Light Amplification by the Stimulation of Radiation (LASER) James Ridgway, MD 3/22/07
Patient is a 18 week old male presenting to pediatrics with a two week history of “noisy breathing” that is worse with crying. This was noted when the child was with mother at work (she works at a daycare facility). This has worsened considerably over the last 5 days with difficulty in feeding and has created a considerable amount of parental concern. Pediatrics has consulted you as med-nebs have had little effect over the last 4 hours.
PMH: Uneventful full term delivery. Child has had unremarkable history until current condition.
SH: Lives with parents, immunizations UTD
FH: Grandparents with DM, HTN
General: Alert, but with nasal flaring and retractions. + biphasic stridor
Ears: TM C/I/M AU
Nose: No evidence of polyp, septal perforation or mass
OC/OP: 2+ tonsils, no cleft or lesion
Neck: Soft, supple and without mass or LAD
Face: Full facial motion and symmetry
On examination of the left abdomen there is a red, slightly raised lesion that has evolved rapidly over the last week
Wavelength is between minimal absorption of water and a small amount of scatter
Solid state laser
Deeper penetration (up to 4 mm) for ablative therapy and hemostasis
Preferentially absorbed by pigmented tissues
Vascular malformations amenable to treatment
Used in a multitude of pulmonary, urology and gastroenterology procedures
Minimally invasive percutaneous laser disk decompression
Greater scatter than CO2
Deep thermal injury
Risk for transmural injury
488 - 514 nm wavelength (ion laser)
Oxyhemoglobin is target chromophore
Small spot size (0.1 – 1 mm) – variable in size and intensity
Flexible delivery system
Retina or middle ear surgery
Facial spider veins
Also absorbed by epidermal and dermal tissues due to melanin
Continuous mode of operation
Higher prevalence of postoperative pigmentary alteration and fibrosis
Pulsed Dye Laser (PDL) – preferred for many roles Argon laser originally used (treatment of vascular lesions, including spider veins, strawberry birthmarks and port wine stains)
532 nm wavelength (potassium-titanyl-phosphate)
Nd: YAG laser passes through a KTP crystal – emission is ½ its wavelength
Oxyhemoglobin is primary chromophore
Continuous wave (CW) mode to cut tissue
Pulsed mode for vascular lesions
Q-Switched mode for red/orange tattoo pigment
Granuloma excision of the respiratory tract
Subglottic/supraglottic cyst excision
Inferior turbinate reduction
Nasal papilloma excision
Laryngeal papilloma excision
Middle ear surgery (Cholesteatoma excision, stapes surgery)
CW/pulsed mode: insulated fiber, fiber handpiece, scanner, or microscope
Q-Switched mode: articulating arm
Education: attendance at a "hands-on" laser surgery course that stresses safety precautions –proven reduction of laser-related complications
Development of protocol for safe laser use (credentials, continued education, ect.)
Dedicated laser technician/ nurse/ engineer
Team approach in fire prevention and anesthetic management
Safest anesthetic gas mixture is 30% oxygen in helium Posting of “Laser in use” signs
Laser specific endotracheal tube
Eye protection (medical personnel & patient)
Saline moistened eye pads
Skin protection: saline-saturated surgical towels
Smoke evacuation: two separate suction set-ups
Ebonized surgical instruments
Placement of signs and additional eye protection outside operative room
While using the CO2 laser in the ablation of laryngeal papillomatosis the ET tube catches fire. What do you do?
A: stop inflammable anesthetics
B: remove ET tube
C: pour water down the ET tube
Time to initiation of fire and burn through the lumen of ET tube:
0.3 second for T-tube (silicone)
0.5 s for jet ventilation tube
0.8 s for PVC endotracheal tube
5 s for Xomed laser shield endotracheal tube
Laser-Flex tracheal tube (stainless) and aluminum foil wrapped PVC endotracheal tube did not catch fire after 30 s of CO2 laser irradiation
In short, the stainless endotracheal tube is the safest tube during CO2 laser surgery.
Patient presents with lesion of the tongue. Which laser is the best choice?
Patient has a predominantly green tattoo that they want to have removed. Which of the following is the best answer?
A. Frequency doubling
B . Q-switched Nd: YAG
C. Q-switched alexandrite
Pros: absorbed by water, no deep penetration into the inner ear
Cons: invisible (requires separate aiming beam), alignment of mirrors can be problematic
Pros: Aiming beam is attenuated, treatment beam can pass through fiberoptic cable
Cons: Requires pigment for absorption, can pass through clear fluids and potentially damage the inner ear
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