10.14639/0392-100X-N0935
Objective: Development of transnasal fiberoptic laryngoscopy, integration of an operative channel (OC), the advent of high-definition television imaging, with improvements in laser technology, cleared the way for office-based laryngology. Three treatment categories can be identified: bioendoscopy-guided biopsy; laryngeal injection; laser-assisted surgery.
Methods: 26 patients underwent OBPs at the Otolaryngology Clinic of IRCCS Policlinico San Martino, Genoa, Italy. Sixty-eight procedures were performed: 60 for recurrent respiratory papillomatosis (RRP), 5 for unilateral vocal fold paralysis (UVFP) and 3 for glottic leukoplakias. Neoblucaine 5% was administrated through the operative channel, for local anaesthesia. All procedures were carried out with the physician standing behind the patient. Narrow band imaging (NBI – Olympus Medical) or i-scan (Pentax Medical) were used to enhance the accuracy of the biopsy thanks to identification of atypical vascular patterns. Laryngeal injections were made using a 25G flexible needle. Opera Evo (Quanta system IEC/EN 60825-1:2007) is a hybrid fibre laser that is used for “blanching” and vaporisation of RRP lesions and to treat selected leukoplakias that were previously biopsied.
Conclusion: No major complications occurred during the procedures.
text/xml
1827-675X
935
en
Giorgio Peretti
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
recurrent respiratory papillomatosis
Office-based procedures in laryngology
Text.Serial.Journal
https://www.actaitalica.it/
41
Laryngology
2020-12-29
2020-06-18
2021-07-08
2021-07-08
243-247
1
Giorgio Peretti
2021
10.14639/0392-100X-N0935
243
IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Italy
1827-675X
recurrent respiratory papillomatosis
247
Office-based procedures in laryngology
https://www.actaitalica.it/article/download/935/489
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:243-247; doi: 10.14639/0392-100X-N0935




Laryngology


Office-based procedures in laryngology
Procedure ambulatoriali in laringologia
Marta Filauro1,2,3, Alberto Vallin1,2, Marco Fragale1,2, Claudio Sampieri1,2, Luca Guastini1,2, Francesco Mora1,2,
Giorgio Peretti1,2
1
 IRCCS Ospedale Policlinico San Martino, Genoa, Italy; 2 Department of Surgical Sciences and Integrated Diagnostics (DISC),
University of Genoa, Italy; 3 Department of Experimental Medicine (DIMES), University of Genoa, Italy


SUMMARY
Objective. Development of transnasal fiberoptic laryngoscopy, integration of an operative
channel (OC), the advent of high-definition television imaging, with improvements in laser
technology, cleared the way for office-based laryngology. Three treatment categories can be
identified: bioendoscopy-guided biopsy; laryngeal injection; laser-assisted surgery.
Methods. 26 patients underwent OBPs at the Otolaryngology Clinic of IRCCS Policlinico
San Martino, Genoa, Italy. Sixty-eight procedures were performed: 60 for recurrent respira-
tory papillomatosis (RRP), 5 for unilateral vocal fold paralysis (UVFP) and 3 for glottic
leukoplakias. Neoblucaine 5% was administrated through the operative channel, for local
anaesthesia. All procedures were carried out with the physician standing behind the patient.
Narrow band imaging (NBI – Olympus Medical) or i-scan (Pentax Medical) were used to
enhance the accuracy of the biopsy thanks to identification of atypical vascular patterns.
Laryngeal injections were made using a 25G flexible needle. Opera Evo (Quanta system
IEC/EN 60825-1:2007) is a hybrid fibre laser that is used for “blanching” and vaporisation
of RRP lesions and to treat selected leukoplakias that were previously biopsied.
                                                                                               Received: June 18, 2020
Conclusions. No major complications occurred during the procedures.
                                                                                               Accepted: July 28, 2020
KEY WORDS: laryngology, videolaryngoscopy, office-based procedures, injection,                 Published online: December 29, 2020
recurrent respiratory papillomatosis
                                                                                               Correspondence
                                                                                               Marta Filauro
RIASSUNTO                                                                                      Department of Surgical Sciences and Integrated
Oggetto. Lo sviluppo della fibrolaringoscopia transnasale, l’integrazione del canale ope-      Diagnostics (DISC), University of Genoa, Italy
rativo e l’avvento dell’alta definizione, associato ai miglioramenti della tecnologia laser,   Department of Experimental Medicine (DIMES),
hanno permesso la diffusione delle procedure laringologiche eseguite ambulatorialmente.        University of Genoa, Italy
Esistono 3 categorie di trattamenti: biopsie guidate dalla bioendoscopia, iniezioni endola-    E-mail: mfilauro@yahoo.com
ringee e chirurgia laser-assistita.
Metodi. 26 pazienti sono stati sottoposti a trattamenti ambulatoriali presso la Clinica Oto-   Funding
rinolaringoiatrica dell’IRCCS Policlinico San Martino di Genova, Italia. Sono state ese-       None.
guite 68 procedure: 60 per papillomatosi respiratoria ricorrente, 5 per paralisi unilaterale
della corda vocale e 3 per leucoplachie glottiche. Tutte le procedure sono state eseguite      Conflict of interest
posizionandosi dietro il paziente. Per aumentare l’accuratezza della presa bioptica, abbia-    The Authors declare no conflict of interest.
mo utilizzato la Narrow band imaging (NBI – Olympus Medical) o i-scan (Pentax Medical).
Le iniezioni endolaringee sono state eseguite con un ago flessibile da 25G. Per eseguire la      How to cite this article: Filauro M, Vallin A, Fra-
vaporizzazione delle lesioni papillomatose e per trattare le leleucoplachie selezionate è        gale M, et al. Office-based procedures in laryngol-
stato utilizzato il laser a fibra ibrido Opera Evo (Quanta system IEC/EN 60825-1:2007).          ogy. Acta Otorhinolaryngol Ital 2021;41:243-247.
Conclusioni. Nessuna complicanza maggiore è incorsa durante le procedure.                        https://doi.org/10.14639/0392-100X-N0935

PAROLE CHIAVE: laringologia, videolaringoscopia, ambulatorio, laringoplastica                  © Società Italiana di Otorinolaringoiatria
iniettiva, papillomatosis respiratoria ricorrente                                              e Chirurgia Cervico-Facciale


                                                                                                              OPEN ACCESS

                                                                                               This is an open access article distributed in accordance with
Introduction                                                                                   the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                               Commercial-NoDerivatives 4.0 International) license. The
Office-based laryngology procedures (OBPs) emerged in the 19th century; at                     article can be used by giving appropriate credit and mentio-
                                                                                               ning the license, but only for non-commercial purposes and
that time, they were performed with the limits of indirect vision through laryn-               only in the original version. For further information: https://
geal mirrors and by the paucity of instrumentation. When transnasal fibreoptic                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                       243
M. Filauro et al.




laryngoscopy became available in 1975, it laid the ground-                                            A                                  B
work for the shift from the operating room (OR) to the of-
fice 1. Moreover, integration of an operative channel (OC)
in the flexible endoscope widely extended the range of pro-
cedures that could be performed, especially those assisted
by the appropriate type of laser beam delivered through fi-
bre. Lastly, the advent of high-definition television fibreop-                                                                           C
tic imaging, together with improvements in laser technol-
ogy, definitively cleared the way for the consolidation of
office-based laryngology 2.
Nowadays several treatments, broadly divided in three cat-
egories, can be performed in an office-based setting:
1. Bioendoscopy-guided biopsy with a more convenient             Figure 1. (A) Neoblucaine 5%; (B) From the left side: endoscopic forceps,
   approach compared to previous transoral access.               5% neoblucaine, tullio-diode laser fibre and bevacizumab; (C) Opera Evo hy-
2. Laryngeal injection has benefited from the possibility        brid laser.
   of inserting an injecting needle through the OC as an
   alternative to a transcutaneous approach to administer
   laryngeal augmentation materials or drugs (i.e., hyalu-       laryngologist in a safer position, avoiding direct exposure
   ronic acid, steroids, botulinum toxin, cidofovir, bevaci-     to nasal and oral secretions, while the patient can follow the
   zumab, etc.).                                                 procedure on the screen, enhancing compliance. Moreover,
3. Laser-assisted surgery to address several selected benign     this modality of performing videolaryngoscopy, as rou-
   or premalignant diseases (i.e., recurrent respiratory pap-    tinely adopted by bronchoscopists, allows the physician to
   illomatosis (RRP), leukoplakias). Different laser fibers      obtain the same laryngeal orientation and exposure achiev-
   are available on the market, each with specific charac-       able in the OR under general anaesthesia while maintain-
   teristics of wavelength, delivery mode, safety and costs:     ing full laryngeal visualisation. Finally, local anaesthesia is
   proper selection of the type of laser is the key to avoid     further administrated directly through the OC, just above
   suboptimal results and undesirable side effects 3.            laryngeal aditus, in order to spray an additional 3-4 ml of
This manuscript aims to give insight into our office-based       neoblucaine 5% directly on the epiglottis, posterior com-
laryngology setting and instrumentation and to define the        missure and glottis: to better convey the anaesthetic effects
type of pathologies that we currently treat with this ap-        and prolong contact with the larynx, during the procedure
proach.                                                          patients are initially asked to sniff vigorously and to pho-
                                                                 nate immediately after (Fig. 2B). After a few minutes, the
                                                                 entire larynx is adequately anesthetised, and the surgical
Methods                                                          procedure can begin.
In the time frame from May 2019 to February 2020, 26             Biopsies were performed with specific flexible forceps
patients underwent OBPs at the Otolaryngology Outpatient         through the OC (Fig. 2D). Narrow band imaging (NBI –
Clinic of IRCCS Policlinico San Martino, Genoa, Italy. A         Olympus Medical) or i-scan (Pentax Medical) were used to
total of 68 procedures were performed.                           select the proper site to enhance the accuracy of the biopsy
An Olympus CV-170 ENT digital platform together with a           thanks to the identification of atypical vascular patterns in-
videoendoscope ENF-VT2 (Olympus medical system) or               side and surrounding suspicious lesions.
Pentax Medical Defina EPK-3000 with Video Naso Phar-             Laryngeal injections were made using a 25G flexible, dedi-
yngo Laryngoscope VNL 1570STK (Pentax Medical) were              cated needle (length of the tip of the needle = 5 mm) through
alternatively used. Both videoendoscopes have an OC for          the OC (Fig. 1B and Fig. 3H). Hyaluronic acid was injected
the insertion of instruments.                                    into the thickest part of the vocal ligament, between this
Before each procedure, in order to obtain the best patient       and the thyroarytenoid muscle, for augmentation of vocal
compliance, we applied a standardised protocol for admin-        cord mass in case of unilateral vocal fold paralysis and bev-
istration of local anaesthesia. Before starting the procedure,   acizumab (12.5 mg) was injected submucosally as adjuvant
2 ml of 5% neoblucaine is sprayed into the patient’s nostril.    treatment for RRP. To avoid retaining of the material inside
(Fig. 1A and Fig. 2A). Subsequently, the physician gets in-      the injection needle and to guarantee that a full dose is ad-
to position behind the patient, inserting the videoendoscope     ministrated, 1 ml of saline solution was introduced inside
into the nose (Fig. 2B). This setting is designed to keep the    the needle at the end of each material injection.



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  A                                                                                                                                                         B




  C                                                                                                                                                         D




Figure 2. (A) Local anaesthesia into patient’s nose; (B) Local anaesthesia through the operative channel; (C) Laser fibre insertionthrough the operative channel;
(D) Endoscopic forceps insertion through the operative channel.


Opera Evo (Quanta system IEC/EN 60825-1:2007) is                                   Results
a hybrid fibre laser that is used for “blanching” and
                                                                                   A total of 26 patients (17 males and 9 females) were treat-
vaporisation of RRP lesions and to treat selected leu-
                                                                                   ed. The mean age was 46.8 years (range 15-82). Of the 68
koplakias that were previously biopsied (Fig. 1B and
                                                                                   OBPs, 60 were performed for RRP, 5 for unilateral vocal
Fig. 1C). This hybrid thulium/diode laser with a dual-
                                                                                   fold paralysis (UVFP) and 3 for glottic leukoplakias. All 60
wavelength (1.9 mm and 1.5 mm) allowed for intraop-                                procedures carried out for RRP included laser vaporisation
erative fine-tuning of the instrument between cutting                              of papillomas and subsequent injection of bevacizumab
function, vaporisation and haemostasis. Pulsed emis-                               submucosally (Figs. 3A, 3B, 3C). For RRP, the endoscopic
sion is our preferred modality (ultrapulsed 4W-1.5W),                              treatment was repeated every 6 weeks, for a maximum of
as it causes less thermal damage to the mucosa and the                             6 times.
vocal ligament. Laser energy is transferred to the target                          During the five injection laryngoplasties for UVFP, hyalu-
by flexible fibres available in different calibers (200                            ronic acid was injected inside the vocal ligament: this injec-
mm; 272 mm; 365 mm; 550 mm; 800 mm; 1000 mm).                                      tion site, together with the high-density material, ensures
In our experience, 200 mm and 272 mm diameters are                                 that the hyaluronic acid remains in the vocal fold, allowing
the most suitable for OBPs as they fit perfectly in the                            a long-lasting augmentation effect (Fig. 3H).
OC. Each fibre is reusable for a maximum of 10 times.                              All three vaporisation procedures for leukoplakia were
A full sterilisation process is carried out after each use.                        performed on patients who were unfit for transoral laser



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M. Filauro et al.




Figure 3. (A) Papilloma laser surgery; (B) Vapourised tissue asportation; (C) Submucosal bevacizumab injection; (D) Bioendoscopy-guided biopsy; (E) Glottic leu-
koplakia vaporisation; (F) Three-month white light follow-up; (G) Three-month NBI follow-up; (H) Hyaluronic acid injection into the vocal ligament.


microsurgery (TLM) under general anaesthesia due to in-                           diffusion of OBPs is related to the possibility for patients
adequate exposure and/or poor general conditions. These                           to be discharged immediately after the procedure, avoiding
endoscopic procedures were preceded by incisional biopsy                          hospitalisation. Secondly, waiting lists for procedures in
of the lesion, which was also performed in an office-based                        general anaesthesia can be shortened without compromis-
setting (Fig. 3D) . During all the incisional biopsies, bioen-                    ing outcomes and with significant cost reduction. Finally,
doscopic tools, such as NBI ore iScan, were used in order                         the safety of frail patients is enhanced by preventing the
to collect the sample in the most representative area. Only                       risks associated with general anaesthesia. Above all, treat-
if the pathological report confirmed a diagnosis of mild or                       ment of highly recurrent diseases, such as RRP, benefits
moderate dysplasia (LIN1-2) was office-based laser vapori-                        from the advantages of OBPs such as the possibility to treat
sation carried out (Figs. 3E, 3F, 3G); otherwise, in case of                      every small recurrence and/or persistence with a shorter in-
diagnosis of squamous cell carcinoma, patients were sub-                          terval of time between treatments, while maintaining good
mitted to radiotherapy, as TLM is unfeasible in terms of                          voice quality and adequate respiratory space and avoiding
definitive and unimodal treatment. No major complications                         the growth of papillomas that would require an intervention
occurred during any procedure. None of the procedures had                         under general anaesthesia. Furthermore, the office-based
to be discontinued.                                                               setting described herein seems to be particularly useful in
                                                                                  RRP and in all cases of highly contagious airway diseases,
                                                                                  allowing proper visualisation of all laryngeal subsites, in-
Discussion
                                                                                  cluding laryngeal ventricle and posterior commissure, and
Office-based procedures (OBPs) are a safe and reliable                            also places healthcare practitioners in a position of greater
treatment modality for selected benign and premalignant                           safety against airborne contamination by microorganisms.
laryngological diseases. Advances in anaesthesia, technol-                        During OBPs, the awake patient provides real-time vocal
ogy, instrumentation and surgical technique have resulted                         outcomes, which is critical for fine-tuning of injection lar-
in a therapeutic shift from the operating room to the office,                     yngoplasty. Furthermore, the disadvantages of direct laryn-
and it is estimated that up to 15% of procedures occur in an                      goscopy, such as dental damage or limitations in exposure,
office-based setting 4. The main reason for the widespread                        can be overcome thanks to the transnasal endoscopy ap-



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proach. On the other hand, ensuring that patients are able to    fibre can lead to the damage of the working channel. On the
tolerate the procedure is the key to ensuring success in this    other hand, endoscopic injecting needles natively carry tip
kind of surgery. Due to gag reflexes and movements, OBPs         protection, which is retractable at the time of injection, and
can be less precise than surgery performed under general         avoids possible damage to the operative channel.
anaesthesia, which may render the treatment less effective
or cause iatrogenic injuries. To overcome this limitation,       Conclusions
adequate local anaesthesia and continuous verbal contact
with the patient can be useful. Cases with exophytic or          In our experience, OBPs are safe and reliable. Moreover,
                                                                 they increase patient quality of life. Better patient selection
bulky lesions, and airway compromise, are not ideal candi-
                                                                 and standardised laser energy parameters based on lesion
dates for OBPs. Complications related to topical anaesthe-
                                                                 pathology and size may help decrease complications and
sia, like vasovagal or allergic reactions, are exceptional but
                                                                 failure rates.
still possible. In our series, we did not have any complica-
tions, but data from the literature 5 point out that OBPs are
not free from complications. The most commonly reported          References
include oedema, purpura or vascular leakage, and laryngo-        1
                                                                     Williams RG, Farquharson IM, Anthony J. Fibreoptic laryngoscopy in
spasm. Oedema can occur if the laser energy is delivered to          the assessment of laryngeal disorders. J Laryngol Otol 1975;89:299-
                                                                     316. https://doi.org/10.1017/S0022215100080403
tissues surrounding the target lesion. Purpura and vascular      2
                                                                     Zeitels SM, Burns JA, Franco RA, et al. Office-based treatment of
leakage are well-known effects of photothermolysis, but in           glottal dysplasia and papillomatosis with the 585-nm pulsed dye laser
the vast majority of cases can be minimised by adjusting             and local anesthesia. Ann Otol Rhinol Laryngol 2004;113:265-276.
                                                                     https://doi.org/10.1177/000348940411300403
the time of exposure of each laser pulse. Laryngospasm can       3
                                                                     Wellenstein DJ, Schutte HW, Takes RP, et al. Office-based proce-
occur in hypersensitive patients: in these cases, swallowing         dures for the diagnosis and treatment of laryngeal pathology. J Voice
and forced inspiration from the nose, with mouth closed, al-         2018;32:502-513. https://doi.org/10.1016/j.jvoice.2017.07.018
low quick resolution of the laryngospasm without the need        4
                                                                     Pynnonen MA, Schmalbach CE. Office-based procedures in otolar-
for further measures. In addition to patient-related compli-         yngology. Otolaryngol Clin North Am 2019;52:xv-xvi. https://doi.
                                                                     org/10.1016/j.otc.2019.03.001
cations, instrumentation-related issues can occur. Attention     5
                                                                     del Signore AG, Shah RN, Gupta N, et al. Complications and failures
must be paid when inserting laser fibres inside the opera-           of office-based endoscopic angiolytic laser surgery treatment. J Voice
tive channel: an incorrect insertion angle of the glass laser        2016;30:744-750. https://doi.org/10.1016/j.jvoice.2015.08.022




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