Feasibility of transnasal flexible carbon dioxide laser surgery for laryngopharyngeal lesions

Indications, Efficacy, Safety, and Clinical Outcomes of 585 nm Pulsed Dye Laser in Non-Malignant Laryngeal Lesions: A Systematic Review

The objective of this manuscript was to review the indications, efficacy, and safety of a 585 nm pulsed dye laser (PDL) in non-malignant laryngeal lesions. Following the PRISMA statement recommendations, three independent authors searched for articles published in PubMed/MEDLINE, the Cochrane Library, Google Scholar, Scielo, and Web of Science. A bias analysis was performed following NICE guidance tools. From the 506 identified publications, 19 observational studies met the inclusion criteria. The PDL improves vocal quality objectively and subjectively in vascular lesions (p < 0.005) and improves vocal quality in patients with dysplasia/leukoplasia without changing the natural history of the disease compared to other treatments. Reinke's edema and granulomas require an average of 1.5 PDL sessions for resolution. Treatment of recurrent respiratory papillomatosis requires multiple sessions, with complete remission achieved in 50-70% of patients. Regardless of the lesion, the tolerance of the procedure under local anesthesia is exceptional (84-97%), and the results in terms of regression and vocal quality are promising. The complication rate is minimal, and the procedure does not interfere with other treatment alternatives. There is no consensus on laser settings. The lack of consistent use in evaluating vocal outcomes, whether objective or subjective, prevents the comparability between studies. The 585 nm pulsed dye laser appears to be an effective and safe therapeutic option in patients with non-malignant laryngeal pathology. Future controlled studies are needed to compare the 585 nm pulsed dye laser with other lasers or cold instrument procedures.

Transoral Flexible Laser Surgery of the Larynx with Blue Laser

INTRODUCTION

Laser surgery of the larynx is currently the standard of clinical practice in a multitude of procedures. Lasers with photoangiolytic properties have a wide application in endolaryngeal lesions. One of their most prominent features is the ability to coagulate blood vessels, reducing unwanted tissue damage. Our objective is to expose the uses of the blue laser (445 nm) in the larynx.

MATERIAL AND METHODS

A retrospective study was carried out including 47 patients treated with blue photoangiolytic laser from October 2021 to January 2023 at a university hospital. Demographic data, type of lesion presented, date of intervention and scope of the procedure, as well as the parameters of the laser used, were recorded. The number of sessions received per patient, the result and complications were also collected.

RESULTS

A total of 47 patients with laryngeal lesions were treated, including vascular angiomas, laryngeal sulcus vocali, vocal cord polyps, Reinke's edemas, laryngeal papillomatoses, subglottic stenosis, laryngeal synechiae, subglottic granulomas, glottic scars, vocal fold leukoplakias, laryngeal dysplasias and tracheostomal granulomas. The mean age was 52.5 years, and 64.3% of the patients were women. The range of power used in the resective surgeries was 2-10 Watts with a 20-millisecond window. The average number of sessions received was 2.1 (range 1-4). A satisfactory situation was obtained in 45 of the 47 patients treated (95.75%), and an evident decrease in lesions was seen in the remaining two. There was no evidence of any complications directly derived from the use of the blue laser. Twenty-seven cases (54%) were treated exclusively in-office.

CONCLUSIONS

The blue laser is safe and effective in the treatment of a wide range of laryngeal pathologies. Its advantages include its portability, its photoangiolytic qualities as well as its ability to vaporize tissue in contact mode, which can treat subepithelial vessels or resect lesions.

Surgical outcome of different surgical modalities for adult recurrent respiratory papillomatosis

BACKGROUND

Surgical debulking remains the mainstay of treatment of adult-onset recurrent respiratory papillomatosis (AO-RRP). But there are no guidelines for decision-making of surgical modality.

OBJECTIVES

This retrospective study aims to obtain a better understanding of AO-RRP, and select the best surgical modality for RRP among microdebrider, CO₂ laser, and KTP laser.

MATERIAL AND METHODS

Medical records of 72 AO-RRP patients were reviewed, with at least a 6-month follow-up. We focused on demographic data, the median treatment intervals (MTI) (Days), the survival curves, and treatment-related complications.

RESULTS

Seventy-two AO-RRP and a total of 172 surgical procedures were included, with either the microdebrider (n = 46), CO₂ laser (n = 102), or KTP laser (n = 24). The MTI of all patients was 230.0[132.0, 455.0] (median[P25-P75]), with microdebrider group (267.50[152.5, 449.5]), CO₂ laser group (247.5[145.5, 474.7]), and KTP laser group (107.5[68.3, 330.5]), and there were no significant differences among three surgical modalities on MTI or survival curves (p > .05). The duration of surgery was 44.9[25.6] in the microdebriders group, 48.4 [29.5] in the CO2 laser group, and 51.3[18.4] in the KTP laser group, but there was no significant difference in the operation duration among the three groups (p > .05). Postoperative glottic webs and scar formations were found in 4.3% of patients in microdebrider group, 16.7% of patients in CO₂ laser group, and 8.3% of patients in KTP group.

CONCLUSION AND SIGNIFICANCE

Microdebrider surgery for RRP took the shortest time and had the lowest rate of postoperative complications. However, different surgical modalities are equally effective in controlling recurrence after RRP surgery.

Safety of different surgical modalities for recurrent respiratory papillomatosis resection: A systematic review and meta-analysis

BACKGROUND

Currently, the most common surgical modalities used for recurrent respiratory papillomatosis (RRP) resection are microdebrider, carbon dioxide (CO₂ ) laser and potassium-titanyl-phosphate (KTP) laser. However, complication rates vary among different surgical modalities and have been controversial in different studies.

OBJECTIVE OF REVIEW

This study systematically reviews the available studies which reported intra-operative and post-operative complications, aiming to compare the safety of microdebrider, CO₂ laser and KTP laser.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

Seven electronic databases (PubMed/MEDLINE, EMBASE[Ovid], Scopus, Cochrane Library and Web of Science) were searched from inception through 28 April 2022. Randomised controlled, prospective or retrospective observational studies that recorded the complications of three different surgical modalities for RRP resection were included in the meta-analysis.

EVALUATION METHOD

Outcomes of interest were intra-operative and post-operative complications, and complication rate was calculated to evaluate the safety of surgical methods.

RESULTS

Twenty different studies were included in quantitative synthesis. Only one study compared outcomes of those three kinds of treatment modalities simultaneously, two studies compared microdebrider and CO₂ laser, and the remaining studies focussed on only one of three treatments. The weighted average complication rate for microdebrider was 0.03 (95% confidence interval [CI] 0.00-0.21), n = 6, for CO₂ laser treatment was 0.16 (95% CI 0.09-0.25), n = 14 and for KTP laser treatment was 0.04 (95% CI 0.00-0.14), n = 4.

CONCLUSION

The limited evidence demonstrated that CO₂ lasers in the surgical treatment of RRP may lead to more surgical complications, and microdebrider and KTP lasers may be safer. However, the heterogeneous data limit any strong comparison of outcomes of different treatment of laryngeal papillomas. Future randomised controlled trials that directly compare the safety of different surgical modalities are needed.

Comparing KTP and CO2 laser excision for recurrent respiratory papillomatosis: A systematic review

Objective

The CO2 laser and 532 nm potassium titanyl phosphate (KTP) laser have been applied to treat recurrent respiratory papillomatosis (RRP). This systematic review sought to compare outcome differences between these two methods.

Data Sources

Embase, Web of Science, PubMed, and the Cochrane Library.

Review Methods

CO2 laser and KTP laser studies were obtained by keyword searches of four authoritative medical databases. Articles were screened and retained when conforming to inclusion criteria. The primary outcome was cure rate; the secondary outcomes were recurrence, death, remission, clearance, and human papillomavirus (HPV)-detected rates, as well as laser effectiveness rates. Postoperative complications rate was the safety outcome measure. All outcomes were summarized within the CO2 and KTP groups, with results statistically compared (p < .05).

Results

Overall, the cure rates were 87.25% (KTP group) and 75.98% (CO2 group; p < .05). Complication rates significantly differed between the KTP (2.32%) and CO2 (17.71%) groups (p < .0001). There was a relatively higher but not significant difference in the recurrence rates between the CO2 (18.6%) and KTP (10.87%) groups (p = .1595). The CO2 group remission rate was considerably lower (38.9%) than the KTP group (88.46%, p < .0001). HPV-detected and clearance rates were only reported for the CO2 group. The bias risks were 13.1 ± 1.45 (CO2) and 13.6 ± 1.52 (KTP) for the two groups, indicating evidence was of fair quality.

Conclusion

Overall, KTP laser excision showed significantly better postoperative clinical outcomes than the CO2 laser, with a lower failure rate. Available fair-quality evidence suggests KTP laser excision might be better for treating RRP. Nevertheless, more high-quality randomized controlled studies are needed to compare these two surgical techniques, particularly in terms of reporting functional data such as vocal outcomes.

Clinical effect of CO2 laser resection of the epiglottic cyst under micro-laryngoscope suspension

BACKGROUND

Epiglottic cysts are common diseases and have multiple morbidity, and traditional surgery causes intraoperative bleeding and postoperative recurrence.

OBJECTIVE

To investigate the therapeutic effect of CO₂ laser resection on epiglottic cyst when compared with traditional surgery.

METHOD

Eighty patients with epiglottic cysts were randomly enrolled into the CO₂ laser group (44 patients) and the high-frequency electrocautery group (36 patients).

RESULTS

The CO₂ laser group had a shorter operation time, less blood loss and fewer intraoperative ruptured cysts (p < .05). The duration of sore throat and the time before wound redness and swelling subsidence in the CO₂ laser group were significantly shorter than those in the high-frequency electrocautery group (p < .05). Within one year after the operation, the incidence of epiglottic scar contracture in the CO₂ laser group was significantly lower than that in the high-frequency electrocautery group (p < .05).

CONCLUSION

The CO₂ laser group has the advantages of minimally invasive, less bleeding, short operation time and less postoperative complications, and it is worthy of applying as clinical routine to treat epiglottic cysts.

The CO2 waveguide laser with flexible fiber in transoral resection of oral and oropharyngeal cancers: a retrospective cohort study on postoperative and quality of life outcomes

The aim of this study was to evaluate the CO₂ waveguide laser (WG CO₂ laser) with flexible fiber (Lumenis Ltd., Yokneam, Israel) in the treatment of oral and oropharyngeal cancers, specifically focusing on postoperative outcomes, pain, and quality of life (QoL). Eighty-one patients, 43 women and 38 men, with oral or oropharyngeal cancer who consecutively underwent transoral resection by WG CO₂ laser from August 2015 to April 2020 were retrospectively enrolled. Resections were performed in super pulsed mode with a power setting ranging between 3 and 10 W. Data about frozen sections, reconstruction, complication rate, length of hospital stay, tracheostomy rate and time to decannulation, nasogastric feeding tube rate and time to oral feeding, pain, and QoL were reviewed. Continuous variables were presented as mean and standard deviation. Concordance between intraoperative frozen section examination and definitive histology was calculated using Cohen's K test of agreement. The mean length of hospital stay was 13 days. The feeding tube rate was 81%; the tracheostomy rate was 35%; the feeding tube was left in place for 8 days on average, and the time to decannulation was 9 days. The only complication was a postoperative bleeding in 4 patients. The median postoperative pain score measured by the Numeric Pain Rating Scale on postoperative days 1, 3, and 5 was 0 and there was a constant decrease in painkiller use over the days. The overall mean composite QoL score was 77 ± 14, with excellent results in saliva, taste, pain, and speech domains. Frozen section evaluation had a specificity of 99% and a negative predictive value of 98%. WG CO₂ laser is a good and safe tool for transoral tailored resection of oral and oropharyngeal cancers. It ensures a good overall QoL and guarantees fast recovery and a very low postoperative pain.

Microwave ablation for the removal of pharyngeal benign lesions: A prospective pilot case series

OBJECTIVE

We evaluated microwave ablation (MWA) for treatment of isolated pharyngeal benign lesions, in terms of technical feasibility, efficacy, and safety.

METHODS

The patients with pharyngeal benign lesions were treated with endoscopic MWA with a 2450-MHz single cooled-shaft microwave antenna and sent for histological examination. Postoperative pain intensity was measured via visual analogue scale (VAS) on the 12th hour and the third postoperative days.

RESULTS

Of the 137 patients with pharyngeal benign lesions who met the inclusion criteria. The most commonly involved site was the uvula (n = 66, 48.2%), followed by the lateral pharyngeal wall (n = 37, 27.0%), the nasopharyngeal posterior wall (n = 23, 16.8%) and the soft palate (n = 11, 8.0%). All of the procedures were completed using local anesthesia and were well-tolerated by the patients. The ablation time was 5-10 min, with an average duration of 6.3 ± 1.8 min. The most common pathology was papilloma (n = 96, 70.1%), followed by nasopharyngeal cysts (n = 21, 15.3%), polyp (n = 10, 7.3%), epidermoid cysts (n = 8, 5.8%) and Thornwaldt cysts (n = 2, 1.5%). The mean VAS pain score was 2.36 ± 1.08 on postoperative 12th hour and 1.21 ± 0.54 on postoperative third day. At the 6-month follow-up examination, there were no severe complications, such as recurrence, bleeding, or synechiae of the nasal cavity, eustachian tube injury, in any of the patients.

CONCLUSIONS

The MWA for the treatment of isolated pharyngeal benign lesion is feasible and alternative to conventional surgical methods, it allows excision of the lesion while providing hemostasis, involves only a short ablation time and has a very low risk of complications. Most of our patients well-tolerate the procedure, which may be performed under local anesthesia in the outpatient setting.

Applications of Office-Based 445 nm Blue Laser Transnasal Flexible Laser Surgery: A Case Series and Review of Practice

BACKGROUND

The recent introduction of 445 nm blue laser to office-based laryngology presents potential advantages. These include a desirable combination of cutting and photoangiolytic qualities and a lightweight, shock-resistant design. Despite its increasing use, current evidence is limited to experimental data and case reports.

OBJECTIVES

The authors present a case series and overview of office blue laser transnasal flexible laser surgery (TNFLS), considering indications, patient selection, safety, technique, and surgical outcomes. We also review the safety and relevance of TNFLS to the ongoing coronavirus pandemic.

METHODS

Retrospective case series and narrative review. Our primary outcome measure was preoperative and postoperative Voice Handicap Index (VHI-10) score. Complications were documented by nature and severity.

RESULTS

Thirty-six cases of office blue laser TNFLS were performed. A statistically significant improvement in VHI-10 score was demonstrated in cases of recurrent respiratory papillomatosis (RRP) and benign laryngeal lesions causing dysphonia (P < 0.01 and 0.045). Blue laser also proved effective in assisting office biopsy procedures. A minor and self-limiting complication was reported.

CONCLUSIONS

Office blue laser TNFLS is safe and effective in the treatment of RRP and a range of benign laryngeal lesions. Future research should compare the efficacy and safety of blue laser with potassium titanyl phosphate laser in office-based treatment of these conditions. Further assessment of the cutting qualities of blue laser, initially in the theater environment, is necessary to refine our understanding of future applications.

Optimizing Settings for Office-Based Endoscopic CO2 Laser Surgery Using an Experimental Vocal Cord Model

OBJECTIVES/HYPOTHESIS

To provide insight in the thermal effects of individual laser settings in target tissues to optimize flexible endoscopic CO₂ laser surgery treatment.

STUDY DESIGN

Experimental laboratory study.

METHODS

Thermal effects of the CO₂ laser using a fiber delivery system were visualized using the color Schlieren technique in combination with a polyacrylamide gel tissue model. Variable settings were used for emission mode, power, laser fiber distance, and laser duration, which were evaluated in every possible combination. Collateral thermal expansion and incision depth were measured. To validate the model, the results were compared to histology after CO₂ laser irradiation of ex vivo human vocal cords, and the intraclass correlation coefficient was calculated. Thermal damage and incision depth were measured by a blinded pathologist.

RESULTS

Of all parameters studied, duration of laser irradiation had the greatest effect on thermal expansion. Increased distance between laser tip and target tissue resulted in significantly reduced incision depth and increased thermal expansion. Pulsed emission modes led to increased incision depths. The intraclass correlation coefficient for consistency between the model setup and the ex vivo human vocal cords was classified as "fair."

CONCLUSIONS

By using high-intensity pulsed lasers at minimal distance to the target tissue, exposure times and subsequent damage to surrounding tissue can be reduced. If an evaporation technique is used, lower power in continuous wave at a larger distance to the target tissue will lead to superficial but broader thermal effects. The model setup used in this study is a valid model to investigate laser-induced thermal effects in vocal cord tissue.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:E680-E685, 2020.

Office-based CO2 laser surgery for benign and premalignant laryngeal lesions

Objective

Patients with laryngeal pathology are often treated with CO₂ laser surgery, usually in the operating room under general anesthesia. Although office‐based laser surgery using several other laser types has been investigated, prospective studies on office‐based CO₂ laser surgery are scarce. Our goal was to investigate the feasibility of office‐based CO₂ laser surgery for benign and premalignant laryngeal pathology by analyzing completion rate, safety, effect on voice quality, and success rate (i.e., no residual or recurrent disease).

Methods

A prospective cohort study was performed of 30 consecutive procedures. Inclusion started in June 2016 and was completed in August 2018. Adult patients with clinically benign or premalignant laryngeal lesions who could not undergo transoral laser microsurgery in the operating room under general anesthesia were included. Reasons were either contraindications for general anesthesia, previously failed therapeutic laryngoscopy under general anesthesia, and preference of a procedure under topical anesthesia by the patient. The mean follow‐up was 9 months.

Results

Thirty procedures were performed in 27 patients (24 males) with an average age of 62 years. Twenty‐nine (97%) procedures were fully completed without complications. The mean preoperative Voice Handicap Index (VHI) score (VHI 44) significantly decreased 2 months (VHI 28, P = 0.032) and 6 months (VHI 14, P < 0.001) after the procedure. Almost two‐thirds of patients showed no residual or recurrent disease at their follow‐up visits.

Conclusion

Office‐based CO₂ laser surgery is a feasible and safe procedure that results in significant voice‐quality improvement. Almost two‐thirds of patients did not require further treatment.

Level of Evidence

2 Laryngoscope, 130:1503–1507, 2020