| Patient
Services
Surgical/procedural
services on the premises of Bastian Voice Institute
First, some history. In the 1800s, surgery in the larynx
was accomplished with the patient sitting in a chair and the
surgeon reaching over the back of the tongue and down into
the larynx with curved instruments. Initially this had to
be performed without the assistance of even topical anesthesia!
Subsequently, topical anesthetics were developed, making this
kind of procedure much easier.
With the development of modern techniques
of general anesthesia and endoscopes with tiny light bulbs
and later fiberoptic light sources at their tips, upright,
“chair” surgery became less and less common. By
the 1970s, it had largely become a lost art.
By the early 1980s, excellent optical endoscopes,
video technology, topical anesthesia, and short-acting sedatives
made “chair surgery” once again logical. In the
United States, Dr. Bastian helped to pioneer the reintroduction
of office-based surgery via his teaching at Loyola University
of Chicago, training of fellows, visiting professorships here
and abroad, teaching at the American Academy of Otolaryngology,
and his publications. Today, these approaches have become
much more common, and they remain a specialty of Bastian Voice
Institute physicians.
The advantage of office-based surgery is
that the procedure – whether biopsy, injection, laser
surgery, or otherwise – is performed in an awake though
sometimes sedated patient whose throat is “numb.”
Unsedated patients can drive themselves home afterwards. The
clinical processes of both diagnosis and treatment are noticeably
sped up, and of course the approach is highly cost-effective.
This methodology is particularly advantageous in individuals
whose anatomy makes operating room direct laryngoscopy difficult
or whose medical condition is poor, increasing the risk of
general anesthesia. The majority of patients find this approach
very tolerable, and Drs. Bastian and Richardson have performed
many hundreds of biopsies, injections, and other procedures
using this tactic.
Laser surgery
at BVI
To our knowledge, Bastian Voice Institute was the second
facility in the U.S. to have a RevoLix (LisaLaser) device
available in the office setting. Particularly advantageous
for minimal/recurrent disease, this laser can be used on selected
lesions in the videoendoscopy procedure room of BVI’s
facilities with the patient awake and topically “numbed,”
rather than in the operating room.
Office esophagoscopy
In keeping with the movement in medicine toward minimally
invasive methodologies, a newer endoscope has been developed
by medical technology companies and called the transnasal
esophagoscope (TNE). This new videoendoscope allows Bastian
Voice Institute physicians to visualize not only the larynx
and throat but also the entire length of the esophagus into
the stomach, to diagnose or to follow conditions such as strictures,
Barrett’s esophagus, and so forth. Instead of requiring
a hospital-based gastroenterology laboratory, these procedures
are typically done in a non-sedated or minimally sedated patient
sitting in a chair after they have gargled / swallowed topical
numbing medicines. Those who do this without sedation can
drive to and from the appointment and even return to work
the same day as the procedure.
Videoendoscopic
swallowing study (VESS)
Beginning in 1983, Dr. Bastian developed and taught
widely a comprehensive virtually stand-alone protocol for
endoscopic, rather than radiographic, evaluation of swallowing.
Published with the moniker VESS (elsewhere aka FEES for “fiberoptic
endoscopic evaluation of swallowing”), this technique
for swallowing evaluation can serve as a stand-alone replacement
for VFSS (“videofluoroscopic swallowing study”
aka “modified barium swallow” aka “the cookie
swallow”) in many circumstances.
VFSS is the better examination for cricopharyngeus
muscle dysfunction and esophageal disease; VESS is arguably
superior for assessing neurological or anatomical deficits,
for the bedfast patient, and for follow-up examinations in
those who have been shown not to have esophageal disease,
as well as for those whose swallowing status is changing rapidly.
Laryngeal videostroboscopy
This diagnostic technique is performed in the state-of-the-art
facilities of BVI. Laryngeal videostroboscopy is a technique
of examining the larynx that includes special endoscopes coupled
to both continuous and strobe light, a video system, a TV
monitor, and a computer. This technique produces highly- magnified
views of the larynx that are videodocumented for later study/review
with patient, speech pathologist, family, and so forth. In
normal light, the vibration of the folds would appear as a
blur; the strobe light allows assessment of apparent individual
cycles of vibration.
Indirect procedures on the larynx
and pharynx
Indirect procedures most commonly use a laryngeal telescope
and video system to illuminate and magnify the larynx and
pharynx. The patient sits in a special chair and is topically
anesthetized and sometimes sedated. In contrast to direct
laryngoscopy, general anesthesia is not needed. Procedures
amenable to indirect surgery include biopsy of a suspicious
lesion; injection of cymetra for vocal fold paralysis; cidofovir
injection for laryngeal papillomatosis. These and other similar
procedures can be performed routinely in the video-endoscopy
procedure room, thereby avoiding the need for general anesthesia
and an operating room facility.
Cidofovir injections
for laryngeal papillomatosis
BVI physicians often inject cidofovir into the base
of lesions that have just been removed surgically via direct
laryngoscopy under general anesthesia. Subsequent injections
are then performed during indirect laryngoscopy on the premises
of BVI. Cidofovir is also known as Vistide™. This is
a newer anti-viral drug originally developed for a different
indication and now appearing to have value in the treatment
of laryngeal papillomatosis. It is increasingly used as an
adjunctive, off-label treatment for human papilloma virus
infection in the larynx (aka recurrent respiratory papillomatosis
(RRP) aka laryngeal papillomatosis).
Cymetra™
injection for vocal fold paralysis
Used primarily but not exclusively as a treatment for
vocal fold paralysis, this procedure is virtually always done
at BVI in the videoendoscopy procedure room, rather than under
general anesthesia in an operating room. Cymetra™ is
a human collagen product. The collagen is micronized (ground
into tiny particles) and treated to remove any possibility
of contamination with bacteria or viruses. It is then made
into a dry powder. Before use, it is reconstituted to create
a paste consistency that can be injected through a relatively
fine needle. Commonest use is to fatten and firm up a paralyzed
vocal fold. Duration of benefit varies between six weeks and
six months. Consequently, this procedure is used when only
temporary assistance is needed – as when it is believed
that the vocal fold’s function will recover.
Biopsy of selected
lesions of the larynx, pharynx, trachea, or esophagus
At BVI, the majority of biopsies are performed on-site,
in the videoendoscopy procedure room. A return to this approach
was pioneered by Dr. Bastian. On-site BVI biopsies are performed
using special endoscopes and other instruments along with
video apparatus. The individual is topically anesthetized
and sometimes mildly sedated. If unsedated, the individual
can drive himself or her-self to and from the procedure. BVI
physicians continue to use “traditional” operating
room biopsy techniques in situations where that approach is
better suited.
Botox injections
for spasmodic dysphonia
BVI physicians treat hundreds
of persons with spasmodic dypshonia. Lifetime caseload is
approximately 1,300 patients. Injections are offered each
week, utilizing a technique developed by Dr. Bastian that
strives to provide consistency between injections. This technique
was designed for use with EMG guidance. Rarely, individuals
prefer to be injected using an indirect approach (see above).
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