Today I saw a patient who self-referred for office-based laser surgery using the pulsed KTP laser. He has had 3 prior surgeries greater than 10 years ago, and he was told that he was an extremely difficult surgical exposure. When I examined his larynx, he had a tremendous amount of papilloma filling the entire airway and involving both vocal folds and the area in between (the anterior commisure).
This patient obviously has a challenging surgical problem; an extensive quantity of papilloma, and challenging anatomy making endoscopy difficult. This is a good case to highlight some key points:
1) The ideal candidate for pulsed KTP laser or pulsed dye laser treatment in the office has a mild to moderate quantity of papillomatous disease. If disease is too extensive, treatment in the office can still be performed, but it can be slow and tedious, and may require more than one session to remove all of the disease.
2) A large quantity of disease in the anterior commisure is problematic in the office. In the operating room, a special instrument (vocal cord spreader) can be used to separate the vocal folds and direct treatment toward only one vocal fold. This prevents "webbing", or scarring of the vocal cords together. In the office we have no such device, and treatment of bulky disease in the anterior commisure should be approached with caution.
3) The ideal candidate should have a mild to moderate gag reflex. A severe gag reflex can preclude treatment in the office.
And how did I approach this case? Despite his difficult surgical exposure in the past, I was confident that I could adequately expose his larynx. Therefore, I recommended his first treatment in the operating room, and subsequent treatments in the office to handle recurrent disease. He will be asked to follow-up regularly in order to treat him before his disease becomes out of control in the future.
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