Topical anesthetic techniques in office-based laryngeal surgery: A comparison of patient preferences.

OBJECTIVES: Multiple topical anesthesia techniques exist for office-based laryngeal surgery. Our objective was to assess patient and surgeon satisfaction for three different techniques. STUDY DESIGN: Cohort study. METHODS: All consecutive patients presenting to an outpatient laryngology office for awake surgical procedures were enrolled. Patients were anesthetized with local anesthesia (2 cubic centimeters of 4% lidocaine) in one of three ways: 1) nebulizer, 2) flexible cannula through a channeled laryngoscope, or 3) transtracheal instillation. Demographics, procedure times, and surgeon satisfaction were recorded. A validated 11-item patient satisfaction questionnaire (Iowa Satisfaction with Anesthesia Survey) was administered after the procedure to calculate an overall satisfaction score (-3[worst] to 3[best]). Descriptive and correlative statistics were performed. RESULTS: One hundred consecutive patients were included (37 females, 73 males), with relatively equal numbers between groups (32 nebulizer, 35 cannula, 33 transtracheal). Seven procedures were aborted (4 nebulizer, 2 cannula, 1 transtracheal) due to movement, anxiety, or technical issues. Three patients did not adequately complete the survey. Of the 90 remaining patients, patient satisfaction was highest with the transtracheal technique (2.04) versus cannula (1.46) or nebulizer (1.45), and this was statistically significant (P = 0.0167). This difference was driven by decreased pain and nausea scores in the transtracheal group. Surgeon satisfaction was lower with nebulizer and higher with transtracheal injection (P = 0.0081). There was a correlation between surgeon satisfaction and patient satisfaction (P < 0.0001). CONCLUSION: Transtracheal instillation was favored by both patients and the surgeon. Choice of local anesthetic techniques may impact patient preferences and surgical success. This may serve as a basis for optimizing anesthetic care in office-based laryngeal surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:166-170, 2020.

Pediatric dysphonia: It's not about the nodules.

OBJECTIVE: Despite the fact that vocal nodules are the most common cause of chronic dysphonia in children, uncertainty and lack of consensus complicates practically every diagnostic and management decision. Selecting an optimal staging system is fundamental to understanding a disease process, mandatory for uniform reporting, and crucial to predicting natural history and treatment outcomes. The ideal prognostic model for vocal nodules is under intense debate. The purpose of this study was to analyze the predictive power of vocal nodule grade to severity of voice metrics in children. METHODS: Seventy-nine patients diagnosed with vocal cord nodules between 2006 and 2012 were drawn from UPMC Children's Hospital of Pittsburgh Voice, Resonance and Swallowing Center Research Registry. Subject age at time of diagnosis, nodule grade, relevant co-morbidities, scores on The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), parent-reported Pediatric Voice Handicap Index (pVHI), the phonotraumatic behaviors profile, habitual speaking pitch fundamental frequencies, pitch range, volume intensity, and s/z ratio were recorded and compiled into a de-identified database for analysis. RESULTS: Based on the Kruskal-Wallis H Test, there was no statistically significant correlation between nodule grade and total pitch range (p = .21), s/z ratio (p = .50), volume intensity (p = .33), overall CAPE-V Scores (p = .15), or pVHI Scores (p = .29). Chi-squared tests also revealed no significant associations between nodule grade and abnormality in habitual speaking pitch (p = .14 for fundamental frequency while sustaining a vowel sound, p = .37 for fundamental frequency while speaking structured tasks i.e. counting, or p = .76 while speaking in conversation). CONCLUSION: The current "gold-standard" for grading vocal nodule size suggests that the nodules themselves are not driving the standard dysphonic metrics that are most commonly collected and monitored in such children. This outcome is consistent with other studies reporting similar findings and was expected based on the inconsistencies in the reported literature to date. By extension, the conventional wisdom of avoiding surgical treatment of vocal nodules in children seems prudent as there is little evidence to suggest that the nodules themselves are "driving" the severity of the dysphonia. Ultimately identifying the true "drivers" of dysphonia in children will suggest alternative therapies that are more specific and directed to the pathophysiology. Most pediatric voice care professionals will welcome such discoveries as those in the front line of patient care are often rendered helpless and frustrated.

Feasibility of transnasal flexible carbon dioxide laser surgery for laryngopharyngeal lesions.

OBJECTIVE: The fiber-guided carbon dioxide (CO2) laser is a useful device for laryngopharyngeal surgery. The flexible CO2 wave-guide laser has been developed and commercially available for several years. However, the transnasal use of CO2 flexible wave-guided laser surgery through the instrument channel of a flexible endoscope (CO2 TNFLS) is not permitted in Japan. This feasibility study aimed to assess the value and the safety of an in-office CO2 TNFLS procedure. METHODS: Patients with small laryngopharyngeal diseases were enrolled from June 2015. Eligible patients had indications with lesions generally localized superficial lesions such as the benign tumor, leukoplakia, and premalignant lesion-like carcinoma in situ (CIS). Patients were locally well anesthetized using xylocaine. After removing as much of the lesion(s) as possible with flexible forceps, the remainder of the lesions were evaporated using CO2 TNFLS through the instrument channel of a flexible endoscope under local anesthesia. RESULTS: Eighteen surgeries involving 13 patients, including 9 papilloma (7 recurrent respiratory papilloma [RRP]), 2 carcinoma in situ, 1 leukoplakia, and 1 large epiglottic cyst), were performed. Four patients with RRP required multiple surgeries. Except for 3 patients with RRP, all patients achieved disease control without additional intervention. All procedures were completed with no severe adverse events. CONCLUSION: Office-based CO2 TNFLS is safe and feasible for patients with laryngopharyngeal pathologies. It is especially valuable for RRP patients with small lesions to avoid surgery under general anesthesia.

Inflammatory myofibroblastic tumor of the epiglottis excised with a carbon dioxide laser: Case report and literature review.

Inflammatory myofibroblastic tumor (IMT) is a benign neoplasm of intermediate biologic potential. It rarely occurs in the larynx, and it has not been previously reported in the epiglottis. We treated a 66-year-old woman who presented with progressive dysphonia and a mass on her suprahyoid epiglottis. The tumor was completely excised with a CO2 laser; no adjuvant therapy was administered. Histopathology revealed that the mass was an IMT. No evidence of recurrence was noted after 6 months of follow-up. We present what we believe is the first case of an epiglottic IMT to be reported in the literature, and we propose CO2 laser excision without adjuvant therapy as an acceptable treatment.

New 445 nm blue laser for laryngeal surgery combines photoangiolytic and cutting properties.

BACKGROUND: Photoangiolytic lasers have broadened the surgical armamentarium for many phonosurgical interventions. However, the pulse dye laser and potassium titanyl phosphate (KTP) laser have technical drawbacks and a smaller spectrum of indications. METHODS AND RESULTS: The new 445 nm wavelength laser, the so-called 'blue laser', proves to show tissue effects comparable to the KTP laser and is also capable of treating subepithelial vessels due to its photoangiolytic properties, it can coagulate and carbonize at higher energy levels, and can be used via glass fibers in non-contact and contact mode for in-office procedures. DISCUSSION: In contrast to the KTP, the new 445 nm laser can also be used as a cutting laser, thus combining very much wanted properties of diode or CO2 lasers with photoangiolytic lasers. Further advantages of the new laser are the; (1) portability of the shoe box sized, shock-proof laser machine for in-office and operating room usage, (2) the selection of pulse rates from continuous wave (cw) to less than a millisecond, (3) stronger tissue effects compared to KTP with similar energy and pulse settings, (4) far better cutting properties than the KTP, and thus (5) more possibilities for usage in laryngology as well as in other fields or surgery. CONCLUSION: We demonstrate the feasibility of the 445 nm laser in several laboratory experiments and show clinical cases where photoangiolysis and cutting was possible. However, this is a preliminary report and further systematic studies in greater numbers are warranted.

Can videolaryngoscopy be a first option in a patient with laryngeal amyloidosis? / ¿Puede la videolaringoscopia ser una primera opción en paciente con amiloidosis laríngea?

Amyloidosis is a term that involves a group of diseases characterised by deposition of extracellular monoclonal light-chain fibrillar immunoglobulin aggregates in the body, including many organs, with the larynx among them. A case is presented of a 78 year-old man who was referred to our institution for strangulated umbilical hernia treatment. He suffered from progressive hoarseness and dysphagia for 5months. He had a history of primary laryngeal amyloidosis. Awake intubation was performed successful with the King Vision® video-laryngoscopy. Sedation was achieved using a remifentanil infusion and midazolam. Haemorrhagic lesions are caused by deposition of amyloid in and around vessels, resulting in increased vascular fragility. Therefore, anaesthetists should take care in intubating the tracheas of these patients.

[Endoscopic ultra dream pulse laser surgery of laryngomalacia. Our experiences gained during the introduction of the method in Hungary]. / A laryngomalacia endoszkópos ultrapulzációs-lézeres (ultra dream pulse) sebészete. A módszer hazai bevezetése során szerzett tapasztalataink.

INTRODUCTION: Congenital stridor and dyspnoe are caused by laryngomalacia in most cases. AIM: In this article we present a new, surgical method for treating severe laryngomalacia in patients under the age of 1, where ultrapulsated (UDP) laser beam is used for supraglottoplasty. Ultra dream pulse laser creates lesser thermical side damage in the tissue, therefore the risk of postoperative laryngeal oedema and scarring is lower. METHOD: We present 10 cases and the endoscopic UDP-laser surgery of patients under the age of 1 with severe laryngomalacia. RESULTS: After the surgery the stridorous symptoms disappeared, and there was no evidence of postoperative laryngeal oedema, there was no need for reoperation or tracheotomy in any of the cases. CONCLUSION: UDP-laser surgery of laryngomalacia is proven to be a safe and effective surgial modality. During the follow up visits we experienced neither recurrence of stridor nor laryngeal scarring. Orv Hetil. 2017; 158(33): 1288-1292.

Upper Airway Obstruction Requiring Emergent Tracheostomy Secondary to Laryngeal Sarcoidosis: A Case Report.

BACKGROUND Laryngeal sarcoidosis is a rare extrapulmonary manifestation of sarcoidosis, accounting for 0.33-2.1% of cases. A life-threatening complication of laryngeal sarcoidosis is upper airway obstruction. In this report we describe our experience in the acute and chronic care of a patient who required an emergent tracheostomy, with the aim to provide further insight into this difficult to manage disease. CASE REPORT A 37-year-old African American female with a 10-year history of stage 1 sarcoidosis presented with severe dyspnea. Laryngeal sarcoidosis was diagnosed three years previously, and she remained stable on low-dose prednisone until six months prior to admission, at which time she self-discontinued her prednisone for the homeopathic treatment Nopalea cactus juice. Her physical examination was concerning for impending respiratory failure as she presented with inspiratory stridor and hoarseness. Laryngoscopy showed a retroflexed epiglottis obstructing the glottis with edematous arytenoids and aryepiglottic folds. Otolaryngology performed an emergent tracheostomy to secure her airway and obtained epiglottic biopsies, which were consistent with sarcoidosis. She was eventually discharged home on prednisone 60 mg daily. Following months of corticosteroids, a laryngoscopy showed the epiglottis continuing to obstruct the glottis. The addition of methotrexate to a tapered dosage of prednisone 10 mg daily was unsuccessful, and she remains on prednisone 20 mg daily for disease control. CONCLUSIONS Laryngeal sarcoidosis, a rare extrapulmonary manifestation of sarcoidosis, uncommonly presents as the life-threatening complication of complete upper airway obstruction. As such, laryngeal sarcoidosis is associated with significant morbidity and mortality, requiring a high index of suspicion for timely diagnosis and treatment.

Surgery or Rehabilitation: A Randomized Clinical Trial Comparing the Treatment of Vocal Fold Polyps via Phonosurgery and Traditional Voice Therapy with "Voice Therapy Expulsion" Training.

OBJECTIVE: Phonomicrosurgery is generally considered to be the treatment of choice for removing vocal fold polyps. However, specific techniques of voice therapy may represent, in selected cases and under certain conditions, a noninvasive therapeutic option for the treatment of such laryngeal lesions. The aim of the present study is to longitudinally assess, in terms of clinical outcomes and quality of life, two groups of patients with cordal polyps, treated either with standard surgery plus standard voice therapy or with a specific training of voice therapy alone, which we have called "Voice Therapy Expulsion." STUDY DESIGN: This study is a randomized controlled trial. METHODS: A total of 150 patients with vocal fold polyps were randomly assigned to either standard surgery or "voice therapy expulsion" protocol. The trial was carried out at the Division of Phoniatrics and Audiology of the Second University of Naples and at the Division of Communication Disorders of Local Health Unit (3 Naples South) from January 2010 to December 2013. A thorough phoniatric evaluation, including laryngostroboscopy, acoustic voice analysis, global grade of dysphonia, instability, roughness, breathiness, asthenia, and strain scale, Voice Handicap Index, and Voice-Related Quality of Life, was performed by using standardized tools, at baseline, at the end of the treatment, and up to 1 year after treatment. RESULTS: We found no significant differences between the two experimental groups in terms of clinical outcomes and personal satisfaction. However, "Voice Therapy Expulsion" was associated with higher scores for quality of life at endpoint evaluation. CONCLUSIONS: Besides phonosurgery, this specific "Voice Therapy Expulsion" technique should be considered as a valid, noninvasive, and well-tolerated therapeutic option for the treatment of selected patients with vocal fold polyps.

Does topical anesthesia using aerosolized lidocaine inhibit the superior laryngeal nerve reflex?

OBJECTIVE: This study was designed to evaluate the effectiveness of topical lidocaine in attenuating the laryngeal reflex and blunting hemodynamic response by inhibition of the superior laryngeal nerve in laryngeal microsurgery, which would be helpful in preventing potential complications. STUDY DESIGN: A prospective, randomized, double-blind study. SETTING: Tertiary medical center. SUBJECTS AND METHODS: Fifty-four patients requiring glottic and supraglottic laryngeal microsurgery were randomly assigned to 1 of 2 groups, with equal numbers. Before surgery, 10% lidocaine was topically applied to the laryngeal surface of the epiglottis and vocal folds under direct vision in the study group and saline aerosol was applied in the control group. Heart rates, arterial blood pressure, and SPO2 were recorded at baseline, after induction, immediately before and after intubation, during the surgery, and upon extubation. Laryngospasm, agitation, and coughing were recorded during the recovery period. RESULTS: Heart rates, arterial pressure, and SPO2 did not differ significantly from baseline to postintubation period among the groups. SPO2 values measured similar in the remaining study. Heart rates and blood pressures were slightly decreased in the study group after lidocaine administration, but only blood pressure at pre- and post-extubation was significantly decreased in the study group (P < .05). Also laryngospasm and coughing were not statistically different between the 2 groups. There was an obvious gap between the 2 groups for agitation. Study group agitation was noted significantly lower (P < .05). CONCLUSION: These findings indicate that preoperative topical lidocaine application may be helpful in attenuating airway-circulatory reflexes in laryngeal microscopic surgery.

Cross-over study of topical anaesthesia with tetracaine solution for transoral rigid laryngoscopy.

BACKGROUND: Transoral rigid laryngoscopy with videostroboscopy is the most practical method to visualise the vocal folds. The optimal topical anaesthesia regimen for transoral rigid laryngoscopy has not yet been established. OBJECTIVE: To compare patient comfort and compliance with various topical anaesthetics for transoral rigid laryngoscopy. METHODS: Each of 10 patients received a random topical administration of either 2 per cent lidocaine gel, 1 per cent tetracaine gel or 1 per cent tetracaine solution, 10 minutes before undergoing rigid laryngoscopy with videostroboscopy. During follow-up laryngoscopies, the agent with the lowest mean visual analogue scale score for discomfort was then used to study the timing of topical anaesthetic application: the agent was given to the patient 5, 10 or 15 minutes before laryngoscopy (with the timing randomly selected). RESULTS: Compared with lidocaine gel or tetracaine gel, laryngoscopy with topical tetracaine solution was more comfortable. There was a statistically significant difference in discomfort score between the 5 and 10 minute application groups, but not between the 10 and 15 minute groups. CONCLUSION: Tetracaine solution, applied topically 10 minutes before transoral rigid laryngoscopy, significantly decreases patient discomfort.

Therapeutic choices for curing dysodia?...three clinical cases.

These three clinical cases provide an approach to the management of anatomical voice disorders. When confronted with a laryngeal diagnosis, talented musicians often suffer a crisis of self-confidence which may propel them toward maladaptive compensations; these may destabilize their usual techniques, already disrupted by the changes in their vocal acoustics. In their forties, each of these patients presents with an angiomatous lesion of the vocal fold, associated in two of the cases with a congenital structural weakness. For the three of them, the recommended therapeutic choice was alternating recorded laryngoscopic follow-up, alternative medicine prescriptions, and "artistic sessions" that required that their phoniatrician adapt to their repertory, their temperament, the constraints of the stage and their laryngeal disorder in order that they achieve a compromise between the needs of their career and the laryngeal anatomic realities of the moment. These "artistic guidance sessions" are recorded so as to allow the patient to become aware of the quality of their public performance and to learn the functional elements contributing to it.

[Effects on function rehabilitation of vocal cord after vocal cord polyps surgery treated with acupuncture at Sheng's four points of throat].

OBJECTIVE: To observe the effects on function rehabilitation of vocal cord after vocal cord polyps surgery treated with acupuncture at Sheng's Four Points of Throat. METHODS: Sixty cases were randomly divided into a combined therapy group of Four Points of Throat and medication (group 1, 30 cases) and a medication group (group 2, 30 cases). In group 1 Four Points of Throat were punctured and routine medication was applied; in group 2, only routine medication was applied. The scores of symptom-sign and status of voice were observed and analyzed before and after treatment in two groups. RESULTS: At 4th day after the surgery, the improvement of the symptom-sign scores in group 1 was more significant than that in group 2 (P < 0.05); and the voice analysis status in group 1 was superior to that in group 2 (all P < 0.05). The total effective rate was 83.3% (25/30) in group 1, which was superior to that of 60.0% (18/30) in group 2 (P < 0.05). CONCLUSION: The effect on function rehabilitation of vocal cord after vocal cord polyps surgery treated with the combined therapy group of Four Points of Throat and routine medication is favorable, superior to that with routine medication therapy.

Office-based laryngeal laser surgery with local anesthesia.

PURPOSE OF REVIEW: Office-based laryngeal laser surgery was created recently and is emerging as a reliable and practical method of treating a number of laryngeal lesions. This style of minimally invasive surgery is becoming increasingly popular in the United States and abroad. RECENT FINDINGS: Fiber-based lasers and distal-chip flexible endoscopy have facilitated a new style of surgery. Epithelial diseases such as dysplasia and papillomatosis are well suited for treatment. Although the initial angiolytic laser used was a 585-nm pulsed-dye laser, the 532-nm pulsed-potassium-titanyl-phosphate laser has been demonstrated to be more effective. The 2013-nm Thulium laser shows promise as an office-based laser that simulates the properties of the carbon dioxide laser. SUMMARY: Evolving technologies to enhance laryngoscopic imaging and lasers along with socioeconomic forces should lead to increasing numbers of laryngeal procedures being performed in the office with local anesthesia.

[The "intra-cordal polyp": a clinical alternative to recognize?]. / Le polype "intra-cordal" : une variante clinique à reconnaitre?

UNLABELLED: The vocal cord polyp is an inflammatory false tumour of the larynx. It is characterized mainly by the specific existence of fibrinous exsudats organized in loose network or mounds, surrounded by newly formed vascular slits. The epithelium covering the polyp is usually more or less impaired. CLINICAL CASES: The authors report two adult patients among whom the initial presentation in video-stroboscopy was that of an intracordal lesion of a cystic type, however; with unusual characteristics (purplish color, angiomatous aspect). The surgery consisted of a cordotomy, the surface epithelium appearing normal. After dissection, the two lesions seemed to be presenting the typical aspect of fibrinoïd mound of a polyp, observation confirmed by the anatomo-pathological study. In these cases, the resection was finally carried out with no mucous loss. CONCLUSION: The particular etiopathogeny of these lesions is been discussed. The treatment, medical and of rehabilitation could achieve a partial recovery. In the event of surgery, an access to the lesion through a cordotomy and not directly by removal with microcissors is advised.

Videoendoscopic surgery for inaccessible glottic lesions.

OBJECTIVES: Lesions in the anterior segment of the vocal fold are sometimes difficult to access by means of conventional suspension microlaryngoscopy under general anaesthesia because of anatomical factors such as short, stout and inflexible necks, reduced jaw protrusion, and long incisors. Various techniques have recently been proposed for the management of inaccessible glottic lesions, most of which are performed under general anaesthesia. The use of flexible videoendoscopic surgery under topical anaesthesia in two cases of anterior glottic lesions that could not be treated by means of conventional suspension laryngoscopy is described. STUDY DESIGN: Case report. METHODS: A flexible videobronchoscope with an instrument channel was inserted transnasally on an out-patient basis. While the examiner carried out the endoscopy, an assistant maneuvered the biopsy forceps through the instrument channel, and removed the lesion. RESULTS: Both patients underwent successful removal of an anterior glottic polyp, and the one-year follow-up evaluation revealed normal anatomy of the vocal folds and normal vocal function. CONCLUSIONS: Flexible videoendoscopic surgery under topical anaesthesia is a safe, simple and minimally invasive procedure that can be considered as an alternative to traditional endoscopic surgery for inaccessible anterior glottic lesions.

[Microlaryngoscopic surgery in the treatment of vocal cord benign lesion under surface anesthesia].

OBJECTIVE: To evaluate the effect of microlaryngoscopic surgery in the treatment of vocal cord benign lesion. METHOD: The operation was performed using suspension laryngoscope and common operative microscope under surface anesthesia with 1% pontocaine. RESULT: In the 872 patients,438 cases had vocal nodules, 353 were vocal polyps and other vocal cord cysts. In 208 patients underwent successful operation, 171 cases were cured clinically and 36 cases improved after the first attempt with a general effective rate of 96.3%. CONCLUSION: The most patients who had vocal cord benign lesions without severe cardiovascular diseases could be operated under surface anesthesia which have the advantages of rare complications and rapid recovery.