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Overcoming Gag Reflex for Awake Transnasal Laryngeal Surgery Case Example

last modified on: Tue, 04/16/2024 - 10:17

Return to:  Glossopharyngeal nerve block (gag reflex, transoral vocal cord surgery);  

Superior Laryngeal Nerve Blocks Instruction VideoMaximum Recommended Doses and Duration of Local Anesthetics

KTP Laser for the LarynxSetup for awake KTP Laser Treatment through Flexible Transnasal Laryngoscopy in Main Operating Room for RRPTransdermal scopolamine and glycopyrrolate for sialorrhea and salivary fistula

Modified Operative Note:

Procedure: Transnasal flexible laryngoscopy with KTP lasing of papilloma (total of 71 J at 30 Watts  15 msec pulses  2 pulses per second) with biopsy (resection)

Preop Diagnosis: Dysphonia with recurrent laryngeal papillomatosis

Postop Diagnosis: Same


       Premedication with glycopyrrolate 2 mg taken orally two hours before the procedure

       Valium 5 mg taken orallly 1/2 hours before remainder of anesthesia below

       Bilateral superior laryngeal nerve blocks employing 1 cc of 2% lidocaine with 1:100,000 epinephrine to each side total of 2 cc

       Bilateral glossopharyngeal nerve blocks 1 cc of 2% lidocaine with 1:100,000 epinephrine to the anterior base of the tonsillar fossa bilaterally (anterior tonsillar fold base) total of 2 cc delivered, then after waiting 10 minutes, repeated

       1 cc of 4% lidocaine with 1% phenylephrine spray to left nostril ; followed by topical lidoaine/epinephrine on cottonoids placed intranasally

       2 cc of topical 4% lidocaine administered through the working channel of the Olympus VT scope placed in the left nostril employing a 25-gauge sclerotherapy needle to the larynx and between the vocal cords the upper trachea

It is noteworthy this anesthesia was very effective in addressing cough gag and other movement which were negligible during this procedure but were substantial during others in this patient without similar preparation


Description of Procedure:

Following identification the patient informed consent and a brief timeout in the minor room in a sitting position with the eyes protected at all laser precautions observed the VT scope was placed in the left nostril with the sclerotherapy needle in place photographs were taken and anesthesia administered the scope was withdrawn and then the KTP laser fiber was preloaded into the VT scope and then placed through the nostril with

30 Watts  15 msec pulses  2 pulses per second

38 Joules (KTP 4 mode) anterior commissure immediately subglottic and on right anteriorly

33 joules (KTP V, 1,2  mode) to right vocal cord

      Debulking was then performed with biopsy forceps through the Olympus flexible VT scope transnasally

F/U targetted in 6 months with understanding that he may call for earlier f/u if needed.



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.

Sabotin RP, Hoffman MR, Van Daele DJ, Stegall H, Hoffman HT. Modified sclerotherapy needle catheter as protective sheath for laser fibre passage in channelled flexible laryngoscopes. Clin Otolaryngol. 2024 Mar;49(2):287-290. doi: 10.1111/coa.14136. Epub 2023 Dec 30. PMID: 38158870.

Sullivan CB, Peterson J, Hoffman H. Optimal positioning to image the subglottis during transnasal flexible laryngoscopy. Clin Otolaryngol. 2018 Jun;43(3):979-980. doi: 10.1111/coa.12945. Epub 2017 Aug 8. PMID: 28736878.