In-Office Excision En Masse of a Vocal Process Granuloma Using the Potassium-Titanyl-Phosphate Laser Marco A. Mascarella and Jonathan Young, Montreal, Quebec, Canada Summary: Background. In-office laryngeal surgery is taking on a more commonplace role in the treatment of laryngeal disorders. The potassium-titanyl-phosphate (KTP) laser has been a resourceful adjunct to the management of patients with mucosal lesions of the vocal cords. However, a paucity of data exists for its use in postintubation granulomas treated in-office. Clinical Case. A 43-year-old female presented with voice hoarseness and found to have a large obstructing postintubation granuloma which was treated by in-office KTP laser and en masse excision. Conclusions. We report the successful case of a patient receiving in-office treatment for a large vocal process granuloma using the KTP laser with en masse excision. The combined use of the KTP laser and forceps inoffice can be valuable to the surgical management of vocal process granulomas, given their numerous recurrences. New avenues in office-based surgical management of laryngeal disorders can offer accessibility and decreased morbidity to patients. Key Words: KTP laser–Vocal process granuloma–In-office surgery–Dysphonia.

BACKGROUND In-office laryngeal surgery has brought about a paradigm shift in offering minimally invasive surgery outside the operating room. The modernization of laser delivery systems and fiber-optic imaging coupled with socioeconomic pressures and patient preferences have facilitated this transition.1,2 Various authors have described the application of pulse-dye and potassium-titanyl-phosphate (KTP) angiolytic lasers in treating mucosal pathologies within the larynx.1,3,4 In particular, the use of the 532-nm KTP laser in the outpatient setting to treat papillomas, leukoplakia, dysplasia, and vascular lesions is growing. Several advantages of in-office interventions are the use of local anesthesia with no postoperative recovery needed as well as the ability to monitor voice quality throughout the procedure.3,4 The surgical management of vocal process granulomas remains controversial as recurrence rates ranging from 30–70% have been reported in the literature because of an incomplete understanding of the disease.5,6 Moreover, the need for multiple operations requiring general anesthesia due to granuloma recurrence is both burdensome to the patient and health care system.7 Accordingly, the main modalities of treatment are antireflux, inhaled steroids, and voice therapy, resolving approximately 75% of granulomas.6,8,9 These therapeutic options primarily target patients with Accepted for publication December 12, 2014. There was no source of funding for this project. All authors have no conflicts of interest to disclose. The study was completed at the McGill University Health Center and Jewish General Hospital in Montreal, Quebec, Canada. From the Department of Otolaryngology – Head & Neck Surgery, McGill University, Montreal, Quebec, Canada. Address correspondence and reprint requests to Jonathan Young, Department of Otolaryngology – Head and Neck Surgery, Jewish General Hospital, Pavilion E-903, 3755 Cote-Sainte-Catherine, Montreal, Quebec, Canada. E-mail: [email protected] com Journal of Voice, Vol. -, No. -, pp. 1-3 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.12.006

laryngopharyngeal reflux and voice overuse. However, conservative management for patients with a vocal process granuloma secondary to prolonged intubation is not as convincing.5,6 Laryngeal surgery is indicated when medical therapy fails, histopathologic diagnosis is needed or for airway obstruction.4,8,10 The literature on in-office removal of vocal process granulomas en masse with KTP laser is scant.11 In this case report, we describe a patient who presented to our hospital with a postintubation granuloma treated with KTP laser and forceps as an outpatient. CASE PRESENTATION We report the case of a 43-year-old female school teacher referred to a laryngologist for voice hoarseness and a choking sensation when supine, necessitating her to elevate her head overnight. These symptoms had progressed over 2 months, with the patient mentioning gradual shortness of breath on exertion. Past medical history was significant for multiple surgeries secondary to complications of ulcerative colitis. The most recent being 6 months from her initial visit at our clinic. On examination, the patient was found to have a large mobile left vocal process mass obstructing the posterior glottis (Figure 1). The lesion was suspicious for a postintubation granuloma. The patient had already undergone a 3-month trial of antireflux medication with little improvement in symptoms. In fact, the granuloma had increased in size since presentation (Figure 2). Given the poor response to conservative management and progression of obstructive symptoms, the initial plan was to have a microlaryngoscopic resection of the granuloma with botulinum toxin injection under general anesthesia. However, the patient was adamant about not undergoing another surgery requiring general anesthesia; she had several postintubation complication in the past. The option of in-office laryngeal surgery was brought forth by the treating laryngologist and the risks involved with a large vocal process granuloma were

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FIGURE 1. Bilateral vocal process granulomas at presentation.

FIGURE 3. In-office use of the KTP laser to coagulate blood vessels at the base of the granuloma.

discussed with the patient. Particularly, the risks about complications during the procedure including significant airway obstruction from loss of the granuloma into the lower airway and recurrence were explained to the patient. Informed consent was obtained. The plan was to undergo an in-office fiber-optic excision of the granuloma using a KTP laser and forceps. The patient was prepared using a local nasal anesthesia and topical decongestant. A flexible fiber-optic laryngoscope was introduced and the vocal process mass visualized. The 532-nm pulsed KTP laser was used to cauterize the base of the granuloma (Figure 3). Subsequently, a flexible bicep forceps was introduced transnasally to grasp and remove the granuloma en masse (Figure 4). The procedure was well tolerated and lasted just over five minutes. There were no intraoperative complications despite being a risky procedure with the patient being able to phonate well postoperatively (Figure 5). The patient continued voice therapy and antireflux mediation after the excision. This is the first documented case of an office-based en masse excision of a large obstructing vocal process granuloma

using the KTP laser and forceps. Great caution was exerted because of the size of the granuloma with risk of airway obstruction as well as the patient being awake during the procedure. After one and a half years posttreatment, the patient continues to be symptom free with no evidence of recurrence (Figure 6). In this case, the vocal process granuloma had a narrow base and was thus less likely to allow for recurrence compared with broader-based lesions.10 Alternative methods of treatment of vocal process granulomas included steroid use, either inhaled or percutaneous injection.12 Although the evidence for these therapeutic options is limited by small studies and often in combination with antireflux medication, making its effectiveness is difficult to assess.6,9 Given the similar recurrence rate of granulomas using the KTP laser in-office and in the operating room, an outpatient treatment is a viable option.7 This technique can possibly be extended beyond the treatment of office-based vocal process granulomas, both for diagnostic and therapeutic purposes. Nevertheless, care must be taken in the appropriate patient

FIGURE 2. Vocal process granulomas after 3 months of antireflux medication and before in-office laryngeal surgery. The right vocal process granuloma has completely resolved.

FIGURE 4. Transnasal forceps removal of the granuloma en masse post-KTP laser angiolysis.

Marco A. Mascarella and Jonathan Young

Vocal Process Granuloma Using the KTP Laser

FIGURE 5. Immediate posttreatment result.

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FIGURE 6. Follow-up at one and a half years after granuloma excision.

selection and caution exercised with excision of large or vascular lesions near the glottis. CONCLUSIONS In conclusion, we reported the case of a patient receiving inoffice treatment for a large vocal process granuloma using the KTP laser with en masse excision. Several medical treatment options should be considered before surgical intervention, namely the use of antireflux and inhaled steroid medication as well as voice therapy. Nonetheless, when conservative therapy fails, the consideration for laryngeal surgery will depend on symptomatology and suspicion for malignant disease. The combined use of the KTP laser and forceps in-office can be valuable to the surgical management of vocal process granulomas, especially given their numerous recurrences, as this procedure can be more accessible and offer less morbidity to the patient. Further studies are needed to validate the use of our technique for vocal process granulomas in the outpatient setting. REFERENCES 1. Zeitels SM, Burns JA. Office-based laryngeal laser surgery with the 532-nm pulsed-potassium-titanyl-phosphate laser. Curr Opin Otolaryngol Head Neck Surg. 2007;15:394–400.

2. Xie X, Young J, Kost K, McGregor M. KTP 532 nm laser for laryngeal lesions: a systematic review. J Voice. 2012;27:245–249. 3. Koufman JA. Introduction to office-based surgery in laryngology. Curr Opin Otolaryngol Head Neck Surg. 2007;15:383–386. 4. Shah MD, Johns MM. Office-based laryngeal procedures. Otolaryngol Clin North Am. 2013;46:75–84. 5. Lin DS, Cheng SC, Su WF. Potassium titanyl phosphate laser treatment of intubation vocal granuloma. Eur Arch Otorhinolaryngol. 2008;265: 1233–1238. 6. Karkos PD, George M, Van Der Veen J, Atkinson H, Dwivedi RC, Kim D, Repanos C. Vocal process granulomas: a systematic review of treatment. Ann Otol Rhinol Laryngol. 2014;123:314–320. 7. Hirano S, Tateya I, Kojima H, Ito J. Fiberoptic laryngeal surgery for vocal process granuloma. Ann Otol Rhinol Laryngol. 2002;111:789–793. 8. Lee KJ. Essential Otolaryngology – Head and Neck Surgery. 9th ed. New York, NY: McGraw-Hill; 2008:562–563. 9. Wang CT, Lai MS, Lo WC, Liao LJ, Cheng PW. Intranasal steroid injection: an alternative treatment option for vocal process granuloma in ten patients. Clin Otolaryngol. 2013;38:77–81. 10. Behrbohm H, Kaschke O, Nawka T, Swift A. Ear, Nose, and Throat Diseases. 3rd ed. New York, NY: Thieme; 2009:309–310. 11. Wang CT, Huang TW, Liao LJ, Lo WC, Lai MS, Cheng PW. Office-based potassium titanyl phosphate laser-assisted endoscopic vocal polypectomy. JAMA Otolaryngol Head Neck Surg. 2013;139:610–616. 12. Emami AJ, Morrison M, Rammage L, Bosch D. Treatment of laryngeal contact ulcers and granulomas: a 12-year retrospective analysis. J Voice. 1999;13:612–617.

In-Office Excision En Masse of a Vocal Process Granuloma Using the Potassium-Titanyl-Phosphate Laser.

In-office laryngeal surgery is taking on a more commonplace role in the treatment of laryngeal disorders. The potassium-titanyl-phosphate (KTP) laser ...
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