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.
Better Can Be Enough
This man has smoked heavily for many years and developed a chronically hoarse voice. Elsewhere, he underwent microlaryngoscopic surgery for removal of “Reinke’s edema” (also called “smoker’s polyposis”). Unfortunately, his voice changed little afterward, and he remained extremely hoarse.
At his first visit with us, he had residual projecting polypoid material of the left vocal cord as well as prominent “nicotine staining” and leukoplakia of the laryngeal mucosa. Because of significant emphysema, he preferred to avoid another trip to the operating room. We therefore planned an office-based procedure using thulium laser coagulation.
The procedure proved extraordinarily difficult due to marked gagging, coughing, and constant laryngeal movement. Even so, we were able to accomplish a meaningful degree of coagulation. In the weeks that followed, the treated tissue sloughed, and the patient achieved a remarkable improvement in voice—despite the fact that the final laryngeal appearance remained quite abnormal.
Sometimes, “better is enough,” and in this case the patient was very pleased with the outcome. Given his ongoing abnormal findings—and continued smoking—he will require regular surveillance.
Residual polyp (1 of 7)
At a distance, a large residual polyp of the left vocal cord remains (at arrow). Voice is extremely rough and effortful, with many syllable dropouts.
Leukoplakia too (2 of 7)
Under narrow band light, closer view shows the projecting polyp and diffuse leukoplakia.
Laser on bucking bronco vocal cords (3 of 7)
The blue 0.5 mm laser fiber is seen attempting to target the projecting polyp. Constant gagging, coughing, and vocal cord movement make this a challenging task.
Surgery terminated (4 of 7)
After coaxing him through a lengthy procedure, the treatment session was terminated due to patient and clinician fatigue. The lesion on the left posterior cord (just out of view indicated by the arrow and seen better in image 5) could not be addressed due to patient intolerance.
Months later after healing (5 of 7)
Several months later, the coagulated left cord polyp has sloughed off, and the patient is extremely pleased with his voice. Though still husky, there is much reduced effort and no syllable dropouts. The posterior commissure polyp (arrow), which could not be addressed, is not on the membranous cord and does not interfere with vocal fold match or vibration.
Abnormal but better is enough (6 of 7)
At close range under narrow band (blue-green) light, the cord remains extremely abnormal, with scattered leukoplakia.
Margins match (7 of 7)
During phonation, the margins match due to absence of the main polyp that was coagulated. Again, “better can be enough.”
Saving an Elderly Man from Repeated Trips to the Operating Room
A 74-year-old man presented with unexplained hoarseness. He had a history of heavy tobacco use earlier in life but had stopped smoking 25 years prior. Laryngeal examination demonstrated stippled vascularity resembling that seen in recurrent respiratory papillomatosis, and the differential diagnosis included early laryngeal carcinoma versus HPV-related papilloma.
He was taken to the operating room for definitive excisional biopsy. Pathology revealed invasive carcinoma; however, excision margins were deemed adequate, and observation was elected rather than adjuvant radiotherapy. Early postoperative healing was excellent, and voice quality was well preserved
At eight months’ follow-up, a small white patch was noted at the prior site. Given his history of carcinoma, this finding required treatment. Instead of returning to the operating room, office-based laser coagulation was performed. Over subsequent years, several additional office laser treatments were required for small areas of recurrent leukoplakia.
This approach proved highly effective. It avoided radiotherapy and repeated operative interventions, preserved vocal function, and allowed the patient to attend treatments independently without the need for anesthesia or accompaniment.
T1 Laryngeal Cancer (1 of 15)
At first examination. Note the combination of leukoplakia and vascular abnormality of the right vocal cord (left of photo).
Narrow band imaging (2 of 15)
At closer range using narrow band imaging, the vascular abnormalities are accentuated.
Inverted view in the operating room (3 of 15)
There is a small amount of bleeding due to the process of intubation.
Excision in progress (4 of 15)
The mucosal flap containing the abnormality has been elevated from close to the underlying ligament.
Excision complete (5 of 15)
The vocal ligament has been exposed by nearly full-thickness excision of all visible abnormality, whether leukoplakia, or areas of aberrant capillaries.
Office exam, one week after excision (6 of 15)
Here the area of excision is seen clearly and not yet mucosalized.
During phonation (7 of 15)
Because the match is relatively good, voice quality is already remarkably functional.
Six weeks after surgery (8 of 15)
The area of excision is remucosalized.
Match during voicing (9 of 15)
While not a perfect match, it is good enough that the speaking (though not singing) voice can pass for normal.
Recurrent abnormality (10 of 15)
At intervals, small white patches appeared. Though this appears bland and benign, with his history of cancer of the same vocal cord, this needed removal. Rather than go to the operating room, the office thulium laser was suggested each time.
Before laser coagulation (11 of 15)
The smaller chip operating scope that will accommodate a laser fiber is in use to see the same lesion as in photo 10.
Coagulation (12 of 15)
The 0.5 mm fiber is seen and the lesion has been coagulated.
An example of his longterm result (13 of 15)
In summary, he has gone to the operating room just once, for excisional biopsy that resolved his disease other than a few instances over time of small white patches managed in an office setting.
Under narrow band light (14 of 15)
Reoriented capillaries of the right cord (left of photo) provide evidence of the surgical procedure years earlier.
At the moment of voicing (15 of 15)
While the right cord (left of photo) does not oscillate as well at high pitch as the left, the match between the cords is sufficiently good that voice can pass for normal.
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 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 & 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.
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