Minimally Invasive Office Phonosurgery
Many lesions of the larynx and pharynx can be treated transnasally with a channeled fiberoptic laryngoscope with distal chip camera. This technique is advantageous for patients who may be difficult to visualize by operative direct laryngoscopy for a variety of anatomic reasons - poor jaw opening, small chin, poor neck mobility, abnormally high BMI - or who present with medical issues that may be compromised by general anesthesia - severe COPD, paraplegia, cardiac issues. It is also excellent for patients whose pathology will require multiple procedures.
Visible light lasers have become increasingly useful in the treatment of benign lesions of the larynx, although the fiberoptic CO2 laser is also useful for selected lesions. The PDL and KTP lasers have the unique ability to remodel collagen in scar tissue which allows for restoration of the mucosal wave of the vocal fold. They are also uniquely suited for ablating lesions with a high vascular content such as angiomatous polyps, papillomas, vascular malformations and hemangiomas. More controversial is their use in treating leukoplakia. Lesions ranging from benign hyperkeratosis to moderately severe dysplasia have been temporized with repeated laser treatments with approximately 40% success rate. The PDL laser designed for in-office laryngology procedures is no longer available. Consequently, the KTP laser is now the predominant visible light wavelength used for laryngeal procedures both in the office and the OR. The 532mn KTP wavelength is distinctly different from the 585 nm PDL wavelength, being in the green spectrum versus the yellow-orange spectrum of the PDL (Figure 1). This changes the laser-tissue interaction and requires adjustments in the power density and radiant exposure applied to lesions as patients are switched from one visible light laser to the other. The KTP fiber can be used in the contact or near-contact modes which enhance its precision and its smaller diameter facilitates suctioning while operating. The treated lesions then resolve over 4 to 6 weeks (Figures 2 & 3).
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Figure 2. KTP laser fiber positioned over small right vocal fold polyp.
Figure 3. Four weeks after single KTP laser of vocal fold polyp.
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Another minimally invasive technique involves injecting scar tissue and tiny polyps with dilute steroids. These lesions usually occur concomitantly and frequently both pathologies will improve with this technique (Figures 4 & 5).
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Figure 4. Right true vocal fold scar and left true vocal fold nodule.
Figure 5. After single injection of dilute steroid.
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Many large lesions can be treated in the office with serial procedures (Figures 6 & 7). This technique is ideal for treating adults with respiratory papillomas since they require multiple procedures.
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Figure 6. Large vascular polyp treated with KTP laser.
Figure 7. Large vascular polyp after two KTP laser treatments.
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Patients can avoid the sequela and cost of general anesthesia and or costs with a combination of KTP laser treatments and injections of antiviral or chemotherapeutic drugs in the office (Figures 8 & 9). Laryngeal cultures, brush and cup biopsies can also be performed through the channeled laryngoscope.
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Figure 8. Laryngeal papillomas treated with KTP laser.
Figure 9. Laryngeal papilloma injected with anti-viral medication.
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Selecting patients appropriate for office based procedures can be challenging. Many times it is truly in the patient's best interest to have an office based procedure for medical and surgical access issues even if the patient doesn't want to be awake. Gentle and compassionate counseling is often quite effective in helping patients make the mental transition to an in-office procedure, especially if they can understand the overall positive benefits of safety, great visualization of the lesion and decreased risk by eliminating general anesthesia. Once that is overcome, the rest of the challenges reside in the patient's anatomy and physiology. Some patients gag severely on the usual office fiberoptic laryngoscopes despite topical anesthesia. They are not candidates for this procedure. Many patients' nasal cavities are quite small in comparison to the diameter of the channeled scope making the procedure more challenging. Occasionally procedures will need to be terminated due to nasal intolerance of the scope. Some patient's larynges will not be adequately anesthetized by the maximum allowable dose of lidocaine and the procedure will need to be stopped. I find that patients do vastly better if they have eaten a light meal 2-4 hours before the procedure. More patients complain of nausea with the topical anesthesia or have a vaso-vagal event if they have an empty stomach.
Our Powerhouse Voice Team
Critical to successful voice restoration is the treatment of the underlying cause of the lesion. Maximum medical management of smoking, allergies, reflux and autoimmune disorders must occur. More importantly, abusive vocal behaviors - chronic throat clearing, yelling, talking with tight neck muscles, poor breath support, poor singing technique - must be corrected with retraining of the involved muscles. Without treating all aspects of the problem, the lesions will come back.
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Deanna McBroom, MM
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To that end, the MUSC Evelyn Trammell Institute for Voice & Swallowing (ETIVS) is proud to announce that our singing voice specialist, Deanna McBroom, MM, Professor of Voice at the College of Charleston will be on site at the ETIVS several days each month. Ms. McBroom has treated our patients for the past 25 years out of her College of Charleston studio. This will further facilitate the already well-established collaboration between Dr. Halstead and Ms. McBroom on singers with issues in their in their singing voices, and will provide singing voice therapy on site in appropriate cases. This is a welcome addition to the superb talents of our highly trained speech language pathologists who have specific expertise in rehabilitating the speaking voice. The ability to have the singing voice specialist, speech language pathologists and laryngologist concomitantly treating a patient provides a Powerhouse approach to the treatment of voice disorders. 
