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5.2 Case Presentations
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43-year-old female with a vocal process granuloma. Given the high recurrence of these lesions,
the authors advocated their en-mass excision in
an ofce setting [25]. Dominguez etal. reviewed
the in-ofce KTP treatment outcome of 26
patients with vocal process granuloma and
reported partial disease regression in 96.2% of
cases. Patients on average underwent 1.65 +1.16
treatment sessions. The etiology of the vocal
process granuloma was not predictive of treatment outcome and there was no signicant
change in voice handicap index score after therapy [26].
5.2 Case Presentations
5.2.1 Case 1: Right Superior Surface
Vocal Fold Granuloma
A 21-year-old female mezzo-soprano with LPR
presented with dysphonia that had started suddenly in association with upper respiratory tract
infection. Dysphonia had persisted despite having had voice therapy and multiple laryngeal
procedures including serial vocal fold 5-FU
injection, left vocal fold fascia implant and mass
excision and right thyroplasty. A granuloma on
the superior surface of the right vocal fold
extending into the ventricle was diagnosed.
Microlaryngeal examination in the operating
room conrmed right vocal fold granuloma
(Figs.5.1 and 5.2). Biopsy was taken for pathological examination. It was a benign mass
(Fig.5.3). Blue laser at 6 W, 40 ms pulse duration, 300 ms pulse pause was used in contact
51
Fig. 5.2 Intraoperative microscopic view showing right
vocal fold granuloma. (Video 5.1 Surgical video showing
right vocal fold granuloma vaporizing using blue laser)
(▶ https://doi.org/10.1007/000- anb)
Fig. 5.1 Laryngeal examination showing right vocal fold
granuloma
Fig. 5.3 Intraoperative microscopic view showing taking
biopsy from right vocal fold granuloma
and non-contact mode to vaporize the granuloma (Fig. 5.4). A total 10 J were used.
Dexamethasone was injected into the resection
area. The nal surgical view demonstrated complete granuloma resection (Fig.5.5, Video 5.1).
6 months after the surgery, there was no recurrence of the granuloma (Fig.5.6).
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Fig. 5.4 Intraoperative microscopic view showing blue
laser using to vaporize right vocal fold granuloma.
(Video 5.2 Surgical video of in-ofce blue laser treatment of right vocal fold granuloma associated with fascia implantation one month prior in operating room.
Blue laser ber used in exible laryngoscope working
channel after topical anesthesia with 4% topical)
(▶ https://doi.org/10.1007/000- ana)
5 Blue Laser Therapy ofVocal Process Granuloma
Fig. 5.6 Laryngeal examination showing no granuloma
recurrence 6 months after laser treatment
5.2.2 Case 2: Extruded Right Vocal
Fold Implanted Fascia
andGranuloma
Fig. 5.5 Intraoperative surgical view showing total gran-
uloma resection
An 18-year-old woman had a long history of
dysphonia related to vocal fold scar and glottic
insufciency. The vocal fold scars had been
treated previously with serial injections of 5-uorouracil and triamcinolone. After maximal
benet from injections had been achieved, the
patient was taken to the operating room for right
vocal fold medialization with homograft fascia
implantation. Adequate vocal fold medialization
was achieved, but one month postoperatively
the patient’s dysphonia recurred. Stroboscopic
exam showed partial extrusion of right vocal
fold implanted fascia versus granuloma formation. Figures 5.7, 5.8, 5.9, 5.10 and Video 5.2
show intra- and post-procedure images of inofce blue laser ablation of right vocal fold
granuloma. 6 months after surgery, there was
complete regression of right vocal fold granuloma (Fig.5.11).
5.2 Case Presentations
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Fig. 5.7 Still image of right vocal fold granuloma medial
to fascia implant site one month previously in operating
room
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Fig. 5.10 Still image of in-ofce blue laser treatment of
right vocal fold granuloma. Image taken near end of treatment sequence. Settings were the same as described in
Fig.5.9
Fig. 5.8 Still endoscopic image of right vocal fold granuloma with vocal folds adducted
Fig. 5.9 Still image of in-ofce blue laser treatment of
right vocal fold granuloma. Image taken near beginning of
treatment sequence. Settings were 10 W, 60 ms pulse
duration, 150 ms pulse pause
Fig. 5.11 Still image taken 6 months postoperatively
showing complete regression of right vocal fold
granuloma
5.2.3 Case 3: Left Posterior Vocal
Fold Granuloma
A 68-year-old man with a history of posterior
glottic stenosis that had been treated with serial
microdirect laryngoscopies with division and
excision of posterior glottic scar and placement of a stent with internal xation with
suture. A posterior left true vocal fold granuloma had developed as a suspected complication of stent placement. In-ofce blue laser
treatment focused on ablation of left posterior
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vocal fold granuloma (Figs. 5.12, 5.13 and
Video 5.3). The patient could only tolerate partial ablation in-ofce and was taken to the
operating room for denitive treatment with
blue laser followed by injection with dexamethasone, with resolution of the lesion
(Figs.5.14, 5.15, 5.16, and 5.17). Postoperative
examination 6 months after procedure is shown
in Fig.5.18.
5 Blue Laser Therapy ofVocal Process Granuloma
Fig. 5.14 Intraoperative still image of posterior left vocal fold
granuloma prior to treatment with blue laser. Suction shown
retracting the left false vocal fold out of the operative eld
Fig. 5.12 In-ofce stroboscopic still image of left posterior true vocal fold granuloma
Fig. 5.13 In-office still image of blue laser treatment of left posterior true vocal fold granuloma. The
blue laser fiber was positioned through the working
channel of the flexible laryngoscope. Settings were
10 W, 60 ms pulse duration, 150 ms pulse pause. The
patient was not able to tolerate the procedure, and it
was aborted after partial vaporization of the
granuloma
Fig. 5.15 Still image showing blue laser ablation of left
posterior vocal fold granuloma
Fig. 5.16 Still image taken intraoperatively during midvaporization of granuloma with the blue laser. (Video 5.3
Surgical video showing intraoperative blue laser vaporization of posterior vocal fold granuloma. Blue laser was
used in contact and non-contact modes at a setting of 6 W,
60 ms pulse duration, and 150 ms pulse pause)
(▶ https://doi.org/10.1007/000- anc)
5.2 Case Presentations
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Fig. 5.17 Intraoperative still image immediately postblue laser ablation of granuloma showing complete
reduction
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index (VTI): 0.025, and maximum phonation
time (MPT): 29.03 seconds. Laryngeal examination using the exible nasopharyngoscope
showed a multi-lobulated grade 3 vocal process
granuloma on the left side. The patient underwent botulinum toxin injection (5IU) into the
interarytenoid muscle with intralesional steroid
injection (0–2 cc og Dexamethasone 8 mg/2 m).
Five weeks after the injection the patient showed
minimal regression on the size of the lesion. Six
months later, the patient was asymptomatic.
However, the granuloma was still present on
laryngeal examination (Fig. 5.19). His Voice
Handicap Index (VHI-10) score decreased to 2.
On acoustic analysis, he had a fundamental frequency (F0) of 93.21 Hz, habitual pitch of 95.79
Hz, jitter (RAP): 1.7, shimmer: 5.75, noise-toharmonic ratio (NHR): 0.145, voice turbulence
index (VTI): 0.054, and maximum phonation
time (MPT): 26.52 s. The patient was advised to
undergo ofce-based blue laser surgery for his
left vocal process granuloma. The setting used
was power 10 W, pulse duration 40 ms, and
pulse pause 300 ms (Figs. 5.20 and 5.21). A
total 87 Joules were used. Six weeks after surgery he had mild decrease in the size of the
lesion but the patient was asymptomatic.
Fig. 5.18 Still image 6 months postoperatively showing
substantial reduction in size of left posterior vocal fold
granuloma
5.2.4 Case 4: Left Vocal Process
Granuloma
A 46-year-old male presented to the Voice
Clinic (ALH) with intermittent hoarseness of a
few months' duration associated with globus
sensation and frequent throat clearing. He
denied any history of smoking, allergy, or phonotrauma. On perceptual evaluation, he had a
normal voice and his VHI-10 score was 2.
Acoustic analysis showed a fundamental frequency (F0) of 96.17 Hz, habitual pitch of 97.86
Hz, jitter (RAP): 1.4, shimmer: 3.38, noise-toharmonic ratio (NHR): 0.096, voice turbulence
Fig. 5.19 Endoscopic view of the larynx showing left
vocal process granuloma extending to the mid-third of the
vocal fold
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Fig. 5.20 Endoscopic view showing the blue laser in a
non-contact mode with blanching of the granuloma at the
site of application
5 Blue Laser Therapy ofVocal Process Granuloma
no known allergies. On perceptual evaluation,
he had a normal voice and his Voice Handicap
Index (VHI- 10) score was 2. Acoustic analysis
showed a fundamental frequency (F0) of 91.02
Hz, habitual pitch of 99.07 Hz, jitter (RAP):
0.86, shimmer: 2.09, noise-to-harmonic ratio
(NHR): 0.119, voice turbulence index (VTI):
0.037, and maximum phonation time (MPT):
26.02 s. Laryngeal examination using the exible nasopharyngoscope showed a left vocal process granuloma grade 1 (Fig.5.22). The patient
was started on proton-pump inhibitor twice
daily and was advised to undergo voice therapy
for 12 weeks. On follow-up, he had no improvement in symptoms; and laryngeal examination
showed no regression in the size of the granuloma. The patient was informed about the different treatment options, namely laryngeal
botulinum toxin injection and laser therapy. He
elected to undergo ofce-based blue laser therapy with steroid injection for his lesion. The
laser was used at setting of 10 W, 40 ms pulse
duration, and 300 ms pulse pause (Figs. 5.23
and 5.24). The procedure was well tolerated by
the patient. On follow-up few weeks later (verbal communication), the patient had complete
resolution of his symptoms.
Fig. 5.21 Endoscopic view of the larynx toward the endtreatment of blue laser therapy of left vocal process
granuloma
5.2.5 Case 5: Left Vocal Process
Granuloma
A 46-year-old male presented to the Voice
Clinic (ALH) with history of frequent throat
clearing and globus sensation of a few months’
duration. He is a former smoker and denied any
history of reux or voice abuse. The patient had
Fig. 5.22 Laryngeal examination showing left vocal process granuloma grade 1
References
https://t.me/medicina_free
Fig. 5.23 Endoscopic view of the larynx showing the
blue laser glass ber in contact mode against the left vocal
process granuloma
Fig. 5.24 Endoscopic view of the larynx showing complete regression of the lesion toward the end of surgery
References
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14. Ylitalo R, Hammarberg B. Voice characteristics, effects of voice therapy, and long-term follow- up of contact granuloma patients. J Voice.
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15. Farwell DG, Belafsky PC, Rees CJ.An endoscopic
grading system for vocal process granuloma. J
Laryngol Otol. 2008;122(10):1092–5.
16. Karkos PD, George M, Van Der Veen J, etal. Vocal
process granulomas: a systematic review of treatment.
Ann Otol Rhinol Laryngol. 2014;123(5):314–20.
17. Smith S, Thyme K.Accent metoden: special paedagogisk forlag AS.Denmark: Herning; 1978.
18. Lemos EM, Sennes LU, Imamura R, et al. Vocal
process granuloma: clinical characterization, treatment and evolution. Rev Bras Otorrinolaringol.
2005;71:494–8.
19. Song Y, Shi L, Zhao Y, et al. Surgical removal followed by radiotherapy for refractory vocal process
granuloma. J Voice. 2012;26(5):666–e1.
20. Lin DS, Cheng SC, Su WF. Potassium titanyl phosphate laser treatment of intubation vocal granuloma.
Eur Arch Otorhinolaryngol. 2008;265(10):1233–8.
21. Rees CJ, Halum SL, Wijewickrama RC, etal. Patient
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to the upper aerodigestive tract. Otolaryngology.
2006;134(6):1023–7.
22. Zeitels SM, Burns JA, Akst LM, et al. Ofcebased and microlaryngeal applications of a berbased thulium laser. Ann Otol Rhinol Laryngol.
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Blue Laser Therapy ofRecurrent
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Respiratory Papillomatosis
6
6.1 Introduction
Papilloma is a common neoplasm of the upper
airway caused by the human papilloma virus
(HPV). More than 70 strains have been reported
with the most common being HPV 6 and 11 [1,
2]. Other strains such as HPV 16 and 18 have also
been identied, particularly in lesions with high
potential for malignant transformation [3].
Another pathogenic factor in the development of
recurrent respiratory papillomatosis (RRP) is
herpes simplex [4, 5]. Formánek etal. reported
the prevalence of herpes simplex type 2in 45%
of adult-onset recurrent respiratory papillomatosis (AO-RRP) in comparison to 0 % in the control
group. The study was conducted using immunohistochemical staining on a cohort of 40 subjects
[5]. Recurrent respiratory papillomatosis has a
bimodal age distribution, with a more aggressive
course in the pediatric age group [6]. The main
mode of transmission in adults is sexual intercourse. In a study looking at risk factors for
AO-RRP, Ruiz et al. reported a signicant association between the number of lifetime sexual
partners and disease prevalence [7]. In the pediatric age group, other forms of transmission have
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 35283- 6_6. 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.
been described such as perinatal and hetero inoculation. Kashima etal. reported the clinical triad
(rstborn, vaginal delivery, and teenage mother)
in 72% of Juvenile onset-RRP (JO-RRP) in comparison to 29% of Juvenile controls. The authors
stressed the distinctive mode of transmission and
epidemiologic features of JO-RRP [8].
Patients with laryngeal RRP can present with
an array of symptoms. The most common are
throat clearing and change in voice quality. In
advanced cases, patients may present with shortness of breath and stridor, particularly in the
pediatric age group [6, 9]. On laryngeal examination, the lesion is usually exophytic with a
cauliower- like appearance. It may be isolated or
diffuse. It is seen most commonly at the transition between the squamous and columnar epithelium, but any structure in the larynx may be
involved. Affected sites include the vocal folds,
arytenoid mucosa, aryepiglottic folds, and epiglottis. Extra-laryngeal sites include base of
tongue, esophagus, and the lower airway including the trachea and bronchi. The use of narrowband- imaging (NBI) increases sensitivity in
diagnosing papilloma. Tjon Pian Gi et al.
inspected 86 excisional biopsies using white light
and NBI and reported an increase in sensitivity
from 80% to 97% using this latter [10]. The diagnosis of laryngeal papilloma hinges on tissue
biopsy. On histologic examination, the lesion
consists of brovascular stalks surrounded by
connective tissue. The epithelial lining also
© 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_6
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6 Blue Laser Therapy ofRecurrent Respiratory Papillomatosis
exhibits changes such as hyperplasia and thickening of the basal layer [6, 9]. Dysplasia is present
in some cases.
The treatment of laryngeal papilloma is a
daunting task given the unpredictable course of
the disease. Controlling disease-spread while
maintaining voice quality and airway patency is
challenging. The most common treatment
modality is surgical excision. A tracheotomy is
rarely needed to secure the airway if early treatment has been initiated. Phono-microsurgical
resection using the microap technique has been
advocated for more than two decades with good
results. Sataloff etal. described the mini-microap which allows complete removal of small
lesions without injury to the deep structures of
the vocal fold. The plane of dissection is between
the papilloma lesion and the underlying supercial layer of the lamina propria [11]. Both diode
and photoangiolytic lasers also have been used
as alternative surgical tools to cold steel instruments with high success rates. Despite advances
in technology mode of delivery and spot size,
inadvertent injury to the deep structures of the
vocal fold remains a concern. In lesions that
involve the anterior commissure, web formation
is the most feared complications, particularly
with the use of diode lasers [12, 13].
Photoangiolytic lasers that target primarily the
chromophore of oxyhemoglobin have markedly
reduced the risk of vocal fold injury and scar formation. In 2001, Valdez etal. described the use
of the pulse dye laser (PDL) in 10 patients with
RRP and reported complete regression in 7 and
partial regression in 2. The authors stressed the
added value of microvascular targeting and
reduced risk of scar in affected patients [14]. In
2009, Burns etal. reported 90% disease regression in 80% of patients with RRP treated with
the potassium titanyl phosphate (KTP) laser in
the operating room [15]. The extended pulse
duration of the potassium titanyl phosphate
(KTP) laser in comparison to the PDL helped
decrease bleeding, particularly when endoscopic
micro-debridement was used as adjunct therapy
[16, 17]. Recently, Balouch et al. reported the
successful use of blue laser (new photoangio-
lytic laser with wavelength of 445 nm) in the
treatment of 31 patients with vocal fold vascular
lesions under general anesthesia. In comparison
to the KTP laser, the authors noted no signicant
differences in the extent of edema and vocal fold
stiffness at the third and fourth visits postoperatively. However, vascular lesions treated with the
blue laser using very low power densities were
more likely to recur compared to those treated
with the KTP laser [18]. Further research is in
progress, but preliminary ndings show that
higher power densities (6 W, 40 ms pulse time,
300 ms pause time) produce results at least as
good as KTP, and these settings also have been
successful for treatment of papilloma.
The recent advances in technology, namely
the introduction of endoscopes with a working
channel and the delivery of lasers using glass
bers have enabled physicians to treat patients
with RRP in the ofce. This advance in laryngology practice has improved time efciency
and hastened patients’ recovery, especially
those in need for frequent surgical intervention. There are numerous reports on the safety
and efcacy of ofce-based laser therapy of
patients with RRP, mostly using photoangiolytic lasers. In 2004, Zeitels etal. reported disease regression by 50% using the PDL in a
cohort of 17 patients with RRP who underwent
ofce-based treatment. All patients had
improvement or no change in voice quality
except for 2 patients who noticed worsening of
voice [19]. Mouadeb and Belafsky reported
their experience with the PDL in a cohort of 47
patients, 21 of whom had RRP.Patients needed
on average 3.5 procedures, and only one in
three required a trip to the operating room during treatment. The overall success rate estimated by disease regression was 89% [20]. In
their review of 59 cases of RRP treated in the
ofce using PDL, Koufman etal. reported no
complications over 17 months of follow-up.
The average number of procedures per patient
was 3.6, and only 9 cases needed subsequent
surgery in the operating room [21]. Zeitels
etal. reviewed their experience with 20 patients
with RRP who underwent 36 in-ofce KTP
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