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Unformatted text preview: Unsedated Office­Based Laryngeal Unsedated Office­Based Laryngeal Surgery Murtaza Kharodawala, MD Michael Underbrink, MD University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation April 16, 2008 Overview Overview • • • • • • • • Historical Perspective Patient Selection Topical Anesthesia Patient Tolerance Specific UOLS Complications Cost Analysis Advantages History History • • 1807: Bozzini develops indirect mirror laryngoscopy 1852: Green describes first direct laryngoscopy and visually controlled endoscopic resection of laryngeal neoplasm History History • c1872: Jacob Solis Cohen • Performed office­ based mirror­guided surgery at his home in Philadelphia •Zeitels et al. Office­based 532 nm pulsed­KTP laser treatment of glottal papillomatosis and dysplasia. Ann Otol Rhinol Laryngol 2006; 115:679­685. History History • • 1884: Koller introduces cocaine­ induced mucosal anesthesia 1884: Koller and Jelinek give a live demonstration of the use of cocaine as local anesthetic for mirror­guided endolaryngeal surgery. History History • 1897: Kirstein performs in­office direct laryngoscopy with an assistant using an electric headlight •Zeitels et al. Office­based 532 nm pulsed­KTP laser treatment of glottal papillomatosis and dysplasia. Ann Otol Rhinol Laryngol 2006; 115:679­685. History History • 1900s: Chevalier Jackson introduces the rigid esophagoscopy and perfects supine direct laryngoscopy •Zeitels et al. Office­based 532 nm pulsed­KTP laser treatment of glottal papillomatosis and dysplasia. Ann Otol Rhinol Laryngol 2006; 115:679­685. History History • 1960s: Operating microscope utilized for laryngeal surgery • • • • • Rigid laryngoscopes Microlaryngeal instruments Optical telescopes CO2 laser with micromanipulator General anesthesia (jet ventilation) History History • • 1970s: Flexible fiberoptic scopes allow examination of awake, unsedated patients in the office 1999: Distal­chip camera for flexible aerodigestive tract endoscopy (TNE, 5.1 mm diameter) • • • Brilliant illumination High resolution Working channel (2 mm) • • • • Air insufflation Suction Flexible foceps and laser fibers • 4.1 mm diameter flexible laryngoscope Integration of lasers Slide­On Sheath Slide­On Sheath • Vision Sciences • Fits over standard flexible nasolaryngoscope •Amin et al. Office evaluation of the tracheobronchial tree. Ear Nose Thr 2004; 83:10­12. Transoral Transoral • Sataloff set of office­based instruments •Simpson et al. Office­based procedures for the voice. Ear Nose Thr J 2004; 83:6­9) Patient Selection Patient Selection • Informed Consent • • • • • • Patients must be cooperative Gag reflex Anxiety Pain tolerance Comorbidities • Cardiopulmonary disease • Movement disorders • Anticoagulation Anatomy • Nasal patency • Adequate oral opening (at least 2 cm interincisor distance) for transoral instrumentation Topical Anesthesia Topical Anesthesia • Sensory innervation to larynx, trachea and esophagus is from vagus nerve • Internal branch of SLN innervates glottic and supraglottic structures • RLN innervates subglottis • Trachea and esophagus are directly innervated from branches of vagus nerve distally Topical Anesthesia Topical Anesthesia • Simpson et al. 2004 (EBM D) Topical anesthesia of the airway and esophagus Step 1 • Step 2 • • • • • Topical 2% oxymetazoline/tetracaine spray into nasal cavities • Topical benzocaine/tetracaine spray on the palate and posterior pharynx Step 3 Drip 3­5 mL of 4% lidocaine onto the tongue base and larynx under fiberoptic guidance • Several 0.5­1 mL aliquots • “Laryngeal gargle” NPO for 45­60 minute following procedure Simpson 2004 Simpson 2004 •Simpson et al. Topical anesthesia of the airway and esophagus. Ear Nose Thr J 2004; 83:2­5. Topical Anesthesia Topical Anesthesia • • • • • • Zeitels et al. 2004 (EBM C­4), MEEI Office­based treatment of glottal dysplasia and papillomatosis with the 585­nm pulsed dye laser and local anesthesia Topical nebulized solution of 2% lidocaine and 0.125% phenylephrine intranasally Nebulized 4% lidocaine to lower pharynx and larynx +/­ Direct application of lidocaine • Through working channel of scope • Direct application with angled rigid cotton holder +/­ Local nerve block Topical Anesthesia Topical Anesthesia • Adverse Reactions are very rare • • • Thorough history Must adhere to maximal dosing guidelines Systemic toxicity • • • Cardiovascular depression/cardiac arrest Convulsions Respiratory arrest • Toxicity may be potentiated in patients with renal, hepatic, and cardiac conditions • Allergic reactions to lidocaine are uncommon • • • Urticaria and rash Anaphylaxis is rare Methemoglobinemia, “chocolate cyanosis” • 1­2 mg/kg intravenous methylene blue • Reactions may be more prevalent with topical esters, tetracaine and benzocaine • Vasovagal syncope • Prodromal nausea, diaphoresis, lightheadedness, parasthesias Patient Tolerance Patient Tolerance • Rees et al. 2006 (EBM C­4), WFU Patient tolerance of in­office pulsed dye laser treatments to the upper aerodigestive tract 328 office­based procedures in 131 patients • 5.1 mm transnasal esophagoscope • Topical anesthesia • • • 54 patients had a previous procedure for UADT disease under GA • TNE KayPentax Model VE­1530 • • • • • 1:1 solution of 0.05% oxymetazoline and 4% lidocaine spray intranasally Cotton pledgets soaked in same solution packed for 5­10 min +/­ 20% benzocaine spray to oropharynx, Tessalon perles 4% lidocaine spray (4­8 mL) to lesion through working channel PDL (Photogenica SV) used to treat lesion until it blanched white Rees 2006 Rees 2006 •Rees et al. Patient tolerance of in­office pulsed dye laser treatments to the upper aerodigestive tract. Otolaryngol Head Neck Surg 2006; 134:1023­1027. Rees 2006 Rees 2006 •Rees et al. Patient tolerance of in­office pulsed dye laser treatments to the upper aerodigestive tract. Otolaryngol Head Neck Surg 2006; 134:1023­1027. Patient Tolerance Patient Tolerance •Rees et al. Patient tolerance of in­office pulsed dye laser treatments to the upper aerodigestive tract. Otolaryngol Head Neck Surg 2006; 134:1023­1027. Vocal Fold Injection Vocal Fold Injection • • • Simpson et al. 2004 (EBM D) Office­based procedures for the voice Augmentation injection laryngoplasty • Unilateral paralysis • Vocal fold bowing • • • Muscular atrophy Paresis presbylaryngis • Transoral approach • Injection into substance of thyroarytenoid muscle at the level of the free edge of the vocal fold • • Avoid injection into SLP Posterior VF injection followed by mid­VF Simpson 2004 Simpson 2004 •Simpson et al. Office­based procedures for the voice. Ear Nose Thr J 2004; 83:6­9) Simpson 2004 Simpson 2004 • Vocal fold injection with collagen •Simpson et al. Office­based procedures for the voice. Ear Nose Thr J 2004; 83:6­9) Scar Reduction Scar Reduction • • • • Woo P. 2006 UOLS may be used following operative resection of tumors to address postoperative synechiae Transoral instrumentation with telescope or transnasal flexible scope may be used Mitomycin topical application is amenable in clinic setting • Mitomycin 0.4 mg/mL, 2 mL Scar Reduction Scar Reduction •Woo P. Office­based laryneal procedures. Otolaryngol Clin N Am 2006; 39:111­133. Steroid Injection Steroid Injection • • Woo P. 2006 Advantages • • • • • • • • • Reduce granulation and promote primary healing Reduce hypertrophic scar and soften scar Reduce acute and chronic inflammation Depo­Medrol 40 mg/mL, 0.1­0.2 mL Kenelog 40, Kenelog 80 Injection around lesion including arytenoid near the vocal process followed by removal of exophytic granulation Treatment for recurrent granulomas of the vocal process, fibrovascular lesions, phonotrauma Hypertrophic scar: unilateral stiffness with hyperemia Vocal scar: fusiform polyps, acute hemorrhagic polyps • • • • Injection into vocal ligament and flap of mucosa superficial to vocal ligament Injection into SLP Vocal fold edge edema, vocal fold nodules, and polypoid corditis May be repeated in 6­12 wk intervals Steroid Injection Steroid Injection •Woo P. Office­based laryneal procedures. Otolaryngol Clin N Am 2006; 39:111­133. • Lasers Lasers PDL • • • 585 nm wavelength Angiolytic Preferentially absorbed by hemoglobin • Microvascular specific property • • • • • 2,000 nm wavelength Intermediate properties between PDL and CO2 Greater thermal penetration than PDL • • • • 10,500 nm wavelength, colorless Absorbed by water Soft tissue cellular vaporization • • • • Relative tissue­sparing (SLP_ 532 nm wavelength Angiolytic and hemostatic Preferentially absorbed by oxyhemoglobin CO2 Thulium:YAG Pulsed KTP • • Greater affinity than PDL ALWAYS PRACTICE LASER SAFETY! PDL PDL • Zeitels et al. 2004 (EBM C­4), MEEI Office­based treatment of glottal dysplasia and papillomatosis with the 585­nm pulsed dye laser and local anesthesia 51 patients underwent 82 procedures All had previously undergone microlaryngeal biopsies Pentax FNL­15RP3: 5 mm diam, 2 mm working channel • Pentax VNL­153OT: 5.1 mm diam, 2 mm working channel • • • • • • Fiberoptic scope • Distal chip Photogenica V 585­nm PDL • • • • • 450 microsec pulse width 2.0 J per pulse max output 2 Hz repitition rate 0.6 mm fiber through 1 mm aluminum channel 1 – 2 mm spot size Zeitels 2004 Zeitels 2004 • Procedure • Anesthetic: topical or block • Silica fiber placed through working channel until it was flush with distal lumen • Scope then passed through nose until larynx and disease visualized • Fiber then advanced several mm until it was in visual field • • Distance to tissue about 2 mm Direct contact for medial surface and anterior commissure lesions Zeitels et al. Office­based treatment of glottal dysplasia and papillomatosis with the 585­nm pulsed dye laser and local anesthesia. Ann Otol Rhinol Laryngol 2004; 113:265­276. Zeitels 2004 Zeitels 2004 • Entire lesion and approx 5 mm around visible margins were treated (600­800 mJ/pulse) Zeitels et al. Office­based treatment of glottal dysplasia and papillomatosis with the 585­nm pulsed dye laser and local anesthesia. Ann Otol Rhinol Laryngol 2004; 113:265­276. Zeitels 2004 Zeitels 2004 • Treatment endpoints • Photocoagulation of sublesional microcirculation seen as intraluminal thrombus formation with darkened vessels • Visible blanching • Separation of epithelial lesion Zeitels et al. Office­based treatment of glottal dysplasia and papillomatosis with the 585­nm pulsed dye laser and local anesthesia. Ann Otol Rhinol Laryngol 2004; 113:265­276. Zeitels 2004 Zeitels 2004 • Disease regression • Assessment at 4­8 weeks posttreatment • 4 level grading scheme based on degree of resolution • • • • • 0% ­ 50% 51% ­ 70% 71% ­ 99% 100% Favorable outcome defined as greater than 50% resolution • Self­assessment of vocal quality by patients • Better, same, slightly worse, substantially worse Zeitels 2004 Zeitels 2004 Zeitels et al. Office­based treatment of glottal dysplasia and papillomatosis with the 585­nm pulsed dye laser and local anesthesia. Ann Otol Rhinol Laryngol 2004; 113:265­276. Zeitels 2004 Zeitels 2004 Zeitels et al. Office­based treatment of glottal dysplasia and papillomatosis with the 585­nm pulsed dye laser and local anesthesia. Ann Otol Rhinol Laryngol 2004; 113:265­276. Zeitels 2004 Zeitels 2004 • Results • 77 of 82 cases were successful • 5 cases aborted • • • • • • • • 2 with inadequate exposure 3 with discomfort 68/77 (88%) had favorable outcome 12% had 25­50% regression 34/77 had an improved voice 39/77 had no change in voice 4/77 had slightly worsened voice 2 mild episodes of epistaxis managed with pressure Zeitels 2004 Zeitels 2004 • PDL does not alter the natural history of recurrance for RRP and dysplasia • • • Biopsy Separation between epithelial basement membrane and underlying SLP without injury to SLP Influences on disease resolution • Photothermal and/or photoacoustic denaturing of BM linking proteins • • • • • • • Tissue ablation when fiber is in extremely close proximity or contacts tissue Moving target Unable to obtain a specimen Difficult to quantify energy delivery and real­time tissue effects Tangential vectors for visualization and laser delivery cannot be overcome with retraction Limitations Contraindications • • • • Bulky papillomatosis Difficult to reach locations: ventricle Surgical fee for UOLS 50%that of OR­based procedure Hospitalization/clinical fee 10% of typical fees PDL PDL • Franco R 2007 (EMB D), MEEI In office laryngeal surgery with the 585­nm pulsed dye laser Non­bulky RRP • Leukoplakia • • • • Non­direct contact • Safe to use at anterior commissure • Safe to use at anterior commissure • Cleavage plane facilitated removal of superficial epithelium while minimizing injury to SLP Recalcitrant keratosis using PDL­activated topical aminolevulinic acid • Aminolevulinic acid is converted to porphyrin IX which has a peak absorption at 585 nm Franco 2007 Franco 2007 • Cleavage plane • Basement membrane is left intact and intraepithelial desmosome junctions are preferentially destroyed • SLP is kept protected •Franco RA. In office laryngeal surgery with the 585­nm pulsed dye laser. Curr Opin Otolaryngol Head Neck Surg 2007; 15:387­393. Thulium Thulium • • • Zeitels et al. 2006 (EBM C­4), MEEI Office­based and microlaryngeal application of a fiber­based thulium laser 74 cases • 32 with topical anesthesia through flexible scope • • • • • • Papillomas 20 Microinvasive Ca 6 Benign supraglottic lesions 3 Edema 2 Granuloma 1 42 with microlaryngeal surgery in OR • 27 partial laryngeal resections • • • • • • • • SCCA Amyloid Sarcoma Hemangioma Papillomas Reinke edema Thulium 2,012 nm laser (Revolix, LISA) Pentax VNL­1530T scope, 5.1 mm diameter, 2 mm working channel Zeitels 2006 Zeitels 2006 • • • • Thulium was designed to function similarly to CO2 laser, however, with delivery possible through a glass fiber (0.365 – 0.55 mm) Diode­pumped solid­state laser with a thulium­ doped yttrium­aluminum­garnet laser rod Wavelength 2,013 Chromophore is water •Zeitels et al. Office­based and microlaryngeal applications of a fiber­based thulium laser. Ann Otol Rhinol Laryngol 2006; 115:891­896. Zeitels 2006 • RRP •Zeitels et al. Office­based and microlaryngeal applications of a fiber­based thulium laser. Ann Otol Rhinol Laryngol 2006; 115:891­896. Zeitels 2006 • • • • Thulium laser was effective at tissue ablation when distance to tissue was increased to several mm in noncontact mode • In contact mode, thulium provided hemostatic cutting • Power less than 4 W was less effective cutting than over 4 W Hemostatic property judged to be better than CO2 laser • Thermal damage zone adjacent to cut was greater with thulium Thulium allowed some tangential cutting with fiber Thulium laser was deemed more effective and easier to use than CO2 during extensive endolaryngeal resections Laser Surgery Laser Surgery • • Koufman et al. 2007 (EBM C­4), WFU Office­based laryngeal surgery: a review of 443 cases using three wavelengths • • • • 5.1 mm Pentax TNE with 2.0 mm working channel 406 pulsed dye laser 10 CO2 laser 27 thulium: yttrium­aluminum­garnet laser Koufman 2007 Koufman 2007 • 406 procedures with PDL in 151 patients •Koufman et al. Office­based laryngeal laser surgery: a review of 443 cases using three wavelengths. Otolaryngol Head Neck Surg 2007; 137:146­151. Koufman 2007 Koufman 2007 • RRP • • • • • • • 3.6 procedures (1­15 procedures/pt) 1.0 J power (0.5 – 2.0 J) Topical anesthesia 61% Nebulized lidocaine 37% Nerve block 1.4% 15% underwent subsequent OR procedure F/U 17 mo (1­45 mo) Koufman 2007 Koufman 2007 • Glottal leukoplakia and dysplasia • • • • • • • 3.2 procedures (1­9) All had biopsies of dysplasia prior to UOLS 1.0 J power (0.75 – 1.5 J) Nebulized lidocaine 76% Topical lidocaine 24% F/U 16 mo (3 – 44 mo) 1 patient went on to develop vocal fold carcinoma Leukoplakia Leukoplakia •Postma et al. Office­based laser procedures for the upper aerodigestive tract: Emerging technology. Ear Nose Thr J 2004; 83(S2):22­24. Koufman 2007 Koufman 2007 • Granulomas • • • • • • • 1.6 procedures (1 – 5) All treated with antireflux therapy 1.0 J power (0.75 – 1.7 J) Topical anesthesia 72.5% Nebulized lidocaine 27.5% F/U 12 mo (1 – 30 mo) 1 had laser tip break off but was retrieved Koufman 2007 Koufman 2007 • Reinke edema • 1.8 procedures (1 – 3) • All were counseled to stop smoking and placed on antireflux therapy • Topical anesthesia only • 1.0 J power (0.75 – 1.5 J) • F/U 7.3 mo (1 – 13 mo) • 2 had vocal fold hemorrhages that resolved Koufman 2007 Koufman 2007 •Koufman et al. Office­based laryngeal laser surgery: a review of 443 cases using three wavelengths. Otolaryngol Head Neck Surg 2007; 137:146­151. Koufman 2007 Koufman 2007 • Flexible CO2 laser (through hollow bore glass filament) • 2 patients had 10 procedures • • • • • Severe RRP Both had previous PDL treatments Hollow­core photonic bandgap optical fibers 7 and 3 procedures 8 – 17 W power Koufman 2007 Koufman 2007 • Thulium: YAG laser (LISA) • 27 procedures in 17 patients • F/U 5.6 mo •Koufman et al. Office­based laryngeal laser surgery: a review of 443 cases using three wavelengths. Otolaryngol Head Neck Surg 2007; 137:146­151. Koufman 2007 Koufman 2007 • 10 RRP patients followed long term > 5y • Interval between procedures was shorter for UOLS • • • • 3.5 mo UOLS vs. 6.5 mo OR Returned sooner for vocal changes Less time lost from work Less expenses Koufman 2007 Koufman 2007 • Bulky nonvascular lesions: CO2 or Tm:YAG laser • Exophytic papilloma • Supraglottic cysts • If hemostasis is a concern: Tm:YAG • Large inflammed vocal process granulomas • • Leukoplakia, Reinke edema, non­bulky papillomas and anterior commissue papillomas: PDL Complication rate 0.9% • • • Vasovagal episode (1) Vocal fold hemorrhages (2) PDL fiber tip breakage (1) Pulsed KTP Pulsed KTP • • • • • • • Zeitels et al. 2007 (EBM D), MEEI Office­based laryngeal laser surgery with the 532­nm pulsed­ potassium­titanyl­phosphate laser Pulsing the laser takes advantage of the fact that energy delivery time is shorter than the thermal relaxation time of tissue • Minimizes collateral extravascular thermal soft tissue trauma compared to continuous mode Pentax VNL­1530T fiberoptic scope, 5 mm diameter, 2 mm working channel Laserscope 532 nm pulsed KTP laser Topical anesthesia Like the PDL, real­time effects are not as easily detected as CO2 laser Zeitels 2007 Zeitels 2007 •Zeitels et al. Office­based laryngeal laser surgery with the 532­nm pulsed­ potassium­titanyl­phosphate laser. Curr Opin Otolaryngol Head Neck Surg 2007; 15:394­400. Zeitels 2007 Zeitels 2007 • PDL 585 nm • Very expensive • Required frequent repair (not solid­state laser) • Short pulse­width that could not be adjusted past 0.5 ms • • Contributes to vessel wal l rupture Blood on epithelial surface inadvertently absorbs energy • PDL on hemorrhagic polyp will destabilize overlying normal epithelium • Treatment of varices and ectasias is susceptible to extravasation of blood into SLP due to vessel wall rupture • Pulsed KTP 532 nm • • • Less expensive More reliable (solid­state laser) Pulse­width 10 – 50 ms (15 ms) • • Better coagulation property as laser energy delivered over a time period is 30 times longer than PDL Minimizes photothermal injury to SLP • More strongly absorbed by oxyhemoglobin • Smaller glass fiber (0.3­0.4 mm diameter) compared to PDL (0.6 mm) • Greater working channel area for suctioning • Does not require recalibration if power setting is changed Zeitels 2007 Zeitels 2007 •Zeitels et al. Office­based laryngeal laser surgery with the 532­nm pulsed­ potassium­titanyl­phosphate laser. Curr Opin Otolaryngol Head Neck Surg 2007; 15:394­400. Zeitels 2007 Zeitels 2007 • Limitations of pulsed­KTP Unable to obtain biopsy with laser Moving target Office­based operations are generally less effective as compared with OR procedures • Threshold for office­based intervention is decreased commensurate with decreased morbidity and improved patient tolerance • • • • • Routine use of UOLS not supported for management of polyps, ectasias, and varices unless GA is contraindicated • Multiple staged procedures required in office­based setting compared to typically single operation in OR Mass lesions arising in SLP should be resected with bimanual phonomicrosurgical techniques Complications Complications • Postma et al. 2005 (EBM C­4), WFU • Transnasal esophagoscopy: revisited (over 700 consecutive cases) • • 5.1 mm transnasal esophagoscope • • 611 patients TNE KayPentax Model VE­1530 Topical anesthesia • • 1:1 0.05% oxymetazolineand 4% lidocaine spray 20% benzocaine spray • • • • 3% cases aborted due to tight nasal vault 2 cases aborted for mild vasovagal reactions No cases of epistaxis required packing • • • • • Epistaxis Vasovagal episodes Anesthetic toxicity Pneumothorax Breakage of fiber tip Potential complications Why The Office? Why The Office? • Patients • • • • • • • • • • • • • • • Convenient Comfort Less invasive, only topical anesthesia Less time: preop, procedural, recovery, work/family Direct feedback Less cost Minimal complications Allows for biopsies Excellent outcomes Low complication rate Time is minimal compared to OR setting Skill may be developed Global cost savings • Less cost Surgeon Insurance companies/Medicare/Medicaid Advantages Advantages •Koufman JA. Introduction to office­based surgery in laryngology. Curr Opin Otolaryngol Head Neck Surg 2007; 15:383­386. Cost Savings Cost Savings • • • • • Rees et al. 2007, WFU Cost savings of unsedated office­based laser surgery for laryngeal papillomas CPT codes 6 CO2 laser for RRP in OR 7 UOLS with PDL for RRP Rees 2007 Rees 2007 •Rees et al. Cost savings of unsedated office­based laser surgery for laryngeal papillomas. Ann Otol Rhin Laryngol 2007; 116:45­48. Rees 2007 Rees 2007 •Rees et al. Cost savings of unsedated office­based laser surgery for laryngeal papillomas. Ann Otol Rhin Laryngol 2007; 116:45­48. Rees 2007 Rees 2007 • • • • • • • • • • PDL $80,000 TNE $18,900 PDL fibers $147/each Dye kit $900/20,000 pulses (6 months) OR avg $7,808 UOLS avg $2,081 • Reimbursement rate $260 ­ $434 for Medicaid, Medicare and major local insurances Savings $5,727 Lost days of work not included (OR) Comparative symptom­free and pathology­free intervals have not been evaluated Anecdotal data suggest that UOLS may be needed more frequently than OR procedures Comparison Comparison • Operating Room • Personnel • • • • • Anesthesia • • • General Cardiopulmonary monitor Office Setting • • • • • Rigid laryngoscope Microscope Laser Endoscopic insrtuments Video Monitor Time • • • • Preop Anesthesia clearance Induction/Intubation Procedure Recovery Personnel • • • • • Topical +/­ Pulse oximetry Equipment • • • • • Surgeon Assistant/Nurse Anesthesia • Equipment • • Surgeon Anesthesiologist Nurse Surgical Tech • Flexible laryngoscope Flexible endoscopic instruments Laser Video Monitor Time • • +/­Sedation Procedure Conclusions Conclusions • • • • • As population demographics change and patients demand preservation or restoration of vocal function, office­based laryngeal surgery will continue to grow Technologic integration of smaller devices and use of different therapeutic drugs will broaden the scope of UOLS As training in endoscopic procedures improves, surgeons may perform procedures that would be technically difficult in the OR setting UOLS cuts unnecessary costs and become more widely accepted and be reimbursed sufficiently A thorough understanding of the capabilities and limitations of UOLS must be achieved in order to optimize patient care Sources Sources • • • • • • • • • • • • • • • • Zeitels et al. Office­based treatment of glottal dysplasia and papillomatosis with the 585­nm pulsed dye laser and local anesthesia. Ann Otol Rhinol Laryngol 2004; 113:265­276. Zeitels et al. Office­based 532 nm pulsed­KTP laser treatment of glottal papillomatosis and dysplasia. Ann Otol Rhinol Laryngol 2006; 115:679­685. Zeitels et al. Office­based and microlaryngeal applications of a fiber­based thulium laser. Ann Otol Rhinol Laryngol 2006; 115:891­ 896. Zeitels et al. Office­based laryngeal laser surgery with the 532­nm pulsed­potassium­titanyl­phosphate laser. Curr Opin Otolaryngol Head Neck Surg 2007; 15:394­400. Koufman JA. Introduction to office­based surgery in laryngology. Curr Opin Otolaryngol Head Neck Surg 2007; 15:383­386. Woo P. Office­based laryneal procedures. Otolaryngol Clin N Am 2006; 39:111­133. Rees et al. Patient tolerance of in­office pulsed dye laser treatments to the upper aerodigestive tract. Otolaryngol Head Neck Surg 2006; 134:1023­1027. Postma et al. Transnasal esophagoscopy: revisited (over 700 consecutive cases). Laryngoscope 2005; 115:321­323. Postma et al. Office­based laser procedures for the upper aerodigestive tract: Emerging technology. Ear Nose Thr J 2004; 83(S2):22­24. Simpson et al. Topical anesthesia of the airway and esophagus. Ear Nose Thr J 2004; 83:2­5. Koufman et al. Office­based laryngeal laser surgery: a review of 443 cases using three wavelengths. Otolaryngol Head Neck Surg 2007; 137:146­151. Amin et al. Office evaluation of the tracheobronchial tree. Ear Nose Thr J 2004; 83:10­12. Simpson et al. Office­based procedures for the voice. Ear Nose Thr J 2004; 83:6­9) Zeitels et al. Office­based laryngeal laser surgery with the 532­nm pulsed­potassium­titanyl­phosphate laser. Curr Opin Otolaryngol Head Neck Surg 2007; 15:394­400. Franco RA. In office laryngeal surgery with the 585­nm pulsed dye laser. Curr Opin Otolaryngol Head Neck Surg 2007; 15:387­ 393. Rees et al. Cost savings of unsedated office­based laser surgery for laryngeal papillomas. Ann Otol Rhin Laryngol 2007; 116:45­48. ...
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This note was uploaded on 12/28/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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