Neurohormonal markers in chronic rhinosinusitis.

Chronic rhinosinusitis (CRS), especially with nasal polyps, continues to elude precise pathogenesis and effective treatment. Prior work in our laboratory demonstrated interleukin-33 (IL-33) and Substance P (SP) activation of mast cells, and inhibitory effect of interleukin-37 (IL-37). Our objective is to study the expression of these neurohormonal mediators in mast cell stimulation of nasal polyposis. This was a prospective research study involving collection of nasal lavage fluid and nasal polyp tissue from adult patients with CRS. The study was divided into two arms. First, nasal lavage fluid was collected from normal controls, and patients with allergic rhinitis, CRS, or CRS with nasal polyposis. The second arm was collection of nasal tissue from normal controls undergoing inferior turbinoplasty, or patients with nasal polyposis. Enzyme-linked immunosorbent assay and quantitative polymerase chain reaction techniques were used to determine levels in the lavage fluid and relative gene expression in the tissue of SP, IL-33, and IL-37. In total, 70 lavage and 23 tissue specimens were obtained. The level of SP was highest in patients with polyps; however, gene expression was reduced compared to normal controls. The level of IL-33 was reduced in patients with polyps as compared to patients with allergy and sinusitis, and its gene expression was not significantly different from normal controls. IL-37 was elevated in the lavage fluid of patients with nasal polyps and its gene expression was increased in the polyp tissue. Levels of SP and IL-37 were elevated in the lavage fluid of patients with nasal polyps as compared to normal controls and other sinonasal pathologies, and gene expression of IL-37 was significantly increased in the polyp tissue itself. These findings implicate these neurohormonal molecules in the pathophysiology of nasal polyposis and provide possible novel therapeutic targets.

Endoscopic sphenoidotomy approach to the sella.

OBJECTIVE: Advances in optics, miniaturization, and endoscopic instrumentation have revolutionized surgery in the past decade. We report our experience with the endoscope in nine patients with sellar lesions who underwent an endoscopic sphenoidotomy approach to the sella. METHODS: An endoscopic transnasal cavity sphenoidotomy approach without a septal dissection was used in the resection of pituitary adenomas and other sellar lesions. RESULTS: This approach provided excellent exposure of the sella and adequate working space. The technique produces less postoperative pain and, in some cases, shortens hospital stay. The sphenoidotomy approach eliminates the problems of lip numbness, septal perforations, and oronasal fistulas. CONCLUSION: The endoscopic sphenoidotomy approach has become our preferred approach to sellar lesions.

Endoscopic diode laser welding of mucosal grafts on the larynx: a new technique.

Epithelial coverage of a laryngotracheal wound is an important factor in preventing stenosis, and endoscopic transplantation of a free mucosal graft without stents or sutures would be a significant therapeutic advance. In vitro and in vivo canine studies were performed to explore the feasibility of transplantation with a low-power diode laser (400 mW) enhanced by indocyanine green dye-doped albumin. The tensile strength of graft adherence in 10 cadaver larynges was strong (35.25 +/- 10.39 g). Survival studies in live canine models with a specially designed endoscopic instrument set showed excellent healing at 6, 14, and 28 days. Healing was documented with photography and by histologic examination. Successful endoscopic transplantation of a free mucosal graft should improve results of treatment for laryngotracheal stenosis and laryngeal reconstructive surgery.

Transtympanic endoscopy of the middle ear.

Modern optical technology has made available fiberoptic and rigid endoscopes with diameters of 2 mm and less with acceptable resolution. Endoscopes of small caliber were introduced through a strategically placed myringotomy or an existing perforation to perform exploration of the middle ear as an in-the-office procedure. This technique is now routinely used as an adjunct in the diagnostic evaluation of patients with suspected middle ear conditions. Exploratory surgery of the middle ear may be avoided or definitive procedures may be planned better based on endoscopic findings.

A combined endoscopic Co2 laser and external approach for treatment of glottic cancer involving the anterior commissure: an animal study.

Endoscopic laser resection usually has been discouraged for anterior commissure (AC) carcinoma because of inadequate exposure and close proximity to underlying cartilage. A new technique combining endoscopic CO2 laser incision and an external approach, creating a window in the thyroid cartilage, was tested in this in vivo study of six dogs. An en bloc specimen including adjacent cartilage was excised while preserving the thyroid framework. The glottic reconstruction was accomplished with external placement of a sternohyoid muscle flap, by either using a bipedicled muscle flap with overlying skin or a unipedicled muscle flap with a graft of free mucosa. The results showed a satisfactory anatomic reconstruction and acceptable functions. The bipedicled muscle flap was superior to the unipedicled muscle flap due to a better AC reconstruction. It is believed that this new combined technique may overcome limited access with endoscopic technique and excessive cartilage resection with the external partial laryngectomy.

A 585-nanometer pulsed dye laser treatment of laryngeal papillomas: preliminary report.

OBJECTIVES/HYPOTHESIS: Standard management of recurrent respiratory papillomatosis (RRP) currently consists of CO2 laser microsurgical ablation of papillomas. Because of the recurrent nature of this viral disease, patients are often faced with significant cumulative risk of soft tissue complications. As a minimally traumatic alternative to management of RRP, we have investigated the use of the 585-nm pulsed dye laser (PDL) to cause regression of papillomas by selective eradication of the tumor microvasculature. STUDY DESIGN: Nonrandomized prospective pilot study. METHODS: Patients with laryngeal papillomas were treated with the PDL at fluences of 6 J/cm2 (double pulses per irradiated site), 8 J/cm2 (single pulses), and 10 J/cm2 (single pulses), at noncritical areas within the larynx, using a specially designed micromanipulator. Lesions on the true cords were treated with the CO2 laser, using standard methodology. RESULTS: Clinical examination of three patients treated to date showed that PDL treatment appeared to produce complete regression of papillomas. Unlike the sites of lesions treated by the CO2 laser, the epithelial surface at the PDL treatment sites was preserved intact. CONCLUSIONS: These preliminary results suggest the PDL may eradicate respiratory papillomas with minimal damage to normal laryngeal tissue. Further analysis of the ongoing study is required to demonstrate potential benefits of the technique.

Benign lesions of the larynx: should the laser be used?

The use of the carbon dioxide (CO2) laser in the treatment of patients with benign laryngeal lesions, excluding respiratory papillomatosis, has been questioned because of potential adverse thermal effects on surrounding tissue. We question whether wound healing and subsequent quality of voice would be better if the surgeon used the "cold technique" with microlaryngeal instruments. Since the advent, in 1987, of a small-spot (0.3 mm) CO2 laser micromanipulator and more precise microlaryngeal instruments, we have redefined our use of the CO2 laser for benign laryngeal lesions. Over the past 4 years, in a series of 68 consecutive patients with vocal cord nodules, polyps, polypoid changes, or granulomas, the CO2 laser was useful for mucosal micro-flap dissection techniques and for vascular lesions. Smaller pedunculated lesions, such as vocal cord nodules, were more efficiently removed with the new microlaryngeal instrumentation. The combined selective use of a microspot CO2 laser at low-power settings (1 to 3 W), with 0.1-second pulses, and with precise microlaryngeal instruments will give the best results.

Holmium: yttrium aluminum garnet laser-assisted endoscopic sinus surgery: laboratory experience.

Endoscopic sinus surgery has gained wide acceptance since its introduction into the United States. Complex sinus anatomy and troublesome bleeding have been associated with complications, which vary in severity from synechia to blindness and leakage of cerebrospinal fluid. Endoscopic sinus surgery using a holmium: yttrium aluminum garnet pulsed solid-state laser oscillating at 2.1 microns with fiberoptic delivery was performed in the laboratory, and the results were compared with those of conventional endoscopic sinus surgery. Three beagle dogs, six human cadaver heads, and one calf head were used in the in vivo and in vitro studies to evaluate the bone ablation, tissue coagulation, and hemostatic properties of the holmium: yttrium aluminum garnet laser. Modified endoscopic telescopes for sinus surgery, a newly developed handpiece for fiberoptic delivery, and other surgical instruments were used. The results indicate that the holmium: yttrium aluminum garnet laser and new delivery instrumentation provide good hemostasis and controlled soft-tissue ablation and bone removal. The access to all sinuses in the human cadaver model was very good. The canine in vivo study showed delayed but complete healing on the laser-treated side. Clinical evaluation of the holmium: yttrium aluminum garnet laser is warranted to increase the precision and safety of endoscopic sinus surgery.

Erbium laser in middle ear surgery: in vitro and in vivo animal study.

Cadaveric human temporal bones, cadaveric rabbits, and live rats were used to demonstrate the utility and safety of the erbium:yttrium-scandium-gallium-garnet (Er:YSGG) laser for otologic applications. The shallow penetration in water of this wave-length and its ability to ablate bony tissue with minimal collateral thermal effects spare underlying and adjacent structures and make it appealing for stapedotomy. The authors were able to satisfactorily perform small fenestra stapedotomy, atticotomy facial nerve decompression, and mastoidectomy. Temperature measurements from the round window area during Er:YSGG stapedotomy recorded an elevation of less than 2 degrees C, which is well within acceptable limits. 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.

The holmium:YAG laser-assisted otolaryngologic procedures.

OBJECTIVE: To determine the effectiveness of the holmium: YAG (Ho:YAG) laser in otolaryngologic procedures that necessitate the ablation of osseous and soft tissue. DESIGN: Case series. SETTING: Lahey Clinic, Burlington, Mass. PATIENTS: Consecutive series of 37 patients; 29 with chronic sinusitis, five with chronic dacryocystitis, one with recurrent choanal stenosis, one with tracheopathia osteoplastica, and one with a sphenoid sinus mucocele. INTERVENTION: The Ho:YAG laser was used to assist in 37 procedures, including endoscopic sinus surgery, dacryocystorhinostomy, treatment of choanal stenosis, ablation of obstructive tracheopathia osteoplastica, and removal of a sphenoid sinus mucocele. MAIN OUTCOME MEASURES: Postsurgical success and complications, satisfaction of the patients, and the ability of the laser to remove tissue. RESULTS: Complications occurred in eight patients: intranasal or ethmoid scarring (four), persistent polyps (one), bleeding (one), stent dislodgment (one), and tracheitis (one). Three patients required revision surgery. None of the complications were related to use of the laser, although the laser may produce increased scarring. The laser was effective for osseous and soft-tissue ablation, but its usefulness was limited for hemostasis. CONCLUSIONS: The Ho:YAG laser can be used in otolaryngologic procedures when surgical access is difficult or when controlled, precise ablation of osseous tissue is necessary.

New technique for laryngotracheal mucosa transplantation. 'Stamp' welding using indocyanine green dye and albumin interaction with diode laser.

OBJECTIVE: To investigate (1) the possibility of survival of free mucosa "stamp" grafts fixed in the airway with a new technique using indocyanine green-dyed albumin solder activated with a diode laser and (2) the degree of improvement of wound healing in the airway by applying modified microskin transplantation techniques from burn surgery to cover a relatively large wound with a few small pieces of mucosa anchored in place with the previously mentioned technique. DESIGN: Three (one control and two experimental) rectangular (10 x 8 mm) wounds in tracheal mucosa were produced in four experimental animals (dogs) using a carbon dioxide laser. The control wound was left uncovered. In the first experimental wound, a mucosal flap was raised and then fixed in place by a trapdoor flap method. In the second experimental wound, two small (each 2 x 3 mm) autogenous mucosa grafts were anchored onto the surface with indocyanine green-dyed albumin activated with an 810-nm diode laser. Histomorphologically, the postoperative results from three wounds were compared. RESULTS: The experimental wounds were completely covered by regenerated squamous cells in 1 week and by ciliated epithelium in 2 weeks after the operation despite the discrepancy in size of the graft to wound area (1:6.7) covered with the stamp mucosa. No thermal damage from the diode laser was noted in the second experimental wounds. In the control wounds, no coverage was observed at 1 week, and only squamous cells were noted 2 weeks postoperatively. All the wounds had normal ciliated epithelium coverage at 4 weeks. CONCLUSIONS: Transplanted stamp grafts provided similar or better healing than trapdoor flap transplants. This new technique made endoscopic mucosal grafting possible and offers a potential breakthrough in the management of laryngotracheal stenosis.

Idiopathic subglottic stenosis.

OBJECTIVE: To review our patients with subglottic stenosis and describe a rare subclass of patients in whom the cause of subglottic scarring and narrowing remains unknown. DESIGN: A retrospective chart review and clinical update were performed on all patients seen with the diagnosis of subglottic stenosis. SETTING: The patient pool represents a collection of primary care patients within a suburb of Boston, Mass, and tertiary referrals from community and out-of-state otolaryngologists. PATIENTS: The charts of 80 patients were reviewed, and 10 of the 80 patients fulfilled the criteria for idiopathic subglottic stenosis. INTERVENTION: Diagnostic and therapeutic intervention ranged from laboratory tests, topography, flexible bronchoscopy, rigid endoscopy and biopsy, laser-assisted dilation, and resection and repair of the lesion. MAIN OUTCOME MEASURES: Attention was directed toward the character of the lesion, treatment modality, and clinical outcome. RESULTS: From 1985 to 1992, 10 patients with idiopathic subglottic stenosis were treated at the Lahey Clinic, Burlington, Mass. Eight patients required therapy for exertional dyspnea. Endoscopic laser incision and dilation were performed in all eight patients, with good initial results. Four patients were treated successfully with endoscopy alone: three required only one dilation, and the fourth required a second dilation. The remaining four patients, who had longer and more complex stenoses, have had repeated restenosis at intervals ranging from 1.5 to 12 months. Two of these patients have undergone laryngotracheal resection and reconstruction and were without evidence of restenosis 10 and 20 months after surgery. CONCLUSIONS: There exists a subclass of patients with subglottic stenosis of unknown cause. Symptomatic idiopathic subglottic stenosis may be treated successfully with laser incision and dilation if the stenosis is simple and short. More complex, longer stenoses are prone to recurrence and are more definitively managed by resection and reconstruction of the narrowed area.

Laser therapy for lymphatic malformations of the upper aerodigestive tract. An evolving experience.

Lymphatic malformations of the upper aerodigestive tract can present therapeutic challenges. Symptoms associated with these lesions include bleeding, dysphagia, changes in speech, and dyspnea. Surgical therapy is recommended, which often leads to functional interference and cosmetic deformities. Laser photocoagulation of these malformations can control symptoms and may be repeated as necessary, preserving tissue and function. The results in four patients treated with the carbon dioxide laser and in five patients treated with the neodymium-YAG laser were reviewed. Reduction of bulk and improvement of symptoms were achieved in all patients, most of whom required multiple treatments. The average duration of each procedure was 30 minutes. All patients were discharged from the hospital on the same day or 1 day after laser therapy with minimal morbidity. The indications, evolving technique, and results of laser therapy are discussed.

Early diagnosis of upper aerodigestive tract cancer by autofluorescence.

OBJECTIVE: To explore the potential of autofluorescence spectroscopy as a tool for early detection of upper aerodigestive tract cancer. DESIGN: Autofluorescence spectral characteristics of 19 untreated oral and oropharyngeal lesions in 13 patients were studied with excitation wavelengths of 370 and 410 nm generated by a nitrogen pumped dye laser. Ten healthy volunteers were recruited to characterize the fluorescence spectra of normal mucosa at different oral sites and to study individual variations. Fluorescence intensity and line shape of the spectra from lesions were compared with the same parameters from the contralateral control site in the same individual. SETTING: Otolaryngology Research Center, Department of Otolaryngology-Head and Neck Surgery, New England Medical Center, Boston, Mass. RESULTS: The ratio of peak fluorescence intensities of the neoplastic lesions to contralateral normal control mucosa were consistently different compared with these ratios in benign lesions or normal mucosa. These differences were seen in 2 distinct regions of the fluorescence spectrum with both of the excitation wavelengths, but were more obvious with the excitation wavelength of 410 nm. Using these differences, we were able to correctly diagnose 17 of the 19 lesions studied, with 2 false-positive results. CONCLUSIONS: Neoplastic oral mucosa shows consistent differences in autofluorescence spectral intensity and line shape when compared with the normal mucosa in the same individual. These early results show that fluorescence spectroscopy may represent a useful technique for noninvasive early diagnosis of cancer of the upper aerodigestive tract.

Autologous fibrin tissue adhesive in endoscopic sinus surgery.

Endoscopic sinus surgery may be complicated by bleeding, formation of synechia, and infection. This study investigated the application of autologous fibrin tissue adhesive during endoscopic sinus surgery in an attempt to avoid packing, to decrease complications, and to improve healing. Fibrin tissue adhesive from pooled human blood is a hemostatic and bacteriostatic agent. Autologous fibrin tissue adhesive avoids the potential infectious and immunologic risks of the pooled blood product. Twelve patients undergoing bilateral endoscopic sinus surgery participated in the study. Phlebotomy and preparation of the adhesive were performed during the procedure. Fibrin tissue adhesive was applied to only one side, with the contralateral side used as a control. Bacitracin ointment was applied to the adhesive-treated side, and packing coated with bacitracin was placed on the contralateral side. Patients were observed for a minimum of 3 months, and results were documented with photographic and video recordings. A uniformly high degree of patient satisfaction was achieved because of the elimination of packing and a sensation of increased nasal airway patency on the fibrin-treated side. Fibrin tissue adhesive provided hemostasis, decreased crusting, accelerated mucosal healing, and diminished synechia. Autologous fibrin tissue adhesive is beneficial in endoscopic sinus surgery, and its application should be considered, especially when the risk of hemorrhage or synechia is increased.

Tracheobronchial obstruction from esophageal carcinoma: bronchoscopic treatment with neodymium: yttrium-aluminum-garnet laser.

Tracheobronchial obstruction resulting from esophageal carcinoma is uncommon. Patients with advanced esophageal carcinoma with tracheobronchial obstruction usually present with severe dyspnea or hemoptysis or both and may die of suffocation. The Lahey Clinic experience using laser bronchoscopy for the palliation of symptoms of airway obstruction in patients with esophageal carcinoma is presented. From 1982 to 1990, nine patients were treated in 13 procedures using the neodymium: yttrium-aluminum-garnet laser. Of the patients, seven had undergone previous treatment of the primary tumor. Tumors were located in the trachea in seven patients and in the main stem bronchi in three patients. Improvement of the airway caliber was achieved in all patients with relief of the dyspnea. The mean hospital stay was 2 days. One patient lived 4 years after laser treatment with no recurrence of tumor, and one patient died 1 week after treatment as a result of his poor general condition. The rest of the patients lived 3 to 41 weeks, with a median survival of 35 weeks. No complications were related to the procedures, and in particular, no tracheoesophageal fistulas developed. Our experience indicates that bronchoscopic application of this laser in conjunction with other treatment modalities can improve the quality and duration of life in selected patients with esophageal carcinoma that invades and obstructs the trachea.

Endoscopic laser therapy for obstructing tracheobronchial lesions.

The Lahey Clinic experience using laser bronchoscopy for relief of obstructive tracheobronchial lesions during a 7-year period from 1982 to 1989 involves 269 patients treated with 400 procedures. The carbon dioxide (CO2) laser was used for tracheal stenosis and granulation tissue. The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was used for all obstructing endobronchial neoplasms. Indications for therapy included severe dyspnea, hemoptysis, and postobstructive pneumonitis. All patients had relatively central lesions. A rigid bronchoscope was used to treat 88% of patients, and 12% of patients were treated with a flexible bronchoscope. One death occurred during the intraoperative period. Eleven deaths occurred within 1 week of therapy and were related to the presence of extensive malignant lesions or to coronary artery disease. Our experience indicates that bronchoscopic application of the CO2 or Nd:YAG laser affords effective palliation for patients with obstructive tracheobronchial lesions. The Nd:YAG laser is recommended for patients with bulky vascular endobronchial neoplasms, and the CO2 laser is best reserved for patients with benign tracheal stenosis and granulation tissue.

"Window" laryngoplasty: a new combined laser endoscopic and open technique for conservation surgery.

Endoscopic laser resection of early laryngeal carcinoma is an increasingly used treatment modality; however, the limited exposure achieved and the alteration of vocal function are still major problems. A new surgical procedure, "window" laryngoplasty, has been devised and tested in an in vivo study in 6 canines with 50 days' survival. The right vocal cord was incised endoscopically with the carbon dioxide laser, and the en bloc specimen with adjacent thyroid cartilage was removed through a window approach made in the thyroid cartilage. A sternohyoid muscle flap based superiorly was inserted into the cartilaginous window to reconstruct a pseudocord with coverage of either mucosa or fascia. A diode laser soldering technique was used to secure the mucosal graft in place. Epithelial transplantation can be accomplished externally with precise endoscopic guidance for reliable placement of the pseudocord. The results show that the new technique, a combination of endoscopic and open approaches, may be a better treatment choice than standard vertical partial laryngectomy in selected patients. Advantages of this technique include adequate en bloc resection, including adjacent cartilage for pathologic evaluation, preservation of the integrity of most of the laryngeal framework, avoidance of tracheotomy, and better functional results.

Endoscopic holmium laser laryngotracheoplasty in animal models.

Subglottic stenosis remains a difficult clinical problem with varied management approaches. An accepted procedure has been anterior and posterior cricoid incisions through an external approach for treatment of severe stenoses without a tracheotomy. The holmium:yttrium-aluminum-garnet laser, 2.1 microns wavelength with a pulsed output, is transmissible through standard fibers and ablates soft tissue and cartilage with minimal surrounding damage. This study in in vitro and in vivo animal models shows that this new laser can be used to incise the anterior and posterior cricoid and tracheal cartilages with precise control and may be suitable for endoscopic laryngotracheoplasty.

Preliminary clinical results of window partial laryngectomy: a combined endoscopic and open technique.

Endoscopic laser resection for anterior commissure glottic carcinoma is difficult, because of inadequate exposure and close proximity to the underlying cartilage. A technique combining endoscopic carbon dioxide laser incision and an external approach creating a window in the thyroid cartilage was initially tested in a canine study and then performed in 5 patients. All patients were men, with T1 or T2 glottic or supraglottic cancer involving the anterior commissure, and had failed radiation treatment. The true or false vocal fold tumors were excised along with the paraglottic space and adjacent cartilage, with preservation of the remaining thyroid framework. The reconstruction was accomplished with placement of a sternohyoid muscle flap, by use of either a bipedicled muscle flap with overlying skin or a unipedicled muscle flap with a graft of free mucosa. The graft was secured in place with fibrin glue and laser soldering. Follow-up ranged from 11 months to 4 years and included biopsies. All patients had voice recordings before and after surgery. A tracheostomy was avoided in all patients. The hospital stays were 4 to 13 days. The voice quality was good after surgery. One patient died of unrelated causes 18 months after his surgery without evidence of recurrence. The other patients are still alive with no evidence of disease. The only complication was subcutaneous neck emphysema in 1 patient that spontaneously resolved. The results showed a satisfactory anatomic reconstruction and acceptable functions. We believe that this new combined technique is oncologically sound, may overcome the limited access seen with the endoscopic technique and the excessive cartilage resection seen with external partial laryngectomy, avoids a tracheostomy, and shortens hospital stays.