return to: KTP Laser for the Larynx; Recurrent Vocal Fold Polyp In-Clinic Treatment; Polyps Nodules Cysts; Vocal Fold Polyps (polypoid corditis) case example of surgical treatment

see also: Superior Laryngeal Nerve Blocks Instruction Video; Glossopharyngeal nerve block (gag reflex, transoral vocal cord surgery)

A nice review of in office procedures for benign laryngeal lesions (Shoffel-Havakuh 2018 epub) identified the evolving nature of information addressing in-office treatment with lack of substantial comparative data outside of retrospective case series. Technical challenges relating to instrumentation and laryngeal movement were listed a potential factors that conceivably could result in less favorable outcomes compared to OR procedures. They identify that uncertainty in laser fluence (energy density delivered) and lead often to the concept of 'CONTROLLED UNDERTREATMENT'

'CONTROLLED UNDERTREATMENT': as a  'prudent approach' to 'deliberately avoid lesion overtreatment, sometimes at the cost of subsequent revision procedure"

Shoffel-Havakuh et al (2018): reported initial use of KTP laser for hemorrhagic polyps was based on laser wavelength selectively targetting hemoglobin - but with expanded experience, has expanded to other lesions (including non-hemorrhagic polyps)

• Goal: preserve by avoiding thermal damage to normal superficial lamina propira and surrounding mucosa
• in recovery perios (4 weeks or more) the polyp is anticipated to regress as the 'surrounding mucosa contrasct to close the wound' (citing  )

Wang et al (2015) reported use comparison of in-office transnasal laser applied to small polyps (less then 1/3 the length of the membranous vocal cord) followed by transnasal deployment of forceps to removal residual with standard microdirect laryngoscopy under general anesthesia. They related that because only smaller polyps were addressed, the "contralateral-reactive nodules, when present, were mostly minimal" 

• In office transnasal approach with laser (N=25)
  • Anesthesia
    • Nasal cavity: cotton pledet soaked in 1:10,000  epinephrine and 2% lidocaine solution placed
    • Oropharynx and vallecula sprayed with 2% lidocaine
    • 5 ml of 2% lidocaine dripped into the laryngeal introitus
  • Laser
    • 0.4 mm laser fiber with KTP2 effect
    • 532-nm wavelengtyh, 6-8 watts per pulse, 20-30 ms pulse width wtih 2Hz repetition rate 
  • Resection
    • Blunt-ended grasping forceps used to remove cauterized vocal polyp
    • The mean duration of the procedure was 14 minutes.
    • They cite previous study suggesting that final outcome comparable whether or not the coagulate polyp removed (Wang 2013)
    • Suggested that use of biopsy forceps to remove coagulated polyp facilitates more rapid removal of coagulated polyp
• ​General anesthesia for microlaryngoscopic surgery (N=25)
  • Small-caliber endotracheal tube (5.0/5.5 for women; 5.5/6.0 for men)
  • Grasping and cutting of the exopyitc vocal polyps done bimanually (microscopic control)
  • Goal to leave free margin of vocal folds straight with avoiding excess removal of mucosal cover and lamina propria
  • All specimens sent for pathologic review
• Findings from comparison of matched pairs (25 each) with hemorrhagic vocal vold polyps
  • Transnasal laser approach: higher subjective effectiveness at 2 weeks post-op compared to microdirect laryngoscopy with resectino
  • 6 week follow showed similar favorable results in both groups
  • they conclude the transasal laser approach 'may be used as an effective, practical, and safe alternative treatment for small vocal polyps"

Mizuta et al (2012) compared vocal fold polyp in-office treatment with KTP in an older group selected for in-office treatment with a younger group treated under general anesthesia with 'microflap' resection showing similar favorable outcomes

• Angiolytic laser surgery - complete resolution in 85% with one treatment (17 cases) and in 155 (3 cases) after two procedures
  • Flexible transnasal endoscope under topical anesthesia - 4% lidocaine spray
  • "Green laser' (532 nm) used to photocoagulate at power of 1.5 W with pulse width of 300 ms and 500 ms interval between each pulse
  • Procedure completed wtih the color of the hemorrhagic polyp changed to white
  • Complete voice rest for one day

University of Iowa Laser Settings:

• Similar to Young et al (2015) - see: KTP Laser for the Larynx
• In-clinic RRP, leukoplakia, cis, early glottic CA: 15 - 30 watts 15 msec pulses 2 pps

References

Tibbetts KM, Simpson CB. Office-Based 532-Nanometer Pulsed Potassium-Titanyl-Phosphate Laser Procedures in Laryngology. Otolaryngol Clin North Am. 2019 Jun;52(3):537-557. doi: 10.1016/j.otc.2019.02.011. Epub 2019 Mar 26. PMID: 30922560.

Eigsti RL, Bayan SL, Robinson RA, Hoffman HT. Histologic effect of the potassium-titanyl phosphorous laser on laryngeal papilloma. Laryngoscope Investig Otolaryngol. 2019 Feb 14;4(3):323-327. doi: 10.1002/lio2.250. PMID: 32025568; PMCID: PMC6997934.

Shoffel-Havakuh H, Sadoughi B, Sulica L, and Johns MM: In-office procedures for the treatment of benign vocal fold lesions in the awake patient: A Contemporary Review. Laryngoscope 2018 Dec 21 doi:10.1002/lary.27731.

Wang CT, Liao LJ, Huang TW, Lo WC, and Cheng PW: Comparison of treatment outcomes of transnasal vocal fold polypectomy versus microlaryngoscopic surgery. Laryngoscope 2015 May;125(5):1155-60

Wang CT, Huang TW, Liao LJ, Lo WC, Lai MS, Cheng PW. Office-based potassium titanyl phosphate laser-assisted endoscopic vocal polypectomy. JAMA Otolaryngol Head Neck Surgery 2013;139:610-616

Kim HT, Auo HJ. Office-based 585 nm pulsed dye laser treatment for vocal polyps. Acta Otolaryngol 2008:1043-1047

Mizuta M, Hiwatashi N, Kobayashi T, Kaneko M, Tateya I, Hirano S. Comparison of vocal outcomes after angiolytic laser surgery and microflap surgery for vocal polyps .Auris Nasus Larynx 2015;42:453-457

Sheu M, Sridharan S, Kuhn M et al Multi-institutional experience with the in-office potassium titanyl phosphate laser for laryngeal lesions. J Voice 2012;26:806-810

Young VN, Mallur PS, Wong AW, Mandal R, Staltari GV, Gartner-Schmidt J, and Rosen CA: Analysis of Potassium Titanyl Phosphate Laser Settings and Voice outcomes int he Treatment of Reinke's Edema  Annals of Otology Rhinology and Larygnolgoy 2015. Vol 124(3) 216-220

Mallur PS, Johns MM, Amin MR, Rosen C Proposed classification system for reporting 532-nm pulsed potassium titanyl phosphate laser treatment effects on vocal fold lesions. Laryngoscop 2014;124(5):11701175