Holmium

Abstract

Although surgical lasers were introduced to the field of otolaryngology more than 20 years ago, their use in rhinologic surgery has remained relatively limited. With the development of the holmium:yttrium-aluminum-garnet (YAG) laser, a device is now available that offers those features necessary for effective sinus surgery:precise bone ablation, efficient soft tissue coagulation, and fiberoptic transmission. This solid-state laser of 2.1-microns wavelength can be coupled with endoscopic instrumentation for the surgical treatment of sinus disease. This study was conducted to determine the clinical efficacy of the holmium:YAG laser for endoscopic sinus surgery. A microscopic analysis of laser-treated sinus tissue was also performed in an attempt to determine the histologic basis of the observed clinical findings. In a prospective, randomized, controlled, single-blinded study, 32 consecutive patients underwent endoscopic sinus surgery using the holmium:YAG laser on one side of the nose and conventional endoscopic instrumentation on the other side. Patients rated symptoms for each side of the nose at 1 week, 1 month, 3 months, 6 months, and 2 years after surgery. Healing parameters were similarly rated by the surgeon. Until the study was completed, patients were not told which side of the nose had been treated with laser surgery. No intraoperative complications occurred. The mean intraoperative blood loss was 24.6 mL less on the laser-treated side of the nose than on conventionally treated side (P < .001). At 1 week after surgery, there was increased mucosal edema on the laser-treated side (P < .01). Crust formation was greater on the conventionally treated side at 1 week and was greater on the laser-treated side at 1 mouth (P < .01). Improvements in symptoms of pain, congestion, and drainage were equivalent for both treatment modalities (P < .001). Microscopic analysis demonstrated the ability of the holmium:YAG laser to remove tissue in relatively thin layers with ablation depths of 260 +/- 8.2 microns, 286 +/- 9.4 microns, and 341 +/- 20.4 microns per pulse at energy levels of 0.5, 1.0, and 1.5 J, respectively. A zone of thermal necrosis extending up to 1 mm beyond the site of laser impact was thought to correlate with the increased postoperative edema observed on the laser-treated side. Endoscopic sinus surgery with the holmium:YAG laser is as effective as nonlaser techniques in relieving the symptoms of chronic sinusitis. Laser surgery offers improved intraoperative hemostasis, but it causes increased postoperative tissue edema. The holmium:YAG laser provides the surgeon with an additional tool for the performance of safe, effective sinus surgery.