The introduction of the laser into nasal surgery has resulted from a need for good hemostasis in a narrow operative field. In using the Nd:YAG, KTP-532, and argon lasers, neighboring structures (eg, the medial rectus muscle, anterior cranial fossa, and optic nerve) are at great risk of thermal damage. Therefore, the versatility of the CO2 and Ho:YAG lasers in this setting has received much recognition.
Reducing turbinate hypertrophy and resecting polyps, papillomas, and synechiae can be performed with the CO2 laser. The physician should be careful not to expose the turbinate bone secondary to thermal damage, which causes scarring, prolonged pain, and persistent crusting. In turbinate resection, the anterior part of the turbinate should always be preserved. The CO2 laser can be used in superpulse mode to provide gradual vaporization. Using an optical wave guide, the laser beam can be directed at the posterior aspect of the turbinate. During the procedure, the laser plume should be vigilantly evacuated. Although the CO2 laser provides good hemostasis and less thermal collateral damage in resecting the previously mentioned lesions, the lack of flexibility in its delivery system constitutes a serious problem. The Ho:YAG laser has tissue interaction characteristics similar to those of the CO2 laser. It is used on pulse mode. Since it can be transferred through a fiberoptic system, it is more advantageous than the CO2 laser. Wedge resection of the inferior turbinate using consecutive interstitial and contact beams from an Nd:YAG laser is also efficient.
Holmium:YAG laser has been used to correct nasal septal cartilage without elevation of the mucoperichondrial flap. Under local anesthesia using a modified speculum, deviated septum was corrected, and then the laser via an optical fiber was applied through the mucosa. Hereditary hemorrhagic telangiectasia can be undergone with Nd:YAG laser therapy to reduce frequency of epistaxis. It should be noted that, overall, although laser systems offer some advantages, they have not replaced the classic surgical approaches.
Katz S, Schmelzer B, Vidts G. Treatment of the obstructive nose by CO2
laser reduction of the inferior turbinates: technique and results. Am J Rhinol
. (Presents techniques of the CO2
laser for inferior turbinate reduction and comparative rhinomanometry results.)
Kuhnel TS, Wagner BH, Schurr CP, Strutz J. Clinical strategy in hereditary hemorrhagic telangiectasia. Am J Rhinol
. (Investigates efficacy of Nd:YAG laser treatment in patients with hereditary hemorrhagic telangiectasia in terms of frequency of nasal bleeding.)
Ovchinnikov Y, Sobol E, Svistushkin V et al. Laser septochondrocorrection. Arch Facial Plast Surg
. (Presents results of nasal septal cartilage reshaping using holmium:YAG laser in 110 patients.)
Rathfoot CJ, Duncavage J, Shapshay SM. Laser use in the paranasal sinuses. Otolaryngol Clin North Am
. (Reviews laser use and its advantages and disadvantages in paranasal sinus surgery.)
Vagnetti A, Gobbi A, Algieri GM et al. Wedge turbinectomy: a new combined photocoagulative Nd:YAG laser technique. Laryngoscope
. (Describes a new method in inferior turbinate reduction using two consecutive applications of interstitial and contact Nd:YAG laser beams.)
The treatment of snoring and sleep apnea is one of the fields in which the laser has gained great popularity. The CO2 laser has been shown to be an effective treatment instrument for snoring and sleep apnea when the obstruction is at the level of soft palate. Although no difference is found in the postoperative snore index between laser-assisted uvulopalatoplasty (LAUP) and conventional uvulopalatopharyngoplasty, LAUP helps avoid most of the postoperative morbidity, as well as providing a good hemostatic benefit during surgery. However, it has been reported that long-term results of snoring and respiratory disturbance index were not as satisfactory as short-term results and tended to deteriorate over time, which was explained with velopharyngeal narrowing and palatal fibrosis caused by the laser.
LAUP can be performed under local-topical or general anesthesia, even in an office setting. The operation can also be staged. The CO2 laser is the laser most commonly used by otolaryngologists for this operation. Since the diameter of the vessels encountered during the procedure is smaller than 0.5 mm, the CO2 laser is effective for hemostasis. Basically, in a LAUP, redundant soft tissue is either excised or ablated. In a typical CO2 laser application, the system is set to a power of 15–20 W. A backstop is used to protect the pharynx from scattering the beam. The system is used in the focused mode for excision and in the defocused mode for vaporization. Bilateral incisions at both sides of the base of the uvula are made with a handpiece. The uvula is shortened to 15 mm, excising redundant soft tissue and preserving its curved shape. The wound then heals within 3–4 weeks. Figure 6–3 shows a postoperative view of immediately after LAUP (Figure 6–3).
Laser-assisted uvulopalatoplasty, immediately after the application of a CO2 laser. (Photo contributed by Andrew N. Goldberg, MD, University of California, San Francisco, Department of Otolaryngology–Head & Neck Surgery.)
Laser tonsillotomy is reserved for patients who are unable to tolerate general anesthesia or unwilling to undergo classic tonsillectomy. The technique requires ablation of tonsillar crypts and gross reduction of tonsillar tissue, which can be staged many times until the level of palatoglossus muscle is achieved. The CO2 laser is set at 15–20 W on continuous mode and applied preferably with a handpiece.
Laser tonsillectomy is not indicated unless a coagulation disorder is diagnosed because of the cost of the laser. The KTP-532 laser is considered the instrument of choice for tonsillectomy because it provides adequate cutting with good hemostasis and little thermal damage. Its optical fiber is held very close to the tonsillar tissue. The first incision is made in a curvilinear fashion along the anterior pillar from the superior pole to the inferior pole to define the dissection plane. Medially and inferiorly, the retracted tonsil is then dissected from the superior pole to the inferior pole.
The excision of the lingual tonsil in the classic fashion is somewhat cumbersome owing to excessive bleeding, postoperative edema, and pain. The use of a laser offers resection with minimal edema, less bleeding, improved visibility during surgery, and less pain postoperatively. The need for a tracheostomy is therefore less likely. The CO2, KTP-532, or Nd:YAG laser can be used along with a rigid laryngoscope. The operation can be staged.
CO2 laser excision or ablation of gingival hyperplasias, pyogenic granulomas, and papillomas is possible with an excellent response rate, good hemostasis, and low morbidity. For especially vascular lesions, photocoagulation with an Nd:YAG laser is preferred. It is set at 32–48 W with a pulse duration of 0.3 seconds. A 2-mm spot size is used with a 2-mm separation between spots.
Oral mucositis associated with chemotherapy or radiation therapy may be prevented with low-level laser use. A few mechanisms underlie the healing effect of the laser. The low-level laser has been demonstrated to increase energy production in the mitochondria. It also facilitates conversion of fibroblasts into myofibroblasts from which fibroblast growth factors are released, and these play a role in epithelial repair. The last effect is that of reducing the formation of free oxygen radicals that are stomatotoxic. The most studied form of low-level laser therapy has been helium-neon laser. The CO2 laser is an alternative. Studies have used low-level laser either prophylactically (before radiation therapy or chemotherapy) or after the appearance of mucosal lesions during the course of radiation therapy or chemotherapy. A recent review showed that even though there is not sufficient evidence to recommend laser use, evidence of its potential usefulness is accumulating.
The CO2 laser is often used for premalignant lesions, including leukoplakia and erythroplakia. Because these lesions are confined to the epithelium, only the superficial layer of the mucosa is removed by leaving 2- to 3-mm margins of normal mucosa. The wound is left to granulate and be covered by a new mucosal layer. These lesions can also be ablated. For ablation, a defocused laser at 10–20 W with a 100-ms pulse is used.
The oncologic literature related to head and neck procedures is encouraging with regard to laser use. Compared with traditional methods, the advantages obtained with laser systems are improved visibility, hemostasis, decreased postoperative edema and pain, and better functional results, including speech and swallowing functions. It allows the surgeon to protect the muscular support of the tongue and the floor of mouth. However, no inherent oncologic benefits result from the laser use. Transoral CO2 laser resection is recommended for superficial T1 and T2 tumors, considering the difficulty in defining the depth of excision with lasers. It is generally accepted that deeply infiltrative tumors, tumors >4 cm, and tumors involving the maxilla or mandible are not suitable for laser resection. Transoral CO2 laser excision of oral cavity carcinomas can be performed with the handpiece or a micromanipulator mounted to the operating microscope. Microscopically abnormal tissues can be detected by using 1% toluidine blue. Normal tissue margins generally measure 1–2 cm beyond the microscopically abnormal tissue.
Resection starts by outlining the margins with the CO2 laser at 6 W and a 100-ms pulse duration. The incision is then made at 10 W on continuous mode. The defect is left for secondary healing or is sutured. The local control rates of T1 and T2 disease addressed with transoral CO2 laser resection is 80–100% at a 2- to 5-year follow-up. The disease-free survival rate is 83–88% at a 5-year follow-up.
Burkey BB, Garrett G. Use of the laser in the oral cavity. Otolaryngol Clin North Am
. (Addresses the indications, techniques, results, and complications of laser use in the oral cavity.)
Finkelstein Y, Stein G, Ophir D et al. Laser-assisted uvulopalatoplasty for the management of obstructive sleep apnea: myths and facts. Arch Otolaryngol Head Neck Surg
. (Presents medium- and long-term subjective and objective results of LAUP.)
Genot MT, Klastersky J. Low-level laser for prevention and therapy of oral mucositis induced by chemotherapy or radiotherapy. Curr Opin Oncol
. (Presents literature review on low-level laser use for prevention of oral mucositis.)
Kaluskar SK, Kaul GH. Long-term results of KTP/532 laser uvulopalatopharyngoplasty. Rev Laryngol Otol Rhinol
. (Presents satisfactory results of KTP-laser uvulopalatopharyngoplasty in 84% of the patients who were evaluated in the 4th year after surgery.)
Linder A, Markstrom A, Hultcrantz E. Using the carbon dioxide laser for tonsillotomy in children. Int J Pediatr Otorhinolaryngol
. (Demonstrates the method using the CO2
laser in tonsillotomy and its results.)
Osman EZ, Osborne JE, Hill PD et al. Uvulopalatopharyngoplasty versus laser assisted uvulopalatoplasty for the treatment of snoring: an objective randomised clinical trial. Clin Otolaryngol
. (Investigates if there was any difference in the snore index following LAUP and UPPP.)
Rathfoot CJ, Coleman JA. Laser utilization in the oral pharynx. Otolaryngol Clin North Am
. (Laser use in the oropharynx is reviewed in a detailed manner from tonsillectomy to malignant disorders.)
Saito T, Honda N, Saito H. Advantage and disadvantage of KTP-532 laser tonsillectomy compared with conventional method. Auris Nasus Larynx
. (Compares pain, intraoperative blood loss, and healing time following conventional and KTP laser tonsillectomy.)
White JM, Chaudhry SI, Kudler JJ et al. Nd:YAG and CO2
laser therapy of oral mucosal lesions. J Clin Laser Med Surg
. (Describes the use of the contact Nd:YAG and CO2
lasers in a variety of benign oral lesions.)
Laser surgery in the respiratory tract requires additional equipment and safety precautions. Microlaryngeal instruments have a black finish to prevent the reflection or misdirection of the laser beam. A microlaryngoscope with smoke evacuation channels is used. Platforms that act as a backstop have been developed to absorb the laser energy and to prevent the spread of the laser beam down into the trachea. In addition, vocal cord protectors are used to protect the other vocal fold.
The delivery systems of various lasers are important considerations in choosing the type of laser for laryngeal surgery. The CO2 laser can be used through a rigid laryngoscope. The spot size of the CO2 laser has been reduced to 160 μm in new systems when it is used at a distance of 400 mm. This offers better precision and prevents collateral damage. The argon, KTP-532, and Nd:YAG lasers can be transmitted through the laryngoscope to the tissue via a fiberoptic cable. They are not preferred for nonvascular glottic lesions because of excessive energy absorption by the surrounding tissue; however, good results are reported in glottic lesions with the contact Nd:YAG laser.
Bilateral Vocal Cord Paralysis
The current therapy for bilateral vocal cord paralysis focuses on static airway enlargement procedures at the posterior glottis; these procedures include posterior cordotomy, medial arytenoidectomy, and total arytenoidectomy. The laser provides better hemostasis compared to classic methods.
In a posterior cordotomy, laser can be used to incise the vocal cord anterior to the vocal process. The anterior vocal process is then excised or vaporized unilaterally or bilaterally. In a medial arytenoidectomy, the vocal process and the medial portion of the arytenoid body are vaporized, preserving the lateral arytenoid body and the aryepiglottic fold. A total arytenoidectomy can also be performed with the CO2, KTP-532, and Nd:YAG lasers.
The use of laser for the excision of nodules, polyps, and cysts is not advantageous over microsurgical techniques in terms of preserving uninvolved mucosal layer and lamina propria. However, the surgical precision of the laser has been increased in new systems by adding a microspot manipulator. For these lesions, the laser is set at as low as 4 W of power in the focused mode. As small a spot size as possible should be used. Cautious excision of the lesion with the involved mucosa is necessary. For submucosal lesions, especially cysts and large sessile polyps, a mucosal incision can be made with the laser. The mucosa is then elevated and the lesion is removed in a standard fashion. However, the additional cost of the laser should be taken into account in these cases.
For vascular lesions, the laser is far superior to microsurgical interventions in terms of surgical precision and hemostasis. The CO2 laser is preferred for small vascular lesions such as symptomatic dilated blood vessels and angiomatous clusters of capillaries. During laser surgery for these lesions, and after achieving endoscopic exposure, the defocused laser with a spot size of 300–400 μm and at 1–2 W is used with a single pulse of 0.1 seconds to coagulate the blood supply. This reduces the size of the capillary lesion. The main capillary lesion is then excised with a focused laser at the same level of power. Large vascular lesions are treated with the Nd:YAG laser for palliation. Under endoscopic exposure, a fiberoptic laser cable is introduced and secured. The lesion is then coagulated with the laser in a noncontact mode (a few millimeters away from the lesion) at 20 W and a 0.5-second pulse. The application can be staged in order to observe the response of the lesion and surrounding tissue.
Granulation tissue around the arytenoid cartilage, which arises from mucosal defects caused by gastric reflux or sustained mechanical trauma, can be excised with the CO2 laser when surgery is warranted. The CO2 laser can also be used to treat superior tracheal granulation tissue.
Recurrent respiratory papillomatosis can be ablated with the CO2 laser, even though it does not provide a better recurrence rate than microlaryngeal surgery. Because the eradication of the virus is not possible, the area of active expression should be addressed. If possible, a 1-mm normal mucosal margin can be included. This intervention should be performed as infrequently as possible to avoid scarring. The laser permits a precise and bloodless excision with less scarring compared with other surgical options. The CO2 laser can be used for either the excision of bulky disease or superficial vaporization. For excision, a focused laser is set at 4 W with 0.1-second pulse and a 0.5-second pulse interval. The same setting can be used in a defocused mode for superficial vaporization. Recurrences are addressed in the same manner. A comparative study showed that excision by microdebrider was less time consuming compared with CO2 laser.
Laryngeal stenosis can be addressed with a laser for cutting or coagulating purpose. However, its only advantage over standard treatment methods (ie, scalpel incision and electrocoagulation) is good hemostasis. To prevent reformation, an anterior membranous or thick glottic web can be incised with a CO2 laser before interposing the tissue flap, keel, or stent placement. In a posterior glottic web, a CO2 laser is used to incise the arytenoid mucosa (the micro-trapdoor flap) and vaporize the submucosal scar tissue between the arytenoids. Subglottic stenosis <1 cm in vertical length can also be addressed with a laser to make radial incisions before bronchoscopic dilatation.
The CO2 laser offers surgical precision, minimal bleeding, less surgical trauma, and rapid healing in the endoscopic management of carcinoma in situ and early glottic carcinoma. For carcinoma in situ, the local control rate and the quality of life obtained in using the CO2 laser are close to what is achieved with radiation therapy and better than with vocal cord stripping. Also, better ultimate laryngeal preservation is obtained with the CO2 laser compared with radiation therapy. This holds true when laser CO2 cordectomy is compared with open surgery. In a typical application, mucosal disease is excised with the CO2 laser in the superpulse mode at a spot size of 0.5–0.8 mm. The output power is set to 2–3 W. If invasion is found in a histopathologic examination, the underlying vocal ligament should also be excised (subligamentous cordectomy), leaving a 1- to 2-mm normal tissue margin. Studies regarding the efficacy of endoscopic laser use for more aggressive disease and tumors invading the anterior commissure are not conclusive.
The transoral excision of the supraglottic carcinoma and selected piriform sinus carcinomas can be facilitated with a laser in the context of organ preservation. The neck is addressed in a staged manner. These techniques offer less postoperative morbidity, including the avoidance of tracheotomy and improved swallowing function.
Brown DH. The versatile contact Nd:YAG laser in head and neck surgery: an in vivo and clinical analysis. Laryngoscope
. (Demonstrates comparable tissue and healing effects of the CO2
and Nd:YAG lasers in rats and presents favorable results obtained with the use of Nd:YAG laser for laryngotracheal lesions and oraloropharyngeal carcinoma.)
Courey MS, Ossoff RH. Laser applications in adult laryngeal surgery. Otolaryngol Clin North Am
. (Reviews safety measures and laser choice, and its use in vocal cord paralysis and benign and malignant lesions.)
Damm M, Sittel C, Streppel M et al. Transoral CO2
laser for surgical management of glottic carcinoma in situ. Laryngoscope
. (Investigates the effectiveness of the CO2
laser in glottic carcinoma in situ.)
Dedo HH, Yu KC. CO2
laser treatment in 244 patients with respiratory papillomas. Laryngoscope
. (Presents results of frequent excision of respiratory papillomas using the CO2
Eckel HE, Thumfart W, Jungehulsing M et al. Transoral laser surgery for early glottic carcinoma. Eur Arch Otorhinolaryngol
. (Includes analyses of rates of local control, regional control, organ preservation, and survival in patients with carcinoma in situ and T1 and T2 laryngeal lesions.)
El-Bitar MA, Zalzal GH. Powered instrumentation in the treatment of recurrent respiratory papillomatosis: an alternative to the carbon dioxide laser. Arch Otolaryngol Head Neck Surg
. (Compares the advantages of microdebrider with CO2
laser in juvenile laryngeal papillomatosis.)
Gluth MB, Shinners PA, Kasperbauer JL. Subglottic stenosis associated with Wegener's granulomatosis. Laryngoscope
. (Evaluates the outcomes of subglottic stenosis in 27 patients with Wegener's granulomatosis with emphasis on CO2
laser and other treatment modalities.)
Maurizi M, Almadori G, Plaudetti G et al. Laser carbon dioxide cordectomy versus open surgery in the treatment of glottic carcinoma: our results. Otolaryngol Head Neck Surg
. (Analyzes oncologic results in patients with glottic cancers treated by either laser CO2
or open surgery.)
Rudert HH, Hoft S. Transoral carbon dioxide laser resection of supraglottic carcinoma. Ann Otol Rhinol Laryngol
. (Describes the use of the CO2
laser in supraglottic malignant disorders with the intents of cure and palliation, and gives outcome results comparable to the conventional surgery.)
Steiner W, Ambrosch P, Hess CF et al. Organ preservation by transoral laser microsurgery in piriform sinus carcinoma. Otolaryngol Head Neck Surg
(Presents the operative technique of transoral excision of piriform sinus carcinoma and its oncologic results with approaches to the neck.)
Laser use in the tracheobronchial system is limited to CO2 and Nd:YAG lasers. In fact, use of the CO2 laser in bronchoscopy remains restricted by the articulated arm. Another limitation of the CO2 laser is its hemostatic capability. In contrast, an advantage of the Nd:YAG laser is the ability to use it with both rigid and flexible bronchoscopes. In addition, better hemostasis, even for deeper lesions, is obtained with the Nd:YAG laser.
Characteristics of the CO2 laser confine its use to superficial lesions, including recurrent respiratory papillomatosis involving the tracheotomy site and the trachea, subglottic and tracheal stenosis, and capillary hemangiomas. The use of the CO2 laser in these lesions is similar to what is described previously for laryngeal applications. For bulky lesions, the Nd:YAG laser is preferred for its vaporization and coagulation effects. In a typical application, the Nd:YAG laser is set at <30 W and exposure should be kept to <90 seconds. Laser use higher than these levels may cause necrosis and perforation in the tracheobronchial wall.
Debulking malignant disorders that obstruct the tracheobronchial system can be performed with the CO2 or Nd:YAG laser for palliation purpose. Photodynamic therapy is useful only for patients with small lesions of squamous cell carcinoma and carcinoma in situ that can be reached with a flexible fiberoptic bronchoscope.
CO2 laser has been introduced to endoscopic management of Zenker's diverticulum. The approach has been called “CO2 laser-assisted diverticulotomy,” and it is preferred in rather primary cases. With this approach, a specially designed endoscope with double lips is introduced into the esophageal lumen. At the level of diverticulum, while the anterior lip of the endoscope is directed toward the esophageal lumen, the posterior lip remains at the bottom of the diverticulum, thereby leaving the common wall and cricopharyngeus muscle between the two lips of the endoscope. Then, through an operation microscope with 400-mm lens and CO2 laser micromanipulator, the common wall is transected with a CO2 laser set at 5–10 W on continuous mode. The transection is recommended to continue down to the distal-most part of the common wall. This procedure also transects the hypertonic cricopharyngeus muscle, which is thought to contribute to the pathogenesis of the diverticulum. Thus, both transecting the common wall and relieving the muscle prevent food entrapment. During the procedure, one should be cautious not to violate fascia that envelops the diverticulum. Compared with open technique, this technique reduces operative time. However, one should be aware of the greater possibility of repeated surgery in this approach.
Chang CW, Burkey BB, Netterville JL et al. Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for Zenker's diverticulum. Laryngoscope
. (Describes CO2
laser use in the management of Zenker's diverticulum and compares the results with those of open technique.)
Cholewa D, Waldschmidt J. Laser treatment of hemangiomas of the larynx and trachea. Laser Surg Med
. (Describes Nd:YAG laser technique and its results in laryngeal and tracheal hemangiomas.)
Rebeiz EE, Shapshay SM, Ingrams DR. Laser applications in the tracheobronchial tree. Otolaryngol Clin North Am
. (Reviews use of the CO2
, Nd:YAG, and KTP lasers in tracheobronchial tree as well as photodynamic therapy.)
Savary JF, Monier PF, Fontolliet C et al. Photodynamic therapy for early squamous cell carcinoma of the esophagus, bronchi, and mouth with m-tetra (hydroxyphenyl) chlorin. Arch Otolaryngol Head Neck Surg
. (Describes the methodology of the photodynamic therapy using m-tetra (hydroxyphenyl) chlorin in carcinoma in situ and microinvasive carcinoma of the upper aerodigestive tract.)
Sipila J, Scheinin H, Grenman R. Laser bronchoscopy in palliative treatment of malignant obstructing endobronchial tumors. ORL J Otorhinolaryngol Relat Spec
. (Describes use of the CO2
and Nd:YAG lasers with the intent of palliation in malignant endobronchial tumors as well as their fatal complications.)