Awake rigid endoscopy-guided laryngeal biopsy in high-risk tracheostomized patients: Our experience

Awake rigid endoscopy-guided laryngeal biopsy in high-risk tracheostomized patients: Our experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Awake rigid endoscopy-guided laryngeal biopsy in high-risk tracheostomized patients: Our experience Tithi Debnath, Subhadeep Chowdhury, Somnath De This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7142556/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Patients presenting with laryngeal lesions and significant comorbidities are frequently unsuitable candidates for biopsy under general anaesthesia (GA). Awake, office-based procedures offer a safer alternative. This study evaluates the feasibility and safety of rigid 70-degree endoscopy-guided laryngeal biopsy in high-risk tracheostomized individuals. Methods: A prospective observational study was conducted on 26 tracheostomized patients with suspected laryngeal or hypopharyngeal lesions deemed unfit for GA. Biopsies were performed under local anaesthesia using a 70° rigid endoscope. Discomfort was assessed via a Visual Analogue Scale (VAS). Haemodynamic responses were closely monitored, and the adequacy of histopathological samples was assessed. Results: The procedure yielded diagnostic tissue in 88.46% of cases. Most patients (65.4%) reported mild discomfort (VAS 5–44); only 11.5% experienced severe discomfort. Statistically significant but clinically stable changes in pulse and blood pressure were observed post-procedure (p < 0.05). No major complications occurred. Histopathology revealed squamous cell carcinoma in 16 patients, premalignant lesions in 5, and benign keratosis in 2 cases. Conclusion: Awake rigid endoscopy-guided biopsy is a safe, effective, and well-tolerated alternative for tissue diagnosis in tracheostomized patients unfit for GA. It ensures timely histopathological confirmation with minimal risk and discomfort. Figures Figure 1 Figure 2 Figure 3 Introduction Over the past decade, there has been a growing trend toward, daycare-based laryngeal procedures for managing various laryngeal pathologies [ 1 ]. According to Steven Marc Zeitels, simple biopsies, laser treatments, and injections are among the commonly performed procedures in such settings [ 1 ]. Although the concept dates back over a century, the practice of awake laryngeal biopsy has re-emerged with the advent of advanced rigid and flexible endoscopes, fiber-optic technology, and high-resolution video systems. The origin of laryngeal topical anaesthesia dates to 1884, when Jellinek introduced its use for awake interventions [ 1 ]. Until the late 20th century, awake laryngopharyngeal biopsy was predominantly performed using long curved forceps under indirect mirror laryngoscopy, similar to techniques used in the 1850s [ 1 ]. Modern visualization using rigid or flexible video-endoscopy has largely replaced mirrors, although the transoral approach in awake patients remains fundamentally similar. Mackenzie, in his seminal work, described various instruments, sprays, and topical preparations for office-based laryngeal procedures [ 2 ]. Likewise, one of the earliest textbooks on operative laryngoscopy by Brünnings emphasized the feasibility of such interventions under local anaesthesia [ 3 ]. Although micro-suspension laryngoscopy under general anaesthesia has low complication rates, a significant subset of patients are medically unfit for GA, necessitating alternative diagnostic techniques [ 4 ][ 5 ]. Awake biopsies can be safely performed in such patients under local anaesthesia on a daycare basis, especially when the lesion is accessible. However, due to limited instrumentation, the risk of inadequate sampling remains. To mitigate this, multiple deep punch biopsies should be obtained, ideally incorporating the lesion base—particularly in pedunculated growths—to ensure inclusion of the basement membrane for accurate histopathological diagnosis. Objectives 1. To assess the feasibility, safety, and diagnostic yield of rigid 70-degree endoscope-guided awake laryngeal biopsy in tracheostomized patients unfit for general anaesthesia. 2. To document patient comfort, haemodynamic stability, and procedural tolerance. 3. To document the clinical features, lesion morphology, and histopathological findings in this patient cohort. Methodology This was a prospective observational study conducted in the Department of ENT of a tertiary care teaching hospital over a six-month period. A total of 26 patients who had previously undergone emergency tracheostomy due to stridor or upper airway obstruction were enrolled. All patients were suspected to have laryngeal or hypopharyngeal lesions based on clinical and endoscopic assessment and were deemed unfit for general anaesthesia (ASA Class III or IV) following anaesthetic evaluation. Inclusion Criteria Patients aged 18 years or above. Presence of tracheostomy performed prior to the procedure. Visible supraglottic, glottic, trans glottic, or hypopharyngeal lesions on 70-degree rigid endoscopy. Patients deemed unfit for general anaesthesia due to significant medical comorbidities. Exclusion Criteria Subglottic lesions not visualized with rigid endoscopy. Patients unwilling or unable to provide informed consent. Known allergy to local anaesthetic agents such as lidocaine. Pre-procedural assessment with detailed clinical histories were obtained, including documentation of systemic conditions like hypertension, diabetes, ischemic heart disease, chronic respiratory disease, and neurological illnesses. Cardiovascular and respiratory assessments were performed to confirm anaesthetic risk. Flexible fiber-optic nasolaryngoscopy was used to assess lesion characteristics preoperatively. Anaesthesia Technique Patients were administered intramuscular glycopyrrolate (0.2 mg) 30 minutes before the procedure to reduce secretions. Nebulization with 3 mL of 4% lidocaine was delivered via the tracheostomy tube. A 4% lidocaine solution was instilled using an Abraham cannula: 1 mL over the tongue base and 2–4 mL on the vocal cords during phonation. Ten sprays of 10% lidocaine were applied to the oropharynx to ensure adequate surface anaesthesia. Biopsy Procedure The procedure was conducted under sterile conditions with the patient in a semi-seated position. One surgeon held the tongue with a gauze pad and guided the rigid 70-degree telescope. The second surgeon introduced either Fraenkel laryngeal forceps (for glottic lesions) (Fig. 1 ) or punch forceps for supraglottic and hypopharyngeal lesions to obtain tissue samples. Multiple biopsies were taken from each lesion to ensure sample adequacy, particularly from the lesion base in pedunculated growths. Minor bleeding was managed using gauze soaked in 1:10,000 adrenaline. All patients were monitored for 30–45 minutes post-procedure and kept nil per oral for two hours pre- and post-procedure. Monitoring and Outcome Measures Vital parameters: Blood pressure, heart rate, and oxygen saturation were recorded before, during, and after the procedure. Discomfort Score: Patient discomfort was assessed using a 100-mm visual analogue scale (VAS), ranging from 0 (no pain) to 100 (worst imaginable discomfort). (Fig. 2 ) Diagnostic Yield : Biopsy specimens were sent for histopathological examination. Diagnostic success was defined as obtaining tissue sufficient for histological analysis. Statistical Analysis Data were recorded in structured case sheets and analyzed using SPSS Version 29 and GraphPad Prism Version 9. Continuous variables were presented as mean ± standard deviation (SD), and categorical variables as percentages. Paired t-tests and one-way ANOVA were used to analyses changes in haemodynamic parameters and VAS scores. A p-value of ≤ 0.05 was considered statistically significant. Results All the 26 patients enrolled in the study underwent rigid endoscopic guided laryngeal biopsy because ineligible for general anaesthesia due to cardiologic 53.85% (14 patients), respiratory 26.92% (7 patients), or neurologic 19.23% diseases (5 patients). Among 26 patients 21(80.77%) were male and 5 (19.23%)were female. All these patients were in the age group between 49 to 81 years with a mean age of 68.5 ± 7.03 years. As far as it concerns the location of the suspected lesions, in 26 cases 11 cases (42.31%) were in the supraglottic region, in 8 cases (30.71%) were the glottic region, while in 4 cases (15.38%) in the glottosupraglottic region, 3 cases in the PFS (11.54%). Diagnostic Yield: The procedure was successful in providing adequate diagnostic samples in 23 of the 26 patients, yielding an overall success rate of 88.46%. Haemodynamic Response: Pulse rate and blood pressure were monitored pre- and post-procedure Statistically significant but clinically minor variations were noted (p < 0.05) No episodes of syncope, aspiration, laryngospasm, or post-procedure bleeding requiring intervention were reported. The most frequent morphology was ulceroproliferative (14 patients, 53.85%), followed by ulcerative (8 patients, 30.77%) and least commonly 4(15.38%) patients had plaque-like lesions. (Figure 3). Hemodynamic parameters i.e pulse and BP were noted before and after the procedure and the result is found in Tables 1, 2 and 3. There is a statistically significant difference between pre and post-operative hemodynamic parameter findings. Table 1 : Before and after procedure pulse rate changes according to growth location(n=26) Growth Location Mean±SD P value Before procedure pulse rate(bpm) After procedure pulse rate (bpm) Supraglotic 76±5.59 87±4.5 0.00007 Glottic 74±3.55 86±4 0.0003 Glotto supraglottic 74.5±5.26 78±5.89 0.0060 PFS 76±8 91.3±6.1 0.0075 Table 2: Before and after procedure Systolic blood pressure changes according to growth location (n=26) Growth Location Before procedure SBP (Mean±SD) After procedure SBP (Mean±SD) P value Supraglotic 124±4 .48 131.63±6.98 0.00003 Glottic 125.5 ±9.78 130.75±9.97 0.00001 Glotto supraglottic 130±7 .4 133.5±7.72 0.0060 PFS 123.33 ±3.06 128±3.46 0.0198 Table 3: Before and after procedure diastolic blood pressure changes according to growth location (n=26) Growth Location Before procedure DBP (Mean±SD) After procedure DBP (Mean±SD) P value Supraglotic 80.18±6.66 85.82±6.18 < .00001 Glottic 79±7.86 84.75±6.5 0.0003 Glotto supraglottic 76±7.66 83±8.72 0.0043 PFS 76.67±6.43 84±5.29 0.0082 Discomfort Score (VAS): Mean score: 33.35 ± 24.02 (range: 4 to 84) Most patients reported mild to moderate discomfort No statistically significant difference in discomfort based on lesion site Categorization of patients according to VAS Score described in figure 3. The bar chart shows pain levels (VAS score) during a procedure in 26 patients. The majority of patients (17 out of 26) experienced only mild pain. A small proportion experienced moderate (5) or severe pain (3). Pain-free experience was rare, with only one patient reporting no pain. This suggests that while the procedure was tolerable for most patients (with pain in the mild range), a minority experienced moderate to severe discomfort, indicating the need for optimizing patient comfort further. Discomfort, as part of the procedure, is described in table 4. Nebulization was the most comfortable step: 22/26 (84.6%) reported no pain, only 1 had moderate discomfort, and none reported severe pain . The P-value of 0.1564 suggests no statistically significant variation in pain perception here. Topical spray caused slightly more discomfort : 7 experienced mild pain, and 1 moderate, indicating possible throat irritation or taste discomfort. Instrumentation (scope insertion via mouth) was the most uncomfortable : Only 1 reported no pain, while 17 experienced mild, 5 moderate, and 3 severe pain . This indicates that scope passage is the most distressing part , possibly due to gag reflex or mechanical stimulation . Table 4 : Discomfort, by part of procedure(n=26) Discomfort By Part Of Procedure (n=26) No pain VAS score (0-4) Mild VAS score (5- 44) Moderate VAS score (45-74) Severe (75- 100) P value Nebulization 22 3 1 - 0.1564 Topical spray of lignocaine 18 7 1 - Instrumentation in oral cavity 1 17 5 3 Table 5 Discomfort, by location of the growth(n=26) Supraglottic growth Glottic growth Glottosupraglottic growth PFS growth P value No pain 1 - - - 0. 5885 Mild pain 5 7 4 2 Moderate pain 4 - - - Severe pain 1 1 - 1 Mild pain was the most common symptom across all locations. Moderate pain was exclusively reported in supraglottic growths, suggesting deeper involvement or higher sensitivity in that area. Severe pain occurred in isolated cases across supraglottic, glottic, and PFS growths. The p-value of 0.5885 indicates that the difference in pain distribution by growth location was not statistically significant.(Table 5) The histopathological examination report of the biopsied tissue showed 16 patients had squamous cell carcinoma, 5 cases of premalignant condition (3 mild dysplasia and 2 moderate dysplasia), and 2 benign condition keratosis. 3 cases had inadequate deeper tissue samples and rebiopsy was required. So success rate of our procedure was 88.46 %. Discussion Laryngeal growths can lead to considerable morbidity, significantly impairing fundamental functions such as speech and swallowing. These symptoms frequently necessitate early tissue diagnosis for timely initiation of treatment. Conventionally, direct microlaryngoscopic surgery under general anaesthesia (GA) has served as the gold standard for such diagnostic procedures. However, this technique is not universally applicable, especially in patients with poor general condition or multiple comorbidities. Suspension laryngoscopy demands not only GA but also adequate cardiopulmonary reserve and favorable anatomical positioning, which is not feasible in high-risk patients [ 4 ][ 5 ]. In light of these limitations, awake, office-based procedures have garnered increasing attention. In particular, rigid endoscopy-guided laryngeal biopsies under local anaesthesia present a promising alternative. The present study highlights our experience with rigid 70-degree endoscope-guided biopsy in patients who were unfit for GA and had undergone tracheostomy due to acute upper airway obstruction. It is crucial to clarify a common misconception although all patients in our study were tracheostomized, they remained unfit for general anaesthesia due to systemic risks. Comorbidities included cardiac disease (53.85%), respiratory compromise (26.92%), and neurological conditions (19.23%), which made GA a considerable hazard. Therefore, the presence of a tracheostomy should not be mistaken for overall surgical fitness. The tracheostomy merely secured the airway during the diagnostic process but did not reduce the systemic risks of GA. Furthermore, all patients had undergone emergency tracheostomy prior to biopsy due to stridor and clinical suspicion of significant airway compromise. While histopathology later revealed premalignant lesions (n = 5) and benign keratosis (n = 2) in a subset of cases, the decision for tracheostomy was based solely on clinical and endoscopic findings of bulky obstructive masses. These lesions, regardless of eventual diagnosis, warranted immediate airway protection. In our cohort, the rigid 70-degree endoscopy-guided biopsy procedure was performed successfully in 88.46% of cases. No procedure-related complications such as vasovagal reaction, aspiration, epistaxis, or bleeding from the biopsy site were reported. This is consistent with the findings of Cohen et al. [ 8 ], who, in a cohort of 390 patients undergoing office-based laryngeal biopsies, reported a very low incidence of adverse events. Similar safety profiles have been observed across multiple studies on in-office laryngeal biopsy [ 9 – 12 ]. To minimize the risk of complications, several precautions were employed in our technique: all patients had a cuffed tracheostomy tube in situ to protect against aspiration, and were monitored for 45 minutes post-procedure. Topical anaesthesia was achieved through a combination of 4% lignocaine via Abraham cannula and nebulization, as well as 10% lignocaine spray to the oropharynx and vocal cords. The adequacy of topical anaesthesia was reflected in the mean discomfort score (VAS) of 33.35 out of 100, which is slightly lower than the VAS score of 36.7 reported by Young et al. [ 16 ]. None of our patients experienced intra-procedural tachycardia or hypertensive spikes, underscoring the effectiveness of our anaesthesia protocol in blunting autonomic reflexes such as coughing, hypertension, and tachycardia [ 13 – 15 ]. Histopathological outcomes revealed squamous cell carcinoma in 16 patients, dysplasia in 5 patients, and benign keratosis in 2 patients. In 3 patients, biopsy samples were deemed inadequate due to superficial sampling, necessitating repeat biopsy. This accounts for a partial procedure rate of 11.54%, which is slightly higher than the 5.4% reported by Young et al. [ 16 ]. The most common technical challenges were achieving the correct endoscopic angulation and managing patient movement during instrumentation. Existing literature reinforces the diagnostic reliability of office-based laryngeal biopsies. Zalvan et al. [ 17 ] reported an 81% concordance between office-based and operative biopsies. Cohen and Fliss [ 18 ] found that office-based biopsies were sufficient for diagnosing malignancy in 57% and 69.2% of cases in two separate studies, though false negatives were also reported (up to 33%). In our study, due to contraindications for GA, confirmatory biopsies under direct laryngoscopy could not be performed. However, none of the non-malignant cases demonstrated progression or change over a 12-month follow-up, suggesting the reliability of our histopathological diagnosis. Limitations This study has several limitations. First, the sample size was relatively small (n = 26), which limits the statistical power and generalizability of the findings. Second, the study was conducted in a single tertiary care center, and all procedures were performed by experienced surgeons; thus, the feasibility and safety may not directly translate to settings with less expertise. Third, while we reported patient discomfort using the Visual Analog Scale (VAS), the subjective nature of this measurement and lack of a validated discomfort assessment tool may have introduced reporting bias. Fourth, histopathological adequacy was noted in binary terms, and more detailed evaluation using scoring systems or inter-pathologist agreement was not assessed. Lastly, there was no direct comparison group (e.g., standard GA-based biopsy), which limits our ability to assess relative diagnostic efficacy. Future research should aim to overcome these limitations by incorporating control groups, larger sample sizes, inter-rater reliability, and multi-institutional data Conclusion Awake rigid endoscopy-guided laryngeal biopsy under local anesthesia appears to be a safe and practical alternative in high-risk tracheostomized patients for whom general anesthesia poses significant risks. Our experience suggests that this technique enables adequate tissue sampling for histopathological diagnosis with acceptable patient discomfort. However, these findings are based on a small cohort, and definitive conclusions regarding its diagnostic accuracy and broader clinical applicability require validation through larger, prospective, multicenter studies. Declarations Funding: None Data availability: Available upon request Code availability: Not applicable Conflict of Interest: None Ethical Approval: Approved by Institutional Ethics Committee (RKC/469 dated 15.01.19) Patient Consent: Obtained Consent for Publication: Obtained from all authors Author contributions First and corresponding author – Conceived and designed the study, performed clinical procedures, supervised data collection, and finalized the manuscript. 2 nd author – Assisted with data acquisition, patient coordination, and contributed to the initial draft of the manuscript. 3 rd author – Conducted literature review, supported statistical analysis, and participated in critical editing and review of the manuscript . References Rosen CA, Amin MR, Sulica L, Simpson CB, Merati AL, Courey MS, Johns MM 3rd, Postma GN. Advances in office-based diagnosis and treatment in laryngology. Laryngoscope. 2009 Nov;119 Suppl 2:S185-212 Mackenzie M. Diseases of the pharynx, larynx, and trachea. Wood’s library of standard medical authors, vol. 77. New York: William Wood; 1880. Bru¨nnings W. Direct laryngoscopy, bronchoscopy and oesophagoscopy, vol. xiv.London: Bailliere, Tindall and Cox; 1912. Klussmann JP, Knoedgen R, Wittekindt C, et al. Complications of suspension laryngoscopy. Ann Otol Rhinol Laryngol 2002;111:972–976. Tessema B, Sulica L, Yu GP, et al. Tongue paresthesia and dysguesia following operative microlaryngoscopy. Ann Otol Rhinol Laryngol 2006;118:18–22 Hogikyan ND. Transnasal endoscopic examination of the subglottis and trachea using topical anesthesia in the otolaryngology clinic. Laryngoscope. 1999 Jul;109(7 Pt 1):1170-3 Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003 Sep;4(7):407-14. Cohen JT, Bishara T, Trushin V, Benyamini L. Adverse events and time to diagnosis of in-office laryngeal biopsy procedures. Otolaryngol Head Neck Surg 2018; 159: 97-101. Lippert D, Hoffman MR, Dang P, McCulloch TM, Hartig GK, Dailey SH. In-office biopsy of upper airway lesions: safety, tolerance, and effect on time to treatment. Laryngoscope 2015; 125:919–923. Cohen JT, Safadi A, Fliss DM, Gil Z, Horowitz G. Reliability of a trans-nasal flexible fiberoptic in-office laryngeal biopsy. JAMA Otolaryngol Head Neck Surg 2013; 139: 341–345. Wellenstein DJ, Schutte HW, Takes RP, Honings J, Marres HAM, Burns JA et al. Office Based Procedures for the Diagnosis and Treatment of Laryngeal Pathology. J Voice 2018; 32: 502-513. Mozzanica F, Ottaviani F, Ginocchio D, Schindler A. Office-Based Laryngeal Biopsy in Patients Ineligible for General Anesthesia. Iran J Otorhinolaryngol. 2020 Nov;32(113):373-378 Yang, C.C. and S.H. Chen, Impact of topical anesthesia on acoustic characteristics of voice during laryngeal telescopic examination . Otolaryngol Head Neck Surg, 2005. 132(1): p. 110-4 Rubin, A.D., et al., The effect of topical anesthesia on vocal fold motion . J Voice, 2009. 23(1): p.128-31. Walsh, J., R.C. Branski, and K. Verdolini, Double-blind study on the effects of topical anesthesia on laryngeal secretions . J Voice, 2006. 20(2): p. 282-90 Young VN, Smith LJ, Sulica L, Krishna P, Rosen CA. Patient tolerance of awake, in-office laryngeal procedures: a multi-institutional perspective. Laryngoscope. 2012 Feb;122(2):315-21 Zalvan CH, Brown DJ, Oiseth SJ, Roark RM. Comparison of trans-nasal laryngoscopic office based biopsy of laryngopharyngeal lesions with traditional operative biopsy. Eur Arch Otorhinolaryngol. 2013 Sep;270(9):2509-13 . Cohen JT, Fliss DM. Flexible fiberoptic in-office laryngeal biopsy Harefuah 2009;148:18–20. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7142556","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495471334,"identity":"1b9bde59-df4b-4c06-a354-7430e49f3399","order_by":0,"name":"Tithi Debnath","email":"data:image/png;base64,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","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Tithi","middleName":"","lastName":"Debnath","suffix":""},{"id":495471335,"identity":"36e0c657-c8c7-4557-bcec-12544767f1f0","order_by":1,"name":"Subhadeep Chowdhury","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Subhadeep","middleName":"","lastName":"Chowdhury","suffix":""},{"id":495471336,"identity":"4e2b69b5-27a4-4212-b245-f11393456a80","order_by":2,"name":"Somnath De","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Somnath","middleName":"","lastName":"De","suffix":""}],"badges":[],"createdAt":"2025-07-16 17:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7142556/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7142556/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88408619,"identity":"f92e7cf3-c1ca-4702-8578-4c851a5663a9","added_by":"auto","created_at":"2025-08-06 08:13:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":149734,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFraenkel Laryngeal forceps specially used for glottic growth biopsy\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7142556/v1/13d8f3f8dea86de3c1dd81dd.png"},{"id":88411911,"identity":"14ae17c1-bb72-4a50-94e3-879717bbb441","added_by":"auto","created_at":"2025-08-06 08:29:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":95051,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eVAS Ruler\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7142556/v1/efdfd4aabc966236cd8e83d5.png"},{"id":88408626,"identity":"f571beec-7aa2-45a3-8c92-4e0514a65e00","added_by":"auto","created_at":"2025-08-06 08:14:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":32351,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7142556/v1/5a6e40a47bd01271f43cd205.png"},{"id":89085125,"identity":"47f9001e-bdb8-4e52-b8aa-675f4bfe78c5","added_by":"auto","created_at":"2025-08-14 13:54:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1280269,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7142556/v1/a5df3379-f564-4b5a-a9f0-5e8de593437c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Awake rigid endoscopy-guided laryngeal biopsy in high-risk tracheostomized patients: Our experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver the past decade, there has been a growing trend toward, daycare-based laryngeal procedures for managing various laryngeal pathologies [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. According to Steven Marc Zeitels, simple biopsies, laser treatments, and injections are among the commonly performed procedures in such settings [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although the concept dates back over a century, the practice of awake laryngeal biopsy has re-emerged with the advent of advanced rigid and flexible endoscopes, fiber-optic technology, and high-resolution video systems. The origin of laryngeal topical anaesthesia dates to 1884, when Jellinek introduced its use for awake interventions [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eUntil the late 20th century, awake laryngopharyngeal biopsy was predominantly performed using long curved forceps under indirect mirror laryngoscopy, similar to techniques used in the 1850s [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. Modern visualization using rigid or flexible video-endoscopy has largely replaced mirrors, although the transoral approach in awake patients remains fundamentally similar. Mackenzie, in his seminal work, described various instruments, sprays, and topical preparations for office-based laryngeal procedures [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. Likewise, one of the earliest textbooks on operative laryngoscopy by Br\u0026uuml;nnings emphasized the feasibility of such interventions under local anaesthesia [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eAlthough micro-suspension laryngoscopy under general anaesthesia has low complication rates, a significant subset of patients are medically unfit for GA, necessitating alternative diagnostic techniques [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. Awake biopsies can be safely performed in such patients under local anaesthesia on a daycare basis, especially when the lesion is accessible. However, due to limited instrumentation, the risk of inadequate sampling remains. To mitigate this, multiple deep punch biopsies should be obtained, ideally incorporating the lesion base\u0026mdash;particularly in pedunculated growths\u0026mdash;to ensure inclusion of the basement membrane for accurate histopathological diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. To assess the feasibility, safety, and diagnostic yield of rigid 70-degree endoscope-guided awake laryngeal biopsy in tracheostomized patients unfit for general anaesthesia.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e2. To document patient comfort, haemodynamic stability, and procedural tolerance.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e3. To document the clinical features, lesion morphology, and histopathological findings in this patient cohort.\u003c/p\u003e\n\u003c/span\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis was a prospective observational study conducted in the Department of ENT of a tertiary care teaching hospital over a six-month period. A total of 26 patients who had previously undergone emergency tracheostomy due to stridor or upper airway obstruction were enrolled. All patients were suspected to have laryngeal or hypopharyngeal lesions based on clinical and endoscopic assessment and were deemed unfit for general anaesthesia (ASA Class III or IV) following anaesthetic evaluation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePatients aged 18 years or above.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePresence of tracheostomy performed prior to the procedure.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eVisible supraglottic, glottic, trans glottic, or hypopharyngeal lesions on 70-degree rigid endoscopy.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePatients deemed unfit for general anaesthesia due to significant medical comorbidities.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSubglottic lesions not visualized with rigid endoscopy.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePatients unwilling or unable to provide informed consent.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eKnown allergy to local anaesthetic agents such as lidocaine.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003ePre-procedural assessment with detailed clinical histories were obtained, including documentation of systemic conditions like hypertension, diabetes, ischemic heart disease, chronic respiratory disease, and neurological illnesses. Cardiovascular and respiratory assessments were performed to confirm anaesthetic risk. Flexible fiber-optic nasolaryngoscopy was used to assess lesion characteristics preoperatively.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAnaesthesia Technique\u003c/em\u003e\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePatients were administered intramuscular glycopyrrolate (0.2 mg) 30 minutes before the procedure to reduce secretions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNebulization with 3 mL of 4% lidocaine was delivered via the tracheostomy tube.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eA 4% lidocaine solution was instilled using an Abraham cannula: 1 mL over the tongue base and 2–4 mL on the vocal cords during phonation.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTen sprays of 10% lidocaine were applied to the oropharynx to ensure adequate surface anaesthesia.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003e\u003cem\u003eBiopsy Procedure\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe procedure was conducted under sterile conditions with the patient in a semi-seated position. One surgeon held the tongue with a gauze pad and guided the rigid 70-degree telescope. The second surgeon introduced either Fraenkel laryngeal forceps (for glottic lesions) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) or punch forceps for supraglottic and hypopharyngeal lesions to obtain tissue samples.\u003c/p\u003e\u003cp\u003eMultiple biopsies were taken from each lesion to ensure sample adequacy, particularly from the lesion base in pedunculated growths. Minor bleeding was managed using gauze soaked in 1:10,000 adrenaline. All patients were monitored for 30–45 minutes post-procedure and kept nil per oral for two hours pre- and post-procedure.\u003c/p\u003e\u003cp\u003e\u003cem\u003eMonitoring and Outcome Measures\u003c/em\u003e\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eVital parameters: Blood pressure, heart rate, and oxygen saturation were recorded before, during, and after the procedure.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDiscomfort Score: Patient discomfort was assessed using a 100-mm visual analogue scale (VAS), ranging from 0 (no pain) to 100 (worst imaginable discomfort). (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003e\u003cem\u003eDiagnostic Yield\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eBiopsy specimens were sent for histopathological examination. Diagnostic success was defined as obtaining tissue sufficient for histological analysis.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were recorded in structured case sheets and analyzed using SPSS Version 29 and GraphPad Prism Version 9. Continuous variables were presented as mean ± standard deviation (SD), and categorical variables as percentages. Paired t-tests and one-way ANOVA were used to analyses changes in haemodynamic parameters and VAS scores. A p-value of ≤ 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll the 26 patients enrolled in the study underwent rigid endoscopic guided laryngeal biopsy because ineligible for general anaesthesia due to cardiologic 53.85% (14 patients), respiratory 26.92% (7 patients), or neurologic 19.23% diseases (5 patients).\u003c/p\u003e\n\u003cp\u003eAmong 26 patients 21(80.77%) were male and 5 (19.23%)were female. All these patients were in the age group between 49 to 81 years with a mean age of 68.5 \u0026plusmn; 7.03 years.\u0026nbsp; As far as it concerns the location of the suspected lesions, in 26 cases 11 cases (42.31%) were in the supraglottic region, in 8 cases (30.71%) were the glottic region, while in 4 cases (15.38%) in the glottosupraglottic region, 3 cases in the PFS (11.54%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic Yield:\u003c/strong\u003e The procedure was successful in providing adequate diagnostic samples in 23 of the 26 patients, yielding an overall success rate of 88.46%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHaemodynamic Response:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003ePulse rate and blood pressure were monitored pre- and post-procedure\u003c/li\u003e\n \u003cli\u003eStatistically significant but clinically minor variations were noted (p \u0026lt; 0.05)\u003c/li\u003e\n \u003cli\u003eNo episodes of syncope, aspiration, laryngospasm, or post-procedure bleeding requiring intervention were reported.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;The most frequent morphology was ulceroproliferative (14 patients, 53.85%), followed by ulcerative (8 patients, 30.77%) and least commonly 4(15.38%) patients had plaque-like lesions. (Figure 3). Hemodynamic parameters i.e pulse and BP were noted before and after the procedure\u003c/p\u003e\n\u003cp\u003eand the result is found in Tables 1, 2 and 3. There is a statistically significant\u003c/p\u003e\n\u003cp\u003edifference between pre and post-operative hemodynamic parameter findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 : Before and after procedure pulse rate changes according to growth location(n=26)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrowth Location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore procedure pulse rate(bpm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter procedure pulse rate\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(bpm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eSupraglotic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e76\u0026plusmn;5.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e87\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.00007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eGlottic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e74\u0026plusmn;3.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e86\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.0003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003eGlotto\u003c/p\u003e\n \u003cp\u003esupraglottic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e74.5\u0026plusmn;5.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e78\u0026plusmn;5.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.0060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003ePFS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 197px;\"\u003e\n \u003cp\u003e76\u0026plusmn;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 173px;\"\u003e\n \u003cp\u003e91.3\u0026plusmn;6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.0075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 2: Before and after procedure Systolic blood pressure changes according to growth location (n=26)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrowth Location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore procedure SBP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean\u0026plusmn;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter procedure SBP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean\u0026plusmn;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eSupraglotic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e124\u0026plusmn;4\u003c/p\u003e\n \u003cp\u003e.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e131.63\u0026plusmn;6.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.00003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eGlottic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e125.5\u003c/p\u003e\n \u003cp\u003e\u0026plusmn;9.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e130.75\u0026plusmn;9.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eGlotto\u003c/p\u003e\n \u003cp\u003esupraglottic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e130\u0026plusmn;7\u003c/p\u003e\n \u003cp\u003e.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e133.5\u0026plusmn;7.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.0060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003ePFS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e123.33\u003c/p\u003e\n \u003cp\u003e\u0026plusmn;3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e128\u0026plusmn;3.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.0198\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Before and after procedure diastolic blood pressure changes according to growth location (n=26)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrowth Location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore procedure DBP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean\u0026plusmn;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter procedure DBP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean\u0026plusmn;SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eSupraglotic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e80.18\u0026plusmn;6.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e85.82\u0026plusmn;6.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u0026lt; .00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eGlottic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e79\u0026plusmn;7.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e84.75\u0026plusmn;6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.0003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eGlotto\u003c/p\u003e\n \u003cp\u003esupraglottic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e76\u0026plusmn;7.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e83\u0026plusmn;8.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.0043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003ePFS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e76.67\u0026plusmn;6.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e84\u0026plusmn;5.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.0082\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eDiscomfort Score (VAS):\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMean score: 33.35 \u0026plusmn; 24.02 (range: 4 to 84)\u003c/li\u003e\n \u003cli\u003eMost patients reported mild to moderate discomfort\u003c/li\u003e\n \u003cli\u003eNo statistically significant difference in discomfort based on lesion site\u003c/li\u003e\n \u003cli\u003eCategorization of patients according to VAS Score described in \u003cem\u003efigure 3.\u003c/em\u003e The bar chart shows pain levels (VAS score) during a procedure in 26 patients. The majority of patients (17 out of 26) experienced only mild pain.\u003c/li\u003e\n \u003cli\u003eA small proportion experienced moderate (5) or severe pain (3). Pain-free experience was rare, with only one patient reporting no pain. This suggests that while the procedure was tolerable for most patients (with pain in the mild range), a minority experienced moderate to severe discomfort, indicating the need for optimizing patient comfort further.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDiscomfort, as part of the procedure, is described in \u003cem\u003etable 4.\u003c/em\u003e \u003cstrong\u003eNebulization\u003c/strong\u003e was the most comfortable step: 22/26 (84.6%) reported no pain, only 1 had moderate discomfort, and \u003cstrong\u003enone reported severe pain\u003c/strong\u003e. The P-value of 0.1564 suggests \u003cstrong\u003eno statistically significant variation in pain perception\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ehere. \u003cstrong\u003eTopical spray\u003c/strong\u003e caused \u003cstrong\u003eslightly more discomfort\u003c/strong\u003e: 7 experienced mild pain, and 1 moderate, indicating possible throat irritation or taste discomfort. \u003cstrong\u003eInstrumentation (scope insertion via mouth)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewas \u003cstrong\u003ethe most uncomfortable\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eOnly 1 reported no pain, while 17 experienced mild, 5 moderate, and 3 \u003cstrong\u003esevere pain\u003c/strong\u003e. This indicates that \u003cstrong\u003escope passage is the most distressing part\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003epossibly due to gag reflex or mechanical stimulation\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 : Discomfort, by part of procedure(n=26)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDiscomfort By Part Of Procedure (n=26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;pain\u0026nbsp;VAS\u003c/p\u003e\n \u003cp\u003escore (0-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eMild\u0026nbsp;VAS\u003c/p\u003e\n \u003cp\u003escore (5-\u003c/p\u003e\n \u003cp\u003e44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eModerate\u0026nbsp;VAS score (45-74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eSevere\u0026nbsp;(75-\u003c/p\u003e\n \u003cp\u003e100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003cp\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eNebulization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.1564\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eTopical\u0026nbsp;spray of\u003c/p\u003e\n \u003cp\u003elignocaine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInstrumentation in\u003c/p\u003e\n \u003cp\u003eoral cavity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDiscomfort, by location of the growth(n=26)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eSupraglottic growth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003eGlottic growth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eGlottosupraglottic growth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003ePFS\u003c/p\u003e\n \u003cp\u003egrowth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eNo pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0. 5885\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eMild pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eModerate\u0026nbsp;pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eSevere\u0026nbsp;pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMild pain was the most common symptom across all locations. Moderate pain was exclusively reported in supraglottic growths, suggesting deeper involvement or higher sensitivity in that area. Severe pain occurred in isolated cases across supraglottic, glottic, and PFS growths. The p-value of 0.5885 indicates that the difference in pain distribution by growth location was not statistically significant.(Table 5)\u003c/p\u003e\n\u003cp\u003eThe histopathological examination report of the biopsied tissue showed 16 patients had squamous cell carcinoma, 5 cases of premalignant condition (3 mild dysplasia and 2 moderate dysplasia), and 2 benign condition keratosis. 3 cases had inadequate deeper tissue samples and rebiopsy was required. So success rate of our procedure was 88.46 %.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLaryngeal growths can lead to considerable morbidity, significantly impairing fundamental functions such as speech and swallowing. These symptoms frequently necessitate early tissue diagnosis for timely initiation of treatment. Conventionally, direct microlaryngoscopic surgery under general anaesthesia (GA) has served as the gold standard for such diagnostic procedures. However, this technique is not universally applicable, especially in patients with poor general condition or multiple comorbidities. Suspension laryngoscopy demands not only GA but also adequate cardiopulmonary reserve and favorable anatomical positioning, which is not feasible in high-risk patients [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn light of these limitations, awake, office-based procedures have garnered increasing attention. In particular, rigid endoscopy-guided laryngeal biopsies under local anaesthesia present a promising alternative. The present study highlights our experience with rigid 70-degree endoscope-guided biopsy in patients who were unfit for GA and had undergone tracheostomy due to acute upper airway obstruction.\u003c/p\u003e\u003cp\u003eIt is crucial to clarify a common misconception although all patients in our study were tracheostomized, they remained unfit for general anaesthesia due to systemic risks. Comorbidities included cardiac disease (53.85%), respiratory compromise (26.92%), and neurological conditions (19.23%), which made GA a considerable hazard. Therefore, the presence of a tracheostomy should not be mistaken for overall surgical fitness. The tracheostomy merely secured the airway during the diagnostic process but did not reduce the systemic risks of GA.\u003c/p\u003e\u003cp\u003eFurthermore, all patients had undergone emergency tracheostomy prior to biopsy due to stridor and clinical suspicion of significant airway compromise. While histopathology later revealed premalignant lesions (n\u0026thinsp;=\u0026thinsp;5) and benign keratosis (n\u0026thinsp;=\u0026thinsp;2) in a subset of cases, the decision for tracheostomy was based solely on clinical and endoscopic findings of bulky obstructive masses. These lesions, regardless of eventual diagnosis, warranted immediate airway protection.\u003c/p\u003e\u003cp\u003eIn our cohort, the rigid 70-degree endoscopy-guided biopsy procedure was performed successfully in 88.46% of cases. No procedure-related complications such as vasovagal reaction, aspiration, epistaxis, or bleeding from the biopsy site were reported. This is consistent with the findings of Cohen et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], who, in a cohort of 390 patients undergoing office-based laryngeal biopsies, reported a very low incidence of adverse events. Similar safety profiles have been observed across multiple studies on in-office laryngeal biopsy [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo minimize the risk of complications, several precautions were employed in our technique: all patients had a cuffed tracheostomy tube in situ to protect against aspiration, and were monitored for 45 minutes post-procedure. Topical anaesthesia was achieved through a combination of 4% lignocaine via Abraham cannula and nebulization, as well as 10% lignocaine spray to the oropharynx and vocal cords.\u003c/p\u003e\u003cp\u003eThe adequacy of topical anaesthesia was reflected in the mean discomfort score (VAS) of 33.35 out of 100, which is slightly lower than the VAS score of 36.7 reported by Young et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. None of our patients experienced intra-procedural tachycardia or hypertensive spikes, underscoring the effectiveness of our anaesthesia protocol in blunting autonomic reflexes such as coughing, hypertension, and tachycardia [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHistopathological outcomes revealed squamous cell carcinoma in 16 patients, dysplasia in 5 patients, and benign keratosis in 2 patients. In 3 patients, biopsy samples were deemed inadequate due to superficial sampling, necessitating repeat biopsy. This accounts for a partial procedure rate of 11.54%, which is slightly higher than the 5.4% reported by Young et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The most common technical challenges were achieving the correct endoscopic angulation and managing patient movement during instrumentation.\u003c/p\u003e\u003cp\u003eExisting literature reinforces the diagnostic reliability of office-based laryngeal biopsies. Zalvan et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] reported an 81% concordance between office-based and operative biopsies. Cohen and Fliss [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] found that office-based biopsies were sufficient for diagnosing malignancy in 57% and 69.2% of cases in two separate studies, though false negatives were also reported (up to 33%). In our study, due to contraindications for GA, confirmatory biopsies under direct laryngoscopy could not be performed. However, none of the non-malignant cases demonstrated progression or change over a 12-month follow-up, suggesting the reliability of our histopathological diagnosis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, the sample size was relatively small (n\u0026thinsp;=\u0026thinsp;26), which limits the statistical power and generalizability of the findings. Second, the study was conducted in a single tertiary care center, and all procedures were performed by experienced surgeons; thus, the feasibility and safety may not directly translate to settings with less expertise. Third, while we reported patient discomfort using the Visual Analog Scale (VAS), the subjective nature of this measurement and lack of a validated discomfort assessment tool may have introduced reporting bias. Fourth, histopathological adequacy was noted in binary terms, and more detailed evaluation using scoring systems or inter-pathologist agreement was not assessed. Lastly, there was no direct comparison group (e.g., standard GA-based biopsy), which limits our ability to assess relative diagnostic efficacy. Future research should aim to overcome these limitations by incorporating control groups, larger sample sizes, inter-rater reliability, and multi-institutional data\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAwake rigid endoscopy-guided laryngeal biopsy under local anesthesia appears to be a safe and practical alternative in high-risk tracheostomized patients for whom general anesthesia poses significant risks. Our experience suggests that this technique enables adequate tissue sampling for histopathological diagnosis with acceptable patient discomfort. However, these findings are based on a small cohort, and definitive conclusions regarding its diagnostic accuracy and broader clinical applicability require validation through larger, prospective, multicenter studies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e Available upon request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e None\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e Approved by Institutional Ethics Committee (RKC/469 dated 15.01.19)\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePatient Consent:\u003c/strong\u003e Obtained\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Obtained from all authors\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eFirst and corresponding author\u003c/strong\u003e \u0026ndash; Conceived and designed the study, performed clinical procedures, supervised data collection, and finalized the manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e2\u003csup\u003end\u003c/sup\u003e author\u003c/strong\u003e \u0026ndash; Assisted with data acquisition, patient coordination, and contributed to the initial draft of the manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e3\u003csup\u003erd\u003c/sup\u003e author\u003c/strong\u003e \u0026ndash; Conducted literature review, supported statistical analysis, and participated in critical editing and review of the manuscript\u003cem\u003e.\u003c/em\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRosen CA, Amin MR, Sulica L, Simpson CB, Merati AL, Courey MS, Johns MM 3rd, Postma GN. Advances in office-based diagnosis and treatment in laryngology. Laryngoscope. 2009 Nov;119 Suppl 2:S185-212\u003c/li\u003e\n \u003cli\u003eMackenzie M. Diseases of the pharynx, larynx, and trachea. Wood\u0026rsquo;s library of standard medical authors, vol. 77. New York: William Wood; 1880.\u003c/li\u003e\n \u003cli\u003eBru\u0026uml;nnings W. Direct laryngoscopy, bronchoscopy and oesophagoscopy, vol. xiv.London: Bailliere, Tindall and Cox; 1912.\u003c/li\u003e\n \u003cli\u003eKlussmann JP, Knoedgen R, Wittekindt C, et al. Complications of suspension laryngoscopy. Ann Otol Rhinol Laryngol 2002;111:972\u0026ndash;976.\u003c/li\u003e\n \u003cli\u003eTessema B, Sulica L, Yu GP, et al. Tongue paresthesia and dysguesia following operative microlaryngoscopy. Ann Otol Rhinol Laryngol 2006;118:18\u0026ndash;22\u003c/li\u003e\n \u003cli\u003eHogikyan ND. Transnasal endoscopic examination of the subglottis and trachea using topical anesthesia in the otolaryngology clinic. Laryngoscope. 1999 Jul;109(7 Pt 1):1170-3\u003c/li\u003e\n \u003cli\u003eJensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003 Sep;4(7):407-14.\u003c/li\u003e\n \u003cli\u003eCohen JT, Bishara T, Trushin V, Benyamini L. Adverse events and time to diagnosis of in-office laryngeal biopsy procedures. Otolaryngol Head Neck Surg 2018; 159: 97-101.\u003c/li\u003e\n \u003cli\u003eLippert D, Hoffman MR, Dang P, McCulloch TM, Hartig GK, Dailey SH. In-office biopsy of upper airway lesions: safety, tolerance, and effect on time to treatment. Laryngoscope 2015; 125:919\u0026ndash;923.\u003c/li\u003e\n \u003cli\u003eCohen JT, Safadi A, Fliss DM, Gil Z, Horowitz G. Reliability of a trans-nasal flexible fiberoptic in-office laryngeal biopsy. JAMA Otolaryngol Head Neck Surg 2013; 139: 341\u0026ndash;345.\u003c/li\u003e\n \u003cli\u003eWellenstein DJ, Schutte HW, Takes RP, Honings J, Marres HAM, Burns JA et al. Office Based Procedures for the Diagnosis and Treatment of Laryngeal Pathology. J Voice 2018; 32: 502-513.\u003c/li\u003e\n \u003cli\u003eMozzanica F, Ottaviani F, Ginocchio D, Schindler A. Office-Based Laryngeal Biopsy in Patients Ineligible for General Anesthesia. Iran J Otorhinolaryngol. 2020 Nov;32(113):373-378\u003c/li\u003e\n \u003cli\u003eYang, C.C. and S.H. Chen, Impact of topical anesthesia on acoustic characteristics of voice during laryngeal telescopic examination\u003cem\u003e.\u0026nbsp;\u003c/em\u003eOtolaryngol Head Neck Surg, 2005. 132(1): p. 110-4\u003c/li\u003e\n \u003cli\u003eRubin, A.D., et al., The effect of topical anesthesia on vocal fold motion\u003cem\u003e.\u0026nbsp;\u003c/em\u003eJ Voice, 2009. 23(1): p.128-31.\u003c/li\u003e\n \u003cli\u003eWalsh, J., R.C. Branski, and K. Verdolini, Double-blind study on the effects of topical anesthesia on laryngeal secretions\u003cem\u003e.\u0026nbsp;\u003c/em\u003eJ Voice, 2006. 20(2): p. 282-90\u003c/li\u003e\n \u003cli\u003eYoung VN, Smith LJ, Sulica L, Krishna P, Rosen CA. Patient tolerance of awake, in-office laryngeal procedures: a multi-institutional perspective. Laryngoscope. 2012 Feb;122(2):315-21\u003c/li\u003e\n \u003cli\u003eZalvan CH, Brown DJ, Oiseth SJ, Roark RM. Comparison of trans-nasal laryngoscopic office based biopsy of laryngopharyngeal lesions with traditional operative biopsy. Eur Arch Otorhinolaryngol. 2013 Sep;270(9):2509-13\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eCohen JT, Fliss DM. Flexible fiberoptic in-office laryngeal biopsy Harefuah 2009;148:18\u0026ndash;20.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7142556/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7142556/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nPatients presenting with laryngeal lesions and significant comorbidities are frequently unsuitable candidates for biopsy under general anaesthesia (GA). Awake, office-based procedures offer a safer alternative. This study evaluates the feasibility and safety of rigid 70-degree endoscopy-guided laryngeal biopsy in high-risk tracheostomized individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nA prospective observational study was conducted on 26 tracheostomized patients with suspected laryngeal or hypopharyngeal lesions deemed unfit for GA. Biopsies were performed under local anaesthesia using a 70° rigid endoscope. Discomfort was assessed via a Visual Analogue Scale (VAS). Haemodynamic responses were closely monitored, and the adequacy of histopathological samples was assessed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nThe procedure yielded diagnostic tissue in 88.46% of cases. Most patients (65.4%) reported mild discomfort (VAS 5–44); only 11.5% experienced severe discomfort. Statistically significant but clinically stable changes in pulse and blood pressure were observed post-procedure (p \u0026lt; 0.05). No major complications occurred. Histopathology revealed squamous cell carcinoma in 16 patients, premalignant lesions in 5, and benign keratosis in 2 cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nAwake rigid endoscopy-guided biopsy is a safe, effective, and well-tolerated alternative for tissue diagnosis in tracheostomized patients unfit for GA. It ensures timely histopathological confirmation with minimal risk and discomfort.\u003c/p\u003e","manuscriptTitle":"Awake rigid endoscopy-guided laryngeal biopsy in high-risk tracheostomized patients: Our experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:13:55","doi":"10.21203/rs.3.rs-7142556/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3b184a14-9f83-4a14-a9c0-0f571ecf14b9","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-14T13:53:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 08:13:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7142556","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7142556","identity":"rs-7142556","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}