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9 Blue Laser Therapy ofLaryngeal Stenosis
References
1. Bogdasarian RS, Olson NR.Posterior glottic laryngeal stenosis. Otolaryngology. 1980;88(6):765–72.
2. Wolf M, Primov-Fever A, Talmi YP, Kronenberg
J.Posterior glottic stenosis in adults. Isr Med Assoc J.
2007;9(8):597–9. PMID: 17877066.
3. Smith ME, Marsh JH, Cotton RT, Myer CM III.Voice
problems after pediatric laryngotracheal reconstruction: video laryngostroboscopic, acoustic, and perceptual assessment. Int J Pediatr Otorhinolaryngol.
1993;25(1-3):173–81.
4. Sataloff RT, Hawkshaw M.Endoscopic internal stent:
a new procedure for laryngeal webs in the presence of
papilloma. Ear Nose Throat J. 1998;77(12):949–50.
5. Stasney CR.Laryngeal webs: a new treatment for an
old problem. J Voice. 1995;9(1):106–9.
6. Sataloff RT, Chowdhury F, Portnoy JE, Hawkshaw
MJ, Deglekar S. Laryngeal surgery. New Delhi:
Jaypee Brothers; 2014. p.130–4.
7. Cotton RT. Management of subglottic stenosis.
Otolaryngol Clin N Am. 2000;33(1):111–30.
8. Cummings CW. Glottic and subglottic stenosis.
In: Otolaryngology: head and neck surgery. 4th ed.
Philadelphia: Mosby; 2005.
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stenosis. Laryngoscope. 1979;89(6):866–77.
10. Cotton RT. Pediatric laryngotracheal stenosis. J
Pediatr Surg. 1984;19(6):699–704.
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12. Orenstein SR, Shalaby TM, Di Lorenzo C, Putnam
PE, Sigurdsson L, Kocoshis SA. The spectrum of
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voice laboratory. In: Sataloff RT, editor. Professional
voice: the science and art of clinical care. 3rd ed. San
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16. Strong MS, Healy GB, Vaughan CW, Fried
MP, Shapshay S. Endoscopic management of
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17. Rahbar R, Shapshay SM, Healy GB, Mitomycin
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18. McArthur CJ, Kearns GH, Healy GB. Voice quality after laryngotracheal reconstruction. Arch
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Rare Applications ofBlue Laser
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Therapy inLaryngology
10
10.1 Introduction
The rst nine chapters of this book have discussed basic information about lasers, considerations for anesthesia for laser procedures in the
ofce and in the operating room, and use of blue
laser for management of common problems
including vocal fold varices, exudative lesions
(e.g., polyps, cysts, Reinke’s edema), granulomas, papillomatosis, dysplasia/cancer, scar and
laryngotracheal stenosis. Blue laser has proven
useful for a variety of less common laryngeal
conditions that have been treated traditionally
with CO2 laser or cold steel instruments. This
chapter illustrates the use of blue laser for creating vocal fold incisions, treating partial extrusion
of implanted fascia without removing the fascia
and sacricing surgical medialization, resection
of a laryngocele, medial arytenoidectomy, and
resection of a false vocal fold mass. These cases
are intended to illustrate the versatility, effectiveness, and minimal tissue damage associated with
blue laser use. The cases presented provide only
a few examples of the many potential uses for
blue laser technology in the larynx. Readers are
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 35283- 6_10. The videos can be
accessed individually by clicking the DOI link in the
accompanying gure caption or by scanning this link with
the SN More Media App.
encouraged to consider this instrument for treatment of a variety of laryngeal pathologies.
10.2 Case Presentations
10.2.1 Case 1: Blue Laser Partial
Cordectomy
A 38-year-old female presented to the Voice
Unit (ALH) with history of stridor and difculty in breathing of 3-month duration following thyroidectomy. The patient’s medical
history was negative for any systemic disease.
On perceptual evaluation, she had grade 2 dysphonia, and her VHI-10 score was 35. Her dyspnea severity index was 36. On laryngeal
examination, she had xed vocal folds in the
median position with a gap of 2 mm during
deep inspiration (Fig.10.1). The patient underwent ofce-based botulinum toxin injection
within the thyroarytenoid/lateral cricoarytenoid
complex (2.5 IU) bilaterally. On follow- up, she
had marked improvement in her breathing with
a 2mm widening of her glottal gap. Six months
later, the patient elected to undergo laser partial
arytenoidectomy. Due to nancial reasons, she
opted to have the surgery in-ofce under local
anesthesia. Using the 400nm blue laser glass
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A.-L. Hamdan et al., Blue Laser Surgery in Laryngology,
https://doi.org/10.1007/978-3-031-35283-6_10
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10 Rare Applications ofBlue Laser Therapy inLaryngology
Fig. 10.1 Endoscopic view of the larynx showing the
vocal folds in the midline during inspiration prior to treatment, with a chink of 1–2 mm anteriorly and 3–4 mm
posteriorly
Fig. 10.2 Endoscopic view showing the blue laser in
contact mode against the thyroarytenoid muscle bers
ber, and setting of 10W power, 40 ms pulse
duration, and 150 pulse pause, a horizontal
incision just anterior to the vocal ligament was
made and was extended down to the lateral
bers of the thyroarytenoid muscle laterally
(Fig.10.2). This was followed by laser ablation
of the vocal process. The procedure was well
tolerated by the patient. On follow-up 6 weeks
later, she had improvement in her breathing
with minimal decrease in voice quality. Her
VHI was 11 and her DSI dropped to 8
(Fig.10.3).
Fig. 10.3 Endoscopic view of the larynx 3 weeks following surgery showing widening of the glottal gap
posteriorly
Fig. 10.4 Endoscopic view of the larynx showing a 2.5 ×
2cm soft hemorrhagic mass abutting the posterior surface
of the right arytenoid cartilage
10.2.2 Case 2: Pharyngeal
Neuroendocrine Tumor
A 59-year-old male presented to the Voice Clinic
(ALH) with throat discomfort and difculty swallowing. He had no change in voice quality or respiratory symptoms. He had a history of reux disease
for which he had been treated with proton- pump
inhibitors for many years. On laryngeal examination, he had a 2.5 × 2cm soft vascular mass abutting
the posterior surface of the right arytenoid cartilage
(Fig. 10.4) The rest of the laryngeal examination
was normal. Computerized tomography of the neck
10.2 Case Presentations
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showed an 8mm polypoid lesion originating from
the right aryepiglottic fold. The lesion did not invade
adjacent structures. The patient underwent suspension microlaryngoscopy and blue laser treatment of
the hemorrhagic lesion. Intraoperatively, the lesion
was pedunculated and originating from the pharyngeal wall. Using the 400nm blue laser glass ber,
pulse 10 W, 10 ms pulse duration, and 300 ms pulse
pause, the lesion was ablated and totally removed
(Fig.10.5). Pathologic examination revealed a welldifferentiated neuroendocrine tumor, grade 1/3, and
it was positive for the following immunohistochemical stains: Synaptophysin, CKAE 1/3, and S100.
Six weeks following the surgery, the patient had
complete resolution of his symptoms. On laryngeal
Fig. 10.5 Intraoperative view showing the surgical bed
of the lesion following application of the blue laser (power
10 W, pulse duration 40 ms, pulse pause 300 ms)
examination, there also was complete resolution of
the lesion (Fig.10.6).
10.2.3 Case 3: Left False Vocal
FoldMass
A 46-year-old male presented to the Voice
clinic (ALH) with hoarseness of a few months’
duration. The patient had no history of dysphagia or shortness of breath. On perceptual evaluation, he had grade 2 dysphonia. On laryngeal
examination, he had bilateral grade 1 Reinke’s
edema with an exophytic polypoid mass arising from the medial surface of the left false
vocal fold. The patient underwent ofce-based
biopsy of the left false vocal fold, and a soft
tissue specimen measuring 0.2 × 0.1 × 0.1cm
was submitted for histopathologic analysis.
The pathologic examination showed unremarkable lining cells with no evidence of atypia or
malignancy. At the same sitting, the patient
also underwent blue laser therapy of his
Reinke’s edema and false vocal fold lesion.
The setting used was power 10 W, pulse duration 40 ms, pulse pause 300 ms (Fig. 10.7).
Three weeks after surgical intervention, the
patient reported improvement in his voice
quality. Laryngeal endoscopic examination
showed complete regression of the left false
vocal fold lesion with decrease in the size of
the Reinke’s edema. The patient was reassured
and instructed to follow-up.
Fig. 10.6 Endoscopic view of the larynx 3 months following surgery showing complete regression of the lesion
Fig. 10.7 Endoscopic view of the larynx showing blue
laser application to the left false vocal fold
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10 Rare Applications ofBlue Laser Therapy inLaryngology
10.2.4 Case 4: Vocal Fold Incision
forHomograft Fascia
A 41-year-old female presented with stable
LPR and dysphonia despite having had voice
therapy and multiple laryngeal procedures
including left thyroplasty, bilateral Cymetra
injection, removal of a brous lesion from the
vocal fold (VF), and bilateral true vocal fold
injection with 5-FU and triamcinolone. Her
neck CT scan demonstrated her thyroplasty
implant in good position. Laryngeal examination demonstrated glottic insufciency due to
left vocal fold atrophy/bowing and stiffness,
mild L ventricle prolapse, and scar of posterior
third of the left vocal fold. In the operating
room, a Sataloff medium female laryngoscope
provided good visualization (Fig. 10.8). An
incision was made lateral to the left thyroarytenoid muscle using a blue laser, at 6 W, 40 ms
pulse duration, 150 ms pulse pause (Figs.10.9
and 10.10). A total 22J were used. Homograft
fascia lata was cut in pieces and inserted lateral
to thyroarytenoid muscle through a tunnel created using Sataloff blunt ball dissector
(Fig.10.11). Tisseel was used to help stabilize
the implanted fascia. The area of scar on the left
vocal fold was injected with FlowGraft
(Fig.10.12). The patient was seen 2 days after
the surgery. She was healing well, and there
was no extrusion (Fig.10.13).
Fig. 10.9 Intraoperative microscopic view showing blue
laser used to make incision lateral to the left thyroarytenoid muscle
Fig. 10.8 Intraoperative view of both vocal folds
Fig. 10.10 Intraoperative view showing nal blue laser
incision
10.2 Case Presentations
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Fig. 10.11 Intraoperative view showing ball probe used
to insert homograft fascia lata
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Fig. 10.13 Endoscopic view of the larynx showing no
fascia lata extrusion and medialized left musculomembranous vocal fold
Fig. 10.12 Intraoperative nal view showing the left
vocal fold is fully medialized
10.2.5 Case 5: Extruded Fascia Lata
A 35-year-old female with a history of right
vocal fold cyst excision with steroid injection
of a vocal fold granuloma presented with LPR
and dysphonia due to glottic insufciency and
right vocal fold mass. She still had dysphonia
despite having had voice therapy and medical
management of LPR. She underwent direct
laryngoscopy to remove the right vocal fold
mass and insert homograft fascia lata in the left
vocal fold. However, 5 days after surgery, fas-
Fig. 10.14 Endoscopic view of the larynx showing partially extruded fascia lata
cia lata had extruded partially from the left
vocal fold (Fig.10.14). There was enough fascia in good position to provide medialization,
so the fascia was not removed. Blue laser in
contact and non- contact modes at 10 W, 60 ms
pulse duration, 150 ms pulse pause was used to
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10 Rare Applications ofBlue Laser Therapy inLaryngology
vaporize the extruded fascia lata. The procedure was performed in the ofce (Fig.10.15).
Extruded fascia lata was vaporized totally
(Fig.10.16, Video 10.1). One month after laser
surgery, her left vocal fold had healed completely (Fig.10.17).
Fig. 10.17 Endoscopic view of the larynx one month
after the procedure showing complete healing of the left
vocal fold
10.2.6 Case 6: Right Laryngocele
Fig. 10.15 Endoscopic view of the larynx showing
blue laser vaporizing the extruded fascia. (Video 10.1
Surgical video showing in office blue laser treatment
of extruded fascia lata. Blue laser seen through distal
end of working channel of flexible laryngoscope. Blue
laser was used in contact and non-contact mode)
(▶ https://doi.org/10.1007/000- ap3)
Fig. 10.16 Endoscopic view of larynx showing complete
fascia vaporizing using blue laser
A 48-year-old male singer with a history of
LPR presented with dysphonia despite having
had extensive voice therapies. He had undergone multiple laryngeal procedures, including
left vocal fold cyst removal, right vocal fold
mass resection, laryngocele excision, and
serial of 5 Fluorouracil injection. His laryngeal
examination demonstrated right ventricular
protrusion. In the operating room, good visualization was achieved with Sataloff medium
female laryngoscope (Fig. 10.18). Blue laser
was used in contact mode at 10 W, 60 ms pulse
time, 150 ms pulse pause to resect the laryngocele (Fig. 10.19). The area of resection was
injected with a mixture of 5 uorouracil and
triamcinolone. The nal surgical view showed
complete resection (Fig. 10.20, Video 10.2).
His examination 6 months after laser treatment
demonstrated no laryngocele recurrence
(Fig.10.21).
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Fig. 10.18 Intraoperative surgical view showing right
ventricular protrusion
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Fig. 10.20 Intraoperative nal surgical view showing
complete laryngocele resection using blue laser. (Video
10.2 Surgical video showing resection of right laryngocele using blue laser in contact mode)
(▶ https://doi.org/10.1007/000- ap2)
Fig. 10.19 Intraoperative surgical view showing resection of the laryngocele using blue laser
Fig. 10.21 Endoscopic view of the larynx 6 months after
the procedure showing no laryngocele recurrence
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10 Rare Applications ofBlue Laser Therapy inLaryngology
10.2.7 Case 7: Medial
Arytenoidectomy
A 49-year-old female singer presented with LPR
and dysphonia after a head concussion. Despite
having had voice therapy and LPR treatment, she
still had glottic insufciency due to left medial
arytenoid protrusion that mechanically separated
her vocal folds and caused compensatory strain,
as well as bilateral vocal fold paresis. Her neck
CT scan demonstrated fullness of the left medial
arytenoid cartilage. We assumed that she had
compensated for the long-standing arytenoid cartilage anomaly until she developed paresis. In the
operating room, encroachment into the posterior
laryngeal airway by protruding arytenoid cartilage was conrmed (Fig.10.22). Using blue laser
at 10 W, 60 ms pulse duration, 150 ms pulse
pause in contact and non-contact mode, left
medial arytenoidectomy was performed
(Fig.10.23, Video 10.3). A total 145J were used.
Dexamethasone was injected into the area of
resection (Fig. 10.24). The patient reported
improvement in her dysphonia. Her 6-month
postoperative view demonstrated improved glottic closure with a small, asymptomatic residual
posterior gap (Fig.10.25).
Fig. 10.23 Intraoperative view showing medial arytenoidectomy using blue laser
Fig. 10.22 Intraoperative surgical view showing
medially protrusion of the left arytenoid cartilage.
(Video 10.3 Surgical video showing medial arytenoidectomy using blue laser in contact mode)
(▶ https://doi.org/10.1007/000- ap1)
Fig. 10.24 Intraoperative nal surgical view showing
complete medial arytenoidectomy with char in the area of
partial cartilage resection
10.2 Case Presentations
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Fig. 10.25 Endoscopic view of the larynx 6 months after
the procedure showing small, asymptomatic posterior gap
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Fig. 10.27 Intraoperative surgical view showing taking
mass biopsy
Fig. 10.26 Intraoperative surgical view showing right
false vocal fold mass. (Video 10.4 Surgical video showing
complete resection of right false vocal fold mass using
blue laser) (▶ https://doi.org/10.1007/000- ap4)
10.2.8 Case 8: Right False Vocal
FoldMass
A 68-year-old male with laryngeal stenosis that
had required multiple surgical procedures presented with stable dysphonia and LPR with no
breathing difculty. His laryngeal examination
demonstrated a right false vocal fold mass. In the
operating room, it was friable and appeared to be
benign tissue (granulation tissue) (Fig. 10.26).
Fig. 10.28 Intraoperative view showing blue laser vaporizing the left false vocal fold mass
Biopsy revealed benign inammatory pathology
(Fig. 10.27). Blue laser at 10 W, 60 ms pulse
duration, 150 ms pulse pause was used to vaporize the false vocal fold mass (Fig.10.28). A total
168J were used. The nal surgical view demonstrated complete vaporization of the mass (Video
10.4). Dexamethasone was injected into the area
of resection (Fig. 10.29). 6 months later, there
was no granulation recurrence on the right false
vocal fold (Fig.10.30).
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