ABSTRACT
Objective
This study sought to compare topical lidocaine delivered through a channeled endoscope versus traditional anesthetic methods for office laryngology procedures.
Methods
A single‐institution prospective, crossover study of adult patients undergoing office laryngology procedures from February 2023 to February 2024 was conducted. Patient‐reported outcomes for procedural tolerance and anesthetic preference were compared between the investigational method of channel‐nebulized lidocaine versus control anesthetic delivery (trans‐tracheal or drip catheter), with each patient serving as his/her own control.
Results
Twenty‐two subjects were included in the study. Control topical anesthesia included: 13 (59.1%) trans‐tracheal and 9 (40.9%) drip catheter. On bivariate analysis, the use of channel‐nebulized lidocaine was associated with reduced lidocaine dosage (0.4 vs. 1.7 mL, p < 0.001), increased anesthesia delivery time (335 vs. 119 s, p < 0.001), and increased total procedure time (543 vs. 321 s, p < 0.001). No significant differences in anesthetic delivery time or total procedure time were observed when comparing channel‐nebulized delivery with drip catheter. Discomfort during lidocaine administration (p < 0.001) and cough/gag during lidocaine administration (p < 0.001) were significantly lower with channel‐nebulized lidocaine. Multiple linear regression revealed these improvements were not significantly influenced by indication for procedure, years undergoing procedures, or control method of anesthesia. A majority (63.6%) of patients preferred channel‐nebulized lidocaine.
Conclusion
Topical laryngeal anesthesia for office laryngology procedures can be challenging due to patient tolerance. Nebulized lidocaine delivered through an endoscopic working channel may improve patient tolerance and reduce lidocaine dosage but may be associated with longer procedure time.
Level of Evidence
3.
Keywords: laryngology, nebulized lidocaine, office‐based procedures, patient preferences, topical anesthesia
Targeted delivery of nebulized lidocaine through a channeled endoscope may improve patient tolerance and reduce lidocaine dosage for office laryngology procedures. Most patients in this study preferred channel‐nebulized lidocaine over trans‐tracheal and laryngeal drip topical lidocaine.
1. Introduction
Office laryngology procedures allow patients to reduce healthcare costs associated with the operating room and avoid risks associated with general anesthesia [1]. Multiple studies have examined patient tolerance of office laryngology procedures and demonstrated varying levels of discomfort, anxiety, and nausea [1, 2, 3]. Effective topical anesthesia is imperative for laryngology procedures in an office setting, although many patients experience undesirable side effects like coughing, gagging, and pain during the delivery of topical anesthesia to the upper aerodigestive tract [4]. Two common methods for laryngeal topical lidocaine include application via a drip catheter and percutaneous trans‐tracheal injection of lidocaine into the tracheal lumen [5]. Despite prior studies on the tolerance and patient preference for laryngeal drip or trans‐tracheal lidocaine, there is variability in practice and a lack of consensus among laryngologists regarding the optimal technique for topical anesthesia, and both techniques may cause considerable discomfort for patients [2, 6]. As a result, UltraEzAir was developed to provide a more tolerable experience for patients. The topical lidocaine is nebulized in the device and delivered through a channeled endoscope.
The purpose of this study was to compare tolerance and preference for topical nebulized lidocaine delivered through a channeled endoscope (UltraEzAir device) versus traditional anesthetic methods (trans‐tracheal or drip catheter) for office laryngology procedures. We specifically sought to evaluate patient‐reported outcomes following each technique via an institutionally created survey. We hypothesized patients would have higher tolerability and satisfaction with channel‐nebulized lidocaine.
2. Materials and Methods
2.1. Study Design
A single‐institution prospective, crossover study of adults undergoing office laryngology procedures was approved by the University of Texas Health San Antonio (UTHSA) Institutional Review Board (#UTHSC20150586HU). Adults over 18 years of age who were undergoing awake office laryngology procedures were included. Participants were excluded if they had not undergone prior office procedural intervention with topical laryngeal anesthesia, that is, patients receiving first‐time office procedures were excluded to minimize confounding related to patient unfamiliarity with anesthesia for office laryngology procedures. Data was collected from February 2023 to February 2024 at UTHSA. Aside from anesthetic technique, each patient underwent the same procedural intervention at both visits, and all procedures were performed by one surgeon (ZMY). The primary outcome was to evaluate discomfort, cough/gag response, anxiety, and patient preference between traditional topical laryngeal anesthesia and channel‐nebulized delivery. The secondary outcomes were to compare the characteristics of each group and analyze the duration of anesthetic delivery and procedure with each method. Demographic data, indication for procedure, adverse events, and procedural findings were collected. All data was collected utilizing the UTHSA Research Electronic Data Capture (REDCap) database. REDCap is a secure, web‐based software platform designed to support data capture for research studies [7].
2.2. Anesthetic Regimen
All patients in the study were first given sprayed topical lidocaine with oxymetazoline for nasal anesthetic. For all patients undergoing peroral procedures, topical Cetacaine was applied to the oropharynx. The control laryngeal anesthetic group consisted of one of two methods of topical anesthetic traditionally used in our practice: trans‐tracheal lidocaine or laryngeal lidocaine drip. Each patient then served as his/her own control for comparison with channel‐nebulized lidocaine for a subsequent procedure. All patients underwent the same procedure as their initial visit. At the conclusion of their second visit, each patient selected their preferred anesthetic method.
For the trans‐tracheal group, local infiltration of the overlying skin and subcutaneous soft tissue was performed with 1% lidocaine with epinephrine. Next, a 25‐gauge needle was used to percutaneously enter the airway, aspiration of air was used to confirm tracheal placement, and 4% lidocaine was instilled within the trachea as the patient was instructed to phonate. For the laryngeal drip group, a working‐channel laryngoscope (Olympus America, model ENF‐VT3) was used with a flexible drip catheter. The scope was placed into the nasal cavity and advanced to the larynx. The flexible cannula was then advanced through the side channel of the scope until visible, and 4% lidocaine was applied directly to the epiglottis and laryngeal surfaces with intermittent patient phonation to perform a laryngeal lidocaine gargle.
The UltraEzAir device consists of a small console that generates nebulized mist from liquid formulations of medication housed in a detachable chamber that connects to the working channel of a laryngoscope via catheter tubing (Figure 1). The nebulized mist can then be directed using the laryngoscope for targeted application of lidocaine. The lidocaine can be delivered at three density settings: high, medium, and low. For the channel‐nebulized lidocaine group, the chamber was filled with 4% lidocaine and adjusted to a density of “high”. Once the flow rate indicator showed sufficient flow, the scope was placed into the nasal cavity and advanced to the larynx. Nebulized mist is visible with the laryngoscope (Figure 2) and was applied to laryngeal surfaces until the patient was deemed to have a satisfactory degree of anesthesia. The dosage of nebulized lidocaine was calculated by a manufacturer‐published formula of 0.077 mL per minute.
FIGURE 1.
The UltraEzAir device attached to a channeled endoscope. Nebulized lidocaine is delivered through the tip of the endoscope through the working channel for targeted delivery. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]
FIGURE 2.
Channel‐nebulized lidocaine demonstrating a stream of nebulized lidocaine to the larynx. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]
2.3. Survey
The primary outcomes of patient procedural discomfort, cough/gag response, anxiety, and laryngeal anesthetic preference were determined via an institutionally adapted previously validated anesthetic discomfort survey. This validated questionnaire was initially developed for assessing discomfort and tolerance of local anesthesia and was altered to include questions specific to laryngology procedural intervention and anesthetic preference (Figure 3) [2]. The survey consists of seven questions, with ratings for overall discomfort, anxiety, and cough/gag response. Rating is on a zero‐to‐ten‐point scale, with a range explanation of zero being no anxiety or discomfort and ten being severe anxiety or discomfort. The survey was provided to patients immediately after their procedures were completed, and patients were given as long as needed to complete the survey.
FIGURE 3.
Survey provided to patients at completion of each visit. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]
Secondary outcomes were recorded to include basic patient demographics, procedural information, anesthetic delivery time by method, and total procedure time, which were collected during each visit. The anesthetic delivery time was calculated as the time from the start of anesthetic delivery (initial skin infiltration or entry of scope into the nasal cavity) to the point of completion of anesthetic delivery. The total procedure time was calculated as the anesthetic delivery time plus the time to complete the procedure.
2.4. Statistical Analysis
Statistical parameters are presented as mean (standard deviation [SD]) for continuous variables and number (percentage) for categorical variables. Wilcoxon signed‐rank test was used to compare procedure characteristics and patient preferences for control versus channel‐nebulized lidocaine. Fisher's exact test was used to compare differences for categorical variables. Multiple linear regression was performed to evaluate for potential confounders (patient demographics and clinical factors) when assessing procedure characteristics and patient preferences for topical lidocaine delivery. Beta‐coefficients and 95% confidence intervals were reported. Alpha was set to 0.05 to determine statistical significance. All statistical analyses were performed using Stata (Stata LLC, College Station, TX).
3. Results
Twenty‐five patients were enrolled in the study. Two patients were excluded due to the inability to pass the larger diameter channeled laryngoscope through their nasal cavities. One patient decided not to proceed with the study at her second visit. As a result, 22 patients were ultimately included in the analysis. Patient characteristics are included in Table 1. The mean age of participants was 58.6 (14.6); 63.6% were female. Most patients included were undergoing procedures for spasmodic dysphonia (63.6%) and were receiving false vocal fold Botox injection (81.8%). Control topical anesthetic methods included 13 (59.1%) trans‐tracheal and 9 (40.9%) drip catheter. Ten (45%) patients had undergone office laryngology procedures for more than 10 years.
TABLE 1.
Basic characteristics of study participants.
| Characteristic | N = 22 |
|---|---|
| Age | |
| Mean (SD) | 58.6 (14.6) |
| Gender (%) | |
| Female | 14 (63.6) |
| Male | 8 (36.4) |
| Disease (%) | |
| Laryngotracheal stenosis | 3 (13.6) |
| Laryngeal tremor | 3 (13.6) |
| Pharyngeal dystonia | 1 (4.6) |
| RRP | 1 (4.6) |
| Spasmodic dysphonia | 14 (63.6) |
| Procedure (%) | |
| False vocal fold Botox | 18 (81.8) |
| Laser | 1 (4.6) |
| Steroid injection | 3 (13.6) |
| Years Undergoing Procedure (%) | |
| ≤ 10 years | 12 (54.6) |
| > 10 years | 10 (45.5) |
| Control Anesthesia Method (%) | |
| Laryngeal lidocaine drip | 9 (40.9) |
| Trans‐tracheal lidocaine | 13 (59.1) |
| Prefer Channel‐Nebulized Lidocaine | |
| Yes | 14 (63.6) |
| No | 8 (36.4) |
Abbreviations: RRP, recurrent respiratory papilloma; SD, standard deviation.
Anesthetic delivery time and total procedure time varied significantly among the two groups. The control anesthetic delivery and procedure time were 119 s and 321 s, respectively, compared to channel‐nebulized anesthetic delivery and total procedure time of 335 s and 543 s, respectively (p < 0.001). On subgroup analysis, laryngeal drip anesthetic delivery time (242 s) and total procedure time (545 s) were significantly longer than trans‐tracheal anesthetic delivery time (33 s) and total procedure time (166 s). When comparing channel‐nebulized and laryngeal drip, there was no significant difference in anesthetic delivery time or total procedure time. Lidocaine dosage was significantly less with channel‐nebulized lidocaine (0.4 mL vs. 1.7 mL, p < 0.001).
Patient anxiety, discomfort during anesthetic administration, coughing or gagging during anesthetic administration, and discomfort during the procedure were compared between the channel‐nebulized lidocaine and control (Table 2). Patients reported lower average discomfort (2.8 vs. 4.9, p < 0.001) and lower coughing or gagging during anesthetic administration (2.4 vs. 5.6, p < 0.001) with channel‐nebulized lidocaine. No significant differences in overall discomfort or anxiety were noted between channel‐nebulized lidocaine and control. When asked to indicate a preference for channel‐nebulized lidocaine versus control topical anesthetic, 63.6% preferred channel‐nebulized lidocaine. On bivariate analysis, patients with over ten years of prior procedures were more likely to prefer channel‐nebulized lidocaine (p = 0.002). Multiple linear regression revealed improvements were not significantly influenced by other covariates in the model, including age, gender, indication for procedure, years undergoing procedures, or control method of anesthesia.
TABLE 2.
Procedure characteristics and patient preferences for control versus channel‐nebulized lidocaine.
| Without UltraEZAir (n = 22) | With UltraEZAir (n = 22) | Average Difference a (n = 22) | p‐value | |
|---|---|---|---|---|
| Lidocaine dosage (mL), mean (SD) | 1.7 (1.4) | 0.4 (0.2) | −1.2 (1.3) | < 0.001 f |
| Anesthesia delivery time (sec), mean (SD) | 119 (182) | 335 (136) | 217 (188) | < 0.001 f |
| Procedure time (sec), mean (SD) | 321 (257) | 543 (287) | 221 (203) | < 0.001 f |
| Anxiety level b , mean (SD) | 2.0 (1.9) | 1.5 (1.9) | −0.5 (1.1) | 0.06 f |
| Discomfort during lidocaine administration c , mean (SD) | 4.9 (2.4) | 2.8 (2.4) | −2.0 (2.4) | < 0.001 f |
| Cough/gag during lidocaine administration d , mean (SD) | 5.6 (2.6) | 2.4 (2.6) | −3.2 (3.1) | < 0.001 f |
| Overall discomfort during procedure e , mean (SD) | 4.2 (1.9) | 4.4 (2.5) | 0.1 (2.3) | 0.718 f |
Abbreviations: mL, milliliters; SD, standard deviation; sec, seconds.
With UltraEZAir minus without UltraEZAir.
Anxiety level from 0 to 10 (0 = no anxiety, 10 = severe anxiety).
Discomfort during lidocaine administration from 0 to 10 (0 = no discomfort, 10 = severe discomfort).
Coughing/gagging during lidocaine administration from 0 to 10 (0 = none, 10 = severe).
Overall discomfort level during procedure from 0 to 10 (0 = no discomfort, 10 = severe discomfort).
Wilcoxon Signed Rank.
4. Discussion
This study demonstrates that nebulized lidocaine delivered through a channeled endoscope may be a preferable option for some patients undergoing office laryngology procedures. We demonstrated significant decreases in patient‐reported coughing and gagging, as well as discomfort during lidocaine administration. Our findings revealed significantly lower lidocaine dosages with channel‐nebulized lidocaine, though anesthetic delivery time and total procedure time may be longer, especially when compared to trans‐tracheal alone. This is the first study to demonstrate patient preference and tolerance with channel‐nebulized lidocaine for office laryngology procedures.
Topical anesthesia for office laryngology procedures varies widely; no standardized approach currently exists, including the dosage used. Lidocaine is the most frequently used topical anesthetic, typically using concentrations of 2%–6% applied topically to mucous membranes [8]. The peak effect of lidocaine occurs within 2–5 min, and the duration is typically 30–60 min [9, 10]. The maximum safe dose is 3–4 milligrams per kilogram [9, 10]. Studies report topical lidocaine amounts ranging from 1.5 to 10 mL, with the most common dosage being around 3 mL [2, 11, 12, 13]. In contrast, in our study using a channel‐nebulized lidocaine delivery device, the average amount required to achieve sufficient laryngeal anesthesia was 0.4 mL. This is significantly less than the 1.7 mL used in the study's control anesthetic group and lower than amounts commonly reported in the literature.
The duration of office procedures is often compared to operating room procedures, but limited data exist on the timing of different methods of laryngeal anesthesia for office procedures. One notable study by Naunheim and Woo examined the differences in ‘preparation time,’ which included patient rooming, administration of local anesthesia, and pre‐procedure discussion, as well as ‘procedure time’ for patients undergoing traditional anesthesia methods: inhaled oral nebulizer, trans‐tracheal lidocaine injection, and laryngeal lidocaine drip. The study found that both preparation and procedure times were longer for the oral nebulizer group compared to trans‐tracheal lidocaine injection and laryngeal lidocaine drip [2]. While direct comparisons to this study are limited due to differing timing metrics, the channel‐nebulized delivery resulted in increased anesthetic delivery time and total procedure time. However, on subgroup analysis, there was no significant difference in either anesthetic delivery time or total procedure time between laryngeal drip and the channel‐nebulized group, but both methods were significantly longer than trans‐tracheal times.
When evaluating patient discomfort during office procedures, multiple factors can contribute, including anxiety levels and pain. However, one of the most frequently cited reasons for intolerance is pronounced gag or cough reflex [3, 14, 15]. Lippert et al. reported that two out of 117 office procedures had to be aborted due to excessive coughing and gagging, requiring the procedures to be rescheduled in the operating room [15]. Similarly, in a multi‐institutional study, 11% of patients struggled with office laryngeal procedures due to an inability to suppress the gag reflex, making it one of the most common reasons for aborting the procedure [3]. Although inadequate anesthesia can exacerbate cough and gag reflexes, the act of applying topical laryngeal anesthesia is also a critical factor. One of the objectives of this study was to assess the level of coughing and gagging specifically during the application of topical laryngeal anesthesia using channel‐nebulized lidocaine compared to traditional methods. Patients reported lower average discomfort and reduced coughing or gagging during lidocaine administration with channel‐nebulized lidocaine compared to trans‐tracheal and laryngeal lidocaine drip. This is interesting considering prior findings that trans‐tracheal lidocaine injection was best tolerated compared to inhaled oral nebulizer and laryngeal lidocaine drip [2]. We believe that channel‐nebulized lidocaine results in less gag and cough, as the lidocaine is delivered via smaller mist particles and avoids large volume liquid administration directly to the larynx and trachea. Channel‐nebulized lidocaine may offer an alternative for patients who experience heightened gag and cough reflexes with traditional topical anesthetic methods.
Only 13.6% of patients in our cohort underwent procedures targeting the subglottis and proximal trachea. Further study is warranted to evaluate for differences in efficacy and patient tolerance for channel nebulized lidocaine at supraglottic, glottic, subglottic, and tracheal levels. Unpublished pilot data using the original prototype of the UltraEzAir device were promising, as several patients underwent tracheobronchoscopy to the level of the carina with the channel‐nebulized lidocaine prototype.
Cost–benefit analysis of channel‐nebulized lidocaine also warrants additional study. The upfront expense for acquisition of the console is currently unknown. The cost of the disposable attachments for the device relative to the cost of disposable or reusable drip catheters is also unknown. Both channel‐nebulized lidocaine and laryngeal drip lidocaine are likely to be more expensive than trans‐tracheal lidocaine, which typically only requires disposable syringes and needles.
Crossover studies with relatively small cohorts have several inherent, unavoidable limitations. By study design, there is an inability to randomize groups, as both patients and providers are aware of the topical anesthetic being administered. Potential confounders exist due to cohort size, and findings may not be supported with larger samples. Additionally, patients were aware they were being included in a study of an experimental device and therefore may have been influenced by the Hawthorne effect, a phenomenon that describes the alteration of participant opinions or behaviors due to being observed. We also recognize this is a single‐institutional design. To address these limitations, larger, multi‐institutional studies may be performed to demonstrate generalizability.
5. Conclusion
Targeted delivery of nebulized lidocaine through a channeled endoscope may improve patient tolerance and reduce lidocaine dosage for office laryngology procedures but may also be associated with longer anesthetic delivery and total procedure times, especially compared to trans‐tracheal instillation. Within this cohort, most patients preferred channel‐nebulized lidocaine over trans‐tracheal and laryngeal drip topical lidocaine.
Conflicts of Interest
C. Blake Simpson is a consultant and shareholder of Airkor. The authors affirm that Airkor had no role in the design, execution, or reporting of this research.
Erwin D. Z., Kennedy A. N., Liu M. Y., Dominguez L. M., Simpson C. B., and Yang Z. M., “Nebulized Lidocaine Through a Channeled Endoscope for Office Laryngology Procedures,” The Laryngoscope 136, no. 3 (2026): 1409–1415, 10.1002/lary.70209.
Funding: The authors received no specific funding for this work.
This abstract was presented as a Podium Presentation at the Fall Voice Conference on October 26, 2024, in Phoenix, AZ, and was the recipient of a Dysphonia International Travel Grant.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.