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

OBJECTIVE: To determine the differences in thermal effects on vocal folds between four fiber-routed lasers. METHODS: In this experimental laboratory study the thermal effects of an AcuPulse Duo CO2 (CO2 AP), UltraPulse Duo CO2 (CO2 UP), KTP, and Blue laser were analyzed using a Schlieren technique on a human tissue mimicking gel model. Power, laser duration, laser fiber distance to tissue and mode (continuous wave [CW] vs pulsed [P] modes) were evaluated in varying combinations in order to compare the effects of the tested lasers and to explore the individual effect on thermal expansion and incision depth of each setting. The model was validated by comparing the results from the Schlieren model with histology of ex vivo fresh human vocal folds after laser irradiation using a selection of the same laser settings, and calculating the intraclass correlation coefficient (ICC). RESULTS: One thousand ninety-eight Schlieren experiments and 56 vocal cord experiments were conducted. In comparison with CW mode, less thermal expansion occurred in P mode in all lasers, while incisions were deeper in the CO2 and more superficial in the KTP and Blue lasers. The mean thermal expansion was found to be minimally smaller, whereas incision depth was pronouncedly smaller in the KTP and Blue compared to the CO2 lasers. Duration of laser irradiation was the most important factor of influence on thermal expansion and incision depth for all lasers in both CW and P modes. The ICC for consistency between the results of the Schlieren model and the vocal cord histology was classified from fair to excellent, except for the thermal expansion of the Blue laser, which was classified as poor. CONCLUSION: This study demonstrates important differences in thermal effects between CO2, KTP, and Blue lasers which can be explained by the different physical characteristics of the P modes and divergence of the fiber delivery system. The Schlieren imaging model is a good predictor of the relative thermal effects in vocal fold tissue. Our results can be used as a guidance for ENT surgeons using fiber-routed lasers, in order to achieve effective treatment of vocal fold lesions and prevention of functional impairment of vocal folds.

Feasibility and Safety of Office-Based Transnasal Balloon Dilation for Neopharyngeal and Proximal Esophageal Strictures in Patients with a History of Head and Neck Carcinoma.

The aim of this study was to assess feasibility and safety of office-based transnasal balloon dilation of neopharyngeal and proximal esophageal strictures in patients with a history of head and neck carcinoma. The secondary objective was to explore its effectiveness. This prospective case series included patients previously treated for head and neck carcinoma with neopharyngeal or proximal esophageal strictures who underwent transnasal balloon dilation under topical anesthesia. The target dilation diameter was 15 mm; if necessary dilation procedures were repeated every 2-4 weeks until this target was reached. Completion rates, adverse events, and patient experiences measured by VAS scores (0 = no complaints - 10 = unbearable complaints), dysphagia scores based on food consistency (0 = no dysphagia - 5 = unable to swallow liquids/saliva), and self-reported changes in swallowing symptoms were recorded. Follow-up was 2 months. Twenty-six procedures were performed in 12 patients, with a completion rate of 92%. One minor complication occurred, i.e. an infection of the dilation site. Tolerance of the procedure was good (median VAS = 2). The dysphagia score improved after a mean of 2.2 procedures per patient, however not significantly. Eight patients reported improvement in dysphagia, of whom 3 had recurrence of dysphagia within 1 month post-treatment. Office-based transnasal balloon dilation is a feasible and safe in-office procedure which is well-tolerated by patients. The dilations can improve dysphagia, although effects might be transient.

Flexible Endoscopic Biopsy: Identifying Factors to Increase Accuracy in Diagnosing Benign and Malignant Laryngopharyngeal Pathology.

OBJECTIVES: To assess the influence that several factors, such as the amount of obtained biopsies, difficult procedures, biopsy site and the experience of the attending physician, have on accuracy of flexible endoscopic biopsy (FEB). MATERIALS AND METHODS: 203 FEB procedures for benign or malignant laryngopharyngeal lesions were prospectively included. During the procedure, three representative biopsies (macroscopically containing vital tumor tissue and not only necrosis or healthy tissue) were obtained. The accuracy of each biopsy was separately analyzed. Difficulties during the procedures leading to failure of acquiring three representative biopsies were recorded and classified into tumor, patient and procedural factors. Histological results of FEB were defined correct when consistent with clinical context, additional biopsies or Positron emission tomography-computed tomography (PET-CT) revealed equivalent pathology, or the lesion was stable or resolved in >6 months follow-up. RESULTS: The first representative biopsy yielded a correct diagnosis in 65% of the cases. After the second representative biopsy, 78% was correctly diagnosed. The contribution of the third and fourth representative biopsies to accuracy was 3%. The overall accuracy of FEB was 85%. Difficult procedures were more likely to result in misdiagnosis, whereas biopsy site or experience of the attending physician did not influence results. CONCLUSIONS: FEB was accurate in diagnosing laryngopharyngeal lesions when at least two representative biopsies were obtained. Accuracy of FEB could be further improved by limiting possible constraints during the procedures, for example by selecting, informing, and anesthetizing patients carefully.

Optimizing Settings for Office-Based Endoscopic CO2 Laser Surgery Using an Experimental Vocal Cord Model.

OBJECTIVES/HYPOTHESIS: To provide insight in the thermal effects of individual laser settings in target tissues to optimize flexible endoscopic CO2 laser surgery treatment. STUDY DESIGN: Experimental laboratory study. METHODS: Thermal effects of the CO2 laser using a fiber delivery system were visualized using the color Schlieren technique in combination with a polyacrylamide gel tissue model. Variable settings were used for emission mode, power, laser fiber distance, and laser duration, which were evaluated in every possible combination. Collateral thermal expansion and incision depth were measured. To validate the model, the results were compared to histology after CO2 laser irradiation of ex vivo human vocal cords, and the intraclass correlation coefficient was calculated. Thermal damage and incision depth were measured by a blinded pathologist. RESULTS: Of all parameters studied, duration of laser irradiation had the greatest effect on thermal expansion. Increased distance between laser tip and target tissue resulted in significantly reduced incision depth and increased thermal expansion. Pulsed emission modes led to increased incision depths. The intraclass correlation coefficient for consistency between the model setup and the ex vivo human vocal cords was classified as "fair." CONCLUSIONS: By using high-intensity pulsed lasers at minimal distance to the target tissue, exposure times and subsequent damage to surrounding tissue can be reduced. If an evaporation technique is used, lower power in continuous wave at a larger distance to the target tissue will lead to superficial but broader thermal effects. The model setup used in this study is a valid model to investigate laser-induced thermal effects in vocal cord tissue. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E680-E685, 2020.

Office-based CO2 laser surgery for benign and premalignant laryngeal lesions.

OBJECTIVE: Patients with laryngeal pathology are often treated with CO2 laser surgery, usually in the operating room under general anesthesia. Although office-based laser surgery using several other laser types has been investigated, prospective studies on office-based CO2 laser surgery are scarce. Our goal was to investigate the feasibility of office-based CO2 laser surgery for benign and premalignant laryngeal pathology by analyzing completion rate, safety, effect on voice quality, and success rate (i.e., no residual or recurrent disease). METHODS: A prospective cohort study was performed of 30 consecutive procedures. Inclusion started in June 2016 and was completed in August 2018. Adult patients with clinically benign or premalignant laryngeal lesions who could not undergo transoral laser microsurgery in the operating room under general anesthesia were included. Reasons were either contraindications for general anesthesia, previously failed therapeutic laryngoscopy under general anesthesia, and preference of a procedure under topical anesthesia by the patient. The mean follow-up was 9 months. RESULTS: Thirty procedures were performed in 27 patients (24 males) with an average age of 62 years. Twenty-nine (97%) procedures were fully completed without complications. The mean preoperative Voice Handicap Index (VHI) score (VHI 44) significantly decreased 2 months (VHI 28, P = 0.032) and 6 months (VHI 14, P < 0.001) after the procedure. Almost two-thirds of patients showed no residual or recurrent disease at their follow-up visits. CONCLUSION: Office-based CO2 laser surgery is a feasible and safe procedure that results in significant voice-quality improvement. Almost two-thirds of patients did not require further treatment. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:1503-1507, 2020.

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.

Geriatric assessment and 1-year mortality in older patients with cancer in the head and neck region: A cohort study.

BACKGROUND: The aim is to describe the association of functional capacity and cognitive functioning with 1-year mortality in older patients with cancer in the head and neck region. METHODS: We performed a cohort study in which all patients aged 70 years and older received a geriatric screening before treatment. Main outcome was 1-year mortality. RESULTS: A total of 102 patients were included. Median age was 78.7 years (interquartile range [IQR], 72.3-84.5), 25% were cognitive impaired, 40% were malnourished, and 28.4% used a walking device. Overall, 1-year mortality was 42.3%. Male sex (hazard ratio [HR], 4.30; 95% confidence interval [CI], 1.35-13.67), malnutrition (HR, 2.55; 95% CI, 1.19-5.16), and using a walking device (HR, 2.80; 95% CI 1.13-6.93) were associated with higher mortality risk, independent of stage and comorbidities. CONCLUSION: In older patients with head and neck cancer, the mortality rates are high. Nutritional status and mobility are determinants of 1-year mortality, independent of tumor stage, age, and comorbidity.

Functional and cognitive impairment, social environment, frailty and adverse health outcomes in older patients with head and neck cancer, a systematic review.

OBJECTIVES: Older head and neck cancer patients are at increased risk for adverse health outcomes, but little is known about which geriatric assessment associates with poor outcome. The aim is to study the association of functional or cognitive impairment, social environment and frailty with adverse health outcomes in patients with head and neck cancer. METHODS: Four libraries were searched for studies reporting on an association of functional or cognitive impairment, social environment and frailty with adverse outcomes in head and neck cancer patients. RESULTS: Of 4158 identified citations, 31 articles were included. The mean age was ⩾60years in twelve studies (39%). Geriatric conditions were prevalent: between 40 and 50% of the included participants were functional impaired, around 50% had depressive symptoms, and around 40% did not have a partner. Functional impairment was assessed in 18 studies, two studies reported on a cognitive test, eight studies examined mood and social status was depicted by 14 studies. None of the included studies addressed frailty or objectively measured physical capacity such as hand grip strength, gait speed or balance tests. In 64% of the reported associations, a decline in functional or cognitive impairment, mood or social environment was associated with adverse outcomes. CONCLUSION: Functional and cognitive impairment, depressive symptoms and social isolation are highly prevalent in head and neck cancer patients and associate with high risk of adverse health outcomes. In the future, these measurements may guide decision-making and customize treatments, but more research is needed to further improve and firmly establish clinical usability.

Arts and ageing; life expectancy of historical artists in the Low Countries.

Practising arts has been linked to lowering stress, anxiety and blood pressure. These mechanisms are all known to affect the ageing process. Therefore, we examine the relation between long-term involvement in arts and life expectancy at age 50 (LE50), in a cohort of 12,159 male acoustic, literary and visual artists, who were born between 1700 and 1899 in the Low Countries. We compared the life expectancy at age 50 of the various artists with the elite and middle class of that time. In the birth cohorts before 1850, acoustic (LE50:14.5-19.5) and literary artists (LE50:17.8-20.8) had a similar life expectancy at age 50 compared to the elite (LE50:18.0-19.0). Only visual artists (LE50:15.5-17.1) had a lower life expectancy at age 50 compared to the elite at that time. For the most recent birth cohorts from 1850 through 1899, the comparison between artists and the elite reversed and acoustic and literary artist had a lower life expectancy at age 50, while visual artists enjoyed a similar life expectancy at age 50. Although artists belonged to the middle socioeconomic class and lived predominantly in urban areas with poor living conditions, they had a life expectancy similar to the elite population. This is in line with observed favourable effects of practicing arts on health in the short-term. From our historical analysis, we hypothesize several mechanisms through which artistic creativity could influence the ageing process and life expectancy. These hypotheses, however, should be formally tested before any definite conclusions on effects of arts on ageing can be drawn.