State-of-the-Art Techniques Are Tempting, but May Not Improve Care

Even in the presence of technology, the most important thing to do is take a good history and talk to the surgeon. Determine what the patient’s requirements for voice are, and ask the surgeon how much nerve is intact and what the degree of injury is to help figure out if the voice will recover, said Stanley Shapshay, MD, Professor of Otolaryngology-Head and Neck Surgery at Mount Sinai School of Medicine in New York City.

EMG can help with certain treatment choices, according to Robert T. Sataloff, MD, Professor and Chair of Otolaryngology-Head and Neck Surgery at Drexel College of Medicine in Philadelphia, Pa.

Some patients have an immobile vocal fold that is actually well innervated. An EMG can be used to do simultaneous recordings of abductor and adductor muscles. In some of those patients the reason the motion is so bad is because of synkinesis-you get simultaneous firing of abductor and adductors and the focal fold just sits there, he said. A treatment option for this would be botulinum toxin injections in the abductors.

Pulsed Dye Laser and Vocal Fold Lesions

The second case presented by Dr. Woo was of an 81-year-old male who presented with dysphonia and a small lesion on the right vocal fold. An excisional biopsy revealed a squamous cell carcinoma in situ with possible micro-invasion and clear margins. After seven years, the patient returned with a recurrence in addition to other comorbidities including unstable angina and congestive heart failure.

When it comes to managing this patient, Dr. Franco suggested doing both an office cup biopsy and pulsed dye laser (PDL) treatment. PDL gets rid of the blood vessels surrounding the lesion and helps separate the epithelium away from the underlying basement membrane. It facilitates the biopsy. You can then remove the entire lesion plus normal tissue around it so you can see what you’re dealing with, he said.

Starting with radiation therapy, in his opinion, would not be the best approach in patients presenting with this sort of lesion, until there is a confirmation of what the lesion is. Also, an elderly patient like this might not fair well from the complications of radiation therapy and could develop breathing problems due to glottic edema.

The appropriateness of PDL depends on the natural history of the patient and the extent of invasion, said Dr. Shapshay. If you’re dealing with carcinoma in situ with questionable invasion, then it is reasonable to treat with PDL, do a brush biopsy and follow-up, or at least some histology follow-up, he said.

Testing, Treatments Depend on Patient Tolerance

As for whether office surgery should be done, it depends on the patient. Some patients are too tense and have a strong gag reflex and would likely be better off in the operating room sedated for the procedure, said Dr. Sataloff. Another option is to do office-based transoral biopsies in patients who have been given a sedative. You have to think about how that person tolerated the routine examination, he said.