The Utility of Narrow Band Imaging in the Treatment of Laryngeal Papillomatosis in Awake Patients
Introduction
Narrow band imaging (NBI) is a technology that uses specific narrow wavelength (2–3 nm) bands of light to better visualize microvascular structures within the mucosa.1 The technology was developed to allow the observer to see vascular structures that are invisible under examination with white light and to allow the discovery of capillary and microvascular structures consistent with pathologic lesions. The technology consists of narrow band pass filters placed in front of a conventional white light source to obtain tissue illumination at selected narrow wavelength bands. These bands produce the greatest contrast between vascular structures and the surrounding mucosa, allowing increased visualization of blood vessels.2 There has been increased utilization of this technology with regards to the larynx, and the results have been promising. The literature is primarily composed of studies using this technology to identify precancerous and cancerous lesions, although benign lesions such as laryngeal papillomatosis (LP; synonymous with recurrent respiratory papillomatosis) have also been studied.
LP is a rare debilitating disease caused by infection with human papilloma virus, most commonly associated with virus subtypes 6 and 11. The prevalence of the disease is generally believed to be 1 to 4 per 100 000 in most Western countries and requires frequent treatments to keep the disease under control.3 Currently, the management of LP is surgical removal of diseased tissue while maintaining the underlying structural architecture of the vocal folds. On occasion, it is supplemented with the use of pharmacotherapy, although surgical removal is the gold standard. The goals of treatment are to maintain a patent airway while preserving vocal quality as much as possible.4 In the past, these operations have been done under general anesthesia with laryngeal forceps, a microdebrider, or laser ablation, with comparable results.5 However, office-based procedures using topical anesthetics combined with laser photoablation have become increasingly popular and offer a viable alternative approach as a treatment option.6 These office procedures have proved to be both safe and effective at treating LP and avoid the additional risks, need, and cost of general anesthesia.7
This article serves to increase awareness of NBI with regards to the larynx and to analyze the utility of NBI in the treatment of LP in the awake patient. Specifically, would NBI alter the decision of a surgeon intraoperatively and could it help identify additional areas of tissue that may need treatment. If more diseased tissue can be identified during the procedure, it can be removed and reduce the burden of disease for the patient between treatments. Importantly, there is a paucity of literature involving NBI use in the larynx, and this technology is deserving of thorough study into its various applications, including its place in office-based procedures.
Section snippets
Materials and methods
The study was conducted at the Emory Voice Center in the Department of Otolaryngology - Head and Neck Surgery. Researchers retrospectively identified all patients who had received treatment for LP under NBI visualization in the office setting. This included patients over a period starting in 2010, when NBI was initially used for office procedures at the Emory Voice Center and ended with patients in November 2012, when the study was initially started. All patients previously had positive biopsy
Results
The returned question sets were compiled together, and for each question, a percentage of “yes,” “no,” and “Couldn't be assessed” were calculated. The results are reported in Table 1. Additionally, confidence intervals of 95% were calculated for each question, using the 3 percentages of “yes” for each question, 1 percentage from each rater. In light of the 3 “Could not be assessed” responses, the percentages were calculated as though the rater responded “no” to the question, avoiding any
Discussion
This article set out to generate more information on the utility of NBI in treating LP, and more importantly, on whether it could influence a surgeon's decision while operating on the awake patient. There have been previous articles published demonstrating the utility of NBI in treating LP, although to our knowledge, none have analyzed the technology outside the operating room. The results from this study suggest that NBI technology has value in treating patients with LP in the awake setting,
Conclusion
The growing data and information on NBI usage in treatment of laryngeal pathology suggest a viable niche for the technology. The laryngeal mucosa is heavily vascularized and an excellent place for NBI visualization, which could lead to more confidence on the surgeon when identifying diseased tissue. The authors are using this technology routinely to aid in the diagnosis and mapping of vocal fold pathology. For a disease like laryngeal papillomatosis, with no cure and multiple sequential
Acknowledgments
The authors thank Dr. Alexander Hillel, Dr. Michael Johns, Dr. Lee Akst for their contributions to the study.
No conflicts of interest or financial disclosures.
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Conflict of interest: None.
Financial Disclosures: None.