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I work here at the Biotech >> I'm Tom Zinnen.
And I'm happy to be partnered with the Wisconsin Alumni
Association and the UW-Madison
help bring you Wednesday Nite at Lifelong Learning Institute to
Tonight, we have Seth Daily, the Lab.
here at UW-Madison's School of Medicine and Public Health.
Seth got his bachelor's of
University in New York. In 1996, he received his M.D.
at the New York University
From 2002-2004, he was an instructor at the Harvard
Medical School in Boston. And since 2004, he's been an
assistant professor here at the University of Wisconsin School
of Medicine and Public Health.
about "Out of the O.R. and Tonight, he will be talking
of Upper Airway Surgery." Please join me in welcoming
Seth Dailey to Wednesday Nite at the Lab.
( applause )
much, Tom. >> Thank you very
to be here. Anything that's associated with
Public Television and Public
participate. Radio, I'm always happy to
childhood memories, for whatever I feel like one of my earliest
Morning Edition for me. rAnyway, tonight we're goingof
talk about the present and
office-based procedures. future state of upper airway
state of upper airway academic This is just to note that the
recent article published on recomplications of sword a
swallowing in the British Journal.
Okay, as you might imagine, the number one complications were
laceration of the esophagus and stomach.
So, I'm glad that as we progress
quality of academic medicine is talso accompanying that.e
So this is actually a woodcut of
But this is what I hope not to early use of ether.
hour. doSo we're going to talk aboutxt
unsedated office-based
And on first pass, it may seem procedures in laryngology.
tip of left distal finger sortsurgery in the future. the
It may seem like something
But it actually represents sort tof an interesting window intoe.
the future of many surgical procedures.
And there are probably a number of buzz words that will come
into play here, minimally invasive, laser, awake,
avoidance of general anesthesia,
Things that are in the to morbidity, things like that.
in kind of public media, public and otherwise, may come to play
here. So my preferred format for
lecturing is to have it be as interactive and teamwork based
as possible.
for questions, and I'm not sure Soif this is okay with Publicend
Television here, okay, I'm
I would prefer, if there are getting the thumbs up.
we go. questions, to just fire away as
I'm not afraid of people I'm from New York.
It's not a big deal. interrupting me.
try to present to you the logic Thof some of the unsedatedto
procedures for the upper airway.
we do both in the larynx and We're going to talk about what
esophagus. then also in the trachea and the
show you what's possible now, things that even I as a fellow,
or I should say as a resident,
would've thought were not only maybe six or seven years ago,
unwise. I'm going to try to show you
quite a few video demonstrations.
My mother used to say that I
now because I could never sit never knew astill.sery rhymes
I could never sit still for a lot of words.
So we're going to do a lot of video tape.
Then I'm going to review the UW experience, some of the pros and
pitfalls of things to take note of, so hopefully this will--
Not everybody is a gigantic lover of the larynx, so I
thought it would be useful, even
some basic anatomy and for a moment, just to review
The larynx is an organ near and dear to my heart, but not near
and dear to the heart.
It starts at the base of the ( laughter )
bone here, which often is called, in layman's terms, the
tongue bone.
this called the thyroid There is acartilage.ke part of
That is most easily identifiable
there that is a little bit more prominent in men than in women.e
This cartilage down here called the cricoid cartilage is
circumferential.
or ring. It's more or less like an oval
circumferential ring of the And iairway. only
You'll note that the larynx sits
It is sort of like the guardian, on top of the trachea.
the lungs and the trachea. the sentinel, the protector of
and out, and nothing else. It's supposed to let only air in
immediately behind the trachea, so that the larynx, in many
ways, functions like a stop/go
Air is supposed to come this valve.
the same entry point in most way, and food, which also has
So it's really the vocal cords cases, goes into the esophagus.
cartilage that allow it to on the interior of this thyroid
valve. function well as a stop/go
it, just with all it's So the larynx, if you look at
and you explode it, here's the cartilaginous or boney parts,
There are these two small cartilages toward the back that.
move back and forth.
like a V-shaped valve. The vocal folds are more or less
that V-shaped valve. These cartilages are in back of
fingers, those cartilages would be where my finger pads are, so
right at the tip. They insert, the vocal folds
insert onto the interior of this
Then here is this sort of serpent's head shaped epiglottis
that folds down every time you
airway from food and drink, and sbeer, and all that sort ofr
stuff.
from the back. So this is the larynx viewed
back of the cricoid cartilage, Again, here is the trachea, the
And the vocal folds would be two arytenoids.
one, into the screen, and insert extending from this one and this
If you were an right about there.
going to put a breathing tube in anesthesiologist, and you were
their back, this, hopefully somewould be your view.n on
So here are the vocal folds,
point of the V is pointing which are pointing, the sharp
And you can see some tracheal towardrings.ront.
That's where the airway goes. So there overall, there are
three main functions to the larynx.
One is to permit air to go back and forth.
The other one is to protect the airway from water.
Then one of the other major ones, although developmentally
this is a late development, is
The sound source so that we can have a resonant communicative
voice.
so we can clear our lungs and Othelp improve our pulmonaryh,
physiology. Then another function is the
so-called Valsalva maneuver,
airports. When people are carrying heavy
bags, that sort of grunting is
intra-abdominal, intra-thoracic force against a closed set of
vocal cords, so that this area
use your arms and legs can remain stable and you can
fashion. independently and in a stable
for generating voice. You need the generator, which is
air.
vibrate. The vibrator, something to
You can use your vocal cords. YThen the resonator.s.
The resonator is everything from
It is what we call our signature your vocal cords up.
This is why I sound like me and you sound like you.
And also why, for example,
They can do all kinds of crazy impersonators can make a living.
It has nothing to do, really, twith their vocal cords.
themselves. It has only to do with your
signature horn, starting here and moving up, to the tip of
your nose and lips. Question, please.
( inaudible ) Right, good question.
So ventriloquists use their vocal folds and they use their
articulators, their tongue, their lips, but they tend to use
them so they don't really have
So they can make sound and to move their lips a whole lot.
components to make all sorts of change thsounds.iculatory
But they tend to have mastered
lips a whole lot. So it appears that they're not
talking.
In general, there are three components for high quality
glottic, and glottic refers to
me say glottic and vocal cord, the vocal cords, so if you hear
Closure, meaning the vocal cords those are synonyms.
order for them to oscillate. have to be nearly closed in
pliable. They need to be soft and
like the other. Let me do a demonstration here.
By Bernoulli's effect, if you have things that are soft, and
you have an air stream that passes by them, they will be
sucked together if they are close enough together.
So like this. There's an air passage.
There's the production of a relatively low flow area.
So things that are soft and pliable will be drawn in.
If I move them apart
( laughter ) and blow again...
Nothing happens, other than me Right?
They don't get drawn together because they're not close
enough. So the vocal folds need that
near closure. They need to be soft and pliable
so that after they're sucked
apart. together, they push themselves
qualities and viscous qualities to be sucked in in the first
place.
that works. TThis is a section of the vocalw
cords.
moving back and forth. It is the vocal cord, again,
this dimension and cut them like However, we'll rotate them in
This is one vocal cord. Can you see that up there if I
do that, or do I need to use the
It's okay? pointer?
surface of the vocal cord, which So this would be the very
Wrap. You can see right through it.
If you had enough epithelium of the vocal fold, you could read a
newspaper through it. It's only, maybe, 200 microns or
a fifth of a millimeter thick.
called the lamina propria, which Then there's a crucial area
oscillate when air passes by. It has both viscous and elastic
properties. It has living cells.
It has non-living things, like
a shock absorber. glycoIt's really kind of anto be
extraordinary area, where we're trying to, as a group in our
division, do quite a lot of work
we can restore voice to a lot of to tissue engineer this so that
Underneath that there is a people.
generate tension on the vocal folds and modulate tension.
In fact, the superficial most layer of this muscle has a neuro
density, which is 50 times that to the hand.
So we think that the hand is a
Well, take for example the very well controlled organ, etc.
density, the control mechanism vocalis muscle, where the neuro
So the voice, over time, has is 50 times greater.
element for our survival. bThis is a picture of somethingt
called a stroboscopy. Stroboscopy is a visual
technique which we use to image the larynx in the office.
And more often than not, we use a rigid telescope through the
mouth that looks down at 70 or
You project that image through a 90 degrees at vocal cords.
And apply stroboscopic light, camewhich takes in essence aor.
composite picture of vocal fold oscillation.
So if I do this, for example. ( hums )
That's about 100 cycles.
eye. So we can't see that with our
down, so according to Talbot's So the stroboscopy slows it
hold an image on your retina for Law, which says that you can
will turn it into a movie. about .2 seconds, your brain
you have a flip book, and you Sosee different pictures of if
somebody sequentially doing something and you flip it, your
brain will turn it into a movie.
This is a stroboscopy. So moving pictures, same thing.
It looks like they're moving You see the vocal folds.
But they're not. back and forth sort of slowly.
with our eye in the clinic and That's just so we can look at it
about the pliability, the msymmetry, the appearance, then
color.
skills. JThis is not necessarily new.
A German thought this up in 1855.
And so, it's taken basically, until the early part of this
century to devise some better methods.
And really until the 1970s to have the imaging technologies,
with the rigid scopes and the flexible scopes to be able to
use it as a clinical tool.
usable for about the last 30 It's really been clinically
We're still using it. I would say it's the standard of
care. So given that we can do a
certain number of things in the office, like a stroboscopy, I'm
sure just about everybody here
office-based procedure. Let's talk about dentistry for a
moment, not to make it too
But we can do all sorts of uncomfortable.
office. things to pWell, why?eth in the
Principally because of
the "caine" drugs of different lidocaine, novacaine or any of
achieve local and topical varietianesthesia.p us to
That is the gateway towards office-based procedures.
A good dentist will also have a nice, what I like to call
anesthesiology voice, so they can come in and...
( speaking softly ) Good morning, I'm going to
drill out your teeth today. It's good to see you.
( laughter )
verbal anesthesia, if you will. If you are a good verbal
anesthesiologist, and you apply your local and topical
anesthetics properly, you can really get away with a lot for a
short period of time. So we can achieve what we call
an anesthetic window. So why should we do things in
the office? First of all, compared to
general anesthesia, usually there is lower patient
morbidity.
way of saying damage to you. Morbidity is just a different
because you're not instrumenting There's often lower pain,
because you can't, for many the persoreasons. as much,
With office-based procedures, there's no sedation.
There's no intravenous line.
There's no fentanyl. There's no valium.
You are awake. There's no falling asleep.
verbal anesthesia working for You have topicyou.nesthesia and
So people, for example, undergo many of the procedures you're
about to see, and then drive
appointment. themselves home from their
there is a similar efficacy for the types of procedures that we
perform in the office and we
The caveat to that, of course, perform in the operating room.
that you simply can not do is there are certain things
There are limits. Most patients who have had a
procedure done in the operating room and a procedure done in the
office will prefer to have it done in the office, even if they
have to repeat it.
have two procedures in the So for example, if they have to
that it would take one in the oOR, most people will probablyl
choose the office.
States, and there's been a lot Importantly, in the United
that we have an aging of talk abdemographic.ently, is
This comes up under talk of Social Security, Medicare.
The $41 trillion to $135
boomers over the next 40 years, about which there is a lot of
debate. So this is a time when people
over 50, people over 60, people over 70, will be having a lot of
voice, so to speak, in their own
This tends to be a generation that knows what it wants.
It tends not to be shy about
And they are overall educated about how the healthcare system
has progressed and how to negotiate it a little bit.
So the last reason to do it is
A lot of these laser procedures, that it's possible.
see, were simply never possible and other thbefore.u're going to
So here is, and some of the numbers may be a little small,
so I'll just say a little bit.
to 100 million. This This is the year 1900., up
This is the year 2000.
These are from the US Census So we're right about here, 2008.
These are projected numbers of Bureau.
number over 85. The number of people over 85 in
2050 will be 20 million people. That's a lot, okay, especially
given in 1960, it was maybe a million.
The number over 65, you can see also where the trajectory is
going.
number and proportion of our This is a reasonably substantial
in healthcare. population that will be involved
consideration. Here's the other important
Anesthesiology Association. You can have a risk score.
So the risk score goes from one to four.
On this axis is the probability of any major complication.
Here is the age in years. This is for folks undergoing
procedures under general
This, you can see, with every pre-operative ASA score, the
risk goes way up. If you have, for example, a
number of medical problems, and you're about 80 years old, and
you're undergoing a procedure under general anesthesia, the
chances of you having a major complication, heart attack,
stroke, problem, is about 15%.
That's a lot. SIf you're going to play thee.
lottery and the chances of
would play. wSo this is a very meaningfulu
number. And when you multiply the
previous slide times this, you
a lot of people undergoing major can see that the possibility of
the future is reasonably complications, or minor ones, in
What about playing my own devil's advocate.
Why would you not do procedures in the office?
First of all, the equipment is
So not everyone can do it. expensive.
and neck surgeon. But certainly not every practice
is going to invest in this sort of thing.
We have a specialty practice. There are only, maybe, 50 people
nationally who do what I do.
And you need to invest. There are reimbursement
problems. So for example, even though we
can bill for a procedure that would otherwise be done in the
operating room, we are not
even though the patient is reimbursed in the same fashion,
So in fact, currently, there's a getting the same service.
companies for physicians to disinlearn and do this.ance
So what we're trying to do over time is to demonstrate to
insurance companies that this is
benefit not only them, but the actually something that would
It takes extra staff and extra whole population.
Again, you know, revenue training.
There are technical challenges. This is not something that you
want, you know, this is not like
and using it. goingEven I can do that. ipod
But the technical challenges are
learning curve, learning how to considerabldo it.erms of the
You know, build some verbal anesthesia, how to coax people
through things that are a little
And anesthetic management both, as I was saying, verbal and the
topical.
studies, which have been done preliminarily to try tof
demonstrate that there are
healthcare system to do these finatypes of procedures.the
Some of my colleagues have been using a laser, which we have
here, called the pulsed dye laser, that we can apply to
folks, to their larynx and their
And they're comparative study, trachea in the office.
$8,000 versus $2,000. frIn the operating room, it'llt
cost $8,000 to the healthcare system to do it, where in the
office, about $2,000. So they calculated in the range
of somewhere of $5,000 per case.
not all that substantial for the The reimbursement, however, is
So again, it's disincentivized physician.
So we have a little bit of work in the cuto do.climate.
For other office-based
injections, some of my other procedures, called vocal cord
analysis where they looked at colletheir experience withid an
office-based vocal cord injections versus those in the
operating room. And they generated a cost
analysis where basically, for the number of vocal cord
injections that are performed nationally, that it would save
the system about $40 million a
So there can be arguments made year.
and that sort of thing, but the abogeneral idea you can see.ues
That basically, it's going to save everybody morbidity and
money.
( inaudible ) It's a wonderful idea.
What I'm really hoping for is for one of them to become
dreadfully hoarse and then need help.
( laughter )
you know? Even BDreadfully hoarse? help,
So, you know, Bill Clinton only needed voice therapy, but man, I
would've been so happy if he had
So distal chip endoscopes are otherwise called chip in a tip..
So just to be geeky for a second.
Original fiber optic technology was used for flexible scopes
starting in about 1968 to 1969
And what they did was they by Olympus in Japan.
a plastic coating, a sheath. passed individual fibers through
could direct the fibers, the And through a mechanism, you
down. dThen, through the fibers itnd
would be attached to a camera.
processor. The camera is attached to a
television screen. The processor is attached to a
just look directly through it and see something that you would
not be able to see otherwise. So this was useful for
bronchoscopy, looking in the
larynx and the nasal pharynx and lungs, and then looking at the
This was a big breakthrough. the rest of the throat as well.
are not that great and the color The problem is that the images
So what people would end up vedoing is being a littlet.
frustrated. So within the last five years,
there's something called chip in
You have a tiny, tiny, little camera at the end of this
flexible, you know, elephant
And so, instead of having the processor back here doing all
the image capture, to a certain extent, it's all being done
right up close and personal.
probably going to screw this up, So also with Moore's Law, I'm
five years, you will half the bucost and double the power ofry
your technology, something close
These distal chip endoscopes are to that.
You'll see images from them. becoming very popular.
esophagoscopy, and We use them in laryngoscopy,
So, larynx, esophagus and traairway.py.
We can perform
So for teaching purposes, for sharing with other physicians,
it's extremely useful.
case they're saying you never For melooked and we did.es, in
New injectables.
cord, this is going to be a big, So things that go into the vocal
the next three to five years, bigbecause we will be in thehin
process of developing something called hydrogels.
Hydrogels are going to be biologically active.
And they are, in fact, instead
kind of sits there like a little of just being a filler that just
initiate biological changes to gel, they're actually going to
people with scar, to help people the lamina propria, to help
maybe people with irreparable wchanges from smoking, a whole,
host of things. So these injectables are
definitely on the horizon for us.
Lasers are something that came
this, I think in 2004, when I was a fellow back in Boston.
My boss was developing the use
papilloma of the larynx. of this laser for people with
generally speaking, and has a propensity to go under the vocal
cords.
very hoarse. So it makes people very,
So the idea is to try to help people while hurting them as
little as possible, both in terms of anesthetic and then in
terms of thermal damage to the
thing. vocal cords and that sort of
some of the things we can do So with all that said, here are
of the vocal cord, laser with these injections: Biopsies
airway examination. So how the heck do we get into
the larynx? The difference in many ways
between hoarseness and
is that with dermatology, you roll up your sleeve and you say,
you know, I was in the shower and I noticed something funny,
doc, what do you think? I can take a look.
But if you have a hoarse voice, really all you can do is say,
you know, there's something wrong with my voice.
Then you know, you can try and
scanner, or whatever, but it's look through there with a larynx
You need to have imaging. So after you have imaging and
you want to do something about
to the larynx. it, you then need to gain access
I'm going to show you a couple So how do you do that?
You can go through the mouth. And the first trans-oral
procedure was done in about 1855
American. He looked inside someone's mouth
and saw this very large cyst
and was able to retract it and sitting on top of the epiglottis
So it wasn't particularly pretty, probably, but it was
historic. It's always a little ugly at the
beginning, I would say. So trans-nasal injections are
done by putting one of these
the nose. dThen they have these, if youh
picture a cylinder, and you core
that would be what we call a a small tunnel in the cylinder,
So in this hose, you can have a have a working channel through
which you can pass the laser
these cute, little needles, so fibers, and do suction, and pass
cord that way. you can also inject the vocal
through the skin. This is a plastic model of a
throat and head, cut right down the middle, more or less.
Here's the voice box. Here's a needle, which you can
see going through the mouth, so that would be trans-oral.
Here's a needle going through the skin, right into what we
call the endolarynx, so the interior of the vocal cords.
And I'll show you some pictures.
Question, please. Thi( inaudible )c set-up.
( laughter )
And in about three slides I will It is a wonderful time to ask.
with that. show you how we begin to work
set-up with a whole lot of So here, this is our general
So this is probably a quarter-million dollars of stuff
just sitting here.
There's a processor. There's a power chair.
There's one laser. There's the video monitor.
There's a bunch of fibers, and There's another laser.
Here's an attachment to the computer system at the hospital.
So when we record these images, they go right into the radiology
system. So that way, if other physicians
or other people want to look at them, they can.
It's really, really good for
These are some of my assistants, patient care.
procedure clinic run. Here's a video, okay, getting to
your question, of how do you
larynx. applyThis is just one way.o the
This is me. And here is the patient.
In my left hand is a rigid
the vocal cords. endoscope, which looks down at
canula, a curved metal tube, In my right hand is a curved
You deliver lidocaine while the patient is phonating, while they
are saying "e". ( inaudible )
You can see it kind of bouncing around here.
He's going to breath it into the
This is a little uncomfortable. tracheOkay? cough.
This is what it looks like if you have a telescope and you're
looking down at the vocal cords.
Here's the drip. There's no sound on this video.
You really don't need a lot, You can see drip, drip, drip.
to a cc two or three times. sAnd by the time that bounces
around, it basically does all the work for you, it's great.
So it bounces around and it anesthetizes all the mucosa of
the interior of the larynx. You have to remember that there
are three major things that we're fighting here.
One, is people's psyche.
which is a very powerful complex Two, is the jaw and tongue,
Three, is the larynx itself. of muscle and bone.
the larynx during a job Tinterview, larynx, you know,k
what really makes you tick? "I like to protect."
So the larynx is a protective organ.
When it gets nervous, it shuts. It's a protective organ.
So we're having to work with all
happen. those thiAnd it can.to make it
But it has to have the right
And it has to have lidocaine. So vocal cord injection is one
of the things we do a fair
And I'm going to say, well, who amcares.f.
So basically people with vocal
When you have vocal cord cord paralysis is one reason.
moves and the other side that paralysis, tdoesn't.ne side that
So when you think about the vocal cords like a valve, vocal
cords work better, again, like
close together. theSo I'll now do a voice of're
someone who has vocal cord
A very breathy voice, and he's air wasting.
The vocal cords don't come together.
You have air leakage. And when you have air leakage,
people get very tired.
And then, even because they can't close well, they can't
protect their airway well, so they have trouble with
swallowing. They also have trouble with
coughing. They can't expel things from the
lungs.
This is something, again, which we can easily address in the
office with vocal cord
The most common reason, probably, in our practice and in
the community as a whole, is
nerve that goes to one side of surgery that challenges the
So there are basically two the larynx.
nerves from the bottom for each nervhalf of the larynx. two
It's usually the bottom nerve,
nerve, which is the one that called the recurrent laryngeal
these types of surgeries. We can inject a lot of other
things, including Botox.
being used in plastic surgery. So Botox gets a lot of press for
really a fabulous and amazing It's a wrinkldrug.ucer and it's
It has uses for chronic pain in certain instances.
It can reduce saliva in people
We do that. And it can also be used, and
this is our primary use, is using it for people with
neurological disorders of the larynx.
So something called spasmodic dysphonia, where people end up
having strained voices. Speaking of Public Radio, etc.,
Diane Rehm is someone who as
to function as a radio announcer spasmodic dysphonia, but is able
Steroids can be injected, sometimes for vocal cord
nodules, for other inflammatory conditions.
So there's a whole host of
there. things which we can get in
Here is a video of a very small, Here's another video.
into the very superficial part this is a 25 gauge needle, going
steroids. of This is for mid-vocal cordng
nodules.
to initiate voice therapy in We find that this can be helpful
of singers get, a lot of moms peowith three kids and a dog,lot
people who use their voices a lot, or in loud places, and
people who really drive their vocal cords with a lot of force.
( inaudible ) I'm injecting some steroids.
So a glucocorticoid steroid,
Glucocorticoids will shrink swelling, and exert only a local
effect. That's kind of the desire there.
Remember I talked about the transcutaneous, so through the
skin approach to the larynx.
with spasmodic dysphonia. HAnd the needle is going righty
here, below the vocal cords, in a place called the cricothyroid
membrane, which is where we do
emergency room. We do it as infrequently as we
can.
superficial part of the vocal cord called the lamina propria
and into the muscle.
effect, on the muscle. That's the Botox is exerting its
chemodenervator. It's a so-called
It weakens muscle, partially It denervates muscle.
It does that both here and here. through a chemical effect.
the doing part of the procedure You canwithin a minute.ne with
But the preparation, all that,
If you think about it like some gigantic airplane taking off or
something, it's taxiing and taxiing, taking up speed, and
then finally it lifts off.
speed that's important. But itQuestion, please.king up
( inaudible ) So the Botox treatment lasts
somewhere between three to 12 months, depending on
the severity of symptoms of the patient.
If we're talking about
larynx, somewhere between three neuroland 12 months.f the
Usually around three or four. It's more unusual to have it
last 12 months. It's usually about every three
to four months. It's not a cure, but it's a
pretty effective, pretty
So we don't have a cure for many minimally invasive treatment.
actually centrally based. So in other words, they have to
do with your central nervous
manifesting in your larynx. systQuestion, please.imply
It's so intricate, how are
human voice? some birds able to imitate the
question. Our anatomy is very intricate in
terms of the larynx, how is that
human voice. birds are able to imitate a
something like that? You mean like a parrot,
Well, I must say I haven't Got it.
But I would say that birds looked into that a whole lot.
larynges. I think they even have something
where they can have two different sets of vibratory
elements. So I'm not so sure that it's any
less intricate than ours. But it does obey all the same
rules of physics, as far as having a generator for air, a
vibratory source or something to
articulatory source. vibrate, and then an
parrot can mimic a human voice So the fact that, for example, a
auditory ability to process what is based in part on their own
But from a physical standpoint, theit's also that they havet.
a tongue, that they have lips,
They have a throat which they can alter to shift the shape
of the sound and all its
can sound like something else. frequencies, etc., so that it
And the anatomy is conserved It's really all basic physics.
they can do that. So if you're going through that
cricothyroid membrane you can't,
through the nose and then as the surginject.ld the scope
You know, with two hands, it's
Here, you have to have an not assistant.ork.
This is one of the residents who
scope while I place the needle is helping me by holding the
there. through the front of the neck
beginning, some of those So another way, you saw at the
thyroid cartilage, that's like a pictures of the larynx, that
And it kind of protects the vocal cords.
So you can go through that, directly through the shield and
into the vocal cord.
the lights up here, I don't know So if you watch here carefully,
If they can't, it's not a if thosdisaster.doused.
But if you look in this area, you'll see that there's sort of
a poking. Thank you, very much.
That's great. You're going to note there's
sort of a poking right there. That's the needle that's gone
through the cartilage, through
propria, and is identifying titself under the epithelium.a
Then I can draw it back just a
medicine, the Botox in this tcase, in the right place.e
We can have the lights back up
Great. please, thank you.
Question, please, yes. So what else is possible?
with a scope, why wouldn't you >> When you go down the throat
instead of subcutaneously? do your injections through that
repeat the question. >> I'm being instructed to
through the nose with a scope, The question is if you can look
channel of that scope as a why wouldn't you use the working
The answer is that you can. The answer is that you can, and
that's a reasonably new technology, for which the
largest series has only just
year. And we, actually just got the
catheters to be able to do that within the last two weeks, to be
able to try that out. Can you?
Absolutely. One of the advantages of that is
that you can do it yourself in
You need less personnel. sort of a one-person show.
One of the disadvantages is that That's nice.
little large. And differences in gauge can
mean a reasonably considerable
potentially. amount of risk in bleeding,
they're over 65, is on 81mg of Because everybody now, if
or some combination therein. aspirin, or plavix, or coumadin,
blood thinners. And so for me, I'm going to feel
more comfortable once-- You okay?
Okay, sorry.
know, I should've brought my All this talk of anesthesia, you
Okay, all right. lidocaine.
possible. I don't have great data for you
yet, about how much better or worse it is than anything else.
But it is, at some point or another, becomes a question of
preference and use. So there's science and then
there's art.
So who benefits from these So it's somewhere in there.
There are a certain number of people who are bad anesthetic
risks.
there's someone who comes in, Let'they're a smoker. that
They have something in their
favorable. vocal cord, it doesn't look
They're going to need treatment for their vocal cord cancer, and
possibly a form of radiation. Okay, because they couldn't get
surgery because they have a bad heart.
Fine. How are you going to get a
sample of their vocal cord to prove that they have cancer?
Well, you can do it in the
These you can also do using a trans-nasal scope, because
there's a little biting forceps you can use.
Or you can go through the mouth.
this. So here's someone on whom I have
done a cancer procedure for vocal cord cancer.
They had a little bit of growth there.
After six to eight weeks in the healing phase, I wanted to make
sure from a screening perspective that it wasn't
recurring cancer or persistent
So here's is a biopsy forceps going through the mouth, after
an anesthetic has been applied, to sample that area.
It's reasonably straightforward and well-tolerated.
You can see that there's really minimal bleeding.
Very good.
If we keep the lights up, can you see most of these videos?
Yes?
Then probably unless I ask Okay.
keep the lights up. specificallThank you. ahead and
So what else is possible? We can do some things with the
larynx using lasers.
General Hospital, Harvard Medical School, who as a medical
student dreamed up this thing called the 585 nanometer pulse
dye laser.
targets. Basically, all lasers have
are different types of tissue Wthat absorb the laser energy
differentially. So for example, using a CO2
laser, probably in human tissue,
most is water. the thing that uptakes that the
explodes it. Okay, so it superheats water,
example, at destroying tissue. And it's pretty good, for
very small, at cutting tissue. Or, if you make the spot size
oxyhemoglobin. The dye laser targets
components of red blood cells. Oxyhemoglobin is one of the
red blood cells within So when you apply this energy to
blood vessels, the oxyhemoglobin microvasculature, so tiny little
denatured. in the red blood cells becomes
And so if you picture small blood vessels almost like small
rivers, then those rivers become
They stop. clogged.
That's what's called They freeze up.
Photoangiolysis is possible due to the application of this
laser.
the pulsed KTP. It stands for potassium titanyl
phosphate.
principles, though. IAnd the most recent one that
we've been using is a holmium based laser.
That has been used in urology and neurosurgery in all sorts of
stuff.
like a CO2, but it can put The advantage of this is it acts
So again, a lot of this is sort thof technical advances..
We've been dreaming about a flexible fiber for the carbon
dioxide laser for the last 37 years.
Finally, basically it's here, so
Previously, the CO2 laser can work in the straight line.
Or, if you want it to bend, you have to produce this really
complicated series of mirrors.
out too well. So finally, after 37 years, it's
been figured out and you can
So who benefits from this? have a CO2 laser equivalent.
recurrent respiratory RRP on tpapillomatosis.tands for
Papilloma of the vocal cords, again, it's a benign lesion.
In pediatric form, it's really
And kids who are six years old devastating.
It's principally for airway can oftenmanagement.ocedures.
Kids are not as concerned about their voices.
Their parents might be. But the kids just want to have a
clean airway. In adults, it tends to be a
little less aggressive. And adults, especially in the
work force, now that we have
society versus, you know, larindustrial or agrarian,sed
everybody has their cell phone
to communicate. and So voice in adults with need
papilloma is really important.
Leukoplakia is basically white Leukoplakia.
Vocal cords, as you saw the pictures before, are very thin
and smooth, and they don't have flaking keratin.
Keratin is house dust, and it comes from your skin.
Your skin is keratinizing epithelium.
So when you see it flaking off, that's the covering that's
keratin.
produce that. When they're irritated, when
they have genetic changes, when people smoke for a long time,
they change.
patches. They start to produce this white
plaque, leukoplakia. Or if you like Greek, white
clear some of that plaque. The laser has been shown to
reversing some of the genetic We don't knchanges.'s actually
It's unclear what's happening.
So far, it has a favorable There's still science to do.
Because a lot of this mucosa, including vocal cord epithelium,
was thought to be condemned because of years of smoking and
irreversible changes, this is actually a very favorable thing.
One thing that gets to me,
coverage of people with vocal spcord cancer and people withdia
leukoplakia.
is because years ago, 40 or 50 The reason that it irritates me
War II vets, for example, ycigarettes were always handedld
out to the GIs, no problem. Everyone started smoking.
It wasn't for many years the
Even if people stopped smoking, r40 or 50 years later, they can.
start to get leukoplakia, and they can get vocal cord cancer.
That's because there are
that happen with smoking. It's the gift that keeps ons
giving, if you will.
they can still get these So even for people who quit,
And a lot of folks in the media do not like to cover these
stories because many people don't have any sympathy for
folks who have smoked.
that that's very nice. And personally, I don't think
grind. So that's just my little axe to
change in vocal cords. So Reinke's edema is another
aged female smokers. This is typically seen in middle
the Simpsons, you will recognize So if you're a fan of watching
Who all talk like this, "Hey, Bart, come here."
So they have very low,
And those are the voices of people with Reinke's edema,
which kind of flop back and forth, and they're very large
vocal cords.
last one. I'll show you some examples
here. So this is the pulse dye laser
in action.
You can see the flashes. It's pulsed.
flash. Flash, flash, flash, flash,
It makes a little noise in the It does pulse.
So you can see that this is not sort of a Star Wars blow up, you
know, thermally based laser.
termed a smart laser because it targets certain things to block
up the blood supply to these
For example, there are a lot of chemo therapeutic approaches
which target blood vessels to tumors.
Same thing. Same idea.
If you can choke off the blood
reduce the bulk and burden of supply, prethe tumor.u can help
Okay, this is a patient with
If you've ever wondered what Reinke's edema.
might look like, this is what Marthey would look like.rds
They're big and floppy. You can still see the flashing
of the laser. And again, you can see the
patient moving. This patient is sitting in a
chair, awake. And you have to, again, kind of
talk them through it. Sometimes with breathing,
distraction.
things, where we'll get them to either count out loud or I will
count to them, give them a break
expectation management. We're going to do this for 30
seconds and then stop.
everyone to do. But we feel that that's probably
beneficial in avoiding the
This is another example of a general anesthetic.
This is the pulsed KTP. And here you see a lot more
flashing. Flash, flash, flash, flash,
flash.
on this laser, which means you You can increase the pulse rate
more quickly. cSo if I go out to my car ande
find $65,000 in the glove compartment, I'm going to go out
and I'm going to buy one of these.
This is, remember I was talking about kind of the holy grail is
getting a CO2 type laser through
Well, it turns out that the holy a flexible fiber.
This is the Holmium laser called grail has arrived.
And when you-- the Revolix Junior.
around too much. This is not a laser that kids
So you want to definitely avoid the part of the vocal cord that
vibrates, the sacred lamina propria.
You want to keep that intact. So here, we're going to stay
back toward the back of the vocal cords for these things
called granulomas.
They used to be described in These happen to people--
So, so-called type A people with vocal hyperfunction.
people with reflux disease, which may perpetuate bad healing
and you get these lumps at the
This is a post-op, or post-procedure video, and so,
after application of the energy.
I can freeze it appropriately. I'll play that again and see if
Hmm, sorry, it's a little bit difficult to get an idea.
The left granuloma is probably
size. aboThis is after six to eightnal
weeks.
Has anyone in this room had a Sbronchoscopy.y.
Okay, so bronchoscopy, where
receive sedation. You get an IV and you get some
lidocaine in your airway. But we prefer to do is to use
only lidocaine, and then verbal anesthesia.
We don't have to go down as far into the lungs as the segmental
bronchi, blah, blah, blah.
laryngological perspective is view the larynx and the trachea,
all the way down to the split off of the trachea into right
and left main stem bronchi, that's called the carina.
So we want to go down to the
Here's the typical airway exam. There's no sound on this video.
So the vocal cords, here and
patient. here, are moving nicely in this
10,000 Leagues Under the Sea. WActually, maybe if you couldt
douse the lights, please. So this is a patient who had
symptoms of airway restriction. That's better.
Then the trachea is supposed to be round.
But here we see this slit-like
And this is a patient who had undergone a previous
tracheotomy.
Had undergone a tracheotomy. Perhaps I'll just play it again.
tracheal canula, which we put in And when you take out the
ventilatory support, in an acute for airway support and
life if they have upper airway situation to save somebody's
out, sometimes this area here in obstruction, when you take that
kind of collapses. the trachea, the front wall,
A-frame deformity of the So you get what we call an
And so this is a patient, as you trachea.
restriction. might expect, with some airway
is basically a fancy way of looking at the larynx, looking
at the trachea. People with stridor.
Stridor is the name that we use for noisy breathing.
That's in the most general
It has three flavors: inspiratory, expiratory, and
biphasic, which is both.
much. ThSo stridor is something thato
we're going to want to
And office laryngotracheoscopy investigate.
do that. is one of the ways that we can
airway exam. This is the remainder of the
yourself, well, how do you know that the rest of the airway past
that is okay? Well, let's look.
If there's enough airway, and sometimes the airway is narrow
enough that you have to ask people to hold their breath or
they get kind of uncomfortable, because the scope is going
through their main small airway.
down to the carina, which is Then you take a peek all the way
left and main stem bronchi. Then you come back and you pull
out.
We'll keep the lights low for a So this iminute.er video.
This is TNE.
esophagoscopy. It stands for trans-nasal
in this room have had esophagoscopies, or upper GIs,
more than they've had bronchoscopies.
This is a pretty common procedure.
Lots and lots of people have had
And for all these procedures, you're sedated.
You get an IV.
And from a general anesthetic risk standpoint, receiving
valium or any type of sedation, from a risk perspective is
almost as dangerous as receiving
So it's almost the same risk general anesthesia.
So by eliminating the sedation, and keeping things only limited
to topical anesthetic, you can
profile. significantly improve the risk
colleagues published a series of So for example, one of my
And the most serious 700 esophagoscopies.
episodes of nosebleed from the complications were a couple
limited with a little pressure, scoor people feeling a littlelf
faint.
So, so far, pretty favorable. So far, there has not been a
single reported case of perforating the esophagus.
So here, by using air insufflation, puffing air in,
you blow up the mucosa so that
The esophagus is sort of a it separates.
of convince it to have the walls floppy tube, so you need to kind
You do that by blowing air in. separate.
there's kind of a muscular And after you blow the air in,
motion. You kind of follow it down,
follow the peristalsis all the
We go all the way down in this way down.
You can go all the way into the stomach.
And because it has this retro flexed ability, the scope does,
you can look back up at yourself
junction. And so there's quite a bit of
flexibility with this.
burping during and after the People tend to do a lot of
that we insufflate. pSo we have to manage that ar
little bit. You have to make sure you suck
all the air out of the stomach
because otherwise, people feel a before pulling the scope out,
So who benefits from this? little funny.
where you're suspecting ulcers. People with a chronic cough,
where you want to make sure the esophagus is not causing the
cough, because that's a cause of
If there's a stricture that you want to examine.
If there's potentially a pouch
to examine. And for people with refractory
what we call globus.
pharyngeus. It's a sensation in the throat
that something is there, a lump in the throat sensation.
A fair number of people have
It has a number of different this.
It's difficult to identify from a diagnostic standpoint.
One thing we want to make sure
in the esophagus. iThese are in people who don'ton
respond to standard medications.
does have some use. SSo in the UW experience, sincet
the time I've been out here,
in about three years. wI'm sorry this slide is wrong.
It's about 450 in three years,
the esophagus. in the larynx, the trachea and
And one was for a laser We'procedure to the airway.ns.
The other one was from a
injectables. reaction to one of the
a reaction, sort of like an One of allergic reaction.caused
So that person had to be
They did fine and went home. admitted, put on steroids.
only two people had to be Buadmitted for any reason.s,
So given that everyone--
people on blood thinners. Given that there were a lot of
people with multiple medical
certain people who simply cannot co-morbidities, there are
They cannot be put to sleep without a tracheotomy.
And any type of procedure for them would be impossible with
this sort of things.
number of people who are over In Wisco200 pounds.ve a fair
And sometimes, for them, it's difficult to have a breathing
tube put in.
And so, offering things in the They're a bad anesthetic risk.
efficient treatment for things office can allow better and more
significant cardiovascular risk. which otherwise put them at
years for vocal cord injections who have needed to go to the
operating room. And for anyone who's been to the
hospital, there's something called the FACES scale, which
shows six faces.
One is a very neutral smiley One is sort of a smiley face.
And they go from a smiley face face.
one that looks extremely that doesn't look very happy to
And so it's used for kids and adults..
It's a validated scale to try to
was at any given time. assess what your level of pain
of asking people what their pain So we've gotten into the habit
And for most people, especially for vocal cord injections, it
will be either a zero or one. For some of the laser
procedures, because it's a
more uncomfortable and anxiety little weirder, and a little bit
that's from a one or a two to a provoking, esthree.ly at first,
Some people don't like these
burping, either for social esophagoscopies because of the
little uncomfortable. rSo this is really an amazinga
shift from the last 50 years of the 20th century, when we've had
the advent of general anesthetics, respirator
machines, endotracheal tubes, paralytic agents, you know, real
control in the operating room.
forced to realize with the But we realized, and we've been
not everything should be done in demographic changes that maybe
And that there's a fair number the operating room.
an out patient office-based of thinunsedated manner. now on
So reimbursement with insurance companies.
This is something that we're
incentivize all of our working on, to try to
Time and familiarity with it. We have a course this summer, a
surgery symposium, where we're
colleagues locally and going to trying to teach
these things. It's really a lot of fun for the
patients, for the staff.
because you know that they're getting great care, and that
you're not exposing them to the same level of risk.
This is just a little mini plug for the University of Wisconsin
Voice and Swallowing Clinics. We have a pretty special set-up
here. And you know, people from the
Midwest tend to be a little more
City, so I'm not as shy about reservetooting our horn.ew York
It's a very effective,
physicians, speech pathologists, professional and caring group of
And we are really trying to advance the field.
We have a very, very busy clinic.
And we try to pride ourselves on
Interestingly, for voice providing world class care.
National Institutes for Health, there's the most extramural
funding of any place in the whole country.
So this is really a place where voice research has been popular
for many years, and many
including, as I mentioned before, tissue engineering with
a vocal fold, the lamina propria
elements of the larynx. and eveQuestions, please. other
You first.
tell whether a person has had adequate training to, like if it
would be somebody you'd go to?
question. I don't know that there's any
one perfect answer for that.
repeat the question rule. ISo the question is, how do youe
know where to go to seek care from an otolaryngologist for
something like this.
that many people who do it, even The answer is that there aren't
So as a general rule, except for on a national basis.
would probably be university trans-nasal esophagoscopy, it
an established line of care for centupper airway disorders.d of
So more often than not, it's
places where they can generally gafford a little more input for
staff and training and
thing. equipment, and that sort of
private practice to support this Because it's hard for folks in
Is there a certification? leve>> No, there's not.ment.
There's no certification for
There's nothing formal like that these procedures.
I think you had a question? >> Yes, I was going to ask if
any of the procedures you discussed would be appropriate
for sleep apnea.
these procedures be appropriate for something like sleep apnea.f
The only one that I can really
the throat with a scope. think of is an examination of
and parcel of an evaluation that Sometimes, that's probably part
severe an obstruction might be we perform to understand how
But in terms of the iinterventional procedures,
probably not. Question.
When people develop what we think of as an old person's
voice, a kind of rattly.
that could remedy this Is there any of your injections
Great question. So the question is when many
people age, develop a gravely or
Is there anything that we can provide to help that.
And the answer is a resounding
The answer is a resounding yes. What we often, let me just
explain in part why people, let's say, over 60, begin to
have changes. There are, I would say, two or
three major changes.
activity, the vim factor, if you One is that the overall muscular
slightly over time. And our voices, you notice, for
example that people always have a louder or better voice when
they're standing versus when
You'll note, sometimes, an they're sitting.
Well, why is that? athletic pose when people sing.
exercise. You have to use your lungs and
your belly, blah, blah, blah. So that's part of it.
Part of it is also that the vocal folds have a slight
recession of three-dimensional
and muscle as we age. So instead of having vocal folds
that line up nicely, they begin to slowly recede, and then
there's more air loss.
the vocal folds as kind of a Remember, we're talking about
So there's more air loss. Then people end up becoming a
little bit frustrated because they can't project as much.
It's a little bit effortful, a
And then, especially in men, the little bit fatiguing.
Okay, I have to do my over 60 voiman voice now.se.
So you end up getting a little
this. Where'd I put my hearing aids,
okay, I don't know. Okay?
So it's a little bit like that. And in women, often the pitch
tends to drop a little bit, but many of the symptoms are the
same. Vocal instability, trouble
making yourself heard, feeling
It can lead to social isolation, fatigued.
accompanying hearing loss in especially because there's also
So one person has trouble making that demographic.
person has trouble hearing them. themselves loud, and the other
It's kind of a frustrating So it's kind of a double whammy.
So, in answer to your question, what do we do?
Usually, we offer some
okay, to enhance voice support, cair support, projection and,
resonance.
cord injection to both sides to Aclose down the valve a littlel
bit to allow for enhanced efficiency.
Some of the newer generation
now, maybe up to a year, maybe injectables last quite a while
It can be re-injected. more.
things we can do to help enhance There are also more durable
injecting your own fat, for the efficiexample.the valve,
There's a funny story I have to tell about that.
One of our previous chairmen in the department reported on this,
I think back in 1991, injecting fat into the vocal cords.
The next day, the switchboards
everybody wanted to donate their at the U lit up because
( laughter ) fat.
have to donate it to yourself Buand you can't really give itu
to somebody else, so there was
But you get the idea. So there are more durable things
like fat. I think there are other options,
something called a
implants and can move the vocal thyrocords closer together.lace
So there's a whole host of
And it's for people over 60 who have that concern, it's often
relieving to know that at least something can be done, and that
it also doesn't involve a gigantic rigmarole like
getting, you know, a heart
It's not a big deal. surgery.
for folks with that problem. So that can be very relieving
techniques in addition to the hydrogels, some other operations
that we're trying to devise to
I don't know who's first. help peI'll migrate back.uation.
Yes?
that a cure or do the papillomas >> With papilloma treatment, is
So the question is for the come back?
cure or do the papillomas come papilloma treatment, is it a
The papillomas come back. We don't have a cure for
papilloma.
don't. I wish that we did, but we
the vocal cords with the laser So we try to limit the damage to
procedure, while trying to procedure or any other
general anesthetic risk as expose the patient to as little
the function of keeping their possible, airway open.maximizing
Is the tumor a virus? >> A papilloma is a benign
growth. I feel like you guys are plants.
This is terrific. You're asking all the right
questions.
of the vocal folds in the airway, which is usually induced
by human papilloma virus. The human papilloma virus
probably initiates and
papillomata. perpetuates the growth of these
way an immune defect in that The disease is probably in some
out. eventually the disease burns
don't have it their whole life. And even in adults who contract
it in their 30s and 40s, they usually don't have it by the
time they have Social Security. So there are changes over time,
which we don't yet have a good
But basically, there's something handle on.
either becomes more competent or about the immune system that
etc. manages to defeat the virus,
There have been research Yes, sir?
And relating to that are there challenges in this whole area.
or clinical trials that you see? any really exciting technologies
of the research challenges, and what are some things that may be
coming over the horizon with new
Is that pretty close? So new technologies include some
of these newer lasers, okay,
popular in general which I think will become more
Right now, it's still sort of peppered amongst some university
places. I would say that there are
research challenges in the
lamina propria. hThe lamina propria is a very
interesting little compartment
And it maintains itself through certain mechanisms and changes.
And in order to provide gels to it, and cells, and scaffolds,
and growth factors in a way that
doing a lot of work in trying to makes sense, we're, as a field,
work, and then what types of understand how those mechanisms
will work the best. thinAnother major challenge.ere
I would say overall there are two major holy grails in
laryngology.
propria. One, is regenerating the lamina
paralyzed vocal cord move again. And the other is making a
muscle tissue engineering will So nerve tissue engineering and
paralyzed hemi-larynx. play into the reanimation of the
we can do that. That's not quite on the horizon
yet.
really big planet, okay. That's on the horizon, but on a
But I would say that trying to That's kind of farther off.
going to be huge. And we'll be able to fix tens
and hundreds of thousands of
It's very, very exciting. Other questions.
Yes, ma'am? >> There are rumors that voice
therapy or music therapy can
larynx and supporting help pemusculature.n their
The question is there any truth to the fact that music
therapy or voice therapy can
age. help maintain larynges as they
say that that's true. I don't think we have hard data
to support that.
articles comparing voicing I don't know that there are
know, reasonably quiet individuals, say over 60, to you
would be maintained. individuals, and what exactly
look better? You know, do their vocal cords
better on objective testing? Would their voice parameters be
stand point, and an experience I would say, from an intuitive
But there's no hard data that I know of that I can look it up
for you.
Yes, so she was saying that it may be helpful in people
with swallowing difficulties, and that we tend to adhere
to the general rule that
you swallow, because it's a whole coordinated neural cycle.
And so voicing in many ways is
The more you can get into good no different.
one of the bases of voice hatherapy for improving yours
voice, is recognition and maintenance of good neural
cycles. So with swallowing, it's
analogous.
be able to come tonight. Okay, I'm really, really glad to
It's about 8:25, so thanks very I apprecimuch.our time.
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)