Laryngeal biopsies are being performed more commonly as in-office procedure. ENT Today asked two otolaryngologists about the ins and outs of performing the procedure in-office.
Timothy Wallace, MD, Assistant Professor of Surgery at Dalhousie University in Halifax, Nova Scotia, spoke about the topic at Otolaryngology Update 2009 in Toronto. He has been performing in-office laryngeal biopsies for five years, and is a supporter of performing a variety of biopsies in this setting.
His first procedure was on a patient who presented with a vocal fold granuloma, but who had an intense fear of the operating room. With his office already situated in a hospital, it wasn’t difficult getting set up to do the procedure in his office.
Indications for In-Office Procedures
The indications he considers as eligible for doing in-office biopsies include retrieval of foreign bodies, the treatment or removal of benign lesions in patients who cannot tolerate general anesthesia or who aren’t good direct laryngoscopy candidates, and biopsy of suspicious lesions.
It is generally comfortable for patients and lacks the stress associated with OR procedures. It is also useful for older patients who have comorbidities or patients with anatomical considerations that preclude surgery. He finds patients need fewer days of voice rest.
When taking someone to the OR for microlaryngoscopy surgery, I have them voice rest for about a week. I ask them to whisper for five days, then gradually shift back to a normal voice. When you do in-office biopsy for small lesions, patients are basically back with a full voice in less than a week, he said.
In-office laryngeal biopsies are also beneficial to patients who require a high number of laryngeal procedures. Less surgery equals less trauma, he said.
There is also the added benefit of doing a procedure in about five minutes that would normally take more than a hour of OR time. Not only is it faster, but the reduced OR time also represents a savings to the health care system.
Which Procedures Can Be Done In-Office?
Many otolarynglogists do angiolytic surgery as an in-office procedure, but Dr. Wallace prefers not to. However, Michael M. Johns III, MD, Assistant Professor of Otolaryngology at Emory University in Atlanta, told ENT Today that he does includes angiolytic surgery on his list of in-office procedures.
I use photoangiolytic therapy using a pulsed KTP laser, he said. However, he had a few tips for general otolaryngologists considering doing this. Spend time observing someone with experience doing the procedure. It is not hard, but it is filled with nuance, which makes the difference between good outcomes and bad ones.
In his experience, Dr. Johns said he quite likes the in-office approach for injections and selected focal papillomas and polyps. However, extensive disease is more easily managed in the OR. Any procedure requiring high levels of precision is better off done under anesthesia.
Spend time observing someone with experience doing the procedure. It is not hard, but it is filled with nuance, which makes the difference between good outcomes and bad ones.
-Michael M. Johns III, MD
Tips for Successful Procedures
Consent and explaining to patients about what to expect are important issues for in-office procedures, Dr. Wallace said. I take extra time and talk about the options-we can do it in the OR, or we can do it here. Most people just want to get it done, he said.
Patient selection is key too. Not everyone who might physically qualify for an in-office procedure will be comfortable there. Some people are nervous or skittish. It’s key to know the patient on whom you are performing a procedure.
As for topical anesthesia, it is important to take the time to do it properly, even if it is tempting to go forward quickly, Dr. Wallace said. Be careful not to overanesthetize, because that can decrease the patient’s ability to handle normal secretions.
The assistant helping with the office-based procedure needs to be trained, but it may be useful to not let the assistant see the monitor while helping. What appears on the monitor can be misleading for someone without much experience, and it is easy for an assistant to overshoot the lesion when opening and closing the forceps.
Dr. Wallace also advises not letting the patient see the monitor-it increases the likelihood they might try to say something or move their vocal fold.
For patients who are on anticoagulants, it is appropriate to reschedule the procedure for at least a week from the point of stopping their anticoagulation medication; otherwise, there is a risk of excessive bleeding. If a patient cannot stop anticoagulation therapy, consider biopsy under anesthesia, Dr. Johns said.
Another contraindication is biopsy of thin superficial lesions of the true vocal fold. This can lead to inadvertent removal of more healthy tissue than desired, leading to scarring and dysphonia, Dr. Johns said.
Patients should preferably not eat two hours before to two hours after the procedure. Sometimes if I see somebody in the clinic and it’s early afternoon, or mid-morning, and I say ‘when did you eat,’ if it’s appropriate, I still do the biopsy if I need to, Dr. Wallace said. Some folks you can do right away; others need to come back later, he said.
It is not difficult to set up the equipment needed to perform in-office biopsies. You need a video camera to add to your flexible fiberoptic laryngoscope, a video monitor to view the video, and, ideally, a recording mechanism. With the advent of add-on disposable sheaths that have a side port, no new special endoscope is required, Dr. Johns said.
Sheaths are a relatively new development that has added to the safety of the procedure by reducing the risk of contamination. Many scopes have a channel through which biopsy forceps are passed, and this channel is difficult to clean, according to Dr. Wallace. But, if you use a sheath, you can just go through the sheath out and clean the scope in a normal way, he said.
When starting out, otolaryngologists should start small and work their way up. I would start with a small lesion just to get a hang on the hand-eye coordination with the biopsy forceps being just off the center of the scope, and work your way to where your comfort level is, Dr. Wallace said. Overall, being able to do this procedure in-office is easier for both the patient and the otolaryngologist.
©2009 The Triological Society