Учебники / Lasers in Otorhinolaryngology Huttenbrink

nostic step, the increased uptake of protoporphyrin IX in

rates ranging from 50 % to 100 % have been reported in

the papilloma cells is used for fluorescent endoscopy of the

the literature [196]. Based on available data, however, it

nose and paranasal sinuses (Fig. 3.13). The mucosal areas

is reasonable to conclude that PDT with ALA is now an

affected by papillomatosis are clearly visualized by fluores-

effective alternative in the treatment of actinic keratosis,

cent endoscopy [193]. Since the 635-nm excitation beam

superficial basal cell carcinoma, and Bowen’s disease

has but a shallow penetration depth, the papillomas are ini-

[206]. Essential advantages of PDT are its excellent cos-

tially removed by excision or ablation with a surgical laser.

metic and functional results and lack of invasiveness. Due

A biopsy sample is taken at this time for histologic confir-

to the lack of histologic control, PDT is not currently rec-

mation. PDT is carried out after all papillomas have been

ommended for the treatment of invasive squamous cell

grossly removed and the carbonaceous debris has been

carcinoma [205].

wiped away. The wound bed and adjacent mucosa are ir-

radiated with laser light delivered through fibers with a

T Summary and Outlook

low-divergent output, applying a total energy dose of

100 J/cm2. To date, three patients have been successfully

In the past few decades, laser surgery has evolved into an

treated according to this protocol.

important therapeutic modality in otorhinolaryngology. At

Extranasal Photodynamic Therapy

many institutions, CO2 laser surgery has become the meth-

od of choice for resecting localized carcinomas of the upper

Resection of premalignant and malignant lesions of the ex-

aerodigestive tract. A number of laser systems have been

successfully used in treating various diseases of the nose

ternal nose and adjacent facial skin is problematic from a

and paranasal sinuses, but laser therapy cannot yet be con-

functional and esthetic standpoint. Plastic reconstructive

sidered an established modality for many disorders. Espe-

options are limited, especially in patients with recurrent

cially in rhinologic applications, lasers offer several advan-

disease after surgery or radiotherapy and patients with

tages over conventional techniques such as improved vis-

multifocal disease. Given this situation, PDT represents a

ualization due to better hemostasis, high-precision tissue

valuable alternative treatment.

ablation, minimal collateral tissue trauma resulting in less

PDT with systemically administered hematoporphyrin de-

postoperative edema, and a reduction in postoperative

pain. Intranasal packing, which is often difficult for pa-

rivatives has yielded good oncologic and cosmetic results

tients to tolerate, can be omitted in many cases.

in the treatment of localized, superficial basal cell carcino-

mas and spindle cell carcinomas. One disadvantage of this

Given the rich vascularity of the nasal mucosa and the

photosensitizer is that it photosensitizes the skin for a pe-

proximity of vulnerable structures such as the orbit and

riod of weeks, which can significantly affect the patient’s

skull base, lasers used for intranasal surgery must meet

quality of life [194].

certain requirements. Ideally, the laser should be equally

Generalized photosensitization in PDT can be avoided by

effective in ablating bone and mucosa. It should provide

good hemostasis, cause no collateral damage, and should

the topical administration of ALA [195]. A 10–20 % ALA

be deliverable through a flexible carrier. The laser systems

cream or gel is applied to the skin lesion and then covered

used in rhinology (argon, KTP, diode, Nd:YAG, Ho:YAG,

with an occlusive dressing for 4–6 hours. Excitation of the

Er:YAG, CO2) meet the above criteria only to a degree, but

tumor with blue light (370–440 nm) induces a typical red

very good therapeutic results can still be achieved when

fluorescence that delineates the tumor boundaries. The tu-

the biophysical effects of the various lasers are taken into

mor area is then lased at a wavelength of 600–800 nm, ap-

account. We feel that laser therapy has an established place

plying a total dose of 100–150 J/cm2 [196]. Patients con-

in the treatment of turbinate hyperplasia, recurrent

sistently report a sunburn-like pain during laser applica-

epistaxis including Osler disease, hemangiomas and vascu-

tion [197]. No side effects besides erythema of the treated

lar malformations, choanal atresia, circumscribed benign

area have been described [198].

lesions, and rhinophyma. Lasers are still questionable as a

The successful PDT of premalignant and malignant lesions

tool for nasal septal and sinus surgery and intranasal lac-

rimal duct surgery, but good results can be achieved by an

with topically administered ALA was first described in

experienced surgeon in carefully selected patients.

1990 by Kennedy et al. [195]. Studies in recent years have

reported cure rates of 79–100 % for superficial basal cell

Further technical advances in laser systems may help to

carcinomas [195, 197, 199–203]. Much less favorable re-

expand the range of indications for laser use in rhinology.

sults have been reported for thicker lesions and nodular

This potential is illustrated by computer-assisted laser sys-

forms [199, 202, 203]. Actinic keratosis, which progresses

tems, which precisely define the area of tissue ablation

to squamous cell carcinoma in up to 60 % of cases, and Bo-

while sparing adjacent structures. In addition, manufactur-

wen’s disease can also be successfully treated with local

ers are developing laser devices for clinical use that com-

ALA PDT. The cure rates after one treatment range from

bine multiple wavelengths in one unit, resulting in cost

70 % to 90 % [202–206]. Actinic keratosis of the facial skin

savings and enabling the physician to select the optimum

responds considerably better to PDT than similar lesions

wavelength for a particular disease. Interest is also focus-

on the trunk or extremities [204].

ing on ways to develop better flexible carriers for the CO2

Since the treatments practiced at different centers are by

laser. Although the CO2 laser is the workhorse of otolaryn-

gology, bulky carriers still limit its capacity for endonasal

no means standardized, it is little wonder that response

use.

References 71

T Acknowledgements

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Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

78

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87

T Abstract

cavity and oropharynx, and it may be necessary to remove

the tumor piecemeal if visualization is poor. The histologic

Good accessibility of the oral cavity and oropharynx has fa-

workup can be difficult in some cases and requires close

teamwork between the surgeon and pathologist.

vored the development of numerous laser applications in

this region. The CO2, KTP, and Nd:YAG lasers are most com-

Some of the most frequent indications for laser use in the

monly used for cutting mucosa and devitalizing tissue. The

oral cavity and oropharynx are listed below:

most important laser applications in these regions are in

•

Tongue base reduction

tonsillar surgery and soft-palate surgery for sleep-disor-

•

Tonsillar surgery

dered breathing. Besides tonsillectomy, various authors

•

Soft-palate surgery

have also described laser tonsillotomies with the goal of pre-

•

Treatment of hemangiomas

venting intraoperative and postoperative bleeding and re-

• Excision of benign tumors

ducing postoperative pain. While these positive effects have

• Treatment of premalignant lesions

been documented in several studies, they have not yet been

• Excision of malignant tumors

widely confirmed. Laser tonsillectomy is more costly and re-

• Frenectomies (of the lip, tongue, or cheek)

quires an elaborate safety protocol. Different problems arise

•

Salivary gland diseases

in association with laser use on the soft palate, as in laser-

assisted uvulopalatoplasty (LAUP). LAUP is a very promising

technique owing to the simplicity of the procedure. Unfor-

Properties and Indications of Lasers Used in

tunately, published data indicate that LAUP should be used

the Oral Cavity and Oropharynx

only in the treatment of primary snoring and is not appro-

priate for sleep apnea. Even with careful patient selection,

CO2 Laser

the potentially severe complications should not be over-

looked. Many other possible laser applications have been

published including the excision of small tumors, the treat-

The CO2 laser was first developed by Patel et al. in 1964 [3]

ment of leukoplakia, frenectomies, and the fragmentation of

and introduced for medical use in the early 1970s [4–6].

salivary stones. Laser application for these indications is just

The CO2 laser is a type of gas laser. It emits light at a wave-

one possible treatment modality offering only marginal ad-

length of 10.6 µm (10,600 nm) in the invisible, infrared re-

vantages over conventional techniques when the added

gion of the spectrum. This requires the use of a coaxial he-

costs are taken into account. Laser use for these indications

lium-neon (HeNE) laser aiming beam, whose 0.633-nm

is basically a matter of individual preference and availability.

wavelength is in the visible (red) region of the spectrum.

T Characteristics of Lasers Used in the

Because of its wavelength, the CO2 laser has strong affinity

for water. This accounts for the good absorption of CO2 la-

Oral Cavity and Oropharynx

ser energy by the oral mucosa, which consists of more than

90 % water. The CO2 laser has excellent cutting and ablating

Importance of Laser Surgery in the Oral Cavity

properties, especially in soft tissue. Its maximum penetra-

tion depth in tissue is less than 1 mm. The CO2 laser beam

and Oropharynx

itself is not reflected or scattered in the mucosa [7]. Ab-

The carbon dioxide (CO2), neodymium:yttrium aluminum

sorption of the laser energy by water causes rapid genera-

tion of heat, which carbonizes the tissue. The laser can be

garnet (Nd:YAG), potassium-titanyl-phosphate (KTP), and

operated in pulsed mode (superpulse or ultrapulse) or in

argon lasers are most commonly used for soft-tissue sur-

continuous mode (continuous-wave [CW]). The CW mode

gery in the oral cavity and oropharynx. The lasers are used

is preferred for oral soft-tissue surgery. The CO2 laser en-

for cutting and ablation of tissue and the coagulation of tis-

ergy is applied to the target tissue using a noncontact tech-

sue surfaces. Depending on the specific indication and the

nique. One disadvantage compared with the Nd:YAG laser

type of laser used, lasers can offer advantages over tradi-

is that the CO2 laser requires a rigid delivery system.

tional surgical methods[1, 2]:

• spontaneous occlusion of small transected vessels, pro-

When applied in the oral cavity and oropharynx, the CO2

viding hemostasis and an almost bloodless field;

laser is used mainly as a cutting instrument to remove be-

•

no-touch operating technique;

nign and malignant lesions [8–12]. It is also used for in-

•

precise incisions under microscopic control with little

traoral incisional and excisional biopsies and frenectomies.

collateral tissue damage;

•

no need for sutures. All therapeutic options remain

Nd:YAG Laser

open, such as repeating the laser therapy or resection of

an extensive tumor in case of a recurrence.

The Nd:YAG laser emits a beam in the invisible, infrared

It is also important, however, to factor in the high costs

part of the spectrum (similar to the CO2 laser) at a wave-

incurred by laser use (e.g., a dedicated laser operating

length of 1064 nm. A coaxial HeNe laser is used to produce

suite) and the necessary safety measures.

a visible aiming beam. YAG, which stands for “yttrium-alu-

minum-garnet,” is the host crystal for the neodymium ion

Some cases may not be amenable to a classic en-bloc re-

and is distinguished by its relatively high thermal conduc-

section, depending on the extent of the tumor in the oral

tivity and good optical quality. The advantage of the

Clinical Uses of Lasers in the Oral Cavity and Oropharynx 79

Nd:YAG laser over the CO2 laser is that the laser energy can

Excimer laser

be delivered into the oral cavity through a flexible carrier

[13] and can be applied through quartz fibers in flexible

The excimer laser, just as the erbium:YAG laser, has mainly

endoscopes. The Nd:YAG laser can be used interstitially,

dental applications in the oral cavity and oropharynx. The

out of contact, or in contact with the target tissue.

active medium of the excimer laser is a noble gas combined

The light emitted by the Nd:YAG laser is weakly absorbed

with a halogen gas, such as xenon–fluoride or argon–fluo-

ride. The composition of the gas determines the wave-

by water, but it has strong affinity for dark and pigmented

length of the laser and is generally in the ultraviolet range

tissues such as hemoglobin and melanin [14]. Because

[1]. As with the erbium:YAG laser, dental hard tissue can

Nd:YAG laser light is transmitted through water, it pene-

be removed by photoablation. The rate of ablation depends

trates more deeply into tissue than the CO2 laser beam. It

on the mineral content and morphologic structural ele-

undergoes minimal reflection. Owing to its properties, the

ments of the dental hard tissue. Tissue affected by caries is

Nd:YAG laser is best for treating more deeply situated ar-

ablated at a considerably faster rate than intact dental

eas in the oral cavity and oropharynx. Because the Nd:YAG

enamel or dentin [21].

laser energy is strongly absorbed by hemoglobin, it is very

effective for coagulation [1]. The laser can be operated in a

A major drawback of the excimer laser is that its light can-

pulsed or continuous mode.

not be transmitted through a flexible carrier. Besides high

equipment costs, the energy density at the target can be

Argon Laser

controlled only by adjusting the focal–object distance, and

the beam must be passed through an aperture to screen off

The argon laser is a type of ion laser that uses a noble gas

areas at the beam periphery [22].

as the lasing medium. It emits primarily at 488 nm in the

blue part of the visible spectrum and at 514 nm in the

T Clinical Uses of Lasers in the Oral Cavity

green part of the spectrum. As with the Nd:YAG laser, the

and Oropharynx

light can be delivered into the oral cavity through a

fiberoptic carrier.

Argon lasers have strong affinity for dark-colored tissue

The following sections deal only with the most frequent

clinical indications and applications of lasers in the oral

and hemoglobin, such as melanin, hemangiomas, Kaposi

cavity and oropharynx.

sarcoma, and nevi, making them particularly useful for co-

agulation [15]. The argon laser beam is not reflected from

Hyperplasia of the Lingual Tonsil

the oral tissues. It undergoes relatively little absorption,

transmission, or scattering. Like the Nd:YAG laser, the ar-

gon laser can be used in or out of contact with the target

Hyperplastic changes in the region of the base of the

tissue.

tongue may result from chronic recurrent inflammation of

Unlike the CO2 and Nd:YAG lasers, the argon laser (blue

the lingual tonsils. However, the differential diagnosis

should also include ectopic thyroid tissue and malignant

wavelength) can also polymerize composite resins [16, 17].

lesions such as lymphoma and squamous cell carcinoma.

This property is used mainly in periodontal therapy, where

Hyperplastic changes can lead to swallowing difficulties,

the laser is used for the photopolymerization and curing of

globus sensation, or fetid breath odor, and chronic infec-

resin materials up to 3 cm thick [18, 19]. The green wave-

tion can lead to febrile episodes of unknown cause with

length is used primarily for intraoral soft-tissue work and

odynophagia. Laser ablation of the hyperplastic tissue is of-

hemostasis, particularly in the treatment of vascular and

ten recommended in such cases, sometimes after an inef-

pigmented lesions in the oropharynx and oral cavity. An-

fectual trial of conservative therapy [2].

giitis can develop as a late reaction in exposed vessels,

leading to vascular occlusion. Superficial coagulation with

Owing to its physical properties and hemostatic effect, the

subsequent scarring has not been observed with this laser

CO2 laser is particularly useful for the reduction of hyper-

system.

plastic lingual tonsils. The CO2 laser markedly reduces the

risk of collateral deep tissue injury compared with the

Erbium:YAG Laser

Nd:YAG laser [23]. As studies by Steiner et al. have shown,

laser resection that is confined strictly to lymphatic tissue

Like the Nd:YAG laser, the erbium:YAG laser belongs to the

and does not injure the muscles of the base of the tongue

causes less intraoperative bleeding [24]. Laser surgery is as-

category of pulsed solid-state lasers. It emits a beam in the

sociated with significantly less postoperative pain (includ-

infrared part of the spectrum at a wavelength of 2.94 µm.

ing neuralgiform pain radiating to the ears) and postopera-

Because it is strongly absorbed by water, the erbium:YAG

tive edema than more extensive resections, which may be

laser is useful for cutting and ablation but is not a very ef-

followed by considerably more complications.

fective coagulator [1]. Because of these properties, the er-

bium:YAG laser is used mainly in dentistry for cutting bone

and dental hard tissue [20]. It is not widely used in oral

soft-tissue surgery.