Treatment:

DESCRIPTION:

Endoscopic laser surgery is a technique for treating diseases of the nasal cavities and paranasal sinuses. Diseases of the oral cavity and the upper respiratory passage can be treated using lasers as well. Dornier offers a variety of lasers that are ideal tools for this purpose including the Medilas fibertom 5100 (Nd:YAG laser), the Medilas H20 (Ho:YAG laser) and the diode laser family Dornier Medilas D.

The field of individual applications is extensive:

• Partial velum resection in the case of sleep apnoea syndrome
  (operation to correct snoring)
• Tonsillectomy
• Lingual tumors
• Hyperplasia of the nasal concha
• Coagulation of nasal polyps
• Dacryocystorhinostomy operation (DCR)
• Papillomatosis of the larynx
• Tumors of the larynx (palliative)
• Septum ridges and spurs
• Concha bullosa
• Maxillary sinus fenestration
• Epistaxis (especially in the case of children and Osler's disease)

In all of these applications tissue ablation is obtained through vaporization, coagulation and cutting of the tissue.  For additional information on these ablation methods see General Surgery.

SYMPTOMS:

Derogated nasal breathing is the primary symptom that often requires surgical intervention.  Secondary symptoms are recurrent infection, olfactory damage, aqueous or mucous rhinorrhea and disturbed tubal and middle ear ventilation. 

INCIDENCE AND CAUSES:

Incidence rates for the individual diseases widely differ. Laser surgery on these indications is most beneficial for the patient if there is no underlying systemic disease (e.g. allergy); however, in some cases, laser surgery may be the optimal tool for polliation (like in epistaxis or Osler´s disease).

ANATOMY:

PROCEDURE:

The first step is collecting patient history and completing a diagnostic work-up, such as endoscopy, to determine if laser surgery is the best treatment method for the patient. Topical anesthesia is needed for the procedure.

The goal of the surgery is to ablate altered mucosal areas, hyperplastic lymphatic tissue or altered bone/cartilage tissue by vaporization, or to reduce modified tissue by coagulation. At the same time the risk of thermal damage to underlying tissue must be minimalized. The laser energy is transported to the target tissue via a flexible lightguide. This allows endoscopic surgery in areas that are difficult to access like the nasal cavity and paranasal sinuses.

Formations in the upper respiratory tract are small therefore middle range output power is sufficient for the most applications. In these cases the Dornier Medilas D Compact (output power: 30 W) is the best laser. The diode laser wavelength of 940 nm is extremely well absorbed by hemoglobin. Its penetration depth in well perfused mucosa is limited to around 1 – 2 mm, reducing the risk of damage to neighboring structures.

Application of high laser power (up to 60 W) and short pulses (10 ms) further reduces the effective depth and allows precise treatment. This can be done with the Dornier Medilas D fibertom and Skinpuls / S. This allows treatment on hard tissue and structures at risk that are close to the eyes and the base of the skull.  Smoke evacuation is essential, if the treatment time exceeds five minutes.

POST PROCEDURE PROTOCOL:

The best post-operative care is to rinse the nasal cavities with saline solution using a nasal douche. Nasal care may be necessary up to three times a week for about 20 days after the treatment, depending on the extent of the laser treatment and the mucosal reaction.

ALTERNATIVE TREATMENT OPTIONS:

• Open surgery – Most of the diseases mentioned above can also be treated by open surgery, which is a more invasive treatment method that is more prone to bleeding. Access to the interior organs is much easier with a laser fiber than with surgical tools, due to the smaller outer diameter and higher flexibility. Side effects are usually greater with open surgery and the healing time for the patient is longer.

Results:

                                        Before                                After

Septum ridge	Septum ridge
Recurrent polyposis in the middle meatus of the nose	Free ethmoidal cells after operation
Epistaxis at the head of the lower nasal concha	Epistaxis at the head of the lower nasal concha

              Pictures: Drs. J. and. M. Hopf, University Hospital Benjamin Franklin, Berlin