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It was not too many years ago that nearly the only office tool available to the laryngologist was the mirror. In the early 1960s Hopkins introduced the rigid fiberoptic rod-lens system for laryngeal examination. Later that decade the world’s first flexible fiberoptic nasolaryngoscope was used. Other than visual inspection, very little could routinely be accomplished by a laryngologist in the office setting. Improvements continued, but it is just in recent years that office-based laryngology has truly began to blossom.
Vocal fold medialization for paralysis, Botox injection for spasmodic dysphonia and swallowing disorders, laryngeal and esophageal biopsy, laryngeal EMG – these are just a few of the modalities now available in the offices of many laryngologists. These changes have been brought about by improvements in fiberoptic and camera chip technology, better computers, new injectable materials, and an ever-increasing fund of knowledge of the larynx.
Office-based procedures may basically be broken down into procedures involving the larynx, procedures involving the esophagus, and those involving the trachea.
The Larynx
Videostroboscopy is generally considered to be the foundation for much that a laryngologist does. This machine offers clear visualization of the larynx and magnified views of the vocal folds and their cycle. Figure1. This information can be recorded to DVD for careful viewing at a later time.
Vocal fold medialization is typically done for vocal fold paralysis or bowing. In the office this may be accomplished in many patients either transorally or transcervically. A variety of materials may be injected including micronized AlloDerm (Cymetra) and calcium hydroxyapatite (Radiesse).
Laryngeal Botox injections are most frequently performed for spasmodic dysphonia. Though this is not a cure, it does offer significant relief for most with this often-disabling dystonia. As neurolaryngology has progressed, laryngeal EMG has also gained a more prominent position for diagnostic purposes.
In very selected cases lesion removal may be accomplished in the office with appropriate instruments or laser. In most cases, however, this is not a good substitute for the precise dissection under a microscope available in the operating suite.
The Esophagus
Transnasal esophagoscopy is a procedure that is a recent addition to the office. A thorough evaluation of the esophagus and stomach can be performed without the need for any sedation. A typical scope is 5.1mm in diameter with a distal-chip camera and may be passed through the nose after applying topical anesthesia. Appropriate biopsies may be taken through the working channel of the scope. Flexible evaluation of swallowing with or without sensory testing is also helpful to the laryngologist and speech pathologist when evaluating dysphagia.
The Trachea
With appropriate topical anesthesia, the trachea can also be clearly examined with a flexible fiberoptic scope. Fewer office-based procedures are currently available for the trachea, though recent technology now allows for a CO2 laser to be passed through a flexible cannula. This procedure is now being used in the operating room to treat tracheal stenosis and for removal of lesions. This will hopefully aid in treatment of these difficult situations. Figure 4.
Summary
Aside from economic considerations, in-office procedures can benefit many patients. Certainly they are not appropriate for all patients in every instance and patients must be evaluated individually. These procedures will continue to grow and play an increasing role in the management of the upper aerodigestive tract.
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