DIODES LASER IN ENT SURGERY 810/980nm

DIODES LASER IN ENT SURGERY

The LASER, a surgical instrument introduced in the 70’s in ENT surgery, has been object of ceaseless improvements thanks to constant technological evolution. Diode LASER contributes to a more selective and less invasive surgery, minimizing the risk and post-operative period in hospital, it is indeed able to transmit to the fabric up to 60 W of LASER energy at a wavelength of 810 nm; this ensures a precise cutting/coagulation and a excellent tissue vaporization. The possibility of using different sizes optical fibers (400, 600 and 1000 nm), both in “contact” and “no contact” modality, allows a very effective use in endoscopy. Technological progress on the LASER, and the Diode LASER employment at the Department of Otolaryngology have made interesting to report our experiences with this surgery means in several pathology in ENT.

E.N.T: laser applications

LASER in the otology field was used to perform tympanotomy and for the placement of ventilation tubes, vaporization of horny pearls and adhesion in the eardrum, remobilisations and ossicular modelings, “spot-welding”; in this field the most argued area of applicability of LASER is the surgery of the otosclerosis (1). The otosclerosis treatment with surgical LASER started with Perkins and Di Bartolomeo in 1980 using Argon LASER; afterwards were used also other sort of LASER: CO 2 , KTP (2) .

Laser benefits in the surgical therapy of otosclerosis are the bleeding control and the limitation of the handling of the platina reducing the risk of “floating platina” and acoustic vibratory trauma. These advantages allow to optimize the functional result and to reduce risks of cochlear damage connected with surgical treatment. The ideal property of tissue interaction of the laser radiation in the otosclerosis surgery is the laser’s energy absorption of the platina, that allows the vaporization and avoids the perilymph thermal

dispersion. The modality of supply of the pulsate energy enables the tissue cooling between the pauses and reduces the risk of thermal damage of the surrounding structures.

Nose and paranasal sinus

The diode laser was used in the treatment of the nose pathology with different methods depending on the entity and the localization of the lesions. The utilization was both dissection and photocoagulation. In the treatment of the lower turbinatum hypertrophy, turbinatums are pre-coagulated and devascularized by the diode laser; the vaporization

was performed with both the contact method and the not in contact method, applying a bigger amount of energy. The nose polyp treatment with the in contact method in the diode laser surgery is innovative: the fibre is inserted inside the polyp and maintained until its disappearance. This method does not cause any haemorrhage.

Oral cavity and pharynx

The treatment of the chronic tonsillitis by diode laser tonsillotomy or tonsillectomy was performed only by the use of in contact procedure. The haemorrhage risk is easily controlled and the coagulation is made possible using a power of 15 W. In the surgery of the chronic snoring by uvuloplate- pharynx -plastic surgery, the diode laser was utilized in the in contact method; the advantages of the laser methodology are the cut precision, the control of the deepness of the incision, the marked haemostatic effect and the reduction of the post operative oedema.

Case study

The diode laser was employed for the surgical treatment of the patients in the care of the Ear Nose and Throat Clinic of the Catania University. The case study, still modest, has concerned subjects aged between 32 and 81, of male and female genders, affected by various pathologies of otolaringological pertinence concerning nose and perinosal sinues, pharynx, larynx and trachea affections. Whit regard to the rhino-sinusal pathology were treated subjects suffering from turbinatum hypertrofia, chronic sinusitis with polyps, antrostomy results. The pharynx pathology concerned subjects with adenoidal relapse. In larynx-tracheal field were treated benign and malign neoformations of larynx and polypoidal formations of the trachea. The follow-up of the treated subjects is very poor and so we can consider only the post-operative results obtained immediately after the treatment. The surgical diode laser can transmit to the tissue up to 60 W of laser energy with a wavelength of 810 nm. The diode laser was utilized both in the”in contact” and in the “not in contact” modality, depending on the entity and on the localization of the lesions. The “not in contact” modality requires more energy and the evacuation of the smoke produced utilizing a continuous aspiration, for this reason we utilized more the”in contact” method. The utilization was performed with dissectory and fotocaugulative proceeding. The optical fiber utilized for the “in contact” and for the “not in contact” treatments are of two size (600 and 1000 um); moreover, the “in contact” ones can have a conical (300 um) or a spherical (800 and 1200 um) tip. In some cases the optical fiber was utilized through a handful, in other cases was set on tradictional pincer, in others it was introduced through the operative channel of the fibroscopy. The anaesthesia practiced was local in the majority of cases; the general anaesthetic was practiced for the treatment of subjects with benign and malign neoformations of the larynx. The surgical diode laser was utilized taking advantage of the photothermal effects and interactions to obtain the excision (so the laser ray was utilized as a cutter) or the vaporization, idest the destruction of tissues trough coagulation necrosis. Both the alternative had met requirements. The vapo- coagulation action was especially employed for the performance of the turbine plastic, that is made on well vascularized tissues. Only in few cases and for a precautional purpose was performed a tamponation of the nasal fossa. In laryngeal field were utilized both the cut action and the vapo-coagulation action. In particular the treatment regarded a subject with a Reinke oedema and collapse of the false chords and a brainvasculopatic subject affected by a supraglottic carcinoma (T2 N0 M0) that underwent a tracheotomy for breathing difficulty. In the first case the false chords plastic was easy tank to the vapo-coagulation possibility, whereas the chords mixomatosis was treated with the cutter function performing a linear cut on the mucosa of the superior surface of the vocal chords. In the supraepligottic carcinoma (carcinoma of the false left chord extended to the inferior part of the subioidal epiglottis and to the beginning of the controlateral false chord -T2 N0 M0-), after the charging of the supra -ioideal epiglottis utilizing a Warda laryngoscope, were exposed the ariepiglottical folders and the laryngeal face of the epiglottis. The section was made starting from the left, on the anterior edge of the arytenoid and going up till the pharynx-epiglottis fold. On the right the section involved the anterior side of the false chords till down to the true chords without touch it and till up to almost the pharynx-epiglottis fold. So was performed an horizontal section from the left pharynx-epiglottis fold to the right one passing through the epiglottis; the section was made at a minimal distance of 0,5 cm from the neoplastic lesion. The section was made deepen in medium-lateral sense in the tissue of the superior paraglottis space and of the anterior pre-epiglottis tissue till to arrive to the superior edge of the tiroideal cartilagine; then was performed the section for inner sottopericondrial way till down to arrive in the bottom of the ventricol. So it was realized a left vestibulectomy enlarged to the omolateral ariepiglottis folder and extended to the inferior portion of the epiglottis and of the pre-epiglottis tissue and a partial right vestibulectomy. During the performance of the section on the inner pericondrium, or because of the traction of the pincer on the operatory piece, or because of the coagulation necrosis, a piece of the operatory piece broken away: also if some Authors suggest to split in two the operatory piece, making easier the domain of anterior caudal limit of the vestibular excision, we believe appropriate the removal in monobloc of the neoformation and of the surrounding tissues. The surgical trauma in the treatment of this pathology has been drastically reduced; the post-surgical course was fast. In relation to the use of the diode laser as cutter, also if in a small amount of cases, it seems to us that

the cut section it is not as linear as other instruments (scalpel, CO 2 laser), having the impression that the surfaces surrounding the section had a certain depth of carbonization. In relation to the vapo- coagulation aspect the result was very satisfactory, having the possibility of obtain the result without haemorrhages.

Conclusions

The LASER employment today is in current use in the ENT clinical practice. The technical evolution allowed the realization and the improvement of various kind of lasers, supplying the e.n.t .specialist with a wide range of devices. In most cases laser is used as an alternative to the traditional surgery methods, not always providing an advantage. The laser methodology is particularly useful and presents reliable advantages for the treatment of the recurrent laryngeal papillomas, of the precancerosis (leucoplachiae and eritroplasis) of the mouth and of the larynx, of the limited neoplasm of the oral cavity of the glottic plane, of the nonspecific chronic ulcer of the oral cavity. The advantages offered by the laser are represented by the absence of instrumentation that stand in the way of the surgeon that operates in a tight space, by the precision of the surgical excision allowed by the distinctive features of the laser ray and by the bloodless field, especially in

Micro surgery. The clinical applications of the diode laser unit have allowed to highlight an excellent section on the soft tissues with power of 5-10 W with CW procedure (or pulse) in contact and a good vaporization with power of 10-15 W with CW procedure not in contact for well vascularised soft tissues and 15-25W with pulse procedure not in contact for bony tissue and hard mother; a good hemostasis with 5-10 W power with not in contact CW procedure (defocalized) on the well vascularized/pigmented tissues. The diode surgical laser, used as a cutter, does not seem to have a section of cutting as linear as the CO 2 laser: it can be the consequence of the fact that the section surfaces have a higher thickness of carbonization. Moreover compared to the other kinds of lasers, the diode laser unit presents significant advantages: a compact equipment, portable, manageable, with high performance (30-40%), that does not require maintenance and that uses the common quartz optical fibres, extremely reliable and held down prices.

Dimed Laser offers the diode lasers 810nm/ 980nm with up to 60W power output, three emission mode CW/sigle pulse/repeat pulse can be changed depending on the treatments.

		BERYLAS	HARLAS	CHERYLAS
Software	standard	√	√	√
	therapy	√	√	√
Wavelength(nm)	810nm	9W/ 15W	30W/ 45W	30W/ 60W
	940nm			30W/ 60W
	980nm	15W	30W/ 45W	30W/ 60W
	1064nm	10W	30W
	1210nm			15W
	1470nm		15W	22W
	1940nm			6W/12W
	810nm+980nm	15W+15W
	650nm+810nm+915nm+980nm	200mw+8W+8W+8W
	980nm+1470nm		15W+10W
	650nm+810nm+980nm+1064nm		2mW+15W+15W+15W
	Operation Mode	CW, Single Or Repeat Pulse
	Pulse Duration	10us- 3s	10us- 3s	50us- 3s
	Repetition Rate	0.2Hz- 50KHz	0.2Hz- 50KHz	0.2Hz- 10KHz
	Pilot Beam	Red Diode Laser Of 650nm, Power<5mW
	Control Mode	True Color Touch Screen (7 inches, resolution 600*1024)
	Transmission System	Medical Fibers With SMA905 Connector
	Dimensions	160(W)*180(L)*235(H) mm	230(W)*180(L)*135(H) mm	380(W)*430(L)*220(H) mm
	Weight	2.1Kg	3.5Kg	11Kg