Laser Surgery
Laser surgery is surgery that uses a beam of laser light, rather than other instruments, to cut, dissect, remove, and so forth. The beam of light has advantages over other cutting instruments, such as scalpel or scissors.
First, at the same time that it cuts, it tends to seal off tiny blood vessels and reduce bleeding. Second, it may be especially useful in endoscopic surgery, where there is not a lot of room for instruments. Third, it is very precise. Both the microspot carbon dioxide laser and the RevoLix laser used at our practice have minimum spot sizes of about 1/5 of a millimeter.
Office Laser, Even Occasionally for Singers
Ordinarily, vocal cord microsurgery is only for otherwise irreversible lesions. This is especially so in singers, even though when done well, such surgery is extremely safe and voice restoring. And if time and therapy approaches fail to resolve a lesion, the typical venue for surgery is in the operating room under brief general anesthesia, with use of an operating microscope and tiny instruments.
Still, there is an office option that can occasionally be considered. Capillary ectasia without a nodule or polyp, for example, can be well managed in the videoendoscopy procedure room using only topical anesthesia. And there are circumstances (medical issues, jaw anatomy, etc.) that cause a specific singer to prefer office-based laser surgery with pulsed-KTP, thulium, or “blue” laser.
Right Vocal Cord Polyp (1 of 8)
This man is a well-trained and experienced musical theater singer with a chronic right vocal cord polyp (left of photo) that would not resolve despite prolonged rest and therapy. The left sided capillary ectasia is unimportant due to its location on the upper surface of the cord.
Polyp interferes with voice (2 of 8)
During voicing the interference of the polyp with match of the cords is seen clearly.
Laser surgery in singer (3 of 8)
At the time of the procedure, with 0.5mm fiber in view. This man is fully awake, sitting in a chair, and the larynx is topically anesthetized with 2% lidocaine.
Coagulated polyp (4 of 8)
Most of the polyp has been “peeled up” and coagulated.
Coagulated polyp (5 of 8)
At the conclusion of the procedure. The residual polyp has been coagulated and should slough off. The patient knows he might need a second “touch up” laser at his postoperative visit, planned for 2 months later, given the distance he must travel.
Voice fully restored (6 of 8)
Approximately 2 months later at his only postoperative visit, the patient says that his voice is fully restored. Even his falsetto is unimpaired. In this view, the right cord is normalized, and there is no residual lesion to remove.
Margins match during phonation (7 of 8)
At the prephonatory instant, the margins appear to match.
Equal vibration (8 of 8)
Under strobe light in high falsetto, subtle, equal margin elevations are seen and the amplitude of vibration is equal bilaterally.
Laser Surgery for Bilateral Vocal Cord Cancer
Squamous cell carcinoma (1 of 6)
This man developed hoarseness across a few months. Biopsy elsewhere revealed squamous cell carcinoma, seen here on both vocal cords. Based upon a friend’s experience, he rejected radiotherapy, opting for laser resection, knowing it could be very hard on voice.
Tumor on the vocal cords (2 of 6)
At closer range and under narrow band (blue-green) light to accentuate the vascular abnormalities associated with this tumor.
Granuloma delays voice recovery (3 of 6)
Six weeks after superficial laser cordectomy, the larynx is almost healed with the exception of a small granuloma, left vocal cord (right of photo). When healing includes granulation, voice recovery is delayed as the granuloma resolves.
Closer view of granuloma (4 of 6)
He has hoarse but functional voice, but under strobe light, the granuloma prevents vibratory closure. Note the medial-to-lateral capillary reorientation so typical after laser cordectomy.
Granuloma is smaller (5 of 6)
Now 3 ½ months from surgery, voice has improved further and he considers it “75%” of original…One can see that the granuloma is smaller.
Granuloma doesn’t impede voice (6 of 6)
Note that the granuloma no longer prevents vibratory closure and this explains further improvement of voice. Compare with photo 4.
Laser Removal of Vocal Cord Cancer with Bilateral Disease
For treatment of early vocal cord cancer, both laser excision and radiotherapy are in competition as good treatment modalities. See also Early Vocal Cord Cancer: Remove with a Laser, or Radiate? Often, radiation is used when disease is bilateral, in the interest of preserving voice. This is an example of the ability to do fairly extensive laser surgery bilaterally, yet preserving good voice. This man had a friend who had severe difficulty with radiation, and he was therefore opposed to that option.
Vocal cord cancer (1 of 10)
This 70-something man is a longterm smoker. Here you see an obvious cancer of his left vocal cord (biopsy-proven), but disease on the right side as well that is more superficial.
Stippling (2 of 10)
At higher magnification and using narrow band light, some of the vascular abnormality (stippling) is better seen (arrows).
1 week after excision (3 of 10)
A week after definitive excision of his cancer. Typical early wound appearance, with a suggestion of granulation on the left side (right of photo).
Reparative Granuloma emerges (4 of 10)
Six weeks later, healing is nearly complete other than a typical reparative granuloma on the left (right of photo).
Granuloma interferes with voicing (5 of 10)
During voicing, the granuloma interferes with closure, explaining in part his ongoing severe hoarseness. Note also the typical medial-to-lateral capillary reorientation.
Granuloma fades away (6 of 10)
Now 3 months postop, the granuloma is smaller. Classic capillary reorientation is again seen.
Closer view (7 of 10)
Under strobe light, closed phase of vibration. Voice is highly functional, since the granuloma no longer interferes with closure.
Granuloma cleft (8 of 10)
Open phase of vibration under strobe light shows the bilobed, clefted nature of the granuloma, where the right vocal fold “fits into” the granuloma (arrows at cleft).
Blood tattoo (9 of 10)
At nearly 5 months postop, the granulation tissue has auto-detached, leaving only a small “blood tattoo.” Here, under strobe light and closed phase of vibration.
Voice is improved (10 of 10)
Voice is somewhat hoarse but highly serviceable, and “better than it has been in years,” according to the patient.
Hemorrhagic Polyp, Treated By Thulium Laser
Hemorrhagic polyp, treated by thulium laser (1 of 8)
Hemorrhagic polyp, right vocal cord (left of image). This professional singer has struggled with severe limitations for six months. Note the feeding vessel, both anterior and posterior to the polyp, at arrows. These will be the first target of treatment.
Hemorrhagic polyp, treated by thulium laser (2 of 8)
Using near-contact mode with a thulium laser, the feeding vessels have been coagulated, to reduce bleeding when the polyp itself is addressed. In contrast to what would be seen with a pulsed-KTP laser, one can see here hazy superficial coagulation affecting epithelium surrounding the vessels—so superficial that it will not affect vibratory flexibility.
Hemorrhagic polyp, treated by thulium laser (3 of 8)
The remaining laser energy is delivered to the polyp in contact mode, while stretching it away from the cord.
Hemorrhagic polyp, treated by thulium laser (4 of 8)
At the conclusion of the procedure, the polyp is released from the fiber. There is no damage to the vocal cord surrounding the polyp. A follow-up visit will be scheduled as “possible laser,” in case there is any residual polyp that did not slough off.
12 weeks after thulium laser treatment (5 of 8)
Twelve weeks after removing the hemorrhagic polyp via thulium laser. View under standard light, at the pre-phonatory instant. Both the patient and physician regard the patient’s voice as completely normal in quality and capabilities.
12 weeks after thulium laser treatment (6 of 8)
During phonation, with vibratory blur. Standard light.
12 weeks after thulium laser treatment (7 of 8)
View under strobe light. During phonation, at the closed phase of vibration, for the pitch B-flat 4 (~466 Hz).
12 weeks after thulium laser treatment (8 of 8)
Open phase of vibration, also at B-flat 4 (~466 Hz).
Capillary Ectasia, Before and After Laser Coagulation
Capillary ectasia (1 of 3)
Bilateral capillary ectasia, made to stand out with the help of narrow-band illumination.
Capillary ectasia, right after laser coagulation (2 of 3)
At the conclusion of pulsed-KTP laser coagulation, performed in a videoendoscopy procedure room with patient awake and sitting in a chair.
Capillary ectasia, 6 weeks after laser coagulation (3 of 3)
Six weeks later; the capillaries have vanished, as expected.
Lidocaine Injection for Aggressive “Office” Laser Treatments
Laser ablations performed in office (1 of 6)
After radiotherapy a few years earlier for vocal cord cancer, this patient continually develops exuberant leukoplakia with severe dysplasia and fragments of carcinoma in situ within weeks after each procedure to remove it, including two aggressive laser excisions in the O.R. In an attempt to avoid hemilaryngectomy or even total laryngectomy, a series of laser ablations is being performed just weeks apart in an “office” videoendoscopy procedure room. Needle for anesthesia is aiming for the spot indicated by the dot, left vocal cord (right of image)
Infiltrating anesthetic (2 of 6)
The needle shaft is seen at close range, infiltrating local anesethetic (lidocaine) into the vocal cord because the procedure is too uncomfortable to do with topical anesthesia alone.
Thulium laser procedure (3 of 6)
At the beginning of this “aggressive” laser procedure. The blue fiber is delivering thulium laser energy to coagulate the abnormal tissue. These vocal cords lost their ability to vibrate long before this procedure.
Post-surgery (4 of 6)
At the conclusion of this episode of treatment, aggressively coagulated tissue which will slough off in coming days and weeks.
Six weeks post-surgery (5 of 6)
Six weeks later, at beginning of next thulium laser treatment.
Second laser sugery (6 of 6)
Near the end of this subsequent thulium laser treatment.
Perfect Candidate for Thulium Laser
Lesion (1 of 4)
Years ago, papillomas covered both true cords. After many surgical and adjuvant treatments, the disease has for several years been virtually in remission, and his voice stable and near-normal. This single, asymptomatic lesion is being addressed “In the chair” under topical anesthesia.
Lesion under narrow-band light (2 of 4)
Narrow-band light and a closer view make the lesion and its true cord extension more evident.
Coagulated with thulium laser (3 of 4)
In the lower left of the photo, the main lesion and true cord extension have been coagulated.
Finishing up (4 of 4)
To finish up, contact mode (while the fiber was touching and even spearing the lesion) has coagulated more deeply the false cord component that does not threaten voice. Pre- and post-procedure voice are unchanged and the coagulum will spontaneously detach within the next few days.
Leukoplakia Battled Over Time
Leukoplakia (1 of 8)
Leukoplakia, recurrent, in a former smoker, several years after initial diagnosis. The patient has had this removed in the operating room several times elsewhere, and pathology has only shown hyperkeratosis. HPV testing is negative. Notice both the “cake icing” (green arrows) and “spilled milk” (white arrow) components of the leukoplakia. At this examination, the patient is severely hoarse.
Spilled Milk (2 of 8)
Closer view, under narrow-band illumination, which accentuates in particular the “spilled milk” component (arrows) of the leukoplakia on the left vocal cord (right of image).
Thulium laser (3 of 8)
In the midst of coagulation using the thulium laser, delivered via glass fiber (right of image).
Coagulated tissue (4 of 8)
The thulium laser session is done. On the left cord (right of image), mostly near-contact mode was used, and the coagulated tissue, which has gone from leukoplakia-white to coagulated-white, will slough off within days. On the right cord (left of image), contact mode was used, to coagulate more deeply and detach the bulkier lesion. An additional surface layer will also slough on this cord.
Leukoplakia (5 of 8)
A year and a half later, after a few interval laser treatments, there is a small persistent patch of leukoplakia.
Detachment (6 of 8)
At the conclusion of another thulium laser procedure, using brief contact mode for superficial detachment of the patch of leukoplakia.
Superficial vascular pattern (7 of 8)
Fourteen months after photos 5 and 6. After roughly a dozen treatments spanning more than a decade, the voice sounds effortless and has no syllable dropouts. It is mildly husky but entirely satisfactory to the patient. Note how well-preserved and “unscarred” the superficial vascular pattern of the mucosa is (arrows), after so many surgical procedures.
Coagulated tissue (8 of 8)
At the conclusion of thulium coagulation of this linear patch of leukoplakia. Arrows show the line of coagulated tissue.
Leukoplakia, Before, During, and After Laser Coagulation
Leukoplakia, not yet seen (1 of 6)
A few years earlier, this patient underwent superficial laser cordectomy of the right vocal cord (left of photo) for cancer. The voice result is excellent, and the patient is being seen this day for a routine interval examination, and has no new complaints.
Leukoplakia (2 of 6)
At closer range, tiny points of leukoplakia (inside the green dotted oval) become evident. The bright white spot in the photo is just a light reflection.
Leukoplakia (3 of 6)
Still closer view, again confirming the tiny patches of leukoplakia. There is another light reflection in this view, right in the middle of the photo.
Leukoplakia, coagulated by laser (4 of 6)
Thulium laser coagulation of the leukoplakia lesions, through a glass fiber (blue-ish cylinder at top-right of photo), as seen under narrow-band illumination. The Thulium laser had been placed on stand-by prior to the routine examination, to save the patient a potential second visit. The coagulated tissue is also white, but will slough off within a few days, and along with it, the leukoplakia.
Leukoplakia, 3 months after laser treatment (5 of 6)
Three months after laser treatment, the patient has healed.
Leukoplakia, 3 months after laser treatment (6 of 6)
Three months after laser treatment, a close up view shows no signs of leukoplakia spots.
Mid-Tracheal Papilloma, Treated By Thulium Laser
Mid-tracheal papilloma, being treated by thulium laser (1 of 5)
The papilloma is seen attached to the posterior tracheal wall, at the midpoint of the trachea. Note the areas of scarring from prior laser procedures. The dots seen indicate reference points for photo 5.
Months after treatment: no papilloma (5 of 5)
Durable resolution of papilloma, many months afterwards. Compare with photo 1.
Mid-tracheal papilloma, being treated by thulium laser (2 of 5)
Using the channel scope, a blue glass fiber is extended from the tip of the scope.
Mid-tracheal papilloma, being treated by thulium laser (3 of 5)
In a closer view, the papilloma has been mostly cauterized using near-contact (not touching) mode.
Mid-tracheal papilloma, being treated by thulium laser (4 of 5)
The papilloma is then penetrated multiple times to deliver laser energy to its base. Some of the papilloma is pulled off by attachment to the fiber, and the remainder will slough off and be swept upwards by the mucociliary blanket (thin layer of mucus being swept upward) within the trachea.
Capillary Ectasia and Hemorrhagic Polyp, Treated by Thulium Laser
Capillary ectasia and hemorrhagic polyp (1 of 7)
Open position for breathing, standard light. There is capillary ectasia on both vocal cords, and there is also a hemorrhagic polyp of the left vocal cord margin (right of photo).
Capillary ectasia and hemorrhagic polyp (2 of 7)
During voicing, the polyp interferes with accurate approximation of the vocal cords, which explains this man’s chronic hoarseness.
Capillary ectasia and hemorrhagic polyp, thulium laser treatment (3 of 7)
Using the thulium laser to spot-coagulate and interrupt the flow in dilated capillaries.
Capillary ectasia and hemorrhagic polyp, thulium laser treatment (4 of 7)
Coagulation of the polyp, with fiber tangential to the vocal cord and sometimes lifting medially during contact mode. A second, similar procedure was needed a few weeks later, only for residual polyp.
Capillary ectasia and hemorrhagic polyp, after treatment (5 of 7)
Several weeks later, capillary areas are blanched, but the vocal cord mucosa is fully mobile.
Vocal cord margin (6 of 7)
Vocal cord margin match and mucosal flexibility are best tested in high voice. This is strobe light, closed phase of vibration, at F4 (~349 Hz).
Capillary ectasia and hemorrhagic polyp, after treatment (7 of 7)
Also at F4 (~349 Hz). The mucosa of both cords is completely supple. The patient considers his voice to be perfectly normal—”original equipment.”
Thulium Laser Surgery, With Local Anesthetic Injection, to Treat Leukoplakia
Leukoplakia, about to be treated with laser (1 of 4)
Leukoplakia of the vocal cords in a patient radiated years earlier for glottic cancer. This disease is mostly benign, but foci of carcinoma-in-situ have also been removed twice in the operating room, yet with rapid return of leukoplakia. The patient has had no glottic voice. In an effort to avoid total laryngectomy, we are managing these visual abnormalities with the thulium laser in an outpatient videoendoscopy room.
Injection of local anesthetic (2 of 4)
Since this patient cannot tolerate aggressive laser therapy with topical anesthesia alone, we are here adding injection of local anesthetic. Note the blanching of tissue surrounding the needle.
Injection of local anesthetic (3 of 4)
Further injection of the local anesthetic.
Right after thulium laser treatment (4 of 4)
At the completion of aggressive laser coagulation of abnormal tissue. Compare with photo 1. The patient will return in a month for additional laser treatment as indicated.
Tracheal Papillomas and the Thulium Laser
HPV 11 (1 of 2)
High tracheal papillomas from HPV subtype 11. If allowed to grow, these eventually cause airway symptoms. This is one of many procedures to keep these papillomas in check.
Post laser coagulation (2 of 2)
After thulium laser coagulation, using not only near-contact mode, but also after inserting the fiber into the substance of the papillomas repeatedly. Most of this material will slough away in coming days.
Office-Based Surgery When General Anesthesia Is too Risky
Involuntary inspiratory voice (1 of 6)
This elderly man is tracheotomy-dependent due to inability to open the vocal cords. Here while breathing in, there is a posterior “keyhole” from the divots caused by pressure necrosis of the breathing tube. Still, due to inspiratory airstream, he produces involuntary inspiratory voice. General anesthesia for laser widening of the airway (posterior commissuroplasty) would be very risky due to his diabetes and many other medical problems. Hence, the decision to attempt this with patient awake and sitting in a chair.
Laser posterior commissuroplasty (2 of 6)
The posterior right vocal cord is injected with lidocaine with epinephrine, in preparation for office laser posterior commissuroplasty. F = false vocal cord. T = true vocal cord, near its posterior end. The left vocal cord is injected similarly prior to the procedure that follows.
During the commissuroplasty (3 of 6)
The thulium laser fiber is being used to excavate the posterior commissure. Note the existing divot of the opposite (right) vocal cord (dotted lines) which will also be enlarged (next photos).
Deepening divot (4 of 6)
With view rotated clockwise approximately 45 degrees, work is commencing to deepen the right vocal cord divot.
Inspiratory indrawing decreased (5 of 6)
At the conclusion of the procedure. Not only is the ‘keyhole’ seen in photo 1 larger, but inspiratory indrawing of the rest of the vocal cords is greatly diminished.
Phonation (6 of 6)
Now phonating, voice is similar to the beginning of the procedure, because the vibrating part of the vocal cord was not disturbed. Of course, number of words per breath is slightly lower, due to increased use of air through the keyhole—air wasting.
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Office Coagulation of Laryngeal Papillomas
This man has had RRP (laryngeal papillomas) for many years. He has had laser ablations both in the O.R. under general anesthesia, and in an “office” laser room.
This video is an operative sequence in the latter setting. He is sitting in a chair and tolerating this procedure with the assistance of topical anesthesia and bilateral superior laryngeal nerve blocks, after which he can even drive himself home. In addition to thulium laser coagulation of the papillomas, this video also illustrates how patient movement and obscuring secretions must be managed.
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Thulium laser
This patient is sitting in a chair under topical anesthesia. He is able to minimize movement of his vocal cords, and is therefore a “perfect” candidate for office-based thulium laser ablation of residual laryngeal papilloma