Office-based laser procedures for the upper aerodigestive tract: emerging technology.

Treatment of laryngotracheobronchial lesions poses a challenge to otolaryngologists. Most tracheobronchial lesions are treated by pulmonologists, who use a flexible bronchoscope and sedation. Otolaryngologists, on the other hand, have typically treated such lesions with a rigid ventilating bronchoscope or with a flexible endoscope passed through a rigid bronchoscope; these procedures must be performed in the operating room with the patient under general anesthesia. Often, the rigid bronchoscope is inadequate to visualize and treat distal lesions.

Laser therapy

Lasers have been a "workhorse" for otolaryngologists. They are used primarily in the operating room with rigid delivery systems. But for office-based procedures, a flexible endoscope equipped with a working channel is required. Successful diagnosis and treatment of esophageal and laryngeal lesions using the newer flexible operating endoscopes have been reported by multiple authors. (1-9)

The carbon dioxide (C[O.sub.2]) laser is the laser of choice for treating the airway, but its usefulness in treating distal tracheal lesions is limited because it cannot be delivered fiberoptically. In general, the delivery of C[O.sub.2] laser energy to the airway requires the use of a microslad.

A variety of fiberoptic carriers can be used to deliver energy from other types of lasers--specifically, potassium-titanyl-phosphate (KTP), argon, and neodymium: yttrium-aluminum-garnet (Nd:YAG) lasers--as well as from pulsed-dye lasers (PDLs) and argon plasma coagulators. Lasers that can be transmitted by a fiberoptic carrier are an effective means of achieving tissue ablation, excision, and hemostasis for those lesions that are beyond the reach of the microslad and the rigid bronchoscope.

The type of lasers used for office procedures varies. For a variety of reasons, our preference is the PDL (PhotoGenicaSV; Cynosure; Chelmsford, Mass.). Recent studies have shown that the 585-nm PDL is sale and effective for treating multiple epithelial lesions, including papillomas. (10-17) The PDL is delivered via a fiberoptic carrier, which is easily passed through an endoscope's operating channel. The PDL penetrates the epithelium and is selectively absorbed by the underlying microvasculature. This disruption results in selective ischemia in the overlying diseased epithelium. (17-19) The PDL's wavelength is optimal for providing hemoglobin absorption while causing minimal collateral damage to normal tissue. These characteristics allow for the aggressive treatment of lesions, including those involving the anterior commissure.

Indications

In our practice, the primary indications for in-office laser therapy are the treatment of recurrent respiratory papillomas, chronic granulomas that have not responded to aggressive antireflux and speech therapy, recurrent leukoplakia, cancer palliation, and sometimes Barrett's esophagus.

Technique

As for the procedure itself, the patient is seated in an examination chair, and the more patent nasal cavity is sprayed with a 1:1 solution of 0.05% oxymetazoline and 4% lidocaine. Cotton pledgets soaked with the same solution are then packed in the nostril. In addition, 1 spray of 20% benzocaine is administered to the oropharynx. When a prolonged procedure is anticipated, we often deliver an additional 3 ml of 4% nebulized lidocaine.

All standard laser safety precautions are rigidly adhered to. These include using a standard laser equipment checklist and providing goggles appropriate for the specific laser wavelength for every individual in the room. The door is kept closed throughout the procedure.

The nasal packing is removed, and a flexible endoscope (VE-1530; Pentax Precision Instrument Corp.; Orangeburg, N.Y.) is lubricated and inserted through the nose. On occasion, a second endoscope is required to grasp and retract a lesion via the contralateral nostril in some patients.

The scope is passed into the nasal cavity. When the larynx is in view, 3 to 6 ml of 1% lidocaine is sprayed onto the larynx, 3 ml onto the tip of the epiglottis, and 3 ml onto the vocal folds. The PDL fiber is then passed through the channel of the endoscope until its tip is visible 1 to 2 cm past the end of the scope (figure 1, A and B). It is critical to ensure that the tip of the laser fiber is visible in order to avoid damage to the endoscope during firing. The tip of the fiber is held close to the lesion (within several millimeters) and fired until the entire lesion blanches white (at 450-[micro]s pulse width; 1 to 2 J per pulse; maximum output of 1 Hz; 1- to 2-mm spot size; 38 to 255 J/[cm.sup.2] fluence) (figure 1, C). This technique has proven to be safe and easily tolerated.

[FIGURE 1 OMITTED]

We have performed in-office laser endoscopies on more than 180 patients at Wake Forest University during the past 2 years, and we have encountered no complications.

Clinical experience

Recently, there has been an increasing interest in the use of the 585-nm PDL in the management of laryngeal and tracheal lesions, including papillomas (figure 2), leukoplakia (figure 3), and hamartomas (figure 4). Dermatologists have been using PDL for years to manage cutaneous vascular lesions, and they have expanded its use to include the treatment of telangiectasias, hypertrophic scars, keloids, and striae. (11-12)

[FIGURES 2-4 OMITTED]

PDL energy penetrates epithelium without causing damage because the energy is selectively absorbed by the underlying microvasculature. (13-17) In view of PDL's epithelium-sparing properties, otolaryngologists have started using it to treat laryngeal lesions. In 2002, Franco et al reported their series of 41 cases of recurrent respiratory papillomatosis of the glottis. (18) Of this group, 26 cases had been treated with PDL alone, and a complete or nearly complete resolution was seen in all 26 cases; there were no complications. A year later, Franco et al reported successful PDL ablation in 21 of 21 cases of vocal fold dysplasia; again, there were no complications. (19) Both studies showed that the PDL is a sale and effective treatment for certain laryngeal pathologies.

We recently reported our initial experience with PDL in the treatment of laryngeal granulomas in 10 patients who failed to respond to traditional management, including voice therapy and aggressive antireflux therapy. (20) Five of the 10 experienced a complete resolution of their lesions, 3 had a partial response, and 2 were unchanged (2 patients had undergone more than one PDL procedure). The average follow-up was 6 months, and there were no complications.

In summary, the use of unsedated PDL treatment via flexible endoscopy provides otolaryngologists with a novel means of effectively diagnosing and treating laryngotracheobronchial lesions without subjecting patients to the risks of general anesthesia. Otolaryngologists who use this procedure will experience significant cost savings while maintaining a high standard of care.

References

(1.) Aviv JE, Takoudes TG, Ma G, Close LG. Office-based esophagoscopy: A preliminary report. Otolaryngol Head Neck Surg 2001;125: 170-5.

(2.) Bach KK, Postma GN, Koufman JA. In-office tracheoesophageal puncture using transnasal esophagoscopy. Laryngoscope 2003;113:173-6.

(3.) Belafsky PC. Office endoscopy for the laryngologist/ bronchoesophagologist. Current Opinion in Otolaryngology--Head and Neck Surgery 2002:10:467-71.

(4.) Belafsky PC, Postma GN, Koufman JA. Replacement of a failed tracheoesophageal puncture prosthesis under direct vision. Ear Nose Throat J 2001;80:862,

(5.) Belafsky PC, Postma GN, Daniel E, Koufman JA. Transnasal esophagoscopy. Otolaryngol Head Neck Surg 2001;125:588-9.

(6.) Cohen JT, Koufman JA, Postma GN. Pulsed-dye laser in the treatment of recurrent respiratory papillomatosis of the larynx. Ear Nose Throat J 2003;82:558.

(7.) Postma GN, Belafsky PC, Koufman JA. Dilation of an esophageal stricture caused by epidermolysis bullosa. Ear Nose Throat J 2002;81:86.

(8.) Postma GN, Bach KK, Belafsky PC, Koufman JA. The role of transnasal esophagoscopy in head and neck oncology. Laryngoscope 2002;112:2242-3.

(9.) Saeian K, Staff DM, Vasilopoulos S, et al. Unsedated transnasal endoscopy accurately detects Barrett's metaplasia and dysplasia. Gastrointest Endosc 2002;56:472-8.

(10.) Valdez TA, McMillan K, Shapshay SM. A new laser treatment for vocal cord papilloma--585-nm pulsed dye. Otolaryngol Head Neck Surg 2001;124:421-5.

(11.) Tan OT, Carney JM, Margolis R, et al. Histologic responses of port-wine stains treated by argon, carbon dioxide, and tunable dye lasers. A preliminary report. Arch Dermatol 1986; 122:1016-22.

(12.) Alster TS. Laser treatment of hypertrophic scars, keloids, and striae. Dermatol Clin 1997;15:419-29.

(13.) Greenwald J, Rosen S, Anderson RR, et al. Comparative histological studies of the tunable dye (at 577 nm) laser and argon laser: The specific vascular effects of the dye laser. J Invest Dermatol 1981;77:305-10.

(14.) Anderson RR, Parrish JA. Selective photothermolysis: Precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524-7.

(15.) Tan OT, Kerschmann R, Parrish JA. The effect of epidermal pigmentation on selective vascular effects of pulsed laser. Lasers Surg Med 1984;4:365-74.

(16.) Anderson RR, Parrish JA. Microvasculature can be selectively damaged using dye lasers: A basic theory and experimental evidence in human skin. Lasers Surg Med 1981;1:263-76.

(17.) Anderson RR, Jaenicke KF, Parrish JA. Mechanisms of selective vascular changes caused by dye lasers. Lasers Surg Med 1983;3:211-5.

(18.) Franco RA, Jr., Zeitels SM, Farinelli WA, Anderson RR. 585-nm pulsed dye laser treatment of glottal papillomatosis. Ann Otol Rhinol Laryngol 2002; 111:486-92.

(19.) Franco RA, Jr., Zeitels SM, Farinelli WA, et al. 585-nm pulsed dye laser treatment of glottal dysplasia. Ann Otol Rhinol Laryngol 2003;112:751-8.

(20.) Cline SB, Koufman JA, Postma GN. Pulsed-dye laser (PDL) treatment of laryngeal granulomas. Presented at the annual meeting of the American Laryngological Association; May 1, 2004; Phoenix.