Reply to letter regarding in-office cup biopsies for pharyngolaryngeal tumors.

To the Editor: We have welcomed the letter to your prestigious journal by Drs. Singh and Kumar. In relation to this, we would like to clarify some points. We feel that Dr. Singh thinks that our article underestimates the value of direct laryngoscopy with biopsy. We want to clarify that this is not so. The proof is the final comment of our article in which we remember that this is the gold standard for the diagnosis of malignant lesions of the pharynx, and even we suggest that health professionals who face a high suspicion of laryngeal malignancy in territories hard to explore, be “faithful to his instinct” and try to go directly to the gold standard for the diagnosis of these lesions. Dr. Singh referred to the risks of in-office biopsies. In our experience, we have not had any adverse event to this procedure, taking the appropriate safeguards listed in our article. One advantage of the in-office biopsy lies in the possibility of avoiding direct laryngoscopy with biopsy. In some cases, direct laryngoscopy with biopsy has several risks to consider: general anesthesia risk, discomfort because of hospitalization (at least 1 day of admission and time for preoperative examinations vs 15 minutes for the in-office procedure), and risks of a difficult intubation, which may even result in an emergency tracheotomy. The incidence of difficult intubation in patients with laryngeal tumors is high. Glottic and subglottic tumors alter the visualization of the laryngeal lumen, and intubation edema can trigger an airway blockage in the anesthesia awaking. Supraglottic tumors, in turn, can hinder exposure of the glottis. In a study by Arn e et al, the incidence of difficult intubation in laryngeal cancer was 15.7% versus 3.4% in general surgery patients. In a study by Ayuso et al, they indicate that of 181 patients undergoing direct laryngoscopy with biopsy, 50 had a difficult intubation (28%) and in 4 of them (2%) intubation was not possible. Because of these difficulties, in some cases, a tracheotomy is needed, which can be avoided in patients susceptible to conservative treatment. In his letter, Dr. Singh referred to the importance of good exploration of pharyngolaryngeal anatomy as another target of direct laryngoscopy with biopsy, with the aim of obtaining accurate tumor staging, and notes that this objective “can only be achieved under general anesthesia.” We agree that it is important for a good exploration of the territory involved, but we believe that this can be achieved in the in-office exploration. In our experience, in most cases, the quality of the laryngeal view is not diminished, and may even be better because of the existence of the HD fiberoscopy with a chip at the tip. The narrow-band imaging has improved the sensitivity of this examination, and in cases of a difficult tumor location (such as the hypopharynx), a series of maneuvers that can be performed with the patient awake can help correct visualization of these areas: Valsalva maneuver, cervical rotation, or Killian maneuver. Regarding the percentage of false-negative tests that in our article corresponds to 19% of the sample, Dr. Singh said that the realization of the subsequent diagnosis with direct laryngoscopy with biopsy to negative tumor samples with in-office biopsy causes psychological and physical disorders in our patients. In our experience, the realization of the in-office biopsy is done on the same day of the first examination in the office, which differs from direct laryngoscopy with biopsy that is a procedure that requires programming and slows the biopsy. Obtaining histological diagnosis of in-office biopsy in our environment takes no more than 3 days, which can be used to perform other diagnostic tests in the study of these patients. Conducting and programming direct laryngoscopy with biopsy requires an operating room, which is not always available as fast as one would like, and also requires a preanesthetic study, which can also slow the procedure. We have not had any patient who underwent a delay on treatment as a result of an in-office biopsy that was not conclusive, which has to be followed by direct laryngoscopy with biopsy. In his letter, Dr. Singh recommends conducting an inoffice biopsy on suspicion of benign lesions, and direct laryngoscopy with biopsy on suspicion of malignancy. We continue to recommend what we noted in our article: if you have the feeling of getting a satisfactory sample, with a well-defined tumor extension fiberoscopy, try an in-office biopsy first in all cases, and in case of obtaining a negative biopsy or doubtful sample, perform a direct laryngoscopy with biopsy. In our experience, we did not get false-positive results in any in-office biopsy procedures, which led us to take this behavior that we believe is quite pragmatic. *Corresponding author: F.C. Far ıas, Department of Otolaryngology and Head and Neck Surgery, Hospital Ram on y Cajal, Carretera de Colmenar Viejo Km 9, 100, Madrid, 28034 Spain. E-mail: [email protected]