The Laryngoscope
© 2020 American Laryngological,
Rhinological and Otological Society Inc,
"The Triological Society" and American
Laryngological Association (ALA)
Awake Laser Laryngeal Stenosis Surgery
Nicole T. Jiam, MD ; Christopher D. Dwyer, MD
Key Words: Awake laser treatment, laryngeal stenosis, glottic stenosis, supraglottic stenosis, flexible CO2 laser.
INTRODUCTION
Laryngeal stenosis (or obstruction) poses a com-
plex situation for the clinician. Patients present with
variable degrees of dyspnea, and balancing airway
demands with phonatory and swallowing function
requires meticulous surgical planning and intervention.
Laryngeal airway management can be challenging as
airway manipulation, trauma from direct laryngoscopy
and stenosis may prevent safe management under gen-
eral anesthesia. In addition, multiple treatments may
be required to achieve adequate and durable airway
patency.
In patients with significant medical comorbidities,
critical airway stenosis, and/or anatomic limitations
deemed unsuitable for intubation or general anesthe-
sia with direct suspension microlaryngoscopy, an
awake procedure with monitored anesthesia care is an
attractive alternative. Furthermore, advancements in
fiber-based lasers, distal-chip flexible laryngoscopes,
and laryngology training have increased the breadth
and applications of awake laryngeal surgical
procedures.1
The advantages of awake procedures are well recog-
nized and discussed previously in the literature.1 Several
reports on patient tolerance and indications for awake
fiber-based laser cases have also been reported. Described
applications have focused on the treatment of benign and
premalignant laryngeal lesions, including papilloma,
polyps, ectasias/varices, Reinke’s edema, leukoplakia, and
dysplasia.2 The literature is limited on descriptions of
awake, fiber-based laser procedures for airway stenosis.
Only a few small case series detail the management of
From the UCSF Voice and Swallowing Center, Division of
Laryngology, Department of Otolaryngology - Head and Neck Surgery
(N.T.J., C.D.D., C.A.R.), University of California, San Francisco, California,
U.S.A.
Additional supporting information may be found in the online
version of this article.
Editor’s Note: This Manuscript was accepted for publication on
November 19, 2020
Clark A. Rosen is a consultant for Olympus America Inc and
Freudenberg Medical. He receives royalties from Instrumentarium and is
a shareholder for Reflux Gourmet LCC.
The authors have no other funding, financial relationships, or con-
flicts of interest to disclose.
Send correspondence to Clark A. Rosen, MD, UCSF Voice and
Swallowing Center, 2233 Post Street, 3rd Floor, San Francisco, CA 94115.
E-mail: clark.rosen@ucsf.edu
DOI: 10.1002/lary.29295
Laryngoscope 00: 2020
; Clark A. Rosen, MD
Laryngoscope, 00:1–5, 2020
subglottic stenosis in the awake patient using the Nd:
YAG laser.3,4 The use of an awake laser surgery has not
yet been reported for glottic or supraglottic enlargement,
and may be an option to traditional microlaryngoscopy
under general anesthesia for patients with significant
medical co-morbidities, difficult intubation, or avoidance
of a tracheotomy. Herein, we describe our techniques,
experience, and pearls for using a fiber-based CO2 laser
for awake treatment of stenosis at the glottic and sup-
raglottic levels.
MATERIALS AND METHODS
A retrospective review of five patients undergoing CO2
fiber-based surgery for laryngeal stenosis/obstruction in the
awake setting by the senior author was performed (Supporting
Video 1). All patients have had prior airway surgeries. Institu-
tional review board approval was not required for this report due
to the small number of patients.
Inclusion Criteria
Our proposed indications for awake management of laryn-
geal stenosis include significant comorbidities with increased
risk of general anesthesia, unfavorable anatomy precluding ade-
quate visualization during direct laryngoscopy, or severe laryn-
geal stenosis that would require awake tracheostomy to safely
proceed with endoscopic management under general anesthesia
in order to overcome peri-operative edema from the surgery. It is
important to note that most, but not all, laryngeal stenosis
patients can have successful surgery with general anesthesia
and traditional microlaryngoscopy – and that these options
should be carefully considered before offering awake CO2 fiber-
based surgery.
Surgical Technique
All awake surgical interventions were performed with a
well-rehearsed airway team comprised of a senior laryngeal sur-
geon, skilled airway anesthesiologist, and nursing colleagues
familiar and comfortable with assisting airway procedures. Pre-
procedural preparation includes nasal anesthetization/deconges-
tion using aerosolized spray and nasal pledgets soaked in a 1:1
mixture of 4% lidocaine:0.5% phenylephrine. Patients undergo a
nebulized treatment of 4 mL of 4% lidocaine. Intravenous
glycopyrrolate (0.2–0.4 mg) and dexamethasone (10 mg) are given
20 minutes prior to procedure initiation. Patients are positioned in the
upright position in the operating theater with monitored anesthesia
care. Intravenous sedation (infusion of remifentanil 2000 mcg/40 mL
Jiam et al.: Awake Laser Airway Surgery
1
0.9%NaCL and/or dexmedetomidine 4 mcg/mL) are our preferred

Tracheotomy
agents and titrated based on the anesthesiologist’s discretion.
Awake laryngoscopy (Model ENF-VT2, Olympus America,

None*
Status

None

None

None
Center Valley, PA) is performed after 4% lidocaine has been topi-

Yes
cally applied using a drip catheter to the endolarynx and tra-
chea. Tracheobronchoscopy is performed to provide a dynamic
airway assessment, identify contributing levels of airway steno-

stenosis

None

None

None

None

None
sis/obstruction, and establish a surgical plan of areas to treat.

Re-
One percent lidocaine with 1:100,000 epinephrine may be
injected submucosally for additional anesthesia and vasocon-

DI: 21 ! 0 VHI-10:

DI: 10 ! 0 VHI-10:

DI: 16 ! 7 VHI-10:
strictive hemostasis. Injections should be performed slowly and

Pre-op!Post-op
with caution as the resulting tissue tumescence/expansion may

Not Collected

Not Collected
DI Score; VHI

29 ! 16

19 ! 20

13 ! 11
cause further obstruction of an already narrowed airway. A uni-
lateral superior laryngeal nerve block, ipsilateral to the surgical
site, with 1% lidocaine with 1:100,000 epinephrine is performed

DI = dyspnea index; F = female; GA = general anesthesia; M = male; s/p = status post; Trach-dep = tracheotomy dependent; VHI-10 = voice handicap index-10.
for patients with glottic stenosis.5

A peri-operative temporary tracheotomy was performed under controlled settings. The tracheotomy tube was removed 14 days after their laryngeal surgery.
For patients with glottic stenosis, an 18-gauge needle is

Laryngeal Stenosis Patients who were Treated with Awake Fiber-based Laser Laryngeal Surgery.

Resolution of stridor and

Resolution of stridor and

inserted percutaneously through the cricothyroid membrane,
with confirmed positioning via flexible laryngoscopy. A guidewire

Resolution of stridor

Relief of exertional
is then placed through the 18-gauge needle and a metal blunt

Improved airway
needle is passed into the subglottic airway. The blunt metal nee-
dle is hooked up to plastic suction tubing to evacuate

dyspnea

dyspnea

dyspnea
Outcome
intraoperative laser smoke. This limits aerosolized irritants to
the patient and decreased visualization of the operative site due
to smoke.
Following assessment and anesthesia, a laser surgical

12 months
Follow-up

4 months

7 months

8 months

7 months
timeout is performed. The AcuPulse DUO surgical CO2 laser

Duration
machine (Lumenis, Israel) uses the following ablative settings:
Off-Time:0.05 seconds; Power:4–10 watts; Airflow:On. The CO2
fiber is passed through the working channel of the flexible laryn-

Post-op temp trach

goscope (Model ENF-VT2, Olympus America, Center Valley, PA)

1. Convert to GA 2.
with a protective sheath (Lumenis, Israel). Targeted stenotic/
TABLE I.

obstructive tissue is removed in an ablative fashion. Multiple

Complication

angles and approaches are used to remove tissue either by

changing the patient’s head and neck position, and/or by which
nostril is used for passing the flexible laryngoscope. The airway
None

None

None

None
is monitored throughout the procedure for evidence of swelling
and for signs of airway enlargement due to the surgery.

stenosis x2 procedures

prolapsing supraglottic
transverse cordotomy

transverse cordotomy

transverse cordotomy

Ablation of supraglottic
Unilateral conservative

Unilateral conservative

Unilateral conservative

Ablation of redundant

Patient had cervical spine fusion and thus, direct laryngoscopy was impossible.
Postoperative Care
Postoperatively, patients are admitted to a monitored set-
Procedure

ting for 23 hours. Perioperative steroids are given for 24 hours

tissue
Surgical

and patients are discharged with a 5-day steroid taper. Patients

with an existing tracheostomy are considered for same-day dis-
charge. Follow-up is arranged 4–6 weeks later to assess treat-
ment response. Some patients require multiple or combination
Trach-dep, Anatomy,

treatments depending on the severity and location of the

Comorbidities**
Awake Procedure

stenosis(ses).
tracheotomy

tracheotomy

tracheotomy

tracheotomy
Avoidance of a

Avoidance of a

Avoidance of a

Avoidance of a
Medical
Indication

RESULTS
We reviewed five patients as representative case
examples of awake CO2 fiber-based laryngeal surgical
Bilateral vocal fold fixation
immobility s/p radiation

Contralateral vocal fold

Supraglottic collapse s/p
trauma, Bilateral vocal
stenosis s/p laryngeal

arytenoid adduction,

airway intervention (Table I).

esophageal cancer

esophageal cancer
Glottic/Supraglottic

Three of the patients had obstruction at the level of

Bilateral vocal fold

Bilateral vocal fold

s/p radiation for

Primary Laryngeal

fold immobility
and advanced

the glottis and two patients at the level of the supra-

glottis. One individual had impossible visualization of the
paralysis
Diagnosis

paresis

glottis via direct laryngoscopy due to her anatomy and

prior cervical spine fusion, and therefore, unintubatable.
One patient was a poor general anesthesia candidate due
to severe pulmonary comorbidities.
**
*

All patients reported subjective improved breathing

53 M

81 M

75 M
Age/

70 F

66 F
Sex

after surgery. In all cases, endoscopic visualization

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Fig. 1. Pre and post-awake laser laryngeal stenosis surgery. A, Pre-intervention endoscopic appearance of the larynx. B, Immediate post-
operative endoscopic appearance of the larynx in the operating room. C, Three-month follow-up endoscopic appearance of the larynx in the
outpatient office setting. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
demonstrated significant improvement in supraglottic/
glottic airway patency at the post-operative appoint-
ment (Fig. 1).
One patient was tracheostomy-dependent due to
severe laryngeal stenosis following distant trauma to the
larynx resulting in posterior glottic stenosis with bilateral
vocal fold immobility and multiple previous laryngeal sur-
geries. She has not been decannulated despite apparent
improved airway diameter.
Patient #3 required emergent intubation and conver-
sion to general anesthesia. This occurred toward the end
of the conservative transverse cordotomy, due to over-
injection of submucosal local anesthetic, resulting in
narrowing of the patient’s already stenosed airway. The
remainder of the operation was uncomplicated. The other
four patients had no complications. Patient #4 required
two awake interventions to achieve symptomatic relief of
dyspnea. There were no instances of bleeding or airway
compromise.
DISCUSSION
Contemporary management of laryngeal stenosis
favors endoscopic surgery under general anesthesia. The
advent of distal chip endoscopes with working channels,
fiber-based lasers, continuous radial expansion balloons,
and increased comfort/training with awake laryngeal sur-
gical techniques has led to the current era of awake
laryngeal surgery. Advantages of awake airway surgery
include maintenance of spontaneous respiration,
decreased FiO2 requirements, avoidance of a tracheos-
tomy (even if temporary), and reduced post-operative
recovery where residual anesthetic effects may compro-
mise respiration leading to increased oxygen require-
ments and hypoventilation.6
In addition, some patients are poor surgical candi-
dates with general anesthesia due to significant com-
orbidities. Utilization of line-of-sight lasers requires
adequate exposure via direct laryngoscopy, which in a
limited subset of patients with anatomic constraints is
Laryngoscope 00: 2020
not feasible. There are some airways so tenuous that
induction of general anesthesia would likely result in
complete airway obstruction or inability to provide ade-
quate ventilation (i.e., endotracheal intubation not possi-
ble and jet ventilation contraindicated due to severe
obstruction). In these scenarios, it may be reasonable to
attempt an awake procedure to improve airway caliber
and avoid tracheostomy.
Notably, these procedures should only be performed by
a well-rehearsed airway surgical team as the possibility of
surgical misadventure is high when managing patients with
critical airway stenosis under monitored anesthesia care.
Patients are routinely counseled about the anticipated
effects of local anesthesia on laryngopharyngeal sensation,
which includes the sensation of being unable to swallow or
even breathe. For this reason, a skilled airway anesthesiolo-
gist should always be present to carefully balance adminis-
tration of intravenous sedation to maintain adequate
respiratory drive while minimizing the patient’s anxiety
and exacerbation of his or her airway stenosis. The airway
team should always be prepared for an emergent tracheos-
tomy, and the patient is counseled on this possibility prior
to the awake surgical intervention. As discussed, we had
one patient who required conversion to general anesthesia
and tracheostomy (see Table I), which occurred in a con-
trolled fashion as a result of a well-prepared airway team.
The CO2 laser provides several advantages for the
treatment of laryngeal stenosis. Due to its wavelength
(10,600 nm), it preferentially vaporizes tissue with high
intracellular water content. In this manner, obstructive or
redundant laryngeal tissue/scar is ablated, resulting in
immediate airway enlargement. The flexible, mechanically-
robust, low optical loss, fiber-based CO2 laser allows for pas-
sage through the working flexible laryngoscope channel for
tissue vaporization and added cutting and hemostasis
features.
An important point of comparison is that our
awake glottic enlargement procedure is more conserva-
tive than the traditional transverse cordotomy. When
completing a formal transverse cordotomy, bleeding is
Jiam et al.: Awake Laser Airway Surgery
3
Fig. 2. The use of additional transoral tissue retraction to improve laryngeal exposure and ablation. A, Endoscopic appearance of larynx at
maximal abduction in a patient with left vocal fold paralysis and significant right vocal paresis. Laryngeal obstruction noted to arise from pro-
lapsing left arytenoid mucosa upon forced inspiration. B, Initial tissue effects of flexible CO2 laser. C/D, Trans-oral use of laryngeal triangle for-
ceps to grasp and retract obstructive supraglottic arytenoid mucosa and provide traction for ongoing fiber-based CO2 laser ablation. [Color
figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

commonly encountered laterally from a small branch of
the superior laryngeal artery. In the awake patient,
this is to be avoided. Thus, the lateral extent of ablated
vocal fold is limited. Redundant supraglottic tissue can
be more aggressively treated. In addition, laryngeal
instruments may be employed trans-orally by an assis-
tant to provide tissue retraction, tension, or improve
exposure of areas requiring laser ablation if
needed (Fig. 2).
An advantage of awake management is the contin-
uous feedback and reassessment provided by the
patient during surgery. Dynamic airway assessment
with forced respiration confirms adequate treatment of
obstructive tissue or identifies areas requiring further
attention as the case progresses. Furthermore, voice
can be intermittently evaluated and balanced in real
time against airway enlargement. These important
aspects of airway surgery are not possible in the gen-
eral anesthesia treated patient.
CONCLUSION
Our described technique provides an alternative to
traditional endoscopic management of laryngeal stenosis
under general anesthesia in unique situations. Laryngeal
airway enlargement procedures using a fiber-based CO2
laser in the awake patient may be an option when gen-
eral anesthesia is contraindicated, direct rigid laryngeal
exposure is not possible, or when adequate airway man-
agement under general anesthesia would necessitate
tracheostomy.

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