State-of-the-Art Techniques Are Tempting, but May Not Improve Care

The patient, according to Dr. Woo, did undergo a work-up by a gastroenterologist but had a negative study. The only interventional change, at that point, was switching to voice therapy.

I’m a laryngeal EMG enthusiast, I think it really does help and offers a slightly more refined level of care. But I’m not a zealot. – Lucian Sulica, MD

Not all these cases are granulomas, and the word granuloma is often to use to describe lesions that actually have differing histology. There are inflammatory lesions with fibroblasts, and collagen fibers, and leukocytes, and maybe some ulceration. And capillary proliferation can make some candidates for management with PDL, said Dr. Sataloff.

Panelists agreed certain anatomic causes can place a patient at risk. Some cases may benefit from judicious use of botulinum toxin, a treatment that is considered state-of-the-art.

Conflicting Advice for Managing Respiratory Papillomatosis

The final case presented by Dr. Woo was of a 58-year old male with adult onset recurrent respiratory papillomatosis (RRP) who presented in 2002, had a recurrence rate of every four months, and underwent surgery for severe dysphonia. He had respiratory papilloma with mild dysplasia.

Physicians at the conference were divided between microdebridement and microlaryngoscopy as the standard of care. The key thing is to maintain function, said Dr. Shapshay. I don’t think it matters if you use the microdebrider or laser, whatever you’re most accustomed to, he said.

Dr. Woo reported he performed microlaryngoscopy followed by office injections of cidofovir. The patient stayed free of disease for close to two years, then presented with a subglottic papilloma. This was treated with laser and more cidofovir which had good results. A later recurrence was then debrided with a wave guide CO₂ laser and more cidofovir.

Have Caution with Lasers

CO₂ lasers should be used with caution on vocal folds, said Dr. Franco. Repeat use can lead to stiffness and scarring.

This particular condition is an epithelial disease, and lasers can go too deep. The only way you get deep papilloma is if you implant it. If you’re not really precise with the laser, and you make little potholes into the muscle on the superior surface of the vocal fold, it’s like planting tulips, Dr. Sataloff said.

Panelists agreed that laser technique is key, but there are risks with microdebriders too.

If you use the microdebrider you have to be sure not to suck up the cord and take off more than you want to… Whatever you use here, use it cautiously to debulk this disease down to a reasonable level, said Dr. Shapshay.