Microlaryngoscopic and Office-Based Injection of Bevacizumab (Avastin) to Enhance 532-nm Pulsed KTP Laser Treatment of Glottal Papillomatosis

Abstract

Objectives: Photoangiolytic lasers effectively treat glottal papillomatosis, but do not reliably prevent recurrence. Therefore, sublesional injections of the antiangiogenic agent bevacizumab (Avastin) were given to assess the effect on disease recurrence and phonatory function. Methods: A retrospective investigation was done in a pilot group of 10 adult patients with bilateral glottal papillomatosis who had prior angiolytic laser treatment with established patterns of recurrence. The patients underwent 5 bevacizumab injections (5 to 10 mg) into the diseased vocal folds along with 532-nm pulsed KTP laser photoangiolysis treatments 4 to 6 weeks apart. Their disease resolution was compared to findings from prior laser treatment alone, and objective measures of vocal function (acoustic, aerodynamic, Voice-Related Quality of Life survey) were obtained. Results: All 10 patients had a greater than 90% reduction in recurrence. Four of the 10 had resolution. Four of the 10 have limited recurrent or persistent disease, receive injections of bevacizumab at 8-to 12-week intervals, and have not required laser treatment. Two of the 10 have ongoing periodic office-based KTP laser treatment along with bevacizumab injections. No patient has required microlaryngeal surgery with general anesthesia, and all 10 have had substantial improvement in vocal function. Conclusions: This pilot investigation provides preliminary evidence that bevacizumab injections enhance photoangiolytic laser treatment of glottal papillomatosis while enhancing phonatory function. Coupling an antiangiogenesis agent with pulsed KTP laser photoangiolysis is conceptually promising, since the mechanisms of action are complementary.

Local Injection of Bevacizumab (Avastin) and Angiolytic KTP Laser Treatment of Recurrent Respiratory Papillomatosis of the Vocal Folds: A Prospective Study

“…Treating RRP by coupling the antiangiogenesis 1 Observations from this prospective second investigation have provided further evidence that pharmacologic antiangiogenesis by local injection is efficacious in treating laryngeal RRP (see Figure). The investigation herein also included key safety monitoring that demonstrated a lack of local or systemic complications, which will assist clinicians who are considering initiating this promising new management strategy.…”

“…The technique was described previously. 1 Saline solution was injected into the other vocal fold in a comparable volume and location.…”

Estimating Subglottal Pressure From Neck-Surface Acceleration During Normal Voice Production

“…Subglottal pressure has been used clinically to differentiate individuals with typical voices from those with voice disorders and to act as a clinical outcome measure (Hartl, Hans, Vaissière, Riquet, & Brasnu, 2001;Hillman, Holmberg, Perkell, Walsh, & Vaughan, 1989;Holmberg, Doyle, Perkell, Hammarberg, & Hillman, 2003;Jiang & Stern, 2004;Speyer, 2008;Zeitels, Hillman, Franco, & Bunting, 2002;Zeitels, Hochman, & Hillman, 1998;Zeitels et al, 2009). In addition, subglottal pressure is a central component of vocal efficiency (Björklund & Sundberg, 2016;Colton, Casper, & Leonard, 2006;Titze, 1992Titze, , 2013Titze, Maxfield, & Palaparthi, 2016) and is associated with aspects of perceived vocal effort (Ramig & Dromey, 1996;Rosenthal, Lowell, & Colton, 2014).…”

In-Office Laryngeal Injection

“…Its use antedates the current re-invigorated interest in office laryngeal procedures by two or three decades; in fact, it may be viewed as the first of the modern in-office laryngeal interventions. Papillomatosis may be treated with in-office injections of cidofovir [24,25] and, more controversially, bevacizumab [26]. Intralesional steroid injections appear to be an alternative to surgery and even voice therapy in benign phonotraumatic vocal fold lesions [27 • , 28, 29].…”