic Review and Meta-Analysis

OBJECTIVES

Recurrent respiratory papillomatosis can be treated in the office or operating room (OR). The choice of treatment is based on several factors, including patient and surgeon preference. However, there is little data to guide the decision-making. This study examines the available literature comparing operative treatment in-office versus OR.

METHODS

A systematic review was performed following Preferred Reporting Items for Systematic Reviews guidelines. Of 2,864 articles identified, 78 were reviewed full-length and 18 were included. Outcomes of interest were recurrence and complication rates, number of procedures, time interval between procedures, and cost.

RESULTS

Only one study compared outcomes of operative in-office to OR treatments. The weighted average complication rate for OR procedures was 0.02 (95% confidence interval [CI] 0.00-0.32), n = 8, and for office procedures, 0.17 (95% CI 0.08-0.33), n = 6. The weighted average time interval between OR procedures was 10.59 months (5.83, 15.35) and for office procedures 5.40 months (3.26-7.54), n = 1. The weighted average cost of OR procedures was $10,105.22 ($5,622.51-14,587.83), n = 2 versus $2,081.00 ($1,987.64-$2,174.36), n = 1 for office procedures.

CONCLUSION

Only one study compares office to OR treatment. The overall data indicate no differences aside from cost and imply that office procedures may be more cost-effective than OR procedures. However, the heterogeneous data limits any strong comparison of outcomes between office and OR-based treatment of laryngeal papillomas. More studies to compare the two treatment settings are warranted.

In-Office vs. Operating Room Procedures for Recurrent Respiratory Papillomatosis

We conducted a study to analyze hospital and patient costs, outcomes, and patient satisfaction among adults undergoing in-office and operating room procedures for the treatment of recurrent respiratory papillomatosis. Our final study population was made up of 17 patients—1 man and 16 women, aged 30 to 86 years (mean: 62). The mean number of in-office laser procedures per patient was 4.2, and the mean interval between procedures was 5.4 months (although 10 patients underwent only 1 office procedure); the mean number of operating room procedures was 13.5, and the mean interval between procedures was 14.3 months. An equal number of patients reported complications or adverse events with the two types of procedures—5 each. The difference in cost between the office procedure (mean: $3,413.00) and the operating room procedure (mean: $12,382.59) was almost $9,000, but these savings were offset by the fact that the office procedures needed to be performed three times as often. Patients reported slightly more anxiety and discomfort during the office procedures and, overall, they appeared to prefer the operating room procedure. We conclude that office procedures are significantly more cost-effective than operating room procedures, but their use may be limited by patient tolerance and the increased frequency of the procedure.

Serial In-Office Intralesional Steroid Injections in Airway Stenosis

Importance

Endoscopic dilation is the mainstay treatment strategy for subglottic and proximal tracheal stenosis (SGS/PTS). Its major limitation is restenosis requiring repeated surgery. Intralesional steroid injection (ISI) is a promising adjunctive treatment aimed at prolonging the effects of dilation.

Objective

To evaluate the association of serial in-office ISI after endoscopic dilation with surgery-free interval (SFI) in adults with SGS/PTS.

Design, Setting, and Participants

A retrospective study of adults with SGS/PTS who underwent at least 2 consecutive in-office ISI at the University of Southern California, Keck School of Medicine, over a 3-year period was conducted.

Exposure

Serial ISI with triamcinolone 40 mg/mL using topical anesthesia, spaced 3 to 6 weeks apart.

Main Outcomes and Measures

Surgery-free interval, number of dilations, need for open airway surgery, decannulation rate, and adverse events. Patients with previous dilations and sufficient follow-up time were included in a comparative analysis of SFI before and after ISI. The Mann-Whitney U test was applied for comparisons.

Results

Twenty-four patients met eligibility criteria. Mean (SD) age was 50.1 (15.1) years; 18 (75%) were female. Ten (42%) patients had idiopathic, 8 (33%) had traumatic, and 6 (25%) had rheumatologic-related SGS/PTS. Mean (SD) follow-up time was 32.3 (33.4) months. Patients underwent mean (SD) 4.08 (1.91) injections. Seventeen (71%) patients have not undergone further surgery after ISI. Mean (SD) SFI was 17.8 (12.8) months overall and was 15.7 (10.6) months for idiopathic, 13.8 (9.9) for traumatic, and 26.7 (16.9) for rheumatologic-related SGS/PTS. Twenty-one (88%) patients underwent dilation(s) prior to ISI. Among patients who fulfilled eligibility criteria for comparison of SFI before and after ISI, SFI improved from 10.1 months before, to 22.6 months after ISI (mean difference, 12.5 months; 95% CI, -2.1 to 27.2 months). Three of 6 patients (all with traumatic SGS/PTS) presenting with a tracheotomy were decannulated. No patients required open airway surgery after ISI. There were no adverse events associated with ISI.

Conclusions and Relevance

Serial in-office ISI are safe and well-tolerated in adults with SGS/PTS. This technique can reduce the surgical burden on these patients and may obviate the need for future airway intervention.

Office-based vs. operating room-performed laryngopharyngeal surgery: a review of cost differences

Purpose

Office-based transnasal flexible endoscopic surgery under topical anesthesia has recently been developed as an alternative for transoral laryngopharyngeal surgery under general anesthesia. The aim of this study was to evaluate differences in health care costs between the two surgical settings.

Methods

PubMed, EMBASE and Cochrane Library were searched for studies reporting on costs of laryngopharyngeal procedures that could either be performed in the office or operating room (i.e., laser surgery, biopsies, vocal fold injection, or hypopharyngeal or esophageal dilation). Quality assessment of the included references was performed.

Results

Of 2953 identified studies, 13 were included. Quality assessment revealed that methodology differed significantly among the included studies. All studies reported lower costs for procedures performed in the office compared to those performed in the operating room. The variation within reported hospital and physician charges was substantial.

Conclusion

Office-based laryngopharyngeal procedures under topical anesthesia result in lower costs compared to similar procedures performed under general anesthesia.

Electronic supplementary material

The online version of this article (10.1007/s00405-019-05617-z) contains supplementary material, which is available to authorized users.

Cost of treating recurrent respiratory papillomavirus in commercially insured and medicaid patients

OBJECTIVES

The study objective was to estimate the first 2 years' direct costs of treating new cases of juvenile-onset and adult-onset recurrent respiratory papillomatosis (RRP) and determine the predictors of treatment costs.

METHODS

Cases were patients diagnosed with RRP in commercial insurance claims in 2011-2014 and Texas Medicaid in 2008-2012 for treatment of RRP. Controls were patients without a diagnosis of HPV-related cancer or RRP, matched with cases by age, sex, geographic area, date of diagnosis of RRP, and propensity score. Total health care costs in the first 2 years after diagnosis were obtained from cases and matched controls. A generalized linear model was created to identify predictors of monthly costs.

RESULTS

In commercially insured patients, a total of 122 cases of juvenile-onset (<18 years old) and 1824 cases of adult-onset (≥18 years old) RRP were identified. The mean first 2 years' cost difference between cases and controls was $58,733 for juvenile-onset disease and $11,185 for adult-onset disease after model adjustments. In the Texas Medicaid population, 73 cases of juvenile-onset and 96 cases of adult-onset RRP were identified. The mean first 2 years' cost difference between cases and controls was $76,115 for juvenile-onset disease and $4,633 for adult-onset disease after model adjustments.

CONCLUSION

The first 2 years' medical costs difference of juvenile-onset and adult-onset RRP among commercially insured and Medicaid population were approximately $60,000 to $70,000 and $5,000 to $11,000, respectively, and should be considered in HPV vaccination promotion investment decisions.

LEVEL OF EVIDENCE

N/A Laryngoscope, 130:1186-1194, 2020.

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.

Practice Patterns in Office-Based Rhinology: Survey of the American Rhinologic Society

BACKGROUND

Recent years have witnessed significant expansion in office-based rhinology. This study assesses practice patterns of the American Rhinologic Society (ARS) membership regarding office-based rhinologic procedures.

METHODS

A 24-item survey was disseminated to the ARS membership from March 15 to May 31, 2016.

RESULTS

A total of 157 physicians (11.9%) completed the survey. Office-based rhinologic procedures were performed by 99% of respondents, with sinonasal debridements (99%), polypectomy (77%), and balloon sinus ostial dilation (56%) being the most common. During a typical month, the number of sinonasal debridements was 0-10 in 23%, 11-20 in 34%, 21-30 in 26%, and >30 in 18%. For polypectomy, 57% of the respondents utilized a microdebrider (reusable electric-24%, disposable vacuum-powered-21%, and both-12%), 36% endoscopic forceps, and 7% a combination of both. With respect to balloon ostial dilation, the frontal sinuses were the most frequently addressed (53%) followed by the maxillary (46%) and sphenoid (39%) sinuses. In-office ethmoidectomies, antrostomies, sphenoidotomies, and frontal sinusotomies without the use of the balloon were performed by 35%, 31%, 24%, and 21% of the respondents, respectively. Thirty percent of respondents used steroid-eluting sinus implants and 10% used computer-assisted surgical navigation in the office setting. Overall, 63% of respondents reported that the number of office-based rhinologic procedures they performed had increased over the last 5 years.

CONCLUSIONS

The present study illustrates the integration of office procedures into rhinologic clinical practice among ARS survey respondents. With ongoing technologic innovations, the scope of office-based rhinology will likely continue to expand in the years to come.

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.

Investigation of the presence of HPV on KTP laser fibers following KTP laser treatment of papilloma

OBJECTIVES

Recurrent respiratory papillomatosis is often treated with in-office laser procedures using a potassium titanyl phosphate (KTP) laser transmitted through a laser fiber. Although effective, this procedure has notable downsides, including the possibility of transmitting human papillomavirus (HPV) in the smoke plume and the high cost of these single-use fibers. The objective of this study is to determine if HPV can be detected on a laser fiber after use, with or without sterilization.

METHODS

Twelve patients with laryngeal papillomas were treated with KTP laser energy transmitted via a KTP fiber. Ten fibers were sterilized in CIDEX (ASP, Irvine, California), a glutaraldehyde disinfectant, for 12 minutes, whereas two fibers were left unsterilized. Human papillomavirus DNA amplification was done on all 12 fiber samples with real-time polymerase chain reaction (PCR) using general primer mediated 5+ and 6+. Human papillomavirus genotyping detection was done using type specific probes and/or Sanger sequencing.

RESULTS

Over 27 strains of HPV were not detected on KTP fibers after use, with or without sterilization.

CONCLUSION

Human papillomavirus was undetectable by PCR on KTP laser fibers that were sterilized or unsterilized after use. Further studies are needed utilizing a transmission model to determine if HPV can be incubated from this fiber after sterilization.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:926-928, 2018.

Cost analysis of injection laryngoplasty performed under local anaesthesia versus general anaesthesia: an Australian perspective

Objective:

To conduct a cost analysis of injection laryngoplasty performed in the operating theatre under local anaesthesia and general anaesthesia.

Methods:

The retrospective study included patients who had undergone injection laryngoplasty as day cases between July 2013 and March 2016. Cost data were obtained, along with patient demographics, anaesthetic details, type of injectant, American Society of Anesthesiologists score, length of stay, total operating theatre time and surgeon procedure time.

Results:

A total of 20 cases (general anaesthesia = 6, local anaesthesia = 14) were included in the cost analysis. The mean total cost under general anaesthesia (AU$2865.96 ± 756.29) was significantly higher than that under local anaesthesia (AU$1731.61 ± 290.29) (p < 0.001). The mean operating theatre time, surgeon procedure time and length of stay were all significantly lower under local anaesthesia compared to general anaesthesia. Time variables such as operating theatre time and length of stay were the most significant predictors of the total costs.

Conclusion:

Procedures performed under local anaesthesia in the operating theatre are associated with shorter operating theatre time and length of stay in the hospital, and provide significant cost savings. Further savings could be achieved if local anaesthesia procedures were performed in the office setting.

Rate of new findings in diagnostic office bronchoscopy

OBJECTIVES

Awake Flexible Tracheobronchoscopy (FTB) is an alternative to rigid bronchoscopy or sedated flexible bronchoscopy and allows an awake examination of the tracheobronchial tree. We hypothesized that the ability to perform office bronchoscopy as the need arises during a clinic visit would lead to a high rate of previously undiagnosed and clinically relevant findings. This study reports the rate and nature of such findings for this procedure at our institution.

STUDY DESIGN

Retrospective chart review.

METHODS

The records of 127 adult patients evaluated at the voice and swallowing disorders clinic between June of 2012 and January of 2015 were reviewed. New findings were defined as new pathology visualized during FTB exam that was not previously diagnosed by means of other diagnostic modalities.

RESULTS

A total of 233 scope procedures (84 transnasal bronchoscopies and 149 tracheoscopies) were reviewed, 232 of which were completed and one of which was incomplete due to severe subglottic stenosis. New, clinically relevant findings were seen in 57% of transnasal bronchoscopies (48 of 84) and 21% of tracheoscopies (32 of 149). All of these findings provided additional information directing workup or resulted in a change in patient management.

CONCLUSION

Office-based evaluation of the tracheobronchial tree yields a high rate of new findings. In our study, office bronchoscopy had a 57% rate of new findings and was performed without complications. The utility of tracheoscopy was also apparent in its ability to quickly and safely examine the trachea, with a 21% rate of new findings.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1376-1380, 2017.

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.

Hemodynamic Parameters during Laryngoscopic Procedures in the Office and in the Operating Room

Objective

Previous research has shown that office-based laryngoscopic procedures can induce hemodynamic changes, including tachycardia and severe hypertension, calling into question the safety of these procedures. However, comparison between office and operating room (OR) procedures has not been carried out. Therefore, we prospectively measured hemodynamic variables in both settings to compare hemodynamic changes between office and OR procedures.

Study Design

Prospective cohort study.

Setting

Single academic center.

Subjects and Methods

Subjects undergoing office and OR laryngoscopic procedures were prospectively identified, and 92 OR and 70 office subjects were included. Heart rate and blood pressure were measured at established time points before, during, and after the procedures. Descriptive and comparative statistical analyses were conducted.

Results

Severe hemodynamic events, either tachycardia or severe hypertension (blood pressure >180 mm Hg systolic or >110 mm Hg diastolic), occurred significantly more frequently in OR than office procedures (41% vs 20%; P = .006). OR severe hemodynamic events occurred more commonly than previously reported rates in the office (41% vs 28%; P = .012). Regression analyses showed that the odds of having a severe hemodynamic event were 3.66 times higher in OR versus office procedures.

Conclusion

Severe hemodynamic events are more likely to occur in the OR than in the office during laryngologic procedures. While larger studies will be required to establish rates of dangerous cardiovascular events in laryngoscopic procedures, hemodynamic parameters indicate that office-based procedures have a safety benefit for procedures that can be conducted in either setting.

Office-based 532-Nanometer pulsed potassium-titanyl-phosphate laser for marsupialization of laryngeal and vallecular mucoceles

OBJECTIVES/HYPOTHESIS

Many laryngopharyngeal disorders are effectively managed in the office. Herein, an in-office method utilizing the 532-nm potassium-titanyl-phosphate (KTP) laser for the treatment of benign laryngeal and vallecular mucoceles is described.

STUDY DESIGN

Retrospective case review.

METHODS

A review was performed of patients who had their vallecular or laryngeal mucoceles marsupialized in the office using KTP laser.

RESULTS

Outcomes included long-term follow-up laryngoscopy for evidence of recurrence, significant intraprocedural complications, tolerance of the procedure, final pathology of the specimen, and resolution of symptoms.

CONCLUSIONS

In-office KTP marsupialization of laryngeal and vallecular mucoceles is effective and well tolerated, with no episodes of recurrence to date.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1116-1118, 2017.

Office-Based Laryngeal Laser Surgery: A Review of 443 Cases Using Three Wavelengths

BACKGROUND: Unsedated office-based laser surgery (UOLS) of the larynx and trachea has significantly improved the treatment options for patients with laryngotracheal pathology including recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. UOLS delivered by flexible endoscopes has dramatically impacted office-based surgery by reducing the time, costs, and morbidity of surgery.

OBJECTIVES: To review our experience with 443 laryngotracheal cases treated by UOLS.

METHODS: The laser logbooks at the Center for Voice and Swallowing Disorders were reviewed for UOLS, and the medical and laryngological histories were detailed, as were the treatment modalities, frequencies, and complications.

RESULTS: Of the 443 cases, 406 were performed with the pulsed-dye laser, 10 with the carbon-dioxide laser, and 27 with the thulium: yttrium-aluminum-garnet laser. There were no significant complications in this series. A review of indications and wavelength selection criteria is presented.

CONCLUSION: Unsedated, office-based, upper aerodigestive tract laser surgery appears to be a safe and effective treatment option for many patients with laryngotracheal pathology.

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.

Safety of paediatric day-stay laryngeal surgery for recurrent respiratory papillomatosis

OBJECTIVES

Safety assessment of day-stay laryngeal surgery in a cohort of children with recurrent respiratory papillomatosis (RRP). Recurrent respiratory papillomatosis is a chronic debilitating disease which usually requires multiple recurrent interventions under general anaesthesia. Day-stay surgery is an attractive option as it allows avoiding the inconvenience and costs of routine overnight admissions while recovering in the safe environment of the family home. This is the first study to assess the safety of day-stay laryngeal surgery in this cohort of patients.

METHODS

Retrospective cohort study of all consecutive RRP procedures performed between December 1998 and May 2015 in a single paediatric tertiary-level hospital.

RESULTS

A total of 465 surgical procedures were performed in 20 patients. Average age on diagnosis was 4.5 years. 415 (89.25%) of the procedures were done as day cases without overnight admission. Average number of procedures per patient was 20 and 25 for Children positive to HPV6 and HPV11, respectively. Only one patient after one single procedure (presenting 0.21% of total procedures, 0.24% of day-stay procedures) represented after discharge.

CONCLUSIONS

Day-stay surgery for children with RRP has a favourable safety profile in selected cases.

Timing of hemodynamic changes during transnasal endoscopic surgery

OBJECTIVES/HYPOTHESIS

Although considered less invasive and therefore less morbid than laryngoscopy under general anesthesia, prior research shows that transnasal flexible endoscopic (TNFE) procedures are associated with a significant increase in heart rate and blood pressure. The purpose of this review was to identify the most stimulating portion of the procedure to potentially provide a target for directed pharmacotherapy to ensure hemodynamic stability.

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective chart review of adult patients who underwent upper airway intervention in the larynx and trachea by TNFE. Vital signs recorded at 5-minute intervals throughout the procedure were examined and analyzed by Wilcoxon signed rank test and Wilcoxon rank sum test.

RESULTS

For heart rate and systolic and diastolic blood pressure, the median change in value was 13 beats per minute (P < 0.0001), 27 mm of mercury (P < 0.0001), and 26.5 mm of mercury (P < 0.0001), respectively. The most significant change in heart rate and saturation was during the application of nasal and laryngeal anesthetic, as well as during the positioning of the scope. Blood pressures were elevated during the procedure itself. With respect to comorbidities, underlying asthma and coronary artery disease were associated with a greater percent change in the heart rate (P = 0.05 for both).

CONCLUSION

There are significant vital sign changes during transnasal endoscopic procedures. Changes in heart rate and oxygen saturation tended to occur during preparation, whereas blood pressure was elevated during the laryngeal intervention. For patients with asthma, the percent change was greater, and perhaps a more controlled environment is warranted.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2047-2050, 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.

Is Nebulized Lidocaine Adequate Topical Anesthesia for Diagnostic Transnasal Tracheoscopy?

OBJECTIVES

To evaluate if nebulized 4% lidocaine alone provides adequate laryngopharyngeal anesthesia for office-based diagnostic transnasal tracheoscopy (TNT).

METHODS

A retrospective chart review (January 2011 to June 2014) and a prospective case series (July 2014 to December 2014) of patients who underwent diagnostic TNT were performed at a university voice and swallowing center. TNT cases were categorized by method of topical laryngopharyngeal anesthesia: nebulized 4% lidocaine and 4% lidocaine drip (phase I) and nebulized 4% lidocaine only (phase II).

RESULTS

TNT was performed a total of 59 times on 38 patients. Eleven (69%) of 16 phase I TNT procedures involved significant patient discomfort and severe cough following the lidocaine drip. Forty-two (98%) of 43 phase II TNT procedures were completed comfortably; 1 case required additional anesthesia by lidocaine drip. Retrospectively, 100% (n=8) of patients who underwent both phase I and phase II TNTs were noted to prefer anesthesia with nebulizer alone. In a prospective case series of 14 phase II TNT cases, 6 (86%) of 7 patients who previously underwent phase I TNT reported preference for anesthesia with nebulizer alone.

CONCLUSIONS

Nebulized lidocaine appears to provide sufficient laryngopharyngeal anesthesia for diagnostic TNT. It is preferred by patients over laryngeal drip.

The Safety of Antithrombotic Therapy During In-office Laryngeal Procedures-A Preliminary Study

INTRODUCTION

In-office laryngeal procedures present an alternative to the risks and costs associated with general anesthesia. However, the inherent control afforded by the operative theater is decreased potentially increasing the risk of complications. Many patients undergoing these procedures have traditional surgical risk factors, such as antithrombotic (AT) medical therapy. We sought to quantify complication rates for in-office procedures as a function of AT therapy.

METHODS

A retrospective review of 127 diverse, in-office laryngeal procedures was performed and patients were then stratified based on AT medication status and type of procedure. The primary dependent variables were intraoperative and postoperative complications. Additionally, in those patients undergoing procedures with the goal of voice improvement, Voice Handicap Index (VHI)-10 scores were used to quantify the success of the procedure as a function of AT therapy.

RESULTS

Of the 127 procedures, 27 procedures (21.2%) involved patients on some form of AT agent that was not ceased for the procedure. Across all patients, no intraoperative complications were encountered, irrespective of therapeutic status. Three postoperative complications were noted; all in patients not on AT therapy. A statistically significant improvement in VHI-10 scores was noted across all patients, irrespective of AT status.

CONCLUSIONS

AT medications do not appear to increase the risk of complications associated with in-office laryngeal procedures. Furthermore, AT therapy seemed to have no negative impact on the voice outcomes of patients undergoing procedures for voice improvement.

Vocal process granulomas: a systematic review of treatment

OBJECTIVES

Vocal process granulomas (VPGs) are benign laryngeal lesions with controversial treatment and a tendency to recur. There are several treatment options with unpredictable results, high recurrence rates, and disappointing long-term outcome. The aims of this article are to focus on evidence-based current treatment strategies for primary lesions and recurrences.

DATA SOURCES

The data came from a systematic review of the literature.

METHODS

Main outcome measures were recurrence rate, reduction, and/or complete resolution. Inclusion criteria included English literature, randomized and nonrandomized trials, prospective and retrospective studies, and primary and recurrent cases. Exclusion criteria included case reports, teaching reviews, and papers not focusing on treatment.

RESULTS

The time frame of the included studies was from 1997 to 2012. There are 6 different treatment options (single or combined) for VPG. Antireflux medication is the mainstay treatment and when combined with lifestyle changes and voice therapy results in the lowest recurrence rate. "Bloodless" in-office or in-theater laser techniques appear to have lower recurrence rates when compared to traditional cold steel microlaryngoscopy techniques, especially for recurrences.

CONCLUSIONS

There is level 2A evidence that antireflux treatment is the main treatment strategy for vocal process granulomas with surgery reserved only for failures of medical treatment or airway obstruction or when diagnosis is in doubt.