RECENT ADVANCES IN
OTORHINOLARYNGOLOGY
LASER
By:INDERDEEP SINGH
ARORA
LASER HISTORY
ACRONYM FOR Light Amplification by Stimulated Emission
of Radiation
A laser is a device that produces and amplifies light by
stimulated emission. It can produce light in the
ultraviolet, visible, and infrared region of the
electromagnetic spectrum.
1960: Theodore Maimen develops first laser (ruby with
694 nm wavelength.
1961: Neodymium-doped (Nd): glass laser.
1964: Nd:YAG and argon ion (Ar).
1965: CO2 laser.
Ordinary light versus laser light
ORDINARY LIGHT
Radiation from conventional
light source is emitted over a
wide range of wavelengths,
or spectrum
The light intensity close to
the source is very high.
The loss of intensity is due to
the divergent nature of the
conventional radiation
LASER
In contrast, the laser
produces a beam with a very
narrow divergence.
Light leaves the source with a
high degree of collimation.
As the beam travels in space,
the directionality is
maintained over a long
distance. As a result, high
beam intensity is also
maintained over a long
distance.
Com ponents ofa laser
A laser consists of the lasing medium, contained in an
optical cavity, and a pumping system, provided by
external energy. The mirrors at each end ensure that
the photons bounce back parallel to the axis, so that
they, in turn, collide with excited atoms and stimulate
further production of photons.
The device where the laser action takes place is called
an optical cavity, a tube containing a suitable lasing
medium which may be gas (e.g., CO2), liquid (e.g.,
dyes), or crystal (e.g., ruby).
Mechanism of production of laser light
An atom consists of a dense nucleus,
around which electrons move in orbit.
The orbiting electrons are free to change
their orbit to a different (higher) level by
absorbing energy from an external
source, which may be light (photons).
And acquire an excited, unstable state.
The unstable electrons cannot stay in the
higher unstable [Link] tend to decay
to a lower, more stable [Link] the
process, they lose the extra energy of the
higher level in the form of packets of
energy, or photons.
This may happen spontaneously and at
random.
Contd
A photon released from an excited
atom might interact with another
similarly excited atom.
This results in the second atom
releasing its photon, which is
identical in every respect to the first
photon.
This phenomenon is called
stimulated emission of radiation.
The two photons have the same
direction of travel, and are in phase.
Properties of laser light
Monochromatic: A single pure colour
emitted by a single wavelength.
Collimated : : A beam in which all, or almost
all, the photons are travelling in the same
parallel direction
Coherent: Waves produced by a laser
travel through space in phase. The property
of being in phase is called coherence and is
responsible for the strength and intensity of
the beam between different points in the
field.
Different types of lasers
Four types of material are used:
Solid-- Nd:YAG laser,
Gas Helium Neon (HeNe) laser, CO2,Argon and
Krypton Gas laser.
LiquidOrganic dye laser.( rhodamin 6G , disodium
fluorescein)
Semiconductors Gallium-Arsenide-Diode laser
Excited dimer(Eximer Laser)-- Argon fluoride (193 nm)
and
Krypton fluoride (248 nm)
Infrared light: primarily absorbed by water.
Visible and UV light are absorbed by hemoglobin and
melanin
As wavelength becomes shorter scatter begins to
dominate the penetration of light
Comparison of the different types of laser
CO2
Nd:YAG
Argon
KTP
532
Wavelength (nm)
10,600
1060
488-514
Tissue absorption
high
low
selective
high in blood
Tissue penetration
0.1
Coagulation
low
high
medium
Cutting effect
high
low
low
selective
high in blood
1
medium
low
Laser-tissue interactions
The active lasing medium in the laser tube
The delivery system
The beam parameters
The power density on the tissue
Irradiance = intensity / area = watts / cm2
Fluence = (intensity X time) / area
The absorption characteristics of the tissue
The surgical skill
Reflection
Absorption
Photothermal effects
Photomechanical effects
Photoablation
Photochemical effects
Conduction
Coagulation
Laser crator
When laser radiation strikes
a tissue, the temperature begins to rise.
10 C 45 C: Conformation change of proteins.
50 C: Reduction of enzyme activity.
60 and 99C: Coagulation begins.
Vaporisation takes place when the temperature
rises to 100C.
Char starts to burn at around
400-500C.
MODES OF LASER
CONTINUOUS :The laser is continuously pumped
and emits light continuously
PULSE: In the superpulse mode, laser energy is
delivered with each peak over an extremely
short period of a few nanoseconds. The peaks
are interspersed with rest periods when no
exposure occurs, allowing time for tissues to
cool down
Q-SWITCHED: Allows a high build-up of energy
within the tube. This is then released over a
very short duration of a few nanoseconds,
reaching an enormous peak power.
Different types of
laser
CO2 Laser
10,600 nm wavelength
Water is target chromophore
Aiming helium-neon (HeNe) beam
Highest power continuous-wave laser
Cutting or ablating tool
Focus to <500 m
Seals blood vessels less than 0.5 mm
Pulsed to accommodate thermal relaxation time, less pain and less
edema
Used in majority of procedures except those requiring coagulation of
larger vessels
No current optical fiber to carry beam
The thermal damage zone is shallow: less than 500
m. Therefore, it is a comparatively poor haemostat,
not being effective in controlling bleeding from
vessels greater than 0.5 mm in diameter.
It is not fibre-transmissible through the common
silica optical fibre, although flexible guides are
available with limited flexibility for delivery.
Its use on the cords has the advantage of producing
minimal scarring,with the preservation of vocal
function. It causes a minimal inflammatory reaction,
and glottic competency is rarely jeopardised, even
after extensive application.
Nd:YAG Laser
1064 nm wavelength (neodymium-doped yttrium aluminum
garnet )
Aiming helium-neon (HeNe) beam
Wavelength is between minimal absorption of water and a small
amount of scatter
Solid state laser
Fiberoptic carrier
Application
Deeper penetration (up to 4 mm) for ablative therapy and hemostasis
Preferentially absorbed by pigmented tissues
Vascular malformations amenable to treatment
Limitations
Greater scatter than CO2
Deep thermal injury
Risk for transmural injury
It is an ideal laser with a deep thermal effect for coagulation and
KTP Laser
532 nm wavelength (potassium-titanyl-phosphate)
Frequency doubling
Nd: YAG laser passes through a KTP crystal
emission is its wavelength
Oxyhemoglobin is primary chromophore
Fiber optic carrier
Continuous wave (CW) mode to cut tissue
Pulsed mode for vascular lesions
Q-Switched mode for red/orange tattoo pigment
Delivery
CW/pulsed mode: insulated fiber, fiber handpiece,
scanner, or microscope
Q-Switched mode: articulating arm
HELIUM NEON
LASER
Helium-Neon (He-Ne) laser: The He-Ne laser
emits at 633 nm in the visible spectrum.
It is a low power laser. Its main use is to act
as an aiming beam for invisible lasers.
The He-Ne laser is superimposed on the
path of invisible lasers, such as the CO2 or
Ho:YAG, and used as an aiming beam.
The low power HeNe beam has also been
used in wound healing and in the treatment
of pain.
Argon Laser
488 - 514 nm wavelength (ion laser) (BLUE GREEN
SPECTRUM)
Oxyhemoglobin is target chromophore
Small spot size (0.1 1 mm) variable in size and
intensity
Flexible delivery system
mainly used in the ophthalmological procedures
Limitations
Also absorbed by epidermal and dermal tissues
due to melanin
Continuous mode of operation
Higher prevalence of postoperative pigmentary
alteration and fibrosis
DIODE LASER
The most common diode laser is
the gallium arsenide diode laser,
with a central emission of 840 nm,
and is fibre transmissible.
The delivery system
Articulated arm The emerging beam
is transferred from the laser aperture
in a hollow metal tube, usually
known as an articulated arm
LASER DELIVERY SYSTEM
Micromanipulator delivery
The micromanipulator is a device
consisting of a system of lenses
and a mirror with a joystick
[Link] is attached to the
microscope
Handpiece delivery The beam
is focused by the system of
lenses and mirrors onto the
handpiece at a fixed point some 2
cm from its emergence at the
distal end. A guide probe extends
from the end of the handpiece
Theatre protocol
Illuminated warning signs All
entrance/exit doors should be
marked with a warning sign,
indicating that a laser is in use and
that entry is only permitted to
authorised persons wearing
protective eye wear
Smoke evacuators Laser surgery
results in considerable pollution of
the operating theatre with smoke
and vapour. The operating theatre
must be well ventilated and
equipped with dedicated smoke
evacuators
Contd.
Fire extinguishers for
electrical fires A fire
extinguisher containing
CO2 gas or dry powder,
together with a fire
blanket, is positioned in
close proximity to the main
entrance door of the
operating theatre
Protective eye wear
Wavelength-specific eye
wear is provided for all
staff working in the theatre
Anaesthesia for laser
airway surgery
The challenge of anaesthesia for laser airway surgery
revolves around three major considerations:
combustion, the airway, and anaesthetic risk.
Combustion The risk is greatest with a collimated
beam such as a CO2 laser.
Risk of combustion is also less in lasers that operate
in a pulsed mode, as heat can dissipate between
bursts.
Commonly used tubes such as red rubber, latex,and
plastics such as PVC, are easily ignited in a typical
anaesthetic gas mixture, burning with a blowtorch-like
flame.
How anaethesist
manage!
Intubation anaesthesia
Water is fire retardant as well as being a
heat sink, so all swabs and fabric should
be wet.
Protection of standard tracheal tubes
-Protection with wet swabs///Reflective
wrapping of tracheal tubes////Protection of
the tracheal tube cuff///Factory-wrapped
tracheal tubes///Silicone rubber tubes with
metallic protection////Metal cuffed tubes///
Jet ventilation anaesthesia
Intermittent apnoeic technique
Tubeless anaesthesia
INDICATIONS FOR LASER IN LARYNX
Functional dysphonia plicae ventricularis- CO2
laser-assisted excision of both ventricular cords.
Chronic inflammatory conditions Exudative lesions in Reinkes space nodules
polyps
Reinkes
oedema
Intracordal mucous retention cysts
Intracordal epidermoid cysts
Sulcus vocalis and sulcus vergeture
Mucosal bridge
Anterior microwebs
Chorditis vocalis
Chronic trauma-
Contd..
Ulceration and granuloma
Scarring
Subluxation of the arytenoid cartilage
Neuromuscular disorders Bilateral vocal cord immobility
CO2 laser-assisted total arytenoidectomy
Subtotal arytenoidectomy
Recurrent respiratory papillomatosis
Neonatal laryngopathy Laryngomalacia
Subglottic haemangioma
Congenital mucous cysts
Benign laryngeal tumours Cysts( Intracordal epidermoid mucous retention cysts)
Laryngocoeles
Contd.
Webs and synechiae
Laryngo-tracheal synechiae
Congenital anterior webs
Anterior synechiae and fibrous bands
Chonic hyperplastic laryngitis-
leucoplakia
white hyperplastic laryngitis
red hyperplastic laryngitis
erythroplakia,
speckled erythroplakia
Excisions for malignancy
Carcinoma in situ (CIS)
Micro-invasive carcinoma
Verrucous carcinoma
management of TIS, T1 and some early T2 glottic, supraglottic
carcinoma
Why lasers for nasal
Lasers offer certain unique advantages in
surgery?
endonasal surgery of the middle meatus
complex (MMC).
The relatively bloodless field in the MMC offered
by lasers means that the surgical procedure is
under better visual control.
The CO2 laser is not commonly used in
endonasal laser surgery for a number of reasons.
Lack of fibre transmissibility
Increased risk of synechiae formation
Poor coagulation
Poor haemostasis
Contd
The KTP/532 wavelength (KTP) is fibre
transmissible. It has a high affinity of
absorption for pigmented tissue, such as
haemoglobin.
The energy conducted into the tissue is well
absorbed by the sinusoidal blood vessels of
the turbinate and results in a coagulation
zone with very little intraoperative bleeding.
The KTP laser has adequate power for
ablation of the bony framework of the MMC.
Benefits to the patient
from laser technology in
Minimally invasive surgery
Nose
Minimal bleeding
Minimal postoperative oedema and
crusting
Revision surgery
Ambulatory surgery
Cost benefit
INDICATIONS
Reduction of turbinates
Nasal polypi
Residual peritubal adenoid tissue, stenosis, and cysts
Dacryocystorhinostomy
Laser-assisted septoplasty
Indications for laser functional endoscopic sinus
Surgery
Removal of polypi as a preliminary procedure
to FESS
Manipulation of middle turbinate
Solitary sphenoid or frontal sinus disease
Intraoperative haemostasis
Revision endoscopic sinus surgery
Contd.
Excision of the uncinate process,removal of
bulla ethmoidales, and creation of middle
meatal antrostomy
Any suspicion of orbital, facial, or
intracranial extension of the disease
process is a contraindication for laser use .
Miscellaneous
Rhinophyma
Recurrent idiopathic nasal bleeding.
Telangiectatic, cavernous or pyogenic septal
granuloma
Hereditary haemorrhagic telangiectasia (HHT)
Choanal atresia or stenosis, nasopharyngeal
stenosis, polyps, adenoid hypertrophy, juvenile
angiofibroma and nasopharyngeal cancer.
Laser cartilaginous eustachian tuboplasty
Laser selection in otology
CO2, KTP and argon lasers have all been used in ear surgery.
In vascular lesions of ear -The Nd:YAG laser, with its deep
scatter,appears to be the laser of choice.
For debulking of tissue,stenosis CO2 laser are used.
The visible KTP laser light is well suited for undertaking temporal
bone surgery.
Fibre transmissibility of the KTP beam gives an added dimension to
laser usage in ear surgery.
Because of the optical property of total internal reflectionsuch
fibres can guide the light around corners.
Laser in otology
External auditory canal
Vascular lesions haemangiomas
,telangiectasias
Aural polyps and granulations
Stenosis of the external auditory canal
Debulking of large, inoperable EAC
carcinoma
Laser reshaping of cartilage
Tympanic membrane lesions
Epidermoid cysts of the tympanic
membrane.
Middle ear cleft
Laser-assisted myringoplasty
Perforations of the tympanic membrane
Graft-welding of tympanic membrane defects
Medialisation of the malleus
Laser-assisted ossicular surgery
Removal of inflammatory disease
Vascular lesions of the middle ear
Laser-assisted, totally implantable electronic
hearing aids
Cholesteatoma surgery
Laser applications in the inner ear
Cochleostomy
Laser labyrinthectomy
Orofacial Surgery:laser
preference
For vaporisation and cutting in soft tissue, a
wavelength such as the carbon dioxide (CO2)
modality at 10.6 m is indicated
For coagulation in soft tissue, a wavelength
which is poorly absorbed by water but is
maximally penetrative, is required. The near
infrared modality of the Nd:YAG at 1.06 m is
most suited for this purpose.
For hard tissue such as bone, dentine or enamel,
hydroxyapatite is the chromophore of
importance so that a wavelength such as the
erbium:YAG at 2.9 m is indicated.
Indications
High intensity laser treatment(HILT)
Oral mucosal premalignant leucoplakia
Mucosal haemangiomatous lesions of the
mouth
Temporomandibular joint :Division of
adhesions, coagulation of redundant capsule
in recurrent dislocation, and shrinkage of
retrodiscal tissue, as an aid to retrieval of an
anteriorly displaced meniscus.
Laser hemiglossectomy
Temporomandibular joint disorder pain
Low intensity laser therapy (LILT)
Post-herpetic neuralgia
Idiopathic neuralgia
Intractable ulcerations :Of Pemphigus
vulgaris, Crohns disease, and AIDS
Surgery for snoring and
obstructive sleep apnoea:
Uvulopalatoplasty
Laser midline glossectomy and
lingualplasty
Laser palatine tonsillectomy
Laser lingual tonsillectomy
Cryptolysis for halitosis
Laser selection in lower
airways
The most common lasers used for the lower
airways are the CO2 and the Nd:YAG.
The CO2 laser beam is directed towards the lesion
through articulated arm, limiting its use to rigid
bronchoscopy
It is presently used more for lesions involving the
larynx and proximal trachea.
The Nd:YAG laser beam can be passed through a
flexible endoscope It affords deeper penetration,
allows better coagulation, and produces better
haemostasis
Its main disadvantage is the unpredictable
interaction of the laser beam with the tissue,
making it difficult to determine the depth of
Lower airway indications
Laser photoresection of obstructive airway lesions
Malignant -------- bronchogenic carcinoma,
metastatic neoplasm, carcinoid tumour
Benign---------- subglottic and tracheal stenosis,
granulation tissues, broncholith,foreign body,
benign tumours,congenital tracheo-oesophageal
fistula
Photodynamic therapy------ curative therapy for
carcinoma in situ, juvenile
laryngotracheobronchial papillomatosis,
unresectable early stage lung cancer palliative
treatment for advanced obstructive lung cancer
Autofluorescence bronchoscopy------ localisation
of carcinoma in situ and superficial bronchogenic
cancer
Hazards of laser
Damage caused unintentionally by laser
strikes on biological but non-target tissue,
such as corneal or retinal eye injuries, skin
and mucosal burns.
Hazards caused by laser strikes on nonbiological material such as the anaesthetic
tube and draping material.
Side-effects due to laser by-products such
as laser-generated smoke.
Laser malfunction such as electric shock
.THANK
YOU!!
A laser produces a beam, like a sunbeam, but
with four fundamental characteristics: intensity
(tremendous energy in a very focused, narrow
beam), coherence (in phase spatially and
temporally),
high collimation (light waves are parallel
with minimal divergence and thus minimal
dissipation
of energy), and monochromacity (uniform
wavelength).
Monochromatic
Coherent
Collimated
A chromophore may be defined in the broad sense
as a group of atoms capable of colouring a
substance.
How Does It Work?
A laser is an optical oscillator, which is made out of a solid, liquid or gas with mirrors at both ends.
To make the laser work, the material is excited or "pumped," with light or electricity. The pumping
excites the electrons in the atoms, causing them to jump to higher orbits, creating a "population
inversion." A few of the electrons drop back to lower energy levels spontaneously, releasing a
photon (quantum of light). The photons stimulate other excited electrons to emit more photons with
the same energy and thus the same wavelength as the original. The light waves build in strength as
they pass through the laser medium, and the mirrors at both ends keep reflecting the light back and
forth creating a chain reaction and causing the laser to "lase."
CRYOTHERAPY:kryos=c
That branch of therapeutics
old
which relies upon its value on
local tissue changes,produced by
rapidly achieved ,profoundly low
temperature.
Procedure based on
JOULE THOMPSON EFFECT-Rapid
expansion of compressed gas
through a small hole produces
cooling.
Cryosurgery was carried out for the
first time by James Arnott in 1845 in
an operation on a patient with
cancer.
Dehydration
The fundamental properties utilized in the
applications of lasers are that the laser is
a beam of light that is collimated and
monochromatic. Thus a laser beam can
travel over large distances without
dispersing (beams of ordinary light spread
out and hence lose intensity). A laser
beam can also be focused down into a
spot of light smaller than an atom. This
allows enormous amounts of heat to be
generated at a very precise spot
D if e
frent types of spray
techniques
Cryosurgery Procedure.
As the temperature falls to less than 0C, water
crystallizes. This results in more significant damage
than with mere prolonged cooling.
Effective cellular dehydration occurs predominantly
between 0C and 20C.
Given enough time in this dehydrated state, the
increased intracellular electrolyte concentration is often
sufficient to destroy the cells.
Cryosurgery Procedure.
As cooling is continued intracellular ice crystal
formation starts.
It is more efficient at rapid cooling rates; slower rates
of cooling will result in cellular dehydration.
Rapid cooling does not allow time for water to leave the
cells.
During thawing, ice crystals fuse to form larger crystals,
a process called recrystallization, which occurs at
temperatures warmer than -40C.
Therefore, upon thawing of the ice, more free water will
exist outside the cells. This will enter the damaged
cells, and the subsequent increase in cell volume might
The initial CO2 laser microwave was
a continuous
wave. At a given power, it provided
continuous output.
The continuous exposure resulted in
much heating of
collateral, nontarget tissue by
conduction. To minimize
the thermal effect; a pulsed mode
was developed for the
Common indications for laser in ENT
1 Oral leucoplakia: Leucoplakia is strikingly responsive to the CO2 laser. Recurrence of new patches of leucoplakia after laser
treatment is also less likely. The operating microscope enables one to see much more of the targeted field. The reduced ground
tissue reaction adds to the advantage of laser.
2 Oral Verrucous carcinoma: Lesions, which are 2 cms or less, are amenable to laser treatment. The results of treating smallcircumscribed oral verrucous carcinomas are excellent, especially if adjacent epithelial dysplasia is limited.
3 Oral carcinomas: Removal of intra-oral carcinomas by CO2 laser is much preferred these days due to the more rapid and
less painful process. Some surgeons do advocate leaving the wound open to facilitate better healing and reduced pain.
Other conditions where laser has been advocated in diseases of the Oral cavity are
Oral and Oropharyngeal haemangiomas.
Pleomorphic adenomas.
Tonsillectomy
Uvulo-palato-pharyngoplasty.
KKR ENT Hospital introduced CO2 LASER in the year 1998 and since then have completed a series of head and neck surgeries
using this technology. The results are outstanding when compared to conventional technique.
Nasal indications: Listed are some of the commonly encountered indications in the nose which can be dealt very effectively
with laser.
Nasopharyngeal Angiofibromas: These are extremely aggressive and vascular tumours of the nose and paranasal sinuses.
The CO2laser attains markedly reduced blood loss and precise incision.
Familial haemorrhagic telangiectasia: This disease has lesions which cause bleeding in the nose due to capillary dilatations.
Ablation of the mucosa by laser is extremely useful to control the bleeding. However, there have been some cases of recurrence
after laser.
Choanal atresia: The major advantage of the CO2 laser in these conditions in infants is the minimal tissue trauma and the
bleeding. The laser beam is directed along the axis close to the floor of the nose using the inferior turbinate as a landmark. The
bleeding is usually minimal and an indwelling elastic or polyvinylchloride tube can be used to prevent contraction of the new
orifice. The surgery may need to be repeated at times.
Nasal polyposis: Polyps in the nose are usually a vascular and have a restricted area of the disease. Ethmoidal polyps have a
high recurrence rate and laser surgery is very useful to reduce it.
Lasers can be used to ablate a given
tissue by vaporising it, layer by layer.
Thus, vaporisation is the prime, and
most important effect in the clinical
application of lasers.
Excision Lasers can also be used to
excise a tissue, by
vaporising a narrow band of tissue
in the line of the incision, in order to
develop a flap, deep enough to hold
