Introduction
Office-based laryngeal procedures are quickly gaining popularity. These procedures are cost effective and provide an important alternative for patients who are not good candidates for operative direct laryngoscopy. Included are those patients with contraindications to general anesthesia or who have anatomic variations that result in poor exposure when direct laryngoscopy is attempted. Advantages of procedures performed on an awake patient in the office include the performance of intraoperative assessment of vocal quality without interference from sedation or an endotracheal tube. Described in this chapter are several procedures that can be successfully and relatively easily undertaken in the office setting under local anesthesia.
Key Operative Learning Points
- 1.
The superior arcuate line is the key landmark lateral to the vocal fold for injection augmentation of the vocal fold.
- 2.
Proper positioning of the patient, strong endoscopy skills, adequate anesthesia, and appropriate patient selection are critical to success of an in-office laryngeal procedure.
- 3.
It is important to know exactly where the tip of the needle is prior to injection for any type of injection procedure. The angle of the needle in an injection procedure is also an important consideration in ensuring success of the procedure.
- 4.
Avoiding multiple injection sites during injection augmentation improves retention of the injected material.
Preoperative Period
History
- 1.
History of present illness—Patients may present a variety of complaints:
- a.
Hoarseness
- b.
Chronic cough
- c.
Shortness of breath
- d.
Throat pain
- e.
Difficulty swallowing
- a.
- 2.
Past medical history
- a.
Recent surgery where the recurrent laryngeal nerve was at risk
- b.
Neurologic disorders (Parkinson’s disease, multiple system atrophy, essential tremor)
- c.
History of recent intubation
- d.
Recent laryngoscopy or laryngeal surgery
- e.
History of laryngopharyngeal reflux
- f.
Occupational voice use, recreational voice use, or vocal misuse
- g.
History of smoking
- a.
Physical Examination
- 1.
Perceptual assessment of voice: Breathy voice in glottic insufficiency or breathy breaks with abductor spasmodic dysphonia, strained–strangled voice in case of adductor spasmodic dysphonia, strained voice in case of vocal fold granuloma
- 2.
Raspy voice quality and/or diplophonia with paralysis, paresis, presence of vocal fold lesions of any kind
- 3.
Oral cavity/oropharyngeal anatomy: Interincisal distance, presence, and strength of gag reflex
- 4.
Neck anatomy: Ease of palpating thyroid and cricoid cartilage landmarks, presence of masses
- 5.
Flexible laryngovideostroboscopy demonstrating:
- a.
Vocal fold atrophy
- b.
Vocal fold hypomobility or immobility
- c.
Vocal fold scar demonstrating a decreased mucosal wave
- d.
Benign vocal fold lesions: Polyps, cysts, Reinke edema, vocal fold granulomata, and papillomas
- e.
Lesions of unknown malignant potential (leukoplakia/ hyperkeratosis)
- f.
Laryngeal dystonia or tremor
- a.
Imaging
No imaging is required preprocedure, although imaging may be recommended in diagnosis of some disease processes being treated by office procedures (outside the scope of this chapter)
Indications
- 1.
Vocal fold injection
- a.
Augmentation: Glottic insufficiency of any kind (due to vocal fold paralysis, paresis, atrophy, scar)
- b.
Modulation of vocal fold scars (steroids) or subglottic/tracheal scar
- c.
Treatment of spasmodic dysphonia
- a.
- 2.
Biopsy
- a.
Establishment of a diagnosis for a laryngeal lesion
- a.
- 3.
Laser
- a.
Treatment of vascular lesions of the vocal fold (i.e., ectasias, varices)
- b.
Treatment of epithelial and selected subepithelial lesions of the vocal fold (i.e., polyps, cysts, papilloma, Reinke edema, granulomata, glottic webs, leukoplakia, dysplasia)
- a.
Contraindications
- 1.
Unstable cardiopulmonary status
- 2.
Allergy to local anesthetics or injectable materials
- 3.
Poor exposure of the endolarynx due to prolapsing arytenoid or severe supraglottic constriction
- 4.
Poorly defined cervical anatomic landmarks (in case of percutaneous injection)
- 5.
Significant tremor in the laryngopharynx
Contraindications to botulinum toxin use:
- 1.
Pregnancy
- 2.
Breast-feeding
- 3.
Impaired abduction of vocal fold (in setting of posterior cricoarytenoid muscle (PCA) injection)
- 4.
Any neuromuscular condition (i.e., myasthenia gravis)
- 5.
Concurrent aminoglycoside treatment
Preoperative Preparation
- 1.
Discontinue antiplatelet/anticoagulants (though no studies to show increased incidence of complications with in office injection).
- 2.
Recommend prescribing a small dose of an anxiolytic (i.e., Xanax 0.5 mg 1 hour prior to procedure and may be repeated once 5 minutes prior to procedure if needed) for patients who know they might experience anxiety.
Operative Period
Perioperative Antibiotic Prophylaxis
- 1.
Not required—rate of infection is very low, despite this being a clean-contaminated surgical environment
Monitoring
No active monitoring is necessary during an in-office procedure; it is advisable to take preprocedure and postprocedure vital signs.
Anesthesia
- 1.
Nebulizer: 5 cc 4% lidocaine delivered over 10 minutes—useful for per-oral procedures to eliminate the gag reflex
- 2.
Flexible drip catheter: Silastic catheter guided through the channel of the flexible laryngoscope, direct application to larynx of 4% lidocaine, elicit laryngeal “gargle”
- 3.
Percutaneous transtracheal/transcricothyroid injection of 4% lidocaine, which induces vigorous coughing
- 4.
Anesthetize the skin with 1% lidocaine with epinephrine for percutaneous techniques (optional).
- 5.
Be mindful of toxic limit of 7 to 8 mL (5 mg/kg; approximately 350 mg in 70-kg patient) .
Positioning
- 1.
Upright position in examination chair for the majority of procedures
- 2.
Option is supine position during electromyographic (EMG)-guided injection of the botulinum toxin
Patient Factors
“the ideal patient has:”
- 1.
Normal or minimal gag reflex
- 2.
Ability to remain calm for 10- to 30-minute duration of procedure
- 3.
Adequate interincisal distance of 20 mm at least (i.e., no trismus)
- 4.
Adequate intranasal airway (to pass laryngoscope, which is 3 to 4 mm in diameter, or TNE scope, which is 5 mm in diameter)
- 5.
Absence of neurologic conditions affecting stability of the head (no torticollis or tremor)
- 6.
Motivated to have the procedure done in the “office” and not the operating room with general anesthesia
Instruments and Equipment to Have Available
- •
Flexible laryngoscope with distal chip with a channel for passage of a flexible catheter for anesthetic and/or flexible needle passage and/or fiber-based laser (or rigid 70-degree telescope for a one-person approach)
Fig. 1.1
Common equipment used for office laryngeal procedures. 1, flexible wire sheath with 27-gauge needle; 2, Xomed orotracheal injector device; 3, Merz -Bioform malleable 25-gauge orotracheal needle; 4, 3-mL syringe attached to Ab raham cannula; 5, end of flexible endoscopic catheter for administration of topical anesthetic; 6, nasal pledgets.
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