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3 Blue Laser Therapy ofVocal Fold Varices andEctasias
Fig. 3.7 Laryngeal examination 4weeks after laser treatment showing complete regression of the lesion with mild
redness at the anterior one-third of the right vocal fold
nation revealed complete regression of the lesion
with mild redness anteriorly (Fig.3.7).
3.2.4 Case 4: Left Vocal Fold Ectasia
A 47-year-old female patient presented to the
clinic with hoarseness of a few months’ duration. She denied any history of voice overuse/
abuse or smoking but reports a history of reux
disease. Her Voice Handicap Index-10 score was
20; and on perceptual evaluation she had grade 1
dysphonia, grade 1 roughness but no strain or
breathiness. Acoustic analysis showed a fundamental frequency (F0) of 208.9 Hz, habitual
pitch of 181.4Hz, jitter (RAP): 2.21, shimmer:
9.02, noise-to-harmonic ratio (NHR): 0.12, voice
turbulence index (VTI): 0.045 maximum phonation time (MPT): 9.03s. Laryngeal examination
using the exible nasopharyngoscope showed a
left vocal fold hemorrhagic lesion (Fig.3.8). The
patient underwent ofce-based blue laser therapy for her lesion under local anesthesia. The
laser was used in a non-contact mode and the
setting was power 10W, pulse duration 10ms,
and pulse pause 300ms. The procedure was tolerated well with no complications. Four weeks
after surgical intervention, the patient presented
for follow-up with marked improvement in her
voice quality which sounded normal. The patient
lled The Voice Handicap Index-10 score was 0.
Fig. 3.8 Endoscopic view showing the laser glass ber
directed in a non-contact mode toward the vessel associated with the hemorrhagic lesion. Note the yellowish discoloration on the upper surface of the vocal fold, a sign of
previous submucosal bleeding
Fig. 3.9 Laryngeal endoscopic view showing complete
regression of the lesion. (Video 3.3 Laryngeal videostroboscopic examination following blue laser therapy of a
left vocal fold ectasia. Note the normal mucosal waves
and complete closure of the vocal folds during phonation)
(▶ https://doi.org/10.1007/000- amq)
Acoustic analysis showed a fundamental frequency (F0) of 211.5 Hz, habitual pitch of
185.6 Hz, jitter (RAP): 1.4, shimmer: 2.14,
noise-to-harmonic Ratio (NHR): 0.115, voice
turbulence index (VTI): 0.038, maximum phonation time (MPT): 8.2s. Laryngeal endoscopic
examination showed complete regression in the
size of the left vocal fold hemorrhagic polyp
(Fig.3.9, Video 3.3).
3.2 Case Presentations
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3.2.5 Case 5: Blue Laser Therapy
forLeft Vocal Fold
VascularMass
A 55-year-old male presented with sudden
onset of dysphonia after an upper respiratory
tract infection. On exam there was a massive
left vocal fold hemorrhage (Fig.3.10). Patient
completed 1 week of voice reset with partial
improvement (Fig. 3.11, Video 3.4). In the
operating room, ectasia and varicosities were
present on the left vibratory margin near the
striking zone. There was also large vascular
mass (Fig.3.12). It was treated with blue laser
at 6W, 40ms pulse duration, 300ms pulse in
contact and non-contact mode (Fig.3.13). See
Fig.3.14 and Video 3.5 for the nal operative
view. A total 19 joules were used during the
procedure. The patient was re- evaluated
6-month post-operation with no recurrence
(Fig.3.15).
Fig. 3.10 Laryngeal examination showing left vocal fold
hemorrhage at the striking zone
Fig. 3.11 Laryngeal examination 1 week after voice rest
showing partial left vocal fold hemorrhage improvement.
(Video 3.4 Laryngeal examination showing incomplete
left vocal fold hemorrhage improvement)
(▶ https://doi.org/10.1007/000- amn)
Fig. 3.12 Intraoperative microscopic view showing vascular mass at the left vocal fold striking zone
Fig. 3.13 Intraoperative microscopic view showing left
vocal fold vascular mass vaporizing using blue laser
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3 Blue Laser Therapy ofVocal Fold Varices andEctasias
Fig. 3.14 Intraoperative microscopic view showing complete vascular mass vaporizing
Fig. 3.15 Laryngeal examination 6months after surgery
showing no vascular mass recurrence
3.2.6 Case 6: Blue Laser Therapy
forBilateral Vocal Folds
Ectasias
Fig. 3.16 Intraoperative microscopic view showing
extensive ectasias and varicosities on both vocal folds.
(Video 3.5 Intraoperative video showing left vocal fold
vascular mass vaporization using blue laser)
(▶ https://doi.org/10.1007/000- ams)
Fig. 3.17 Intraoperative microscopic views showing
vaporization of left vocal fold abnormal blood vessels and
ectasias using blue laser. (Video 3.6 Intraoperative video
showing bilateral vocal folds ectasias vaporization with
blue laser) (▶ https://doi.org/10.1007/000- amt)
A 47-year-old male with stable LPR who presented with a history vocal fold hemorrhage and
dysphonia despite having had appropriate voice
therapy. His laryngeal exam motion demonstrated bilateral vocal fold ectasias more in the
left vocal fold, and scar. Good visualization was
obtained with the female medium Sataloff laryngoscope. Extensive ectasia and varicosities were
seen both vocal fold (superior surface, vibratory
margin and anterior portion) (Fig.3.16).
Blue laser at 6 W, 40 ms pulse duration,
300 ms pulse pause was used in non-contact
mode to vaporize blood vessels in the left vocal
fold (Figs. 3.17 and 3.18). Blue laser was also
used to vaporize the blood vessels in the right
vocal fold (Fig.3.19). See Fig.3.20 and Video
3.6 for nal surgery view. A total 227 joules were
used during the procedure. Patient was reevaluated 6 months later and had no ectasia
recurrences (Fig.3.21).
3.2 Case Presentations
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Fig. 3.18 Intraoperative microscopic views showing
blue laser using to vaporize abnormal blood vessels in the
left vocal fold
Fig. 3.19 Intraoperative microscopic views showing
vaporization of right vocal fold abnormal blood vessels
and ectasias using blue laser. (Video 3.7 Intraoperative
video showing right vocal fold hemorrhagic mass vaporization with blue laser) (▶ https://doi.org/10.1007/000- amv)
Fig. 3.20 Intraoperative microscopic view showing complete ectasias vaporization
Fig. 3.21 Laryngeal examination showing no ectasias
recurrence 6months after the surgery
3.2.7 Case 7: Blue Laser Therapy
forRight Vocal Fold
Hemorrhagic Mass
A 52-year-old female singer presented with
dysphonia due to bilateral vocal fold scar and
sulcus. At the time of operation, there was a
new hemorrhagic mass in the middle third of
the right vocal fold with ectasias (Fig. 3.22).
Blue laser was used to vaporize the hemor-
rhagic mass (Fig.3.23). Blue laser was used to
vaporize right vocal fold ectasia (Fig. 3.24).
Scar was injected inter- lesionally and hydrodissected with a mixture of 5 FU uorouracil
with triamcinolone (Fig.3.25 and Video 3.7). A
total 14 joules were used during the procedure.
Six months postoperative stroboscopic examination demonstrated no hemorrhagic mass and
no postoperative stiffness. Voice was good
(Fig.3.26).
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3 Blue Laser Therapy ofVocal Fold Varices andEctasias
Fig. 3.22 Intraoperative microscopic view showing right
vocal fold hemorrhagic mass
Fig. 3.23 Intraoperative microscopic view showing
vaporization of the right vocal fold hemorrhagic mass
with blue laser
Fig. 3.24 Intraoperative microscopic view showing
vaporization of the right vocal fold ectasias with blue laser
Fig. 3.25 Intraoperative view showing right vocal fold
injection with 5 FU and triamcinolone
References
https://t.me/medicina_free
Fig. 3.26 Laryngeal examination showing no recurrence
6months after the surgery
3.2.8 Surgical Steps inOce-Based
Blue Laser Therapy ofVocal
Fold Varices andEctasias
Step 1: The patient is seated in the upright posi-
tion in a standard examination chair commonly used in otolaryngology practice. A pad
behind his or her head may be placed to stabilize the head during the procedure.
Step 2: Topical anesthesia to the larynx and phar-
ynx is applied using the transnasal, transoral,
or percutaneous cervical approach.
Step 3: A exible laryngoscope with a working
channel and a side-port suction is introduced
through the nasal cavity to perform indirect
laryngoscopy.
Step 4: The laser glass ber is introduced
through the working channel until the tip of
the ber is seen at the end of the endoscope.
Note that the introduction of the glass ber
is done while the scope is not exed to avoid
injury to the working channel. The glass
ber can be introduced when the exible
endoscope is either in the nasal cavity or
before inserting the endoscope into the
nose.
Step 5: The exible endoscope with the glass
ber is introduced through the nasopharynx,
oropharynx, and hypopharynx until the targeted lesion is observed.
25
Step 6: The glass ber is pushed further distally
and directed toward the lesion.
Step 7: The laser is used in the non-contact, near-
contact, or contact mode (occasionally). The
distance-to-target is of extreme importance to
avoid excess thermal injury and yet achieve
the desired outcome. The aberrant vasculature
should disappear by the end of therapy.
References
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Sugita M. Microvascular structure of the larynx a
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2. Frenzel H, Kleinsasser O. Ultrastructural study on
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3. Franz P, Aharinejad S. The microvasculature of
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15. Hochman II, Zeitels SM. Phonomicrosurgical management of vocal fold polyps: the subepithelial microap resection technique. J Voice. 2000;14(1):112–8.
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24. Del Signore AG, Shah RN, Gupta N, Altman KW,
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Blue Laser Therapy ofExudative
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Lesions oftheVocal Folds
4
4.1 Blue Laser Therapy ofVocal
Fold Polyps
4.1.1 Introduction
Vocal fold polyps are benign lesions of the vocal
folds that occur predominantly in men [1]. The
main precipitating factors are phonatory stress,
smoking, and laryngopharyngeal reux [2–7].
Meng etal. reviewed 112 samples of vocal fold
polyps and found positive staining for pepsin in
67.8% of the cases. Moreover, there was an asso-
ciation between the degree of recovery of the
vocal fold lesion and the presence of pepsin [7].
Additional predisposing factors to the development of vocal fold polyps are the use of anticoagulants, vocal fold paresis, and the presence of
vocal fold structural anomalies most common of
which is sulcus vocalis [8, 9].
Patients with vocal fold polyps typically present with hoarseness, voice fatigue, and difculty
in projecting the voice, although occasionally
polyps are asymptomatic. Other symptoms
include repetitive throat clearing, globus sensa-
tion, and difculty swallowing [10, 11].
Professional voice users also may complain of
contracted voice range and difculty sustaining
notes. On perceptual evaluation, the voice is
often described as rough, breathy, and strained.
Large polyps may cause diplophonia due to the
mass effect of the lesion causing a non-vibrating
area in the middle of the vocal folds with adjacent
anterior and posterior vibrating segments that
may produce different frequencies. Notably,
there is no consensus on the correlation between
the size of the polyp and extent of voice alteration
[4]. Commonly, acoustic analysis shows decrease
in fundamental frequency and an increase in
noise-to-harmonic ratio and perturbation parameters [12, 13]. Laryngoscopy with (ideally) or
without stroboscopy is the gold standard method
for diagnosis [14]. Polyps are usually unilateral
and can occur anywhere on the vocal fold. The
lesion can be angiomatous/hemorrhagic or gelatinous, with a sessile or pedunculated base. In a
review of 93 patients who underwent microlaryngeal surgery, Ido Filho et al. reported a higher
prevalence of angiomatous polyps in men com-
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 35283- 6_4. 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.
© 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_4
27
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4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
pared to women, with a predilection to the middle
third of the vocal fold. Angiomatous polyps
accounted for 64.74% of their total study group
[15]. Very often a vessel is seen submucosally at
the base of the lesion or coursing toward it.
Usually, these are referred to as “feeding vessels.” However, using contact endoscopy, the
author (RTS) has determined that most of them
are feeding vessels, with blood owing away
from the polyp. Laryngeal videostroboscopic
examination helps determine the type of polyp
and its submucosal content. Common ndings
are aperiodicity and vibration asymmetry. In case
of a brotic lesion, there is decrease in the vocal
fold cover malleability with impairment in mucosal waves [12, 14, 16]. High-speed imaging is a
diagnostic method used less commonly, but it can
be very useful especially when dysphonia is
severe [17]. On histologic examination, vocal
fold polyps are relatively acellular lesions characterized by brovascular changes because of an
increase in shearing/collision forces during phonation. There is neovascularization with or without epithelial hyperplasia and thickening of the
basement membrane [12, 14]. Courey et al.
investigated the immunohistochemistry characteristics of vocal fold polyps (n=19) and reported
abnormal patterns of collagen type IV and bronectin, namely in the form of clustering [18].
The mainstay therapy for vocal fold polyps is
surgery although pre-operative voice therapy is
advised. Traditionally the surgery is performed
in the operating room while the patient is under
general anesthesia. Using ne microlaryngeal
instruments, the lesion is excised via a microap
or a mini-microap that spares the overlying
mucosal cover [19, 20]. Meticulous dissection is
advocated, and injury to the vocal ligament
should be avoided. Following surgery, additional
voice therapy is recommended to treat compensatory hyperfunctional laryngeal behavior when
present. Particularly in patients with small vocal
fold polyps, voice therapy is particularly effective [21], but at least brief pre-operative therapy
helps eliminate hyperfunction and its related
inammation, teaches voice hygiene, and prepares patients for postoperative voice rest and
return to phonation. Advances in technology led
to a partial shift in surgical treatment of vocal
fold lesions from the operating room to the
ofce. Otolaryngologists can perform various
therapeutic options in-ofce under local anesthesia. Intralesional steroid injection, for
instance, has been proven to be a successful
treatment modality in patients with various
benign lesions of the vocal folds, including vocal
fold polyps [22, 23]. It has also been shown to be
effective in reducing the need for surgery and/or
in delaying the time of surgical intervention.
Another treatment modality performed in-ofce
is laser therapy. The laser of choice for many
otolaryngologists is the photoangiolytic laser.
Given its high selective absorption by oxyhemoglobin, its use is associated with the least injury
to the mucosal cover and to the intermediate and
deep layers of the lamina propria [24–26] compared with other lasers. In 2007, Mouadeb and
Belafsky reported their experience with the pulse
dye laser (PDL) in the treatment of 47 patients, 7
of whom had vocal fold polyps. The in-ofce
treatment was successful in ve of the seven
patients. The other two patients required further
intervention under general anesthesia [24]. In
2008, Ivey etal. reviewed 29 cases of vocal fold
polyps treated in-ofce using the PDL and
reported 70% improvement in 38% of the cases.
Patients with small vocal fold polyps had more
improvement than patients with large vocal fold
polyps. In total, the need for surgery was deferred
in all but four cases [25]. Similarly, Kim and
Auo investigated the use of PDL in-ofce management of 75 patients with vocal fold polyps
and noted complete regression of the lesion following therapy with improvement in aerodynamic and acoustic measures [27]. In 2016, Del
Signore et al. reviewed the complications and
failures of ofce-based angiolytic laser of 255
patients, 46% of whom had vocal fold polyps,
and reported failure in only 16 cases (which also
included cases of vocal fold varices). Three cases
had complications, namely hyperemia of the
vocal folds [28]. In 2020, Hamdan etal. reported
the effectiveness of thulium laser in the treatment of 20 cases of vocal fold polyps. All
patients had either partial or complete decrease
in the size of the lesion with marked improve-
4.1 Blue Laser Therapy ofVocal Fold Polyps
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ment in perceptual voice evaluation and a
decrease in the VHI-10 score [29]. In 2021, Ma
et al. reported their experience with in-ofce
KTP laser treatment of 25 patients with vocal
fold polyps and noted a marked decrease in the
size of the lesion in 21 cases and complete
regression in 4. The authors also noted better
glottal closure, and improvement in amplitude
and mucosal waves on laryngeal videostroboscopic examination. Moreover, the VHI-30 score
decreased signicantly along with improvement
in the acoustic parameters, albeit not commensurate with the degree of disease regression [30].
Recently, a new photoangiolytic laser with a
wavelength of 445 nm (blue laser) was introduced. Its hybrid properties, cutting, and coagulating have increased its in-ofce use among
otolaryngologists. Reports on blue laser therapy
of vocal fold polyps are scarce. Hamdan and
Ghanem reported the use of blue laser in the
management of various vocal fold pathology
which included four cases of vocal fold polyps.
The authors noted improvement in voice quality
and a decrease in VHI-10 score following treatment [31]. In another study, Miller etal. reported
the successful application of blue laser in a
cohort of 29 patients, 11% of whom had benign
lesions of the vocal folds that included
polyps[32].
29
Fig. 4.1 Endoscopic view of the larynx showing a polypoid lesion near the midmembranous portion of the left
vocal fold with reactive lesion on the right vocal fold
4.1.2 Case Presentations
4.1.2.1 Case 1: Left Vocal Fold Polyp
A 48-year-old female heavy smoker presented to
the Voice Clinic (ALH) with a few months’ history of hoarseness following voice abuse. The
patient denied any history of reux disease or
allergy. Her Voice Handicap Index-10 score
(VHI-10) score at presentation was 16. On perceptual evaluation she had grade 2 dysphonia,
grade 2 roughness, grade 1 breathiness, grade 0
asthenia, and grade 0 strain. On laryngeal examination, she had a polypoid lesion at the mid-third
of the left vocal fold with a reactive lesion on the
opposite vocal fold (Fig.4.1). The patient underwent blue laser therapy in-ofce (power 10W,
pulse duration 10ms, pause time 300ms) using
Fig. 4.2 Intraoperative view of the blue laser beam
directed toward the left vocal fold polyp in a non-contact
mode
non-contact and contact modes (Fig. 4.2). On
follow-up 6 weeks later, she had marked improvement in her voice quality with decrease in her
VHI-10 score to 12. On perceptual evaluation,
she had a normal voice. Acoustic analysis showed
a decrease in jitter from 1.56 to 0.45 and in shimmer from 4.4 to 1.81. There was also marked
improvement in maximum phonation time (8.46s
pre-operatively vs. 16.1 s postoperatively). On
laryngeal examination, she had complete regression of the polyp except for mild residual edema
(Fig.4.3).
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