|Year : 2014 | Volume
| Issue : 3 | Page : 264-267
Acoustic comparison between two different techniques of endoscopic resection of benign laryngeal lesions
MH Abdel-Monam1, AH Gaafar1, RM Maghraby1, SS Abdel Gawad2
1 Department of Otorhinolaryngology, Faculty of Medicine, Alexandria, Egypt
2 M.M.B.CH Faculty of Medicine, University of Alexandria, Alexandria, Egypt
|Date of Submission||12-May-2014|
|Date of Acceptance||28-May-2014|
|Date of Web Publication||12-Aug-2014|
R M Maghraby
Lecturer of Phoniatrics, Department of Otorhinolaryngology, Unit of Phoniatrics, Faculty of Medicine, Alexandria University, 12 Street El-Nahda Roushdy, Alexandria
Source of Support: None, Conflict of Interest: None
Microdebrider as a new technology in the management of laryngeal lesions is a powered rotatory dissection device with suction assistance; it was used before in orthopedic surgery and sinus surgery. The aim of this work was to assess the microdebrider as a tool for excision of benign laryngeal lesions and compare its results (intraoperative and postoperative) with those of microlaryngeal surgery by cold instruments.
Patients and methods
Forty patients with benign vocal fold lesions were included (25 women and 15 men), with age ranging from 24 to 51 years. Group I was subjected to excision of lesions by the conventional instruments. Group II was subjected to excision of lesions by the microdebrider. Each patient was subjected to the protocol of voice assessment preoperatively and 3 weeks postoperatively. The patients were assessed subjectively by Voice Problem Self-Assessment Scale and objectively by laryngoscopy, stroboscopy, and acoustic analysis.
No significant difference in the acoustic parameters between the two groups was observed, but there was significant difference between the preoperative and the postoperative acoustic parameters for each group. Postoperative parameters satisfactorily improved with resolution of the lesions in both groups.
The microdebrider was determined to be a safe, accurate, and reliable method in removal of benign vocal fold lesions but does not offer major advantages compared with the standard instruments.
Keywords: benign laryngeal lesions, microdebrider, microlaryngeal surgery
|How to cite this article:|
Abdel-Monam M H, Gaafar A H, Maghraby R M, Abdel Gawad S S. Acoustic comparison between two different techniques of endoscopic resection of benign laryngeal lesions. Egypt J Otolaryngol 2014;30:264-7
|How to cite this URL:|
Abdel-Monam M H, Gaafar A H, Maghraby R M, Abdel Gawad S S. Acoustic comparison between two different techniques of endoscopic resection of benign laryngeal lesions. Egypt J Otolaryngol [serial online] 2014 [cited 2019 Nov 22];30:264-7. Available from: http://www.ejo.eg.net/text.asp?2014/30/3/264/138491
| Introduction|| |
Benign vocal folds mucosal lesions such as vocal nodules, laryngeal polyps, and contact granuloma are common among patients with voice disorders, being present in about 45-50% of those patients [1,2]. Benign vocal fold lesions are caused mainly by repeated vocal fold trauma (excessive voice use) . Surgical management of benign laryngeal lesions include laser ablation and cold knife excision . Dealing with vocal fold lesions presents challenge to physicians; most studies reported good results applying laser surgery to vocal fold lesions [4,5]. However, other studies have indicated that cold knife surgery has the benefit of protecting vocal fold from thermal injury [6,7]. Microdebrider as a new technology in management of laryngeal lesions is a powered rotatory dissection device with suction assistance, which is designed to minimize trauma to the surrounding tissues [8,9]. Its application in laryngeal surgery is relatively new, but it has been in use for decades in orthopedic and temporomandibular joint surgery . This electrically powered instrument combines suction and irrigation functions with an oscillating blade within a protected sheath that provides continuous suction . The microdebrider is able to remove tissues within a tight space and allows an unobstructed operative field. Microdebrider use in endoscopic sinus surgery was first reported in 1996, and it was subsequently adapted for laryngeal applications in 1999. Its first use in the larynx was as an effective debulking tool for laryngeal papillomas and later for various other laryngeal disorders . More delicate laryngeal surgery using smaller blades at low rotational speeds has been mentioned for epithelial lesions, including polyps and granulomas; its use in the treatment of Reinke's edema was first described in 2000 [10,11]. The procedure is performed under indirect visualization through a video monitor; the 0 and 30° telescope attached to the video camera is held in one hand, whereas the other hand holds the hand piece similar to a pencil. The blade is inserted under endoscopic guidance; alternatively, a video laryngoscope, which allows bimanual tissue manipulation with excellent visualization of small glottis and supraglottic lesions, can be used in selected cases . The cutting tip engages the free edge of the lesion and should always be in view. Gentle rotational movements of the wrist allow removal of the lesion; the resected tissue from the microdebrider can be collected for histological analysis .
| Patients and methods|| |
This study was conducted as a prospective randomized, double-blind clinical trial on 40 patients aged 18 years and above, attending the ENT Department of Alexandria Main University Hospital, presenting with voice complaints or respiratory distress, and diagnosed as benign laryngeal lesions, and the decision was made to proceed with a surgical intervention. The inclusion criteria were patients presenting with voice complaints and diagnosed as benign laryngeal lesions namely polyps, nodules, granuloma, papilloma, or cyst, patients not responding to voice therapy, and patients who are fit for general anesthesia. The exclusion criteria were patients with malignant laryngeal lesions, with acute inflammatory laryngeal pathology, under the age of 18 years, or who refused consent to participate in the study.
Materials and methods
All patients were subjected to history taking including detailed history taking and auditory perceptual assessment using the grade, roughness, breathiness, asthenia and strained (GRBAS) scale and clinical examination including indirect and direct videolaryngoscopy and stoboscopy. Subjective evaluation of voice was performed using Voice Problem Self-Assessment Scale, which is a five-point scale and constitutes four clusters (functional, physical, emotional, and phonathenic). Acoustic analysis of voice was performed by Multidimensional Voice Program (Model 4305, New Jersey, USA) using Computerized Speech Lab (Model 4300B; Kay Elemetrics Corporation, New Jersey, USA), and informed consent was taken from patients before beginning the study. All patients were randomly divided into two groups depending on the technique used for surgical removal. Group I was subjected to microlaryngeal surgery using the cold instruments and group II was subjected to microlaryngeal surgery excision using the microdebrider (skimmer). After 3 weeks from surgery, patients were re-evaluated using the same protocol of voice assessment.
| Results|| |
Of the total population, there were 33 cases of vocal fold polyps, three cases of vocal fold nodules, two cases of vocal fold cyst, one case of granuloma, and one case of papilloma. With respect to GRBAS scale, there was no statistically significant difference between the groups neither at baseline, nor after 3 weeks. In Voice Problem Self-Assessment Scale, at the baseline (preoperatively) there was no significant difference between the groups in all parameters of the scale except the emotional and the total clusters where their P values were 0.027 and 0.030, respectively. After 3 weeks, all the clusters showed significant difference between the two groups except the phonathenic parameters (P = 0.412). There was no statistically significant difference between the groups after 3 weeks [Figure 1]. There was no statistically significant difference between the groups either at baseline or after 3 weeks with respect to short-term frequency perturbation [Figure 2]. There was general tendency for decline in the parameters; however, this was not enough to yield statistically significant change in group I and group II. Group II showed significant decline in the amplitude perturbation quotient and shimmer in dB [Figure 3]. With respect to the Dysphonia Severity Index, no significant difference was found between the two groups [Figure 4]. Being a new tool in management of benign laryngeal lesions, the microdebrider was assessed intraoperatively in the following aspects:
|Figure 1: Comparison between the two groups regarding the total score of Voice Problem Self-Assessment Scale (VPSS).|
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|Figure 2: Comparison between the two studied groups among the different follow-ups regarding Jitter (Jitt) percent.|
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|Figure 3: Comparison between the two studied groups among the different follow-ups regarding shimmer in dB (ShdB).|
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|Figure 4: Comparison between the two studied groups among the different follow-ups regarding Dysphonia Severity Index (DSI).|
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(1) Operative time (measured between introduction and removal of direct laryngology (DL)) ranged from 15 to 25 min in both groups.
(2) Intraoperative bleeding was less than 100 ml in 40 (100%) patients, which was easily stopped by adrenaline pledgets.
(3) No safety measures were taken in 40 (100%) patients. No risk for fire damage was observed to both surgeon and patient as occurred in laser microlaryngeal surgery.
(4) No trauma occurred to the surrounding tissues either in surgery patients or in the microdebrider group.
With respect to the postoperative complications, no complications were detected in 40 (100%) patients.
| Discussion|| |
In this study, the powered microresectors were used to remove benign laryngeal lesions, with a standard suspension laryngoscope in position; the debrider was used under microscopic guidance. The suction and irrigation were incorporated with an oscillating blade; laryngeal lesions were removed rapidly while the surgeon manipulates the lesion with the blade. This manipulation allowed laryngeal anatomy to be confirmed as much as possible, despite the presence of significant distortion. Thus, the surgeon maintained visual and tactile contact with the laryngeal lesion, maximizing the surgeon's ability to remove disease and minimizing any risk for injury. Pasquale et al. , in a prospective study, compared the microdebrider with CO 2 laser removal of recurrent respiratory papillomas. On comparison with the CO 2 laser group, the microdebrider group showed similar postoperative pain scores, a greater improvement in voice quality, shorter procedure times, and lower overall procedure costs. Powered surgical instrumentation also allows fast debulking of obstructive laryngeal and tracheal tumors and avoidance of tracheotomy. The microdebrider uses suction to pull laryngeal papillomas into the shaft of the instrument where they are resected by a rotating or oscillating blade. When used appropriately, tissue injury is limited to the mucosal layer of the vocal folds. In contrast, the CO 2 laser uses light energy, which is absorbed and converted to heat energy, causing water molecules within the targeted tissues to vaporize. This process inevitably results in collateral thermal injury to the surrounding and deeper tissues [13,14]. Injury to the deeper structures may significantly alter the vibratory characteristics of the mucosa and lamina propria of the vocal folds, resulting in permanent voice changes. Rogerson et al.  compared voice outcomes following microdebrider or CO 2 laser treatment of juvenile onset recurrent respiratory papillomatosis. The results of their study suggested that treatment with the microdebrider results in a better immediate and early postoperative voice outcome. Moreover, the data demonstrated a correlation of worsening voice quality with increased exposure to the CO 2 laser.
The present study showed that jitter values declined in both groups across the follow-up. This finding is in agreement with results of Uloza et al.  and Benninger and Jacobson , showing decreasing jitter values after treatment of nodules and polyps. Shimmer is a cycle-to-cycle, short-term perturbation in amplitude of voice. It increases with poor and inconsistent contact between the vocal fold edges . It was reported to relate with the perception of breathiness . The present study showed that there was no statistically significant difference between the groups in the short-term and long-term amplitude perturbation measurements. Shimmer percent showed more decline in group I (the surgery group) than in group II (the microdebrider group) across the follow-ups, although being nonstatistically significant (P value after 3 weeks was 0.914). This study showed that the microdebrider was determined to be a safe, accurate, and reliable method in removal of benign vocal fold lesions but does not offer major advantages compared with the standard instruments.
| Acknowledgements|| |
The authors thank Allah for his entire benediction and for helping them in accomplishing this work. They express their deepest appreciation and cardinal thanks to professor Dr Mohamed Hesham Abdel-Monam, Professor of Otorhinolaryngology, Faculty of Medicine, University of Alexandria for his kind supervision, generous cooperation, and keen interest. Their sincere thanks goes to professor Dr Alaa Gaafar, Professor of Otorhinolaryngology, Faculty of Medicine, University of Alexandria for his kind cooperation, planning ideas, energetic help, and continuous valuable guidance that created this thesis.
| References|| |
|1.||Brodnitz FS. Results and limitations of vocal rehabilitation. Arch Otolaryngol Head Neck Surg 1963; 77:1148-1151. |
|2.||Kleinsasser O. Pathogenesis of vocal cord polyps. Ann Otol Rhino Laryngol 1982; 91:378-380. |
|3.||Sulica L, Behraman A. Management of benign vocal fold lesions: a survey of current opinion and practice. Ann Otol Rhino Laryngol 2003; 112:827-833. |
|4.||Bastian RW. Benign vocal fold mucosal disorders. In: Cummings CW, Flint PW, Harker LA, et al., editors. Cummings otolaryngology head and neck surgery. 4 th ed. Singular Publishing Group: Mosby Inc.; 2005; 95:2150-2186. |
|5.||Kotby MN. Classification of voice disorders. In: Kotby MN. The accent method of voice therapy. 1 st ed. Singular Publishing Group Inc. 1995; 1:1-24. |
|6.||Jaroma M, Pakrinen L, Nutinen J. Treatment of vocal cord granuloma. Acta Otolaryngol 1989; 107:296-299. |
|7.||Ossoff RH, Werkharen JA, Dere H. Soft tissue complications of laser surgery for recurrent respiratory papillomatosis. Laryngoscope 1991; 101:1162-1166. |
|8.||Flint PW. Powered surgical instrument for laryngeal surgery. Otolaryngol Head Neck 2000; 122:263-266. |
|9.||Pasquale K, Wiatrak B, Woolley A, Lowis L. Microdebrider versus CO 2 laser removal of recurrent respiratory papillomatosis: a prospective analysis. Laryngoscope 2003; 113:139-143. |
|10.||Patel N, Rowe M, Tunkel D. Treatment of recurrent respiratory papillomatosis in children with the microdebrider. Ann Otol Rhinol Laryngol 2003; 112:7-10. |
|11.||Simoni P, Peters GE, Magnuson JS, Carroll WR. Use of the endoscopic microdebrider in the management of airway obstruction from laryngotracheal carcinoma. Ann Otol Rhinol Laryngol 2003; 112:11-13. |
|12.||McGarry GW, Gana P, Adamson B. The effect of microdebriders on tissue for histological diagnosis. Clin Otolaryngol 1997; 22:375-376. |
|13.||Speyer M, Joe J, Davidson JM. Thermal injury patterns and tensile strength of canine oral mucosa after carbon dioxide laser incisions. Laryngoscope 1996; 106:845-850. |
|14.||Reinisch L. Laser physics and tissue interactions. Otolaryngol Clin North Am 1996; 29:893-914. |
|15.||Rogerson AR, Clark KF, Bandi SR. Voice and healing after vocal fold epithelium removal by CO 2 laser vs. microlaryngeal stripping. Otolaryngol Head Neck Surg 1996; 115:352-359. |
|16.||Uloza SV, Uloziene I. Perceptual and acoustic assessment of voice pathology and the efficacy of endolaryngeal phonomicrosurgery. J Voice 2005; 19:138-145. |
|17.||Benninger MS, Jacobson B. Vocal nodules, microwebs and surgery. J Voice 1995; 9:326-331. |
|18.||De Krom G. Consistency and reliability of voice quality ratings for different types of speech fragments. J Speech Hear Res 1994; 37:985-1000. |
|19.||Hill P, Haley J, Wynder L. Cigarette smoking: carboxyhemoglobin, plasma nicotine, cotinine and thiocyanate versus self-reported smoking data and cardiovascular disease. J Chronic Dis 1983; 36:439-449. |
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