Keypoints:
  1. Office base laryngeal biopsy has been increasingly spreading around the world.
  2. Benefits from office based procedures including time saving and avoidance of general anesthesia and saving of hospital cost.
  3. Short description of the setting and tools and approaches used in office based biopsy.
  4. Short description of the types of local anesthesia used.
  5. 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.