Presentation - ENT Society

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Presentation - ENT Society

Office based procedures

Dr. Peak Woo

Clinical Professor

Mount Sinai School of Medicine

New York NY

Presented at: ENT/SAHNOS/SAA/SASLAH CONGRESS SOUTH AFRICA,

October 2010

Goal

Propose a re-vitalization re vitalization of office based

interventional laryngology

Give one or two examples of office based

intervention that may be applicable

NOT NEW!

(M. Mackenzie 1880)

What is State of the Art?

What is Standard of Care?

Office Management- Management Dysphonia

Treatment

office based medical treatment

office based procedures

office based rehabilitation

Brunnings: Brunnings:

1910

1


2010: So, who moved my

cheese?

Why consider other

Rx?

Forces beyond our

control

Good, bad, ugly

truths.

Office based procedures?

Patient demand

Cost effectiveness

Patient safety

What should we explore?

Target tissue specific

lasers

New bio-implants bio implants that can

be used in office

Technology for office

tissue histology sampling

New drugs useful for local

delivery

Improved equivalent

outcomes in an office

setting

New forces favoring office

Aging of America

not suitable for anesthesia

patient perception of invasive procedures

Changing re-imbursement

re imbursement

New Technology

Sustainable health care system

What should we keep?

Bi-manual Bi manual operations

Magnification

Wide binocular views

Large exposure

The Good

Better drugs that have a therapeutic effect

when applied locally

Steroids, Mitomycin, Cidofovir

New/ better lasers that can be used

through a fiberscope

CO2 waveguide, Pulsed dye laser, KTP, Nd- Nd

YAG

Better visualization systems

Chip-tip Chip tip scopes, flexible strobes, video- video

telescopes

Immediate functional feedback for surgery

2


Office RX: 1996-2007 1996 2007

Office Pulsed dye laser treatment 164

Injection laryngoplasty with Micronized dermis 74

Cidofovir injection for adult respiratory papilloma 78

Brush biopsies of larynx 59

Steroid injection 45

Biopsy of laryngeal carcinoma /granuloma 17

Lysis of anterior commisure scar /granuloma 9

Office CO2 laser waveguide and other 21

Office intervention

Injection laryngoplasty

Injection of steroid

Cidofovir application

Brush biopsy of the larynx

Office laser

PDL and KTP

CO2 waveguide

Success = Anesthesia +

Patient selection Show video please

Office based lasers

Laser Absorption

3


Three main chromophores in

tissue

Water

Melanin

Oxyhemoglobin (blood)

Minor

Carbonized residue

methhemoglobin

The theory of selective photo-

thermolysis

Goldberg D 2005

Condition for Photo-thermolysis

Photo thermolysis

The energy fluence is sufficiently high to

damage the target

The pulse duration is less than or equal to

the thermal relaxation time (TRT).

The TRT is the time taken for the target to

dissipate about 63% of the incident

thermal energy.

Netter 1976

Fluence =

Power x Time

AREA

Skin vs. Vocal folds

Hirano 1993

Surgery: Office PDL

and CO2 waveguide

Valdez et al: Microvascular targeting with the 585-nm pulsed dye

laser (PDL) may provide a new form of therapy to control symptoms

caused by recurrent respiratory papillomatosis (RRP).

Laryngeal papillomas are very vascular lesions with multiple

vascular loops, which provide an excellent target for PDL radiation.

problem is not expected to occur when performed in an outpatient

setting under topical anesthesia.

TULIO A. VALDEZ, MD, KATHLEEN MCMILLAN, PhD, and

STANLEY M. SHAPSHAY, MD A new laser treatment for vocal cord

papilloma—585-nm pulsed dye Otolaryngol Head Neck Surg 2001;124:421-5.

McMillan K, Shapshay SM, McGilligan JA, et al. A 585-nanometer pulsed dye laser treatment of laryngeal

papillomas:preliminary report. Laryngoscope 1998;108:968-72.

4


Animal vocal fold study

Survival study on 2 canines ( 6 weeks)

Single pulse 6 Joules-10 Joules 10 Joules /cm2

Ablation of vessel 100um or less

Normal epithelium

Vascular ablation with peri-vascular peri vascular cuffing

Minimal collagen deposition around vessel

Purpura at higher fluences

Woo P, Wang Z, Perrault DF, Jr., McMillan K, Pankratov MM: “Pulsed diode

laser application in ablation of vascular ectasis of the larynx:

preliminary animal study.” Lasers in Surgery: Advanced Characterization,

Theraputic and Systems, V. In: Proc. SPIE. 2395:336-341. 1995.

Pulsed Dye laser

chromophore for the 585-nm PDL is

oxyhemoglobin, causes intravascular

coagulation and “photoangiolysis”

585-nm PDL 450-µs pulse width, 5–J per

pulse maximum output, 1-Hz repetition

rate, 1-mm fiber, 1- to 2-mm spot size, 19to

76-J/cm2 fluence

Vascular lesions Treatment goal

end point was photocoagulation of

microcirculation as evidenced by intraluminal

thrombus formation with darkening

of the vessels.

Visible blanching and/or separation of the

epithelial lesion can be identified.

Photo-thermolysis or combined with

thermal

Set-up Set up Office laser

5


PDL for scar, polyp

Involution after PDL (4 Wk)

PDL: vascular polyp Case AO

17 year old Broadway

singer with

dysphonia.

Bleeding and varix

noted 2/09 treated

with steroid x 3

Still notes hoarse

voice with singing

therapy

Recommended MDL

Case AO Case AO: Rx

Patient treated with

24 joules to lesion in

office

Photothermolysis of

varix

6


Case AO post treatment video Case RR

Case 6 R R : Rx

Office KTP ablation

with local anesthesia

Avoided GA

No concern for airway

or vibratory edge

Use in thermal

ablative mode

Applications of injection

laryngoplasty

Unilateral vocal fold paralysis

Vocal cord scar

Vocal atrophy

Minimal glottal incompetence due to

presbyphonia

Sulcus vocalis

Laryngeal reconstruction of arytenoid

Intubation defect

48 year chief of

anesthesiology with

laryngeal papilloma

Had excellent result

with resection and

Cidofovir injection 1.5

yr ago

Has small residual

disease on epiglottis

Case 6: RR Rx

Preparation of Alloderm

7


Trans-cervical Trans cervical Injection Site of Injection - Lateral View

Case

67 yr. female judge with dysphonia after

mediastinoscopy for staging of cancer of

the lung.

Date of procedure 4 weeks ago

Receiving Chemotherapy

Active chief justice

Exam: left Vocal fold paralysis

PRE

Vocal fold paresis

1 wk PO

Case

Finding:

Breathy dysphonia

VHI: 44

Left vc immobile with PT of 7 seconds

Can not be heard in court.

Methods

20 gauge needle inserted in skin and

directed perpendicular to ala

Finding the lower border of thyroid

cartilage and aim perpendicular to cord

Palpate the CT membrane to see level

Second operator passes flexible scope

through nose to visualize the larynx

Needle position confirmed

Injection performed under direct vision

8


Trans-cervical Trans cervical injection Case

69 year old Radio

personality with

hoarse voice, x-

smoker for 6 months

Treated with Diflucan,

antibiotics and PPI

Case video Case : Rx

Summary

Phonosurgery have moved more from the

operating theater to the office

There are a variety of treatment options in the

office setting that can be employed safely in

singers without anesthesia. These include

lasers, injection, medications and brush biopsy

Micro-laryngoscopy Micro laryngoscopy continues to be a key tool in

selected cases where dissection and mucosal

freeing is critical

Office Brush biopsy

Final path: Chronic

inflammation with

benign epithelial cells,

no malignancy

Pt. on the air in 48

hours.

9

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