[Current status of laser surgery in the area of the soft palate and adjoining regions]

Tonsillitis and sore throat in children

Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.

The influence of water/air cooling on collateral tissue damage using a diode laser with an innovative pulse design (micropulsed mode)-an in vitro study

Since the diode laser is a good compromise for the daily use in dental offices, finding usage in numerous dental indications (e.g., surgery, periodontics, and endodontics), the minimization of the collateral damage in laser surgery is important to improve the therapeutical outcome. The aim of this study was to investigate the effect of water/air cooling on the collateral thermal soft tissue damage of 980-nm diode laser incisions. A total of 36 mechanically executed laser cuts in pork liver were made with a 980-nm diode laser in micropulsed mode with three different settings of water/air cooling and examined by histological assessment to determine the area and size of carbonization, necrosis, and reversible tissue damage as well as incision depth and width. In our study, clearly the incision depth increased significantly under water/air cooling (270.9 versus 502.3 μm-test group 3) without significant changes of incision width. In test group 2, the total area of damage was significantly smaller than in the control group (in this group, the incision depth increases by 65 %). In test group 3, the total area of damage was significantly higher (incision depth increased by 85 %), but the bigger part of it represented a reversible tissue alteration leaving the amount of irreversible damage almost the same as in the control group. This first pilot study clearly shows that water/air cooling in vitro has an effect on collateral tissue damage. Further studies will have to verify, if the reduced collateral damage we have proved in this study can lead to accelerated wound healing. Reduction of collateral thermal damage after diode laser incisions is clinically relevant for promoted wound healing.

Excision biopsy of tongue lesions by diode laser

OBJECTIVE

The aim of this study was to evaluate the diode laser in excision biopsy of superficial proliferative tongue lesions under local anesthesia.

BACKGROUND DATA

Most mobile tongue lesions present as surface projections and have similar clinical features. They are usually excised for diagnostic purposes using conventional surgery or electrosurgery. The diode laser has proven itself useful in different oral surgeries.

METHODS

We report the results of a prospective pilot study where contact diode laser was used in excision biopsy of six mobile tongue lesions. All excised tissues were pathologically examined. To assess post-operative pain, patients were asked to correlate it to an 11-point Visual Analogue Scale (VAS); patients were also asked to assess their impression of alteration in tongue size on a 4-point scale. Healing, functional results, and recurrence rate were assessed.

RESULTS

All interventions were uneventful and done at the same out-patient setting. All lesions were benign. Healing occurred by secondary intention in the six cases with no residual ulceration. Postoperative pain was mild in four cases, while two cases suffered from moderate pain. Post-operative impression of tongue swelling occurred in all cases. The mild impression disappeared by the end of the first week and the moderate one by the end of the second week. No recurrence was observed over a mean follow-up period of 15 months.

CONCLUSION

The diode 980-nm laser is optimal for excision biopsy of superficial and benign proliferative lesions of the mobile tongue.

Laser-tonsillotomy for treatment of obstructive tonsillar hyperplasia in early childhood: a retrospective review

INTRODUCTION

Tonsillar hyperplasia leading to dyspnea, dysphagia and other symptoms of obstruction represents a common problem especially in young children where tonsillectomy should be avoided in order to preserve the immunological function of the tonsils. Aim of the study was to assess carbon-dioxide-laser-tonsillotomy as a considered alternative procedure to reduce the tonsillar volume in these children.

METHODS

Between 1993 and 2004, 109 children with tonsillar hyperplasia without former episodes of tonsillitis received laser-tonsillotomy mostly (n=98) combined with adenoidectomy. The protruding part of the tonsil was reduced by a CO2-laser. Seventy-five children were available for follow-up with a standard questionnaire. Five patients required a subsequent tonsillectomy due to a recurrence of tonsillar hyperplasia. Histological investigations were performed. Twenty-two children were reevaluated by clinical examination.

RESULTS

Most of the patients were relieved from obstructive symptoms. There was no occurrence of postoperative hemorrhage or peritonsillar abscesses. The histological investigations on the specimens from later performed tonsillectomy (n=5) showed no evidence of inflammation or scar formations, but open and deep crypts. The clinical examination did not reveal any signs of chronic infections.

CONCLUSION

In this retrospective study tonsillotomy with CO2-laser in early childhood leads to a long-term elimination of obstructive symptoms due to tonsillar hyperplasia with minimal discomfort for the patient while preserving normally functioning immunocompetent tonsillar tissue. Further prospective studies are planned.

[Tonsillectomy by CO@ laser microsurgery--an analysis of clinical and morphological data]

BACKGROUND

Tonsillectomy by CO(2) laser microsurgery is an almost bloodless procedure that has developed to an alternative to traditional dissection tonsillectomy during recent years. It has been suggested that the laser technique more precise than the conventional one, however, attempts to investigate this morphologically have not yet been undertaken. In addition, there is a need for large clinical studies to compare the postoperative bleeding risk of both procedures.

METHODS

The charts of 617 patients who underwent routine tonsillectomy between 1995 and 1998 at the ENT department of Darmstadt Hospital, were retrospectively investigated with regard to postoperative bleeding events. A total of 467 patients were treated by the conventional technique and 150 by CO(2) laser microsurgery (continuous mode, 5 W). Moreover, 2 mm serial sections of tonsils of 56 consecutive patients treated in 1999 (31 conventional and 25 laser tonsillectomies) were used to determine peritonsillar (Vp) and tonsillar tissue volumes (Vt).

RESULTS

The postoperative bleeding risk following laser tonsillectomy differed slightly from that following the conventional technique (12.0% vs 14.6%; P=0.499; Fisher's exact test). However, the incidence of severe bleeding events requiring revision in general anesthesia was significantly reduced (0.7% vs 4.9%; P=0.015; Fisher's exact test). Tonsillar specimens that were removed by laser surgery contained significantly less peritonsillar tissue than those from conventional procedures (Vp/Vt 5.1%+/-0.6% vs 10.8%+/-1.1%; P below 0.001; Mann-Whitney U-test).

CONCLUSION

CO(2) laser microsurgery improves the precision of tonsillectomy and provides a maximum protection for the peritonsillar tissue. The incidence of severe bleeding events is markedly reduced. Laser tonsillectomy is therefore recommended for patients with clotting disorders or those requiring a particularly exact preparation technique.

[Treatment of the hypertrophic inferior turbinate. 1]

Chronic nasal obstruction is a common disorder, mostly caused by hypertrophied inferior turbinates. If there is inadequate response to conservative medical management, the inferior turbinates should be reduced. The choice of treatment is mainly influenced by whether the nasal airway obstruction is due to hypertrophic mucosa or to an enlarged turbinate bone. The first part of this review describes the various surgical modalities for treatment of swelling of the turbinal mucosa. The indications, advantages, disadvantages, complications, and controversies of each modality (submucous diathermy, cryosurgery, infra-red coagulation, argon-plasma coagulation, radiofrequency, laser surgical techniques) are reviewed and discussed.

Effects on oral soft tissue produced by a diode laser in vitro

BACKGROUND AND OBJECTIVES

This investigation determined incision characteristics and soft-tissue damage resulting from standardized incisions using a wide range of laser modes and parameters of a diode laser at 810 nm.

STUDY DESIGN/MATERIALS AND METHODS

Histologic examinations were performed to verify vertical and horizontal tissue damage as well as incision depth and width.

RESULTS

Incision depth and width correlated strongly with average powers, but not with laser parameters or the used tips. No laser damage was visible to the naked eye in the bone underlying the incisions in the range between 0.5-4.5 W.

CONCLUSION

The remarkable cutting ability and the tolerable damage zone clearly show that the diode laser is a very effective and, because of its excellent coagulation ability, useful alternative in soft-tissue surgery of the oral cavity.

Using the carbon dioxide laser for tonsillotomy in children

Carbon dioxide laser tonsillotomies were performed on 33 children aged 1-12 years for the relief of obstructive symptoms due to tonsillar hyperplasia. As opposed to conventional tonsillectomy, only the protruding part of each tonsil was removed. A carbon dioxide laser delivering 20 W was used for the excision. Twenty-one children were seen in active short-term follow-up and the records of all the children were checked for possible surgery related events up to 20-33 months after surgery. Laser tonsillotomy was uniformly effective in relieving the obstruction, with good hemostasis. The tonsillar remnants healed completely within 2 weeks. No major adverse events occurred. Post-operative pain appeared slight and easily controlled. There was no gain in operating time compared with conventional tonsillectomy. The laser tonsillotomies were in most cases done in day surgery. No recurrence of obstructive problems was reported up to 20-33 months after surgery. It was concluded that tonsillotomy, using a carbon dixoide laser, is a valid treatment for obstructive symptoms caused by enlarged tonsils, which can be performed with little bleeding and post-operative pain. The improved hemostasis may enable a shift from in-patient to day surgery.

The influence of laser parameter configurations at 9.3 microns on incisional and collateral effects in soft tissue

These investigations were performed to determine histologic and incisional consequences of varying pulse duration, duty cycle, and average powers during laser incision at 9.3 microns in soft tissue. In 19 fresh pigs' jaws six standardized incisions 3 cm long were made per parameter with a template and motorized jig. Laser parameters investigated were average power: 1 to 9 W, duty cycle: 10% to 80%, and pulse duration: 1 to 200 msec. The gated Cw mode was used. Incision width and depth and collateral tissue effects were assessed statistically with general linear procedures. Multiple factors were found to influence the outcome of laser irradiation. Depth of incision correlated positively with average power. Tissue damage correlated strongly and negatively with all three variables. These results demonstrate that a wide range of surgical and collateral effects can be achieved with one specific laser device depending on the parameter configuration selected.

Investigating the range of surgical effects on soft tissue produced by a carbon dioxide laser

The authors investigated the surgical and collateral effects on soft tissue of a carbon dioxide laser emitting at 9.3 micrometers. Specifically, incision widths and depths as well as effectiveness were studied. Three different laser modes were investigated: gated continuous wave, or Cw, Superpulse and OptiPulse (Medical Optics). Incision depths correlated positively with average power; higher powers produced deeper incisions. The gated Cw mode quickly produced wide, deep incisions; Superpulse achieved narrower, deep incisions; OptiPulse caused very narrow, shallow incisions. Collateral damage to adjacent tissues was reduced by a factor of about 2 using Superpulse, and by a factor of 10 using OptiPulse. A wide range of effects is achieved in soft tissue, depending on the laser parameter combination used.

Incision properties and thermal effects of three CO2 lasers in soft tissue

OBJECTIVES

It was the aim of this study to determine thermal and histologic events resulting from soft tissue incision with three CO2 lasers: one emitting light energy via a hollow waveguide at 9.3 microns; the others emitting light energy at 10.6 microns, one via a hollow waveguide, the other through an articulated arm delivery system.

STUDY DESIGN

Thirty standardized incisions were made in the oral mucosa of pig's mandibles with three different lasers at actual power levels of 1, 4 and 12 W. Thermal events were recorded with thermocouples, and a histologic examination was performed to determine vertical and horizontal tissue damage as well as incision depth and width.

RESULTS

Thermal and histologic results were related to parameters and beam characteristics rather than wavelength.

CONCLUSION

In addition to wavelength, many variables can contribute to the surgical characteristics of a laser.