HSC Section 6 Nov2016 Green Book

Fig. 1. Flow of office biopsy patients. (Operating room biopsy diagnoses are listed in the last row). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Traditionally, patients warranting direct microlar- yngoscopy after office biopsy are those with limited tis- sue obtained during attempted office biopsy, a concern regarding false-negative office biopsy results, a require- ment for disease volume reduction to avoid respiratory or swallowing impairment, and a need for excision of the lesion to improve the voice. Other advantages of direct microlaryngoscopy include a more detailed examination of the extent of a tumor, more accurate biopsy capabil- ities, and the option for definitive treatment by excision for many lesions. Despite the popularity of office biopsy, there is a paucity of data in the literature evaluating the accuracy compared to histologic diagnosis at operation. The goals of this study are to determine the accuracy of office biop- sies when compared to direct microlaryngoscopy and to evaluate its role and diagnostic value. MATERIALS AND METHODS A retrospective medical chart review was performed from January 1, 2010, to July 31, 2013, after receiving approval from the Institutional Review Board Human Subjects Committee. This review identified 261 patients in the clinical practices of the authors who underwent office biopsy (current procedural terminology code 31576) for laryngeal and pharyngeal lesions. Patients’ records were then reviewed to determine those who underwent direct microlaryngoscopy with biopsy. Patients who had resolution of the lesion following biopsy, surveillance of a previously histologically proven benign diagno- sis, and a definitive diagnosis of cancer who proceeded to non- surgical definitive treatment were excluded from the study. We also excluded current anticoagulation, anterior commissure lesions, submucosal lesions, and anatomically obstructive pathology. Patients with brush biopsy alone were also excluded.

The pathology reports were reviewed for consistency between office and surgical specimens and compared to clinical diagno- ses. The flow of the patients is summarized in Figure 1. Office biopsies were performed using distal chip video endo- scopes (ENT-5000, Vision Sciences, Inc. or VNL-1570STK, KayPENTAX Montvale, NJ) in conjunction with a 2-mm channel endosheath and 1.8-mm nonserrated cup biopsy forceps. The nasal cavity was anesthetized with aerosolized 4% lidocaine with epinephrine 1:100,000 or 4% lidocaine with phenylephrine hydro- chloride. The channel-sheathed video endoscope was then passed transnasally into the laryngopharynx. Topical laryngopharyngeal anesthesia was achieved by delivering 0.5 cc of plain 4% lido- caine to the laryngeal surface of the epiglottis. Once supraglottic anesthesia was achieved, 1 to 2 cc of plain 4% lidocaine was then delivered topically to the glottis. The 1.8-mm biopsy forcep was then passed under videoendoscopic guidance and biopsies were performed. Direct microlaryngoscopy with biopsy was performed under general anesthesia, and lesions were visualized with a zero- degree telescope and binocular microscope. Lesions were excised or sampled for pathologic evaluation using phonosurgical instru- ments. The procedures included a submucosal dissection in order to obtain epithelial basement membrane in the specimen. Office biopsy results were divided into clinically relevant groups that would normally used to direct patient care algo- rithms. For example, mild to moderate dysplasia was separated from severe dysplasia and carcinoma in situ (CIS)/squamous cell carcinoma (SCC). For statistical analysis, we considered three groups: 1) malignant and premalignant (SCC, CIS, and severe dysplasia); 2) lesions of uncertain significance (mild– moderate dysplasia and hyperkeratosis); and 3) benign lesions. Patients who were noted to have a dual diagnosis on histology (e.g., inflammation with mild dysplasia) were analyzed within the group that would direct their final treatment. To test interrater reliability, we utilized Kendall’s coeffi- cient of concordance for the numerically coded ordinal responses

Laryngoscope 125: April 2015

Richards et al.: Office-Based Biopsy for Laryngopharyngeal Lesions

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