Advances in office‐based diagnosis and treatment in laryngology

INTRODUCTION Many leading laryngologists have revived the century-old tradition in the field of laryngology of providing therapeutic treatment to patients in an office-based setting. The history of laryngology is rooted in an officebased, local anesthesia tradition. Laryngology developed over 100 years ago with the focus of treating conditions of the airway due to obstruction from infectious etiologies. As medical science advanced (general anesthesia, endotracheal intubation, surgical microscope, the surgical laser) the majority of therapeutic interventions in the field of laryngology were moved to the operating room, which afforded the laryngeal surgeon increased precision and bimanual dexterity. With this move from the office to the operating room, the field of laryngology ‘‘lost’’ or ‘‘forgot’’ the many advantages achieved with evaluating and treating patients when they are awake, sitting in an upright position and, most importantly, able to phonate. The biggest of these advantages is the ability to monitor voice quality before, during, and after a therapeutic intervention, which is vital to most laryngologic procedures. In addition, office-based procedures often increase patient safety and decrease patient cost compared to the operating room. This article is aimed at describing many of the recent advances in office-based diagnosis and treatment in laryngology, completing on a selective basis, the return of the field of laryngology to its office-based roots. A variety of factors have allowed laryngologists to dramatically expand their office-based diagnostic and therapeutic armamentarium. Most of these advances have been in the area of technology changes. These technologic advances include high-speed imaging, chip-tip flexible endoscopes, ultrathin esophagoscopes, new injection materials, and fiber-based lasers. As with any time period of exploration, a great amount of introspection and critical review is required to optimize the advances and make cogent decisions regarding different treatment options and different approaches. There are still many patients who benefit from surgical treatment in an operating-room environment (general anesthesia using the operative microscope). The distinct advantages of highpowered magnification, a still operating field, and bimanual dexterity, will most likely never be replaced in certain aspects of laryngology. On the other hand, there is an exciting opportunity for otolaryngologists to provide high-quality laryngologic care for their patients in an office-based setting that will be equivalent, and in many situations superior, to performing a similar procedure under general anesthesia in an operating room. From the Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (C.A.R.); Department of Otolaryngology, New York University of School of Medicine, New York, New York (M.R.A.); Department of Otorhinolaryngology, Weill Cornell Medical College, New York, New York (L.S.); Department of Otolaryngology–Head and NeckSurgery,University ofTexasHealthSciencesCenter, SanAntonio,Texas (C.B.S.); Department of Otolaryngology–Head andNeck Surgery, University of Washington, Seattle, Washington (A.L.M.); Department of Otolaryngology– Head and Neck Surgery, University of California, San Francisco, California (M.S.C.); Department of Otolaryngology–Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia (M.M.J.); Department of Otolaryngology, Medical College of Georgia, Augusta, Georgia (G.N.P.), U.S.A. Editor’s Note: This Manuscript was accepted for publication August 26, 2009. This work was supported in part by the MLL Foundation. Authors with no conflict of interest disclosure include M.J., A.L. M. and L.S. M.A., C.A. R. , G.N. P. and C.B.S. are paid speakers for Bioform Medical. C.A. R. is a consultant for Bioform Medical. G.N. P. has received course support from Bioform Medical, Olympus America and KayPentax, and equipment support from MedEnergy and Olympus. M.C. is scientific advisor for Lumenis and receives equipment support from Olympus America. Send correspondence to Clark A. Rosen, MD, FACS, UPMC Mercy, Bldg. B-11500, 1400 Locust Street, Pittsburgh, PA 15219. E-mail: rosenca@upmc.edu