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Laser application in Otolaryngology

Laser application in Otolaryngology. Babak Saedi Otolaryngologist Imam Khomeini hospital. Background. Maiman built the first laser in 1960. With synthetic ruby crystals, this laser produced electromagnetic radiation at a wavelength of 0.69 µm in the visible range of the spectrum.

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Laser application in Otolaryngology

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  1. Laser application in Otolaryngology Babak Saedi Otolaryngologist Imam Khomeini hospital

  2. Background • Maiman built the first laser in 1960. • With synthetic ruby crystals, this laser produced electromagnetic radiation at a wavelength of 0.69 µm in the visible range of the spectrum. • Although the laser energy produced by Maiman's ruby laser lasted less than 1 ms, it paved the way for explosive development and widespread application of this technology

  3. LASER SURGERY IN OTOLARYNGOLOGY: INTERACTION OF CO2 LASER AND SOFT TISSU • 1968 was first used by Jako in larynx (C02) • 1966 used in the ear surgery (Argon , ND YAG) Mihashi, S., Jako, G. J., Incze, J., Strong, M. S. and Vaughan

  4. Background • Two important advances allowed the laser to be useful in otolaryngology: • (1) 1965, the carbon dioxide (co2) laser was developed • (2) 1968, Polanyi developed the articulated arm to deliver the infrared radiation from the co2 laser to remote targets. • Simpson and Polanyi described the series of experiments and new instrumentation that made this work possible.

  5. Background • Two important advances allowed the laser to be useful in otolaryngology: • (1) 1965, the carbon dioxide (co2) laser was developed • (2) 1968, Polanyi developed the articulated arm to deliver the infrared radiation from the co2 laser to remote targets. • Simpson and Polanyi described the series of experiments and new instrumentation that made this work possible.

  6. Background • Strong and Jako in 1972 introduced CO2 laser excision for the treatment of laryngeal disease. • The advantages they noted were precise control, minimal bleeding, and the absence of post-operative edema. • Steiner further developed the technique of TLM with a study in Gottenberg, Germany

  7. ND YAG

  8. obstructing neoplasms of the tracheobronchial tree

  9. The Argon Laser

  10. Argon laser stapedotomy

  11. KTP Laser • 532 nm wavelength (potassium-titanyl-phosphate) • Frequency doubling • Nd: YAG laser passes through a KTP crystal – emission is ½ its wavelength • Oxyhemoglobin is primary chromophore • Fiberoptic carrier • Continuous wave (CW) mode to cut tissue • Pulsed mode for vascular lesions • Q-Switched mode for red/orange tattoo pigment • Applications • Granuloma excision of the respiratory tract • Subglottic/tracheal stenosis • Subglottic/supraglottic cyst excision • Inferior turbinate reduction • Nasal papilloma excision • Nasopharyngeal stenosis • Supraglottoplasty • Laryngeal papilloma excision • Middle ear surgery (Cholesteatoma excision, stapes surgery) • Delivery • CW/pulsed mode: insulated fiber, fiber handpiece, scanner, or microscope • Q-Switched mode: articulating arm

  12. CO2 laser

  13. Attachment of CO2 laser articulated arm to operating microscope

  14. The CO2 Laser • CO2 lasers produce light with a wavelength of 10,600 nm in the infrared (invisible) range of the electromagnetic spectrum. • A second, built-in, coaxial helium-neon laser is usually necessary • This laser acts as an aiming beam for the invisible CO2 laser beam. • The laser energy is aimed with a microscope-mounted micromanipulator.

  15. The CO2 Laser • The radiant energy produced by the CO2 laser is strongly absorbed by pure, water and by all biologic tissues high in water content. • Reflection and scattering are negligible.

  16. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370-374 (B) • Table 2. Indication by Stage for Laser Resection

  17. Laryngeal tumor

  18. CO2 laser ablation of a laryngeal tumor

  19. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370-374 (B) • Cordectomies performed using a CO2 laser mounted on a Zeiss surgical microscope. • Performed under general anesthesia. • En-bloc excised tissue was completely detached • the specimen was whole-mounted on a slide and oriented to mark the anterior and the medial margins. • An accompanying legend was drawn adjacent to the lesion • If the histologic examination revealed a positive margin, on frozen sections, the resection was extended until healthy margins were obtained.

  20. Gallo, et al. Laryngoscope. Volume 112(2), February 2002, pp 370-374. (B) • They recommended that • the transmuscular cordectomy (type III) is indicated in cases of small superficial tumors of the mobile vocal fold (T1a); • the total cordectomy (type IV) is indicated in cases of T1a cancer with extension to the anterior commissure, and/or when the tumor involves the vocal fold in an infiltrative pattern and/or when the tumor size is more than 0.7 mm; • the extended cordectomy encompassing the contralateral vocal fold (type Va) is indicated in cases of T1b cancer involving the anterior commissure or in horseshoe lesions

  21. Moreau: Laryngoscope, Volume 110(6).June 2000.1000-1006 (B) • Retrospective study of 160 patients treated from 1988 to 1996 • determine if laser endoscopic microsurgery is a reliable and appropriate approach in the treatment of laryngeal cancers. • Glottic tumors were treated with either type I, type II, or type III cordectomy • For supraglottic cancers, excision limited to • a part of the vestibule, • a trans-preepiglottic resection, or • a radical supraglottic resection

  22. Subglottic Hemangioma • Sie et al. with 10 year experience with CO2 laser in SGH • Serial procedures and 20% rate of post-treatment subglottic stenosis • Madgy et al. reviewed six cases of SGH managed with the KTP laser • Steroids after surgery • End point was to achieve 60 to 70% airway patency • 3 with mild post-procedural SGS • Barlow et al. - spastic diplegia in 20% of 26 children less than 2 years of age treated with IFN • Life threatening • Hemangiomas respond to steroids in 30 to 60% of cases – IFN administered in non-responders

  23. Complications • Granuloma formation at the anterior commissure was a common occurrence in the study by Moreau. • These granulomas tended to last for several months before spontaneous resolution. • Other complications, which were few, included: • laryngeal hemorrhage, • pneumothorax, • aspiration pneumonia, • subcutaneous air, and p • relaryngeal abscess. • Anterior webs can result from anterior commissure resection; these were treated with repeat endoscopic procedures.

  24. Conclusions • Microendoscopic laser surgery • provides an excellent alternative to radiotherapy in the treatment of early-stage glottic cancer. • Advantages of laser resection include • minimal bleeding, precise control of resection, and the absence of postoperative edema. • Cure rates of patients with early-stage glottic carcinoma treated with CO2 laser are equal to those achieved with radiation therapy. • Nevertheless, the role and the indications of this technique in the treatment of early-stage glottic cancer has not been defined accurately and remains controversial.

  25. Otosclerosis • Modern laser stapedotomy is performed to correct the conductive hearing loss resulting from otosclerosis. • Otosclerosis is an osseous dyscrasia limited to the temporal bone.

  26. Otosclerosis • Approximately 10% of the caucasian population is affected. • Otosclerosis is inherited in an autosomal dominant pattern with incomplete penetrance. • Women are 2 times more likely to develop the disease than men.

  27. Tongue with tumor

  28. Tongue following laser excision of tumor

  29. Laser in Rhinology • Nasal plastic surgery!!!!!!!!! • Synechia

  30. Laser tonsillectomy!!!!!!! • Sleep apnea

  31. Laser Safety in Otolaryngology-Head and Neck Surgery: Anesthetic and Educational Considerations for Laryngeal Surgery • "hands-on" laser surgery course that stressed safety precautions • characteristics of three endotracheal tubes Ossoff, Robert H

  32. References Einstein, A. On the quantum theory of radiation. Physikal Zeitschr 1917; 18:121. Reinisch L. Laser physics and tissue interactions. Otolaryngol Clin North Am 1996;29(6): 893–912. Lai HC, et al. Fires of endotracheal tubes of three different materials during carbon dioxide laser surgery. Acta Anaesthesiol Sin. 2002 Mar;40(1):47-51. Batta K, Goodyear HM, Moss C, Williams HC, Hiller L, Waters R. Randomised controlled study of early pulsed dye laser treatment of uncomplicated childhood hemangiomas: results of a 1-year analysis. Lancet 2002; 360: 521–527. Ossoff RH:  The co2 laser in otolaryngology-head and neck surgery: a retrospective analysis of complications.   Laryngoscope  1983; 93:1287. Abramson AL, DiLorenzo TP, Steinberg BM:  Is papillomavirus detectable in the plume of laser-treated laryngeal papilloma?.   Arch Otolaryngol Head Neck Surg  1990; 116:604. Tanaka R, Miyasaka M, Taira H, Tanino R. Comparison of pulsed dye laser and wait and see policy in treatment of childhood hemangioma. Lasers Surg Med 2005; 17: 35. Barlow CF, Priebe CJ, Mulliken JB, et al.: Spastic diplegia as a complication of interferon Alpha-2a treatment of hemangiomas of infancy. J Pediatr 1998, 132:527–530. Sie KC, McGill T, Healy GB: Subglottic hemangioma: ten years’ experience with the carbon dioxide laser. Ann Otol Rhinol Laryngol 1994, 103:167–172. Madgy D, Ahsan SF, Kest D, Stein I: The application of the Potassium-Titanyl- Phosphate (KTP) laser in the management of subglottic hemangioma. Arch Otolaryngol Head Neck Surg 2001, 127:47–50. American National Standards Institute :  American national standard for the safe use of lasers, Z136.1,   New York, American National Standards Institute, 1996. Shah H:  Benign tumors of the tracheobronchial tree. Endoscopic characteristics and role of laser resection.   Chest  1995; 107:1744. Karamzadeh, AM, et al. Lasers in pediatric airway surgery: current and future clinical applications. Lasers Surg Med. 2004;35(2):128-34. Strunk Jr CL, Quinn Jr FB:  Stapedectomy surgery in residency: KTP-532 laser versus argon laser.   Am J Otolaryngol  1993; 14:113. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. 2005 Mosby, Inc. Landthaler, M, Hohenleutner, U. Laser therapy of vascular lesions. Photodermatol Photoimmunol Photomed 2006; 22: 324–332 Brown, DH. The Versatile Contact Nd:YAG Laser in Head and Neck Surgery: An in Vivo and Clinical Analysis. Laryngoscope 110: May 2000. 854-867. Pransky, SM, Canto, C. Management of subglottic hemangioma. Curr Opin Otolaryngol Head Neck Surg. 2004 Dec;12(6):509-12.

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