In-Office Laryngeal Procedures in Awake Patients a Viable, and Often Preferable, Option

Overall, physicians should take their time with awake procedures, advised Dr. Postma. You need to take your time with topical anesthesia, and you need to let patients know everything you are going to do, he said.

Physicians should also keep in mind that some patients who are on certain anticoagulants may need to be under full sedation in case bleeding problems arise, said Dr. Klein.

Treating patients who are anticoagulated was problematic when we used the PDL but has not been a problem with the KTP due to enhanced hemostasis associated with the longer pulse width, said Dr. Zeitels.

Equipment and Training

A number of opportunities exist to acquire experience in performing in-office awake procedures for patients with laryngeal disease, and many otolaryngologists already have some of the needed equipment.

Most otolaryngologists already have a flexible scope in their office, said Dr. Klein. To perform in-office laryngeal procedures using existing equipment, all one needs are scope sheaths that provide side ports through which one can introduce biopsy forceps, topical anesthetic, or a laser fiber, he explained. Also available are flexible endoscopes with side ports that don’t require a sheath, he added.

One is first exposed to these types of procedures in residency, said Dr. Klein. However, a fellowship in laryngeal surgery and care of the professional voice helps the otolaryngologist acquire a better knowledge of the procedures, he said.

For otolaryngologists who are done with their training and have been in practice for a number of years, continuing medical education (CME) courses provide the opportunity to learn more about these procedures, said Dr. Klein.

These courses are available through the American Academy of Otolaryngology-Head and Neck Surgeons, noted Dr. Zeitels. Courses are also available at major medical institutions such as Harvard Medical School (http://cme.hms.harvard.edu/ ) and Massachusetts General Hospital, he said.

With any sort of novel approach, technology, or procedure, it’s important to proceed cautiously as you work your way through the learning curve, concluded Dr. Klein.

What Patients Should Know

Physicians should keep patients well informed about what to expect when undergoing in-office awake procedures, said the experts interviewed for this article.

Patients should be prepared to experience some mild discomfort during awake procedures. But even old or infirm patients tolerate these procedures pretty well, said Dr. Klein.

Patients should be advised not to eat or drink an hour or two before the procedure because they may experience some gagging. Additionally, Dr. Postma recommends that they avoid food and drink postprocedure because their throats may still be numb and they can aspirate.