Office-Based vs Traditional Operating Room Management of Recurrent Respiratory Papillomatosis: Impact of Patient Characteristics and Disease Severity | Laryngology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Figure.  Office-Based Ablation of a Papilloma With Pulsed Potassium-Titanyl-Phosphate Laser
Office-Based Ablation of a Papilloma With Pulsed Potassium-Titanyl-Phosphate Laser

A, Shown are a small bulky lesion of the right anterior vocal fold, a small-surface papilloma on the right superior vocal fold, and a small surface papilloma on the left anterior vocal fold. B and C, Application of the laser. D, Most of the devascularized papilloma was debrided using the laser fiber. Remnants will slough off after several days.

Table 1.  Patient Demographics and Disease Characteristics by Management Group
Patient Demographics and Disease Characteristics by Management Group
Table 2.  Comorbidities by Management Group
Comorbidities by Management Group
Original Investigation
January 2017

Office-Based vs Traditional Operating Room Management of Recurrent Respiratory Papillomatosis: Impact of Patient Characteristics and Disease Severity

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
  • 2Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle
  • 3Department of Otolaryngology–Head and Neck Surgery, University of Michigan Medical School, Ann Arbor
  • 4Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Arizona Medical Center, Tucson
  • 5Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University, Bethesda, Maryland
JAMA Otolaryngol Head Neck Surg. 2017;143(1):55-59. doi:10.1001/jamaoto.2016.2724
Key Points

Question  Do demographic or disease characteristics differ between patients with recurrent respiratory papillomatosis (RRP) undergoing office-based (office group) vs traditional operating room (OR group) surgical approaches?

Findings  In this medical record review of 57 adult patients with RRP treated between 2011 and 2013 at a tertiary care center, sex, age, and weight were not statistically significantly different between the 2 study groups, but patients in the OR group had earlier diagnosis of the disease and a significantly higher mean Derkay score. There were no statistically significant differences in comorbidities between the 2 groups except for type 1 or 2 diabetes, which was more common in the OR group.

Meaning  Patients with earlier age at diagnosis of RRP and greater disease severity are more likely to be managed in the OR.

Abstract

Importance  Management of recurrent respiratory papillomatosis (RRP) in adults has evolved to include office-based laser techniques.

Objective  To determine whether demographic or disease characteristics differ between patients undergoing office-based (office group) vs traditional operating room (OR group) surgical approaches for RRP.

Design, Setting, and Participants  This study was a medical record review of adult patients with RRP treated between January 2011 and September 2013 at a tertiary care center. Patients were divided into 2 groups according to the setting in which the patient had the most procedures during the past 2 years.

Main Outcomes and Measures  Demographic and disease characteristics were compared between patients receiving predominantly office-based vs predominantly OR management.

Results  Of 57 patients (47 male and 10 female, with a mean [SD] age of 53.5 [16.4] years) treated during the 2-year period, 34 patients underwent predominantly office-based management and 23 patients underwent predominantly OR management. Sex, age, and weight were not statistically significantly different between the 2 groups. Patients in the OR group had a younger age at RRP diagnosis (mean [SD], 28.7 [22.0] years in the OR group and 45.5 [20.5] years in the office group), with a mean difference of 16.8 years (95% CI, −28.3 to −5.4 years). Patients in the OR group also had a significantly higher Derkay score (mean [SD], 15.1 [5.7] in the OR group and 10.7 [5.0] in the office group), with a mean difference of 4.4 (95% CI, 1.6-7.3). No statistically significant differences in comorbidities were observed between the 2 groups except for type 1 or 2 diabetes, which was more common in the OR group. There were 5 patients (22%) with diabetes in the OR group and 1 patient (3%) with diabetes in the office group, with a mean difference of 19% (95% CI, 2.7%-35%). In a subanalysis that excluded patients with juvenile-onset RRP, Derkay score (mean [SD], 13.9 [4.5] in the OR group and 10.8 [5.1] in the office group), with a mean difference of 3.1 (95% CI, 0.5-6.1), and the incidence of diabetes (25% [4 of 16] in the OR group and 3% [1 of 31] in the office group), with a mean difference of 22% (95% CI, 3%-40%), remained significantly higher in the OR group, while age at diagnosis of RRP was no longer statistically significant (mean [SD], 40.2 [15.6] years in the OR group and 49.6 [16.4] years in the office group), with a mean difference of 9.4 years (95% CI, −19.4 to −0.7 years).

Conclusions and Relevance  There were no sex or age differences between patients with RRP treated in the office compared with those treated in the OR. Patients with earlier age at diagnosis of RRP and greater disease severity were more likely to be managed in the OR.

Introduction

Recurrent respiratory papillomatosis (RRP) is a challenging chronic disease caused by human papillomavirus infection. Sequelae of RRP range from voice changes that have a significant effect on quality of life to life-threatening airway compromise. The propensity for frequent recurrences requires numerous successive surgical procedures and further affects quality of life.1,2

Management of RRP involves removal of obstructing lesions to preserve normal tissue and function. While traditional management includes surgical excision under general anesthesia in the operating room (OR),1,3 availability of pulsed-dye laser and pulsed potassium-titanyl-phosphate laser, which can be delivered through a flexible fiber, has expanded management options to include office-based techniques.4,5

With availability of both office-based and surgical options, clinicians are faced with considering multiple factors in selecting the best management for each patient. An understanding of the clinical and demographic data behind prior decisions will guide the surgeon to determine which technique may be more appropriate for an individual patient. The objective of this study was to determine whether demographic or disease characteristics differ between patients undergoing primarily office-based (office group) vs traditional OR (OR group) surgical approaches for RRP at a tertiary care center (University of Washington School of Medicine, Department of Otolaryngology–Head and Neck Surgery) where both techniques are readily available.

Methods

The study was approved by the University of Washington Internal Review Board, which waived the requirement for informed consent of participants. Medical record review of adult patients with RRP treated at the University of Washington School of Medicine Department of Otolaryngology–Head and Neck Surgery between January 2011 and September 2013 was performed. Patients were divided into 2 groups according to predominant management of the disease during the past 2 years, which was determined for this study by the setting in which the patient had the most procedures (office group vs OR group). In the office group, pulsed-dye laser or pulsed potassium-titanyl-phosphate laser was used via flexible fiber delivery (Figure).

Patients with a recent diagnosis of RRP and patients new to the Department of Otolaryngology–Head and Neck Surgery routinely undergo microdirect laryngoscopy under general anesthesia for thorough examination and biopsy as their initial procedure. Therefore, each patient’s first procedure in the department was excluded from the analysis to avoid bias toward placing patients in the OR group. Also, we excluded patients who had no procedure performed during the past 2 years. A subanalysis was performed that excluded all patients with juvenile-onset RRP.

Anatomic Derkay scores at the time of each procedure were calculated for each patient. According to the anatomic portion of the staging system by Derkay et al,6 the aerodigestive tract is divided into 25 subsites, each of which is given a score of 0 to 3 (0 is no lesion, 1 is a surface lesion, 2 is a raised lesion, and 3 is a bulky lesion). The scores at each involved subsite were summed to generate a composite anatomic score. Sex, age, weight, and age at diagnosis of RRP were compared between the 2 groups using a 2-tailed t test. The mean Derkay scores were compared using the Mann-Whitney test, and prevalences of comorbidities were compared using the Fisher exact test. Data were analyzed using a software program (SPSS, version 15.0; SPSS Inc).

Results

Of 57 patients (47 male and 10 female, with a mean [SD] age of 53.5 [16.4] years) meeting the inclusion criteria, 34 underwent predominantly office-based management and 23 underwent predominantly OR management. A total of 237 procedures were performed, including 144 office-based procedures and 93 OR procedures. Demographic and RRP disease characteristics are listed in Table 1.

Sex distribution was similar in both groups (83% male [28 of 34 in the office group and 19 of 23 in the OR group]), and there were no statistically significant differences in age or weight between the groups. Patients in the OR group had earlier diagnosis of the disease and a significantly higher mean Derkay score. The mean difference between the OR group and the office group in the time of diagnosis was 16.8 years (95% CI, −28.3 to −5.4 years), and the mean difference in Derkay score was 4.4 (95% CI, 1.6-7.3) (Table 1). Reasons for choosing OR vs office-based treatment were stated in the medical record for 58% (33 of 57) of patients. When available, the most common one for recommending OR treatment was the extent of disease, cited for 26% (15 of 57) of all patients. Other reasons for OR treatment were intolerance of office laser procedures in 9% (5 of 57), unfavorable location of disease in 9% (5 of 57), need for biopsy in 7% (4 of 57), airway concerns in 5% (3 of 57), and comorbidity in 2% (1 of 57).

Medical comorbidities were cited as the reason for OR management in only 1 patient who had a history of cardiac transplantation. In another patient, a history of difficult intubation led to office-based treatment.

Type 1 or 2 diabetes was significantly more common in the OR group (Table 2). No other statistically significant differences in comorbidities were observed between the 2 groups, although there was a trend toward a higher prevalence of substantial cardiac disease in patients treated in the OR.

The exclusion of patients with juvenile-onset RRP from the analysis resulted in 16 patients in the OR group and 31 patients in the office group. In this subanalysis, the Derkay score remained significantly higher in the OR group (mean [SD], 13.9 [4.5] in the OR group and 10.8 [5.1] in the office group), with a mean difference of 3.1 (95% CI, 0.5-6.1). Similarly, the incidence of diabetes remained significantly higher in the OR group (25% [4 of 16] in the OR group and 3% [1 of 31] in the office group), with a mean difference of 22% (95% CI, 3%-40%). Age at disease diagnosis was no longer statistically significant in the subanalysis (mean [SD], 40.2 [15.6] years in the OR group and 49.6 [16.4] years in the office group), with a mean difference of 9.4 years (95% CI, −19.4 to −0.7 years).

Discussion

Recurrent respiratory papillomatosis is the most common benign neoplasm of the larynx, with an estimated incidence of 1.8 cases per 100 000 adults.7 The recurrent nature of RRP necessitates successive surgical procedures to control the disease, maintain the airway, and improve voice quality. Approximately 9284 such procedures were performed during a 13-month period from 1993 to 1994, accounting for $42 million in health care costs.7 However, office-based laser management of RRP allows for decreased cost per procedure. Furthermore, office-based laser procedures have epithelium-sparing properties, as well as the substantial benefit of avoiding general anesthesia.8,9

While many features of office-based management of RRP appear attractive to both patients and clinicians, surgical management using general anesthesia remains a viable approach in the management of RRP. Our study aimed to elucidate patient factors that may have a role in the decision for a surgical approach.

When we reviewed our cohort of adult patients with RRP treated at a tertiary care center where both office-based and OR techniques are regularly used, we noted that office-based laser approaches were chosen more often than OR procedures. In cases in which a reason for choosing an OR approach was stated in the medical record, the main one cited was the extent of disease. Likewise, we found that patients who underwent OR management had a statistically significantly higher anatomic burden of disease. These findings are not surprising, but they may be important for understanding which patients are more appropriate for the OR vs the office setting. The difference in the mean Derkay scores between the 2 groups was only 4.4, but the standard deviations were large. Therefore, we did not identify a Derkay score cutoff at which office-based management is not feasible because the location and nature of disease may be more important than the overall burden. For instance, a large, bulky lesion may be less amenable to pulsed potassium-titanyl-phosphate laser treatment but may have the same Derkay score as 3 small-surface lesions that would be easily treatable in the office.

We found that a younger age at diagnosis of RRP was more common in the OR group. When patients with juvenile-onset RRP were excluded, age at diagnosis of the disease was no longer significantly different between the office-based and OR groups. This finding suggests that the age difference is driven by the juvenile-onset patients who may prefer OR management because of their familiarity with it.

Demographics were similar between the 2 groups, suggesting that sex and age do not appear to have a significant role in patient or surgeon preference for treatment setting. When we compared comorbidities, diabetes was the only comorbidity that differed between the 2 groups. Diabetes has not been shown to be correlated with increased RRP severity,10 suggesting that the observed association is independent of the anatomic burden of disease. It is possible that a larger study would detect differences in the prevalence of other medical comorbidities, such as cardiac disease, that we did not find in this cohort.

Conclusions

In this cohort of adult patients with RRP, no sex or age differences were detected between patients who were treated in the office compared with those who were treated in the OR. Patients with earlier age at diagnosis of RRP, greater disease severity, and diabetes were more often managed in the OR.

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Article Information

Corresponding Author: Emel Çadallı Tatar, MD, Department of Otolaryngology–Head and Neck Surgery, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Dışkapı, Ankara, Turkey 06110 (ectatar@gmail.com).

Accepted for Publication: July 24, 2016.

Published Online: September 22, 2016. doi:10.1001/jamaoto.2016.2724

Author Contributions: Dr Tatar had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Tatar, Kupfer, Allen, Merati.

Acquisition, analysis, or interpretation of data: Kupfer, Barry.

Drafting of the manuscript: Tatar, Kupfer.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kupfer.

Administrative, technical, or material support: Tatar, Kupfer, Barry, Allen.

Study supervision: Kupfer, Allen.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.

Previous Presentation: This study was presented as a poster at The Fall Voice Conference; October 23-25, 2014; San Antonio, Texas.

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