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Office-based Laser Laryngeal Surgery
27th October 2006, Harvard Medical School, Boston, Massachusetts, USA
Report – by John Rubin
The first course on office based laser laryngeal surgery was held by Harvard Medical school on 27th October 2006. The course director, Steven Zeitels and the faculty were all from Mass General Hospital or had been trained there. The focus of the course was advances in laser technology that allow for selective targeting of the fine vascular architecture underlying epithelial pathology. This is known as selective photo thermolysis. Basically, by devascularising a lesion, the lesion can then be peeled off of the underlying submucosa, in the case of the true vocal fold, off of the superficial layer of the lamina propria. Or if the lesion itself is vascular, the technology allows for direct ablation with minimal damage to surrounding structures.
The key issue is getting the power setting and dosage right. This is not straight forward as it involves issues such as pulse width in milliseconds, energy delivered per laser pulse in milijoules, number of pulses per second, distance of fibre from target (up to 3 mm) and tangentiality of strike. Smaller vessels need to be allowed to cool down to avoid excessive scarring, and target vessels need to be ablated without exploding, as the latter leads to bleeding into the soft tissues.
The technology underlying photo thermolysis has broad applications, the most popular use worldwide now being removal of body and facial hair. It has also found a role in tattoo removal, haemangioma management and acne treatment.
However management of the larynx is far more complex as voice depends on the viscoelastic properties of a soft vibratory superficial layer of the lamina propria. In the larynx the technology appears to have a role in the following types of disorders: microvascular malformations and ectasias, viral papilloma, epithelial dysplasia. It may also prove to have a role in microinvasive and early epithelial cancer, as well in some benign lesions such as polyps and granuloma.
The laser technology is suited for office (as well as operating theatre) use due to its wavelength in the visible spectrum. This allows for its passage through small fibres which in turn can be passed via a flexible scope. During the course it was demonstrated on two patients, one with papilloma and another with dysplasia.
The two lasers currently in use for this type of treatment include pulse dye laser (PDL) with a wavelength of 585 nanometres and pulsed KTP laser with a wavelength of 532 nm. The course directors had both types of lasers available for hands on demonstration, and made a good case for their current preference, the latter. These lasers are used in ablative mode rather than the cutting mode that most Laryngologists are familiar with in the CO2 laser. The cutting laser that the course espouses is a Thulium laser in the infrared range at 2013 nanometres. Unlike the CO2 this can easily be used through a fibre. The course participants were able to use this on an ex vivo animal model.
Overall it was a focused and fascinating course. Only time will tell as to whether these new lasers prove popular in general laryngologic practice.
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