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.
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.
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, using 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).