The use of forced ventilation during microlaryngoscopy with laser CO<Subscript>2</Subscript>

CO(2) laser is currently used in the treatment of laryngeal lesions. The technique leads to vaporisation of the tissues on which it is focused, resulting in the production of smoke that remains in the laryngoscope and in the area of the exposed larynx. The fumes can only be partially removed with an aspiration tube. As a result, the vision of the operative field becomes obscured, thus making it difficult to perform surgery. We present a method to resolve this problem consisting in forced ventilation of the air present in the laryngoscope and the exposed larynx. Simultaneous use of the forced ventilation air and the aspiration tube permits a more efficient withdrawal of fumes from the operative field and a better view of the larynx for the surgeon. Since 1986, we have performed 200 CO(2) laser cordectomies in patients with early stage glottic cancer without any kind of complication.     

CO<Subscript>2</Subscript> laser treatment of laryngeal stenoses after reconstructive laryngectomies with cricohyoidopexy,cricohyoidoepiglottopexy or tracheohyoidoepiglottopexy

Supracricoid laryngectomy with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP) is a conservative laryngeal surgery tailored to T1b-T2-T3 glottic-supraglottic carcinomas. Tracheohyoidopexy (THP) and tracheohyoidoepiglottopexy (THEP) allow a chance of conservative surgery also for selected transglottic carcinomas. These techniques are comprehensively named reconstructive laryngectomies (RLs). Post RL laryngeal stenosis not due to carcinoma persistence or recurrence is an unusual occurrence. The aim of the present study has been to analyse retrospectively and describe the treatment of the cases of laryngeal stenosis after RL, which occurred in Vittorio Veneto Otolaryngological Department in a 6 year period. In the period between 1999 and 2004, 225 patients underwent RL in our Department. In 18 of them (8%) a laryngeal stenosis after RL was diagnosed. The same evidence was shown in 2 patients who underwent RL in other Institutions. All patients underwent CO₂ laser surgical treatment of the laryngeal stenosis. The 14 patients who underwent RL-CHEP, the 5 patients who underwent THEP and the patient who underwent CHP were treated on average with CO₂ laser 1.2 (range 1–2), 4.2 (range 2–7), and 2 times, respectively. Decannulation was possible in all patients but one after CO₂ laser treatment of the stenosis in a mean period of 3.4 months. Laryngeal stenoses after RLs can be successfully treated with CO₂ laser excision with a very limited morbility. The only reasonable contra-indication to CO₂ laser excision could be a cranio-caudal length of the laryngeal stenotic tract longer than 1 cm: in this occurrence diagnosed after THP or THEP, an external surgical approach could be preferred.     

New computer-guided scanner for improving CO<Subscript>2</Subscript> laser-assisted microincision

The objective was to clinically test a new computer-guided scanner designed for CO₂ laser-assisted microincision. The scanner-assisted beam travels across the target as a straight or curved incision line. Line length and beam penetration can be adjusted. The studied population, 155 cases, encompassed benign lesions as well as early cancers of the larynx. Operating time was compared with that required for similar operations performed with the Acuspot micromanipulator. Laser-produced coagulation thickness at the incision was measured on 41 operative specimens. The scanner-assisted incision and dissection were more accurate and required up to 30% less time than with a manually guided beam. Postoperative follow-up was straightforward. The coagulation thickness was less than 10 µm for phonomicrosurgery and less than 20 µm for other surgical procedures. The scanner-assisted incision is more accurate than that attained manually.     

Prognostic significance of surgical margins in transoral CO<Subscript>2</Subscript> laser microsurgery for T1–T4 pharyngo-laryngeal cancers

Histological affected or close margin is an adverse factor in conventional surgery of larynx-hypopharynx cancer. Our objective was to analyze the relevance of the margins in transoral laser microsurgery (TLM). A retrospective study of 357 consecutive patients with cancer of the larynx and hypopharynx (T1-T4) treated with TLM. Three possible margins were considered: tumor free, affected, and uncertain. An affected margin showed marked tumor infiltration. An uncertain margin was defined when the sample was insufficient, when it showed carbonization impeding accurate evaluation, or when tumor cells were less than 2 mm. Margins were free in 254 (71.1%) patients, affected in 64 (17.9%) and uncertain in 39 (10.9%). One hundred and three patients (28.9%) presented tumor relapse. The margins were associated with tumor relapse (P < 0.001), but were not significantly related to the tumor site (P = 0.307), the pT classification (P = 0.183), or the difficulty of surgical exposure (P = 0.427). Distant metastases were found in 4.7% of the patients with free margins, in 7.7% of those with uncertain margins, and in 14.1% with affected margins. These differences were statistically significant (P = 0.028). Tumor involvement of the surgical margin was associated with higher rates of local relapse, distant metastasis and the necessity of salvage surgery, together with a lower specific actuarial survival rate.     

One-year follow-up results of combined use of CO<Subscript>2</Subscript> laser and cold instrumentation for Reinke’s edema surgery in professional voice users

The purpose of this study was to present our experience with combined use of CO₂ laser and cold instrumentation for Reinke’s edema surgery and to evaluate 1-year follow-up results of the technique in a series of professional voice users. Fifteen patients with Reinke’s edema who underwent microlaryngoscopic surgery were included. Videolaryngostroboscopy, perceptual and acoustic voice analyses were performed before and after surgery. During the 1-year follow-up, no recurrence of Reinke’s edema was encountered. Significant postoperative improvement was obtained in the quality of voice, in terms of GRBAS scores, Fo, jitter, shimmer and NHR. No evidence of laryngeal cancer was found on the histological examinations. Combined use of CO₂ laser and cold instrumentation provides a reliable and safe method for Reinke’s edema surgery, and cessation of smoking, voice rest and control of the laryngopharyngeal reflux contribute to the success of surgery. We consider that the removal of redundant mucosa of the vocal fold reduces the risk of the recurrence of Reinke’s edema and provides better quality of voice. However, it does not imply that our method is superior to others’, but this procedure constitutes an effective treatment of choice for Reinke’s edema patients, including professional voice users.     

Surgical management of scleromatous laryngotracheal stenosis

Objective

Scleroma is a chronic specific granulomatous disease of the upper respiratory tract caused by Klebsiella Rhinoscleromatis. It usually affects the subglottic region and upper trachea resulting in various degrees of stenosis. Patients with laryngotracheal stenosis may present with stridor, shortness of breath or exercise intolerance and may be tracheostomy dependent. In this work, we presented the experience of our Institute in the management of patients with scleromatous laryngotracheal stenosis using the already designed procedures for traumatic laryngotracheal stenosis.

Patients and methods

The study was a non controlled prospective study. It was conducted in Oto-Rhino-Laryngology and Head and Neck Surgery Department of Zagazig University Hospitals, Egypt. It included 38 patients with scleromatous subglottic stenosis and/or upper tracheal stenosis. The patients were classified into four grades according to Myer–Cotton's scale. The surgical treatment modalities included endoscopic CO₂ laser surgery with dilatation, laryngotracheal reconstruction, and partial cricotracheal resection with thyrotracheal anastomosis.

Results

The average follow-up period was 32.1 months. Twenty four patients (63%) had an excellent outcome. Nine patients (24%) had a good outcome. Five patients (13%) were still tracheostomy dependent. Eleven patients (29%) developed postoperative granulation tissue. The overall success rate was 87%.

Conclusion

Scleromatous laryngotracheal stenosis is considered a challenging surgical problem. It requires a multidisciplinary approach by well-trained personnel. The surgical techniques designed for cases of laryngotracheal stenosis of a traumatic etiology can be applied for cases of scleroma with approximately the same success rates.     

Laryngeal solitary fibrous tumor treated with CO<Subscript>2</Subscript> laser excision: case report

The solitary fibrous tumor is an uncommon unilateral benign lesion that usually arises from the pleura. Recently, these tumors have been described in many other locations, such as the mediastinum, head and neck, orbit and urogenital system. To date, only two cases of solitary fibrous tumor arising from the larynx have been reported in the scientific literature. We describe a new case of laryngeal solitary fibrous tumor localized at the right false vocal fold. A 29-year-old man presented with a 6-month history of progressive hoarseness and foreign body sensation in the throat. A mass lesion was recognized in the right false vocal fold, and CT scan demonstrated a large, well-defined tumor without signs of infiltration. The tumor was removed by transoral CO₂ laser surgery. The definitive diagnosis was obtained by immunohistochemical analysis that showed vimentin and CD34-positive cells. The patient remains free of tumor after 15 months of follow-up.     

喉气管狭窄外科治疗效果的分析

目的 分析喉气管狭窄患者的病因、诊断手段和外科治疗方法,总结喉气管狭窄患者外科治疗的经验.方法 回顾性分析自1989年至2005年就诊于北京大学第一医院耳鼻咽喉头颈外科的53例喉气管狭窄患者的临床资料.手术方法主要包括支撑喉镜下喉气管腔内和颈外人路喉气管重建手术.其中,支撑喉镜下手术主要为瘢痕切除术、激光辅助杓状软骨切除术和喉腔内黏膜微瓣吻合术;颈外入路手术包括喉裂开瘢痕切除术、喉裂开肌骨瓣修复和气管端端吻合术.部分病例使用了扩张子.疗效差异比较采用X2检验.结果 53例患者中,38例拔管成功且无明显呼吸困难,总体成功率为71.7%;3例失随访;12例手术治疗失败,带管生存.颈外入路手术19例中,成功14例,成功率为73.7%;支撑喉镜手术34例中成功24例,成功率为70.6%.从狭窄类型来看,孤立的狭窄31例中成功27例,成功率为87.1%;复合多层面的狭窄共22例中成功11例,成功率为50.0%,两者差异有统计学意义(X2=8.727,P=0.003).从狭窄长度来看,47例狭窄长度＜3 cm成功率38例(80.8%);6例长度≥3 cm的患者均未拔管成功,两者差异有统计学意义(X2=17.140,P=0.000).从最狭窄部位的横径来看,按照Cotton分度,Ⅰ度与Ⅱ～Ⅳ度,成功率分别为96.4%(27/28)和44.0%(11/25),差异有统计学意义(X2=17.891,P=0.000).扩张子使用中橡皮指套l例治疗成功,自制扩张子成功率为72.2%(13/18),T管扩张成功率为25.0%(1/4).舌骨肌瓣植入均成功.结论 喉气管狭窄的治疗应根据病变部位、性质、狭窄的程度选择手术方法,同时应注意扩张子及喉腔肌骨瓣移植物的适当应用.     

Treatment with laser CO2 cordectomy and clinical implications in management of mild and moderate laryngeal precancerosis

All the classification of precancerous lesions are based on the progression of specific histopathological characteristics, which in turn considers the grade of epithelial hyperplasia and dysplasia, nevertheless the transformation of laryngeal keratosis into carcinoma occurs through progressive modifications of normal epithelium in keratosis without dysplasia, to the point of degenerating into carcinoma in situ. The treatment of laringeal precancerosis has not yet defined a gold standard: according to some authors, a simple excision biopsy may be sufficient, others, instead, perform the stripping of the involved vocal cord, while others yet perform vaporization by means of CO₂ laser. The aim of this paper is to evaluate and possibly validate the treatment of mild and moderate laryngeal dysplasia (LIN1-2) by CO₂ laser, with particular attention to oncological and functional results. Fifty-eight patients (44 males and 14 females, mean age 54.3 years) affected by mild and moderate dysplasia (32 LIN I and 26 LIN II) diagnosed by a bioptic exam, were treated by performing a CO₂ laser cordectomy (following the European Society of Laryngology’s criteria). Before surgery to the patients was given a questionnaire to identify primary risk factors such as smoking, alcohol use and gastroesophageal reflux, were also handed a Vocal Performance Questionnaire. In all patients was performed a pH measurement over a 24-h period, a voice evaluation using a Kay digital Strobe 920. 84% of patients were smokers; the presence of reflux was reported in 11 patients (19%). The 32 LIN1 cases treated with type I cordectomy determined four recurrences (12.4%), of which two LIN1, one LIN2 and one carcinoma in situ. Of the 26 LIN2 cases examined, the 12 treated with type 1 cordectomy generated 1 recurrence alone with the presence of an invasive carcinoma (T1a) (8.3%), while no recurrences were reported in the group of 14 LIN2 cases treated with type II cordectomy. 93.1% (54/58) of cases showed a complete closing of the glottal plane over time. Considering the results in terms of disease control, and functional outcomes, our experience suggests subepithelial cordectomy (ELS I) for LIN 1 and subligament cordectomy (ELS II) for LIN 1 recurrences; therefore we suggest subligament cordectomy (ELS II) in LIN 2 cases.     

Endoscopic laser excision in the management of laryngotracheal stenosis

Sixteen cases of Chronic laryngotracheal stensis were included in the study. They underwent endoscopic CO₂ laser excision of the stenotic segment. Three patients were decannulated. giving a success rate of 18.75%.     

CO2 laser supraglottoplasty for severe laryngomalacia: a study of symptomatic improvement

OBJECTIVE: To investigate post-operative symptom improvement in patients with severe laryngomalacia. STUDY DESIGN: Severe laryngomalacia was diagnosed in 138 patients (average age of 6.97 months) by bronchoscopy. Laryngomalacia was defined by the direction of supraglottic collapse: type A (posterolateral), type B (complete), and type C (anterior). As multiple laryngomalacia types within an individual were common, patients were further categorized into group I (type A only), group II (type B or B+A), and group III (type C, C+A, or C+B+A). CO(2) laser supraglottoplasty was performed. Improvements in inspiratory stridor, suprasternal retraction, substernal retraction, feeding difficulty, choking, post-feeding vomit, failure to thrive, and cyanosis were investigated. The presence of a symptom was scored as 1, and the absence as 0. The total score of symptoms was calculated for each patient. General medical history, age at time of surgery, type of laryngomalacia, post-operative intubation period, duration in ICU and dates of postoperative admission were recorded. RESULTS: Overall symptom improvement was observed in 82.6% of patients, with statistically significant resolution evident in group III (B-value=0.79, 95% CI: -0.01, 1.59). Symptoms were not well improved in patients with cerebral palsy (n=32, B-value=-1.02, 95% CI: -1.80, -0.25; p<0.01). The two most improved symptoms were substernal retraction and suprasternal retraction, while the two least improved symptoms were choking and feeding difficulties. CONCLUSION: CO(2) laser supraglottoplasty is an effective treatment option for severe laryngomalacia, especially for group III laryngomalacia cases in the absence of cerebral palsy. It has the superiority of facilitating significant symptomatic resolution and reducing the post-operative complications.     

Treatment of lingual tonsillitis by transoral CO2 laser endoscopy

The authors report on their clinical experiences concerning 100 cases of chronic lingual tonsillitis. The surgical treatment employed was endoscopic vaporization of affected tissues with the CO₂ laser. Prior to surgical intervention, predisposing conditions such as allergy, rhinosinusitis, and gastroesophageal reflux were identified and treated. The surgical technique consisted of progressive vaporization of the lymphoid tissue at the base of the tongue until the lingual fascia was reached. A slightly defocused (700 mm) continuous 10–15W laser beam was used at a working distance of 400 mm. Following surgery, no dyspnea was observed secondary to epiglottis edema and only one patient required postoperative hemostasis. Symptoms related to tonsil or tongue inflammation were eliminated or alleviated in 87 patients, remained unchanged in 12 patients and were worse in 1 patient.     

CO2 laser resurfacing of intraoral lymphatic malformations: A 10-year experience

Objective

To evaluate the safety and efficacy of CO₂ laser resurfacing in the symptomatic treatment of intraoral lymphatic malformations (LM).

Design

Retrospective review.

Methods

Charts were reviewed on 26 patients (16 male, 10 female) from January 1997 to July 2007 who underwent CO₂ laser resurfacing for symptomatic treatment of intraoral LM. A questionnaire was given in order to elucidate effectiveness in controlling symptoms and speed of postoperative recovery.

Results

Mean age at time of first treatment was 9.2 years (median 6.8). Mean number of treatments was 3.0 (median 2.5). Average time between treatments was 9.7 months (median 5.6). Questionnaires were returned for 17 patients (65%). Common preoperative symptoms included swelling, bleeding, vesicle formation, and pain. All 17 patients reported symptomatic improvement after laser treatment. Five patients (29%) tolerated oral intake immediately, 10 (59%) the following day, and 1 (6%) was gastric tube dependent. Four patients (24%) returned to normal activity immediately after treatments, six (35%) by the following day, six (35%) within a few days, and one (6%) within a week. No postoperative complications were seen.

Conclusion

CO₂ laser resurfacing appears to be both safe and efficacious in treatment of symptoms related to intraoral LM. Intermittent treatments for recurrent symptoms is expected.     

Reliability and efficacy of a new CO<Subscript>2</Subscript> laser hollow fiber: a prospective study of 39 patients

We present the first series of patients treated by transoral laser surgery (TLS) using the new AcuPulse 40WG CO₂ laser with the FiberLase flexible waveguide (CO₂ LWG) (Lumenis, Santa Clara, CA) with the objective to test its reliability and efficacy. Patients older than 18 years, with oral, pharyngo-laryngeal or tracheal benign or premalignant lesions were enrolled after signing an informed consent. This prospective study was conducted between October 2010 and May 2011 in two tertiary care university hospitals. Thirty-nine patients were enrolled in the study. The mean age was 47.9 years (range 18–86 years). There were 21 women and 18 men. Thirteen patients had hypertrophy of lymphoid tissue (palatine and or lingual), nine patients had granulomas, four patients had an exudative glottic lesion, three patients had severe dysplasia (glottic and supraglottic), three patients had leukoplakia, two patients had glottal cysts, two patients had laryngeal papilloma, two patients had bilateral paralysis of the vocal folds and one patient suffered from spasmodic dysphonia. Eighty-two percent of the procedures were performed under general anesthesia with laryngo-tracheal intubation. The CO₂ fiber passed through a handpiece was used with a microscope in the majority of the procedures. The laser delivery mode parameter used was: SuperPulse or Continuous Wave. Power levels were 3–15 Watts (W), continuous delivery. Each procedure utilized one CO₂ fiber which performed adequately throughout the procedure. No complications were noted with the use of this technology. A bipolar cautery was needed to control bleeding in eight procedures; all these procedures were tonsillectomies. The CO₂ LWG is a safe and reliable tool for TLS. It is durable enough to last through the entire surgical procedure without the need for replacement. Its use must be tailored depending on the type and location of the lesion, the CO₂ lasers tissue effects as well as the surgeon’s experience.     

Combined therapy with Isoprinosine and CO2 laser microsurgery for the treatment of laryngeal papillomatosis

Summary Recurrent laryngeal papillomas and their potential malignant degenerations in adult patients have been known clinically for about 100 years. An early effective treatment has great importance in preventing possible obstruction of the airway or malignant change. The use of endoscopic microsurgery with the CO₂ laser has resulted in a significant improvement in the eradication of papillomatous nodules. The advantages of laser surgery are: better visualization of the larynx to allow more precise and deeper resection of papillomas, limited bleeding, and a reduced possibility of seeding uninvolved mucosa. Although laser surgery is the current method of choice for treating laryngeal papillomatosis, it has not solved completely the problems of recurrences. To make treatment more effective, we have developed a therapeutic regimen that combines laser microsurgery with the immunostimulant methisoprinol (Isoprinosine). Our observations in 18 patients have shown that this combined management was more successful than using a single modility with either the laser or Isoprinosine alone. The combined approach was also effective in recurrent cases, with the timing of the combination influencing the results of the treatment given.     

Use of the CO2-laser micropoint micromanipulator for the treatment of laryngomalacia

Between September 1989 and June 1994, 21 children (17 boys, 4 girls) with moderate to severe symptoms due to laryngomalacia underwent endoscopic surgery using the CO₂-laser micropoint manipulator (shot-by-shot, 0.1 s, super-pulse, 2–3 W power; 280 m beam; 400 mm working distance). Mean age of the children was 5 months (range, 1–11 months). The procedure was performed under high-frequency jet ventilation and consisted in the resection and/or vaporization of the aryepiglottic folds. This tissue removal could be extended to the laryngeal mucosa of the arytenoids and the lateral edge of the epiglottis. Results of surgery were excellent with normalization (8 patients) or, at worst, a very definite improvement of symptoms (4 patients). Furthermore, no complications occurred due to the technique used. These results have convinced us that the CO₂-laser micropoint manipulator technique, with the super-pulse shooting mode and high-frequency jet ventilation, is by far superior to microsurgery with cold instruments when endoscopic treatment of laryngomalacia is indicated.