Complications of CO2 laser surgery of the aerodigestive tract: experience of 4416 cases

Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires

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Novel Device for Tissue Cooling during Endoscopic Laryngeal Laser Surgery: Thermal Damage Study in an Ex Vivo Calf Model

Objectives:

Minimizing collateral thermal damage during endoscopic laryngeal laser surgery remains a priority, and tissue cooling is one way to achieve this goal. Cooling systems utilizing compressed air have been shown to reduce the extent of thermal trauma on the vocal folds, but these units are not ideal for endoscopic applications because cooling is inefficient at the low airflows needed. We examined whether a novel vortex cooling device that generates cooled air at low flow rates would provide a cooling benefit beyond that which could be obtained by using room-temperature air for cooling tissue or by using no cooling during simulated laryngeal laser surgery.

Methods:

A continuous-wave thulium laser was used to incise glottic tissue in 12 calf vocal folds. Cooling was achieved with a prototype vortex cooler (9°C air output; flow rate, 3 L/min), and tissue temperature measurements were compared to those with room-air cooling and no cooling. Thermal damage was analyzed histologically by measuring the depth of lactate dehydrogenase inactivation surrounding the mucosal incision. The cooling conditions were tested during time-constant cuts (8 seconds) and depth-constant cuts (into the thyroarytenoid muscle).

Results:

During time-constant cuts, comparison between vortex cooling and room-air cooling revealed that vortex cooling resulted in a thermal damage zone that was 14% smaller (519 versus 603 μm; p < 0.05). During depth-constant cuts, vortex cooling created a thermal damage zone that was 32% smaller than that created with no cooling (p < 0.01) and 9% smaller than that created with room-air cooling (p < 0.01).

Conclusions:

Vortex cooling reduces thermal damage more effectively than room-air cooling or no cooling during both time-constant and depth-constant thulium laser cuts.

[The complications after CO2 laser endoscopic surgery for early glottic cancer]

INTRODUCTION

CO(2) laser endoscopic surgery, introduction in the treatment of early glottic malignancies in the early seventies is the method has been well studied in such cases, and its utility for these lesions is well-established. Transoral resection with the CO(2) laser, open partial laryngectomy and radiotherapy are the main options for treatment of early laryngeal cancer. As all the therapies are all equally effective in controlling an early glottic cancer the choice of treatment must consider such factors as possible complications, functional outcome and patient compliance. For properly selected patients the laser therapy provides equivalent oncologic outcomes when compared to traditional surgical therapies while improving the functional aspects of postoperative speech, voice and swallowing. Its advantages over open surgery include quicker recovery, less morbidity, fewer side effects and greater cost-effectiveness too. The disadvantages of radiotherapy are: duration of treatment, loss of time for work and social activities, higher rate of other possible complications, and partial preclusion of further conservative salvage surgery. Some authors report radiotherapy offers the better quality of voice but further investigations are needed to compare the voice following endoscopic resections with that obtained after radiotherapy.

AIMS

The aim of the study was to analyze the character of the peri- and postoperative complications after CO(2) laser endoscopic surgery for the early glottis cancer.

MATERIAL AND METHODS

[corrected] This was a retrospective study of a files of 55 patients (7 female and 48 male) in age range 38-85 with early glottic carcinoma (Tis - T2) treated by cordectomy. Diagnosis was based on histopathological examination of the biopsy specimen of the lesion and ultrasonographical examination of the lymphonodules of the neck. Videolaryngostroboscopy and acustic analize of the voice was complicated. All of them underwent one of the types of cordectomy using a CO(2) laser, between 2007 and 2010. Cordectomies were categorized according to the classification of the European Laryngological Society (2000 and rev. 2007). In our series most cordectomies were type III 24 patients. Type IV - 2 patients, type Va - 18, type Vb - 4, type Vc - 6 and type VI - 1 patient. We observed peri-and postoperative complication and functional result of the treatment such as quality of voice and swallowing difficulties.

CONCLUSIONS

Among 55 patient postoperative bleeding was the most commonly seen complication. It appeared in 34 of them (62%). All the cases of bleeding were easy to control. In 23 cases pain and mild laryngeal oedema were observed. It resolved in 3-4 day after medical treatment. None of our patient required tracheotomy. Eight patients needed revision procedures: four due to granulation tissue formation, two due to adhesion and another two due to laryngocele. This entire patient was manageable locally with repeated surgery. Our functional data, including stroboscopic findings and perceptual and objective voice evaluations, demonstrate that patients who underwent cordectomy and foniatric rehabilitation presents social efficient voice but with pathological components. All the patients have good long-term swallowing function.

Acute and chronic changes in the subglottis induced by graded carbon dioxide laser injury in the rabbit airway

OBJECTIVE

To investigate the repair process following carbon dioxide laser injury to the upper airway mucosa (UAM) during the development of chronic subglottic stenosis (SGS).

DESIGN

Animals were assigned to either sham control (cricothyroidotomy only) or injured (cricothyroidotomy and posterior subglottic laser) groups using various carbon dioxide laser exposures (8, 12, and 16 W) for 4 seconds.

SUBJECTS

Twenty-four New Zealand white rabbits.

INTERVENTIONS

The subglottis was approached via cricothyroidotomy. Sham control airways were immediately closed, whereas injured airways were subjected to graded carbon dioxide laser exposures prior to closure. Airways were endoscopically monitored preoperatively, postoperatively, and on postoperative days 7, 14, 28, 42, 56, 70, and 84. Animals were killed at 14 and 84 days. Subglottic tissue was harvested for histologic evaluation (reepithelialization, extracellular matrix, vascularity, and inflammation).

MAIN OUTCOME MEASURES

Endoscopic visualization and histologic analysis.

RESULTS

(1) Increases in UAM thickness (up to 5 times the thickness of normal mucosa) were observed but were limited primarily to the lamina propria. The mucosal epithelium regenerated without chronic changes. Focal areas of cartilage repair were encountered acutely after injury and to a greater extent in the chronic phases of repair. (2) Acutely, the thickened lamina propria comprised poorly organized extracellular matrix components and demonstrated increases in blood vessel size and number. (3) Histologic changes present in the acute phase only partially resolved in progression to chronic SGS. Chronic SGS was characterized by thick collagen fiber bundles extending into the remodeled subglottic cartilage.

CONCLUSIONS

The carbon dioxide laser induces acute changes to lamina propria architecture and vascularity that persist chronically. Elucidating responsible signaling pathways may facilitate the development of therapeutic agents to prevent or reduce the formation of SGS.

Thermal damage during thulium laser dissection of laryngeal soft tissue is reduced with air cooling: ex vivo calf model study

OBJECTIVES

The 2-microm-wavelength thulium laser has recently been shown to be an effective cutting instrument in endolaryngeal surgery, although there is increased thermal trauma as compared with the carbon dioxide laser. This study investigated temperature changes and thermal trauma during thulium laser dissection of laryngeal tissue, with and without air cooling, in an ex vivo model.

METHODS

A continuous-wave thulium laser (400-microm fiber, 4-W continuous power, 4-second duration) was used to incise 10 calf vocal folds. Paired cooled and uncooled cuts were made in each fold with a dermatologic cooling device. A thermistor inserted into the glottic subepithelium was used to measure tissue temperatures. Thermal damage was analyzed histologically by measuring the depth of the zone of lactate dehydrogenase inactivation surrounding the mucosal incision.

RESULTS

The initial vocal fold temperature averaged 24.3 degrees C without cooling and 4.4 degrees C with cooling. The peak temperature during cutting averaged 59.1 degrees C without cooling and 28.0 degrees C with cooling. The thermal damage zone surrounding the cooled incisions was approximately 27% less than that surrounding the uncooled incisions.

CONCLUSIONS

Air cooling can reduce the extent of thermal trauma associated with thulium laser surgery of the vocal folds, and the high-temperature plume generated during laser cutting is effectively cleared.

Transoral laser microresection for cancer of the larynx involving the anterior commissure

OBJECTIVE

To share the authors' experience of transoral laser microresection in the treatment of squamous cell carcinoma of the anterior commissure of the larynx.

STUDY DESIGN

Retrospective review of 39 patients with squamous carcinoma involving the anterior commissure of the larynx, all managed with transoral laser microresection between September 1996 and December 2001. Twenty-three patients had pT1 or pT2 cancers. Sixteen patients had pT3 or pT4 disease, two with N2b neck metastases. Twenty patients had cancers exhibiting spread to the subglottis. Twenty-five patients had received prior treatment(s).

METHODS

Specific data points entered into a portable database were retrospectively verified against the patient's electronic medical record. Sorting and analysis were completed in a desktop spreadsheet. We evaluated tumor recurrence, cause of death, tracheostomy, hospital length of stay, and voice quality.

RESULTS

None of the 17 patients with early cancers (pT1 or pT2a) had local recurrence, and none received postoperative radiotherapy. Five of the 22 patients with intermediate or advanced disease (pT2b/pT3 or pT4 cancer) required second treatments for persistent or recurrent disease. Of these, two had small residual foci amenable to second-stage resection by laser. One patient developed a prelaryngeal soft tissue recurrence and retained his larynx after wide local excision and radiotherapy. Two patients (both previously irradiated) developed delayed recurrences requiring total laryngectomy. Four retreated patients remained alive without disease. One patient died of other causes. Voice remained no worse after transoral laser microresection in 19 patients. It was one level worse (on a scale of 0 to 5) for 16 patients. Eleven patients received temporary tracheotomies, some for airway, some for exposure. Twelve patients left the hospital on a same-day basis. The average hospital stay was 3.3 days.

CONCLUSION

Transoral laser microsurgery is one of the options to be considered for the treatment of squamous cell cancer involving the anterior commissure of the larynx.

Carbon dioxide laser debulking for obstructing endolaryngeal carcinoma: a 10-year experience

The results of the carbon dioxide (CO2) laser debulking procedure for obstructing endolaryngeal carcinoma were analyzed in terms of efficiency, complications, secondary tracheotomy rate, and peristomal recurrence rate in a series of 50 patients consecutively managed at our department. The CO2 laser was used to reestablish a safe airway without resorting to tracheotomy and without performing a transoral resection. Our series included 42 patients in a pre-definitive treatment group (group 1) and 8 patients in a palliation group (group 2). Complications included death, pneumonia from inhalation, and cutaneous burns in 2 patients, 1 patient, and 1 patient, respectively. Thirty-two percent of patients required a repeat laser treatment to maintain the airway. Overall success rates of 92.8% and 87.5% were achieved in group 1 and group 2 patients, respectively. None of the variables under analysis could predict the success of the CO2 laser debulking procedure. The overall incidences for secondary tracheotomy were 4.7% and 0% in group 1 and group 2 patients, respectively. Peristomal recurrence was not encountered in patients managed with definitive therapy with curative intent.

Apneic anesthesia with intermittent ventilation for microsurgery of the upper airway

Apneic anesthesia with intermittent ventilation (AAIV) has been used in 250 procedures on the larynx and trachea at Indiana University Medical Center since October 1989. Initially employed for laryngeal papilloma removal in children, this anesthetic technique is now used for other procedures and in adult patients. The advantages of AAIV include improved visualization of the airway, absence of combustible material, and lack of vocal cord motion during surgery. No significant complications have occurred with AAIV. The high degree of safety for this anesthetic technique relates largely to the constant monitoring of oxygen saturation using pulse oximetry and the periodic measurement of end-tidal carbon dioxide (CO2) levels. Contraindications to AAIV are age less than 2 years, significant cardiopulmonary disease, and any hypermetabolic state. Relevant pulmonary physiology includes the unique aspects of oxygen and CO2 metabolism in children.

The incendiary characteristics of the laryngeal and reinforced laryngeal mask airway to CO2 laser strike--a comparison with two polyvinyl chloride tracheal tubes

The incendiary characteristics of the laryngeal and reinforced laryngeal mask airway to the CO2 laser have been compared with two polyvinyl chloride tracheal tubes. Three different power densities (2.35, 4.7 and 9.8 x 10(3) watt/cm2) were used, with either oxygen or a 30% oxygen/70% nitrous oxide mixture flowing down the tube. The laryngeal mask airway (and reinforced model) was shown to be more resistant than the polyvinyl chloride tracheal tubes. The laryngeal mask tube could not be ignited at a power density of 2.25 x 10(3) watt/cm2 after five minutes, although penetration occurred in 20-30 seconds. A layer of silica ash built up at the impact site and protected the underlying tube. The laryngeal mask airway cuff was penetrated at 3 to 5 seconds. At this power density the polyvinyl chloride tube ignited in 2 to 8 seconds and the cuff was penetrated in 0.1 seconds. At the highest power density the tubes of all airways ignited within 0.2 seconds. The possibilities for improving the incendiary characteristics of the laryngeal mask airway are discussed.

Lasers in anorectal surgery

Laser technology has been applied widely in the treatment of hemorrhoids, condylomas, and anorectal neoplasms. It is claimed by its proponents to result in less pain, improved healing, and more rapid recovery as compared with conventional surgery. Laser therapy, however, is expensive and potentially dangerous, and advantages generally have not been substantiated by controlled clinical trials. The possible benefits and potential risks of laser treatment of anorectal disorders are examined.

Anesthesia for microlaryngeal surgery: the case for subglottic jet ventilation

Although the techniques for surgery on the endolarynx using suspension and the operating microscope have been fully developed, the safest, and least obtrusive anesthetic technique has yet to be manifested, as evidenced by more than 200 references to anesthesia for microlaryngoscopy in the world literature. This study reviews the physiology, physics, and problems of each anesthetic technique. In light of this review, animal and human studies are reported demonstrating the utility and safety of subglottic ventilation when provided with proper monitoring using an automatic ventilator. A modified Ben-Jet tube is reported, which has a 1-mm ID channel to monitor PCO2 and tracheal pressure. This self-centering 3.0-mm tube, which extends 6 to 8 cm below the glottis, is unobtrusive for the surgeon. The subglottic tube, which is much less likely to be malaligned, is much more acceptable to the anesthesiologist. Anesthesia, by intravenous sedation, utilizes neuromuscular blockade while ventilating through the jet tube powered by an automatic ventilator with an automatic shutdown feature attached to the monitor tube to prevent inadvertent barotrauma. The third phase of this study compared fluoroplastic, used in a prototype jet ventilation tube, with 6-mm Silastic, Red Rubber, and polyvinyl chloride (PVC) tubes when struck by maximum power of CO2, Nd-YAG, and K-532 lasers. The test was performed in a closed chamber in which concentrations of oxygen and nitrogen were controlled. Although damaged by the CO2 laser beam, the fluoroplastic tubes did not continue burning when the laser was turned off in 100% oxygen, even when coated by blood. The other three tubes continued to burn in 23% oxygen. Neither the KTP nor Nd-YAG laser damaged the Teflon tube, while they ignited a sustained flame in 30% oxygen. This study supports the use of fluoroplastic for a laser safe jet ventilation tube. It also demonstrates the danger of tube fires, even in low oxygen concentrations, when using Silastic, rubber, and PVC tubes in laser laryngeal surgery. There was no difference in the flammability of Silastic, rubber or PVC when struck by these lasers in this study. For these reasons, subglottic ventilation using a fluoroplastic, monitored, self-centering, subglottic, jet ventilation tube driven by an automatic ventilator with a shutdown feature, in the event of excessive pressure buildup, is proposed for anesthetizing healthy patients undergoing suspension microlaryngoscopy, and who have no airway obstructing lesion. A large tube with inflatable cuff is indicated when a supraglottic lesion may obstruct the airway.

Clinical applications of lasers in otolaryngology--head and neck surgery

The use of lasers in otolaryngology--head and neck surgery is described from the invention of the laser in 1960, through the current uses of the laser, and concludes with a summary for the future directions of laser surgery. The various lasers, including the argon, the KTP, and the carbon dioxide lasers used in otolaryngology, are briefly described. The applications of lasers in the larynx, sinuses, and the ear are separately covered, as well as pediatric otolaryngology. In addition to a brief description of the procedure, the complications and limitations are given. Anesthetic considerations are also covered.

Which is the safest endotracheal tube for use with the CO2 laser? A comparative study

STUDY OBJECTIVE

To compare the efficacy of special endotracheal tubes manufactured for carbon dioxide (CO2) laser surgery with foil-wrapped and plain red rubber (RR) endotracheal tubes.

SETTING

Research laboratory of a metropolitan, university-affiliated medical center.

DESIGN AND INTERVENTIONS

Six types of endotracheal tubes were studied. Each had 5 L/min of oxygen passing through it and was exposed to 69 watts of continuous CO2 laser radiation for 1 minute or until combustion occurred.

MEASUREMENTS AND MAIN RESULTS

The plain RR endotracheal tube burned within 15 seconds of laser impact. Aluminum foil-wrapped and copper foil-wrapped RR endotracheal tubes were not affected by the CO2 laser. The shaft of a specially manufactured stainless steel endotracheal tube was not affected by 1 minute of CO2 laser exposure. The shafts of two special endotracheal tubes made of silicone and metal burned vigorously under laser fire.

CONCLUSION

Copper foil-wrapped RR tubes, aluminum foil-wrapped RR tubes, or stainless steel tubes are recommended for laser airway surgery.

Ventilatory complications of carbon dioxide laser laryngeal surgery

STUDY OBJECTIVE

To evaluate complications associated with ventilatory techniques accompanying endolaryngeal carbon dioxide laser surgery.

DESIGN

Retrospective survey of the Society of Academic Anesthesia Chairmen.

SETTING

Operating room at an urban medical center.

PATIENTS

Data from 15,701 patients were analyzed.

MEASUREMENTS AND MAIN RESULTS

Twenty-six percent of patients were ventilated with Venturi jet ventilation and the rest through an endotracheal tube. Reported complications were classified as ventilation related and ventilation unrelated, as well as by severity. A total of 49 complications occurred in the Venturi jet group (1.2%). Of these complications, 24 were ventilation related (0.58%) and 18 were serious or life threatening (0.43%). There were no deaths in this group. Ventilation through an endotracheal tube was associated with a lower frequency of overall complications (0.36%), ventilation-related complications (0.15%), serious or life-threatening complications (0.15%), and serious or life-threatening ventilation-related complications (0.11%) (p less than 0.001). However, there were eight airway fires in this latter group, one resulting in a fatality.

CONCLUSIONS

No clear choice of ventilatory technique is supported by this survey, but teamwork and experience give the best results.

Complications in head and neck surgery and how to avoid trouble

Increasing litigation in recent years has made it more and more necessary for the surgeon to be aware of the problems, pitfalls and complications which may arise as a result of surgery. The risks are compounded in the head and neck not only because of its complex anatomy but also because of additional difficulties relating to surgery of the upper aero-digestive tract. Some problems are unavoidable. The potential risks of surgery and its complications should be carefully weighed against the natural history of the pathological process and a realistic expectation of the surgical outcome compared with alternative treatments. Other problems may result from genuine mistakes, but a number of complications are caused through actions or omissions which are avoidable and which in certain circumstances may be construed as professional negligence. Some of the more common pitfalls and complications in head and neck surgery are discussed with particular reference to their causation and possible avoidance.

Morphology of tracheal scar after resection with CO2-laser and high-frequency cutting loop. A study in normal pigs

In 6 pigs a bronchoscopical resection of the tracheal mucosa was performed using CO2-laser on one side, and an electric high-frequency cutting loop (ECL) on the other. The pigs were sacrificed 3 months later. On macroscopic examination the tracheal mucosa appeared almost normal on the laser-resected side, while severe deformation was seen after ECL treatment. Microscopically the respiratory epithelium had regenerated irrespective of the instrument used. After laser resection the subepithelial tissue had a normal width and consisted of collagen fibrils with few vessels and sparse fragmented elastic tissue. The cartilage showed necrosis and pericellular fibrosis. The scar tissue after ECL was a broad cellular and richly vascularized connective tissue. The content of elastic fibres was markedly greater than after laser resection. The cartilage showed small irregular necroses lined by pyknotic nuclei. In neither case had the gland regenerated. Both CO2-laser and ECL caused severe (but not identical) damage to the tissue, clearly visible after 3 months. However, the deformation caused by ECL was not seen at the laser-resected sites, which makes the laser technique seem preferable--where economy permits.

The carbon dioxide laser in soft tissue preprosthetic surgery

The surgical carbon dioxide laser has the ability to vaporize soft tissues with little bleeding, pain, swelling, or wound contraction. The laser was evaluated on 27 patients requiring soft tissue preprosthetic surgery, including frenectomies, tuberosity reduction, hyperplasia removal, and sulcus deepening. Surgery was performed on an ambulatory basis with no bleeding or infection. Swelling was minimal and pain, as measured on a linear pain scale, was moderate. One third of the patients required no analgesics. Wound contraction did occur but was less than is historically quoted for scalpel wounds. The carbon dioxide laser would appear to have advantages for soft tissue preprosthetic surgery that warrant further evaluation.

High incidence of CO2 laser beam contact with the tracheal tube during operations on the upper airway

Polyvinyl chloride tracheal tubes from 50 consecutive CO2 laser operations of the larynx and trachea were collected after tracheal extubation. In all cases, the helium protocol for laser operations was used, which includes the following: helium in the anesthetic gas mixture at 60% or more during laser resection (FIO2 less than or equal to 0.4); tracheal intubation with plain, unmarked polyvinyl chloride tubes; laser power density less than or equal to 1,992 W/cm2; and laser bursts of less than or equal to 10-second duration. No tracheal tube fires or airway burns occurred. The polyvinyl chloride tubes were examined for marks caused by the laser, and cuffed tubes were tested for cuff viability. Of the 50 tubes examined, 18 were noncuffed and 32 were cuffed. Although most contacts did not penetrate the tubes, 58% of the tubes showed evidence of contact with the laser as a brown mark on the tube or as a cuff leak. Cuffed tubes were more likely to incur laser contact (69%) than noncuffed tubes (39%), a significant difference (p = 0.04). Most of the cuffed tubes that came in contact with the laser sustained damage at the cuff (77%). It was concluded that the risk of tracheal tube contact with a laser beam is at least 1 in 2, that cuffed tubes are more likely to be hit with a laser beam than noncuffed tubes, and that cuffed tubes that are hit usually sustain damage to the cuff. Because no fires occurred in this series despite frequent laser contact with the tube, these data indicate that the helium protocol helps to prevent polyvinyl chloride tube fires.

Complications of laser surgery for recurrent respiratory papillomatosis

During an 8-year period, 66 patients with recurrent respiratory papillomatosis underwent 890 laser microlaryngoscopy procedures. A retrospective analysis of immediate and delayed complications occurring with laser microlaryngoscopy in the treatment of these patients revealed that complications secondary to anesthetic technique and laser methodology were remarkably low (0.3%). Delayed complications of tissue injury (36% of pediatric patients and 17% of adult patients) were more frequent and included anterior glottic webbing, interarytenoid scarring and arytenoid fixation, vocal fold fibrosis, and generalized endolaryngeal glottic stenosis. All patients were evaluated by direct visualization and recording at the time of the operative procedure, as well as by review of intraoperative photographs. A smaller group of patients underwent analysis of voice recordings and laryngeal stroboscopy. The frequency and severity of tissue injury was higher in the patients with more severe disease who underwent multiple operative procedures.

Injuries as an adverse reaction to clinically used laser devices

Since the first use of lasers in ophthalmology in the early 1960s, applications for the medical laser have been found in many medical specialties. Despite their increasing usefulness, lasers have been reported to induce injuries. Few studies have tried to quantify the number of injuries caused by the clinical use of lasers. To address this issue, we surveyed physicians at the 5th Annual Meeting of the American Society for Laser Medicine and Surgery, May 1985. Forty-two of the 226 physicians attending the meeting responded to the questionnaire about their experience with lasers in their practice. An average of 25 laser procedures per month were performed by the responding physicians, and 61.9% of them reported at least one complication. Of the complications reported in the survey, 33 occurred within the last 12 months for an overall rate of 2.7 incidents per 1,000 procedures performed. The most common complications reported were burns and scarring; however, bowel perforation and pneumothorax were among the more serious. The mean number of reported complications varied by the length and type of training in the use of the laser, with the lowest number of complications reported by respondents who had taken a training course lasting longer than 7 days within the last year. Our findings show that both minor and life-threatening injury can be caused by the clinical use of medical lasers. Evaluation of the adverse effects of any medical technology, such as lasers, is needed to help guide recommendations for its safe use.

Precaution and safety in carbon dioxide laser surgery

The introduction of the carbon dioxide laser--(in 1972) by Strong and Jako as a surgical tool for removal of laryngeal papilloma--heralded a new period of surgical refinement and precision in otolaryngology and also led to adjustment and precautions in operating room setup and in the administration of anesthetics. This article recounts 8 years of experience in carbon dioxide laser surgery on 3500 head and neck patients. Techniques and precautions of administering anesthetics for laser surgery are presented. The management of a laser-ignited burn is also discussed.

Implementing the ANSI Z 136.3 laser safety standard in the medical environment

The American National Standards Institute (ANSI) is an organization comprising several committees of expert volunteers who have traditionally determined the industry consensus standards in various fields. The existing federal legislation and the suggested state laser-safety regulation are based on the 1980 ANSI Standard, "For the Safe Use of Lasers." It was quickly recognized that the safety needs of the industrial and medical environments differed sufficiently to prompt the American National Standards Institute to form a committee to write a new set of standards for "Laser Safety in the Health Care Environment" (ANSI Z 136.3). This standard will apply not only to hospitals but also to offices, clinics, and anywhere else that the laser is used for medical purposes. This paper will outline this important laser-safety standard and describe in detail how best to implement it in the environment in which the otolaryngologist--head and neck surgeon practices.

Laryngo-tracheal laser surgery and general anesthesia

The use of the carbon dioxide laser in treatment of laryngo-tracheal lesions is extremely effective when combined with general anesthesia. However, the potential for intraoperative complication is increased due to a pathological reduction in the size of the airway and the presence of an endotracheal tube. To avoid the hazard of endotracheal tube ignition, specific techniques are employed.

Benign lesions of the nose, oral cavity, and oropharynx in children: excision by carbon dioxide laser

The carbon dioxide laser was used to treat a group of pediatric patients with benign lesions of the upper aerodigestive tract exclusive of the larynx. Prior to development of the CO2 laser, excision of these lesions by conventional means often resulted in incomplete removal, significant bleeding, and postoperative edema resulting in airway obstruction. The CO2 laser, with its unique properties of precise excision, hemostatic effect, and minimal postoperative edema, has become the instrument of choice in the removal of these lesions.