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Transoral Awake Potassium Titanyl Phosphate (KTP) Laser Treatment of Recurrent Respiratory Papillomatosis

This video demonstrates an awake transoral approach for laser ablation of recurrent respiratory papillomatosis. A side-channel flexible laryngoscope is introduced transorally until the laryngeal introitus is visualized and anesthetized. The laryngeal disease is then treated with the KTP laser.

Procedure: Transoral awake potassium titanyl phosphate (KTP) laser treatment for recurrent respiratory papillomatosis (RRP) Introduction: Awake transnasal flexible laser treatment is often used to treat recurrent respiratory papillomatosis.  A subset of patients, however, cannot tolerate the trasnasal approach because of nasal discomfort. Indications: Laryngeal recurrent respiratory papillomatosis Materials and Methods: A chart review of all patients undergoing awake transoral KTP laser treatment for RRP from September 2018 to September 2019 was undertaken. Data was collected on number of treatments. Results: Three patients underwent a transoral approach for awake laser treatment. Patients underwent a mean number of 2 treatments per year. The patients reported better tolerability of the transoral approach compared to transnasal approach. Conclusions: The transoral flexible laryngoscopy can be considered in patients who cannot tolerate transnasal flexible laryngoscopy, allowing office-based treatment of benign laryngeal lesions in these patients.
The incidence of recurrent respiratory papillomatosis (RRP) is about 3.9 adults per 100,000 persons.1 The disease results in chronic papillary growth of stratified squamous epithelium of the larynx, often necessitating that individuals undergo multiple procedures per year to remove the lesions.1 A variety of treatment modalities exist, including debridement or laser ablation of the lesions under general anesthesia.1Over the last several years, awake potassium titanyl phosphate (KTP) laser ablation has become an increasingly widespread option for many individuals.2 Awake KTP laser treatment has many benefits over treatment under general anesthesia, including the reduction of costs associated with the operating room and eliminating the risks of general anesthesia and orodental injury from suspension microlaryngoscopy.2 Awake laser treatment is often more convenient for patients, as awake procedures have shorter treatment times and do not require pre-procedure fasting and recovery from general anesthesia.2 The traditional approach for awake KTP laser treatment involves passing a laser fiber through a channeled flexible laryngoscope, and passing the scope through the nasal passage in order to visualize the larynx to treat the disease.3 Some patients, however, report an inability to tolerate the transnasal approach because of the nasal discomfort.4 In the current report, we demonstrate a transoral approach for laser treatment of RRP that could serve as a potential alternative for these patients.
As illustrated in the accompanying video, in the awake transoral approach, the patient is seated upright and then asked to grasp his or her tongue with gauze in order to displace the tongue anteriorly.  A side-channel flexible laryngoscope (Pentax VNL-1570STK) is introduced transorally until the laryngeal introitus is visualized. About 6-8 cubic centimeters of lidocaine 2% is dripped through the side-port of the scope for topical anesthesia.  The scope is then removed, and a 0.4-millimeter KTP laser fiber (ForTec Medical, model number 11718) is passed through the side-port of the scope until the tip of the laser is visualized. The scope is then reintroduced transorally, and the laryngeal disease is treated with the laser at a setting of 30 watts, 15 milliseconds, and 2-3 pulses per second. All equipment is then removed, and the patient is discharged home. A retrospective chart review was conducted for patients who underwent awake KTP laser treatment for laryngeal lesions from September 1, 2018 to September 1, 2019 in the Division of Laryngology at the Emory Voice Center. All cases included in the study had recurrent respiratory papillomatosis based on previous biopsy and underwent a transoral approach for KTP treatment.
A total of 3 patients underwent awake transoral KTP treatment of benign laryngeal lesions. The patients underwent a total of 2 treatments per year. Patients report good tolerability of the procedure.
The transoral awake KTP treatment using a flexible channeled laryngoscope was first hypothesized by Verma et al in 2011.4 To our knowledge, this is the first report to expand on this hypothesis by demonstrating its efficacy. The transoral approach for awake KTP treatment has been reported using a laser fiber passed through an Abraham cannula.4 The surgeon then uses a rigid telescope to visualize the larynx with the non-dominant hand and the fiber directed by the Abraham cannula in the dominant hand to treat laryngeal disease. The use of a channeled scope, however, allows closer visualization of the lesions,4 as well as suction capabilities in order to debride treated disease during ablation. Its use beyond treatment of papilloma can be considered, including KTP ablation of laryngeal diseases including leukoplakia, granulomas, vocal fold polyps, and Reinke’s edema.5 A larger prospective study is needed comparing transoral and transnasal flexible endoscopy to further understand the tolerability and efficacy in patients. Conclusion: The transoral approach to awake KTP treatment of recurrent respiratory papilloma is a suitable alternative in individuals who cannot tolerate the transnasal flexible laryngoscopy, particularly in individuals who have to undergo repeat procedures.
There are no conflicts of interest to report.
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1. Derkay CS, Wiatrak B. Recurrent respiratory papillomatosis: a review. The Laryngoscope 2008; 118:1236-1247. 2. Hillel AT, Ochsner MC, Johns MM, 3rd, Klein AM. A cost and time analysis of laryngology procedures in the endoscopy suite versus the operating room. The Laryngoscope 2016; 126:1385-1389. 3. Zeitels SM, Akst LM, Burns JA, Hillman RE, Broadhurst MS, Anderson RR. Office-based 532-nm pulsed KTP laser treatment of glottal papillomatosis and dysplasia. The Annals of otology, rhinology, and laryngology 2006; 115:679-685. 4. Verma SP, Dailey SH. Overcoming nasal discomfort--a novel method for office-based laser surgery. The Laryngoscope 2011; 121:2396-2398. 5. Lechien JR, Burns JA, Akst LM. The Use of 532-Nanometer-Pulsed Potassium-Titanyl-Phosphate (KTP) Laser in Laryngology: A Systematic Review of Current Indications, Safety, and Voice Outcomes. Ear, nose, & throat journal 2020:145561319899183.

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