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Anesthesia Considerations
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inOce-Based andOR-Based
Laryngeal Surgery
2
2.1 Application ofLocal
Anesthesia inOce-Based
Laryngeal Surgery
Ofce-based laryngeal surgery has gained popularity over the last two decades as a safe alternative to laryngeal performed under general
anesthesia This evolution in laryngology practice
is due in part to advances in technology and the
effective use of topical anesthesia to the upper
airway. The introduction of the exible nasopharyngoscope with a working channel has enabled
physicians to apply local anesthetics to the laryngopharyngeal mucosa safely and efciently.
In-ofce surgery has several advantages, one of
them is the ability to operate on the vocal folds
while the larynx is in neutral position. The patient
is instructed to breath quietly and slowly during
surgery to minimize the vertical movement of the
laryngeal complex and brisk abduction of the
vocal folds during inspiration. The patient also
may assist the surgeon by executing different
phonatory tasks that help optimize surgical precision and voice outcome. Another advantage to
ofce-based laryngeal surgery is improved time
efciency. The short duration of procedures per-
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 35283- 6_2. The videos can be
accessed individually by clicking the DOI link in the
accompanying gure caption or by scanning this link with
the SN More Media App.
formed in-ofce and possibly reduced time for
recovery in some cases are of paramount importance to professional voice users and others
whose voice is their source of income [1–3].
Different types of topical anesthetics are used
in ofce-based laryngeal surgery. These are classied as amides and esters. Amides include lidocaine and prilocaine, whereas esters include
benzocaine, procaine, and tetracaine. The surgeon should be familiar with the time of onset
action and duration of each anesthetic, as well as
with the dosage needed to optimize the surgical
time. The surgeon also should know the maximum appropriate dose in order to avoid complications associated with overdose. The application
of topical anesthesia to the upper airway starts
with the nose in order to facilitate the introduction of the exible nasopharyngoscope into the
laryngeal inlet. The local anesthetic is applied to
the nasal cavity using cotton pledgets, spray, or
gel. Superiority of one method over the other has
not been established. Decongestants such as
0.05% oxymetazoline may also be used to widen
the nasal passages and improve hemostasis.
Anesthesia is applied to the oropharynx and
hypopharynx by spraying the anesthetic solution
(lidocaine 2 or 4%) or by dripping a mall aliquot
at the base of the tongue via a curved cannula.
Asking the patient to gargle with the anesthetic
solution for few minutes can improve the dispersion of the anesthetic to the pharyngeal mucosa
[4]. An alternative method is the use of a cotton
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A.-L. Hamdan et al., Blue Laser Surgery in Laryngology,
https://doi.org/10.1007/978-3-031-35283-6_2
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2 Anesthesia Considerations inOce-Based andOR-Based Laryngeal Surgery
ball (soaked with the anesthetic) that is held by a
forceps and introduced through the oral cavity.
This method allows access to caudal structures in
the hypopharynx such as the epiglottis, the pyriform sinuses, and even the vocal folds. Different
types of local anesthetics can be used, and these
include lidocaine 2.5%, or a combination of
anesthetic solutions such as benzocaine 14%,
butamben 2%, and tetracaine hydrochloride 2%
[3, 5–9]. In past decades, cocaine was used
routinely.
Application of topical anesthesia to the larynx
should be tailored to each patient accounting for
individual variation in anatomy and threshold for
pain and for gagging. The surgeon must be
trained well to apply local anesthesia to the upper
airway using more than one method. The goal is
to achieve a numb surgical bed for at least
15–20 min during which the procedure is performed safely and with minimal discomfort.
Persistence of laryngeal sensation and inability to
attenuate the brisk adductor reex of the vocal
folds can lead to termination of the procedure or
to suboptimal results. Application of local anesthetic to the larynx can be achieved via different
ways. The oral route is used very commonly by
otolaryngologists. While the patient is seated in
the “snifng” position and the tongue is protruded and grasped forward, the anesthetic solution is installed at the tip of the epiglottis using a
cannula or a curved suction. Under direct visualization of the larynx using a exible nasopharyngoscope (or even a mirror if a exible
laryngoscope is not available), more anesthetic
solution can be applied to the supraglottic and
glottic structures (Fig.2.1). The working channel
of the exible nasopharyngoscope also may be
used instead of a curved cannula. An aliquot of
2–4mL of anesthetic solution such as lidocaine 2
or 4% is dripped on the laryngeal surface of the
epiglottis or just above the vocal folds while the
patient is asked to sustain a vowel such as /e/.
Gentle laryngeal gargle can be used to disperse
the anesthetic solution throughout the laryngeal
inlet (Video 2.1) [2, 10].
Local anesthesia to the larynx also may be
achieved using a nebulizer. After its introduction
by Thawley in 1987, nebulized anesthesia to the
Fig. 2.1 Transoral administration of topical anesthetic
using a curved cannula introduced through the oral cavity.
(Video 2.1 Laryngeal gargle with the anesthetic solution
(Lidocaine 2%). Note the dispersion of the solution in the
laryngeal inlet and to surrounding structures)
(▶ https://doi.org/10.1007/000- amm)
larynx has been advocated as a safe method with
a success rate reaching 94% [11]. Its two main
advantages are the “non-touch” mode of application which minimizes discomfort and pain to the
patient and the even distribution of the anesthetic
solution to different anatomic sites of the upper
airway. The size of the atomized particles is an
important determinant of the distribution and
deposition of the aerosols. Large particles are
more likely to deposit in the supraglottis and
glottis, whereas small particles are more likely to
reach the lower airway such as the tracheobronchial tree and lungs [12]. Laryngeal anesthesia
also can be administered using a percutaneous
approach. Under direct visualization of the vocal
folds using a exible nasopharyngoscope held by
an assistant, a 25-gauge needle is introduced percutaneously through the thyrohyoid membrane,
cricothyroid membrane, or thyroid cartilage into
the laryngeal inlet, and a 2–4cc of 2 or 4% lidocaine is injected after ensuring safe position of
the needle by withdrawing air into the syringe. A
cough is usually elicited following the injection,
which helps disperse the anesthetic solution into
the larynx [13]. A far less commonly used
approach to topical application of anesthesia to
the larynx is the superior laryngeal nerve block.
This approach usually is reserved for those who
do not reach the desired anesthetic effect using
2.2 Anesthesia forOperating Room-Based Laser Surgery
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the topical approaches mentioned. Local anesthetic is injected between the greater cornu of the
hyoid bone and the superior cornu of the thyroid
cartilage at the entry of the internal branch of the
superior laryngeal nerve into the larynx. The needle should not penetrate the laryngeal lumen, and
the anesthetic solution should be injected in the
space between the hyoid bone and thyroid
cartilage.
Before the application of local anesthesia to
the upper airway, the patient should be notied of
the disturbance in swallowing and breathing that
occur afterward. Blocking the voltage-gated
sodium channels at the surface membrane creates
a decrease in chemosensory input and an increase
in sensitivity threshold, all of which lead to
impairment in oral sensation. Clinically, there is
an increase in the swallowing time and interval
between swallows [14, 15]. Local anesthesia to
the larynx also may affect upper airway reexes
resulting in increase in airway resistance and
decrease in maximal inspiratory ow rate [16].
The alteration in upper airway sensitivity and
reexes often is accompanied by hemodynamic
changes of which the surgeon needs to be aware.
These may include transient increase in systolic
and diastolic pressure and increase in heart rate
[17, 18]. Systemic toxicity following topical
anesthesia to the larynx and pharynx in ofcebased laryngeal surgery has not been previously
reported, although methemoglobinemia from
excessive cetacaine is a potential adverse event
that opts for preventive measures such as the use
of methylene blue. To that end, numerous authors
have conrmed the safety of various ofce-based
procedures including esophagoscopy and injection laryngoplasty [19, 20]. The lack of toxicity
reports has been attributed mostly to the decline
in the use of cocaine and its substitution with
other local anesthetics such lidocaine.
Nevertheless, surgeons should be familiar with
the symptoms and signs of toxicity should the
plasma level of the local anesthetic used reach a
toxic level (above 5μg/mL in case of lidocaine).
These include neurologic symptoms such as
light-headedness, confusion, tinnitus and muscle
twitching, and hemodynamic symptoms such as
bradycardia and hypotension. In severe cases,
respiratory distress, arrythmia, and convulsion
may occur [21–25].
2.2 Anesthesia forOperating
Room-Based Laser Surgery
This topic has been discussed by the author (RTS)
previously and will be summarized here [26].
Probably the most important consideration in
general anesthesia for voice patients is the choice
of the anesthesiologist. Laryngologists performing voice surgery must insist on the collaboration
of an excellent anesthesiologist who understands
vocal fold surgery and the special needs of voice
patients. When a gentle, skilled, well-informed
anesthesiologist and laryngologist collaborate,
the choice of anesthetic depends solely on the
patient and lesion, and safe, effective surgery can
be performed.
The choice of agents for general anesthesia is
beyond the scope of this chapter. Usually, the
regimen includes short-term paralytic agent to
avoid patient motion or swallowing. Intubation
and extubation should be accomplished atraumatically, using the smallest possible tube. Most
laryngeal endoscopic procedures are short in
duration, and a 5–0 tube is generally sufcient
even for most moderately obese patients. When a
laser is used, a laser-resistant endotracheal tube
should be placed.
Antireux medications are prudent especially
in patients with symptoms and signs of reux, but
reux may occur under anesthesia even in
patients who do not have routine, troublesome
clinical reux. The combination of acid exposure
and direct trauma from the endotracheal tube can
lead to laryngeal mucosal injury. So, preoperative reux treatment (usually a protonpump inhibitor) should be considered.
Intravenous steroids (e.g., 10mg of dexamethasone) may be helpful in minimizing inammation and edema and possibly in protecting against
cellular injury, and intravenous steroids should
be used at the surgeon’s discretion, if there is no
contraindication.
Endotracheal intubation provides the safest,
most stable ventilation under general anesthesia,
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2 Anesthesia Considerations inOce-Based andOR-Based Laryngeal Surgery
and it permits adequate visibility for most lesions
in most patients. However, in some cases, even a
small endotracheal tube may interfere with surgery especially for lesions in the posterior portion of the larynx. Alternatives include general
anesthesia without intubation (intermittent mask,
or high-ow oxygen which might add risks if a
laser is being used), with intubation with apnea
and repeated extubation and reintubation by the
surgeon during the procedure, and with jet
ventilation.
Venturi jet ventilation is a useful technique.
Anesthetic and oxygen can be delivered through
a catheter placed in the airway through the
laryngoscope. Placing the jet catheter below the
vocal folds causes less mechanical interference at
the vibratory margin during surgery than supraglottic jet ventilation. The airway must remain
unobstructed for expiration. If the laryngoscope
moves or is removed obstructing the airway without a warning to the anesthesia team, pneumothorax may result. During laser surgery, oxygen
concentration (FiO2) must be 30% or less to avoid
laser re, and ventilation (especially jet) is
stopped during laser use and resumed when oxygen saturation decreases.
All the care exercised in gentle intubation may
be for naught unless similar caution is exercised
during extubation. The most common error during extubation is failure to deate the endotracheal tube cuff fully. This may result in vocal fold
trauma or arytenoid cartilage dislocation/subluxation. The anesthesia team should be aware of
these problems. The surgeon should be present
and attentive during intubation and extubation to
help minimize the incidence of such problems. If
vocal fold injection medialization has been performed, the author (RTS) usually extubates the
patient himself with the laryngoscope in place.
This holds the tube posteriorly and prevents the
tube from contacting the musculomembranous
portions of the vocal folds and squeezing out the
injected material. This technique also may be
used following other delicate surgery such as
mini-microap. The patient is then managed by
mask or laryngeal mask ventilation during emersion. If the patient requires voice rest, it is essential for the surgical team to communicate
instructions to the recovery room staff and the
patient’s family.
It also should be noted that surgery in the
operating room does not necessarily mean surgery under general anesthesia. For patients who
would benet from the approaches used during
in-ofce procedures but who either cannot tolerate them, or who have medical comorbidities
that present unacceptable risk, transnasal or
transoral surgery can be performed in an operating room with the patient in a sitting position,
with assistance from the anesthesiologist who
can provide sedation and monitoring. Suspension
laryngoscopy also can be performed with the
patient awake. It usually is accomplished best
using superior laryngeal nerve blocks, topical
oral and transtracheal anesthesia, pharyngeal
nerve block, and tongue base block. Although
the author (RTS) uses this technique most commonly for problems such as arytenoid dislocation, it also works well for laser procedures for
conditions such as supraglottic stenosis. For
such cases, patients may be managed awake and
breathing spontaneously while the airways is
opened, sometimes avoiding the need for tracheotomy (although the patient always is prepared for urgent tracheotomy during such
procedures, with the neck having been injected
with lidocaine with epinephrine and with the
tracheotomy set opened) prior to beginning the
procedure.
References
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2. Wang SX, Simpson CB.Anesthesia for ofce procedures. Otolaryngol Clin N Am. 2013;46(1):13–9.
3. Woo P. Ofce-based laryngeal procedures.
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4. Chan CK, Fok KL, Poon CM. Flavored anesthetic
lozenge versus Xylocaine spray used as topical pharyngeal anesthesia for unsedated esophagogastroduodenoscopy: a randomized placebo-controlled trial.
Surg Endosc. 2010;24(4):897–901.
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6. Özkırış M, Aydın R, Gencer ZK, Saydam
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7. Bourolias C, Gkotsis A, Kontaxakis A, Tsoukarelis
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9. Zainudin BM, Raa MH, Sufarlan AW.Topical nasal
anaesthesia for breoptic bronchoscopy: lignocaine
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RN, Kimbell JS.Ideal particle sizes for inhaled steroids targeting vocal granulomas: preliminary study
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13. Hamdan AL, Sataloff RT, Hawkshaw MJ. Topical
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Ofce-based laryngeal surgery. NewYork: Springer;
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14. Chee C, Arshad S, Singh S, Mistry S, Hamdy S.The
inuence of chemical gustatory stimuli and oral
anaesthesia on healthy human pharyngeal swallowing. Chem Senses. 2005;30(5):393–400.
15. Raphael JH, Stanley GD, Langton JA.Effects of topical benzocaine and lignocaine on upper airway reex
sensitivity. Anaesthesia. 1996;51(2):114–8.
16. Liistro G, Stãknescu DC, Veriter C, Rodenstein DO,
D’odemont JP. Upper airway anesthesia induces airow limitation in awake humans. Am Rev Respir Dis.
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M, Courey M, et al. Current practice in injection
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Publishing; 2017. p.1382–4, 1510–1511.
Blue Laser Therapy ofVocal Fold
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Varices andEctasias
3
3.1 Introduction
The microcirculation of the vocal fold is unique.
There is marked disparity in the microvascular
anatomy of the vocal fold cover and body. The
blood vessels in the lamina propria run along the
longitudinal axis of the vocal folds with little or
no communication with the microvasculature of
the vocalis muscle. This vascular pattern contributes to the pliability of the vocal fold cover
despite the stress of phonation. Other contributing factors to the patency and resilience of the
submucosal vocal fold vessels are their undulating pattern, abundance of arteriovenous anastomosis, and presence of thin and short intermediate
laments within the endothelial cells [1–3].
Despite the sophisticated histologic structure and
course of these vessels, aberrant microvasculature structures within the supercial layer of the
lamina propria are encountered frequently in otolaryngology practice. Based on a review by
Hochman et al. in 1999, these are stratied
mainly as varices or ectasias [4]. Vocal fold varices are abnormally dilated or tortuous vessels,
whereas ectasias are more coalescent aggregations of blood that can be mistaken for hemangio-
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 35283- 6_3. The videos can be
accessed individually by clicking the DOI link in the
accompanying gure caption or by scanning this link with
the SN More Media App.
mas (which are extremely rare on the vocal
folds). Varices and ectasias are more common in
women compared to men. This has been attributed to changes in hormonal environment in
women, the impact of which on the vocal fold
microvascular structure has been investigated
thoroughly. Abitbol et al. reported engorgement
of the vocal fold submucosal capillaries prior to
menstruation in one-third of women. This change
in vasculature, in addition to desquamation of the
vocal folds and change in mucus consistency, is
responsible for a constellation of vocal symptoms referred to as “pre-menstrual vocal syndrome” or “dysphonia premenstrualis.” This
syndrome is characterized by voice fatigue, pitch
breaks, and contracted voice range [5, 6]. The
prevalence of varices and ectasias is also higher
in professional voice users, particularly singers
with high vocal demand [7–9]. Postma et al.
reported varix incidence of 5% in male professional voice users in comparison to only 1.6% in
male non-professional voice users. The incidence
was also markedly higher in female professional
voice users in comparison to female nonprofessional voice users (14% vs. 4.5%, respectively) [7]. The high prevalence of varices and
ectasias in professional voice users is generally
ascribed to phonotrauma, although denitive evidence is lacking. The increase in the collision
forces during phonation in professional voice
users leads to engorgement of these vessels in the
supercial layer of the lamina propria and aberra-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A.-L. Hamdan et al., Blue Laser Surgery in Laryngology,
https://doi.org/10.1007/978-3-031-35283-6_3
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3 Blue Laser Therapy ofVocal Fold Varices andEctasias
tion in their direction. Similar ndings might be
expected in non-professional voice users who
experience voice overuse, abuse, or misuse, especially those with muscle tension dysphonia, but
research will be needed to test this hypothesis.
Patients with vocal fold varices and ectasias
may be asymptomatic or complain of a range of
voice symptoms. These include hoarseness, voice
fatigue, contracted voice range, pain on phonation,
voice instability, diplophonia and aphonia. On
laryngeal examination the most common location
of these lesions is on the superior lateral surface of
the vocal fold, and on the superior surface near its
mid-point, an area that corresponds to the most lateral extent of mucosal waves. They are also frequently encountered in the middle third of the
vocal fold on or near the contact edge, the injuryprone region often referred to as the “striking
zone.” In a review of 42 patients with 87 vocal fold
ectasias and varices, 77% of the lesions were found
on the upper surface of the vocal fold and 83% at
the middle of the musculomembranous portion of
the vocal fold [4]. This is in alignment with the
study by Jiang etal. that showed that the mid-portion of the vocal fold is subject to maximum stress
during phonation, particularly in patients with
laryngeal hyperfunction [10]. Other ndings for
which the physician should be alert are the presence of a yellowish discoloration of the vocal fold
cover and/or a feeding vessel to an angiomatous
polyp or other mass. The presence of yellowish
vocal fold cover secondary to hemosiderin deposition suggests previous vocal fold hemorrhage. The
hemorrhage usual was recent, but duskiness and
even yellowish discoloration can persist long-term
in some patients. The risk of hemorrhage in patients
with vocal fold varices is ten times higher in comparison to patients without varices. Tang et al.
reviewed the risk of hemorrhage in patients with
vocal fold varices and reported an incidence rate of
3.3 per 1000in comparison to 0.5 per 1000in those
with no varices [11]. The study group included 499
patients, 22.4% of whom had vocal fold varices.
The use of anticoagulants also is a precipitating
factor for bleeding within the supercial layer of
the lamina propria once there is rupture in the aberrant vasculature. Laryngeal videostroboscopy is
invaluable in determining the extent of hemorrhage
and the need for voice rest, voice therapy, and/or
surgical intervention. A decrease or absence of
mucosal waves at the site of the dilated varices in
patients with change in voice quality can be an
ominous sign [12].
Varices and ectatic vessels of the vocal folds are
not always treated because many of them are
asymptomatic. The main indications for treatment
are enlarging varices, engorgement associated
with phonation that affects voice quality or endurance, history of hemorrhage, recurrent hemorrhage especially within the vocal fold, and
co-existence of vocal fold mass such as angiomatous polyp [7, 13, 14]. The rst step in management of vocal fold varices or ectasias is voice
therapy. The aim of voice therapy is to improve
vocal hygiene, minimize phonotrauma, and control confounding factors that could have contributed to the presence of aberrant vasculature.
Common examples of such factors are laryngopharyngeal reux and allergy. Poor response of the
vocal fold pathology to medical intervention and
voice therapy may suggest the need for surgical
intervention. The advances in instrumentation
have paved the way for renement in the surgical
technique [14, 15]. Sataloff etal. described dissection and removal of aberrant vocal fold vessels
through a cordotomy placed lateral to the lesion.
Using a vascular knife and a micro- scissor, the
vessel is isolated, dissected, and removed [14]. A
main limitation of surgical excision of varices and
ectasias is the high risk of vessel rupture during
dissection, although it is unlikely to happen and
has not been reported by the author (RTS) or in the
literature. As an alternative, diode lasers were
introduced to minimize the risk of hemorrhage
[16–18]. Gökcan and Dursun reviewed their expe-
rience with 162 patients with vascular lesions of
the vocal folds who were treated using the carbon
dioxide (CO2) laser in a pulse mode and reported
improvement in the acoustic parameters following
surgery [19]. A feared complication of the CO2
laser therapy of vocal fold varices is thermal injury
to the mucosal lining and deep structures of the
vocal folds. In a review of 42 patients with vocal
fold varices or ectasias (19 of whom were treated
in the operating with the CO2 laser with or without
cold instrument excision), Hochman et al. noted
3.2 Case Presentations
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vocal fold stiffness in 4 patients [4]. This adverse
effect led to the introduction of photoangiolytic
lasers as a safer alternative to diode lasers. Their
high afnity for oxyhemoglobin made them more
precise when treating vascular lesions. Usually,
the lesion is targeted from a distance and ablated in
a non-contact mode [20, 21]. Zeitels etal. reported
the successful use of pulsed angiolytic laser in the
treatment of ectasias and varices in singers. In
their review of 39 patients who underwent 40 procedures (25 cases using the pulse dye laser (PDL)
and 15 cases using the potassium titanyl phosphate
(KTP) laser under endotracheal anesthesia), none
of the patients had decrease in mucosal waves on
stroboscopy. All patients had improvement in
voice quality and returned to normal active singing
[13]. Selecting a wavelength that targets oxyhe-
moglobin, and choosing a pulse mode that reduces
thermal impact, was key to optimize surgical outcome. Aligheiri etal. described timeline postoperative changes following KTP vaporization of vocal
fold varices characterized by edema on day 1 and
extravasation of blood submucosally 1 week
later[22].
With the evolution in laryngology practice
toward ofce-based laryngeal surgery, laser photoangiolysis is now performed often in the ofce.
The laser glass ber is introduced through the
working channel of a exible endoscope and
used safely to treat vocal fold lesions [23, 24]. In
a review of 386 cases of endoscopic laryngeal
surgery performed in the ofce, Burns et al.
stressed the versatility of the KTP laser in treating diverse vocal fold lesions among which were
three cases of vocal fold varices or ectasia [25].
In 2013, Centric etal. reviewed their experience
in ofce-based PDL therapy of 33 patients, 6 of
whom had vascular lesions of the vocal folds.
The authors noted complete regression of the
lesion at 6months following surgery and none of
the patient needed surgical intervention in the
operating room [26]. In another review of 255
patients treated endoscopically using angiolytic
laser, 11% of whom had vocal fold varices, Del
Signore etal. reported good patient tolerance and
low risk of complications. The authors advocated
careful patient selection and standardization of
laser parameters to optimize surgical outcome
[24]. Balouch etal. reported satisfactory results
using the blue laser, then a new photoangiolytic
laser with a wavelength of 445nm, in the treatment of 31 subjects with vocal fold vascular
lesions, intentionally using very low power density. In comparison with the KTP laser, the risk of
hemorrhage was less at the rst and second visit
postoperatively, but the long-term recurrence rate
was higher [27]. The authors believed that that
was due to power density, and their preliminary
experience at higher settings suggests the recurrence rates are comparable to those achieved with
KTP. Data were being analyzed at the time of
writing of this book.
3.2 Case Presentations
3.2.1 Case 1: Right Vocal Fold
Ectasia
Forty-seven-year-old female presented to the
Voice Clinic (ALH) with hoarseness of a few
months’ duration. The patient was a heavy smoker
with a history of voice overuse and abuse. She
denied any history of allergy or reux disease.
Her Voice Handicap Index-10 score was 21. On
perceptual evaluation, she had grade 2 dysphonia,
grade 2 roughness, and grade 1 breathiness.
Acoustic analysis showed a fundamental frequency (F0) of 207.43 Hz, habitual pitch of
190.73 Hz, jitter (RAP): 1.21, shimmer: 2.78,
noise-to-harmonic ratio (NHR): 0.08, voice turbulence index (VTI): 0.02. Her maximum phonation
time (MPT) was 9.51s. On laryngeal examination
she had a right vocal fold hemorrhagic mass at the
mid-third of the vocal fold with dilated vessels
feeding the lesion (Fig. 3.1). The patient underwent ofce-based blue laser therapy for her lesion
under local anesthesia. The power used was 10W,
pulse duration 10 ms, and pulse pause 300 ms.
This high-power setting was chosen in view of the
size of the vascular mass lesion. The laser was
used in a non-contact mode 2–3mm distant from
the vocal fold mucosa (Fig.3.2, Video 3.1). The
procedure was tolerated well. The patient presented 2 weeks later with improvement in her
voice quality. The Voice Handicap Index-10 score
18
https://t.me/medicina_free
3 Blue Laser Therapy ofVocal Fold Varices andEctasias
Fig. 3.1 Endoscopic view of the larynx showing a right
vocal fold vascular lesion at the mid- musculomembranous
portion of the vocal fold with dilated vessels around the
lesion
Fig. 3.2 Intraoperative endoscopic view showing the
laser beam targeting the vascular lesion. Note that the
laser glass ber is used in a non-contact mode. (Video 3.1
A laryngeal endoscopic view of blue laser therapy of right
vocal fold ectasia. The laser was used in near-contact
mode) (▶ https://doi.org/10.1007/000- amr)
decreased to 18, and on perceptual evaluation she
had a normal voice. Acoustic analysis showed an
increase in Fo and HP to 216.64 and 202.11Hz,
respectively, with no signicant change in the
remaining acoustic parameters. Laryngeal endo-
Fig. 3.3 Postoperative endoscopic view 2 weeks later
showing complete regression of the lesion
scopic examination showed complete regression
of the lesion (Fig.3.3).
3.2.2 Case 2: Right Vocal Fold
Dilated Submucosal Vessels
withReinke’s Edema
A 55-year-old female presented to the Voice
Clinic (ALH) with history of hoarseness and
deepening of her voice of a few months’ duration. She reported no history of reux disease or
other systemic illness. Her VHI-10 score was 26.
Perceptual evaluation revealed grade 3 dysphonia, grade 3 roughness, grade 1 breathiness, and
grade 1 strain. On laryngeal examination, she had
bilateral grade 1 Reinke’s edema, with dilated
vessels on the upper surface of the vocal folds.
Laryngeal videostroboscopy showed mild
increase in mucosal waves with good closure of
the vocal folds during phonation. The patient
underwent blue laser therapy for both vocal folds
using 3W power, 10ms pulse duration and single
pulse for the treatment of the dilated vessels, and
10W power, 40 ms pulse duration, and 300ms
pulse pause for the treatment of the Reinke’s
edema (Fig. 3.4) One month following surgery
there was reduction in Voice Handicap Index-10
3.2 Case Presentations
https://t.me/medicina_free
19
Fig. 3.4 Laryngeal endoscopic view showing the laser
beam in a non-contact mode 2–3mm above the surface of
the vocal fold
Fig. 3.5 Laryngeal examination 1 month later showing
almost complete regression of the Reinke’s edema with
mild residual blanching of the upper surface of the vocal
fold which resolved later
score to 21 and improvement in perceptual evaluation parameters (grade 2 dysphonia, grade 2
roughness, grade 1 breathiness, and no asthenia
or strain). Her F0 increased from 134.9Hz preoperatively to 144.56 Hz postoperatively.
Laryngeal examination showed almost complete
regression of the Reinke’s edema with mild residual blanching of the upper surface of the vocal
fold (Fig. 3.5). Laryngeal videostroboscopy
Fig. 3.6 Blue laser glass ber aiming at the Reinke’s
edema of the right vocal fold. (Video 3.2 Blue laser therapy of right vocal fold dilated vessels in a patient with
type 1 Reinke’s edema. Note blanching of the vessels following treatment) (▶ https://doi.org/10.1007/000- amp)
showed improvement in mucosal waves with
good closure of the vocal folds.
3.2.3 Case 3: Right Vocal Fold
Tortuous Submucosal Vessels
A 66-year-old female with history of smoking
presented to the Voice Clinic (ALH) with hoarseness and deepening of her voice of 1-year duration. VHI-10 score was 16. On perceptual
evaluation she had grade 3 dysphonia, grade 3
roughness, grade 1 breathiness, grade 2 asthenia,
and grade 3 strain. Laryngeal examination using
the exible endoscope revealed grade 1 rightsided Reinke’s edema with tortuous vessels on
the upper surface of the vocal fold. The patient
underwent ofce-based blue laser therapy for the
right vocal fold dilated vessels with power 10W,
pulse duration 10ms, pulse pause 300ms. A noncontact mode was used (Fig.3.6, Video 3.2). Four
weeks following the procedure, the patient
reported improvement in voice quality. VHI-10
score was 0. On perceptual evaluation, she had
grade 1 dysphonia, and grade 1 strain, but no
roughness or breathiness. The laryngeal exami-
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