Voice Articles
Office-Based Laryngology
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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