Dysphonia Panel: Benign Lesions. Learner Objectives. Panelists 7/31/2017

Transcription

1 Dysphonia Panel: Benign Lesions Jonathan M. Bock, MD, FACS Associate Professor Division of Laryngology & Professional Voice Department of Otolaryngology & Communication Sciences Medical College of Wisconsin Learner Objectives After this presentation you should: Better comprehend indications for surgical intervention for benign lesions Understand the role of speech therapy in chronic management of benign laryngeal disease Have improved knowledge of evolving surgical techniques and adjuvant therapies for laryngeal polyps, nodules, and RRP Panelists Dr. Al Merati Professor & Chief Laryngology University of WA Caroline Ziegler, CCC SLP Singing Voice Specialist Speech Pathology Froedtert Hospital Dr. Christopher Long Associate Professor Comprehensive Oto Medical College of WI Dr. Joel Blumin Professor & Chief Laryngology Medical College of WI 1

2 Panelists Drs. Merati, Friedland, Poetker, Ettema, and Martin (clockwise) 25yo elementary school music teacher with years of fluctuating hoarseness Avocational singer with country band and jazz wedding band AND church Unable to perform lately, significant vocal fatigue after school days, voice loss at end of week Voice therapy trial locally without sig benefit plateaued Otherwise healthy Voice sample: 2

3 What is your diagnosis? What is your diagnosis? Bilateral nodules R TVC extensive varices Evidence of recent/ongoing hemorrhage Emergency? Initial treatment options? 3

4 Initial treatment options? Further voice therapy? Who benefits? Professional Demands? Voice rest/steroids? How long and how much? Botox forced voice rest? (Belafsky et al 2009) Steroid injection? 2013 Wang et al Laryngoscope meta analysis 6 papers 321 pts, good outcomes Reflux treatment? No evidence to support without HB symptoms (upcoming guideline) Cochrane Review 2012: No evidence for surgical vs nonsurgical interventions No suitable trials were identified Indications for surgery? Adults vs peds Surgical approaches Cold excision Laser treatment clinic? debulking Steroid injection Dealing with varices? Laser treatment KTP vs CO2 OR: Direct microlaryngoscopy with KTP laser treatment bilateral nodules, laser ablation of R TVC varices, bilateral kenalog injection Laser settings: Pulsed, 3 PPS, 35 Joules, 15 ms pulse width 4

5 OR: Direct microlaryngoscopy with KTP laser treatment bilateral nodules, laser ablation of R TVC varices, bilateral kenalog injection Post op instructions: Voice rest, steroids, reflux meds, antibiotics, follow up? Voice rest duration? Three week follow up: Voice nearly back to normal No fatigue with speaking, has not yet tried singing Follow-up instructions? Performance schedule w/ teaching load? Return to work/teaching Return to singing? Recurrence risk? Further clinic based interventions? 5

6 6 mos follow up: 8 9 hours/day music teaching Improved pain, but ongoing loss of high range and fatigue Using voice amp system in classroom but struggling Ongoing care? Need for revision surgery? Profession switch? 50yo female with 6 months stable ongoing hoarseness Relatively sudden onset of during gospel performance at church No pain, no dysphagia, no tob hx Stay at home mom Voice sample: 6

7 Diagnosis? Cause? Blood thinner use? Gospel singing? Increased singing voice handicap in gospel singers - Cohen 2008 Therapy recommendations? Who benefits? Treatment plan? Clinic vs OR? Garrett & Francis 2013 Trio Best Practice Guideline: From a clinical standpoint, it is not a question of whether voice therapy or surgical management offers the best outcome, but whether a conservative approach can offer sufficient improvement to eliminate the inherent risks of surgery. Based on the observational studies described earlier, conservative approaches can be used with success in patients with vocal fold polyps. As expected, smaller lesions tend to be most responsive to vocal hygiene measures with or without voice therapy. Surgery remains a viable initial option for those with larger polyps and in those who require a rapid definitive approach. Nonetheless, the shared decision-making process should always include counseling regarding the potentially curative role of conservative therapy. Laryngoscope 124(2):

8 OR: DML with R TVC microflap exicison TVC polyp, L TVC KTP treatment to reactive changes OR: DML with R TVC microflap exicison TVC polyp, L TVC KTP treatment to reactive changes OR strategies? Treat both sides? Use of laser? Steroid injection? One month follow up: Speaking voice is back to normal Has not attempted any real singing yet Referred to therapy for return to singing eventually back to normal baseline 8

9 Long term outcomes? Recurrence rate? Use of KTP in clinic to treat superficial varices? Singing recommendations? 60yo female with h/o 3 prior surgeries for vocal polyps 2 by Dr. Toohill at VA? Seen at H&N Cancer Screening event at FMLH with reported possible lesion on mirror exam came for checkup Referred to Laryngology Clinic Denies throat pain, otalgia, SOB Mild vocal roughness and breathiness Voice Sample Clinic visit WHOA. 9

10 RRP discussion: Diagnosis? Why did I get this? Pregnancy? HPV Vaccine Airway management Procedure? Technique Microdebrider, laser? OR: Awake oral intubation Debulking with microdebrider Airway management? Jet, trach, oral/nasal intubation Procedure? Technique Microdebrider, laser? Which laser? Post-op f/u 4 weeks Voice stable, no hoarseness Clinic based KTP treatment of small residual disease Role of KTP laser in treatment Prevention strategies? 10

11 Adjuvant therapies? Cidofovir? I3C? Celecoxib? Retinoic Acid? Acyclovir? Systemic therapies? Interferon alpha? Pembrolizumab (anti PD 1) Phase 2 NCI Trial Good antitumor effect in SCC Lancet Oncol Jul;17(7): Bevacizumab (anti VEGF A) Phase I trial at Harvard (Zeitels) Published in Europe Oncol Lett Nov; 8(5): Available for injection HHT treatment Case 3b: Worst RRP Ever 10/28/16 L TVC SCC 12/16/16 L TVC lesion gone, minimal TVC RRP 10/28/16 posterior glottis verrucous SCC 12/16/16 resolving posterior glottic verrucous lesion Intravenous Avastin 10mg/kg x 2 treatments 11

12 Summary Do Implement speech therapy early and often for treatment and improved long term vocal outcomes in phonosurgery patients Consider use of clinic and OR KTP laser in treatment of varices, papilloma, and nodules Encourage all patients to vaccinate for HPV Consider intralesional steroids and conservative treatment for small volume benign lesions Summary Do not: Recommend prolonged courses of voice therapy and steroids Forget to discuss patient profession and avocation in voice load and treatment plan Skip follow up exams for your RRP for 15 years. 12