In-Office Laryngeal Procedures in Awake Patients a Viable, and Often Preferable, Option

The vocal folds are privileged organs, meaning that early malignant lesions very seldom metastasize to lymph nodes in the neck, added Dr. Johns. It’s protected from lymphatic spread, which allows for treating lesions in a graded fashion, he explained. We can treat early carcinoma in stages to slowly get rid of the cancer.

The effectiveness of photoangiolytic laser therapy for carcinoma in situ and early invasive laryngeal cancer needs to be compared to radiotherapy, and data are forthcoming, said Dr. Johns.

Carcinoma in situ has been treated in the office for about seven years, noted Dr. Zeitels. And we have had great success with microlaryngoscopic angiolytic laser treatment of early glottic cancer, he said, citing a study.10

However, reliable office-based flexible laryngoscopic treatment of glottic cancer with optimal voice results is unlikely due to limitations of magnification, flexible laryngoscopic tissue handling and dissection, tangential exposure of the curving glottis, and a moving microcirculatory tissue target, he said.

Laser Cost Considerations

In addition to their proven efficacy, other benefits of in-office laser procedures are that they are faster, safer, and less expensive than operating room procedures requiring full anesthesia, said Dr. Postma, citing a study of which he was one of the authors.11

He and his colleagues evaluated the cost savings of office-based PDL treatment compared with operating room-based laryngoscopy under general anesthesia for the treatment of recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. The researchers found that in-office PDL saved more than $5000 per case; however, they noted that current reimbursement rates do not cover the cost of the laser procedure.

The biggest issue for a lot of us is reimbursement, said Dr. Postma. Laser technology is way ahead of the reimbursement system.

Indirect costs, such as lost workdays due to undergoing full anesthesia and surgery, also need to be considered, said Dr. Postma. With in-office procedures, patients often go back to work right away, he said.

Injections

In-office injections are another common and effective in-office procedure for treating a number of laryngeal disorders in awake patients. About 90 percent of my patients who need injections are awake, said Dr. Klein.

Otolaryngologists should learn to perform awake injections for the benefit of the patient, said Dr. Johns. Patients with paralyzed vocal folds can often benefit from injection, especially if they aren’t suitable for general anesthesia, such as those who have undergone cardiac thoracic surgery, he explained. Injections get these individuals out of the hospital faster, gets them eating and swallowing faster, and improves their quality of life, he said.