In-office Laryngeal Procedures: a Modern Perspective for Vocal Fold Interventions

Introduction: The purpose of this article is to discuss in-office laryngeal procedures as an alternative to surgical intervention under general anesthesia. In-office procedures have become more common due to technological advancements. As a result, these approaches are less invasive and more patient-friendly, with increased pain tolerance and reduced procedure time and cost. Methods: We conducted a thematic analysis of published reports regarding the best known and performed in-office laryngeal interventions. Three questions guided our analysis: What laryngological procedures can be performed in the office setting? What are the advantages of in-office laryngology procedures compared to operating room surgical procedures? Why aren't more in-office procedures performed in some Latin American countries? Discussion: Despite being performed more frequently, there is still controversy whether in-office procedures should be performed as often due to the risk of complications. Furthermore, procedures that are done in the office setting are more popular in some countries than in others, even though their benefit has been well demonstrated. This article describes various in-office procedures, including biopsy, vocal fold injections, and laser surgery. We also discuss what factors might contribute to having office-procedures being performed more frequently in some countries than others. Conclusion: Awake interventions offer numerous benefits, including shorter procedure time, reduced costs, and lower patient morbidity. These advantages have significantly transformed the treatment of laryngeal diseases in modern laryngology practice in a global manner.

Introducción: El propósito de este artículo es discutir los procedimientos laríngeos en el consultorio como una alternativa a la intervención quirúrgica bajo anestesia general. Los procedimientos en consultorio se han vuelto más comunes debido a los avances tecnológicos. Como resultado, estos enfoques son menos invasivos y más amigables para el paciente, con mayor tolerancia al dolor y reducción del tiempo y costo del procedimiento. Métodos: Realizamos un análisis temático de los informes publicados sobre las intervenciones laríngeas más conocidas y realizadas. Tres preguntas guiaron nuestro análisis: ¿Qué procedimientos laringológicos se pueden realizar en el consultorio y cuales sin los más frecuentes?, ¿cuáles son las ventajas de los procedimientos laringológicos fuera del quirófano frente a los que se realizan bajo anestesia general?, ¿por qué no se realizan más procedimientos laringológicos en el consultorio en la mayoría de los países en Latinoamérica? Discusión: A pesar de que se realizan con mayor frecuencia, aún existe controversia sobre si los procedimientos en consultorio deben realizarse con tanta frecuencia debido al riesgo de complicaciones. Además, los procedimientos que se realizan en el consultorio son más populares en algunos países que en otros, aunque sus beneficios han sido bien demostrados. Este artículo describe varios procedimientos en el consultorio, incluida la biopsia, las inyecciones de cuerdas vocales y la cirugía con láser. También se discutieron los factores que podrían contribuir a que los procedimientos en el consultorio se realicen con más frecuencia en algunos países que en otros. Conclusión: Las intervenciones con pacientes despiertos ofrecen numerosos beneficios, incluido un tiempo de procedimiento más corto, costos reducidos y una menor morbilidad para el paciente. Estas ventajas han transformado significativamente el tratamiento de las enfermedades laríngeas en la práctica de la laringología moderna a nivel mundial.

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

PURPOSE: The introduction of fiber-guided lasers was a breakthrough in laryngology practice, opening the path for treating different pathologies with minimally invasive procedures, both in the operating room and in the office. The most recent technology in the area is the blue laser, which combines photoangiolytic and cutting properties, characteristics that make this equipment suitable for its use in upper aerodigestive tract surgery. However, there is not enough experience in this area. The authors present a case series of patients with different pharyngeal, laryngeal, and tracheal pathologies who were treated by means of transoral procedures using fiber-guided blue laser. METHODS: The surgical records of patients with different upper aerodigestive tract pathologies who were treated with fiber-guided blue laser in the operating room, under general anesthesia with jet ventilation or supraglottic ventilation using suspension laryngotracheoscopy techniques between February 2018 and March 2022 were reviewed. RESULTS: A total of 80 surgical interventions in a group of 38 patients were performed. A wide variety of procedures was executed, either using the laser alone or in combination with other techniques to treat different pathologies of the aero-digestive tract safely and effectively, with adequate functional results. CONCLUSIONS: Following all necessary precautions, blue laser is a reliable tool to perform minimally invasive surgeries in the operating room using TOFLS techniques. It can be used alone or in combination with other devices to achieve the desired goals.

Laringoscopia directa vs videolaringoscopia en la intubación del paciente con COVID-19 / Direct laryngoscopy versus videolaryngoscopy in COVID-19 patient intubation

Introducción: Muchos enfermos de COVID-19 requieren ser ventilados. La laringoscopia directa (LD) es el método tradicional empleado en el manejo de la vía aérea; sin embargo, la videolaringoscopia (VL) es una alternativa en estos pacientes. Objetivo: Comparar la laringoscopia directa y la videolaringoscopia en el manejo de la vía aérea en pacientes con COVID-19. Métodos: Se realizó un estudio observacional retrospectivo. El universo y la muestra estuvieron conformado por los pacientes intubados por médicos de la brigada Henry Reeve en hospitales de Cancún y Ciudad de México. Se conformaron dos grupos; el Grupo laringoscopia directa con 91 pacientes y el Grupo videolaringoscopia con 103. Las variables estudiadas fueron: edad, sexo, número de predictores de una vía respiratoria anatómicamente difícil (VRAD), visualización de la apertura glótica, intentos de intubación y las complicaciones de la intubación. El análisis estadístico de los datos se realizó con el paquete estadístico SPSS 23.0. Resultados: Los grupos fueron comparables en cuanto a edad, sexo y predictores de vía respiratoria anatómicamente difícil. La visualización glótica completa o parcial en el grupo videolaringoscopia fue de 97 por ciento, mientras que en el grupo laringoscopia directa fue de 86 por ciento. La intubación endotraqueal al primer intento superó el 70 por ciento en el grupo VL y el 50 por ciento en el grupo LD. Las principales complicaciones encontradas fueron la desaturación y la hipotensión arterial con una mayor frecuencia en el grupo LD (40,7 por ciento y 49,5 por ciento). Conclusiones: La videolaringoscopia mejoró la visualización glótica y la intubación endotraqueal al primer intento, con menos complicaciones en los pacientes estudiados(AU)

Introduction: Many COVID-19 patients require ventilation. Direct laryngoscopy is the traditional method used for airway management; however, videolaryngoscopy is an alternative in these patients. Objective: To compare direct laryngoscopy and videolaryngoscopy for airway management in COVID-19 patients. Methods: A retrospective observational study was carried out. The universe and the sample consisted of patients intubated by physicians from Henry Reeve brigade at hospitals in Cancun and Mexico City. Two groups were formed: the direct laryngoscopy group, with 91 patients, and the videolaryngoscopy group, with 103 patients. The variables studied were age, sex, number of predictors of an anatomically difficult airway, visualization of the glottic opening, intubation attempts, and intubation complications. Statistical analysis of the data was performed using the SPSS 23.0 statistical package. Results: The groups were comparable in terms of age, sex and predictors of an anatomically difficult airway. Complete or partial glottic visualization in the videolaryngoscopy group was 97 percent , while in the direct laryngoscopy group it was 86 percent . Endotracheal intubation at the first attempt exceeded 70 percent in the videolaryngoscopy group and 50 percent in the direct laryngoscopy group. The main complications observed were desaturation and arterial hypotension with a higher frequency in the direct laryngoscopy group (40.7 percent and 49.5 percent , respectively). Conclusions: Video laryngoscopy improved glottic visualization and endotracheal intubation at the first attempt, with fewer complications in the patients studied(AU)

Tracheal intubation while wearing personal protective equipment in simulation studies: a systematic review and meta-analysis with trial-sequential analysis.

BACKGROUND: Tracheal intubation in patients with coronavirus disease-19 is a high-risk procedure that should be performed with personal protective equipment (PPE). The influence of PPE on operator's performance during tracheal intubation remains unclear. METHODS: We conducted a systematic review and meta-analysis of simulation studies to evaluate the influence of wearing PPE as compared to standard uniform regarding time-to-intubation (TTI) and success rate. Subgroup analyses were conducted according to device used and operator's experience. RESULTS: The TTI was prolonged when wearing PPE (eight studies): Standard Mean Difference (SMD) -0.54, 95% Confidence Interval [-0.75, -0.34], p <  0.0001. Subgroup analyses according to device used showed similar findings (direct laryngoscopy, SMD -0.63 [-0.88, -0.38], p < 0.0001; videolaryngoscopy, SMD -0.39 [-0.75, -0.02], p =  0.04). Considering the operator's experience, non-anesthesiologists had prolonged TTI (SMD -0.75 [-0.98, -0.52], p < 0.0001) while the analysis on anesthesiologists did not show significant differences (SMD -0.25 [-0.51, 0.01], p = 0.06). The success rate of tracheal intubation was not influenced by PPE: Risk Ratio (RR) 1.02 [1.00, 1.04]; p = 0.12). Subgroup analyses according to device demonstrated similar results (direct laryngoscopy, RR 1.03 [0.99, 1.07], p = 0.15, videolaryngoscopy, RR 1.01 [0.98, 1.04], p =  0.52). Wearing PPE had a trend towards negative influence on success rate in non-anesthesiologists (RR 1.05 [1.00, 1.10], p = 0.05), but not in anesthesiologists (RR 1.00 [0.98, 1.03], p = 0.84). Trial-sequential analyses for TTI and success rate indicated robustness of both results. CONCLUSIONS: Under simulated conditions, wearing PPE delays the TTI as compared to dressing standard uniform, with no influence on the success rate. However, certainty of evidence is very low. Performing tracheal intubation with direct laryngoscopy seems influenced to a greater extent as compared to videolaryngoscopy. Similarly, wearing PPE affects more the non-anesthesiologists subgroup as compared to anesthesiologists.

Comparison of King Vision video laryngoscope and Macintosh laryngoscope: a prospective randomized controlled clinical trial / Comparação entre o videolaringoscópio King Vision e o laringoscópio Macintosh: um ensaio clínico prospectivo randomizado e controlado

Abstract Background and objectives We compared the efficiency of the King Vision video laryngoscope and the Macintosh laryngoscope, when used by experienced anesthesiologists on adult patients with varying intubating conditions, in a prospective randomized controlled clinical trial. Methods A total of 388 patients with an American Society of Anesthesiologists physical status of I or II, scheduled for general anesthesia with endotracheal intubation. Each patient was intubated with both laryngoscopes successively, in a randomized order. Intubation success rate, time to best glottic view, time to intubation, time to ventilation, Cormack-Lehane laryngoscopy grades, and complications related to the laryngoscopy and intubation were analyzed. Results and conclusions First pass intubation success rates were similar for the King Vision and the Macintosh (96.6% vs. 94.3%, respectively, p > 0.05). King Vision resulted in a longer average time to glottic view (95% CI 0.5-1.4 s, p < 0.001), and time to intubation (95% CI 3-4.6 s, p < 0.001). The difference in time to intubation was similar when unsuccessful intubation attempts were excluded (95% CI 2.8-4.4 s, p < 0.001). Based on the modified Mallampati class at the preoperative visit, the King Vision improved the glottic view in significantly more patients (220 patients, 56.7%) compared with the Macintosh (180 patients, 46.4%) (p < 0.001). None of the patients had peripheral oxygen desaturation below 94%. Experienced anesthesiologists may obtain similar rates of first pass intubation success and airway trauma with both laryngoscopes. King Vision requires longer times to visualize the glottis and to intubate the trachea, but does not cause additional desaturation.

Resumo Justificativa e objetivos Comparamos a eficiência do videolaringoscópio King Vision e do laringoscópio Macintosh, quando usados por anestesiologistas experientes em pacientes adultos com diferentes condições de intubação, em um estudo clínico prospectivo randomizado e controlado. Métodos Foram selecionados 388 pacientes com estado físico ASA I ou II (de acordo com a classificação da American Society of Anesthesiologists - ASA), programados para anestesia geral com intubação traqueal. Cada paciente foi intubado com ambos os laringoscópios sucessivamente, em uma ordem aleatória. A taxa de sucesso da intubação, o tempo até a melhor visibilização da glote, o tempo de intubação, o tempo de ventilação, a classificação de Cormack-Lehane (graus) e as complicações relacionadas à laringoscopia e intubação foram analisados. Resultados e conclusões As taxas de sucesso na intubação na primeira tentativa foram similares para o King Vision e o Macintosh (96,6% vs. 94,3%, respectivamente, p > 0,05). As médias dos tempos até a melhor visibilização da glote (IC 95% 0,5-1,4 s, p < 0,001) e de intubação (IC 95% 3-4,6 s, p < 0,001) foram maiores no King Vision. A diferença no tempo de intubação foi semelhante quando as tentativas malsucedidas de intubação foram excluídas (IC 95% 2,8-4,4 s, p < 0,001). Com base na classificação de Mallampati modificada na consulta pré-operatória, o King Vision melhorou significativamente a visibilização da glote em mais pacientes (220 pacientes, 56,7%) em comparação com o Macintosh (180 pacientes, 46,4%) (p < 0,001). Nenhum dos pacientes apresentou dessaturação periférica de oxigênio abaixo de 94%. Os anestesiologistas experientes podem obter taxas semelhantes de sucesso na primeira tentativa de intubação e de traumas das vias aéreas com ambos os laringoscópios. O King Vision requer tempos mais longos até a visibilização da glote e de intubação traqueal, mas não causa dessaturação adicional.

[Comparison of King Vision video laryngoscope and Macintosh laryngoscope: a prospective randomized controlled clinical trial]. / Comparação entre o videolaringoscópio King Vision e o laringoscópio Macintosh: um ensaio clínico prospectivo randomizado e controlado.

BACKGROUND AND OBJECTIVES: We compared the efficiency of the King Vision video laryngoscope and the Macintosh laryngoscope, when used by experienced anesthesiologists on adult patients with varying intubating conditions, in a prospective randomized controlled clinical trial. METHODS: A total of 388 patients with an American Society of Anesthesiologists physical status of I or II, scheduled for general anesthesia with endotracheal intubation. Each patient was intubated with both laryngoscopes successively, in a randomized order. Intubation success rate, time to best glottic view, time to intubation, time to ventilation, Cormack-Lehane laryngoscopy grades, and complications related to the laryngoscopy and intubation were analyzed. RESULTS AND CONCLUSIONS: First pass intubation success rates were similar for the King Vision and the Macintosh (96.6% vs. 94.3%, respectively, p>0.05). King Vision resulted in a longer average time to glottic view (95% CI 0.5-1.4s, p<0.001), and time to intubation (95% CI 3-4.6s, p<0.001). The difference in time to intubation was similar when unsuccessful intubation attempts were excluded (95% CI 2.8-4.4s, p<0.001). Based on the modified Mallampati class at the preoperative visit, the King Vision improved the glottic view in significantly more patients (220 patients, 56.7%) compared with the Macintosh (180 patients, 46.4%) (p<0.001). None of the patients had peripheral oxygen desaturation below 94%. Experienced anesthesiologists may obtain similar rates of first pass intubation success and airway trauma with both laryngoscopes. King Vision requires longer times to visualize the glottis and to intubate the trachea, but does not cause additional desaturation.

A comparison of King Vision video laryngoscopy and direct laryngoscopy as performed by residents: a randomized controlled trial.

STUDY OBJECTIVE: For more than 40 years, direct laryngoscopy (DL) has been used to assure the airway during endotracheal intubation. The King Vision video laryngoscope is one of the latest devices introduced for endotracheal intubation. We hypothesize that, relative to direct laryngoscopy, it improves the intubation success rate with fewer intubation attempts and no difference in intubation time or complications. DESIGN: This randomized controlled clinical trial included. SETTING: The operating room and postanesthesia care unit of an academic hospital. PATIENTS: Eighty-eight patients with American Society of Anesthesiologists status I to II and aged ≥18 years who were scheduled for elective surgery under general anesthesia and had no predictors of difficult airway. Patients were randomized (44 per group) to undergo intubation using either DL or King Vision video laryngoscopy (KVVL) performed by first year residents in anesthesia and intensive care. MEASUREMENTS: During endotracheal intubation by residents, measurements were success rate, number of attempts, time to intubation, visualization of the glottis, and presence of complications. MAIN RESULTS: Both groups had a 100% success rate. A greater frequency of grade 1 laryngoscopy was reported with KVVL (86.4%) relative to DL (59.1%) (P < .05). There were no differences in time to intubation or the number of attempts between the groups (P = .75 and P = .91, respectively). Complications after intubation were low and included oral trauma, esophageal intubation, and sore throat. CONCLUSIONS: The use of KVVL by residents with less than 1 year of training (considered nonexperts) significantly improves visualization of the glottis in patients without predictors of difficult airway. The incidence of complications was too low to draw conclusions.

Correspondencia entre test predictivos de vía aérea difícil y la laringoscopia directa / Correspondence between predictive test of difficult airway and directlaryngoscopy

Fundamento: Una de las responsabilidades del anestesiólogo es establecer y mantener la vía aérea (V.A.) permeable en cualquier situación clínica que conlleve un compromiso de la misma (anestesia, urgencias, reanimación, etc). El fundamento básico para conseguirlo es la valoración sistemática de la VA y el reconocimiento de las posibles dificultades. Objetivo: Establecer la correspondencia entre los test predictivos de vía aérea difícil y la laringoscopia rígida directa. Método: Se realizó un estudio analítico transversal en pacientes que fueron sometidos a algún tipo de cirugía que requirió anestesia general endotraqueal, en el período comprendido de Enero del 2007, a Septiembre del 2007, en el Hospital Provincial Clínico-Quirúrgico Docente Manuel Ascunce Doménech. De un universo de trescientos noventa y ocho pacientes, la muestra quedó constituida por ciento ochenta que fueron intervenidos de manera electiva y urgente, con administración de dicha anestesia. Resultados: La mayoría no presentó entidad clínica asociada a la vía aérea, y en los que existió se encontraron con mayor frecuencia la obesidad y la Diabetes Mellitus. Conclusiones: El test predictivo de mayor sensibilidad fue la apertura bucal. Los test predictivos de más especificidad fueron la extensión Atlanto-occipital, la apertura bucal y Mallampati. El mejor predictor de una laringoscopia difícil se correspondió con la apertura bucal. Los mejores predictores para la identificación de una laringoscopia fácil, fueron la apertura bucal, Mallampati, distancia tiromentoniana y extensión Atlanto-occipital.

Background: One of the anesthesiologist's responsibilities is to establish and to keep permeable the airway in any clinical situation that involves a commitment (anesthesia, urgencies, resuscitation, etc). The basic principle to attain it is the systematic valuation of the airway and the recognition of the possible difficulties. Objective: To establish the correspondence among the predictive test of difficult airway and the direct rigid laryngoscopy. Method: An analytic cross-sectional study was carried out in patients that were subjected to a kind of surgery that required endotracheal general anesthesia, from January 2007 to September 2007, at the Clinical-Surgical Educational Provincial Hospital Manuel Ascunce Domenech. Of an universe of three hundred ninety eight patients, the sample was constituted by one-hundred eighty that were intervened in an elective and urgent way, with administration of this anesthesia. Results: Most didn't present clinical entity associated to the airway, and in those that it existed, obesity and Diabetes Mellitus with more frequency were found. Conclusions: The predictive test of more sensibility was the oral opening. The ones of more specificity was the atlanto-occipital extension, the oral opening and Mallampati. The best predictor in a difficult laryngoscopy belonged to the oral opening. The best predictors for the identification of an easy laryngoscopy, were the oral opening, Mallampati, thyromental distance and atlanto-occipital extension.