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Nguyen DD, Pang JY, Novakovic D. Comparison of Angiolytic Effects Between the 445-nm Blue Laser and 532-nm Pulsed KTP Laser. Laryngoscope 2024. [PMID: 38409660 DOI: 10.1002/lary.31364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/28/2024] [Accepted: 02/08/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE This study aimed to compare the selective absorption of the 445-nm Blue laser (BL) and the 532-nm pulsed potassium-titanyl-phosphate (KTP) laser by blood vessels. METHODS Thirty-six chicken eggs at day 14 of incubation were dissected to expose the chick chorioallantoic membrane (CAM). Third-order vessels of the CAM were identified and irradiated using BL and KTP lasers using various settings at a laser-to-vessel distance of 3 mm using 0.4 mm fiber size. In total, 494 vessels segments were irradiated. Mean (standard deviation) number of irradiations for each setting was 26.0 (4.6), range from 15 to 39. Outcome measures included ablation rate (AR) and rupture rate (RR). RESULTS The two lasers were compared for AR and RR at long and medium pulse width (PW) associated with different power levels. At long PW (above 100 ms), BL showed significantly higher AR than KTP at high energy (600 mJ/pulse) and low energy (400 mJ/pulse); they did not show different AR and RR at medium energy levels (500 mJ/pulse). Using medium PW settings plus high and medium energy levels, BL and KTP showed relatively high AR and did not significantly differ in performance. However, at medium PW plus low energy (400-450 mJ/pulse), KTP showed significantly higher AR compared to BL. CONCLUSION At long PW, BL appeared to show higher AR than KTP at high or low energy levels, but they showed equivalent performance at medium energy. At medium PW, both performed similarly from high to medium energy, but KTP appeared to perform better than BL at lower energy settings. LEVEL OF EVIDENCE NA Laryngoscope, 2024.
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Affiliation(s)
- Duy Duong Nguyen
- Voice Research Laboratory, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- National Hospital of Otorhinolaryngology, Hanoi, Vietnam
| | - Jing-Yin Pang
- Department of Ear-Nose-Throat, Khoo Teck Puat Hospital, Yishun Central, Singapore
| | - Daniel Novakovic
- Voice Research Laboratory, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- The Canterbury Hospital, Sydney, New South Wales, Australia
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Balouch B, Garabet R, Maxwell PJ, Sethi HK, Bress E, Ramadan O, Sataloff RT. The Safety and Efficacy of the 445-nm Blue Laser for Operative Management of Benign Nonvascular Laryngeal Lesions. J Voice 2023:S0892-1997(23)00286-2. [PMID: 37805300 DOI: 10.1016/j.jvoice.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 10/09/2023]
Abstract
The 445-nm blue laser combines the features of photocoagulative vascular lasers and cutting lasers in one device. The purpose of the present study was to evaluate the safety and efficacy of the 445-nm blue laser for the treatment of benign laryngeal pathologies, other than vascular lesions. Outcomes were compared to those when already-established therapies were used. METHODS Adult voice center patients who underwent surgical intervention for vocal fold (VF) mass, VF scar, laryngeal stenosis, laryngeal web, or Reinke's edema were included in this retrospective study. Outcomes were compared to those achieved when traditional treatment modalities were used, including cold steel, CO2 laser, potassium-titanyl-phosphate (KTP) laser, and coblator. Strobovideolaryngoscopy footage was evaluated using a previously described model at four time points: postoperative visit #1: 1-14 days, postoperative visit #2: 30-60 days, postoperative visit #3: 61-365 days, postoperative visit #4: >365 days. RESULTS Eighty cases using the blue laser and 153 controls (n = 78 cold steel, n = 51 KTP laser, n = 22 CO2 laser, n = 2 coblator) were included in this study. Procedures performed using blue laser included VF mass excision (n = 45), VF scar reduction (n = 16), laryngeal stenosis resection/repair (n = 25), laryngeal web excision (n = 7), and reduction of Reinke's edema (n = 1). On postoperative strobovideolaryngoscopy examination, the surgical objective score did not differ significantly between the blue laser cohort and all controls at any postoperative visit. VF edema did not differ significantly between the blue laser cohort and all controls at any postoperative visit. VF hemorrhage scores were significantly lower in the blue laser cohort compared to all controls at the first postoperative visit, but hemorrhage had resolved almost entirely by the second postoperative visit in all groups. Postoperative VF stiffness was worse in the blue laser group at the third postoperative visit compared to controls, but both groups had improved to similar levels by the fourth postoperative visit. The rate of lesion recurrence (24.29% versus 17.19%) did not differ significantly between the blue laser cohort and controls on multivariate analysis (Odds ratio [OR] = 1.081 [0.461-2.536]). The complication rate (12.50% versus 10.46%) did not differ significantly between the blue laser cohort and all controls on multivariate analysis (OR = 0.992 [0.375-2.624]). The blue laser was associated with a lower rate of revision surgery (30.00% versus 34.64%) on multivariate analysis (OR = 0.380 [0.168-0.859]). CONCLUSION The 445-nm blue laser is safe and effective for the management of benign laryngeal lesions. It has efficacy and safety similar to those of traditional treatment modalities (including cold steel, CO2 laser, and KTP laser). Use of the blue laser may lead to lower rates of early postoperative hemorrhage and revision surgery. No adverse effects attributed directly to the use of the blue laser were observed in this study. Further research is encouraged to confirm or refute these findings.
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Affiliation(s)
- Bailey Balouch
- Division of Otolaryngology - Head and Neck Surgery, Cooper University Health Care and Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Razmig Garabet
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Philip J Maxwell
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Harleen K Sethi
- Department of Otolaryngology, Facial Plastic Surgery and Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Eli Bress
- Department of Otolaryngology, Facial Plastic Surgery and Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Omar Ramadan
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
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González-Herranz R, Martínez-Ruiz-Coello M, Hernández-García E, Miranda E, García-García C, Arenas O, Plaza G. Transoral Flexible Laser Surgery of the Larynx with Blue Laser. J Clin Med 2023; 12:5250. [PMID: 37629292 PMCID: PMC10456013 DOI: 10.3390/jcm12165250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION Laser surgery of the larynx is currently the standard of clinical practice in a multitude of procedures. Lasers with photoangiolytic properties have a wide application in endolaryngeal lesions. One of their most prominent features is the ability to coagulate blood vessels, reducing unwanted tissue damage. Our objective is to expose the uses of the blue laser (445 nm) in the larynx. MATERIAL AND METHODS A retrospective study was carried out including 47 patients treated with blue photoangiolytic laser from October 2021 to January 2023 at a university hospital. Demographic data, type of lesion presented, date of intervention and scope of the procedure, as well as the parameters of the laser used, were recorded. The number of sessions received per patient, the result and complications were also collected. RESULTS A total of 47 patients with laryngeal lesions were treated, including vascular angiomas, laryngeal sulcus vocali, vocal cord polyps, Reinke's edemas, laryngeal papillomatoses, subglottic stenosis, laryngeal synechiae, subglottic granulomas, glottic scars, vocal fold leukoplakias, laryngeal dysplasias and tracheostomal granulomas. The mean age was 52.5 years, and 64.3% of the patients were women. The range of power used in the resective surgeries was 2-10 Watts with a 20-millisecond window. The average number of sessions received was 2.1 (range 1-4). A satisfactory situation was obtained in 45 of the 47 patients treated (95.75%), and an evident decrease in lesions was seen in the remaining two. There was no evidence of any complications directly derived from the use of the blue laser. Twenty-seven cases (54%) were treated exclusively in-office. CONCLUSIONS The blue laser is safe and effective in the treatment of a wide range of laryngeal pathologies. Its advantages include its portability, its photoangiolytic qualities as well as its ability to vaporize tissue in contact mode, which can treat subepithelial vessels or resect lesions.
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Affiliation(s)
- Ramón González-Herranz
- Department of Otorhinolaryngology, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28042 Madrid, Spain; (R.G.-H.); (M.M.-R.-C.); (E.H.-G.); (E.M.); (C.G.-G.); (O.A.)
- Department of Otorhinolaryngology, Hospital Universitario Sanitas La Zarzuela, 28023 Madrid, Spain
| | - Mar Martínez-Ruiz-Coello
- Department of Otorhinolaryngology, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28042 Madrid, Spain; (R.G.-H.); (M.M.-R.-C.); (E.H.-G.); (E.M.); (C.G.-G.); (O.A.)
| | - Estefanía Hernández-García
- Department of Otorhinolaryngology, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28042 Madrid, Spain; (R.G.-H.); (M.M.-R.-C.); (E.H.-G.); (E.M.); (C.G.-G.); (O.A.)
| | - Estefanía Miranda
- Department of Otorhinolaryngology, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28042 Madrid, Spain; (R.G.-H.); (M.M.-R.-C.); (E.H.-G.); (E.M.); (C.G.-G.); (O.A.)
| | - Cristina García-García
- Department of Otorhinolaryngology, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28042 Madrid, Spain; (R.G.-H.); (M.M.-R.-C.); (E.H.-G.); (E.M.); (C.G.-G.); (O.A.)
| | - Oscar Arenas
- Department of Otorhinolaryngology, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28042 Madrid, Spain; (R.G.-H.); (M.M.-R.-C.); (E.H.-G.); (E.M.); (C.G.-G.); (O.A.)
- Department of Otorhinolaryngology, Hospital Universitario Sanitas La Zarzuela, 28023 Madrid, Spain
| | - Guillermo Plaza
- Department of Otorhinolaryngology, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28042 Madrid, Spain; (R.G.-H.); (M.M.-R.-C.); (E.H.-G.); (E.M.); (C.G.-G.); (O.A.)
- Department of Otorhinolaryngology, Hospital Universitario Sanitas La Zarzuela, 28023 Madrid, Spain
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Transoral flexible laser surgery of the upper aerodigestive tract with blue laser. Eur Arch Otorhinolaryngol 2023; 280:765-774. [PMID: 36138227 DOI: 10.1007/s00405-022-07606-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/10/2022] [Indexed: 01/21/2023]
Abstract
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.
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Jonas RH, Lear T, Zaninovich A, Joshua C, McGarey PO. Malignant Transformation in Glottic Dysplasia Treated With Photoangiolytic LASER - A Systematic Review and Meta-analysis. J Voice 2022:S0892-1997(22)00173-4. [PMID: 35850887 DOI: 10.1016/j.jvoice.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This systematic review and meta-analysis seeks to characterize the rate of malignant progression among patients with laryngeal dysplasia treated with photoangiolytic laser and compare to prior systematic reviews of conventional surgical approaches. METHODS OVIDMedline, Pubmed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar were searched, including terms related to patients with vocal fold dysplasia who were treated by angiolytic laser ablation. Some articles already known to authors or identified through hand searching were included. RESULTS Six articles with 155 cases were included. Two studies used potassium titanyl phosphate exclusively, one solely used the pulsed dye laser, and three studies utilized both laser types during the study period. The pooled overall mean of malignant progression for patients with laryngeal dysplasia treated with photoangiolytic laser was 12%, as calculated by conducting a meta-analysis of single arm proportion. CONCLUSION Laryngeal dysplasia is a premalignant lesion which confers a risk of progression to malignancy. After biopsy to establish the diagnosis there are multiple surgical techniques available for treatment with the goal of lesion eradication and voice preservation. In our review, there is a low malignant transformation rate for patients treated via with photoangiolytic laser.
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Affiliation(s)
- Rachel H Jonas
- Department of Otolaryngology, Head and Neck Surgery, University of Virginia, Charlottesville, Virginia.
| | - Taylor Lear
- University of Virginia, School of Medicine, Charlottesville, Virginia
| | - Andrew Zaninovich
- University of Virginia, School of Medicine, Charlottesville, Virginia
| | - Cate Joshua
- University of Virginia, Health Sciences Library, Charlottesville, Virginia
| | - Patrick O McGarey
- Department of Otolaryngology, Head and Neck Surgery, University of Virginia, Charlottesville, Virginia
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Balouch B, Ranjbar PA, Alnouri G, Omari AIA, Martha V, Brennan M, Sataloff RT. Surgical Outcome of Low-Power-Density Blue Laser for Vascular Lesions of the Vocal Fold. J Voice 2022:S0892-1997(22)00140-0. [PMID: 35781175 DOI: 10.1016/j.jvoice.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/11/2022] [Indexed: 10/17/2022]
Abstract
Photoangiolytic lasers such as the 532-nm potassium-titanyl-phosphate (KTP) and the novel 445-nm blue laser (introduced into the United States in 2020) are absorbed selectively by hemoglobin, permitting targeted ablation of vascular structures such as vascular malformations of the vocal fold (VF). Previously, we reported the high rate of success of KTP laser photocoagulation for VF vascular lesions. Compared with other photoangiolytic lasers, blue laser has the highest absorption in hemoglobin, and therefore it can be operated at lower power densities to minimize thermal injury to adjacent tissue. OBJECTIVE The purpose of this study was to determine the efficacy and safety of blue laser for treatment of VF vascular lesions using low power densities, and to compare outcomes of blue laser with those of KTP laser. METHODS Adult voice patients who underwent blue laser treatment of VF vascular lesions in the operating room at the lowest power densities that appeared clinically to cause the effect desired were included in this retrospective study. Baseline lesion characteristics and postoperative outcomes were assessed with a model that we had described previously. Postoperative outcomes were compared to those of previously reported KTP laser. RESULTS Thirty-one subjects (54 VFs treated) underwent blue laser vaporization of VF vascular lesions (average age was 40.63 ± 17.51). Data were compared to those of 66 subjects (100 VFs) who had undergone KTP laser vaporization of VF vascular lesions. There were no significant differences in subject demographics, past medical or surgical history, or preoperative location or severity of vascular lesions. Surgical success for blue laser at the low power densities used was 3.74 ± 0.50, 3.55 ± 0.94, 3.90 ± 0.94, and 3.70 ± 1.11 (out of 5) at postoperative visits 1-4, respectively. Surgical objective score was significantly greater following KTP laser at every postoperative visit. Treatment with KTP laser resulted in significantly greater generalized postoperative edema, and blue laser resulted in significantly greater localized edema at postoperative visits one and two. At visit three and four, there are no significant differences. VF stiffness following blue laser was 2.41 ± 0.67, 1.91 ± 0.69, 1.33 ± 0.47, and 1.10 ± 0.18 (out of 4) at postoperative visits 1-4, respectively. Postoperative VF stiffness did not differ significantly from KTP laser. Postoperative hemorrhage severity after blue laser was 1.79 ± 0.54, 1.59 ± 0.48, 1.15 ± 0.25, and 1.14 ± 0.26 (out of 4) at postoperative visits 1-4, respectively. Blue laser resulted in significantly less VF hemorrhage than KTP laser at the first (1.79 ± 0.54 versus 2.26 ± 0.83) and second (1.59 ± 0.48 versus 1.98 ± 0.72) postoperative visits. Vascular lesions treated with low-power-density blue laser were significantly more likely to recur than those treated with KTP laser (40.74% versus 10.00%). New vascular malformations were significantly more likely to form after blue laser than KTP (24.07% versus 6.00%). Subjects treated with low-power-density blue laser were significantly more likely to undergo repeat surgery than those treated with KTP (31.48% versus 14.00%). Significant predictors for the need for repeat blue laser included lesion recurrence, a lower surgical objective score at the third or fourth postoperative visit and a higher baseline lesion severity grade. CONCLUSION Blue laser is an effective tool for the surgical management of VF vascular lesions. Although overall surgical success ratings were inferior to KTP laser at the power densities used, the severity of postoperative edema and VF hemorrhage were significantly less with blue laser. Re-evaluation of blue laser using higher power densities is in progress.
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Affiliation(s)
- Bailey Balouch
- Medical Student, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | | | - Ghiath Alnouri
- Assistant Professor, Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ahmad Issa Al Omari
- Laryngology Fellow, Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Vishnu Martha
- Research Fellow, Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Matthew Brennan
- Otolaryngology Resident, Department of Otolaryngology - Facial Plastic Surgery and Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Robert T Sataloff
- Professor and Chair, Department of Otolaryngology - Head and Neck Surgery, Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine, Director of Otolaryngology and Communication Sciences Research, Lankenau Institute for Medical Research, Philadelphia, Pennsylvania.
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Nguyen DD, Pang JY, Madill C, Novakovic D. Effects of 445-nm Laser on Vessels of Chick Chorioallantoic Membrane with Implications to Microlaryngeal Laser Surgery. Laryngoscope 2021; 131:E1950-E1956. [PMID: 33459366 PMCID: PMC8247896 DOI: 10.1002/lary.29354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/02/2020] [Accepted: 12/17/2020] [Indexed: 11/22/2022]
Abstract
Objective Previous research has shown that effective application of angiolytic lasers in microlaryngeal surgery is determined by wavelength, pulse width (PW), and fluence. Recently, a 445‐nm (blue) laser (BL) has been developed with a potentially greater hemoglobin absorption than previous lasers. The chick chorioallantoic membrane (CAM) represents a suitable model for testing various settings to find out the most optimal settings of this laser. This study used the CAM model to examine whether successful photoangiolytic effects could be obtained using BL. Methods Seven hundred and ninety three third‐order vascular segments of viable CAM were irradiated using BL via 400‐μm diameter fiber, 1 pulse/second, with PW and power varied systematically at standardized fiber‐to‐vessel distances of 1 and 3 mm. Outcome measures including vessel ablation rate (AR), rupture rate (RR), and visible tissue effects were analyzed using Chi‐square test. Results Energy levels of 400, 540, and 600 mJ (per pulse) were most effective for vessel ablation. A working distance of 3 mm resulted in higher ablation and less vessel rupture compared with 1 mm at these optimal energy levels. At 3 mm, a longer PW resulted in higher AR. At 1 mm, AR increased with shorter PW and higher power. The 1‐mm working distance resulted in lower tissue effects than 3 mm. Conclusion Findings in this study showed that BL was effective in vessel ablation using relevant combination of working distance, PW, and energy levels. To obtain high AR, longer working distance plus longer PW was required and if working distance was reduced, shorter PW should be set. Level of Evidence NA Laryngoscope, 131:E1950–E1956, 2021
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Affiliation(s)
- Duy Duong Nguyen
- Voice Research Laboratory, Susan Wakil Health Building, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Jing-Yin Pang
- Department of ENT, Khoo Teck Puat Hospital, Singapore
| | - Catherine Madill
- Voice Research Laboratory, Susan Wakil Health Building, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Daniel Novakovic
- Voice Research Laboratory, Susan Wakil Health Building, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Otolaryngology-Head and Neck Surgery, The Canterbury Hospital, Campsie, New South Wales, Australia
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Miller AJ, Gardner GM. In-Office vs. Operating Room Procedures for Recurrent Respiratory Papillomatosis. EAR, NOSE & THROAT JOURNAL 2019. [DOI: 10.1177/0145561319889538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We conducted a study to analyze hospital and patient costs, outcomes, and patient satisfaction among adults undergoing in-office and operating room procedures for the treatment of recurrent respiratory papillomatosis. Our final study population was made up of 17 patients—1 man and 16 women, aged 30 to 86 years (mean: 62). The mean number of in-office laser procedures per patient was 4.2, and the mean interval between procedures was 5.4 months (although 10 patients underwent only 1 office procedure); the mean number of operating room procedures was 13.5, and the mean interval between procedures was 14.3 months. An equal number of patients reported complications or adverse events with the two types of procedures—5 each. The difference in cost between the office procedure (mean: $3,413.00) and the operating room procedure (mean: $12,382.59) was almost $9,000, but these savings were offset by the fact that the office procedures needed to be performed three times as often. Patients reported slightly more anxiety and discomfort during the office procedures and, overall, they appeared to prefer the operating room procedure. We conclude that office procedures are significantly more cost-effective than operating room procedures, but their use may be limited by patient tolerance and the increased frequency of the procedure.
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Affiliation(s)
- Anya J. Miller
- ENT of Denver, 4500 E. 9th Ave., Suite 610, Denver, CO 80220, USA
| | - Glendon M. Gardner
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital,
Detroit, Michigan
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Kim D, Siegel J, Chouake RJ, Geliebter J, Zalvan CH. Implication and Management of Incidental Oropharyngeal Papillomas-A Retrospective Case Series Review. EAR, NOSE & THROAT JOURNAL 2019; 100:546-551. [PMID: 31581834 DOI: 10.1177/0145561319871228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Incidental papillomas of the pharynx can be found while examining the nasopharynx, oropharynx, and hypopharynx for other disorders of the head and neck. Purpose of the study is to explore the location, biopsy protocol, and decision to perform office-based versus operative management via potassium titanyl phosphate (KTP) laser when an oropharyngeal papilloma is discovered incidentally. METHODS A retrospective review of the senior author's patient population was performed using Current Procedural Terminology and/or International Classification of Diseases codes to identify patients who had KTP laser removal of incidental oropharyngeal papillomas. Patients were included based on the incidental nature of the papilloma and confirmed pathology report of squamous papilloma. Demographics, presenting complaint, lesion location, pathological analysis, type of intervention, and outcomes were recorded. When available, human papillomavirus (HPV) subtype was noted. RESULTS A total of 26 cases were identified, 13 females and 13 males. The median age at time of surgery was 58 years (range: 21-77). The most common presenting symptoms were difficulty swallowing and throat pain. The most common locations were the base of tongue, uvula, tonsils, and the soft palate. Of the 26 patients, 23 patients received KTP laser ablation therapy as an office-based procedure, while the remaining 3 were performed under general anesthesia in the operating room. Only 5 patients had a recorded recurrence that required reoperation. There were no operative or postoperative complications. There were 16 biopsy samples tested for HPV, where 12 were negative for HPV and 4 were positive for HPV. CONCLUSION Oropharyngeal papillomas, when present, can be found incidentally during examination of the oropharynx for other symptoms. Office-based biopsy and KTP laser is a safe and efficient means of identifying and removing most oropharyngeal papillomas.
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Affiliation(s)
- Daniel Kim
- Department of Otolaryngology, New York Medical College, Valhalla, NY, USA
| | - Justin Siegel
- Department of Otolaryngology, New York Medical College, Valhalla, NY, USA
| | - Robert J Chouake
- Department of Otolaryngology, New York Medical College, Valhalla, NY, USA
| | - Jan Geliebter
- Department of Microbiology and Immunology, 8137New York Medical College, Valhalla, NY, USA
| | - Craig H Zalvan
- Department of Otolaryngology, New York Medical College, Valhalla, NY, USA.,The Institute for Voice and Swallowing Disorders, Sleepy Hollow, NY, USA
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Angiolytic laser stripping versus CO2 laser microflap excision for vocal fold leukoplakia: Long-term disease control and voice outcomes. PLoS One 2018; 13:e0209691. [PMID: 30596718 PMCID: PMC6312374 DOI: 10.1371/journal.pone.0209691] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/10/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Vocal fold leukoplakia, white plaque on the epithelium, has the potential for malignant transformation regardless of dysplasia grade. It is treated with different laser types (CO2 or angiolytic) and various techniques (vaporization, stripping, or excision); however, only a few studies exist regarding comparative laser surgery results. This study was conducted to investigate clinical outcomes of CO2 versus angiolytic laser microdissection with regard to long-term disease control and voice preservation in vocal fold leukoplakia. MATERIALS AND METHODS Seventy patients with vocal fold leukoplakia treated by CO2 or angiolytic laser (pulsed dye laser or potassium titanyl phosphate) were identified retrospectively. Data regarding patient characteristics, treatment details, treatment outcomes including disease control (recurrence and progression) and the Voice Handicap Index, GRBAS scale, and acoustics were evaluated. The mean follow-up duration after initial treatment was 32 ± 26 months. RESULTS The study group comprised 14 patients who underwent CO2 laser microflap excision and 56 who underwent angiolytic laser stripping. Of the patients treated with CO2 laser, 11 (79%) had no recurrence and three (21%) showed recurrent leukoplakia, of which one patient (7%) showed histologic grade progression. Of patients who underwent angiolytic laser stripping, 12 had disease recurrence (21%), among whom three (5%) showed disease progression. Laser surgery type, disease extent, and histologic grade showed no significant differences in recurrence or progression rates. The postoperative Voice Handicap Index significantly improved (P = .03) and the G score significantly decreased (P < .001) in the angiolytic laser treatment group. In contrast, the Voice Handicap Index increased postoperatively in the CO2 laser group (P = .046). CONCLUSIONS The long-term recurrence or progression rates were not significantly different between angiolytic and CO2 laser treatment. The angiolytic laser stripping group showed better voice preservation compared with the CO2 laser group. Angiolytic laser stripping is suggested as an effective treatment option for vocal fold leukoplakia with comparable disease control and better voice preservation.
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Nouraei SAR, Dorman EB, Macann A, Vokes DE. Outcomes of Treating Early Glottic Neoplasms With a Potassium Titanyl Phosphate Laser. Ann Otol Rhinol Laryngol 2018; 128:85-95. [DOI: 10.1177/0003489418806914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: The aim of this study was to assess the outcome of treating glottic dysplasia and early squamous cell carcinoma (SCC) with potassium titanyl phosphate (KTP) photoangiolytic laser ablation. Methods: Patient demographics, comorbidities, and tumor characteristics were recorded. Perceptual, patient-reported, and objective voice outcomes were assessed. Use of treatment modalities in addition to the KTP laser, development of locoregional or metastatic SCC, and overall survival were recorded. Results: There were 23 patients with glottic dysplasia and 18 patients with glottic SCC. Mean age at treatment was 69 years. Most patients (95%) were male. Posttreatment fundamental frequency fell from 132 ± 35 to 116 ± 24 Hz ( P = .03). Overall, 61% of patients achieved a normal voice. There was a learning-curve, and most treatment failures occurred in the first half of the series. Five-year KTP-only disease-control rates were 87.1% and 53.5% for dysplasia and malignancy, respectively. Five-year overall survival was 56%, with no laryngectomies or deaths due to SCC. Conclusions: Ablating dysplasia and early glottic cancer using a KTP laser is a viable treatment option. It has a learning curve and a failure rate but, in this series, no ultimate loss of oncologic control. Its introduction into clinical practice should be managed carefully in the context of multidisciplinary cancer care. Level of Evidence: 4.
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Abstract
PURPOSE OF REVIEW The purpose of this article is to provide an update on English-language literature evaluating the current understanding of incidence, management, and prevention of vocal fold leukoplakia focusing on premalignancy. RECENT FINDINGS Recent studies have continued to try to elucidate factors influencing recurrence and progression of dysplastic disease, though results vary. Although advanced diagnostic techniques have attempted to predict disease behavior, tissue diagnosis continues to be essential. Studies reinforce the necessity of removal of disease as the primary treatment, whereas use of photoangiolytic lasers via the ablative technique has increased, as has transition of some patients into the office-based settings for treatment. Although genetic and molecular testing may hold promise for predictive purposes, further study is necessary, and chemotherapy for recalcitrant disease continues to be an area of study with few case studies being reported. SUMMARY Management of vocal fold leukoplakia continues to progress in terms of identification and treatment. Although many work to advance our knowledge in the field and push treatment strategies toward newer avenues, pathologic diagnosis, eradiation of disease on the basis of experience and skill, and close surveillance continue to be paramount.
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Ivancic R, Iqbal H, deSilva B, Pan Q, Matrka L. Current and future management of recurrent respiratory papillomatosis. Laryngoscope Investig Otolaryngol 2018; 3:22-34. [PMID: 29492465 PMCID: PMC5824106 DOI: 10.1002/lio2.132] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/17/2017] [Accepted: 11/11/2017] [Indexed: 01/01/2023] Open
Abstract
Objectives Recurrent respiratory papillomatosis (RRP) is a chronic disease of the respiratory tract that occurs in both children and adults. It is caused by the human papillomavirus (HPV), in particular low‐risk HPV6 and HPV11, and aggressiveness varies among patients. RRP remains a chronic disease that is difficult to manage. This review provides perspectives on current and future management of RRP. Results The current standard of care is surgical excision, with adjuvant therapies as needed. Surgical management of RRP has evolved with the introduction of microdebriders and photoangiolytic lasers; the latter can now be used in the office setting. Numerous adjuvant pharmacologic therapies have been utilized with some success. Also, exciting preliminary data show that HPV vaccines may prolong the time to recurrence in the RRP population. There is also optimism that wide‐spread HPV vaccination could reduce RRP incidence indirectly by preventing vertical HPV transmission to newborns. Conclusion To date, the biology of RRP is not well understood, although it has been noted to become more aggressive in the setting of immune suppression. Additional research is needed to better understand immune system dysfunction in RRP such that immunomodulatory approaches may be developed for RRP management. Level of Evidence 4
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Affiliation(s)
- Ryan Ivancic
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center Columbus Ohio U.S.A
| | - Hassan Iqbal
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center Columbus Ohio U.S.A
| | - Brad deSilva
- Department of Otolaryngology-Head and Neck Surgery The Ohio State University Wexner Medical Center Columbus Ohio U.S.A
| | - Quintin Pan
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center Columbus Ohio U.S.A.,Department of Otolaryngology-Head and Neck Surgery The Ohio State University Wexner Medical Center Columbus Ohio U.S.A
| | - Laura Matrka
- Department of Otolaryngology-Head and Neck Surgery The Ohio State University Wexner Medical Center Columbus Ohio U.S.A
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Kim JH, Hwang HJ, Kim JH, Kang MS, Choi HS, Byeon HK. Secondary submucosal vocal cyst following pulsed dye laser application for sulcus vocalis. Acta Otolaryngol 2017; 137:563-566. [PMID: 27879157 DOI: 10.1080/00016489.2016.1255991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSION Submucosal vocal cyst can occur as a distinct long-term sequelae following pulsed dye laser (PDL) application for sulcus vocalis. It is recommended that the cyst lesion should be surgically removed for treatment. Optimal and precise irradiation of PDL is considered important to avoid the development of a such complication. OBJECTIVE After several years of clinical practice and an extended period of follow-up of the patients who received PDL application in treating sulcus vocalis, the authors have encountered several cases of secondary submucosal vocal cyst development. Therefore, this study aims to investigate this late complication following PDL laryngeal surgery. METHODS Patients who developed secondary submucosal vocal cyst after last PDL laryngeal surgery between March 2008 and January 2016 were analyzed after retrospectively reviewing clinical and operative data. RESULTS There were a total 11 patients who had been identified as presenting secondary submucosal vocal cyst among 186 patients who underwent PDL laryngeal surgery (5.9% incidence). All five patients who received surgery showed complete resolution and were free of symptoms. The remaining six patients were closely observed with conservative measures, with only one patient who showed resolution of the cyst.
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Affiliation(s)
- Joo Hyun Kim
- Department of Otorhinolaryngology, Institute of Logopedics and Phoniatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Jin Hwang
- Department of Otorhinolaryngology, Institute of Logopedics and Phoniatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyung Kim
- Department of Otorhinolaryngology, Institute of Logopedics and Phoniatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Seok Kang
- Department of Otorhinolaryngology, Institute of Logopedics and Phoniatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hong-Shik Choi
- Department of Otorhinolaryngology, Institute of Logopedics and Phoniatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyung Kwon Byeon
- Department of Otorhinolaryngology, Institute of Logopedics and Phoniatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
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Koss SL, Baxter P, Panossian H, Woo P, Pitman MJ. Serial in-office laser treatment of vocal fold leukoplakia: Disease control and voice outcomes. Laryngoscope 2017; 127:1644-1651. [DOI: 10.1002/lary.26445] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 10/18/2016] [Accepted: 11/08/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Shira L. Koss
- Department of Otolaryngology-Head and Neck Surgery; New York Eye and Ear Infirmary of Mount Sinai
| | - Peter Baxter
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center
| | - Haig Panossian
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center
| | - Peak Woo
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center
| | - Michael J. Pitman
- Department of Otolaryngology-Head and Neck Surgery; Voice and Swallowing Institute, Columbia University Medical Center; New York New York U.S.A
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Del Signore AG, Shah RN, Gupta N, Altman KW, Woo P. Complications and Failures of Office-Based Endoscopic Angiolytic Laser Surgery Treatment. J Voice 2016; 30:744-750. [DOI: 10.1016/j.jvoice.2015.08.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/31/2015] [Indexed: 10/20/2022]
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17
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Ihenachor EJ, Dewan K, Chhetri D. Pulsed dye laser treatment of primary cryptococcal laryngitis: A novel approach to an uncommon disease. Am J Otolaryngol 2016; 37:572-574. [PMID: 27654751 DOI: 10.1016/j.amjoto.2016.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/12/2016] [Indexed: 10/21/2022]
Abstract
An 82-year-old supplemental oxygen dependent woman with severe COPD presented with an eight month history of worsening hoarseness and stridor. Office laryngoscopy revealed laryngeal edema and ulcerative masses throughout the larynx. In-office biopsies were positive for Cryptococcus neoformans. This report details a novel approach to the treatment of cryptococcal laryngitis, a combination of in-office pulsed-dye laser (PDL) ablation and medical therapy. Despite treatment with oral fluconazole, the recommended treatment for cryptococcal laryngitis the patient continued to be symptomatic with dysphonia and throat discomfort. Repeated laryngeal exam demonstrated persistent cryptococcal nodules. The patient was subsequently effectively treated with an in-office PDL laser. This case demonstrates the efficacy of in-office laser treatment for residual laryngeal Cryptococcus. For patients like this one, who have failed medical therapy and are unfit for general anesthetic, the in-office laser provides an excellent alternative treatment approach.
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Clyne SB, Halum SL, Koufman JA, Postma GN. Pulsed Dye Laser Treatment of Laryngeal Granulomas. Ann Otol Rhinol Laryngol 2016; 114:198-201. [PMID: 15825568 DOI: 10.1177/000348940511400305] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Laryngeal granulomas are effectively treated with antireflux therapy and speech therapy. Failure to respond leads to treatment with Botox or surgical excision. We report on the use of the pulsed dye laser for treating chronic granulomas that do not respond to standard therapy. We performed a retrospective review from September 2002 to September 2003. Patients identified with chronic granulomas that were not responding to standard therapy were treated in our office with the pulsed dye laser. Ten patients were identified; the mean age was 58 years. Two patients underwent more than one pulsed dye laser treatment. Five of the 10 had resolution of their lesions, and 3 had a partial response. Two were unchanged. The average follow-up was 6 months, and there were no complications. We conclude that in-office use of the pulsed dye laser is a relatively safe and effective method for treating laryngeal granulomas that do not respond to antireflux therapy and speech therapy.
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Affiliation(s)
- Stephen B Clyne
- Center for Voice and Swallowing Disorders, Department of Otolaryngology, Wake Forest University Medical Center, Winston-Salem, North Carolina 27157, USA
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Zeitels SM, Akst LM, Bums JA, Hillman RE, Broadhurst MS, Anderson RR. Pulsed Angiolytic Laser Treatment of Ectasias and Varices in Singers. Ann Otol Rhinol Laryngol 2016; 115:571-80. [PMID: 16944655 DOI: 10.1177/000348940611500802] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Varices and ectasias in singers are typically the result of phonotraumatic shearing stresses and/or collision forces on the microcirculation within the superficial lamina propria. These lesions can be debilitating in performing vocalists because of the effect of recurrent hemorrhage and/or as a contributing factor to the morbidity of other mass lesions such as polyps, nodules, and cysts. Phonomicrosurgical treatment of performers is understandably approached with great trepidation, as the vocal liability of surgically disturbing the superficial lamina propria and epithelium must be balanced with the inherent detrimental vocal effect(s) of the lesion(s). Pulsed angiolytic lasers that emit radiation at high absorbance peaks of oxyhemoglobin were examined to determine whether they were an efficacious treatment approach for ectasias and varices based on these lasers' mechanisms of action and prior experience in phonomicrosurgery. Methods: A prospective trial was done in 39 patients (40 procedures in 54 vocal folds) without complication to evaluate the effectiveness of a 585-nm pulsed dye laser (PDL; 25 cases) and a 532-nm pulsed KTP laser (15 cases) in a noncontact mode to treat 65 varices and 43 ectasias. Twenty-nine of 39 patients had varices and ectasias associated with other phonotraumatic mass lesions that required resection. Results: All patients have resumed full vocal activities, and no patient has had a subsequent hemorrhage or vocal deterioration. Conclusions: Both the 585-nm PDL and the 532-nm pulsed KTP laser were found to be efficacious and relatively safe treatment modalities for vascular abnormalities of the vocal folds in singers. Noncontact selective photoangiolysis of the aberrant vessels prevented future bleeding without substantial photothermal trauma to the overlying epithelium and surrounding delicate superficial lamina propria, thereby allowing for optimal postoperative mucosal pliability and glottal sound production. However, the pulsed KTP laser was substantially easier to use because of its enhanced hemostasis due to its longer pulse width. Vessel wall rupture was commonplace during use of the 585-nm PDL, but rarely occurred during photoangiolysis with the 532-nm pulsed KTP laser.
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Affiliation(s)
- Steven M Zeitels
- Department of Surgery, Harvard Medical School, Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, MA 02114, USA
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20
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Zeitels SM, Blitzer A, Hillman RE, Anderson RR. Foresight in Laryngology and Laryngeal Surgery: A 2020 Vision. Ann Otol Rhinol Laryngol 2016. [DOI: 10.1177/000348940711600901] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Laryngology and laryngeal surgery have been in the vanguard of minimally invasive human procedural interventions for approximately 150 years. The natural passages through the oral cavity, nose, and pharynx have provided an accessible gateway to the larynx that has allowed for rapid translation of a variety of diagnostic and therapeutic technologies. Transoral and transcervical laryngeal surgery have been further facilitated by progressive advancements in local, topical, intravenous, and general anesthesia. With rapid developments in engineering disciplines (ie, tissue, chemical, mechanical) and voice science, there are a variety of current and near-term opportunities to advance our field. This report represents a panel at the 2005 American Broncho-Esophagological Association meeting that sought to use present perspectives, combined with cutting-edge research insights, to provide foresight into key aspects of laryngology that we believe will be developed by the year 2020. We hope that aspiring laryngeal surgeons will find elements of this discussion valuable for devising a strategic roadmap for research initiatives in laryngology and laryngeal surgery.
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21
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Zeitels SM, Akst LM, Burns JA, Hillman RE, Broadhurst MS, Anderson RR. Office-Based 532-nm Pulsed KTP Laser Treatment of Glottal Papillomatosis and Dysplasia. Ann Otol Rhinol Laryngol 2016; 115:679-85. [PMID: 17044539 DOI: 10.1177/000348940611500905] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Treatment of glottal papillomatosis and dysplasia was mirror-guided and done in surgeons' offices in the 19th century. It migrated to the operating room in the 20th century to accommodate direct laryngoscopic surgery, which required assistants to administer anesthesia and procedural support. The primary treatment goals, which are disease regression and voice restoration and/or maintenance, are tempered by the morbidity of general anesthesia and potential treatment-induced vocal deterioration. To obviate general anesthesia, office-based laser laryngeal surgery was first done in 2001 with the 585-nm pulsed dye laser (PDL), because it employs a fiber delivery system and its energy is selectively absorbed by oxyhemoglobin. Since then, this new angiolytic laser treatment paradigm has become a mainstay of management for many surgeons; however, there are a number of shortcomings of the PDL. To further develop this concept and address the limitations of the PDL, we used a 532-nm pulsed potassium titanyl phosphate (KTP) laser. Methods: A prospective assessment was performed on 48 patients in 72 cases of recurrent glottal dysplasia (36) or papillomatosis (36). All individuals had previously undergone microlaryngoscopic management with histopathologic evaluation. Results: Two dysplasia patients did not tolerate the procedure. Of the treatable dysplasia cases, there was follow-up in 29 of 34. Disease regression was at least 75% in 18 of 29 cases (62%), 50% to 75% in 7 of 29 (24%), and 25% to 50% in the remaining 4 of 29 (14%). Papilloma patients returned for treatment when symptoms recurred, so disease regression could not be assessed accurately. Similar to data obtained with the PDL, these data confirmed that dysplastic mucosa could normalize without resection. Conclusions: Our observations revealed that the 532-nm pulsed KTP laser provided enhanced performance over the PDL laser in a number of ways. The ability to use smaller glass fibers precluded mechanical trauma to the channels of the flexible laryngoscopes and allowed for improved suctioning of secretions. Oxyhemoglobin absorbs energy better at 532 nm than at 585 nm, and the KTP laser can be delivered through a longer pulse width. These factors provide enhanced hemostasis and improved intralesional energy absorbance. Finally, unlike the PDL, the KTP laser is a solid-state laser and is not prone to mechanical failure.
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Affiliation(s)
- Steven M Zeitels
- Department of Surgery, Harvard Medical School, and the Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital Boston, MA 02114, USA
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22
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Zeitels SM, Franco RA, Dailey SH, Burns JA, Hillman RE, Anderson RR. Office-Based Treatment of Glottal Dysplasia and Papillomatosis with the 585-NM Pulsed Dye Laser and Local Anesthesia. Ann Otol Rhinol Laryngol 2016; 113:265-76. [PMID: 15112968 DOI: 10.1177/000348940411300403] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Treatment of glottal papillomatosis and dysplasia was mirror-guided and performed in surgeons' offices in the 19th century. It migrated to the operating room in the 20th century to accommodate direct laryngoscopic surgery, which required assistants to administer anesthesia and procedural support. Presently, the primary treatment goals, which are disease regression and voice restoration or maintenance, are tempered by the morbidity of general anesthesia and potential treatment-induced vocal deterioration. In fact, general anesthesia has been appropriately considered to be an acceptable source of morbidity for the promise of a precise procedure, which usually ensures airway safety and an optimal vocal outcome. However, patients with recurrent glottal papillomatosis and keratosis with dysplasia are typically monitored with various degrees of watchful waiting until there is a subjective judgment (on the part of the patient and surgeon) that the disease is more of a liability than is the procedure to treat it. Innovations in the 585-nm pulsed dye laser delivery system have allowed for its use in the clinic with local anesthesia through the working channel of a flexible fiberoptic laryngoscope. A prospective assessment was done on 51 patients in 82 cases of recurrent glottal papillomatosis (30) and dysplasia (52). All individuals had previously undergone microlaryngoscopic management with histopathologic evaluation. Five procedures could not be completed because of impaired exposure (2) or discomfort (3). Of those patients who could be treated, there was at least a 50% disease involution in 68 of 77 cases (88%) and 25% to 50% disease regression in the remaining 9 (12%). Patient self-assessment of the voice revealed that 34 of 77 were improved, 39 were unchanged, 4 were slightly worse, and none were substantially worse. These data confirm that diseased mucosa can be normalized without resection or substantial loss of vocal function. The putative mechanisms, which vary according to the fluence (energy) delivered by the laser, are photoangiolysis of sublesional microcirculation, denaturing of epithelial basement membrane linking proteins, and cellular destruction. Furthermore, this relatively safe, effective technique allowed for treatment of many patients (in a clinic setting) in whom classic surgery-related morbidity would have often delayed intervention.
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Affiliation(s)
- Steven M Zeitels
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
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Rees CJ, Postma GN, Koufman JA. Cost Savings of Unsedated Office-Based Laser Surgery for Laryngeal Papillomas. Ann Otol Rhinol Laryngol 2016; 116:45-8. [PMID: 17305277 DOI: 10.1177/000348940711600108] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Unsedated office-based laryngeal laser surgery (UOLS) is now an effective alternative to traditional operating room-based suspension microdirect laryngoscopy under general anesthesia. This procedure includes pulsed dye laser (PDL) treatment of recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. The objective of this study was to determine the magnitude of the cost savings derived by moving these types of procedures from the operating room to the office setting. Methods: Retrospective cost-identification analysis was performed by comparing the billing records of patients who underwent surgical laser treatment for recurrent respiratory papillomatosis in the operating room to the costs and charges for patients who underwent similar procedures with the in-office PDL. Results: In performing surgery with the PDL in the office, the average cost savings was more than $5,000 per case. Current reimbursement rates do not cover the cost of performing UOLS. Conclusions: The potential cost savings of UOLS are tremendous; however, at present significant financial disincentives prevent proliferation of this technology.
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Affiliation(s)
- Catherine J Rees
- Department of Otolaryngology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Rees CJ, Halum SL, Wijewickrama RC, Koufman JA, Postma GN. Patient Tolerance of In-Office Pulsed Dye Laser Treatments to the Upper Aerodigestive Tract. Otolaryngol Head Neck Surg 2016; 134:1023-7. [PMID: 16730550 DOI: 10.1016/j.otohns.2006.01.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Accepted: 01/30/2006] [Indexed: 11/22/2022]
Abstract
INTRODUCTION: Recent advances in technology have facilitated a movement toward unsedated in-office treatment of laryngeal, tracheal, and esophageal lesions. The objective of this study was to determine patient tolerance of inoffice pulsed-dye laser (PDL) treatment of upper aerodigestive tract pathoses via the transnasal esophagoscope. METHODS: Three hundred twenty-eight unsedated in-office PDL cases were performed at a university-based tertiary referral center in 131 patients. These procedures were performed for various upper aerodigestive pathoses, including recurrent respiratory papillomatosis, chronic granulomas, and recurrent leukoplakia. Eighty-nine subjects completed a phone survey concerning their discomfort level after the PDL procedure. They were also asked specific questions about recovery time, pain medication, and preference of operating room versus inoffice procedures. RESULTS: The average comfort score was 7.4 (10 being minimal discomfort). Eighty-four percent did not use any pain medication; 87% stated that, if possible, they would prefer to undergo unsedated inoffice procedures rather than surgeries under general anesthesia for further treatment of their upper aerodigestive tract pathosis. CONCLUSIONS: Unsedated transnasal treatment of upper aerodigestive tract pathoses is readily accepted and well-tolerated by otolaryngology patients. Patients overwhelmingly prefer the inoffice PDL over surgeries under general anesthesia.
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Affiliation(s)
- Catherine J Rees
- Center for Voice and Swallowing Disorders, Department of Otolaryngology, Medical College of Georgia, Augusta, GA 30912-4060, USA
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Franco RA. Aminolevulinic acid 585 nm pulsed dye laser photodynamic treatment of laryngeal keratosis with atypia. Otolaryngol Head Neck Surg 2016; 136:882-7. [PMID: 17547974 DOI: 10.1016/j.otohns.2007.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 01/22/2007] [Indexed: 11/29/2022]
Abstract
Objective To evaluate the safety and efficacy of aminolevulinic acid photodynamic therapy (ALA-PDT) with the 585 nmpulsed dye laser. Methods A 5-year prospective study was performed with 12 male patients with keratosis. Twenty percent ALA was sprayed into the larynx and activated with the 585 nm pulsed dye laser (PDL). Of the 12 patients, four were not included (one lost to follow-up, two developed cancer, one papillomatosis), which reduced the number to eight. Twenty-eight procedures were performed in these eight patients; 18 (64%) procedures were performed in the clinic setting. Results There was a 78% reduction (range, 10% to 100%) in the keratosis. No major side effects were noted. Mean follow-up was 34.5 months (range, 12 to 50 months). There were no statistical differences between the outpatient and operating room treatments. Conclusions ALA-PDL PDT is effective and safe in treating laryngeal keratosis in the awake clinic setting and reduces morbidity without sacrificing treatment efficacy.
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Affiliation(s)
- Ramon A Franco
- Department of Otology and Laryngology, Harvard Medical School, Division of Laryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts 02114, USA.
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Mouadeb DA, Belafsky PC. In-Office Laryngeal Surgery with the 585nm Pulsed Dye Laser (PDL). Otolaryngol Head Neck Surg 2016; 137:477-81. [PMID: 17765779 DOI: 10.1016/j.otohns.2007.02.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Revised: 01/08/2007] [Accepted: 02/05/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVES: The 585nm pulsed dye laser (PDL) is a promising tool for in-office laryngeal surgery. Data with respect to the safety and efficacy of the PDL for office laryngeal use is sparse. The purpose of this study is to review our experience with unsedated office PDL surgery. METHODS: Records of individuals undergoing in-office PDL between September 1, 2004, and September 1, 2006 were abstracted from a clinical database. RESULTS: Forty-seven patients underwent 117 treatments. The most common indications were recurrent respiratory papillomatosis (RRP), Reinke's edema, and vocal fold polyps. One hundred and four of 117 procedures were felt to be a success ablating all disease. Thirteen treatments requred early termination. The most common factor responsible for termination was an inability to achieve a comfortable level of anesthesia. One patient with Reinke's edema developed postprocedure stridor that required a 3-day hospital admission for observation and corticosteroids. There was no incidence of any vocal fold scarring, web formation, or other complications. CONCLUSIONS: The 585nm PDL is a promising tool for in-office treatment of various laryngeal disorders. Complications are rare.
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Affiliation(s)
- Debbie Aviva Mouadeb
- The Center for Voice and Swallowing, University of California at Davis Medical Center, Department of Otolaryngology-Head and Neck Surgery, Sacramento, CA, USA.
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Koufman JA, Rees CJ, Frazier WD, Kilpatrick LA, Wright SC, Halum SL, Postma GN. Office-Based Laryngeal Laser Surgery: A Review of 443 Cases Using Three Wavelengths. Otolaryngol Head Neck Surg 2016; 137:146-51. [PMID: 17599582 DOI: 10.1016/j.otohns.2007.02.041] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Accepted: 02/27/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND: Unsedated office-based laser surgery (UOLS) of the larynx and trachea has significantly improved the treatment options for patients with laryngotracheal pathology including recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. UOLS delivered by flexible endoscopes has dramatically impacted office-based surgery by reducing the time, costs, and morbidity of surgery. OBJECTIVES: To review our experience with 443 laryngotracheal cases treated by UOLS. METHODS: The laser logbooks at the Center for Voice and Swallowing Disorders were reviewed for UOLS, and the medical and laryngological histories were detailed, as were the treatment modalities, frequencies, and complications. RESULTS: Of the 443 cases, 406 were performed with the pulsed-dye laser, 10 with the carbon-dioxide laser, and 27 with the thulium: yttrium-aluminum-garnet laser. There were no significant complications in this series. A review of indications and wavelength selection criteria is presented. CONCLUSION: Unsedated, office-based, upper aerodigestive tract laser surgery appears to be a safe and effective treatment option for many patients with laryngotracheal pathology.
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Kishimoto Y, Suzuki R, Kawai Y, Hiwatashi N, Kitamura M, Tateya I, Hirano S. Photocoagulation therapy for laryngeal dysplasia using angiolytic lasers. Eur Arch Otorhinolaryngol 2016; 273:1221-5. [DOI: 10.1007/s00405-015-3887-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 12/29/2015] [Indexed: 11/28/2022]
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Treatment of Hemorrhagic Vocal Polyps by Pulsed Dye Laser-Assisted Laryngomicrosurgery. BIOMED RESEARCH INTERNATIONAL 2015; 2015:820654. [PMID: 26557700 PMCID: PMC4628719 DOI: 10.1155/2015/820654] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/19/2015] [Accepted: 03/19/2015] [Indexed: 11/24/2022]
Abstract
Objective. Conventional surgical techniques of laryngomicrosurgery (LMS) on hemorrhagic vocal polyps are often difficult due to obscuration of the surgical field by inadvertent bleeding from the lesion, and there are often significant amounts of mucosal epithelium loss. Here, we introduce our surgical technique using pulsed dye laser (PDL), which can effectively resect the polyp with vocal fold mucosa preservation. Methods. Patients who were diagnosed with hemorrhagic vocal polyp and who were surgically managed using PDL from March 2013 to October 2014 were retrospectively reviewed. Preoperative and postoperative clinical outcomes and surgical findings were evaluated. Results. A total of 39 patients were treated with PDL-assisted enucleation LMS. The average age was 43.7 years (range 20–73), and there were 20 males and 19 females (17 professional voice users). In all cases, the hemorrhagic polyp was successfully enucleated after application of PDL, thereby preserving the overlying epithelium. Postoperative voice outcomes were favorable with clear preservation of the vocal fold mucosal wave. Conclusion. PDL-assisted enucleation LMS for the treatment of hemorrhagic vocal polyps can be a safe and effective surgical technique. It can be considered a promising treatment option for hemorrhagic vocal polyps.
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Comparison of vocal outcomes after angiolytic laser surgery and microflap surgery for vocal polyps. Auris Nasus Larynx 2015; 42:453-7. [PMID: 25933587 DOI: 10.1016/j.anl.2015.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 02/16/2015] [Accepted: 03/20/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The microflap technique is a standard procedure for the treatment of vocal fold polyps. Angiolytic laser surgery carried out under topical anesthesia is an alternative method for vocal polyp removal. However, it is not clear whether angiolytic laser surgery has the same effects on vocal outcomes as the microflap technique because of a lack of studies comparing both procedures. In the current study, vocal outcomes after both procedures were compared to clarify the effects of angiolytic laser surgery for vocal polyp removal. METHODS Vocal outcomes were reviewed for patients who underwent angiolytic laser surgery (n=20, laser group) or microflap surgery (n=34, microflap group) for vocal polyp removal. The data analyzed included patient and lesion characteristics, number of surgeries required for complete resolution, and aerodynamic and acoustic examinations before and after surgery. RESULTS In the laser surgery group, complete resolution of the lesion was achieved with a single procedure in 17 cases (85%) and with two procedures in 3 cases (15%). Postoperative aerodynamic and acoustic parameters demonstrated significant improvement compared to preoperative parameters in both the laser surgery group and the microflap surgery group. There were no significant differences in any postoperative aerodynamic and acoustic parameters between the two groups. CONCLUSION The current retrospective study demonstrated that angiolytic laser surgery achieved complete resolution of vocal polyps within two procedures. Postoperative effects on aerodynamic and acoustic functions were similar to those after microflap surgery.
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Park YM, Jo KH, Hong HJ, Choi HS. Phonatory outcome of 585nm/pulsed-dye laser in the management of glottic leukoplakia. Auris Nasus Larynx 2014; 41:459-63. [DOI: 10.1016/j.anl.2014.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 05/04/2014] [Accepted: 05/13/2014] [Indexed: 10/25/2022]
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Centric A, Hu A, Heman-Ackah YD, Divi V, Sataloff RT. Office-Based Pulsed-Dye Laser Surgery for Laryngeal Lesions: A Retrospective Review. J Voice 2014; 28:262.e9-262.e12. [DOI: 10.1016/j.jvoice.2013.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/21/2013] [Indexed: 10/26/2022]
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Panwar A, Lindau R, Wieland A. Management of premalignant lesions of the larynx. Expert Rev Anticancer Ther 2014; 13:1045-51. [DOI: 10.1586/14737140.2013.829643] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sridharan S, Achlatis S, Ruiz R, Jeswani S, Fang Y, Branski RC, Amin MR. Patient-based outcomes of in-office KTP ablation of vocal fold polyps. Laryngoscope 2013; 124:1176-9. [DOI: 10.1002/lary.24442] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 07/02/2013] [Accepted: 09/05/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Shaum Sridharan
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
| | - Stratos Achlatis
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
| | - Ryan Ruiz
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
| | - Seema Jeswani
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
| | - Yixin Fang
- Division of Biostatistics; Department of Population Health; New York University School of Medicine; New York New York U.S.A
| | - Ryan C. Branski
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
| | - Milan R. Amin
- NYU Voice Center, Department of Otolaryngology-Head and Neck Surgery; New York University School of Medicine; New York New York
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Hwang CS, Lee HJ, Ha JG, Cho CI, Kim NH, Hong HJ, Choi HS. Use of Pulsed Dye Laser in the Treatment of Sulcus Vocalis. Otolaryngol Head Neck Surg 2013; 148:804-9. [DOI: 10.1177/0194599813479909] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective The pulsed dye laser (PDL) has been shown to be effective in the treatment of hypertrophic scars and keloids in dermatology. On the basis of histopathologic similarities between sulcus vocalis and scar tissue and numerous reports on the treatment of laryngeal lesions, especially scar tissue, with PDL, we evaluated the efficacy of treating sulcus vocalis with PDL. We named this surgical procedure PDL glottoplasty. Study Design Case series with planned data collection. Setting A university-based, tertiary care medical center. Subjects and Methods This study was conducted on 25 patients diagnosed with sulcus vocalis by videostroboscopy at the Gangnam Severance Hospital Otorhinolaryngology Department between August 2006 and February 2012. Energy delivery was fixed at 0.75 Joules (J) per pulse, and each vocal fold was administered 60 to 110 pulses (average 72.5 pulses) during each procedure. Aerodynamic, stroboscopic, and acoustic voice analyses were performed pre- and postoperatively. Results Although assessment was necessarily subjective, our study indicated that vocal folds showed decreased stiffness and improved mucosal wave properties after treatment, resulting in improved vibration and dysphonia. In the objective assessments, most patients who underwent PDL glottoplasty showed improvement in several postoperative voice analysis indices. The differences between preoperative and some postoperative voice parameter indices were statistically significant. Conclusion We found PDL glottoplasty to be beneficial in the treatment of sulcus vocalis. Objective measurements of voice quality and normalization of vocal fold vibration improved after PDL treatment in most cases. Our results warrant further studies with larger numbers of participants and longer follow-up periods.
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Affiliation(s)
- Chi Sang Hwang
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jin Lee
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Gyun Ha
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Il Cho
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Na Hyun Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jun Hong
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Hong-Shik Choi
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
- Institute of Logopedics & Phoniatrics, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
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Sheu M, Sridharan S, Kuhn M, Wang S, Paul B, Venkatesan N, Fuller CW, Simpson CB, Johns M, Branski RC, Amin MR. Multi-Institutional Experience With the In-Office Potassium Titanyl Phosphate Laser for Laryngeal Lesions. J Voice 2012; 26:806-10. [DOI: 10.1016/j.jvoice.2012.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 04/18/2012] [Indexed: 11/27/2022]
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Burns JA, Friedman AD, Lutch MJ, Zeitels SM. Subepithelial Vocal Fold Infusion: A Useful Diagnostic and Therapeutic Technique. Ann Otol Rhinol Laryngol 2012; 121:224-30. [DOI: 10.1177/000348941212100407] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Preservation of the maximum amount of subepithelial superficial lamina propria (SLP) remains an important goal during microlaryngoscopic surgery of phonatory mucosa. Volume expansion of the SLP (Reinke's space) with subepithelial infusion of saline solution has been widely adopted since its introduction in 1991. This technique has evolved so that it is currently used to assist with determining the depth of vocal fold disease, defining residual pliable SLP, enhancing microsurgical precision, and identifying unrecognized disease. The purpose of this investigation was to examine the indications, methods, and benefits of subepithelial infusion of saline solution as an adjunct technique during phonomicrosurgery. Methods: In a prospective case series, we collected data on 280 consecutive microlaryngoscopy procedures performed over a 12-month period. Subepithelial infusion of saline solution was included in 178 procedures. Results: New disease was identified in 20 of the 178 patients (scar in 15, sulcus in 4, and a mucosal bridge in 1). The depth of needle placement varied depending on the specific disease: 118 of the 178 infusions were done just below the epithelial basement membrane, and 60 infusions were performed deeper within the SLP, just superficial to the vocal ligament. The infusion technique provided surgical assistance in multiple ways, including identifying residual SLP (130 patients), defining the SLP-lesion interface (65 patients), lifting scar (60 patients), providing tension for cordotomy (47 patients), expanding the SLP volume to protect against laser damage (45 patients), and providing hydrostatic compression of vascular ectasias or varices for photoangiolysis (7 patients). The microlaryngoscopy procedures during which infusion was not performed (102 of 280 procedures) were primarily for nonglottic cancer (46 patients), stenosis (30 patients), or arytenoid granuloma (13 patients). Conclusions: Subepithelial infusion of the SLP with saline solution is a useful microsurgical adjunct during diagnosis and treatment of phonatory mucosal lesions.
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Burns JA, Lopez-Guerra G, Kobler JB, Faquin W, LeClair M, Zeitels SM. Pulsed potassium-titanyl-phosphate laser photoangiolytic treatment of mucosal squamous cell carcinoma in the hamster cheek pouch. Laryngoscope 2011; 121:942-6. [PMID: 21495047 DOI: 10.1002/lary.21811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 02/28/2011] [Accepted: 03/09/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Early glottic cancer has been involuted by treatment with the 532 nm pulsed potassium-titanyl-phosphate (KTP) laser in initial clinical studies. Selective photoangiolysis of the sublesional circulation that allows for relative sparing of surrounding tissue is the presumed mechanism. No prior controlled animal-model study has analyzed the ability of selective coagulation of lesional microvasculature coagulation with the KTP laser to involute malignant lesions. This study tests the efficacy of photoangiolysis with the KTP laser in treating squamous cell carcinoma in an established animal model. STUDY DESIGN In vivo. METHODS Malignant lesions were induced unilaterally in the cheek pouches of 21 hamsters by applying 9,10-dimethyl-1,2-benzanthrancene. The contralateral cheek pouch served as a control. Weekly lesion photodocumentation and pulsed KTP laser (30 W, 15 msec pulse width, 2 pulses/sec) treatments were done. The endpoint of each treatment was a uniform white-blanching of the lesion. Hamsters were sacrificed 1 week after the last treatment and cheek pouches were analyzed histologically. RESULTS Carcinoma was confirmed in 19 hamsters, and lesions that were initially <2 mm were more effectively treated than lesions that were >2 mm (P = .0004). Every lesion (10/10) that initially measured <2 mm resolved completely after laser treatment with minimal scarring noted at the treatment site based on histology. Lesions measuring between 2 and 5 mm resolved 33% of the time (2/6), and none (0/3) of the lesions >5 mm resolved after completion of the treatment period. CONCLUSIONS Pulsed KTP laser photoangiolysis can effectively involute small malignant lesions, but may be less effective at involuting larger (>2 mm) lesions.
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Affiliation(s)
- James A Burns
- Department of Surgery, Harvard Medical School, Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Mallur PS, Tajudeen BA, Aaronson N, Branski RC, Amin MR. Quantification of benign lesion regression as a function of 532-nm pulsed potassium titanyl phosphate laser parameter selection. Laryngoscope 2011; 121:590-5. [DOI: 10.1002/lary.21354] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 08/30/2010] [Accepted: 08/24/2010] [Indexed: 11/07/2022]
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Lin Y, Yamashita M, Zhang J, Ling C, Welham NV. Pulsed dye laser-induced inflammatory response and extracellular matrix turnover in rat vocal folds and vocal fold fibroblasts. Lasers Surg Med 2010; 41:585-94. [PMID: 19746432 DOI: 10.1002/lsm.20839] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Disruption of the vocal fold extracellular matrix (ECM) can induce a profound and refractory dysphonia. Pulsed dye laser (PDL) irradiation has shown early promise as a treatment modality for disordered ECM in patients with chronic vocal fold scar; however, there are limited data addressing the mechanism by which this laser energy might induce cellular and extracellular changes in vocal fold tissues. In this study, we examined the inflammatory and ECM modulating effects of PDL irradiation on normal vocal fold tissues and cultured vocal fold fibroblasts (VFFs). STUDY DESIGN/MATERIALS AND METHODS We evaluated the effects of 585 nm PDL irradiation on inflammatory cytokine and collagen/collagenase gene transcription in normal rat vocal folds in vivo (3-168 hours following delivery of approximately 39.46 J/cm(2) fluence) and VFFs in vitro (3-72 hours following delivery of 4.82 or 9.64 J/cm(2) fluence). We also examined morphological vocal fold tissue changes 3 hours, 1 week, and 1 month post-irradiation. RESULTS PDL irradiation altered inflammatory cytokine and procollagen/collagenase expression at the transcript level, both in vitro and in vivo. Additionally, PDL irradiation induced an inflammatory repair process in vivo that was completed by 1 month with preservation of normal tissue morphology. CONCLUSIONS PDL irradiation can modulate ECM turnover in phenotypically normal vocal folds. Additional work is required to determine if these findings extend to disordered ECM, such as is seen in vocal fold scar. Lasers Surg. Med. 41:585-594, 2009. (c) 2009 Wiley-Liss, Inc.
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Affiliation(s)
- Ya Lin
- Division of Otolaryngology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Zeitels SM, Lopez-Guerra G, Burns JA, Lutch M, Friedman AM, Hillman RE. Microlaryngoscopic and office-based injection of bevacizumab (Avastin) to enhance 532-nm pulsed KTP laser treatment of glottal papillomatosis. Ann Otol Rhinol Laryngol 2009; 201:1-13. [PMID: 19845188 DOI: 10.1177/000348940911800901] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Photoangiolytic lasers effectively treat glottal papillomatosis, but do not reliably prevent recurrence. Therefore, sublesional injections of the antiangiogenic agent bevacizumab (Avastin) were given to assess the effect on disease recurrence and phonatory function. METHODS A retrospective investigation was done in a pilot group of 10 adult patients with bilateral glottal papillomatosis who had prior angiolytic laser treatment with established patterns of recurrence. The patients underwent 5 bevacizumab injections (5 to 10 mg) into the diseased vocal folds along with 532-nm pulsed KTP laser photoangiolysis treatments 4 to 6 weeks apart. Their disease resolution was compared to findings from prior laser treatment alone, and objective measures of vocal function (acoustic, aerodynamic, Voice-Related Quality of Life survey) were obtained. RESULTS All 10 patients had a greater than 90% reduction in recurrence. Four of the 10 had resolution. Four of the 10 have limited recurrent or persistent disease, receive injections of bevacizumab at 8- to 12-week intervals, and have not required laser treatment. Two of the 10 have ongoing periodic office-based KTP laser treatment along with bevacizumab injections. No patient has required microlaryngeal surgery with general anesthesia, and all 10 have had substantial improvement in vocal function. CONCLUSIONS This pilot investigation provides preliminary evidence that bevacizumab injections enhance photoangiolytic laser treatment of glottal papillomatosis while enhancing phonatory function. Coupling an antiangiogenesis agent with pulsed KTP laser photoangiolysis is conceptually promising, since the mechanisms of action are complementary.
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Affiliation(s)
- Steven M Zeitels
- Department of Surgery, Harvard Medical School, Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Value and utility of 532 nanometre pulsed potassium-titanyl-phosphate laser in endoscopic laryngeal surgery. The Journal of Laryngology & Otology 2009; 124:407-11. [DOI: 10.1017/s0022215109991824] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjectives:Recently, the 532 nm pulsed potassium-titanyl-phosphate laser has emerged as an effective angiolytic laser for treating mucosal lesions of the larynx in the operating theatre and clinic. We sought to assess the current impact of potassium-titanyl-phosphate laser on our laryngeal surgery practice.Study design:Retrospective review of 710 patients undergoing endoscopic laryngeal surgery over a one-year period.Methods:Medical records of the endoscopic laryngeal procedures were reviewed; 386/710 had been performed in the clinic and 324/710 in the operating theatre under general anaesthesia. Indications for the procedures were classified by pathology.Results:Pulsed potassium-titanyl-phosphate laser was used in 209/386 clinic procedures. The indications for these procedures were: dysplasia (114/209 procedures), papillomatosis (89/209), varices or ectasia (three of 209), and ‘other’ (three of 209). Pulsed potassium-titanyl-phosphate laser was used in 178/324 operating theatre endoscopic laryngeal procedures. The indications for these procedures were: cancer (54/178 procedures), dysplasia (52/178), papillomatosis (38/178), varices or ectasia (13/178), polyps (six of 178), nodules (six of 178), stenosis (five of 178), granulation (three of 178), and amyloid (one of 178).Conclusions:Due to its versatility, the 532 nm pulsed potassium-titanyl-phosphate laser is our most commonly utilised instrument for performing endoscopic laryngeal surgery.
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Yan Y, Olszewski AE, Hoffman MR, Zhuang P, Ford CN, Dailey SH, Jiang JJ. Use of lasers in laryngeal surgery. J Voice 2009; 24:102-9. [PMID: 19487102 DOI: 10.1016/j.jvoice.2008.09.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 09/22/2008] [Indexed: 10/20/2022]
Abstract
Lasers are a relatively recent addition to laryngeal surgery. Since their invention, laser use and applications have expanded rapidly. In this article, we discuss the benefits and disadvantages of lasers for different procedures, as well as ways to overcome commonly faced clinical problems. The use of lasers in surgery has offered a time- and cost-efficient alternative to cold surgical techniques, and has been used in the treatment of numerous laryngeal pathologies, including stenoses, recurrent respiratory papillomatosis, leukoplakia, nodules, malignant laryngeal disease, and polypoid degeneration (Reinke's edema). However, lasers can incur adjacent tissue damage and vocal fold scarring. These problems can be minimized through understanding the mechanisms by which lasers function and correctly manipulating the parameters under a surgeon's control. By varying fluence, power density, and pulsation, tissue damage can be decreased and lasers can be used with greater confidence. The various types of lasers and their applications to the treatment of specific pathologies are reviewed with the intention of helping surgeons select the best tool for a given procedure. Recent applications of lasers to treat benign laryngeal lesions and severe laryngomalacia demonstrate that additional research must be conducted to realize the full potential of this surgical tool.
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Affiliation(s)
- Yan Yan
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Abstract
OBJECTIVES/HYPOTHESIS Dysphonia due to vocal fold scarring is a challenging problem to the laryngologist. Vocal fold scarring after radiation, phonosurgery, and laser cordectomy causes moderate to severe dysphonia. Surgical attempts at scar removal and voice restoration have limited success. Pulsed dye laser (PDL) treatment has been shown to be effective in softening scarred skin by serial office treatments. The objective of this preliminary study was to evaluate the use of the PDL in the management of patients with established vocal fold scar. STUDY DESIGN This is an Institutional Review Board-approved prospective study involving 11 patients. The causes of scarring were phonosurgery (n = 7), radiation (n = 2), and partial laryngectomy (n = 2). The subjects were evaluated pre- and postprocedure using the voice handicap index (VHI), laryngeal stroboscopy rating, voice recordings with acoustic and aerodynamic analysis, and self-evaluation. METHODS The PDL was applied with the fiberoptic delivery system by three treatments at 1-month intervals in the office setting. Each treatment endpoint was blanching of the treatment site. RESULTS : There were three women and eight men in our study group. Ten of 11 patients subjectively improved by self-rating. No patients were worse. VHI improved from 48.44 pretreatment to 35.55 at 6 months posttreatment (P < .05). The jitter at 6 months improved from 2.230% to 1.654% (P = NS) and shimmer improved from 3.679% to 3.196% (P = NS). The noise to harmonic ration improved from 0.1428 to 0.1316 (P = NS). The mean phonotory flow went from 0.177 to 0.254 L/S (P < .05). Three raters blinded to treatment sequence rated the posttreatment stroboscopy findings as better than pretreatment in a forced choice comparison, kappa score 0.903. CONCLUSION PDL is a safe and potentially promising treatment for established vocal fold scar. Subjectively, no patients were worse and 10 of 11 patients reported improved voice. There was improvement in the VHI, acoustic measures of shimmer and jitter, and stroboscopy findings. Further study using this approach in a larger cohort seems to be warranted.
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Zeitels SM, Burns JA, Lopez-Guerra G, Anderson RR, Hillman RE. Photoangiolytic Laser Treatment of Early Glottic Cancer: A New Management Strategy. Ann Otol Rhinol Laryngol 2008. [DOI: 10.1177/000348940811700701] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 532 nm pulsed KTP (potassium titanyl phosphate) laser and the 585 nm pulsed dye laser (PDL) are photoangiolytic lasers that have been demonstrated to be effective for managing vocal fold dysplasia. The putative mechanism of action is selective photoangiolysis of the sublesional microcirculation. On the basis of this experience, early glottic cancers were treated by selectively targeting the intralesional and sublesional microvasculature. This approach was derived from Folkman's concepts of neoplastic growth resulting from tumor angiogenesis. Staged microlaryngeal treatment was adopted, because it facilitated optimal functional results, and was considered safe, because early glottic cancer rarely metastasizes. Furthermore, intercurrent disease during conventional incremental radiotherapy is typical in treating early glottic cancer. A pilot group of 22 patients with early glottic cancer (13 T1, 9 T2) were treated with a fiber-based angiolytic laser. Eleven of the 22 had unilateral disease and were entirely treated by laser photoangiolysis as a sole modality. Eleven of the 22 had bilateral disease; 5 of the 11 were treated entirely (bilaterally) by laser photoangiolysis, and 6 of the 11 only underwent laser treatment of the less involved vocal fold, with conventional resection being done on the dominant side of the cancer. The initial 8 of the 22 were treated with the PDL, and the latter 14 of the 22 were treated with the pulsed KTP laser. No patient has cancer presently, and none have undergone posttreatment radiotherapy or open surgery. The mean follow-up is 27 months, 13 of the 22 patients have at least 2 years of follow-up, and the first patient was treated just over 5 years ago. Objective measures of vocal function revealed that photoangiolytic treatment of early glottic cancer resulted in significant postoperative improvements despite the fact that half of the patients had bilateral disease. Angiolytic lasers effectively involuted early glottic cancer, with microsurgically directed nonionizing radiation of the dense neoplastic blood supply resulting in complete tumor regression. This approach is conceptually attractive, because it is repeatable, it preserves all conventional cancer treatment options, and it results in excellent vocal function by improving phonatory mucosal wave vibration. Observations from this investigation suggest that this new and novel cancer treatment strategy is effective; however, larger patient cohorts, longer follow-up, and multi-institutional confirmation will be necessary to establish incontrovertible oncological efficacy.
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Zeitels SM, Burns JA, Lopez-Guerra G, Anderson RR, Hillman RE. Photoangiolytic Laser Treatment of Early Glottic Cancer: A New Management Strategy. Ann Otol Rhinol Laryngol 2008; 199:3-24. [DOI: 10.1177/00034894081170s701] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 532 nm pulsed KTP (potassium titanyl phosphate) laser and the 585 nm pulsed dye laser (PDL) are photoangiolytic lasers that have been demonstrated to be effective for managing vocal fold dysplasia. The putative mechanism of action is selective photoangiolysis of the sublesional microcirculation. On the basis of this experience, early glottic cancers were treated by selectively targeting the intralesional and sublesional microvasculature. This approach was derived from Folkman's concepts of neoplastic growth resulting from tumor angiogenesis. Staged microlaryngeal treatment was adopted, because it facilitated optimal functional results, and was considered safe, because early glottic cancer rarely metastasizes. Furthermore, intercurrent disease during conventional incremental radiotherapy is typical in treating early glottic cancer. A pilot group of 22 patients with early glottic cancer (13 T1, 9 T2) were treated with a fiber-based angiolytic laser. Eleven of the 22 had unilateral disease and were entirely treated by laser photoangiolysis as a sole modality. Eleven of the 22 had bilateral disease; 5 of the 11 were treated entirely (bilaterally) by laser photoangiolysis, and 6 of the 11 only underwent laser treatment of the less involved vocal fold, with conventional resection being done on the dominant side of the cancer. The initial 8 of the 22 were treated with the PDL, and the latter 14 of the 22 were treated with the pulsed KTP laser. No patient has cancer presently, and none have undergone posttreatment radiotherapy or open surgery. The mean follow-up is 27 months, 13 of the 22 patients have at least 2 years of follow-up, and the first patient was treated just over 5 years ago. Objective measures of vocal function revealed that photoangiolytic treatment of early glottic cancer resulted in significant postoperative improvements despite the fact that half of the patients had bilateral disease. Angiolytic lasers effectively involuted early glottic cancer, with microsurgically directed nonionizing radiation of the dense neoplastic blood supply resulting in complete tumor regression. This approach is conceptually attractive, because it is repeatable, it preserves all conventional cancer treatment options, and it results in excellent vocal function by improving phonatory mucosal wave vibration. Observations from this investigation suggest that this new and novel cancer treatment strategy is effective; however, larger patient cohorts, longer follow-up, and multi-institutional confirmation will be necessary to establish incontrovertible oncological efficacy.
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Ivey CM, Woo P, Altman KW, Shapshay SM. Office pulsed dye laser treatment for benign laryngeal vascular polyps: a preliminary study. Ann Otol Rhinol Laryngol 2008; 117:353-8. [PMID: 18564532 DOI: 10.1177/000348940811700505] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The 585-nm pulsed dye laser (PDL) was recently deemed relatively safe and effective for treatment of laryngeal papilloma, dysplasia, and granuloma. We report on in-office PDL treatment of laryngeal vascular polyps. METHODS Retrospective case results from 29 consecutive cases of laryngeal polyps were evaluated to determine the percent change in polyps after PDL treatment. Preoperative and postoperative measurements of polyp size, total power delivered to the site, and whether patients opted for postprocedure phonomicrosurgery were analyzed. RESULTS After PDL treatment, the results varied from complete to partial resolution of the polyp. Four patients requested conventional phonomicrosurgery, and the rest had enough improvement to defer surgery. Almost 40% of patients with larger polyps desired operative intervention after laser treatment, whereas only 13% of those with small polyps opted for phonomicrosurgery. Thirty-eight percent (11 of 29) of the lesions had greater than 70% improvement after 1 or 2 laser treatments (average of 1.1 procedures). Smaller lesions responded better. Thirty-nine percent of small polyps resolved by greater than 70%, whereas only 20% of larger lesions improved by the same amount. There were no adverse events from the office procedure. CONCLUSIONS In-office use of the PDL for treatment of vascular polyps may be a safe alternative to phonomicrosurgery. Small polyps seem to show a better response.
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Affiliation(s)
- Chandra M Ivey
- Department of Otolaryngology, Mount Sinai School of Medicine, New York, NY 10029, USA
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