Percutaneous fibre guided laser surgery of the endolarynx

Occasionally, getting access to the larynx for an intervention can be challenging. Markus Hess and Susanne Fleischer describe a novel way to perform laser treatment in such difficult instances.

Method and results: Our patient (male, aged 33) with progressive adult onset recurrent respiratory papilloma (RRP) could not be treated satisfactorily with in-office transnasal fibre guided photoangiolytic laser surgery due to pronounced gag response and hypersalivation and, unfortunately, his larynx also could not be entirely exposed during direct suspension microlaryngoscopy.

A laser glass fibre could easily be advanced and retracted within the cannula and its tip was proud of the tip of the cannula bevel by a few millimetres. This is always visualised on the monitor. With joystick-like movem_ents of the cannula's hub combined with advancement or retraction of the glass fibre, the glass fibre tip could be positioned close to or into the papilloma tissue at different endolaryngeal sites. With a photoangiolytic laser at 445nm wavelength (WOLF TruBlue®, A.R.C. Laser Comp, Nuremberg, Germany) we treated RRP at different sites, including the free edge of both vocal folds, inferior aspects of vocal folds, ventricular folds, inside of Morgagni's ventricles, and papilloma within the anterior commissure. We used various laser effects such as photoangiolysis, coagulation, carbonisation, and vaporisation. For all laser applications during anaesthesia, laser safety precautions were complied with, especially lowering of ventilation oxygen saturation far below 50% during anaesthesia.

"The technique allows one to deliver laser light into the larynx via glass fibre in cases where office-based indirect surgery, as well as direct microlaryngoscopy, are not possible."

Conclusions: In patients with difficult-to-expose larynges in suspension microlaryngoscopy and impossible transnasal or transoral office laser approach, this new percutaneous laser technique can be a very helpful alternative to achieve access to the endolarynx while avoiding open neck surgery. A 20G cannula serves as an introduction tool and joystick-like guiding instrument, enabling access even to endolaryngeal regions that cannot be accessed easily in transnasal flexible channelled endoscopy or in direct microlaryngoscopy. This approach extends our armamentarium for endolaryngeal surgery.