TORONTO-While state-of-the-art care is appealing, standard care is often an equally effective choice for treatment of laryngological disorders. This was one of the key messages from a panel discussion on state-of-the-art versus standard care here at the meeting of the Eastern Section of the Triological Society.
The session was moderated by Peak Woo, MD, Professor of Otolaryngology at the Mount Sinai School of Medicine in New York, NY. He presented four cases that may be seen in a typical practice.
Assessing Immobile Vocal Cords
The first was of an 18-year-old female who had undergone total thyroidectomy for Graves disease and who had an immobile vocal fold and a primary complaint of voice problems. Diagnostic options include waiting to see what happens because the nerve appears to be intact, getting a laryngeal electromyography (EMG) performed, or referring the patient for voice therapy.
Dr. Woo said he opted for an EMG, which he considers to be somewhere between state-of-the-art and standard care. In this case, EMG readings showed no fibrillation potential and no complex discharges on the left thyroarytenoid. There was only 20% recruitment with variable motor units, with only a few of them polyphasic, he said. The question was what should be done next.
Generally, the panelists favored EMG, but use it to varying degrees.
I’m a laryngeal EMG enthusiast, I think it really does help and offers a slightly more refined level of care. But I’m not a zealot, said Lucian Sulica, MD, Assistant Professor of Otorhinolaryngology Director of Voice Disorders/Laryngology at Weill Medical College of Cornell University in New York City. While EMG is more state of the art, it’s not necessary for providing good care to this sort of patient, he noted.
EMG is useful as a negative predictor to get a feel of where the condition is headed. He added that voice testing and phonograms are useful, but one needs to be scholarly about tracking outcomes.
EMG is Predictive, but Utility Still Evolving
EMG has lead to a deeper understanding of what vocal fold paralysis is. One of the reasons I’m an EMG enthusiast, Dr. Sulica said, is because since we started EMG we understand that a lot of immobile vocal folds are not innervated vocal folds…giving us this new concept about what vocal fold paralysis is.
Ramon Franco, Jr., MD, Instructor in the Department of Otology and Laryngology and Acting Director of the Voice Center at Harvard Medical School in Boston, Mass., said that EMG can be predictive and provide something to show the patient. Yet, there are many issues related to the way it’s performed, how it’s interpreted. This is still in its infancy in terms of how we use it as a diagnostic tool, he said.
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. – Stanley Shapshay, MD
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.
As for performing cup biopsies of the vocal fold, he cautioned that many younger physicians have no experience in doing this, and that technique is vital or damage is done.
Another way to manage the patient is to watch, said Dr. Sulica. This is a contralateral lesion, more than five years out after the second. This is a new primary. You cured the first primary…But you’re being told this is microinvasive. I was surprised that not more people felt they could watch this reliable patient, who gives a good stroboscopic exam. If it comes back, I don’t think you need a new biopsy to treat him with radiation, he said.
With the recurrence, and taking into account the patient’s comorbidities, Dr. Woo considered radiation because the patient was a poor surgical risk and wasn’t likely to live long enough to see some of the complications from radiation therapy. Also, Dr. Woo didn’t want to see the condition progress into something more severe.
Reflux Testing for Granulomas
The third case was of a 58-year-old trial lawyer with a suspected contact granuloma of the larynx. Biopsy was not recommended. Management of this sort of case varies widely, with treatments ranging from oral steroids to proton pump inhibitors (PPI) to speech therapy. The patient was put on a double-dose of PPIs for six months and speech therapy.
Even in the presence of technology, the most important thing to do is take a good history and talk to the surgeon.
After four months, the patient had minimal relief. Dr. Woo reported that he excised the granuloma and injected steroids.
Dr. Sataloff suggested making sure any reflux was under control because studies show that reflux can cause granuloma. However, he was critical of the methodology behind some of the 24-hour monitoring studies in the medical literature.
Most of the 24 hour monitors are normed to pH 4, and there is about 10% or so of pepsin activity up to pH 5. I personally use pH impedance studies for everything now, he said. With some patients, 24-hour monitor study normed to pH 4 might show little or no acid, but if it is renormed to pH 5 more episodes appear, he said.
However, reflux is common yet this lesion is rare, said Dr. Shapshay. It’s sometimes reasonable to give [patients] steroids for several weeks, and that granulation tissue will disappear, he said. Over time, most granulomas resolve.
The patient, according to Dr. Woo, did undergo a work-up by a gastroenterologist but had a negative study. The only interventional change, at that point, was switching to voice therapy.
I’m a laryngeal EMG enthusiast, I think it really does help and offers a slightly more refined level of care. But I’m not a zealot. – Lucian Sulica, MD
Not all these cases are granulomas, and the word granuloma is often to use to describe lesions that actually have differing histology. There are inflammatory lesions with fibroblasts, and collagen fibers, and leukocytes, and maybe some ulceration. And capillary proliferation can make some candidates for management with PDL, said Dr. Sataloff.
Panelists agreed certain anatomic causes can place a patient at risk. Some cases may benefit from judicious use of botulinum toxin, a treatment that is considered state-of-the-art.
Conflicting Advice for Managing Respiratory Papillomatosis
The final case presented by Dr. Woo was of a 58-year old male with adult onset recurrent respiratory papillomatosis (RRP) who presented in 2002, had a recurrence rate of every four months, and underwent surgery for severe dysphonia. He had respiratory papilloma with mild dysplasia.
Physicians at the conference were divided between microdebridement and microlaryngoscopy as the standard of care. The key thing is to maintain function, said Dr. Shapshay. I don’t think it matters if you use the microdebrider or laser, whatever you’re most accustomed to, he said.
Dr. Woo reported he performed microlaryngoscopy followed by office injections of cidofovir. The patient stayed free of disease for close to two years, then presented with a subglottic papilloma. This was treated with laser and more cidofovir which had good results. A later recurrence was then debrided with a wave guide CO2 laser and more cidofovir.
Have Caution with Lasers
CO2 lasers should be used with caution on vocal folds, said Dr. Franco. Repeat use can lead to stiffness and scarring.
This particular condition is an epithelial disease, and lasers can go too deep. The only way you get deep papilloma is if you implant it. If you’re not really precise with the laser, and you make little potholes into the muscle on the superior surface of the vocal fold, it’s like planting tulips, Dr. Sataloff said.
Panelists agreed that laser technique is key, but there are risks with microdebriders too.
If you use the microdebrider you have to be sure not to suck up the cord and take off more than you want to… Whatever you use here, use it cautiously to debulk this disease down to a reasonable level, said Dr. Shapshay.
As with many things, it’s the surgeon, not the tool, he said.
©2006 The Triological Society