Powered instrumentation in the treatment of recurrent respiratory papillomatosis: an alternative to the carbon dioxide laser

OBJECTIVE: To assess the advantages of powered instrumentation vs the carbon dioxide laser in treating patients with juvenile-onset recurrent respiratory papillomatosis. DESIGN: A retrospective study. SETTING: Tertiary care children's hospital. PATIENTS: Patients operated on for juvenile-onset recurrent respiratory papillomatosis between January 1, 1999, and December 31, 2000. Papillomas were excised using the microdebrider in one group and the carbon dioxide laser in the second group. INTERVENTIONS: Direct laryngoscopy and bronchoscopy, suspension microlaryngoscopy, and excision of papillomas by the carbon dioxide laser or the microdebrider. MAIN OUTCOME MEASURES: Operative time and postoperative complications. RESULTS: Seventy-three operations were performed (23 with the laser and 50 with the microdebrider). Sixteen patients were included, 10 with active disease and 5 with disease in remission; 1 was lost to follow-up. They had a mean age of 3.75 years, and the male-female ratio was 7:9. The patients presented mostly with hoarseness (13 [81%]). Four (25%) had soft tissue complications with the laser. The microdebrider was less time-consuming than the laser, although those treated with the microdebrider had more active disease. No factor could be used to measure treatment outcome due to disease variability. Those who were older, female, and African American tended to have less severe manifestations of disease. CONCLUSIONS: The microdebrider proved to be less time-consuming than the carbon dioxide laser when used in patients with juvenile-onset recurrent respiratory papillomatosis. Soft tissue complications were nonexistent. In addition to safety, the microdebrider is more appealing to the surgeon, anesthesiologist, and parents, especially because these children often need subsequent surgical procedures.     

Recurrent lingual tonsil hyperplasia

Clinically significant lingual tonsil hypertrophy is a rare entity in children. We describe a child, status postadenotonsillectomy, with recurrent hypertrophy of the lingual tonsil after carbon dioxide laser ablation. Workup was negative for immunodeficiency, cystic fibrosis, and allergies. The findings of examination of multiple biopsy specimens of the tissue suggested follicular hyperplasia, and cytometery showed no evidence of a lymphoproliferative disorder. Empiric treatment with a histamine2-receptor blocker after the sixth carbon dioxide laser ablation prevented lingual tonsil hypertrophy.     

New microspot micromanipulator for carbon dioxide laser surgery in otolaryngology. Early clinical results

A new micromanipulator with microspot capability has been developed for carbon dioxide laser surgery in otolaryngology. The instrument features new infrared optics, which provide smaller laser spot sizes than those achievable with conventional micromanipulators (300 micron using a 400-mm operating microscope lens). The conventional red helium-neon aiming laser is replaced with a nonlaser fiberoptic image, and a power defocus control on the joystick manipulator eliminates external defocus controls. Less surrounding tissue trauma occurs with this new instrument by using a higher power density with average power settings of 1 to 2 W for cutting and ablation of tissue. Eight patients with benign laryngeal disease and one patient with dysplastic changes of the vocal cord were treated successfully without complications.     

Intractable chronic myringitis treated with carbon dioxide laser microsurgery

OBJECTIVE: To determine the effect of carbon dioxide laser microsurgery in the treatment of intractable chronic myringitis (CM). DESIGN: Retrospective 10-year case note review. SETTING: Tertiary referral hospital. PATIENTS: We reviewed retrospective case notes for 30 treated ears in 29 consecutive patients with CM (ie, loss of the tympanic membrane for longer than 1 month, refractory to conservative medical treatment) who underwent carbon dioxide laser microsurgery between 1995 and 2004, excluding patients who had undergone previous otologic surgery such as tympanoplasty. INTERVENTIONS: Carbon dioxide laser microsurgery for resurfacing the nonepithelialized tympanic membrane was performed using local anesthesia. MAIN OUTCOME MEASURES: Resolution of disease in the affected tympanic membrane. RESULTS: Of 30 affected ears, 22 demonstrated total resolution of CM, 7 demonstrated partial resolution, and the status of 1 ear remained unchanged at the end of follow-up (mean,19.7 months). Revision laser therapy was performed in 3 ears, resulting in total resolution of disease in 1 ear. Time to total resolution of disease ranged from 1 to 16 months (mean, 2.95 months). CONCLUSIONS: We used carbon dioxide laser microsurgery to treat intractable primary CM and describe its efficacy in a retrospective review of laser resurfacing covering 10 years. We believe that laser microsurgery has the advantages of less invasiveness and higher applicability compared with aggressive surgical treatment. In patients with CM refractory to conservative medical treatment, carbon dioxide laser microsurgery could be an effective alternative when aggressive surgical procedures are not under consideration.     

脂肪组织鼓膜修补术中CO2激光的应用

目的选择慢性化脓性中耳炎或外伤性鼓膜穿孔91例,探讨CO2激光脂肪组织鼓膜修补术临床效果。方法全部患者随机分两组,治疗组为应用CO2激光脂肪组织鼓膜修补术,对照组为颞肌筋膜鼓膜修补术。SPSS13.0统计软件统计,采用校正的卡方检验。结果治疗组言语频率气导平均听阈（15.4±5.5）dBHL,平均听力提高（9.8±4.7）dBHL,纯音听力测试6例鼓膜未愈合者无听力损失加重,鼓膜已愈合的42例中气骨导差无改变者5例;对照组言语频率平均气导听阈（16.6±4.7）dBHL,平均听力提高（8.6±5.5）dBHL,纯音听力测试4例鼓膜未愈合者无听力损失加重,鼓膜已愈合的39例气骨导差无改变者6例。治疗组鼓膜愈合的42例中,30例鼓膜平整,色泽正常,12例鼓膜穿孔处稍增厚,但平整。鼓膜均无内陷、粘连改变。患者无耳鸣、面瘫、耳垂外形改变。经检验外伤组与中耳炎组的鼓膜穿孔愈合率差异无统计学意义。分别比较不同大小鼓膜穿孔愈合率表明不同大小穿孔愈合率（直径4.5mm以下）,差异无统计学意义。结论采用CO2激光切除部分鼓膜上皮层,脂肪组织鼓膜修补,是简单、方便、有效的鼓膜修复方法。     

Laser surgery for the treatment of glottic carcinomas

PURPOSE: The standard treatment for patients with early glottic carcinoma in Israel has been radiotherapy. In recent years, encouraging results with laryngo-microscopic carbon dioxide laser surgery as a treatment for early glottic carcinoma has changed our treatment strategy. We conducted a retrospective study to investigate the results of carbon dioxide laser excisional technique for early glottic carcinoma (T1, T2). MATERIALS AND METHODS: Twenty-six had squamous cell carcinoma (SCC), (21 patients with T1 and 5 patients with T2 lesions), 3 had carcinoma in situ, (CIS) and 3 had verrucous carcinoma (VC). RESULTS: All patients were free of disease after salvage treatment at the most recent follow-up. CONCLUSIONS: Careful patient selection with endoscopic staging and strict follow-up are essential to secure good results in the treatment of carbon dioxide laser for early laryngeal carcinoma.     

CO2激光喉显微手术治疗喉癌前病变的疗效分析

目的探讨CO2激光喉显微手术治疗喉癌前病变的疗效。方法在显微支撑喉镜下,对94例喉癌前病变(喉角化症77例,成人喉乳头状瘤17例)患者,分别采用CO2激光黏膜表皮剥脱术、黏膜下切除术和声带部分切除术。结果对94例患者6个月～5年的随访显示,发声均恢复良好,一次性治愈率为86.2%(81/94);行两次或两次以上手术的有10例,占10.6%(10/94);最终癌变3例,其中喉角化症2例,成人乳头状瘤1例,占3.2%(3/94)。结论CO2激光喉显微手术治疗喉癌前病变,其疗效显著,具有创伤小、术后嗓音恢复快、不易复发等优点;且早期激光干预治疗可以打断癌前病变癌变的病理学基础,使其向良性转归方向发展。     

Endoscopic laser surgery. An alternative in laryngeal cancer treatment

Thirty-three patients with newly diagnosed laryngeal carcinoma underwent endoscopic treatment with the carbon dioxide laser under microscopic control and venturi jet ventilation. Ten of these patients underwent emergency tumor debulking to relieve airway obstruction and to avoid emergency tracheotomy for airway control, and 23 had definitive treatment of superficial or frankly invasive carcinoma. Among the first group, all had an adequate airway after tumor debulking and could be treated with elective laryngectomy with or without radical neck dissection once their metabolic conditions had improved and they had been appropriately evaluated. Among the second group, two died of lung carcinoma but were free of laryngeal disease and two were lost to follow-up at one year. With a minimal three-year follow-up, six of the remaining 19 patients underwent additional laser procedures. None have required external laryngeal surgery or radiation therapy. Endoscopic laser therapy appears preferable to a more radical approach for carcinoma in situ, microinvasive carcinoma, or superficially invasive carcinoma of the larynx.     

Hylan B gel restores structure and function to laser-ablated canine vocal folds

OBJECTIVES: We evaluated cross-linked hyaluronic acid (hylan B gel) as a scaffold for tissue regeneration and mucosal wave restoration in carbon dioxide laser-ablated canine vocal folds. METHODS: Five beagles underwent stroboscopy before ablation of the left vocal fold with a carbon dioxide laser. Four weeks later, stroboscopy was repeated before and after submucosal injection of hylan B gel into the left vocal fold of 4 animals and of saline solution in 1 animal. Stroboscopy was repeated 12 weeks later, and histologic analysis was performed. RESULTS: Four weeks after laser ablation, all animals had soft tissue defects and absence of mucosal waves. Hylan B injection restored mucosal waves, and saline injection did not. Twelve weeks after injection, hylan B-injected larynges had tissue regeneration and mucosal waves, and the saline-injected larynx had neither. Histology showed regenerated lamina propria with residual foci of hylan B in the hylan B-injected larynges and dense submucosal scar in the saline-injected animal. CONCLUSIONS: Submucosal hylan B gel injection in laser-ablated canine vocal folds restored tissue volume and mucosal waves and facilitated functional tissue regeneration over 12 weeks. Hylan B gel may have utility as a soft tissue scaffold for rehabilitation of phonatory function in vocal folds with lamina propria defects.     

Total cervical tracheal stenosis: treatment by laser, dilation, and stenting

Twelve patients with total cervical tracheal stenosis were treated by endoscopic laser excision (neodymium:yttrium aluminum garnet or carbon dioxide laser), bronchoscopic dilation, and prolonged stenting with a silicone T-tube. All patients had previous traumatic or prolonged endotracheal intubation requiring a tracheotomy and presented with aphonia as the major complaint. Multiple laser and dilation treatments were necessary in ten patients. Average duration of T-tube placement was 6 months. Excellent results (decannulation and good voice) were achieved in eight patients with a follow-up of 9 months to 6 years. Persistent granulation tissue and some degree of fibrosis were the most common complications (eight of 12 patients). Two patients died of medical complications. A high success rate with this endoscopic technique justifies this approach as our initial therapy, with open surgical techniques reserved for failure.     

Palliative laser surgery for melanoma metastatic to the larynx: Report of two cases.

Melanoma metastatic to the larynx is an extremely rare entity. This paper describes two patients previously treated for cutaneous melanoma who developed recurrent melanoma involving their larynges. Surgical excision of these lesions was accomplished with the carbon dioxide laser. Apparently, these two patients are the first reported cases of successful management of melanoma metaslatic to the larynx using laser surgery. The paper also discusses the evolving history and diagnosis of laryngeal melanoma, the use of the carbon dioxide laser in the treatment of other laryngeal and tracheobronchial lesions, the incidence of cutaneous and mucosal melanoma of the head and neck, and the diagnostic evaluation and management of melanoma.     

General techniques and clinical considerations in laryngologic laser surgery

The carbon dioxide laser, one of the great advances in otolaryngology, has the characteristics of accuracy, reduced bleeding, reduced reaction, faster healing, and less scarring as compared with conventional surgery. Its beam is produced by creating an electric discharge within a cylinder containing carbon dioxide, nitrogen, and helium. The emitted beam is invisible, and special means are used to show exactly where the beam is going to impinge on the tissue. The effect of the power delivered to the tissue by the laser beam depends on the character of the tissues, the presence of char, the delivery device, and the condition of the lenses and mirrors. The imprint size varies with the power and the duration of exposure and is not necessarily the same as spot size. Repeated exposures increase the amount of tissue destruction and can be used to completely eradicate a lesion until the junction of normal and abnormal tissue is encountered. The following points and techniques are important in determining the results of carbon dioxide laser surgery. Increasing the power and reducing the duration of the beam result in less charring, less reaction, and faster healing. Overheating of tissues is avoided by using a skip technique. Char must be removed to prevent overheating of tissues and to aid in identifying accurately the junction of normal and pathologic tissues. Palpation may help identify pathologic tissue not readily apparent on inspection alone. The edge of the beam can be used to shave away pathologic tissue accurately while preserving normal tissues.(ABSTRACT TRUNCATED AT 250 WORDS)     

Powered laryngeal shavers and laryngeal papillomatosis: a preliminary report

Carbon dioxide (CO2) laser ablation is widely accepted as the most effective first line surgical treatment of recurrent laryngeal papilloma. However, vaporization of papilloma with the CO2 laser exposes the patient and staff to a potentially infective plume. Furthermore, unsuitable pathological tissue specimens and scarring of the surrounding laryngeal architecture are inevitable consequences of the thermal energy generated by this instrument. Following their innovative use in endonasal surgery, powered laryngeal microresecting instruments (Xomed Shavers) have been developed for laryngeal surgery. We assessed the value of these new instruments in five patients who had previously undergone laser ablation. All of the patients reported that their postoperative recovery was the 'same as' or 'better than' that following laser surgery. The surgeon reported that though there was more bleeding, shaver excision of papilloma provided good clearance of disease; easy collection of pathological samples; and a potentially safer and faster alternative to laser excision.     

Bone conduction variation poststapedotomy

We evaluated the variation in bone conduction auditory thresholds in patients undergoing surgical intervention for otosclerosis as part of our report on the use of surgery in patients with a small air-bone gap. Of the 110 patients who underwent stapedotomy, 45 were treated by traditional surgery and 65 with carbon dioxide laser, with a follow-up of 3 years at 500-, 1000-, 2000-, and 3000-Hz frequencies. Both surgical techniques resulted in improvements in air conduction in more than 95% of cases; bone conduction improved more in patients treated with carbon dioxide laser (7.1 dB) compared to those treated with traditional surgery (4 dB) (P < .01). Furthermore, improvement in bone conduction was greater and more frequent in younger subjects (below 45 years) (P < .05). In conclusion, this study allows us to express a positive prognosis when considering otosclerotic patients with sensorineural hearing loss and small air-bone gap.     

Laryngeal amyloidosis: localized versus systemic disease and update on diagnosis and therapy

The clinical and pathological characteristics, possibility of systemic disease, and effect of local therapy were studied in laryngeal amyloidosis. Records of all patients with localized laryngeal amyloidosis in a single tertiary referral center were examined retrospectively at diagnosis and after local therapy. Of 188 new patients with amyloidosis between 1990 and 2003, 5 patients had localized laryngeal amyloidosis. A sixth patient with localized laryngeal amyloidosis turned out to have systemic AL (immunocyte-derived) amyloidosis 8 years later. Free light chains were found in this patient, as well as in 1 of the other 5 patients. Amyloid interfering with laryngeal or airway function was removed during microlaryngoscopy with a carbon dioxide laser or cold endoscopic excision. The best results were seen when glottic deposits were removed by cold endoscopic excision, and supraglottic deposits by a carbon dioxide laser. Four patients had recurrent disease. A systematic workup, including measurement of free light chains, helps to rule out systemic disease.     

Laser uvulopalatoplasty in treatment of habitual snoring

Velopharyngeal sonorous snoring is best treated with uvulopalatopharyngoplasty (UPPP). To reduce surgical risks and minimize the morbidity, a simplified carbon dioxide laser uvulopalatoplasty (LUPP) was performed under local anesthesia. Among a total of 146 patients who had a LUPP performed, there was no significant bleeding or postoperative episodes of asphyxia. The procedure was well tolerated even by those patients with strong vomiting reflexes. The operation time was halved, as was the convalescence. Two patients (1.4%) developed scarring with nasal obstruction, but the impact of factors other than the laser approach itself seemed to be the cause. By scored questionnaires the effect on snoring, family complaints, and daytime somnolence was evaluated in two comparable random groups of patients. Sixty-three patients had LUPP procedures, and 37 had UPPP. The short-term results showed that about 90% of the patients considered themselves essentially improved as regarded snoring and that most patients felt more alert, irrespective of the surgical method used.     

Transoral carbon dioxide laser ablation for cancer, tumors, and other diseases

A carbon dioxide laser was used on 71 patients for the removal of oral cavity or oropharyngeal cancers, premalignant lesions, benign tumors, or elongated soft palates. Evaluation of patient morbidity, speech, and swallowing, as well as survival data, suggests that the use of this modality for treatment of these conditions is highly successful, with excellent preservation of oral and pharyngeal function and minimal patient morbidity. Deep excisions of tumors that could lead to restricted motion of the tongue and/or jaw tended to have an adverse effect on both speech and swallowing. Immediate reconstruction should be considered, especially for defects created by excision of large tumors in the anterior oral cavity or in the lateral oropharyngeal wall cancers. Multimodality cancer therapy should be considered for large oral cavity and oropharyngeal cancers that have been treated by carbon dioxide laser excision.     

Posttracheotomy granulation tissue managed by carbon dioxide laser excision

The problem of accumulation of granulation tissue and scar at the superior edge of the tracheostoma is a frequent problem in the management of chronic tracheotomy patients. This traditionally has been managed by cup forceps excision or by eversion through the tracheostoma with a skin hook and blind resection. These methods often lead to hemorrhage, and incomplete removal in a bloody field. We have used the carbon dioxide laser via a bronchoscope for ablation of the granulation tissue and/or scar at the stomal edge and at the tracheotomy tube proximal tip without morbidity in 13 pediatric cases. With experience, removal with the laser often proceeds more quickly than conventional methods. The scar and granulation tissue are excised under direct vision with minimal hemorrhage. We believe this to be a reasonable alternative in the management of this recurring problem.     

Applications of the diode laser in otolaryngology

We undertook a study to determine the usefulness and effectiveness of a relatively new, portable 980-nm wavelength diode laser with a fiberoptic delivery system. We tested the laser in several clinical situations, both in the operating room and in the office. We used it while performing 14 turbinate reduction procedures, one nasal polypectomy, one ablation of an oral papilloma, and one photocoagulation of nasal telangiectasias. Our preliminary findings indicate that the use of this laser was helpful in alleviating nasal congestion in the patients with turbinate dysfunction and in controlling epistaxis in the patient with telangiectasias. It was also effective in treating the polyp and papilloma patients. We did not experience any intra- or postoperative complications. The laser's flexible fiber delivery system is compatible with hollow instruments, allows for coaxial vision, and is ideally suited for intranasal use. Its portability and functional diversity make it an attractive alternative to the conventional carbon dioxide, argon, and neodimium:yttrium-aluminumgarnet lasers.     

CO_2激光扁桃体切除术的临床研究

目的:探讨CO2激光切除扁桃体的临床疗效。方法:随机将102例患者分为CO2激光组和对照组。CO2激光组用CO2激光系统切除扁桃体;对照组则采用常规剥离法切除扁桃体,手术均由同一术者完成。观察并记录两侧扁桃体切除所需手术时间、术中出血量、术后疼痛时间及程度、术后创面反应程度、创面修复时间(假膜出现及脱落时间)、术后再出血、术后术区瘢痕共7项指标。结果:CO2激光组手术时间较对照组短;CO2激光组术中平均出血量(7.2±2.1)ml,而对照组为(92.0±35.0)ml;CO2激光组术后疼痛及创面反应程度均轻于对照组;CO2激光组较对照组假膜出现时间早、脱落晚;两组均无术后再出血患者;术后12周动态观察CO2激光组与对照组术区瘢痕情况,仅对照组有2例(3.92%)出现明显术区瘢痕。结论:CO2激光扁桃体切除术出血量少,术后疼痛小,反应轻,手术方法易掌握,是扁桃体切除术中一种安全、有效、微创的术式。