HSC Section 6 Nov2016 Green Book

Otolaryngology–Head and Neck Surgery 152(6)

lesions, with the latter demonstrating preserved or improved mucosal wave and glottic closure after treatment. 14,15 Pitman et al evaluated the effect of office-based KTP laser treatment in 7 patients with Reinke’s edema and found sig- nificant improvement in subjective measures for voice qual- ity as well as a trend toward improvement in objective measures. 13 Although these studies provided important initial support for the use of office-based photoangiolytic laser therapy in the management of Reinke’s edema, they are limited by a modest sample size and measurement of few objective voice para- meters. As such, larger studies addressing the safety, tolerabil- ity, and voice outcomes for this approach are necessary. We report on 19 patients who underwent office-based photoangio- lytic laser treatment of Reinke’s edema. We hypothesized that no complications would occur, patients would tolerate the pro- cedure, Voice Handicap Index would decrease, and objective voice parameters would move toward the normal ranges. Specifically, we hypothesized that posttreatment assessment would show increased fundamental frequency range, decreased jitter, decreased phonation threshold pressure, and increased maximum phonation time (MPT). Approval for this study was obtained from the University of Wisconsin Health Sciences Institutional Review Board. The study was designed as a retrospective case series of patients treated at the University of Wisconsin–Madison. Patient data were obtained from the University of Wisconsin–Madison Voice and Swallow Outcomes Database. Appropriate patients were identified by the University of Wisconsin–Madison Voice and Swallow Outcomes database manager by cross-matching diagnosis with the existence of a procedure, and data extraction was performed by a separate researcher. All patients presented to the University of Wisconsin Hospital and Clinics between January 2007 and November 2013 and underwent voice analysis by a speech-language pathologist, as well as evaluation and treatment by an otolaryngologist. All patients with documented Reinke’s edema who underwent at least 1 office-based treatment were considered for inclusion. Patients were excluded if they were \ 18 years old, had a history of laryngeal malignancy, had a history of a neurolaryngologic disorder (eg, cerebrovascular accident, amyotrophic lateral sclerosis, vocal tremor, or recurrent laryngeal or superior laryngeal nerve injury), had a history of airway stenosis, or were unable to provide consent. Treatment All procedures were performed in a clinic setting without seda- tion. Patients are positioned sitting upright. Local nasal anesthesia is obtained by placing 4% lidocaine and 0.05% oxymetazoline-soaked sponges in the nasal cavities. A flexible endoscope is passed through the nasal cavity for indirect visua- lization of the endolarynx. Laryngeal anesthesia is obtained by instilling 3 aliquots of 0.5 mL of 4% lidocaine through the working channel of the endoscope during sustained phonation Materials and Methods Subjects

Figure 1. Endoscopic view of glottis immediately before (A) and immediately after (B) treatment. Note the superficial blanching without reduction in tissue mass immediately following application of laser energy.

(the ‘‘laryngeal gargle’’). The laser fiber is passed through the working channel and advanced until the tip of the fiber is visualized. Laser energy is then applied to the involved tissues. Of note, tissue ablation is not desired during these procedures; rather, enough energy is applied to blanch the superficial tis- sues ( Figure 1 ). Importantly, no immediate reduction is tissue size is desired. Twelve procedures were performed using the KTP laser, and 13 were performed using the PDL. Experimental Data Patient demographics, chief complaint, and social history were collected. Endoscopic findings and physician impres- sion were recorded to ensure diagnosis, as well as to docu- ment unilateral versus bilateral involvement. Treatment of laryngopharyngeal reflux disease was also documented. Reported complications and patient tolerance data were also collected by extracting physician documentation from the University of Wisconsin–Madison Voice and Swallow Outcomes database. This included whether a procedure was truncated, as well as the number of procedures performed for each patient and whether operative interventions were ultimately required. Minor complications included nasal or pharyngeal pain, minor nosebleed, and vasovagal events. Major complications included need for emergent airway intervention, hospitalization or presentation to the emer- gency department after treatment, airway bleeding, airway stenosis, reported myocardial infarction or cerebrovascular accident, and extralaryngeal tissue injury. Patients were requested to report complications at follow-up visits; how- ever, our data set did not allow for standardized follow-up of all possible complications. Objective voice measures were obtained as part of a stan- dard comprehensive voice assessment. Aerodynamic para- meters included MPT, mean airflow rate, laryngeal resistance, phonation threshold pressure, and mean peak air pressure. Aerodynamic parameters were measured using the Phonatory Aerodynamic System (model 6600, KayPENTAX, Montvale, New Jersey); the device was calibrated prior to each use according to manufacturer specifications. For MPT, patients produced a sustained /a/ at a modal pitch for as long as possible; this was repeated 3 times, and the longest trial taken as the

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