O R I G I N A L A R T I C L E

Sinonasal and nasopharyngeal applications of the hand-heldCO2 laser fiber

Garima Agarwal, MD1,2, Michael E. Kupferman, MD1, Floyd C. Holsinger, MD, FACS1,Ehab Y. Hanna, MD, FACS1

Background: Carbon dioxide (CO2) laser provides preci-sion and excellent hemostasis, leading to healing with min-imal discomfort and complications. In spite of the advan-tages, the application of CO2 laser has been limited in thesinonasal region due to the difficulty in delivering laser en-ergy to the deep, narrow, and confined spaces. The avail-ability of flexible laser fibers and custom-designed handpieces has rectified these limitations but, until this date,there are no data on their safety and efficacy profile.

Methods: We conducted a retrospective chart review ofpatients who underwent sinonasal and nasopharyngealsurgery with a hand-held CO2 laser at M.D. Anderson Can-cer center between 2007 and 2009.

Results: Out of 12 patients, 3 patients had postradiotherapyadhesions, 2 patients had a recurrent sinonasal mucoepi-dermoid carcinoma and 1 patient each had a ganglioneurob-lastoma of the nasopharynx involving the basisphenoid andclivus, recurrent spindle cell melanoma of the nasophar-ynx, juvenile nasopharyngeal angiofibroma, papilloma ofthe nasal cavity, pituitary adenoma, spindle cell lipoma of

the nasopharynx, and intranasal Rosai-Dorfman disease.The CO2 laser, along with conventional endoscopic tech-niques and instruments, was used at 6–12 W continuousmode, to excise the disease. Median blood loss was 88 mLwith no laser-related complication in any patient.

Conclusion: In sinonasal and nasopharyngeal regions, useof hand-held CO2 laser fiber provides precision, excellenthemostasis and minimizes tissue manipulation thereby re-ducing risk to the underlying structures. Thus, it can be animportant tool for rhinologists and skull-base surgeons, es-pecially for revision and postradiotherapy cases. C© 2011ARS-AAOA, LLC.

Key Words:CO2 laser; rhinology; sinonasal; nasopharynx; skull base

How to Cite this Article:Agarwal G, Kupferman ME, Holsinger FC, Hanna EY.Sinonasal and nasopharyngeal applications of the hand-held CO2 laser fiber. Int Forum Allergy Rhinol, 2011; 1:109–112

S urgical lasers were introduced more than 30 yearsago and offer many advantages in otolaryngologic

surgery. Specifically, in sinonasal surgery, application oflaser has potential advantages, including precision, excel-lent hemostasis, less edema, few direct tissue contacts andinstrumentation, and healing with minimal discomfort andcomplications.

There have been reports of nasal applications of vari-ous lasers including carbon dioxide (CO2) laser,1–3 potas-

1University of Texas, M.D. Anderson Cancer Center, Houston, TX;2University of Texas, Health Science Center, Houston, TX

Correspondence to: Ehab Y Hanna, M.D., Professor, Department of Headand Neck Surgery, M.D. Anderson Cancer Research Center, 1515 HolcombeBoulevard, Unit 441, Houston, TX 77030; e-mail: EYHanna@mdanderson.org

Potential conflict of interest: None provided.

Received: 14 May 2010; Revised: 6 September 2010; Accepted: 1 October2010DOI: 10.1002/alr.20017View this article online at wileyonlinelibrary.com.

sium titanyl phosphate (KTP) laser,1,4 holmium: yttriumaluminum garnet (Ho:YAG) laser,1 and neodymium: YAG(Nd:YAG) laser.5 In view of limited data on use of lasersin rhinology, the role of lasers in sinonasal surgery has re-mained on fringes.

CO2 lasers have become one of the most common sur-gical lasers due to excellent tissue interaction propertiesthat offer precise control of cutting and ablation depth,minimal thermal damage to surrounding tissue, and goodhemostasis.6,7 A number of fundamental tissue interactionaspects, contribute to the wide acceptance and perceivedsafety and predictability of using CO2 laser for tissue cut-ting, ablation, and coagulation.6 However, the use of CO2

laser in endoscopic sinus surgery has been limited due tothe inability to deliver laser energy into the deep, narrow,and confined sinonasal spaces with a conventional deliverysystem for CO2 laser. Conventionally, CO2 laser is deliv-ered through an articulated arm and has been used witha microscope, which makes it difficult to use for sinonasal

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surgery. Recently, novel hollow-core photonic band-gapoptical fibers for CO2 lasers have been developed that offerhigh flexibility and mechanical robustness with good op-tical performance under tight bends.6 These fibers can beused by endoscopic and skull-base surgeons to perform del-icate and precise surgeries in a minimally invasive manner.We report our experience with the flexible fiber CO2 laserand describe its various applications in sinonasal, skull-base, and nasopharyngeal surgery.

Patients and methodsWe did a retrospective chart review of patients who under-went endoscopic surgery for sinonasal and nasopharyngeallesions using hand-held CO2 laser at M.D. Anderson Can-cer center, between 2007 and 2009. CO2 laser was usedeither alone or as an adjunct with conventional endoscopicsinus surgery instruments in these patients. There were noexclusion criteria. Data regarding age, sex, ethnicity, indi-cations for surgery, extent of the lesion, use of stereotacticnavigation, complications, and blood loss were extractedfrom the charts. Data are presented as mean/median forcontinuous variables and as percentage for discrete vari-ables.

ResultsA total of 12 patients met our inclusion criteria. Thesepatients had a median age of 66 years, with a sex ratioof 1:1 and were predominantly Caucasians (92%) (Table1). Operating surgeons were E.Y.H. and M.E.K., who per-formed 10 and 2 surgeries, respectively. CO2 laser wasused at 6–12 W continuous mode. Indication for the useof the laser was postradiotherapy adhesionolysis in 3 pa-tients, recurrent mucoepidermoid carcinoma excision in 2patients, and ganglioneuroblastoma, recurrent spindle cellmelanoma, juvenile nasopharyngeal angiofibroma, papil-loma, pituitary adenoma, spindle cell lipoma, and extra-nodal Rosai Dorfman disease excision in 1 patient each.Disease was present in the nasal cavity in 8 patients, in thenasopharynx in 3 patients, and in the sphenoid sinus ex-tending to the sella turcica in 1 patient (Table 1). In the 8patients with disease in the nasal cavity, disease was limitedto the nasal cavity in 6 patients; whereas it extended to thenasopharynx in the other 2 (Table 1). The one patient withnasopharyngeal disease had the disease extending into thesphenoid, basisphenoid, and clivus. None of the patientshad dural involvement or skull-base erosion. Median esti-mated blood loss was 88 cc, ranging from <5 mL to 1500mL. None of the patients had complications related to theuse of CO2 laser.

DiscussionOur study, for the first time, describes the nasal andsinonasal applications of the hand-held CO2 laser fiber ina series of patients. In the last 2 years, we have used flexi-

ble fiber CO2 laser alone or as an adjunct to conventionalendoscopic instruments to remove diverse pathologies ofsinonasal region and skull base, with minimal blood lossand absence of complications.

In rhinology, especially in the revision cases, there is aneed for accurate tools. The current available modalities areneither very precise nor maneuverable and moreover do notprovide hemostasis. We initially used the hand held laseras an ablating and cutting tool for lysis of intranasal ad-hesions. We realized that conventional cutting instrumentsresulted in bleeding and did not respect the intranasal mu-cosa due to scarring. On the other hand, the hand-heldlaser fiber helped us to deliver energy precisely on the scartissue, maintaining hemostasis and the integrity of the nor-mal surrounding mucosa. Similar advantage was observedin precisely dissecting lesions like papillomas and lipomas.As we realized the accuracy and easy maneuverability ofthe tool, we extended our indications to include more ex-tensive lesions. In tumors like ganglioneuroblastoma, pitu-itary adenoma, and nasopharyngeal angiofibroma, use ofthe laser helped us to cauterize the capsule and dissect thetumor precisely from the surrounding soft tissue, maintain-ing the integrity of critical structures including orbit, skullbase, and Eustachian tube.

In contrast to the existing instruments, laser is a no-touchtool that minimizes tissue manipulation. Minimal bloodloss, especially in the patient with nasopharyngeal angiofi-broma, and absence of complications in this series, demon-strates the excellent hemostatic properties and ability forprecise dissection of CO2 laser. On the other hand, oncethe field is already bloody, the low wattage precludes theuse of lasers. In such situations we used more traditionalmethods to control the bleeding such as electrocoagula-tion. Once excessive bleeding was controlled, the laser wasused for further resection and/or ablation. Thus, althoughthe laser minimizes blood loss, once the field has a lot ofblood conventional techniques are better for controlling thebleeding.

The only other study on the use of hand-held CO2 laserwas a case report by Casiano et al.,8 who used it for re-vision transnasal transsphenoidal endoscopic resection ofa suprasellar pituitary macroadenoma. They used the CO2

laser to dissect the scar tissue accurately, create a pathwaythrough the scarred sellar floor, and debulk the tumor. Sim-ilarly, we have also used hand-held CO2 laser for similarindications. In our patient, the primary pituitary macroade-noma was a highly vascular lesion with a tough capsule,eroding the sella. Use of the laser helped us to dissect andcauterize the capsule of the tumor precisely. Thus, our studyconfirms the results of the existing case report and adds tothe current body of literature.

Previously, Sato et al.3 used CO2 laser (nonflexible) tovaporize the base of an antrochoanal polyp and then a mi-crodissector to remove the polyp through wide maxillaryantrostomy in a conventional manner. Similarly, Lippert etal.2 have used nonflexible CO2 laser for treating hypertro-phied inferior turbinates, septoplasty, and choanal atresia.

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CO2 laser in rhinology

TABLE 1. Baseline characteristics of the patients, indications for surgery and outcomes, in the study population

Subject Age Gender Primary Site of Stereotactic

number (years) (M/F) Ethnicity diagnosis Indication lesion EBL (mL) navigation Complication

1 58 M C Squamous cell CA Post RTadhesions

NC 5 No No

2 75 F C Ganglioneuroblastoma Tm Np, sphenoid,basisphenoid,

clivus

150 Yes No

3 88 F C Spindle cell melanoma Recurrent Tm NC, Np 5 No No

4 63 M C Spindle cell lipoma Tm Np 50 No No

5 18 M C JNA Tm NC, Np 200 No No

6 68 F C Mucoepidermoid CA Recurrent tm NC 125 No No

7 35 F C Pituitary adenoma Tm Sphenoid, sellaturcica

1500 Yes No

8 63 M C Papilloma Tm NC 5 No No

9 68 M C Adeno CA of maxillarysinus

Post RTadhesions

NC 2 No No

10 38 F H Np CA Post RTadhesions

NC 5 No No

11 81 M C Rosai Dorfman disease Tm NC 150 No No

12 71 F C Mucoepidermoid CA Recurrent tm Np 300 Yes No

C = Caucasian; CA = carcinoma; EBL = estimated blood loss; F = female; H = Hispanic; JNA = juvenile nasal angiofibroma; M = male; NC = nasal cavity; Np =nasopharynx; RT = radiotherapy; Tm = tumor.

In spite of these 2 studies, use of CO2 lasers did not be-come mainstream, as laser energy could only be directedstraight ahead or angled off front-facing mirrors. This isthe first case-series on the flexible CO2 laser, which hasdemonstrated both efficacy and safety of this modality forsinonasal, nasopharyngeal and skull-base surgery.

The KTP laser, with a visible light output with frequencyof 532 nm, uses flexible fibers that can be used to treatlesions inside the nasal and paranasal cavities.1,4 How-ever, the KTP/532 laser wavelength is highly absorbed inhemoglobin, but not absorbed in water.4 As a result, itis capable of producing more thermal damage than CO2

lasers. Therefore, its role and safety for extensive sinonasaland skull-base diseases remains controversial. In contrast,the CO2 laser has a wavelength of 10.6 nm. Its wavelengthpermits excellent absorption by water, a major componentof cells, resulting in very little damage to adjacent tissue.Generally, it can coagulate blood vessels up to 0.5 mmin diameter, thereby permitting reasonable hemostasis forsinonasal lesions. There is a shallow depth of penetrationdue to rapid heat loss caused by the evaporation of intra-cellular water that makes it relatively safe for sinonasal andskull-base application.

To date, hand-held flexible fiber CO2 laser system hasbeen used in myriad of procedures across surgical spe-cialties spanning neurosurgery and spine oncology,9 headand neck oncology,10 laryngology,11 airway procedures,12

otology13 and gastroenterology.14 Holsinger et al.10 pub-

lished the various applications of the CO2 laser system inthe management of laryngeal and tongue base cancer inwhich direct visualization required for the traditional CO2

laser system cannot be acquired.

LimitationsThis was a retrospective chart review on the feasibility ofuse of lasers in different settings. Our study is not a com-parative study, comparing laser to conventional techniques,which will require prospective controlled trials. The ad-vantage of laser that we have described is based on ourexperience and that reported in the literature.

ConclusionBased on this study, we believe the introduction of CO2

laser fiber may expand its use in sinonasal and skull-basesurgery. This study for the first time shows the efficacyand safety of this modality and should provide a plat-form for future prospective comparative studies on lasers inrhinology.

Case series has inherent limitations. It is retrospective,has no control group, and is not blinded. In the absence ofany previous study, apart from a case report, this case seriesis the first step toward validation of hand-held CO2 lasers inrhinology. Future studies will be required to compare thismodality with other forms of lasers and/or conventionaltechniques.

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