advances in office‐based diagnosis and treatment in ... · based, local anesthesia tradition....

The LaryngoscopeVC 2009 The American Laryngological,Rhinological and Otological Society, Inc.

Contemporary Review

Advances in Office-Based Diagnosis andTreatment in Laryngology

Clark A. Rosen, MD, FACS; Milan R. Amin, MD; Lucian Sulica, MD; C. Blake Simpson, MD;

Albert L. Merati, MD; Mark S. Courey, MD; Michael M. Johns, III, MD; Gregory N. Postma, MD

Key Words: Vocal fold injection, laser therapy,office-based approach, high speed video, laryngealbiopsy, awake vocal fold biopsy, vocal cord paralysis,stroboscopy, dysphonia, voice disorders, laryngology,dysphagia.

Laryngoscope, 119:S185–S214, 2009

INTRODUCTIONMany leading laryngologists have revived the cen-

tury-old tradition in the field of laryngology of providingtherapeutic treatment to patients in an office-based set-ting. The history of laryngology is rooted in an office-based, local anesthesia tradition. Laryngology developedover 100 years ago with the focus of treating conditionsof the airway due to obstruction from infectious etiolo-gies. As medical science advanced (general anesthesia,

endotracheal intubation, surgical microscope, the surgi-cal laser) the majority of therapeutic interventions inthe field of laryngology were moved to the operatingroom, which afforded the laryngeal surgeon increasedprecision and bimanual dexterity. With this move fromthe office to the operating room, the field of laryngology‘‘lost’’ or ‘‘forgot’’ the many advantages achieved withevaluating and treating patients when they are awake,sitting in an upright position and, most importantly,able to phonate. The biggest of these advantages is theability to monitor voice quality before, during, and aftera therapeutic intervention, which is vital to most lar-yngologic procedures. In addition, office-basedprocedures often increase patient safety and decreasepatient cost compared to the operating room. This articleis aimed at describing many of the recent advances inoffice-based diagnosis and treatment in laryngology,completing on a selective basis, the return of the field oflaryngology to its office-based roots.

A variety of factors have allowed laryngologists todramatically expand their office-based diagnostic andtherapeutic armamentarium. Most of these advanceshave been in the area of technology changes. These tech-nologic advances include high-speed imaging, chip-tipflexible endoscopes, ultrathin esophagoscopes, new injec-tion materials, and fiber-based lasers. As with any timeperiod of exploration, a great amount of introspectionand critical review is required to optimize the advancesand make cogent decisions regarding different treatmentoptions and different approaches. There are still manypatients who benefit from surgical treatment in an oper-ating-room environment (general anesthesia using theoperative microscope). The distinct advantages of high-powered magnification, a still operating field, and bima-nual dexterity, will most likely never be replaced incertain aspects of laryngology. On the other hand, thereis an exciting opportunity for otolaryngologists to pro-vide high-quality laryngologic care for their patients inan office-based setting that will be equivalent, and inmany situations superior, to performing a similar proce-dure under general anesthesia in an operating room.

From the Department of Otolaryngology, University of PittsburghSchool of Medicine, Pittsburgh, Pennsylvania (C.A.R.); Department ofOtolaryngology, New York University of School of Medicine, New York, NewYork (M.R.A.); Department of Otorhinolaryngology, Weill Cornell MedicalCollege, New York, New York (L.S.); Department of Otolaryngology–Head andNeckSurgery,University ofTexasHealthSciencesCenter, SanAntonio,Texas(C.B.S.); Department of Otolaryngology–Head andNeck Surgery, University ofWashington, Seattle, Washington (A.L.M.); Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco, California(M.S.C.); Department of Otolaryngology–Head and Neck Surgery, EmoryUniversity School of Medicine, Atlanta, Georgia (M.M.J.); Department ofOtolaryngology, Medical College of Georgia, Augusta, Georgia (G.N.P.), U.S.A.

Editor’s Note: This Manuscript was accepted for publicationAugust 26, 2009.

This work was supported in part by the MLL Foundation.Authors with no conflict of interest disclosure include M.J., A.L.M.

and L.S. M.A., C.A.R., G.N.P. and C.B.S. are paid speakers for BioformMedical. C.A.R. is a consultant for Bioform Medical. G.N.P. has receivedcourse support from Bioform Medical, Olympus America and KayPentax,and equipment support from MedEnergy and Olympus. M.C. is scientificadvisor for Lumenis and receives equipment support from OlympusAmerica.

Send correspondence to Clark A. Rosen, MD, FACS, UPMC Mercy,Bldg. B-11500, 1400 Locust Street, Pittsburgh, PA 15219. E-mail:[email protected]

DOI: 10.1002/lary.20712

Laryngoscope 119: November 2009 Rosen et al.: Office-Based Treatment in Laryngology

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The term ‘‘office-based setting’’ for this article refersto an awake patient in an upright position, typicallywith no sedation and receiving local topical anesthesiaalone. Some otolaryngologists have found that the proce-dures described here and the technology required toperform them can be best achieved not in their office,but rather a hospital-based site of service, similar to agastroenterology or pulmonary procedure care center,where hospital staff are present to assist with patientcare, and hospital resources can be used to procure criti-cal resources for these procedures, but maintaining thecore concept of office-based treatment: an awake patient,sitting upright, and able to provide phonatory feedbackthroughout the therapeutic intervention.

The goal of this article is to introduce and explore thepresent possibilities of office-based laryngologic procedures,including diagnosis and treatment of a host of laryngologicdisorders. The indication, contraindications, and technol-ogy required to perform many of these procedures areoutlined in great detail and are heavily referenced. Giventhis renaissance period of office-based diagnosis and treat-ment in laryngology, dissemination and implementation ofthese new approaches for the treatment of laryngologic dis-orders is vitally important for the quality of care providedto our patients. The authors hope that this document willencourage otolaryngologists to expand the role of office-based diagnosis and treatment in laryngology for the bet-terment of their patients’ care.

VISUALIZING THE LARYNX AND PHARYNXLaryngoscopy—more aptly termed laryngopharyng-

eal endoscopy—has always been central to both diagnosisand treatment in laryngology. The renewed interest inoffice-based aspects of laryngology, which is the subject ofthis article, owes its momentum in large part to impor-tant advances in laryngopharyngeal endoscopy. Withoutthese, many of the procedures described herein would notbe feasible. Advances are built upon the coevolution of op-tical quality and illumination. Because of the centralimportance of these, it is useful to have a thorough andprecise understanding of each topic and of the relation-ship between the two.

Laryngoscopy or laryngopharyngeal endoscopy can beperformed with direct, rigid instrumentation or indirectinstrumentation. Office-based laryngology is principallyconcerned with indirect laryngoscopy. Indirect endoscopyinvolves using mirrors, prisms, fiberoptic rods, or miniaturechip cameras to bend or reflect the image of the pharynxand larynx back to the surgeon’s eye. Direct endoscopy, incontrast, is currently most commonly performed in the oper-ating room under general anesthesia. Indirect laryngoscopyallows the patient to maintain a relatively comfortable posi-tion while the examiner views the larynx and pharynx. Thisallows observations and procedures to be performed withoutgeneral anesthesia, and thus allows dynamic assessment oflarynx and pharynx. Various aspects of pharyngeal and la-ryngeal function can thus be observed and evaluatedincluding respiration, vegetative tasks, phonation, andswallowing.

Historical BackgroundA reliable technique for visualizing the laryngo-

pharynx in an awake and cooperative patient was notdeveloped until the middle part of the 19th century. Thetechnique of peroral mirror laryngoscopy was developedby Manuel Garcia, a vocalist and celebrated voice in-structor. The description of his ‘‘eureka’’ moment, whilewalking in the gardens of the Palais Royal in Paris, isone of the foundation stories of laryngology. Struck bythe flashing of sunlight on the many window panes sur-rounding the enclosure, Garcia suddenly saw how twomirrors could be aligned to direct sunlight to the larynxand return an image to the examiner. He reported hissubsequent laryngeal observations to the Royal Collegeof Surgeons in 1855, but his technique was not immedi-ately embraced. Two years later, the Viennese physicianLudwig Turck, claiming no prior knowledge of Garcia’swork, worked to adapt the same technique for clinicaluse. His efforts, including his important cadaver investi-gations, provided scientific validation of the technique,but were stymied by the poor and inconsistent illumina-tion provided by sunlight, and abandoned the laryngealmirrors as impractical.

The illumination problem was solved by JohannCermak, who borrowed Turck’s instruments and substi-tuted artificial light for sunlight. This transformedmirror laryngoscopy into a useful clinical tool, and—notby coincidence—serves to illustrate the dependence ofoptics and illumination, a central and recurring themein laryngological progress. Unfortunately, it also set off avicious and unseemly brawl over precedence, with bothTurck and Czermak hurrying to publish and demon-strate the technique, compete for the same prizes, andthreaten at least one lawsuit. Czermak, at least, had thecourtesy to credit Garcia for his pioneering work.1

Development of Endoscopic TechnologyThe technique of mirror laryngoscopy requires some

manual dexterity and finesse. Over the century sinceintroduction, the technique of indirect mirror laryngo-pharyngoscopy has been supplanted by technologicaldevelopments that allow better visualization of thestructures through improved image resolution, improvedlight transfer, and greater patient comfort.

In 1927, Baird, a British physicist, described lighttransmission down a glass fiber through internal refrac-tion. Baird went on to show that if fibers produced fromglass with a high refractive index are surrounded byfibers with a lower refractive index, then light from oneend is transmitted efficiently through the highly refrac-tive central core. This led to the development of the‘‘clad fiber,’’ the core technology for fiberoptic imagetransmission.2

In 1959, Harold Hopkins, another British physicist,patented rod-lens technology. Essentially, Hopkins hadfound that if high-quality rod-shaped lenses were placedin a series, an endoscope could be produced that trans-mitted an image from the distal tip to the proximal end.By placing a prism at the distal end of the endoscope,objects at various angles from the distal tip could be


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visualized and then transmitted through the rod lensesback to the proximal end of the endoscope. Provided thelenses were aligned properly, high image quality waspreserved.3 The importance of Hopkins’ work was notrecognized by his countrymen. However, Karl Storz, aGerman medical instrument manufacturer, grasped thepotential of the technology, and married the principles offiberoptic light transmission combined with rod-lensimage transmission. The resulting so-called Hopkins rodtelescope remains a mainstay of otolaryngologic endos-copy. Indirect endoscopy through the rod-lens systemprovides excellent visualization due to the high fidelityof the optical system and stability of the light transmis-sion system. In combination with a 70� or 90� prism,peroral laryngeal observations can be made in mostpatients. However, due to expense and the need for tech-nical skill in examination similar to those required formirror laryngoscopy, indirect endoscopy with a rod-lenssystem has never become the principal method for laryn-geal and hypopharyngeal examination. The resolutionprovided by rod-lens systems still exceeds that providedby all other forms of indirect laryngoscopy (mirror laryn-goscopy and flexible fiberoptic laryngoscopy), includingmodern distal chip flexible systems. Clinicians concernedwith extreme vocal fold detail, as can be observed whenthe system is combined with a stroboscopic light source,have chosen to employ it routinely.

At the same time as the rod-lens endoscope wasbeing developed, both the power of artificial light sour-ces and fiberoptic technology were improving. By themiddle of the 1960s, researchers in Japan, working withnewer halogen light sources, had developed fiberoptictechnology sufficiently to allow adequate transmission ofan image. Sawashima and Hirose found that by placingthe clad fibers in parallel, images could be transmittedfrom the distal end to the proximal end of a flexibleendoscope. They packaged clad fibers designed to carrythe halogen light and those used to transmit the imageinto a single sheath small enough to be passed throughthe nasal cavity, and demonstrated that the laryngo-pharynx could be illuminated and an image transferredback to the observer.4 The transnasal approach reducedthe stimulation of the patient’s gag reflex and permittedobservations of complex laryngeal and pharyngealbehaviors in a more physiologic posture than thatrequired for transoral examination. Although these flexi-ble fiberoptic endoscopes did not provide the sameimage resolution as the rod-lens system, this was of lit-tle importance to clinicians who were principallyinterested in visualizing vocal fold structure and grossmotion of abduction and adduction rather than detailsof mucosal vibration. In 1975, Williams, Farquharson,and Anthony demonstrated that flexible endoscopic ex-amination with these endoscopes was at least assensitive in the evaluation of laryngeal motion and grossdisease as indirect laryngoscopy with a mirror. Due topatient tolerance and the technical ease of the examina-tion, transnasal flexible indirect endoscopy of thelaryngopharynx (also know as transnasal flexible laryn-goscopy) soon became a common method used toexamine the larynx and hypopharynx.5

Developments in Endoscopic IlluminationThe ability to see or resolve an image is at least as

dependent on the illumination of the object to be visual-ized as it is on the lens system used to transmit theimage to the endoscopist. Over the 160 years since theinception of indirect laryngopharyngoscopy, light sourcesfor all forms of endoscopy continuously evolved. Garcia’stechnique depended on reflected sunlight. Czermak usedcandles, and later physicians adopted incandescentbulbs. Advances in flexible fiberoptic technology for clini-cal application would not have been possible unless thesources of light used for illumination had improved aswell. Halogen lighting is a form of incandescent lightingin which the tungsten filament is enclosed in a containerfilled with halogen and bromide gas. This allows the fila-ment to burn hotter and provide greater light intensitythan available through standard incandescent bulbs.Due to heat production, halogen lighting is not appropri-ate for internal use, but can be combined with fiberoptictechnology for use in laryngopharyngeal endoscopy.Without halogen lighting, illumination for standard flex-ible fiberoptic light transmission would not be intenseenough to permit visualization.

Stroboscopic illumination is distinct from the regu-lar continuous light illumination of routine clinicalexamination, and uniquely suited to clinical observationof vocal fold vibration during phonation. Vocal fold vibra-tion during phonation occurs at 80 to 1,000 cycles persecond, a rate that readily overwhelms the inputcapacity of the retina, which can only resolve about fiveimages per second. In the latter part of the 19th century,Oertel discovered that he could shutter a constant lightsource used to view the larynx at a rate just slightly dif-ferent from that of the vibration of the vocal folds toselect slightly different images from different vibratorycycles of the vocal fold for presentation to the humanvisual system. Because an image presented to the eye isheld on the visual cortex for 0.2 seconds, a phenomenonknown as persistence of an image, the visual cortexfuses these images, actually a montage, into a slow-motion, apparently continuous sequence of vibration.

Oertel used a spinning disk to shutter the lightsource, which was cumbersome and difficult to synchron-ize correctly. By the 1950s, the xenon arc lamp lightingsystem had been developed expressly for the purpose ofcreating a very bright short pulse of light to illuminatean object. The inherent properties of the xenon gas per-mit rapid ignition and production of a bright short flashof light in the range of 1 ls (1 millionth of a second).The application of quickly pulsed xenon light, timed tovocal fold vibration by means of a microphone, permittedlaryngoscopic examination under stroboscopic light tobecome clinically practicable.

It is important to note that illumination and exami-nation technique are two completely independentfactors. Both stroboscopic and continuous light examina-tion may be performed through flexible or rod-lenssystems. Stroboscopy was initially best performed withrod-lens examination techniques, because the relativelylarge and stable fibers for light transmission present insuch systems were far more effective than light-carrying


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fiber bundles in early flexible endoscopes. Because bothlight-carrying fiber bundles and the image-carrying bun-dles need to be small enough to pass through the nasalcavity, developers of fiberoptic instruments reduced theoverall number of light-carrying fibers, compared to thenumber built into rigid transoral endoscopes. This reduc-tion in light compromised the utility of fiberoptic flexibleendoscopes for stroboscopy. For image transmission toequal that of a rod-lens system, the clad fibers need tobe 5 lm in diameter and placed in parallel, a technologywhich may never be feasible because of cost andfragility.

Distal Chip EndoscopyIn laryngology, fiberoptic image transmission is

being replaced by computer chip technology, a transitionthat has already occurred in pulmonary and gastro-enterological endoscopy. This couples fiberoptic lighttransmission with digital image acquisition andtransmission. Although the laryngopharynx remainsilluminated with the fiberoptic light system (constant orstroboscopic), the image is captured distally by the mini-aturized camera chip at the scope tip and transmittedelectronically by wire. Minimal degradation occurs andimage quality/resolution is dependent primarily on thecharacteristics of the distal chip camera, and the qualityof light through the flexible fiberoptic bundles. Theimage quality of such endoscopes is markedly superiorto most fiberoptic systems, and significantly more stable,as the electrical systems hold up better on repeated usethan fiberoptic bundles. In addition, due to the reducedsize of the chip camera as compared to the fiberopticbundle, relatively greater numbers of fibers can be usedto transmit light in distal chip flexible endoscopes. Dis-tal chip endoscopy, or ‘‘chip-tip’’ endoscopy, provides areliable image nearly as good as rod-lens technology andmakes possible detailed clinical observations, includingstroboscopy, via a transnasal approach.6

High-Speed CinematographyHigh-speed cinematography has recently become

available for office use, although it remains expensive.High-speed filming developed concurrently with xenonlight technology, and was initially designed to study jetengine performance. It was adapted to visualize laryn-geal vibration during the middle of the 20th century, butits true clinical value in the study of laryngeal vibrationremains undefined. Therefore, the technology has yet tobe widely applied in clinical practice, a situation thatmay change as companies commercialize the technology.

In high-speed cinematography, between 2,000 and6,000 separate images can be captured each second. It isthe first imaging technology with a capture rate fasterthan vocal fold vibration. This allows the evaluation ofvocal fold vibration without the problem of missingaspects of the vocal fold vibratory activity, particularlywhen vibrations are aperiodic, as is often the case withvocal fold scar (Fig. 1). Because stroboscopy depends onaliasing, or producing a representation of vibration from

a montage of images across multiple vibratory cycles, itis virtually blind in the latter situation. Original high-speed cinematography units actually used 35 mm film,which was exposed with a xenon arc lamp so rapidlythat the exposed film could not be spooled rapidlyenough by any available winder, and had to be allowedto roll out onto the floor. Video technology now allowsimages to be captured and digitized for instant playback.The few commercially available units allow the user toselect the rate of image capture. At present, only rod-lens technology transfers light from the xenon lightsource efficiently enough to allow adequate resolution,and thus high-speed imaging via flexible laryngoscopy isnot presently possible.

The obvious advantage of the higher capture rate isgreater detail in mucosal movement during voicing. Thedisadvantage is that the sheer amount of data requiresa substantial amount of time to analyze. If we assumethat most video technology plays images back at rate of30 frames per second, then viewing 4,000 frames cap-tured in 1 second of voice production just once willrequire over 2 minutes at the standard playback rate.Commercially available units allow the examiner tochoose 2-second segments of voice production to image.Practically, it is often difficult to determine which 2 sec-onds of voicing are clinically important, and thenequally challenging to analyze those 2 seconds. Severalresearchers have focused on vibratory patterns at onsetof phonation, in vocal folds with lesions, and after peri-ods of extended voice use.7–9 These studies, althoughwell done, have not yet resulted in information that hasimpacted clinical practice. In contrast, even though stro-boscopy only provides a representation of mucosalvibration, it does allow/encourage extended observationacross multiple pitches and intensities. From this infor-mation, clinicians have been able to identify alteredvibratory patterns that are associated with clinically rel-evant disease states. As we learn more with clinicalstudy, we may find that high-speed cinematography pro-vides useful data at certain points during voiceproduction, such as vocal onset or offset, so that the in-formation achieves clinical relevance.

KymographyKymography is an outgrowth of high-speed cinema-

tography with video capture. In kymography, theexaminer selects one horizontal plane (essentially oneraster line of the video image) of the glottis for detailedvisualization. The vibratory motion of the vocal fold inthat plane, as it moves toward and away from the mid-line, is then plotted in the vertical axis. This allows theexaminer to study the movement of the most medial as-pect of the vocal fold toward and away from the midline.In this manner, provided that the endoscope is orientedexactly perpendicular to the long axis of the glottis, themovement of the medial edges should appear symmetricduring normal voice production. In patients with alteredvoice, vocal fold edges may be plotted to show asymmet-rical movement or movement at different speeds(Fig. 2).10 Again, as with any examination technique,


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there are many variables, ranging from the placement ofthe endoscope to choosing the correct plane of vibrationfor study and the correct voice segment. With furtherstudy, videokymographic observations may help improveour ability to diagnose altered laryngeal vibratorypatterns.11

Narrow Band ImagingNarrow band imaging (NBI) is a technique of visu-

alizing mucosal surfaces using selected portions of thelight spectrum, or ‘‘narrow bands.’’ Visible light, per-ceived as white light, is energy from the electromagnetic

spectrum of wavelengths between 400 and 700 nm. Dif-ferent wavelengths are perceived as different colors. Theshorter wave lengths are blue in hue, whereas the lon-ger wavelengths are red. Color is perceived from thewavelength that is reflected back from the object. Forexample, an apple appears red because the surfaceabsorbs the blue/green wavelengths and reflects backthe red. As light encounters tissue, it is absorbed andscattered. The long wavelengths (red) diffuse deeply,whereas the shorter wavelengths (blue) diffuse moresuperficially. Because some cancers arise in the superfi-cial epithelium of tissue, and are associated with theabnormal proliferation of blood vessels due to

Fig. 1. Montage of high-speed imaging from two vibratory cycles. These 36 frames actually represent consecutive images captured duringphonation. These were captured at a frame rate of 2,000 images per second. Therefore, these 36 images represent less than 0.002 sec-onds of phonation. (Image courtesy of Kay Pentax, Lincoln Park, NJ; color high-speed camera, model 9710).


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Fig. 2. Examples of kymography obtained from high-speed video examination of the larynx. Right hand image shows from where along theanterior-posterior aspect of the membranous vocal fold the kymography is being recorded. (A) Kymography during voice onset using aloud, breathy voice. Note large amplitude of the vocal fold and symmetry. (B) Kymography during voice offset with marked asymmetry. (C)Kymography during a break in the voice. Note the irregular amplitude and loss of periodicity in the middle of each kymography recording.(Image courtesy of Kay Pentax, Lincoln Park, NJ; color high-speed camera, model 9710.)


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angiogenesis, NBI technologies select only the shorterwavelengths of light to view tissue.12 By filtering lightto limit it to bands in the 400 nm (blue spectrum) and540 nm (green spectrum) range, which are preferentiallyabsorbed by the hemoglobin pigment in the superficialvasculature,13 abnormal superficial blood vessels can bemade to appear dark, and thus more obvious to the ex-aminer. In esophageal neoplasia, NBI imaging is beingstudied to determine if routine surveillance can pick upthese abnormal vascular patterns in individuals withBarrett’s esophagus before they can be identified withstandard visible light endoscopy (Fig. 3). Similar studiesare being carried out for cancers in the head and neckarea.14,15 This work has not yet been conclusive, but forcancers not associated with keratosis, NBI screeningmay provide an advantage for early detection (Fig. 4). Inlesions that are keratinized, such as many laryngeallesions, the technology may be less useful, as keratosisreflects all of the visible light and appears white. Thishas been the case in autofluorescence, in which the oxi-dized flavin mononucleotide emission of a greenfluorescence is hidden by the presence of keratosis.16

ConclusionContemporary office indirect endoscopy depends on

high-quality images of the laryngopharynx, achievablewith an array of readily available technology. Continu-ous light sources, such as halogen light, can be pairedwith standard flexible endoscopic technology to examine

the hypopharynx for the condition of the mucosa, poolingin the pyriform sinus, vallecula and esophageal inlet,motion in the lateral pharyngeal walls, motion in thetongue base, and motion in the larynx. Motion in the lar-ynx is evaluated at the level of the vocal fold proper andin the supraglottic tissues during phonation and othervegetative laryngeal tasks, such as coughing and throatclearing. Some debate exists as to whether using a Hop-kins rod-lens endoscope provides equivalent informationas a flexible transnasal endoscope, especially withrespect to vocal fold motion (adductory and abductoryrange of motion). The argument has many variables,especially since the introduction of distal chip technol-ogy, and is in some part an artificial one, because thereis usually nothing to prevent both examinations frombeing performed in the same patient if there is a need.In any case, no empirical equivalence study that specifi-cally compares the two tests has been performed. Theexaminer should use whichever technique obtains therequired information, and many clinical situations mayrequire both a flexible and rigid scope approach.

In cases in which detailed examination of vocal foldmucosa and its vibratory characteristic are indicated,stroboscopic examination may be undertaken using ei-ther rigid or flexible instrumentation. The best com-bination of light carriers and image transmission for thisexamination technique remain the rigid Hopkins rod-lens endoscopes, but rigid instruments should in no waybe considered the only means by which stroboscopic ex-amination may be performed. Stroboscopy is possible

Fig. 3. (A) During transnasal esopha-goscopy an irregular area of thesquamocolumnar junction is seenabove the gastroesophageal junc-tion. (B) Narrow band imaging of thesame individual clearly shows thearea of abnormal epithelium alongwith 2 small ‘‘islands’’ of abnormalmucosa. (Olympus 280 K 001,Olympus America, Center Valley, PA)(C) View of slight mucosal irregular-ity in left pyriform sinus whenviewed with a halogen light source.(D) View of same left pyriform sinuslesion with narrow band light filter.Punctate vascular pattern is pres-ent. On biopsy this was an invasivesquamous lesion. (Olympus ENF-V2;Olympus America, Center Valley, PA)


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with fiberoptic endoscopes, particularly now that distalchip technology has greatly improved image transmis-sion compared to all-fiberoptic instruments, althoughthe image still falls somewhat short of that obtained byrigid rod-lens examination.

At this time, high-speed cinematography, kymogra-phy, and narrow band imaging remain experimentalmeans of imaging laryngeal and hypopharyngeal anat-omy and function.

ANESTHESIA FOR OFFICE-BASEDLARYNGOLOGY PROCEDURES

The success or failure of office-based procedures ofthe larynx hinge on patient comfort. An inadequatelyanesthetized patient is apt to be uncomfortable, anxious,hyper-responsive, and unlikely to tolerate office-basedprocedure; conversely, a patient who is well informed,well prepared on what to expect, reassured, and thor-

oughly anesthetized can undergo most any officelaryngeal procedure.

When one begins to incorporate these techniquesinto their practice, a steep learning curve can beexpected for some procedures, especially injection aug-mentation and laser procedures. It is best to choose‘‘ideal’’ candidates for these first five to 10 procedureswhile a level of comfort is achieved. An ideal candidatehas minimal to no gag reflex, reasonable pain tolerance,low level of anxiety, and is able to remain still and coop-erative for a 20- to 30-minute period. Most patients arereasonable candidates for office-based laryngeal proce-dures. The following criteria are used:

Indications and Contraindications

• The patient must tolerate a flexible laryngoscopicexam without an excessive gag response. Monitoringwith a flexible endoscope is key to maintaining visual-ization, and a hyper-responsive gag may render anyprocedure impossible. However, it should be notedthat gagging with a mirror or rigid transoral endo-scope is not a contraindication.

• The patient must have a patent nasal airway, at leastunilaterally, to pass the flexible examination scope(around 3–4 mm for standard flexible laryngoscope,and approximately 5 mm for transnasal esophago-scopy and working channel flexible laryngoscope.)This rarely presents a problem.

• The patient must be able to remain reasonably stilland upright in the exam chair for the duration of theprocedure (typically 5–15 minutes). Patients withsevere torticollis or head tremor (from essentialtremor) are sometimes difficult to treat.

Relative contraindications for performing office-based laryngoesophageal procedures are as follows:

• Use of anticoagulants (acetylsalicylic acid, nonsteroi-dal anti-inflammatory drugs, Plavix, Coumadin).Ideally, the patient should be taken off of these priorto any planned biopsy or injection; however, clinicalexperience has shown that almost all of these patientsseem to do well despite being on these medications atthe time of their procedure.17 A theoretical risk of he-matoma and airway swelling is always possible withbiopsies and injection augmentation, and the patientshould be informed of this if the anticoagulants can-not be discontinued.

• Anxiety disorder/overly anxious patient. Obviouslythe patient’s anxiety level comes into play, and mustbe taken into account when determining the patient’ssuitability for a clinic-based procedure. In somepatients, a 2- to 5-mg diazepam tablet taken perorally30 minutes before the procedure seems to help. How-ever, this may necessitate monitoring the patient

Fig. 4. (A) Microinvasive squamous cell cancer of the left vocalfold viewed with halogen light through a distal chip endoscope.(B) Microinvasive laryngeal carcinoma visualized with narrow bandlight filter. Keratosis of primary lesion site that reflects all light,thus the image does not change with narrow band imaging.(Olympus ENVF-2, Olympus America, Center Valley, PA.)


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with pulse oximetry during the procedure, andrequires that someone else drive the patient home,thereby negating some of the prime benefits of unse-dated, office-based procedures.

A methodical approach where the patient isinformed of each upcoming step before it occurs is veryhelpful in alleviating patient anxieties. When manipula-tion of the larynx (injection/biopsy) is performed, thepatient should be instructed to concentrate on (their)breathing during this portion of the procedure. This canbe quite successful in patients with hyper-responsivegag reflex. Slow, shallow breathing is best to minimizethe abductive effects of deep inspiration. In somepatients, increased participation in their procedureseems to help. For example, some patients prefer to holdtheir own tongue with a gauze (as opposed to the sur-geon) during the procedure. Forcing the patient to focuson a task such as this may act as a useful distraction.Last, some patients benefit from viewing the monitor asthe procedure takes place, something akin tobiofeedback.

Anatomy of Laryngotracheal/Esophageal Sen-sory Innervation

The sensory nerves of the larynx, trachea, andesophagus are derived from the vagus nerve. The inter-nal branch of the superior laryngeal nerve suppliessensation to the glottic and supraglottic structures,whereas the subglottic sensory innervation is from therecurrent laryngeal nerves. The trachea and esophagushave sensory innervation from branches of the vagusnerve distally. The internal branch of the superior laryn-geal nerve (SNL) pierces the thyrohyoid membrane at apoint halfway between the hyoid bone and the superiorborder of the thyroid cartilage, and roughly halfwaybetween the thyroid notch and the superior cornu of thethyroid cartilage. This entry point of the SLN throughthe thyrohyoid membrane can be located for SLN nerveblocks in certain cases18; however the vast majority ofpatients achieve excellent results via topical anesthesiaonly, as described in the following section.

Anesthesia Techniques of the Larynx andTrachea

Topical anesthesia for laryngeal procedures, such asinjection, laser and biopsy, require the following sequen-tial application19:

• Topical oxymetazoline/tetracaine 2% spray to nasalcavities

• Topical Cetacaine spray to oral cavity (palate/poste-rior pharynx)

• Lidocaine 4% drip on tongue base and larynx underflexible laryngoscope guidance (3–5 cc)

To achieve step 3, a flexible laryngoscope with avideo monitor is used. The assistant can be a physician;however, paramedical office personnel can be trained to

manipulate the endoscope. The endoscope is generallymaintained slightly below the palate so that the tonguebase and larynx can be easily viewed on a video monitor.The patient is bent forward at the waist with the neckextended in a ‘‘sniffing’’ position to maximize laryngealexposure (Fig. 5). The tongue is grasped with a 4 inch �4 inch gauze with the surgeon’s left hand. A 3-cc syringeof 4% lidocaine attached to an Abraham cannula (Pilling;Teleflex Medical, Research Triangle Park, NC) isadvanced into the oropharynx. Approximately 1 cc isdeposited over the tongue base, and 2 to 4 cc aredripped onto the vocal folds during phonation, producingthe characteristic ‘‘laryngeal gargle’’ described byHogikyan.20 It is optimal to deposit the 4% lidocaine inseveral 0.5- to 1-cc aliquots, instead of one large dose.The initial dose is usually followed by a brisk cough, asthe anesthetic is aspirated and then distributed over thelaryngotracheal mucosa. Absence of the laryngeal gargleand cough may indicate that the patient has swallowedthe anesthetic, and additional topical applications maybe indicated until the desired effect is obtained.

The preceding description is also adequate forachieving tracheal anesthesia; however, an alternatemethod is to perform a puncture of the cricothyroidmembrane with a 27-gauge needle and instill 2 to 4 cc of4% lidocaine transtracheally. Aspiration for air to con-firm intraluminal needle position is essential prior toinjecting transtracheal lidocaine. If the patient has a

Fig. 5. Sniffing position to maximize laryngeal exposure.


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tracheostomy tube, then this is removed and lidocaine isadministered through the stoma. After instillation, thestoma is occluded to insure that the anesthetic is distrib-uted proximal to the stoma as well. This technique isespecially helpful when evaluating patients with sub-glottic/tracheal stenosis.

Another administration option is to deliver the lido-caine via a syringe attached to the working channel of aflexible scope. The only disadvantage of this method isthat this tends to result in a sudden release of 2 to 3 ccof anesthetic through the channel, which is often poorlytolerated and results in waste, as a large portion of theanesthetic is swallowed. A much more efficient and bet-ter-tolerated method to deliver lidocaine is through aspecial catheter (PW-6P-1; Olympus America, CenterValley, PA) placed through the working channel of theflexible endoscope (Fig. 6). This catheter allows the phy-sician to drip the lidocaine in a more controlled andwell-tolerated fashion. Also, lidocaine delivered throughan inhalation nebulizer is another efficient way toachieve local anesthesia of the upper aerodigestive tract.Typically 3 to 4 cc of 4% lidocaine are used. Often, asmall amount of supplemental lidocaine must be used toachieve complete anesthesia of the larynx with thismethod.

Within 90 seconds of topical administration, the lar-yngopharynx and trachea are adequately anesthetized toperform any number of office-based procedures. The lido-caine results in 45 to 60 minutes of anesthesiatheoretically; however 20 minutes is often the maximumwindow of time that the patient can tolerate the proce-dure before discomfort and/or gagging occur. For thisreason, the surgeon must work very efficiently to com-plete some of the more time-consuming procedures, suchas laser treatment of laryngeal lesions, or they mayneed to reapply anesthesia. In some cases of longer du-ration, additional 2 to 3 cc of 4% lidocaine can be used ifadequate time has elapsed since the commencement ofthe anesthesia.

Anesthesia for Transnasal EsophagoscopyTopical anesthesia for transnasal esophagoscopy

(TNE) can be achieved quite effectively with the follow-ing protocol involving only nasal anesthesia: Thepatient’s more patent nasal cavity is sprayed with a 1:1oxymetazoline 0.05% and lidocaine 4% solution, andthen packed with cotton pledgets soaked in the same so-lution. If any oropharyngeal anesthesia is required (it isusually not needed), one spray of 20% benzocaine(Hurricaine) is administered to the oropharynx. No addi-tional anesthesia is needed for esophageal biopsies.

Precautions/Adverse Effects of Local AnesthesiaDrug reactions to local anesthetics are always a

concern, although quite uncommon if some basic safetyguidelines are followed. The following maximal dosageguidelines are recommended: 4% lidocaine (40 mg/cc), 7to 8 cc (4.5 mg/kg; approx 300 mg in 70 kg pt); 2% Pon-tocaine (20 mg/cc), 0.9 cc (Pontocaine is administered fornasal anesthesia only, via an atomizer, therefore only0.1–0.2 cc is typically used.); Cetacaine spray, spray for2 seconds; Tessalon Perles, 100 mg, two 100-mgperles.21,22

Excessive use of any of the above anesthetic agentscan lead to systemic toxicity involving cardiovasculardepression, convulsions, and respiratory/cardiovasculararrest. Caution should be exercised when using combina-tions of different local anesthetics, because the toxic sideeffects may be additive. Toxicity can also be potentiatedin patients with renal or hepatic compromise, heartblock, and certain cardiac conditions. Allergic reactionsare uncommon with lidocaine, but may be more preva-lent with the amino esters (Pontocaine/Cetacaine). Theallergic response is typically limited to urticaria andrash formation; anaphylaxis is very rare. Another rarecomplication related to local anesthetics (especially Ceta-caine) is methemoglobinemia. This condition results inimpaired oxygen delivery to tissues and presents with

Fig. 6. Drip catheter for application of anesthesia. (A) Drip catheter inserted into working channel of flexible endoscope for anesthesia deliv-ery. (B) Drip catheter coming out of working channel of flexible endoscope to deliver anesthetic to the endolarynx.


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‘‘chocolate cyanosis’’ of the mucous membranes—a browndiscoloration of the lips and oral cavity mucosa. Thismay progress to more serious cardiac/central nervoussystem damage if methemoglobin levels rise above 70%.Treatment is IV methylene blue (1–2 mg/kg).

Rarely during laryngotracheal and esophageal officeprocedures vasovagal syncope can occur.23 Precipitatingfactors may include patient anxiety, diffusion of anes-thetic to the sympathetic trunk, or strong vagalstimulation from the procedure itself. The patient oftenhas prodromal nausea, sweating, light-headedness, andparesthesia seconds to minutes before syncope occurs.Therefore, the procedure should be discontinued if thepatient reports these symptoms. They should be placedin a reclining or supine position (an alternative is tohave the patient place their head between their legs),and vital signs should be monitored. If syncope doesoccur, maintain the patient in a supine position and con-tinue to monitor vital signs until the patient recoversconsciousness (typically seconds later).

Monitoring RequirementsBecause sedation is not employed, no monitoring

equipment or intravenous lines are needed as a generalrule. However, common sense will dictate that certainparticularly ill or medically fragile patients with severeunderlying pulmonary disease and/or supplemental oxy-gen requirements should be monitored with pulseoximetry at the very least. These patients may be bettersuited for the operating room under monitored anesthe-sia care or a hospital-based endoscopy suite withnursing and monitoring capabilities.

Postprocedure Patient InstructionsBecause of the profound anesthesia of the upper

aerodigestive tract, the patient is at risk for aspiration.We routinely instruct the patients to remain nil per os(NPO) for 60 minutes following the procedure, until fullsensation in the throat returns. Postoperative pain isunusual, and acetaminophen is usually all that isnecessary.

ConclusionTopical anesthesia can be successfully achieved for

almost all endoscopic procedures of the larynx, trachea,and esophagus. If strict guidelines for anesthetic dosingare followed, there is no need for pulse oximetry moni-toring, and the risk of an adverse reaction is extremelylow.24

UPPER AIRWAY EVALUATION ANDTREATMENT

Most patients with airway complaints related to theupper aerodigestive tract can be assessed under topicalanesthesia during a routine clinic visit. Furthermore,intervention for disorders affecting the laryngotrachealairway can also be accomplished in the awake setting inmany cases. In this section, the indications, advantages,

and disadvantages related to these practices are out-lined. As with all patient-care discussions, theprocedures and techniques reviewed here require amature degree of clinical sensibility: What can thepatient tolerate? What is appropriate in an awakepatient? Is this evaluation/treatment safe in this setting?What are the diagnostic and therapeutic alternatives?These are decisions that otolaryngologists make everyday; this discussion is particularly cogent in the area ofin-office airway assessment and treatment.

With a few exceptions, flexible endoscopic examina-tion is advantageous over transoral rigid examinationfor most patients with airway complaints. This approachallows for assessment of dynamic and fixed airwayobstruction and facilitates topical anesthesia (by way ofthe channeled laryngoscope) if desired. A few exceptionsare noted in the following sections. The clinician mustalso be aware of the potential for varying impressions ofthe airway depending on the modality used to assess it.This has been documented for inflammation around theglottis, for example, with a higher likelihood of abnor-malities being described on flexible laryngoscopy thantransoral rigid endoscopic exam of the larynx.25 In a pro-spective study comparing flexible airway endoscopy torigid airway endoscopy and radiographic imaging (com-puted tomography), Carretta et al. noted that there wassome variation between clinic and operative airway en-doscopy in predicting presence and characteristics ofsubglottic stenosis, for example.26 Radiographic imagingwas not ideal in assessing the length of stenosis,although it is particularly useful when investigating theairway distal to a tight stenosis that cannot safely beexamined in clinic. With these caveats in mind, the sec-tions below review several clinical entities and theirevaluation in the office setting.

Cricoarytenoid Joint FixationCricoarytenoid (CA) joint fixation may occur follow-

ing prolonged or even routine intubation. CA ankylosisor arthritis may be present in as many as 25% ofpatients with generalized rheumatoid arthritis (RA), butthere are no existing reports of the diagnosis of RA hav-ing been made with the initial presentation of CAarthritis in the absence of generalized or previouslydiagnosed RA.27,28 Two basic findings can help the clini-cian distinguish between neurologic and mechanicalmotion impairment in the awake patient. One is the‘‘jostle’’ sign, in which the denervated but mechanicallymobile arytenoid is moved, or jostled, by the workingvocal fold-arytenoid complex in neurologic impairment;in contrast, the CA joint with fixation will not be movedby the impact from adduction of the other side. Thus ab-sence of a jostle sign suggests possible CA jointfixation.29,30

Palpation of the CA joint as an awake evaluation todetermine its function has been described.31,32 When me-chanical impairment of CA joint function is suspected,the larynx is anesthetized topically (as presented in theprevious section). Once anesthetized, the patient graspstheir own tongue with a gauze, as the otolaryngologist


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examines the larynx with a rigid telescope (70�) in onehand (the laryngeal visualization can alternatively beprovided by flexible laryngoscopy) while manipulatingthe CA joint with a curved laryngeal forceps (or Abra-ham cannula) placed transorally with the other hand.The instrument is placed next to the immobile vocal pro-cess and gentle pressure is applied laterally andposteriorly to determine its passive mobility (Fig. 7). Thecontralateral arytenoid can also be manipulated duringthis exam, and with bimanual retractions of the aryte-noids (patient holds own tongue), an excellentassessment of the posterior commissure can be donelooking for posterior glottic stenosis.

Bilateral Vocal Fold Immobility AssessmentThe importance of distinguishing the varying types

of posterior glottic stenosis, as described by Bogdasar-ian,33 can also be accomplished in the office setting.Retrograde subglottoscopy is very valuable and can beperformed under local anesthesia via a tracheostomy.For this procedure, topical lidocaine is sprayed into thetracheotomy tube, after which the patient is asked tocough, thus distributing lidocaine to the subglottis andtrachea. Decongestants, especially Neosynephrine, arenot used in the airway due to concerns regardingsystemic uptake and cardiovascular effects. The trache-ostomy tube is removed briefly as the flexible endoscopyis passed distal to visualize the entire trachea and main-stream bronchi. The scope can then be retroflexed intothe subglottis for evaluation of the subglottis, posteriorcommissure, and infraglottic aspect of the vocal folds.

Paradoxical Vocal Fold Motion DisorderOne of the most vexing conditions faced by otolar-

yngologists, speech-language pathologists (SLP), pulmo-nologists, and many other clinicians is paradoxical vocalfold motion disorder (PVFMD). Referred to in the gen-eral medical literature as vocal cord dysfunction, thisdisorder is characterized by inappropriate adduction ofthe vocal folds during respiration (inspiration and/or ex-piration). Although the etiology and pathophysiology of

this disorder continues to be debated, its treatment withexperienced speech-language pathologists is the main-stay of management.34,35

Flexible laryngoscopic examination of these patientsis helpful in establishing the diagnosis in many cases,and in ruling out other laryngeal abnormalities.36 Anec-dotally, the patient’s ability to understand the upperairway and participate in their respiratory retraining issignificantly enhanced by their experience viewing theirown larynx during the clinic examination, including theuse of biofeedback during therapy sessions in severecases.

When evaluating a suspected case of PVFMD, sev-eral options are available to the otolaryngologist. Inpatients with exercise-related dyspnea, one may havethe patient run up and down stairs; once the patient isshort of breath or otherwise experiencing symptoms, lar-yngoscopy is performed immediately to evaluate forinappropriate closure of the larynx during inspiration(Fig. 8). This exam is compared to the baseline flexiblelaryngoscopy. If the patient is not able to do so, or it isnot otherwise convenient for the clinic setup, asking thepatient to perform rapid counting serves as a reasonablesurrogate to exert the patient.37 In this task, the patientis asked to count from one to 100, for example, in onebreath without stopping. If necessary, this is repeateduntil the patient experiences some shortness of breath.The larynx is closely scrutinized during the patient’s re-covery period and the images are reviewed following theexam. Ideally, an expert SLP is available to intervenewith the scope in place to demonstrate the patient’s ownability to positively impact their laryngeal airway. Inmore elusive cases, for example with elite athletes orpatients in whom there has been no response to therapy,exercise laryngoscopy38 can also be performed in a moreformal manner. Although the impact of detecting para-doxical motion during any exam on the patient’s overalloutcome is not known, it may help to avoid other evalua-tions and to reassure the patient and family that theproblem has been localized to the upper airway.

In a similar approach, patients with dyspnea symp-toms related to environmental stimuli (such as odors)can be evaluated by flexible laryngoscopy with and with-out odor provocation.39

Subglottic and Tracheal StenosisIn-office evaluation of the airway can be highly use-

ful in ruling out distal or secondary stenoses andcharacterizing the nature of the obstruction. As outlinedin the anesthesia section, the complete tracheobronchialtree can be evaluated in the clinic setting, althoughsound judgment is necessary to anticipate whichpatients may be too fragile or intolerant of the exam.Once anesthesia of the trachea is established (as dis-cussed earlier), the airway may be assessed by passing astandard flexible laryngoscope; this will easily reach thecarina and will often allow visualization into the princi-pal bronchi. The transnasal esophagoscope or pediatricbronchoscope can easily proceed distally and instill topi-cal anesthetic if required. Furthermore, without direct

Fig. 7. Laryngeal cannula palpating arytenoid vocal process.


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topical anesthesia to the bronchi, such as administeredthrough the working channel of a flexible scope, thisexam is not well tolerated. For most otolaryngology eval-uations, the standard scope and anesthetic will suffice.In-office airway examination is also safe and feasible inchildren.40

This examination is most useful in characterizingsubglottic and tracheal stenosis. If the airway is notmuch larger than the scope, the exam is still possiblebut must be done quickly, as the patient will rapidlysense airway obstruction. If the area is notably inflamedor friable, routine or elective examination is best delayedso as to not exacerbate the condition. Tracheomalacia isparticularly well suited to the awake examination, asdynamic collapse of the thoracic trachea leading tocough or airway obstruction is seen in this setting moreeasily than under general anesthesia.

In terms of intervention in the subglottis and tra-chea, the advent of fiber-delivered laser energy andballoon dilation has expanded the scope of in-office prac-tice for otolaryngologists.

For the treatment of airway stenosis, balloon dila-tion has not been studied to the same extent asesophageal dilation, but this technique does appear to bea promising method to endoscopically open the narrowedairway.41 With appropriate anesthesia, several laryngolo-gists have pioneered the use of balloon dilation in theawake patient, even in nontracheotomized patients.

In this approach, a multidiameter hydrostatic radialexpansion balloon (CRE Pulmonary Balloon DilationCatheter and Guidewire; Boston Scientific, Boston, MA)is used to dilate the narrowed airway. In a series of 12patients, no serious complications were encountered.42

The authors explicitly outline the steps for this proce-dure as follows: following topical anesthesia, flexibleairway endoscopy is performed and a guidewire is placedacross the stenotic segment. The guidewire is left inplace with the tip at the carina as the scope is with-drawn. Great care should be taken to prevent the distaladvancement of the guidewire. The scope is reintroducedalongside the guidewire, and a balloon dilator is posi-tioned across the stenosis. The authors make the explicitpoint that ‘‘the patient is asked to take a deep breath,then expire, and hold his/her breath for the length of di-lation (usually 30 seconds).’’ The authors also highlightthe importance of establishing signals and communica-tion between the patient and clinicians prior to theprocedure.

Following intervention, the airway is examinedagain; as many as 50% of patients will have notable lac-erations, but these have not proved clinical significant.43

The patient is then closely monitored for chest pain anddyspnea after the dilation. Treatment of the airway canalso be accompanied by fiber-delivered lasers (CO2, po-tassium titanyl phosphate [KTP], gold) that may beplaced in the working channel of a laryngoscope. This is

Fig. 8. Collegiate athlete with paradoxical vocal fold motion disorder on portable rowing machine being examined in clinic during exercise.


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further outlined in the section on in-office laser treat-ment of the larynx.

USE OF THE LASER FOR TREATMENT OFLARYNGEAL CONDITIONS IN THE OFFICESETTING

Since the introduction of the CO2 laser to operativelaryngoscopy, surgeons have been testing and using a va-riety of different lasers on laryngeal tissues. Each laserhas a unique absorption spectrum that, when coupled to aspecific tissue type, yields a specific response. It should benoted that lasers in otolaryngic surgery are generallyused for their photothermal effects. In this capacity, laserstarget a specific chromophore and cause heating of the tis-sue in this region. The laser settings, including the spotsize, power, pulse width, and pulse interval all alter theeffect of the laser-tissue interaction. In addition, the spe-cific tissue characteristics, including the presence andlocation of chromophores and heat dissipation capabilitiesof the tissue will also govern the response of the tissue tothe laser energy delivery.

The CO2 laser has remained popular due to itsunique absorption characteristics with respect to laryn-geal tissues. The ideal laser for vocal fold surgery shouldhave fairly superficial penetration (effect within the su-perficial lamina propria layer), produce little collateralthermal injury, be adjustable to allow for both coagula-tion and precise cutting, and allow for deflection of thebeam path while inside a rigid or flexible laryngoscope(i.e., flexible delivery system). Although traditionally theCO2 laser has had most of these characteristics, untilrecently it has lacked an adequate flexible delivery sys-tem. Because of this, surgeons have continued to testfiber-based lasers on the larynx, in the hopes of discover-ing a laser that has ideal tissue effects in the larynx, yethas the capability of traveling along a flexible fiber.

The recent interest regarding in-office laryngeal sur-gery has redoubled the interest of surgeons to have aflexible laser delivery system to allow lasers to be usedthrough flexible laryngoscopes. In the late 1990s, thepulsed dye laser (PDL) was adapted for laryngeal sur-gery.44 Since then, other groups have adapted fiber-basedlasers, such as the PDL, pulsed KTP laser, thulium laser,neodymium yttrium aluminum garnet (Nd:YAG laser),and gold laser.45–47 Additionally, fiber-based systems havebeen developed in recent years to allow for transmissionof the CO2 through a flexible laryngoscope.

Patient/Laser SelectionAs with any office-based procedure, patient selec-

tion is critical to procedural and outcome success.Although intolerance to routine laryngoscopy is not acontraindication, patient comfort levels with unsedatedsurgery must be assessed and considered. Oftentimes,inability to tolerate the procedure may not be knownuntil it is initiated. It is notable that although patientsare anesthetized, they may feel burning and gaggingfrom the use of the laser. There is some variabilitydepending on the type of laser and settings used and thelaryngeal subsite being targeted.

In addition to tolerance issues, medical conditionshould be assessed. Although there are no specific guide-lines regarding patient selection for in-office laryngealsurgery, poor pulmonary and cardiac status are risk fac-tors for medical complications related to this type ofprocedure. Caution should therefore be taken when con-sidering in-office laser procedures on these patients, andmonitoring may be considered by doing the procedures ina hospital-based endoscopy setting or in an operatingroom. This being said, there is little evidence to showmajor cardiopulmonary effects from this type of proce-dure. In fact, the safety profile of in-office laryngealsurgery is excellent.48–50

The choice of laser is largely theoretical. There areno good studies to date comparing the various lasers on avariety of different pathology types or for patient-relatedissues. Technically, the currently used lasers can be di-vided based on their targeted chromophores. The CO2 andthulium lasers primarily target water, whereas the PDLand KTP primarily target oxyhemoglobin (Fig. 9). Thegold laser and Nd:YAG target other chromophores, suchas melanin and carbon, and are only partially absorbed bywater and oxyhemoglobin. However, depending on powersettings, spot size, and other parameters, each of the

Fig. 9. Laser absorption. (A) Water absorption spectrum. (B) Oxy-hemoglobin absorption spectrum. (From Burns, et. al. from Laryn-goscope 118:1109-1124, 2008).


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described lasers can have a range of effects from cuttingto coagulation. Generally, though, lasers that target watertend to cut more precisely with less surrounding thermalinjury, and those that target oxyhemoglobin tend to coag-ulate better. Other lasers that target other chromophoresmay provide a mixture of coagulation and cutting.

IndicationsIn-office laser treatment is indicated for a variety of

epithelial lesions of the larynx, including papilloma,granuloma, leukoplakia, dysplasia, Reinke’s edema, andvocal fold polyps.46,48,51,52 It has also been used inselected other lesions, such as vascular ectasias and ste-nosis.47,48,53 It is not indicated for certain specificsubepithelial lesions, such as intracordal cysts and rheu-matoid nodules. Use in scar has been reported,54 but isexperimental and unsubstantiated.

During clinical use, it is evident that there is avariable tissue response when treating different lesionswith the various commonly used laryngeal lasers.Although there are claims of superiority of one lasertype over others for a variety of laryngeal lesions, suchstatements are not borne out by careful study on laryn-geal tissues. In fact, as mentioned above, the tissueresponse to laser energy is dependent on a host of fac-tors in addition to wavelength.

Other Laser IssuesIn addition to the matters mentioned above, there

are a variety of issues related to in-office laser surgery,including laser safety, endoscope maintenance, cost, andreimbursement. Prior to considering use of this technol-ogy, all these issues must be considered.

As with laser surgery done in the operating room,laser safety and standardized reporting protocols shouldbe adhered to. While the risk of laser fires is signifi-cantly reduced, due to the absence of an endotrachealtube and lack of high-concentration oxygen, many othersafety issues remain the same. Additionally, lasers mustbe maintained to ensure consistency of energy deliveryand safety of function.

The fibers used to convey the laser energy are gen-erally small and will fit through small side channels onflexible laryngoscopes (<2 mm). There has been recentconcern over scope damage due to scratching of the sidechannel walls with the laser fibers and laser energydelivery to the endoscope. Unfortunately, the use of asheath may not protect the endoscope channel,55 leadingto costly repairs.

The issue of cost is certainly a concern. Each of thelaser systems are quite expensive and may be costly tomaintain. Additionally, the very practice of in-office lasersurgery may increase costs due to additional personnel,equipment (channel endoscopes, fibers, sheaths), andcleaning costs necessary for the procedures. These addi-tional costs may be difficult to bear, given the lack ofestablished billing codes for these procedures and thespotty reimbursement. However, these initial and ‘‘local’’cost issues may be significantly counterbalanced by the

substantive overall healthcare cost savings afforded byproviding care in an office setting versus the operatingroom.56

Individual Laser CharacteristicsCO2 laser (flexible). As mentioned above, the CO2

laser has many ideal characteristics for laryngeal sur-gery. The wavelength of the laser is 10,600 nm, and it ishighly absorbed by water. Because water is ubiquitousin laryngeal tissues, the laser energy is dissipatedquickly in the superficial tissues without deeppenetration.

With the recent introduction of a photonic bandgapfiber assembly (OmniGuide, Cambridge, MA), it is nowpossible to direct the CO2 laser through thin flexiblefibers capable of passing through the side channel offlexible laryngoscopes.57 This ability has allowed the useof the CO2 laser for in-office unsedated laryngeal sur-gery. The one ongoing concern has been the cost of thefiber, which is expensive to manufacture.

Used with the fiber, the CO2 laser has almost allthe capabilities previously enjoyed in the operatingroom. The most appealing feature is that it producesminimal surrounding thermal injury when used prop-erly.58 One technical difference with the flexible systemis that the beam cannot be focused in the traditionalmanner with a micromanipulator. Instead, like otherfiber-based lasers, spot size is related to distance fromthe target tissue. Additionally, unlike the CO2 laser sys-tems in the operating room, there is no associatedaiming beam.

Generally, the CO2 laser is excellent for purelyepithelial-based vocal fold lesions, such as papillomaand granulomas, and for cutting tissue (such as with ste-nosis). It can also be used effectively for ablating lesionsoff the true vocal folds. Lesions such as vocal foldvascular ectasia and Reinke’s edema require largeramounts of energy delivered to the true vocal folds thatmay lead to excessive heat delivery and surrounding tis-sue injury.

Thulium laser. The thulium laser has a wave-length of 2,013 nm and its target chromophore is water.Because of the strong absorption by water, the thuliumlaser behaves much like the CO2 laser.59 However,because of the shorter wavelength, the laser is capableof traveling through a thin glass fiber. Therefore, thethulium laser possesses much of the cutting capabilitiesof the CO2 laser without the comparable expense of thespecially made fiber. Additionally, the thulium laser, ascurrently configured, is fairly small and does not requirea gas tank, making it somewhat more convenient thanthe CO2 laser.

The thulium laser has been shown to be safe andeffective in treating a variety of pathology related to thelarynx.45,48 Previous authors have suggested that its tis-sue effects are similar to those of CO2, but that it hasbetter coagulation capabilities and may produce morethermal injury.45 The latter issue may be amelioratedwith cooling of the tissues with use.60


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Pulse dye laser. The PDL was the first specifi-cally adapted for laryngeal surgery in the late 1990s,and was quickly adopted for in-office laryngeal sur-gery. Because of its 585-nm wavelength (targetchromophore is oxyhemoglobin), it has been suggestedthat its mechanism of action may be to destroy theblood supply of a lesion, leading to involution.61 How-ever, the laser’s indications have been expanded toinclude relatively nonvascular lesions, such as Rein-ke’s edema and leukoplakia, with considerable clinicalsuccess,48,49 adding some uncertainty to the exactmechanism of action.

Only a single study could be found carefullyexamining the pathology of the PDL lesion on thevocal fold. This study showed coagulation of the vas-culature and the development of a cleavage planebetween the basement membrane and the superficiallamina propria.62 However, deeper tissues were notexamined, so effects within the entire lamina propriaare not known.

Potassium titanyl phosphate laser. The KTPlaser (532-nm wavelength) has been used in otolaryn-gology for a long time.63 However, it has recently beenadapted for use in office-based laryngeal surgery (Fig.10).46 Recent versions of the laser have allowed formillisecond pulse widths, which should lessen thermalinjury compared to earlier versions of the laser. TheKTP laser’s target chromophore is oxyhemoglobin, andtherefore it has excellent coagulation capabilities likethe PDL. However, it does not possess the same cuttingcapabilities as CO2 or thulium, and may createincreased thermal injury when used to vaporizetissues.

Despite its extensive clinical use, little basicresearch has been done to study the effects of this laseron the vocal fold. Amin and colleagues have recently cre-ated an animal model for studying its effects on ratvocal fold epithelium.64

Other lasers. The gold laser and Nd:YAG havealso been used for laryngeal surgery, but their use is

Fig. 10. Treatment of vocal fold polyp with pulsed potassium titanyl phosphate (KTP) laser (30-W, 30-ms pulse width, two pulses per sec-ond). (A) Vocal fold polyp receiving pulsed KTP treatment via a working channel of a flexible endoscope in an office setting with local anes-thesia. (B) Vocal fold polyp during pulsed laser treatment. (C) Two weeks following treatment. (D) One month following treatment.


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somewhat limited at this point in time. They have simi-lar wavelengths (in the range of 1,000 nm) and, asmentioned above, primarily target melanin and carbon.The exact mechanism of action in laryngeal tissues isnot known.

The depth of penetration has been a concern forNd:YAG. Its use has been shown to result in longerhealing times compared to CO2, largely attributed to itsincreased zone of tissue necrosis at the base of the sur-gical site.65 At the time of publication of this article,there is no clinical data regarding the use of the goldlaser.66

ConclusionThe use of in-office laryngeal laser surgery has

flourished in the last decade due to the availability ofnew flexible laser systems that are compatible with flexi-ble endoscopic technology. There is increasing evidencein the literature that such surgical procedures are safeand effective for a variety of lesions. Although the vari-ous laser types vary in their physical properties, there isno consensus as to the overall advantage of one lasertype versus another for the various pathologies encoun-tered in the larynx. This may be due to the difficultiesinherent in doing such case controlled studies or due tothe almost unlimited variables present when dealingwith laser tissue interactions. Hopefully, with time andcareful study, specific indications and contraindicationsfor this type of surgery will be developed.

VOCAL FOLD INJECTIONOf all the techniques described in this article, in-

office injection augmentation of the vocal fold may bethe most therapeutically useful in routine, day-to-dayclinical practice. Described for use in the awake patientalmost a century ago,67 in-office injection augmentationis in fact not new, but a tried technique that fell outof use principally because of problems withinjectable materials—specifically polytetrafluoroethylenepaste (Teflon)—rather than any intrinsic shortcomings ofthe procedure. Vocal fold injection remained well-estab-lished in the repertoire of procedures performed in theoperating room, however, and now has only gained inscope and utility with its return to the office setting.Indications have expanded to uses that would not neces-sarily have merited exposing the patient to a generalanesthetic, including even treatment trials when thepotential for improvement is uncertain.68 The conven-ience of the procedure readily appeals to many a patientwho would otherwise turn down an operating roomintervention as a treatment option. Its efficacy is satisfy-ing for the otolaryngologist, as is the lack of financial ortechnical barriers to its adoption—the clinician mayembark on in-office injection for little more than the costof the injectable. All of this is not to make light of thetechnical demands and limitations, and the potential pit-falls of the procedure; recall that these have caused theprocedure to be nearly abandoned once before. As in anysurgery, insight, prudence, and practice are essential forsafe, effective use.

Indications and Treatment ConsiderationsThe majority of in-office injections are performed

for vocal fold augmentation. The discussion in this sec-tion will restrict itself to this use, although theadaptability of the technique for injections of substanceslike steroids or cidofovir should be clear (superficialvocal fold injection is discussed later). The technique isnot typically limited by anatomic considerations, giventhe variety of potential approaches to the larynx, eachdetailed below. On the other hand, it does depend on acalm and cooperative patient who is appropriatelyinformed. In fact, the participation of the awake patientwho can cough, phonate, and swallow during the proce-dure frequently provides useful feedback to guideinjection amount and placement, and constitutes a sub-stantive advantage over injection under generalanesthesia. Patient anxiety and a nonsuppressible gagreflex are relative contraindications; techniques for anes-thesia have been discussed earlier and are reviewedbelow as well.

Any material that can be injected in the operatingroom can be used in the office, with the obvious excep-tion of autologous fat. In general, control of theinjectable bolus is somewhat less precise than what canbe achieved in the operating room, so some technical ex-perience is strongly advised prior to the use of long-termmaterials, such as calcium hydroxylapatite in the awakepatient. Inadvertent placement of durable injectable ma-terial into the subepithelial layers of the vocal fold willresult in prolonged dysphonia, inflammation and scar,and constitutes one of the significant complications ofthe technique.69

The indications for in-office injection augmentationencompass those four conditions that cause glottic insuffi-ciency: 1) vocal fold paralysis; 2) vocal fold paresis; 3)atrophy, age-related or otherwise; and 4) scar and its relatedconditions, such as sulcus vocalis and postsurgical defect.

In patients with vocal fold paralysis, in-office injec-tion is particularly useful for prompt, temporarysymptomatic relief shortly after onset. This may includebedside injections in the first postoperative days on inpa-tients with vocal fold paralysis status post skull-baseprocedures, esophagectomy, pneumonectomy, and othermajor thoracic procedures; in this population, vocal foldparalysis is a source of considerable morbidity. The in-office technique lowers the barriers to treatment ofseverely debilitated patients, such as those with late-stage malignant disease, by obviating the need for a gen-eral anesthetic. Ambulatory, otherwise healthy patientstypically appreciate the prompt results and minimaldowntime.

Paresis, or partial paralysis, is often challenging toidentify because signs may be subtle and/or variable.70

It is not rare for the physician to make the diagnosistentatively. In such cases, in-office injection with a tem-porary material offers a means of testing a provisionaldiagnosis. Although it certainly does not yield conclusiveproof of disease, it answers clinically important ques-tions regarding the utility of augmentation ormedialization as a treatment modality.68


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Atrophy is typically a chronic condition that is rela-tively mild. Patients, either because of age or becausethey do not perceive the resulting vocal handicap to begrave, are often reluctant to pursue treatment if itinvolves general anesthesia. Typically, injection is bilat-eral and symmetric.

In cases of scar, glottic insufficiency is typicallyonly part of the cause of hoarseness, the other being mu-cosal stiffness. Of the two, the glottic insufficiency is byfar the easier to address, and may provide relief fromthe increased phonatory effort affected individuals arefrequently obliged to exert. It may make their voice eas-ier to understand in challenging acoustic situations aswell. Paradoxically, placing damaged vocal folds in closerapproximation may sometimes exacerbate the roughnessof the voice quality. A trial injection offers a means ofassessing the result of vocal fold augmentation in thesecases, for both patient and physician.68 In general, it isdifficult to augment only the area of the deficit in theoffice, especially if the deficit is extremely focal. Thistask requires great precision and frequently some sube-pithelial dissection, both of which make directlaryngoscopy the preferred technique when such delicacyis called for.71

We have made much of the safety and convenienceof the technique, particularly for patients in suboptimalmedical condition. This should not create complacencyregarding patient selection. Awake laryngeal injection istypically performed under local anesthesia without vitalsign monitoring, in the manner of routine diagnostic en-doscopy. Occasional vasovagal reactions are triggered,usually in young, fit patients in robust cardiovascularhealth, and these are of little consequence. Nevertheless,they do serve notice that awake laryngeal injection rep-resents a stress that should not be underestimated inpatients prone to significant arrhythmia.

Vocal Fold Injection TechniquesVisualization. The essential requirement for in-

office injection of the larynx is adequate visualization.The larynx is visualized via flexible laryngoscopy per-formed by an assistant, with the image projected to amonitor viewed by the surgeon and assistant. As is trueof every technique described in this report, the practical-ity of in-office injection has been enhanced in no smallpart by the advent of distal chip technologies for flexiblelaryngoscopy. In-office injection may certainly be per-formed with fiberoptic instrumentation, however,provided that illumination and resolution are adequateto place the injectable appropriately. Alternatively, thelarynx may be visualized perorally with a Hopkins rodlaryngoscope, although this requires the injector tooccupy one hand with the scope, and the patient to holdhis own tongue during the procedure.

Anesthesia. Because the procedure is likely torequire the presence of the laryngoscope for a longer pe-riod than the typical diagnostic examination thoroughnasal anesthesia is recommended, even including pre-procedure packing with lidocaine and decongestantsoaked pledgets, as for transnasal esophagoscopy. For

percutaneous approaches, the skin overlying the antici-pated puncture site may be anesthetized in the normalmanner. When the injection needle is not anticipated tobreach mucosa, as in transthyroid cartilage or cricothy-roid technique, no further anesthetic is necessary. Forevery technique in which the needle must cross the mu-cosal surface, anesthetic may be administered to themucosa of the oropharynx, larynx, and hypopharynx in avariety of ways. Anesthesia options for these approacheshave been discussed earlier. A formal superior laryngealnerve block is virtually never necessary. Surgeonsshould avoid injecting epinephrine into the airway, andshould bear in mind the toxicity threshold of lidocaine(as previously discussed). Mucosal anesthesia may be ex-cessive in some cases, resulting in secretionsoverwhelming the larynx, making the patient uncomfort-able and obscuring the injection site.

Injection location and amount. There is cur-rently no injectable with appropriate rheologicproperties for injection into the subepithelial plane.The role of such superficial injection is limited at pres-ent due to this, and the required precision renders itgenerally inappropriate for the office setting. Further,there is no material that does not cause some tissuereactivity. In transient injectables, this is probably oflittle consequence, as it disappears along with the ma-terial. In longer-lasting injectables, this may besignificant, particularly when it occurs close to superfi-cial structures. The more soft tissue between theinjectable and membranous vocal fold, the less thechance that the injectable itself or the inflammatoryreaction that it typically triggers will adversely affectvocal fold vibration. In all office-based injection aug-mentations, then, injected material should be placedwithin the vocal fold muscle, lateral to the superior ar-cuate line. Placement too far lateral, into theparaglottic space, will result in no harm to the patient,but typically yields little augmentation in proportion tothe amount of material injected.

The placement of the material along the length ofthe vocal fold depends on the deficit to be corrected. Inparalyzed vocal folds with a large posterior gap, theinjection should be placed lateral to the vocal process ofthe arytenoid cartilage. For patients with membranousvocal fold glottic insufficiency as a result of atrophy orparesis, an injection at approximately the midpoint ofthe membranous vocal fold will address the problemmost effectively. Injection in the anterior half of themembranous vocal fold is generally to be avoided, as in-advertent overmedialization with consequent mucosalwave dysfunction is easily induced, analogous to anteriorovermedialization with a laryngoplasty implant.

The amount injected is determined primarily by thevoice quality, and secondarily by the appearance of thevocal fold itself. Most injectables require some degree ofovercorrection, as they contain an aqueous componentthat will resorb. The extent of overcorrection varies frommaterial to material, but a very gentle convexity of thevibratory margin of the vocal fold usually suffices. Mostvocal folds are adequately medialized with 0.5 mL orless of injectable; the exception is an extremely


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hypotonic and/or atrophic denervated vocal fold in alarge male larynx. It is important to understand thatinjection augmentation is not a stereotyped procedure,and the amount and placement of the injectable is deter-mined in each case by a number of individual factors,including degree of glottic insufficiency, anatomy andthe patient’s vocal requirements and expectations. Infact, one significant advantage of awake injection aug-mentation is that voice quality and glottic closure can bemonitored throughout the procedure.

In the event that the injectable is unevenly distrib-uted, yielding an irregular or ‘‘lumpy’’ vocal fold contour,a throat clear or sharp cough by the patient may helpdistribute it more evenly.

Peroral approach. Peroral injection is probablythe most technically demanding approach, requiring thesurgeon to guide the needle past sensitive structuresincluding base of tongue, epiglottis, and ventricularfolds. Because of this, it requires that the oropharyngealmucosa be well anesthetized. This approach offersunparalleled precision, because the surgeon can visual-ize the needle down the entire path to the larynx.

Typically, the patient is placed in the same position asfor peroral stroboscopy, leaning forward with the chinthrust forward. The tongue is grasped by the patient orthe surgeon, and an appropriately curved needle isguided just past the faucial arches under direct visual-ization. The needle typically is bent 90�, but the propercurve to navigate the path to the glottis varies frompatient to patient, and may only be determined by expe-rience. The surgeon may gain valuable informationregarding this curve for delivery of topical anesthesiawith an Abraham cannula. Once in the oropharynx, theneedle is identified on the monitor (view from assistantusing the flexible laryngoscope) and guided to the injec-tion site. The shaft of the needle may be used to nudgethe medial edge of the ventricular fold aside as the nee-dle is inserted into the lateral aspect of the vocal fold tothe required depth.

Long needles (220–250 mm) are available with theBrunings syringe (18 gauge), the Medtronic Oro-Tra-cheal Injector (27 gauge), or are supplied free (25 gauge)with the purchase of an injectable by some manufac-turers (BioForm, San Mateo, CA; CoApt, Palo Alto, CA).Some of these are marked 5 mm from the tip to aid ingauging depth of injection. It is important to prime theneedle with injectable material prior to insertion, asinjection of air into the vocal fold may cause unpredict-able swelling.

Transcricothyroid membrane approach. Thetranscricothyroid approach has evolved out of the tech-nique used to inject botulinum toxin. The skin overlyingthe cricothyroid space is anesthetized. With the patient’shead in the neutral position, a 25-gauge needle, bentabout 45� about 1 cm behind its tip, is inserted at the in-ferior border of the thyroid cartilage, some 3 to 7 mm offof the midline towards the side to be injected. The goalis to keep the entire path of injection submucosal, and toprevent the needle from entering the airway; if this ispossible, no intralumenal or laryngeal anesthetic isrequired at all. Once the tip of the needle passes the in-ferior lip of the thyroid cartilage, it is angled cephaladand laterally, in approximately a 1 o’clock direction onthe patient’s left and 11 o’clock on the right. The cepha-lad angle may need to be sharper in women, as theanterior-posterior length of the vocal folds is less. Theglottis is visualized on the monitor via a flexible

Fig. 11. In-office injection of a paralyzed right vocal fold via the cricothyroid space. (Left) Preoperative examination reveals an atrophic rightvocal fold. (Center) After identification of transmitted motion from the needle tip (not visible in this still image), gentle injection produces thebeginnings of a mass effect in the floor of the ventricle. Compare with image to the left. (Right) At endpoint, the vocal fold is overmedializedsome 20%. The voice sounds pressed, but will improve over 1 to 4 days. There is no blood visible, as the entire injection is performedsubmucosally.

Fig. 12. Transthyrohyoid membrane vocal fold injection in an officesetting. The surgeon passes the needle into the larynx via the thy-roid cartilage notch and the assistant positions the distal chipendoscope for optimal visualization. Both are monitoring the injec-tion on the display to the right of the patient.


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laryngoscope, and signs of transmitted motion aresought. The needle may be rocked left and right slightlyto make the transmitted motion easier to perceive. Onceidentified, the injection is performed (Fig. 11).

Occasionally it is not possible to identify the needle.No injection should ever be performed unless the sur-geon is sure where the needle is, and thus, where thematerial will be deposited. When needle visualization isproblematic, the trachea may be anesthetized, and theneedle may be inserted in the midline. This will allow itto be identified in the airway via flexible laryngoscopy,and it can then be guided into the appropriate site. Ifthe mucosa is inadvertently breached in the unanesthe-tized trachea, the patient will frequently cough orswallow to the extent that the procedure may need to beaborted.

Transthyroid cartilage approach. The skin over-lying the thyroid cartilage on the side to be injected isanesthetized. With the patient’s head in the neutralposition, an unbent 23- or 25-gauge needle is insertedapproximately perpendicular to the ala of the thyroidcartilage at the point that the surgeon estimates corre-sponds to the midpoint of the membranous vocal fold.The vocal fold lies substantially closer to the lower bor-der of the thyroid cartilage than to its superior border,contrary to some descriptions, so the needle should enterthe thyroid cartilage at no more than 3 to 5 mm aboveits inferior border. Gentle pressure will usually allow theneedle to pass through the cartilage; care should betaken to avoid a sudden advance of the needle (past-pointing) with consequent mucosal puncture once itpasses through the cartilage. Transmitted motion shouldbe identified on the view from the flexible laryngoscopeprior to injection. The injector should also be aware thata cartilage plug may initially obstruct the needle; gentlepressure on the plunger usually suffices to clear it. Ifapplied too forcefully, plunger pressure may causeuncontrolled expulsion of the injectant, resulting ingross overmedialization. Medtronic ENT makes an injec-tion device specifically designed for this approach, whichis able to overcome the cartilage plugging problem(Casiano needle; Medtronic ENT, Jacksonville, FL).

The transthyroid cartilage approach is best foryounger patients without extensive calcification of laryn-geal cartilage. In the event that extensive cartilagecalcification prevents needle entry, it can be converted tothe transcricothyroid membrane approach with littledifficulty.

Transthyrohyoid membrane approach. The skinoverlying the thyroid notch is anesthetized. The laryn-geal mucosa must also be topically anesthetized aspreviously described. The patient’s head may need to beextended or turned slightly to expose the thyrohyoidnotch. A straight 25-gauge needle is inserted into thenotch and guided sharply downward; its tip should enterthe laryngeal lumen near the petiole of the epiglottis(Fig. 12). Once identified on the view from the flexiblelaryngoscope, it is guided to the injection site. Both vocalfolds may be injected via the same puncture by redirect-ing the needle as necessary. This approach shares withthe peroral approach good visualization of needle place-

ment in the vocal fold, which may offer an advantage ininjection placement72 (Fig. 13).

Perioperative Care and ComplicationsAntibiotics and steroids are not routinely used for

in-office vocal fold injection. Patients are typicallyobserved for 15 to 30 minutes postprocedure to ensurehemostasis and no dyspnea. They are discharged withinstructions to take nothing by mouth for 2 to 3 hours ifthe larynx and pharynx have been topically anesthe-tized; otherwise they may eat sooner. Discomfort issometimes quite sharp during the injection, and painoccasionally radiates to the ear on the side injected.Patients are no more than mildly uncomfortable at thetime of discharge, and acetaminophen is usuallyadequate for postoperative pain. Patients should beadvised that the immediate postprocedure voice is typi-cally quite poor because of overcorrection and edema.Recommendations for voice rest are not uniform, butrarely extend beyond 1 to 3 days. The patient should beaware that it may take up to 2 weeks in some cases forthe voice quality to stabilize; this will prevent many ananxious telephone call.

The most serious complication is airway obstruc-tion. The potential for this should be significantly less inthe awake patient than in the patient under general an-esthesia, in whom the functional respiratory glotticaperture cannot be assessed during the procedure. Somebleeding is common during procedures in which the mu-cosa is breached, and is usually of little consequence.Vocal fold injection is probably best avoided in fully anti-coagulated patients (but can be done when no otheroption is available), although aspirin and similar anti-platelet agents are no barrier to the procedure.Hematoma at the skin puncture site may occur, particu-larly when multiple passes are necessary. Inadvertentsuperficial injection may cause prolonged hoarseness.Under no circumstances should materials be injectedunless the surgeon is precisely aware of the location ofthe tip of the needle.

As for many new procedures, there is no acceptedCPT code for in-office vocal fold injection according to

Fig. 13. Transthyrohyoid membrane vocal fold injection, endo-scopic view. Needle has been introduced via the thyrohyoid mem-brane and enters the laryngeal lumen below the petiole. It is thendirected into the posterolateral aspect of the vocal fold.


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the techniques presented above, and reimbursement forthe material itself outside of the hospital setting is espe-cially challenging. This is despite the obvious financialbenefit in avoiding hospital and anesthesia expenses.73

This, rather than any technical issue, may represent themost significant problem with in-office injection. Otolar-yngologists should pursue a correction to this situationrather than pass an expense for an indicated medicalprocedure on to the patient, or, worse yet, deny thepatient effective remediation for glottic insufficiencybecause of administrative obstruction. In settings wherein-office injection is not reimbursable, awake injection inthe hospital setting, such as a hospital endoscopy suite(gastroenterology or pulmonary), may be a viable alter-native offering patients the benefits of awake injections.

ConclusionIn-office vocal fold injection is a useful adaptation of

a familiar procedure that enhances its benefit topatients. Regardless of the evolution in injectable mate-rials, the technique is likely to remain useful, and evenprovides a means of delivery of other therapeutic sub-stances (cidofovir, Botox, steroids).

TRANSNASAL ESOPHAGOSCOPYOffice-based procedures have had an extraordinary

impact in the evaluation of dysphagia, reflux, and headand neck cancer primarily via the introduction of TNE.

Since the pioneering work of Chevalier Jackson,esophagoscopy has undergone many changes.74–76 Withthe use of distal video chip technology, ultrathin esopha-goscopes with high-resolution images can now beinserted through the nose using topical anesthesia alone.This allows the otolaryngologist to perform esophago-scopy as a rapid, in-office procedure without sedation.The entire upper aerodigestive tract from the nose tothe gastroesophageal junction (GEJ) and gastric cardiais readily examined.77–79 In addition, biopsies and otherprocedures can easily be performed.

Since 2000, otolaryngologists have popularized TNEand expanded its diagnostic applications for head andneck cancer, dysphagia, globus, laryngopharyngealreflux, and gastroesophageal reflux disease (GERD).77–80

Technique and Overview of TNEThe individual should be NPO for 3 hours prior to

the procedure for optimal examination, but a recentmeal is not a contraindicaton to TNE. The patient isseated in a standard ear, nose, and throat examiningchair. No cardiac or oxygen saturation monitoring isnecessary.

The patient’s more patent nasal cavity is sprayedwith a 1:1 oxymetazoline 0.05% and lidocaine 4% solu-tion, and then packed with cotton pledgets using thesame solution. (Other anesthetic and decongestantagents may be used.) If oropharyngeal anesthesia isrequired (it is usually not needed), one spray of 20%benzocaine (Hurricaine) is administered to the orophar-ynx. The endoscope (VE-1530: KayPentax Precision

Instrument Corporation, Orangeburg, NJ; OlympusPEF-V: Olympus America Inc., Melville, NY; or Med-tronic ENT Esophagoscope TNE-5000 with sheaths) isthen lubricated and passed through the nasal cavity andinto the pharynx. The patient’s head is then flexed for-ward toward their chest as the endoscope is passedtoward the esophageal inlet. The patient is asked toswallow or belch and the instrument is advanced intothe esophagus. The scope is gently but rapidly advancedthrough the esophagus into the stomach for a retroflexedview of the gastric cardia and GEJ. This is done byrotating the entire scope 180� and maximally deflectingthe endoscope’s tip 210�. Commonly, extra air must beinsufflated into the stomach to provide room for visual-ization. After the cardia and GEJ are examined, the airshould be suctioned from the stomach (Fig. 14).

Using air insufflation, suction, and irrigation themucosa of the entire esophagus is examined as the scopeis withdrawn. This is performed carefully to insure thatall mucosal surfaces are examined. Because the esopha-gus is collapsed at rest, air insufflation, drinking waterwith a straw, or voluntary swallows by the patient maybe needed to allow for better visualization. If mucosallesions or irregularities are noted, 1.8-mm biopsy forcepsare passed through the working channel and multiplebiopsies are obtained.

Difficulty in passing through the upper esophagealsphincter (UES) should alert the examiner to the possi-bility of a hypertonic UES, proximal esophagealstricture, or a Zenker’s diverticulum, and a very carefulexamination should be performed or the procedureaborted.

IndicationsThe reasons for the transnasal evaluation of the

esophagus include patients with esophageal and extrae-sophageal indications, and various procedures requiringTNE.81,82

Esophageal indications includes dysphagia, esopha-geal symptoms that persist despite an appropriate trialof antireflux therapy, odynophagia, screening, and

Fig. 14. Barrett’s esophagus.


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possibly surveillance of Barrett’s esophagus, causticingestion evaluation, foreign body evaluation, visualiza-tion and biopsy of radiologic abnormalities, monitoringof esophageal varices, and longstanding (>5 years)GERD.

Extraesophageal indications for TNE includepatients with chronic cough, cervical dysphagia, headand neck cancer (initial panendoscopy with biopsy andlong-term follow-up), poorly controlled asthma, moderateto severe laryngopharyngeal reflux and globuspharyngeus.

Procedural indications include biopsies of the laryng-opharynx and esophagus, esophageal, neopharyngeal, andnasopharyngeal stricture balloon dilation,83–85 secondarytracheoesophageal puncture,86,87 the delivery of flexiblelasers, delivery of feeding tubes, injection of Botox intothe esophagus,88 and the insertion of wireless pH monitor-ing devices.89

ContraindicationsThere are no absolute contraindications to TNE.

Concerns have been raised in reference to anticoagula-tion, but in the authors’ experience, performing TNEand obtaining biopsies in patients taking Coumadin orPlavix has not been a problem. The presence of a knownZenker’s diverticulum will make the procedure morechallenging, but would not be considered a reason torefrain from TNE if otherwise indicated.

ComplicationsMost complications during sedated endoscopy are

related to sedation. Cardiopulmonary complicationsaccount for more than 50% of all adverse events.90 Arecent survey of endoscopists reported that adverse car-diopulmonary events secondary to conscious sedationconstitute the majority of endoscopic complications; infact, 67% of complications and 72% of mortalities werecardiopulmonary related.91 The unsedated aspect ofTNE eliminates all sedation-related complications.

Esophageal perforation is a rare but catastrophiccomplication, and among the thousands of TNE andTNE-gastroduodenoscopy cases performed, there hasbeen only a single case of esophageal perforationreported.92 Minor complications are also uncommon. Inthe two largest series reported, involving 1,800 totalpatients, rates of epistaxis were between 0.85% to 2%,and vasovagal events were 0.3%.81,93

Coding and BillingAt this time, TNE uses the same coding procedures

as conventional endoscopy. Diagnostic TNE (43200) andTNE with biopsy(s) (43202).

TNE Versus Conventional EsophagoscopySince the introduction of TNE, there have been

many studies comparing TNE with the ‘‘gold standard’’of conventional esophagoscopy (CE), which is performedtransorally with sedation. Studies utilizing small-calibervideo endoscopes have almost all concluded that TNEimage quality and diagnostic capability is equivalent to

CE, and that the majority of patients prefer TNE toCE.94–102

A summary review of these and other comparativestudies was recently published as a portion of the Ameri-can Academy of Otolaryngology position paper onTNE.82

TNE is also less expensive than CE. The increaseddirect costs of CE include longer procedure time, recov-ery room and recovery time, and the costs associatedwith medications, monitoring, and nursing.103 The dif-ference in cost has been found to be greater than $2,000per procedure.104 Indirect costs are also important butdifficult to quantify. This includes loss of work time byboth the patient and a driver or caretaker. In contrast,with TNE, most patients are able to return to work orhome shortly after the completion of the examinationand do not need a caretaker.

Studies have shown a very high patient satisfactionrate, often greater than with CE.81,93 Crossover studieshave shown that in patients who had both sedated andunsedated examinations, the unsedated transnasal en-doscopy was better tolerated.97

The FutureWe anticipate that the future will bring continued

refinements, such as still smaller endoscopes and the de-velopment of novel instruments to be used inconjunction with them. In addition, new techniques inimaging have emerged showing promise for enhance-ment and better visualization of the microvascularpatterns of mucosal surfaces. Of particular interest isNBI optical technology, as noted earlier.105,106 NBIemploys the filtering of light into three narrow band-widths. This allows for optimal visualization of surfacecapillary and mucosa patterns, which the literature hassuggested may allow for better evaluation and diagnosisof esophageal lesions. This may very well lead toimprovement in the diagnosis of Barrett’s metaplasia,adenocarcinoma, and head and neck squamous cellcancer.

ConclusionIn-office TNE has become an important part of the

evaluation and management of patients with dysphagia,extraesophageal/gastroesophageal reflux disease, andhead and neck cancer. TNE provides a number of advan-tages over conventional endoscopy with equivalentclinical results. These advantages are improved safety,decreased overall costs, and patient preference.

MISCELLANEOUS LARYNGEAL PROCEDURESIN THE OFFICE SETTING

Laryngeal BiopsyThe revival of interest in awake laryngeal techni-

ques has led to the development of additional proceduresthat offer novel value in care of the laryngology patient.Perhaps the largest and most widely applicable is awakelaryngopharyngeal biopsy. Although its roots are over


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100 years old, awake laryngeal biopsy has seen a resur-gence with the development of new endoscopes,endoscope sheaths, and instrumentation. Until approxi-mately 15 years ago, the primary means for awakelaryngopharyngeal biopsy was similar to the approachused by the fathers of laryngology in the mid 1850s:transoral passage of long curved biopsy forceps withindirect mirror laryngoscopy guidance. Although visual-ization is now achieved with rigid or flexible endoscopeswith video display of the image rather than laryngealmirrors, the technique remains largely unchanged. How-ever, in addition to the peroral biopsy approach,laryngeal biopsy can be done via the working channel ofa flexible endoscope.

After adequate laryngopharyngeal anesthesia (asdescribed previously), the patient is positioned sittingupright in the sniffing position. When using a rigidendoscope transorally, the patient holds their tongueprotruded. The otolaryngologist holds the rigid endo-scope in one hand and the biopsy forceps in the other.The patient is asked to breathe comfortably throughtheir mouth as the forceps are introduced into the laryn-geal introitus. The forceps are directed to the biopsy siteand a representative sample is taken. Today, this stillremains a valuable tool for the otolaryngologist, butrequires skill and patience on the part of the otolaryng-ologist and patient.

With the introduction of flexible channeled endo-scopes or flexible endoscopes with a channeled sheath(Medtronic ENT, Jacksonville, FL), the procedure hasbecome considerably better tolerated by patients andeasier to perform. The patient is anesthetized and posi-tioned similarly to the previous descriptions. The flexiblelaryngoscope is passed transnasally and held in positionviewing the biopsy target. A 2.0-mm flexible cup forcepsis introduced by an assistant through the channel of theendoscope or the endosheath until they appear severalmillimeters beyond the tip of the scope (Fig. 15) (Olym-pus Biopsy Forceps, SB-34C-1, 1.8 mm diameter, 1050mm length. Olympus America, Center Valley, PA). Theforceps are opened and then the endoscope is advancedonto the target. The assistant closes the forceps and thesample is taken. The specimen can be withdrawn via theforceps, leaving the endoscope in place most of the time,which facilitates a rapid additional biopsy if needed. Ifthe biopsy tissue is very large, then the entire endoscopecan be withdrawn, allowing the specimen to be placed inthe collection cup without being withdrawn through theworking channel.

When combined with transnasal esophagoscopy andbronchoscopy, awake panendoscopy, staging, and biopsyhas become a reality. Awake laryngeal biopsy and tumorstaging has been demonstrated to be equally as effectiveas operative staging.83,107 Time from presentation to ini-tiation of treatment is reduced by elimination of thetraditional panendoscopy and biopsy under general anes-thesia. Patients are spared from additional generalanesthesia, physician efficiency is improved, and health-care costs are reduced. Additional value of awakelaryngeal biopsy lies in the evaluation and surveillance

of laryngeal lesions that do not warrant operative exci-sion, and culturing of lesions suspicious for bacterial orfungal infection.

Secondary Tracheoesophageal PunctureAdditional value for the head and neck cancer

patient rests in awake tracheoesophageal puncture(TEP).87 The visualization that is achieved with thetransnasal esophagoscope greatly facilitates placementof a secondary TEP. The procedure is performed withthe patient sitting upright in the examination chair. Af-ter anesthesia of the nasal cavity and pharynx, thetransnasal esophagoscope is passed into the cervicalesophagus. Transillumination can be used to localize thescope at the level of the tracheostoma. The endoscope iswithdrawn slightly and the position for the

Fig. 15. (A) Cup forceps for biopsy of larynx, pharynx, or esopha-gus via a working channel endosheath. Note that this type ofendosheath allows a flexible endoscope used for diagnostic pur-poses to become a useful instrument for therapeutic purposes. (B)Biopsy of vocal fold lesion with cup forceps passed through aworking channel of a chip-tip flexible endoscope done under localanesthesia in an office-based setting.


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tracheoesophageal puncture is chosen. Local anesthesiais injected into the chosen site and blunt instrumenta-tion can be used to identify the internal position for thepuncture on the esophagoscopy monitor. Air insufflationassists in expanding the esophagus at the puncture site.A small puncture is made with a #15 or #11 blade, tak-ing care not to lacerate the posterior esophageal wall,which is directly visualized by the flexible scope in theesophagus. Blunt spreading with a curved hemostatdilates the puncture slightly. A soft rubber tube is thenintroduced into the esophagus with the hemostat andthe tube is directed inferiorly. The tip of the endoscopecan facilitate this. The puncture is cared for identicallyto a puncture performed intraoperatively.

Superficial Vocal Fold InjectionSuperficial vocal fold injection can be done under

local anesthesia in an office-based setting. This vocalfold injection technique involves the use of a fine-gaugeneedle to inject in a subepithelial plane a material suchas a steroid or collagen substance. Given there is nopresent superficial lamina propria replacement materialfor patients with vocal fold scar or atrophy of this por-tion of the vocal fold, sometimes wound healing behaviorfollowing inflammation, trauma to the vocal folds, orsurgery can be modified by superficial vocal fold injec-tion with a steroid substance or placement of a collagen-based material.

The most common indication for superficial vocal foldinjection in an office setting is to modify the wound heal-ing response following phonomicrosurgical procedures.This is especially true for patients who have had exten-sive lamina propria dissection, such as is often the casewith removal of ligamentous lesions or extensive fibrousmass lesions. Superficial injection of steroids in the imme-diate perioperative time period (2 weeks to 3 months) mayimprove the overall pliability of the vocal fold followingphonomicrosurgery. It is also possible to inject collagen-based products (Cymetra, Zyplast, Cosmoplast) into thesuperficial aspect of the vocal fold for vocal fold scar or at-rophy of the superficial aspect of the lamina propria.However, this procedure requires significant precision,and is thus not well suited for an office-based, local anes-thesia procedure. This type of vocal fold injection is bestsuited for microlaryngoscopy using general anesthesia.108

A variety of different steroid substances can be

injected superficially into the vocal fold. Only a rela-

tively small volume of material can be injected into the

superficial aspect of the vocal fold, and thus, a high-con-

centration steroid solution is usually selected. Examplesof these solutions include dexamethazone, 10 mg/mL or

Kenalog 40. There have been concerns raised regarding

the use of Kenalog given that the solution has a carrier

that has been reported to serve as a nidus for altered

vocal fold vibration following superficial vocal fold

injection.Anesthesia required for superficial vocal fold injec-

tion is described in the Anesthesia for Office-BasedLaryngology Procedures section. After adequate anesthe-sia has been achieved and confirmed by palpation of the

vocal folds with a blunt instrument (drip catheter for an-esthesia or an Abraham cannula), then one can proceedwith superficial injection of the vocal fold. This can bedone using two different approaches, a peroral approachor a transnasal endoscopic approach. The peroralapproach is identical to the previously described deepvocal fold injection (see the Vocal Fold Injection section),and differs only in the use of a fine gauge injection nee-dle (Orotracheal injector, Medtronic ENT, Jacksonville,FL) and the location and depth of the injection. Thetransnasal endoscopic approach for superficial vocal foldinjection involves passing a fine-gauge needle, which issheathed through the working channel of the flexibleendoscope or an endosheath with a working channel(Olympus injection needle and sheath, NM-101C-0427,27 gauge, Working length 1050mm, Needle length 4mm, Olympus America, Center Valley, PA). Once thesheathed needle has been passed all the way throughthe working channel and can be visualized in the phar-ynx, the needle can be unsheathed and then passed viaadvancement of the endoscope to within 1 to 2 mm ofthe intended vocal fold injection location. The endoscopeis then held steady as the assistant advances the needleslowly into the tissue of the vocal fold, keeping the depthof the needle at a very superficial level of penetration. Asmall test injection is then performed, and if the needleis in the proper location, a visual confirmation of superfi-cial placement of the material is seen with blanchingand a small bleb formation on the vocal fold. The injec-tion should be done relatively slowly to minimizedisruption of superficial vocal fold vasculature andinducing a vocal fold hemorrhage. A relatively small vol-ume is typically injected into a single vocal fold(approximately 0.1–0.2 cc).

A short period of postoperative voice rest is recom-mended to minimize leakage of the vocal fold injectionmaterial and trauma to the swollen vocal fold. Thepatient should be counseled that there will be a shortperiod of onset dysphonia following the vocal fold injec-tion lasting approximately 5 to 7 days. Steroidinjection(s) placed superficially into the vocal fold are of-ten done in a serial fashion: 3 injection treatments donewith 2 to 4 weeks between each treatment.

Atypical Botox Injections to the Larynx (FalseVocal Fold and Interarytenoid Muscle)

Recent office-based approaches have facilitated theexpansion of the role of Botox to treat select individualswith movement disorders of the larynx. This includesBotox injection to the false vocal folds and the interary-tenoid muscle. These two atypical Botox injectionlocations in the larynx have enhanced the ability of theotolaryngologist to care for the challenging/difficultpatient with the rare movement disorders that does notrespond to standard percutaneous, electromyography(EMG)-guided Botox injections to the larynx (thyroaryte-noid-lateral cricoarytenoid, posterior cricoarytenoid, and/or cricothyroid muscle). There are two indications for afalse vocal fold Botox injection: 1) adductor spasmodicdysphonia (SD), and 2) essential tremor of the voice.


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The former involves a very small number of adduc-tor SD patients that have a profound amount ofpostinjection dysphonia with a relatively short period of‘‘good voice’’ with standard percutaneous, EMG-guidedBotox injection approaches. For these individuals, oftena Botox injection to the false vocal folds will result in asignificant diminution of the post-Botox injection dys-phonia and an overall ‘‘smoother’’ response to Botox.These patients, however, do have a slightly decreasedoverall duration of the Botox injection compared to thetraditional percutaneous approach.109 Botox injections ofthe false vocal folds can also help patients with severeessential tremor of the voice that is primarily focused inthe supraglottic region.

Botox injection to the interarytenoid muscle can beeffective for patients with severe essential tremor of thevoice that appears to have a dominance at the level of theglottis arising from or including the interarytenoid mus-cle. A relative contraindication to either of these Botox-injection approaches include dysphagia. If the patientshave significant dysphagia prior to the Botox injection,one should proceed with great caution given that theseBotox injections may further enhance the patient’s under-lying difficulties with dysphagia. Possible complicationsof these injections include prolonged dysphonia and dys-phagia, although this is quite uncommon with the falsevocal fold injection approach. Selecting the dose carefullyand starting with a low dose and working up will mini-mize the risk of these complications.

Both of these Botox-injection approaches requiresimilar levels of local anesthesia applied to the endolar-ynx, similar to vocal fold injection of different materialsin different locations as previously described (see theAnesthesia for Office-Based Laryngology Procedures andthe Vocal Fold Injection sections).

Botox Injection to the False Vocal FoldBotox injection to the false vocal fold can be done

via a peroral approach (see the Vocal Fold Injection sec-tion) or via a transnasal endoscopic approach. The latteris preferred due to patient tolerance and has equal effi-cacy. The decision to proceed with either of theseapproaches is usually dependent on equipment availableto the surgeon. If a flexible scope with a working chan-nel or an endosheath (Channeled Slide-On Endosheath,33-5401, Medtronic ENT, Jacksonville, FL) with a work-ing channel is available, the transnasal endoscopicapproach is preferred. The goal of Botox injection to thefalse vocal fold is to deposit a small volume and smalldose of Botox submucosally into one or both of the falsevocal folds. Anesthesia for this procedure can be donewith nebulized lidocaine and/or a direct application oftopical lidocaine onto the false vocal fold region as previ-ously described. In the transnasal endoscopic approach,a fine-gauge needle with a sheath (as previouslydescribed) can be passed through the working channel ofthe flexible scope, and once the sheath is visualized inthe pharynx, the sheath can be withdrawn exposing thefine gauge needle. The needle is positioned to a distanceof 2 to 3 mm from the false vocal fold, and then the nee-

dle is advanced into the submucosal space of the falsevocal fold to deposit the Botox, creating a characteristicbleb formation from the superficial plane of the injection.Ideal locations for false vocal fold Botox injections havenot been elucidated, however, typically midfalse vocalfold from an anterior-posterior perspective and approxi-mately 5 mm above the inferior aspect of the false vocalfold are good guidelines for injection location. Typicaldoses for false vocal fold Botox injection for adductorspasmodic dysphonia range from 2.5 to 5 U per side.

Botox injection into the interarytenoid muscle can bedone via a transnasal endoscopic approach or a combinedpercutaneous and endoscopic visualization. The latterapproach is superior, given that it allows for simultaneousEMG guidance. Anesthesia is achieved within the endo-larynx via the approaches described above. Afteradequate anesthesia has been achieved, flexible laryngos-copy is performed and the endoscope is placed down intothe endolarynx to visualize the infraglottic portion of theanterior larynx. An EMG needle (bipolar or concentric) isthen passed percutaneously at the midline immediatelyunder the inferior border of the thyroid cartilage directlyinto the lumen of the endolarynx. Once the needle hasentered the lumen of the endolarynx, needle guidance canbe switched to the endoscopic visualization from the flexi-ble endoscope and the needle is then directed posteriorlyand slightly cephalad to enter into the posterior commis-sure of the endolarynx. Once the EMG needle pierces theposterior commissure of the endolarynx, EMG guidance isused to identify the interarytenoid muscle prior to inject-ing Botox (Fig. 16).

After each of these procedures, the standard patientinstructions, including avoiding eating and drinkinguntil all the anesthesia has worn off, is advised (approxi-mately 1–2 hours).

CONCLUSIONThe dramatic and substantive changes that have

occurred in office-based diagnosis and treatment in

Fig. 16. Interarytenoid muscle Botox injection via a cricothyroidapproach done with local anesthesia. Note the electromyographyneedle enters from the anterior subglottis and then is passed pos-terior and cephalad into the interarytenoid muscle, which is con-firmed by electromyography prior to injection.


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laryngology in the last decade have been reviewed inthis article. The significant benefits of the office-basedapproach include convenience for the patient and sur-geon and the potential for improved voice outcomes dueto the ability to monitor voice quality throughout theprocedure. As noted throughout the article, there arestill many aspects of office-based diagnosis and treat-ment in laryngology that require further critical reviewas the field moves forward. Some of these issues arepatient selection, cost of technology, insurance and reim-bursement problems, and the need for comparativestudies. Despite these hurdles and unanswered ques-tions, many of the procedures described in this articleare rapidly becoming the preferred technique in mostlaryngologists’ hands, and may in the future become thestandard of care. As the area of office-based diagnosisand treatment in laryngology advances, improvedpatient care will be driven by scientific inquiry, innova-tion, and the delineation of what diagnostic andtherapeutic interventions are provided in an office-basedsetting versus an operating-room–based setting will beclarified.

AcknowledgmentsThe authors would like to acknowledge the essential

assistance and support for the manuscript production ofDiane Keane.

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