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

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.

Assessment and Treatment of Pain during In-Office Otolaryngology Procedures: A Systematic Review

OBJECTIVE

To qualitatively assess practices of periprocedural pain assessment and control and to evaluate the effectiveness of interventions for pain during in-office procedures reported in the otolaryngology literature through a systematic review.

DATA SOURCES

PubMed, CINAHL, and Web of Science searches from inception to 2018.

REVIEW METHODS

English-language studies reporting qualitative or quantitative data for periprocedural pain assessment in adult patients undergoing in-office otolaryngology procedures were included. Risk of bias was assessed via the Cochrane Risk of Bias or Cochrane Risk of Bias in Non-Randomized Studies of Interventions tools as appropriate. Two reviewers screened all articles. Bias was assessed by 3 reviewers.

RESULTS

Eighty-six studies describing 32 types of procedures met inclusion criteria. Study quality and risk of bias ranged from good to serious but did not affect assessed outcomes. Validated methods of pain assessment were used by only 45% of studies. The most commonly used pain assessment was patient tolerance, or ability to simply complete a procedure. Only 5.8% of studies elicited patients' baseline pain levels prior to procedures, and a qualitative assessment of pain was done in merely 3.5%. Eleven unique pain control regimens were described in the literature, with 8% of studies failing to report method of pain control.

CONCLUSION

Many reports of measures and management of pain for in-office procedures exist but few employ validated measures, few are standardized, and current data do not support any specific pain control measures over others. Significant opportunity remains to investigate methods for improving patient pain and tolerance of in-office procedures.

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.

Potassium titanyl phosphate laser-induced inflammatory response and extracellular matrix turnover in rabbit vocal fold scar

PURPOSE

The objectives of this study were to observe the regulating effect of KTP laser and Nd:YAG laser in the repair of vocal fold scars.

METHODS

All rabbits were injured in the muscular layer with a sharp instrument, and then the vocal folds were treated with a KTP laser and a Nd:YAG laser at a power of 2, 4, 6 and 8 W 1 month after the injury. One month after treatment, the rabbits were killed and the throats were removed to detect changes in histology and gene expression of the vocal fold scar after laser therapy.

RESULTS

The best efficacy of all KTP laser treatment groups was the KTP laser 6 W group. Regarding the detection of gene expression, in the KTP laser 6 W and Nd:YAG laser 6 W groups, col-3A1 was decreased compared to the scar group (P < 0.05), and col-1A1 was decreased only in the KTP laser 6 W group (P < 0.05). TGF-β1 levels in the two groups were lower than in the scar group. There were also significant differences in the levels of IL-1β, COX-2 and TNF-α in the two laser groups compared with the scar group (P < 0.05).

CONCLUSION

KTP laser and Nd:YAG laser treatments for vocal fold scars have particular therapeutic effects. The KTP laser may be better than the Nd:YAG laser for the regulation of vocal fold scars.

LEVEL OF EVIDENCE

NA.

Serial office-based steroid injections for treatment of idiopathic subglottic stenosis

OBJECTIVES/HYPOTHESIS

Current treatment options for idiopathic subglottic stenosis include endoscopic interventions, resection, and tracheotomy. Recently, serial office-based steroid injections were proposed as an alternative that may stabilize or induce regression of airway stenosis without the need for repeated operations. Procedure completion rate, pain, complications, effect on stenosis, time since the last operation, and limitations have not been described.

STUDY DESIGN

Retrospective case series.

METHODS

Retrospective series of 19 patients undergoing serial office-based steroid injection for idiopathic subglottic stenosis. Outcome measures included completion rate, procedure-related pain scores, complications, percentage of airway stenosis, and time since the last operative intervention.

RESULTS

Procedure completion rate was 98.8%. Average pain score during the procedure was 2.3 ± 1.7 on a 10-point scale. There were no immediate complications. One patient underwent awake tracheotomy 8 days after her second injection and was later decannulated. Average stenosis decreased from 35% ± 15% to 25% ± 15% (n = 16; P = .086) over the first of three injections and 40% ± 15% to 25% ± 10% to 20% ± 10% (n = 8; P = .002) for those patients completing two sets of three injections. Fourteen of 17 patients undergoing at least three injections have not returned to the operating room since the first injection.

CONCLUSIONS

Office-based steroid injection represents a promising new treatment pathway for a disease that requires long-term management, offering a purely pharmacologic approach to a disorder that has traditionally been approached from a mechanical perspective. It is safe, well tolerated, and effective. Furthermore, it may help patients and physicians avoid repeated trips to the operating room and the associated risks.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2475-2481, 2017.