Keypoints:
- Office base laryngeal biopsy has been increasingly spreading around
the world.
- Benefits from office based procedures including time saving and
avoidance of general anesthesia and saving of hospital cost.
- Short description of the setting and tools and approaches used in
office based biopsy.
- Short description of the types of local anesthesia used.
- Transoral approach in obtaining biopsy has a higher sensitivity and
specificity.
Abstract
Objective: The aim of this study is to explore the accuracy of
two different approaches; trans-oral versus trans-nasal office-based
laryngeal biopsy.
Design: cohort-selection cross-sectional study.
Setting: outpatient clinic of Phoniatrics [removed for blind
peer review]
Participants: The study was a that included all patients aged
18 years or more with suspicious lesions of the larynx or the oropharynx
who are eligible for biopsy who came to the outpatient clinic, due to
different reasons during the period of March 2017 and March 2020.
Main outcome measures: Patients with suspicious lesions were
referred for office-based-based biopsy; either trans-nasal biopsy or
trans-oral biopsy. Then, all patients were referred for subsequent
direct laryngoscopy for definitive diagnosis.
Results: The overall sample was 60 cases; 30 in each group. The
majority in both groups are smokers. The most frequent cause of referral
for biopsy was suspicious laryngeal mass. The number of biopsies
obtained was significantly higher in the trans-oral group. Both
approaches were tolerated by all patients with few limited aspiration or
epistaxis.
The sensitivity of trans-oral approach compared with that of direct
laryngoscopy was 95.8% and the specificity was 83.3%. On the other
hand, the sensitivity of trans-nasal approach compared with that of
direct laryngoscopy was 26.3% and the specificity was 90.9%.
Conclusion: The trans-oral approach to obtain a biopsy from the
upper aero-digestive tract has better diagnostic accuracy than the
trans-nasal approach. When combined with trans-nasal visualization and
transcricothyroid anesthesia.
Keywords: Trans-nasal approach; trans-oral approach;
office-based laryngeal biopsy; sensitivity; specificity; diagnostic
accuracy.
Introduction
Cancer is still the most disastrous disease in the world. The fifth most
common cancer is that of head and neck cancer, with more than 500
thousands newly diagnosed cases every year with the laryngopharynx as
one of the most frequent sites. It is considered the second most
prevalent malignancy of the head and neck. Moreover, squamous cell
carcinoma (SCC) of the larynx continues to be the commonest cancer of
the head and neck in many countries. Also, cancer of the oropharynx has
been on the rise. [1-3]
The milestone in diagnosis is the tissue diagnosis by obtaining a biopsy
for histopathological examination which is a crucial step that must be
completed before any treatment. Traditionally, laryngopharyngeal
biopsies have been obtained in the operating room under general
anesthesia. [4-5]
The advent of the technology of the flexible fiber-optic and the distal
chip scope allow these procedures to be performed in awake, non-sedated
patients under local anesthesia in an office-based setting. Office-based
biopsies are performed in clinic examination suite. This suite consists
of an examination chair and a video tower with photo-documentation
capability. No cardiopulmonary monitoring is performed during the
procedure; however, the patient’s vital signs are collected before the
visit. [4-5]
A flexible trans-nasal laryngoscope with instrumental channel is used to
obtain the biopsy through the biopsy forceps passing through the channel
of the laryngoscope. Alternatively, a trans-oral approach may be used.
[4-5]
Obtaining the biopsy in the office rather than in the operating theatre
has several advantages as there is no need for general anesthesia with
all its subsequent risks. Also, many patients have bad general health
conditions that add to the risk of general anesthesia especially in old
age, cardiac patients and many other conditions. [6]
There is little written on office-based biopsy of the oropharynx and the
larynx. Thus, the rationale intended for this current study was to
explore the accuracy of two different approaches; trans-oral versus
trans-nasal office-based laryngeal biopsy.
Methods
The current study was a cross-sectional diagnostic accuracy study that
included all patients aged 18 years or more with suspicious lesions of
the larynx or the oropharynx who are eligible for biopsy who came to the
outpatient clinic of [removed for blind peer review]due to different
reasons during the period of March 2017 and March 2020.
The objective of the study as well as the steps of the procedures was
explained plainly to the study participants. All participants included
in the study have provided an informed consent. The Ethical Review Board
has approved this study.
Suspicious lesions were a lesion on an immobile vocal fold, ulcer,
leukoplakia or erythroplakia, a mass with cauliflower appearance.
Exclusion criteria were: age less than 18 years, refusal to participate,
patients with benign-appearing lesions such as polyps, nodules, Reinke
space edema, and chronic laryngitis due to GERD.
Patients with suspicious lesions were referred for office-based-based
biopsy; either trans-nasal biopsy or trans-oral biopsy; to determine
whether the lesion was malignant or benign. Then, all patients were
referred for subsequent direct laryngoscopy for definitive diagnosis.
Findings of carcinoma in situ (CIS) were added to those of invasive
carcinoma when sensitivity and specificity measurements were calculated.
Histopathologic results of the specimens from both approaches were
compared to the results of direct laryngoscopy biopsy.