Coblation technology (Arthrocare Corp., Sunnyvale, CA, USA) uses plasma-mediated ablation (PMA) for
soft-tissue removal. The application of PMA for tonsillectomy has evolved since 1998 through changes in
equipment, and surgical techniques. This paper reviews the evidence to date for Coblation tonsillectomy,
and offers perspective on novel applications of this maturing technology.
The history of lasers in otolarygngolgoy-head and neck surgery (ORL) demonstrates the advances seen in the application of laser energies. This paper is the beginning of our review of the five pillars which support the long and mutually-beneficial relationship between laser technologies and ORL: (1) "necessity is the mother of invention" -- organ systems which require innovative approaches for diagnosis and treatment; (2) clinicians who seek and incorporate new technologies; (3) "feedback" effect of technology leading to changes in clinical care which may obviate the need for that technology itself; (4) "right place, right time" -- the close collaboration between corporate, clinical and basic science realms, and (5) financial. These principles provide the context for following the progressive application of laser energy in ORL for ablation, tissue-altering and most recently, sensing.
Cochlear implantation provides auditory stimulation for children who are deafened beyond the aid of traditional amplification. While cochlear implantation has been available for nearly twenty years, improvements in surgical technique and device design, and growing evidence regarding the communication and social benefits ofimplantation, have all contributed to wider application and acceptance of this technology. This paper is intended to update a multi-disciplinary audience on (1) the basic science behind auditory stimulation using cochlear implants and (2) technical challenges. Specific technical challenges include implantation of dysplastic cochleas and minimally invasive techniques for implantation.
Evaluating the benefits of new surgical technologies does not end with the observation of successful instrument-to- tissue interaction. The impact of new technologies in medicine today is also gauged by improvements in patients' daily activities and performance. We present our outcomes assessment tool for judging the value of applying a novel tonsillectomy technique, plasma- mediated ablation using Coblation technology. Plasma- mediated ablation (PMA) achieves soft tissue resection in the oropharynx by energizing protons to break bonds. Less heat is released, allowing for less thermal injury, and possibly less pain, than with tonsillectomy performed using electrocautery alone. Children undergoing tonsillectomy by PMA, were evaluated using our outcomes-based scale, which asked families to report the degree of interruption of normal activities for the patient and their family during the post-tonsillectomy recovery period. A preliminary review of several outcomes assessments exemplify the benefits and limitations of this tool. The tracking of valuable data is weighed against the limitations of a short time course relative to the duration of disability, and a poor response rate. Future work aims to improve this data collection tool to allow application to other new technologies in otolaryngology.
A new technology (OtoLAM) to fenestrate the tympanic membrane with the carbon dioxide laser (CO2), in the office or the operating room, has been introduced over the last three years. While not new conceptually, this product offers the ability to easily create a precise window into the middle ear using a portable system. Controversy regarding the indications and benefits of this technique, amplified by the costs of the system and the marketing of the technology prior to extensive clinical testing, has plagued the clinical application of this technology. We report our experience over the past year with this system in a busy pediatric otolaryngology practice. Laser fenestration of the tympanic membrane has been useful for the insertion of tympanostomy tubes, and for the minimally invasive evaluation of the middle ear. Our small experience to date reveals that there is a limited role for laser tympanic membrane fenestration in a busy pediatric otolaryngology practice.
Laryngomalacia is the most common cause of inspiratory stridor in children. This disease of excess tissue collapse most often does not require surgical correction. Surgery when necessary is best performed with the aid of the carbon dioxide (CO2) laser, delivered through a mirrored-arm micromanipulator- controlled system, while the supraglottis is exposed using a bivalved laryngoscope. This paper reviews the details of surgical technique used for the safe alleviation of airway distress due to larnyngomalacia.
Plasma-mediated ablation (PMA) removes tissue by developing an electrically induced plasma layer between the instrument and target tissue. Charged particles within the plasma field then accelerate toward the tissue, breaking the molecular bonds within the top layer of tissue. Thermal damage to collateral tissue is minimal, resulting in the moniker, 'cold' ablation, for this method. Recently, instrumentation has been developed to permit application for soft tissue resection in Otolaryngology. Presentation of the theory, as well as the benefits and disadvantages associated with CoblationTM technology will be followed by examples of its use. A brief videotape will demonstrate the application of PMA for UPPP, tonsillectomy and nasal turbinate reduction. Preliminary experience from our institution, including eighteen children treated with tonsillectomy and followed for at least one month post-operatively, has provided an initial cohort for comparing the risks and benefits of the approach. The advantage of CoblationTM technology identified thus far, that of less thermal damage, is balanced against a decreased level of hemostasis (compared to MES) and an increased cost.
Cochlear implantation is a treatment for deafness that requires the surgical placement of electrodes within the cochlea, using a high-speed drill. While the drill is effective, the tip of the drill or the drill shaft may damage critical adjacent structures, such as the facial nerve. In addition, the narrow working spaces involved in this surgery make the drill a relatively cumbersome tool for such delicate work. The use of a flexible fiber to deliver the laser energy may make the surgery easier by allowing a more maneuverable instrument to access the region, while reducing the risk of injuring adjacent structures. We report our preliminary investigation of fiber delivery of CTH:YAG energy ((lambda) equals 2091 nm) for the purpose of bony ablation. A 550 micron diameter low-OH silica fiber was used to drill through up to 2.5 mm thick human temporal bone specimens. An average of 14 pulses was required for 1 mm thick bones, and an average of 33 pulses required to ablate 2 mm of bone. The holes drilled were precise, and showed limited adjacent tissue effect by gross and histopathologic evaluation. This work demonstrates the effective fiberoptic delivery of CTH:YAG energy for bone ablation. Further work is warranted to explore the clinical possibilities offered by this technique for precise bony ablation with limited adjacent tissue effect.
Laryngomalacia is a common cause of airway obstruction in neonates and infants that, when severe, may be treated surgically via laser supraglottoplasty. Despite individual surgeons' successful experience with this technique, an objective broadly applied assessment of patient outcomes has been lacking. This is worrisome since the provision of health care is increasingly judged by the ultimate result: whether a person's quality of life is better for having undergone a particular procedure. Institutions that lack evidence of such benefit will face difficulty in justifying, and in obtaining compensation for, their services. We share our tool for the measurement of outcomes following laser supraglottoplasty. Over the past year, we have found this tool to be easily and rapidly applied. The wide range of possible combinations of patient presentation and the specific anatomic conformation of the laryngomalacia are effectively organized into standard database format, allowing for relevant clinical and anatomic information to be compared to post-operative indicators of outcome. We hope that this discussion prompts the development of similar tools for patient assessment following other laser airway procedures. Our ability as health care provides to control patient care depends upon the presentation of cogent, convincing evidence of improved patient well-being following treatment.
Laryngomalacia is the most common cause of newborn stridor. Management can usually be accomplished without surgery. When surgery is necessary, the carbon dioxide (CO2) laser plays an essential role in enabling precise, hemostatic dissection. The authors present their application of the CO2 laser with microspot control for laser correction of laryngomalacia, with emphasis upon the use of the Boston University suspension system to achieve external suspension of the larynx and the bivalved laryngoscope to achieve tissue distension. Review of indications, technique and results is shared to detail the utility of the CO2 laser in supraglottoplasty.
Cadaveric human temporal bones, cadaveric rabbits, and live rats were used to demonstrate the use and safety of the erbium:yttrium-scandium-gallium-garnet (Er:YSGG) laser for otologic applications: for dissection and precise drilling of bone. The shallow penetration of this wavelength and hence minimal collateral thermal effects spare underlying middle and inner ear structures and make it appealing for stapedotomy. Temperature measurements from the round window area during Er:YSGG stapedotomy recorded an elevation of less than 2 degree(s)C, which is well within acceptable limits. Ablation of bone was good and efficient. An acoustic shock produced at the impact site is the major disadvantage and requires further in vivo investigation of the transient and sustained deleterious effects away from the application site. This work supports further investigation into potential applications of the Er:YSGG laser in otology.
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