In-office Laryngeal Procedures: a Modern Perspective for Vocal Fold Interventions

Introduction: The purpose of this article is to discuss in-office laryngeal procedures as an alternative to surgical intervention under general anesthesia. In-office procedures have become more common due to technological advancements. As a result, these approaches are less invasive and more patient-friendly, with increased pain tolerance and reduced procedure time and cost. Methods: We conducted a thematic analysis of published reports regarding the best known and performed in-office laryngeal interventions. Three questions guided our analysis: What laryngological procedures can be performed in the office setting? What are the advantages of in-office laryngology procedures compared to operating room surgical procedures? Why aren't more in-office procedures performed in some Latin American countries? Discussion: Despite being performed more frequently, there is still controversy whether in-office procedures should be performed as often due to the risk of complications. Furthermore, procedures that are done in the office setting are more popular in some countries than in others, even though their benefit has been well demonstrated. This article describes various in-office procedures, including biopsy, vocal fold injections, and laser surgery. We also discuss what factors might contribute to having office-procedures being performed more frequently in some countries than others. Conclusion: Awake interventions offer numerous benefits, including shorter procedure time, reduced costs, and lower patient morbidity. These advantages have significantly transformed the treatment of laryngeal diseases in modern laryngology practice in a global manner.

Introducción: El propósito de este artículo es discutir los procedimientos laríngeos en el consultorio como una alternativa a la intervención quirúrgica bajo anestesia general. Los procedimientos en consultorio se han vuelto más comunes debido a los avances tecnológicos. Como resultado, estos enfoques son menos invasivos y más amigables para el paciente, con mayor tolerancia al dolor y reducción del tiempo y costo del procedimiento. Métodos: Realizamos un análisis temático de los informes publicados sobre las intervenciones laríngeas más conocidas y realizadas. Tres preguntas guiaron nuestro análisis: ¿Qué procedimientos laringológicos se pueden realizar en el consultorio y cuales sin los más frecuentes?, ¿cuáles son las ventajas de los procedimientos laringológicos fuera del quirófano frente a los que se realizan bajo anestesia general?, ¿por qué no se realizan más procedimientos laringológicos en el consultorio en la mayoría de los países en Latinoamérica? Discusión: A pesar de que se realizan con mayor frecuencia, aún existe controversia sobre si los procedimientos en consultorio deben realizarse con tanta frecuencia debido al riesgo de complicaciones. Además, los procedimientos que se realizan en el consultorio son más populares en algunos países que en otros, aunque sus beneficios han sido bien demostrados. Este artículo describe varios procedimientos en el consultorio, incluida la biopsia, las inyecciones de cuerdas vocales y la cirugía con láser. También se discutieron los factores que podrían contribuir a que los procedimientos en el consultorio se realicen con más frecuencia en algunos países que en otros. Conclusión: Las intervenciones con pacientes despiertos ofrecen numerosos beneficios, incluido un tiempo de procedimiento más corto, costos reducidos y una menor morbilidad para el paciente. Estas ventajas han transformado significativamente el tratamiento de las enfermedades laríngeas en la práctica de la laringología moderna a nivel mundial.

Induced Paresis for Awake Laryngoscopy Procedures.

This article describes an anesthetic technique that induces temporary adductor vocal fold paresis and dense sensory loss of the posterior glottis. This method allows for improved precision of treatment and patient tolerance during awake office-based laryngeal surgery. Laryngoscope, 133:1673-1675, 2023.

Dynamics of lidocaine in topical anesthesia for office-based laryngeal procedures: A pilot study.

OBJECTIVES: To study topical lidocaine for office-based laryngeal procedures recording onset, duration, and subjective experience of topical anesthesia. STUDY DESIGN: Nine healthy volunteers were anesthetized with 4 % lidocaine endoscopically. Laryngeal sensitivity prior to and during anesthesia was recorded until normal sensation returned measured by air-puff sensory testing. Subjective experience of the process was recorded. METHODS: Questionnaires regarding subjective experience were completed prior to, during, and after anesthesia. Laryngeal sensitivity via air-pulse trigger of the laryngeal adductor reflex (LAR) prior to and after 3 mL shower of 4 % lidocaine was recorded at 30 second intervals until the larynx was insensate with no LAR at 10 mmHg. Time to anesthesia was recorded and post-endoscopy questionnaire was given. Upon subjective change in sensation, sensitivity via air-pulse trigger of the LAR was recorded until baseline sensation returned. A post-anesthesia questionnaire recorded the subjective experience. RESULTS: Average time to full anesthesia was 110 s (±31.2). Subjective return of sensation was noted at 10 min (±2.5), however time to return to normal LAR was 22 min (±5.8). Based on three standard deviations, 99.7 % of the population will be anesthetized at 3.4 min, report subjective change at 18.2 min and regain full sensation at 40 min. CONCLUSIONS: Office-based laryngeal procedures should be performed at least 2 min following topical 4 % lidocaine with a window for manipulation of at least 16 min. Oral intake should be delayed for over 45 min to ensure complete return of sensation. The laryngeal shower of lidocaine is subjectively tolerated. LEVEL OF EVIDENCE: 2C Outcomes Research.

30-Day readmission rates, diagnoses, and risk factors following pediatric airway surgery.

BACKGROUND: In the last few decades, the increased survival of premature infants and critically ill children have led to the increased frequency and complexity of pediatric airway procedures. Minimizing readmission rates following these procedures is important to maximize health outcomes and cost effectiveness. This study examines the incidence, reasons, and risk factors for hospital readmissions following pediatric airway surgeries in a large, nationally representative sample. METHODS: Pediatric airway surgeries performed across 22 states in 2014 were identified using data from the Nationwide Readmissions Database (NRD). Airway surgeries were identified and categorized using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes into the following categories: tracheostomy, repair of larynx, repair of trachea, laryngeal excision, tracheal excision, bronchoscopy, laryngoscopy, laryngotracheal diagnostic procedures, other operations on larynx, and other operations on trachea. Univariate and multivariate analyses were used to identify factors significantly correlated with readmissions. RESULTS: 10,289 pediatric airway procedures over 7120 visits were identified. 954 readmissions were identified for an overall readmission rate of 13.4%. 613 of these readmissions were related to the initial procedure, yielding a relevant readmission rate of 8.6%. On univariate analysis, factors that varied significantly with readmission rates included number of diagnoses on record (OR 1.06), number of chronic conditions (OR 1.18), number of procedures (OR 1.07), public insurance status (OR 1.39), bottom quartile median household income in patient zip code (OR 1.29), teaching hospital status (OR 1.60), and chronic perinatal respiratory disease (OR 1.45). On multivariate analysis, significant predictors included number of diagnoses (OR 1.02), number of chronic conditions (OR 1.13), and bottom quartile median household income in patient zip code (OR 1.20). The most common categories for readmission were respiratory distress (36%), infection (24%), and pneumonia (14%). The top overall individual reasons for readmission were stenosis of larynx (7.3%) and pneumonia (5.9%). CONCLUSIONS: Pediatric airway surgeries have relatively high rates of readmission. Strategies to reduce readmissions should involve addressing health disparities and employing a multidisciplinary approach to improve care for medically complex patients.

Technical description of a modified jet ventilation injector for airway laser surgery in neonates and infants: retrospective analysis of 20 cases.

INTRODUCTION: The authors modified an adult jet ventilation injector (Hunsaker Mon-Jet Ventilation Tube(®)) to be able to provide transglottal high-frequency jet ventilation (HFJV) in small children undergoing laryngeal procedures with CO2 laser. METHODS AND MATERIAL: Retrospective review of the anesthetic records of all children younger than 2years undergoing transglottal HFJV for CO2 laser laryngeal procedures using this modified adult injector between 2006 and 2013. RESULTS: Nine children (5 boys, 4 girls) were identified who underwent a total of 20 procedures. Mean age was 7.4 ± 6.9months, and mean weight was 6 ± 2.8 kg. No complications were observed with the use of HFJV or this modified injector. CONCLUSION: In experienced hands, this modified injector ensures excellent visibility and field access to the surgeon as well as adequate ventilation during laryngeal laser surgery in infants.