Carbon Dioxide Laser Scores Well on Patient Tolerance in the Office

A flexible carbon dioxide laser caused patients less pain and burning than the more traditionally used pulsed-dye laser in office-based treatment of benign diseases of the larynx, researchers have reported.

In a pilot study performed by Stacey Halum, MD, Director of the Indiana University Clinic for Voice, Swallowing, and Airway Disorders, 10 patients underwent treatment with both kinds of lasers- with half of each lesion treated using the OmniGuide flexible CO2 laser, a kind of water-targeting laser now used mainly in operating rooms, and the other half with the Cynosure 585-nm flexible pulsed-dye laser, a photoangiolytic laser commonly used in office procedures.

Unsedated office-based laryngeal surgery with the flexible carbon-dioxide laser is extremely well tolerated, said Aaron Moberly, MD, a resident working with Dr. Halum in the Department of Otolaryngology-Head and Neck Surgery at Indiana University School of Medicine in Indianapolis. Patients consistently rated their pain and burning with the carbon-dioxide laser to be less than that with the pulsed-dye laser.

In his oral presentation at the 88th annual meeting of the American Broncho-Esophagological Association, Dr. Moberly stated that the CO2 laser can easily be used in the office and offers some distinct advantages, but just how much pain it causes patients hasn’t been determined yet. That was the question Dr. Halum and Dr. Moberly attempted to explore in their study.

Cambridge, MA-based OmniGuide, Inc., provided the flexible lasers for the study at no cost to the investigators or the patients, Dr. Moberly disclosed.

The patients in their study were diagnosed with pathologies such as recurrent respiratory papillomatosis, granuloma, amyloidosis, and leukoplakia. They were asked to rate their pain and burning during the procedure on a scale of 1 to 10, with 1 meaning no pain or burning and 10 meaning pain or burning that was intolerable.

The results were encouraging for the use of the flexible laser in office procedures. In the pain category, the CO2 laser drew a score of 2.0, a better rating than the pulsed-dye laser’s score of 3.0. As far as the burning sensation, patients rated the CO2 laser at 2.3, whereas the pulsed-dye laser received a score of 3.0. Three of the patients took a single dose of oral pain medication, and none of them needed any medication after that, Dr. Moberly stated. None of the patients had scar tissue or impaired mucosal wave form postoperatively.

Advantages of Office-Based Surgery

Laryngeal surgery performed right in the office is better in many ways than more involved procedures that require general anesthesia. According to Dr. Moberly, Office-based laryngeal surgery has multiple advantages over traditional laser surgery performed in the operating room. These include decreased cost, recovery time, and discomfort, as well as increased patient safety and satisfaction.

Recurrent glottal dysplasia and recurrent respiratory papillomatosis are among the benign disorders suited to office treatment. Most of these benign diseases require multiple surgical treatments, Dr. Moberly said. Office-based surgery offers the option of treating more frequently and at an earlier disease stage.

The CO2 laser uses a photonic band-gap fiber assembly with a dielectric mirror and supportive cladding surrounding a hollow center that delivers the laser beam and nitrogen gas. A water-targeting laser such as the CO2 laser is better in some ways than the photoangiolytic pulsed-dye laser, which is limited by its depth of penetration and therefore is not particularly suited for diseases with a large amount of bulky disease.

Dr. Moberly added that with the pulsed-dye laser, you can see a mild blanching appearance, but the office use of the pulsed-dye laser is limited by an inability to determine how much of the bulky disease is being treated. With the CO2 laser, on the other hand, you can see obvious physical debulking of the diseased tissue.

He recommended that further research explore other subtleties of office-based treatment using the different laser types. Future studies would be beneficial to compare differing laser power settings as well as patient outcomes.

Comments on the Study

Clark Rosen, MD, Associate Professor of Otolaryngology at the University of Pittsburgh and Director of the University of Pittsburgh Voice Center, called it an important study.

There’s been a recent move afoot to perform some of these procedures in the office under local anesthesia, which is a huge advantage, Dr. Rosen said. This study very nicely demonstrated that the procedure was very well tolerated.

But he said there might not be a sudden spike in office-based procedures because of an insurance snag.

The technology has moved faster than the insurance companies have recognized, Dr. Rosen said. It’s still not something that’s probably appropriately reimbursed.

©2009 The Triological Society