Principles and Practice of Lasers in Otorhinolaryngology and Head and Neck Surgery

In this era’s informational paradigm, while pondering the considerations to be penned in this foreword, the relevance of a text such as this emerged progressively as the focal point. After all, for years, one established source for accessing large amounts of valuable information had been the Encyclopaedia Britannica, a printed tome, which is no longer relevant. Instant access to the latest scientific information is freely available to all with an internet. So, what can this text provide that cannot be readily accessed?

In contemplating given topics, the Editors, as most certainly occurred in this publication, chose clinical authorities to author chapters in their areas of expertise. The experienced clinician often finds such a forum a unique opportunity to reflect on years of knowledge acquisition and then render an insightful discourse on the lineage of his/her current understanding of the topic. On the other side of the coin, the reader instantly acquires a knowledge base, which was validated with an exhaustive literature search and gains the senior authors’ perspective of it. A less experienced author will benefit from thoroughly reviewing the currently available science and technology and moreover, gain experience in scientific writing. In the latter scenario the senior author is at once mentor and expert.

Under ordinary circumstances, from the concept outline submission to a publisher, the time line to completion of the text is approximately one and a half to two years. Recruiting and assigning authors, awaiting late manuscript submissions and editing are unquestionably time consuming. Yet a passionate, dedicated Editor will take seemingly varied submissions and script them into a worthy finished product. Such was the case with this publication. The end result is a superbly structured text covering most of the concepts relating to the topic in a format that is both logical and intuitive.

At the risk of some redundancy, I share with you my thoughts on some of the significant number of new additions and improvements made to this second edition. The chapter on risk management is a welcome contribution. The rationale for the shift in the current decision tree for laryngeal cancer as it relates to macro versus micro margins, improvements in voice quality and the choice of initial therapeutic considerations are appropriately vetted. The rethinking of HPV associated malignancies is a new and most important addition. Zeitels’ presentation of angiolytic lasers for benign and malignant pathology is state of the art. I particularly enjoyed reading about lasers and the association with tropical diseases. The chapters on robotic surgery, non-invasive cartilage reshaping and photo-diagnostics puts the latest technical innovation in our discipline into perspective. The excellent illustrations and photographs are a bonus. There are other areas that could be mentioned e.g. paediatrics, however, the aforementioned has more than adequately established the tenor of the text.

In their quest to provide a one-stop knowledge base of a reference quality, it is inescapable that the size of the final proof would surpass the typical numbers of between four and five hundred pages for the hard bound volume. Tightening the text by removing some peripheral material would deprive the book its very objective of a reference quality publication. The obvious solution was to present the work in a set of two volumes, and the editors and the publishers have to be congratulated in achieving this seamlessly. The natural anatomical split provides the reader with a convenience of picking up the volume of relevance for the task at hand.

An unusual feature is the inclusion of MCQs after each chapter, to serve as a test for recall of knowledge, the result of which can be assessed simply by going back to the chapter!

The Editors and the publishers have exploited the now ubiquitous electronic media network to their advantage. Operating on various platforms a dedicated website will complement the book with updates, operative videos, and means of communication to share the knowledge globally.

It was the focus of this brief foreword to explore the relevance of this text in the current informational climate. It provides the essential foundation for informed thought on this topic. Agree or disagree with the information contained within, the reader has acquired the knowledge to be able to do such.

With this text you will be rewarded for sitting in your most comfortable chair, thumbing through the pages and sensing the new print. Immediately understood will be the time and effort it took to complete a text of this calibre. Read the chapters first that initially appeal to you and then without question you will read the remainder. This book should be in the library of any serious student of the subject. I feel privileged to have been asked to write the foreword.

Marshall Strome

Marshall Strome, MD, MS, FACS
Professor and Chairman Emeritus Cleveland Clinic Head and Neck Institute, USA
Co-Founder and CEO Aero-Di-Namics (ADN)
Co-Chair Scientific Advisory Board Medrobotics
Director Head and Neck Surgery
Roosevelt/St Lukes Medical Center, USA

Volume I

Foreword
Preface
Introduction to Multiple-Choice Questions
About the Editors
List of Contributors

Section I: Basic Laser Science

1. History of Laser Light
2. Laser Biophysics
3. Risk Management in Laser Technology: Primum Non Nocere – First do no Harm
4. Equipment and Instrumentation
5. Theatre Protocol and Surgical Technique
6. Anaesthesia for Laser Airway Surgery

Section II: Transoral Laser Laryngeal Surgery

Section II-A: Lasers for Non-Obstructing Laryngo-Tracheal Pathology

7. Transoral Laser Laryngeal Surgery
8. Laser Surgery for Common Laryngeal Pathology
9. Human Papilloma Virus Infections: Recurrent Respiratory Papillomatosis
10. Voice Surgery and Lasers
11. Lasers in the Management of Laryngeal Malignancy
12. Voice Outcome After Laser Management of Early Glottic Carcinoma

Section II-B: Lasers for Compromised Laryngo-Tracheal Airway

13. An Overview of the Transoral Management of the Compromised Laryngo-Tracheal Airway
14. Laryngeal Trauma
15. Bilateral Vocal Fold Immobility
16. Endoscopic Laser Management of the Compromised Laryngotracheal Airway
17. Transoral Endoscopic Management of Acute Obstruction Caused by Laryngeal Malignancy

Section II-C: Neonates and Paediatric Laser Laryngeal Surgery

18. Paediatric Laryngo-Tracheal Airway
19. Neonatal Laryngopathy

Section III: Lasers in Endonasal Surgery

20. Endonasal Laser Applications
21. Laser-Assisted Dacryocystorhinostomy
22. Nasal Turbinate Surgery
23. Laser-Induced Microbial Reduction in Acute Bacterial Rhinosinusitis
24. Laser-Assisted Functional Endoscopic Sinus Surgery
25. Lasers for Endonasal (Revision) Surgery in Chronic Rhinosinusitis
26. Transantral Laser Surgery and Balloon Dilatation
27. CO2 Laser Management of Rhinophyma
28. Laser Management of Recurrent Epistaxis
29. Hereditary Haemorrhagic Telangiectasia
30. An Overview of Laser Surgery in the Posterior Nose/Nasopharynx
31. Laser Management of Pathology in the Posterior Nose/Nasopharynx

Answers MCQ volume I

Volume II

Section IV: Lasers in Otology

32. Lasers in Otology: General Considerations
33. An Overview of Lasers in Otology
34. Functional Orthogonal Cholesteatoma Surgery
35. Laser Myringotomy
36. CO2 Laser in Stapes Surgery
37. Laser Cartilaginous Eustachian Tuboplasty

Section V: Oropharyngeal and Head & Neck Surgery

Section V-A: Laser Applications in Oro-Pharyngeal Surgery

38. Lasers in Oral Surgery
39. The Use of Carbon Dioxide Laser in the Management of Oral Pathology
40. CO2 Laser Endoscopic Microsurgery of Zenker’s Pharyngo-Oesophageal Diverticulum

Section V-B: Photodynamic Therapy

44. Laser Tonsil Surgery
45. Laser Tonsillectomy
46. Laser-Assisted Serial Tonsillectomy
47. Laser Management of the Lingual Tonsils
48. Laser Ablation of Biofilm-Loaded Tonsillar Crypts with Tonsilloliths

Section VII: Snoring and Sleep Apnoea

49. An Overview of the Management of Snoring and Obstructive Sleep Apnoea
50. Laser-Assisted Surgery for Snoring and Obstructive Sleep Apnoea
51. Laser-Assisted Uvulopalatoplasty
52. Palatal Stiffening via Transoral, Retrograde Interstitial Laser Coagulation
53. Laser-Assisted Septoplasty
54. Laser Midline Glossectomy and Lingualplasty for Obstructive Sleep Apnoea Syndrome

Section VIII: Lasers in Lower Airways

55. Lasers in the Lower Airways

Section IX: Lasers in Chronic Tropical Inflammatory Diseases in Otolaryngology Section

56. Lasers in Chronic Tropical Inflammatory Diseases in Otolaryngology

Section X: Emerging Trends in Laser Applications

X-A: Office-Based Management of Laser Laryngeal Procedures

57. Office-Based Procedures – an Emerging Trend
58. Topical Anaesthesia for Office Based Laryngeal Interventions
59. The Current Status of Flexible Hollow Waveguides for Carbon Dioxide Lasers in Head and Neck Surgery
60. Angiolytic Lasers in the Management of Benign and Malignant Laryngeal Disease and the Establishment of Office-Based Laryngeal Laser surgery

Section X-B: Laser Cartilage Reshaping

61. Basic Science of Laser Cartilage Reshaping
62. Clinical Application of Laser Cartilage Reshaping for Deviated Nasal Septum
63. Clinical Application of Laser Cartilage Reshaping for Protruding Ears

Section XI: Future Developments in Laser Applications

64. Clearing Biofilms via Laser Shockwave
65. Transoral Robotic Surgery
66. Optical diagnostics: An Update on the Most Commonly Applied Techniques in the Head and Neck
67. Photochemical Internalisation

Section XII: Appendices

Appendix I. Core of Knowledge
Appendix II. Optical Radiation: Local Rules
Appendix III. Glossary
Appendix IV. Low-Level Laser Therapy in the Management of Chronic Cochlear Tinnitus

Answers MCQ volume II
Subject Index
Index of Authors

I must declare an interest here. In 1985 I sat in my consultant appointment committee, facing the lead Editor of this work, Vasant Oswal. I well recall him warning me not to expect the facilities in Middlesbrough that I must have grown used to in a London teaching hospital. Having visited twice and knowing the Boro’s developing reputation for laser surgery, I assured him that the North (back then, anyway) was far healthier than the capital, for funding.

Vasant was the driving force behind acquiring the first Middlesbrough laser, but all through community fund raising. Our new mega hospital still has a mural showing some very young, slimmer and more hirsute members of our current staff, pushing a barrow through the town in the 80s. It carried a sign saying “Florence Nightingale had a lamp; we want a laser”. Vasant is not the sort to then sit back, but instead ran a series of annual international instructional courses (now over 25 held). In 1988 he published a book on CO2 lasers, which I played a very small part in co-editting¹.

He went on to edit the first edition of this textbook, covering the whole range of surgical lasers, in 2002. He is said to be “retired” from clinical practice for over a decade but, if anything, his academic output has increased. Only last year, sitting in the Royal Society of Medicine lecture theatre, I watched a live video link from India and who should be sitting in the centre of the trio addressing us from across the globe?

Dr Remacle, from Belgium, again joins Vasant in editing this second edition, but he has clearly been a busy author as well, most notably in his specialties of laryngology and robotic surgery. The four co-editors are household names in the field of laser surgery and the list of authors really is a Who’s Who exercise.

The scope, the scale, even the weight of this two volume set does impress. Until I saw it I did question the price, in this cash strapped era, but, to quote the Cold War phrase, you do get “more bang for your buck”. There are 67 chapters from 59 international authors and to have gathered updated work from so many busy and eminent contributors is quite an editorial achievement. To name but a few; I was glad to see Bik Kotecha on snoring surgery, as that still forms a major part of my own work. John Hamilton on lasers in cholesteatoma surgery reminded how my wife and I enjoyed many a laser course dinner with him. We were always on the same table and usually very late into the evening indeed! Vinidh Paleri has helped me greatly with NICE guidance and, here, writes on obstructive laryngeal malignancy. Paul O’Flynn is a very old friend and describes his work in developing a flexible CO2 laser for head and neck surgery, having reported the first UK applications in Clinical Otolaryngology². Equally memorably, in an earlier paper in this journal, he and his co-authors described removal of a foreign body from the ear canal, which exhibited “the characteristic smell of cannabis”³. I have often wondered.

Volume one does take some lifting at 509 pages. The six opening chapters cover basic laser science, including risk management, thesia and biophysics of the various wavelengths employed. In any textbook claiming to be updated, it is worth checking the dates of references and, throughout, they do confirm that the authors have met the challenge. You would expect good coverage of lasers for benign and malignant laryngeal disease and for the obstructed airway, but indications have cleared increased dramatically for endonasal and otologic surgery. I will not touch a turbinate now without my Holmium laser, but did find chapters on laser assisted endoscopic sinus surgery and usage with balloon dilatation thought provoking (and very photogenic).

The second volume shows more novelty, with updated applications in some unexpected territory. Laser cartilaginous Eustachian tuboplasty, palatal stiffening, working on the upper surface (less painful and I never thought of that!) and laser cartilage reshaping for pinnaplasty (no skin incision!) are just three inspiring chapters. My favourite had to be Chapter 66 “Optical Diagnosis etc”. This has a huge bibliography and is highly topical. It proved a Godsend source to me, in pretending to NICE that I am expert on the subject.

There are high quality and new illustrations throughout. Instead of the CD ROM of the first edition, there is now to be a website demonstrating surgery, which of course allows for further updating. It is still under construction, as of April 2014. Finally, each chapter closes with MCQs, which vary in value. They are especially good at the end of the excellent chapter on recurrent respiratory papillomatosis. MCQ writing is difficult as little in medicine is totally yes/no, or true/false.

One might be forgiven for thinking that lasers are so established in surgical practice, that there is little new to say. Conversely I do recall a sceptic , addressing us at the RSM in the early 80s, stating that “If you give a child a hammer, it will hit everything with it, until it finds a use for it”. This massive textbook addresses the limitations as well as the values of the full range of surgical lasers and hints at the prospects for further developments. It is a must for any unit undertaking such work, but is also an excellent reference for the training facing final examinations.

Liam M Flood FRCS FRCSI
Middlesbrough, UK

V, Kahima H, Flood L (eds) The CO2 Laser in Otolaryngology Head and Neck Surgery (1988) Butterworth Scientific
O’Flynn PE, Kotary P, Awad Z, Vaz F (2010) Application of Flexible CO2 Laser in Head and Neck Surgery Clinical Otolaryngology 35; 139-142
Mason J, O’Flynn P, Gibbin K (1993) Cannabis in the External Ear. Journal of Laryngology and Otology 107; 444