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.

Electromagnetic navigational bronchoscopy-directed dye marking for locating pulmonary nodules

BACKGROUND

Small peripheral pulmonary nodules, which are usually deep-seated with no visual markers on the pleural surface, are often difficult to locate during surgery. At present, CT-guided percutaneous techniques are used to locate pulmonary nodules, but this method has many limitations. Thus, we aimed to evaluate the accuracy and feasibility of electromagnetic navigational bronchoscopy (ENB) with pleural dye to locate small peripheral pulmonary nodules before video-associated thoracic surgery (VATS).

METHODS

The ENB localisation procedure was performed under general anaesthesia in an operating room. Once the locatable guide wire, covered with a sheath, reached the ideal location, it was withdrawn and 0.2-1.0 mL of methylene blue/indocyanine green was injected through the guide sheath. Thereafter, 20-60 mL of air was instilled to disperse the dye to the pleura near the nodules. VATS was then performed immediately.

RESULTS

Study subjects included 25 patients with 28 nodules. The mean largest diameter of the pulmonary nodules was 11.8 mm (range, 6.0-24.0 mm), and the mean distance from the nearest pleural surface was 13.4 mm (range, 2.5-34.9 mm). After the ENB-guided localisation procedure was completed, the dye was visualised in 23 nodules (82.1%) using VATS. The average duration of the ENB-guided pleural dye marking procedure was 12.6 min (range, 4-30 min). The resection margins were negative in all malignant nodules. Complications unrelated to the ENB-guided localisation procedure occurred in two patients, including one case of haemorrhage and one case of slow intraoperative heart rate.

CONCLUSION

ENB can be used to safely and accurately locate small peripheral pulmonary nodules and guide surgical resection.

TRIAL REGISTRATION NUMBER

ChiCTR1900021963.

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.

Wound healing after transoral angiolytic laser surgery for early glottic carcinoma

OBJECTIVES/HYPOTHESIS

Wound healing after transoral angiolytic laser surgery for early glottic carcinoma was analyzed to identify factors influencing healing and clinical significance of persistent granulation tissue.

STUDY DESIGN

Retrospective review.

METHODS

A retrospective review of 100 consecutive patients undergoing endoscopic angiolytic laser surgery for T1 and T2 glottic carcinoma was performed. Patients with prior radiation or incomplete data were excluded. Postoperative endoscopic images were analyzed for time to healing, size and location of wound, and presence of granulation tissue. Three blinded, independent raters graded wound appearance and presence of granulation tissue.

RESULTS

Seventy-nine patients healed without need for intervention at a median of 3.5 months. Two patients had office-based ablation of granulation without biopsy and healed. The remaining 19 patients had biopsy for granulation tissue. Wounds that underwent biopsy at >3 months were more likely to contain carcinoma (5/6 patients, 83%) than wounds that were biopsied <3 months (2/13 patients, 15%) (P = .004). Presence of granulation significantly correlated with resection involving anterior commissure (P = .01), > 75%vocal fold length (P = .006), and depth into muscle (P = .001). Delayed healing (>3 months) correlated with T2b tumors (P = .02), depth into ligament (P = .002) and anterior commissure involvement (P = .04). T1a carcinomas more commonly healed in <3 months (P = .005).

CONCLUSIONS

Many vocal fold wounds heal completely within 3.5 months after angiolytic laser surgery for early glottic carcinoma. Larger and deeper wounds are more likely to heal with granulation tissue. Granulation can resolve without surgical intervention; however, granulation present > 3 months warrants biopsy due to increased risk of malignancy.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:435-440, 2019.

Can "Indirect" Contact Laser Surgery be Used for Fluorescence-Image Guided Tumor Resections? Preliminary Results

Ensuring the complete removal of tumor tissue is the main challenge during resection operations. Recently, a technique of “indirect” contact laser surgery has been developed. In this study we assess the possibility of using such surgery for fluorescence image-guided tumor resection. Mouse colon adenocarcinoma CT-26 cells stably expressing the fluorescent protein mKate-2 was used as the tumor model. Resections of the tumor nodes were performed with either a scalpel blade, a laser scalpel with a bare tip, or a laser scalpel with a strongly absorbing coating on the fiber tip. Tumor-positive resection margins were detected using an IVIS Spectrum fluorescence imaging system. After tumor resection with the scalpel blade over half of the animals needed one additional resection to remove residual tumor cells. Animals in this group showed tumor recurrence within 7 days. Fluorescence imaging of the tumor bed, performed after resection to assess the presence of tumor cell clusters, was sufficiently effective only with a bloodless resection. The laser scalpels both with the bare tip and with the strongly absorbing coating on the tip provided such bloodless tumor resection in contact mode. Fewer animals required additional resections when the bare tipped scalpel was used and this also resulted in a reduction in tumor recurrence. After resections were carried out with the laser scalpel with the strongly absorbing coating on the tip, fluorescence was detected in the operative field and this led to undertaking additional resections, although subsequent investigation suggested that this was “false” fluorescence, resulting from the effects of the scalpel rather than the presence of residual tumor cells. The method of laser resection with a strongly absorbing coating on the tip therefore did not appear to demonstrate definite advantages over laser resection with a bare tip when removing tumors.

Middle fossa approach to a temporosphenoidal encephalocele -technical note-

Temporosphenoidal encephalocele (TSE) is a rare entity caused by herniation of the anteromedial temporal lobe into the sphenoid sinus (SS) through a middle fossa (MF) defect. A 45-year-old woman presented with a spontaneous TSE manifesting as a 4-year history of recurrent cerebrospinal fluid rhinorrhea and meningitis. Coronal computed tomography showed a skull defect in the superior wall of the right lateral recess of the SS. This homogeneous intrasphenoidal lesion appeared hypointense on T(1)-weighted magnetic resonance (MR) imaging and hyperintense on T(2)-weighted MR imaging. The patient underwent a frontotemporal craniotomy and extradural MF exploration. The encephalocele was amputated and the temporal base dura primarily sutured and reinforced with fat graft. The MF hole was plugged with temporalis fascia and a calvarial graft layered over the bone defect. Histological examination confirmed meningoencephalocele. Rhinorrhea resolved and the patient remained asymptomatic. Resection of an anteromedial TSE and closure of the craniodural defect in the MF floor via a less invasive extradural skull base approach is effective.