|Year : 2015 | Volume
| Issue : 2 | Page : 29-33
Use of pulsed dye laser in the management of laryngeal lesions: The current perspective
Ashwani Sethi, Avinash Das
Department of ENT, Army College of Medical Sciences, Base Hospital, New Delhi, India
|Date of Web Publication||13-Jun-2016|
Dr. Ashwani Sethi
Associate Professor, Army College of Medical Sciences, Delhi Cantt - 110 010
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Since the introduction of lasers to laryngeal surgeries, CO 2 laser has remained the most commonly used laser for a variety of purposes. Recently, a wide range of lasers have been developed and introduced for laryngeal surgeries with their own sets of advantages and disadvantages. The aim of this systematic review is to explore current evidence pertaining to the application of 585 nm pulsed dye laser (PDL) in the management of laryngeal disorders. The methodology involves a comprehensive analysis of pertinent data in MEDLINE. A total of 16 studies meeting the inclusion criteria are included for analysis. Most of the studies are recent and show promising results with PDL in selective group of pathologies. PDL has been used effectively in a wide range of pathologies with distinct advantages over other lasers and cold knife surgeries according to most of the studies. It has been documented as a safe and effective laser for in-office treatment.
Keywords: CO 2 laser, larynx, leukoplakia, papilloma, potassium titanyl phosphate laser, pulsed dye laser
|How to cite this article:|
Sethi A, Das A. Use of pulsed dye laser in the management of laryngeal lesions: The current perspective. J Laryngol Voice 2015;5:29-33
| Introduction|| |
The invention of micromanipulator by Brademeir to deliver CO 2 laser though micromanipulator heralded the new era of lasers for laryngeal surgeries.  Since then, a variety of lasers including potassium titanyl phosphate (KTP), holmium, Neodymium-Yttrium Argon Granet, thulium, and pulsed dye laser (PDL). ,, Of these, the KTP laser has been used widely across the globe in various laryngeal pathologies as evidenced by the supporting literature. PDL has been relatively recently introduced in the management of laryngeal lesions, primarily based on its photoangiolytic property and ability to be transmitted through the fiberoptic systems.  Most of the studies have reported its use in the management of vascular lesions and respiratory papillomatosis, but its role in other benign and malignant laryngeal pathologies is still evolving as evidenced by some recent data. ,,,,,, PDL has also been used as an activating laser for photodynamic therapy in laryngeal keratosis. 
The aim of the present systematic review is to analyze the relevant medical literature to evaluate the current indications for the use of PDL. We also aim to make an evidence-based assessment of the outcomes of using this laser in terms of voice, safety, ease of use, and cost-effectiveness as compared to some of the other currently used lasers.
| Methods|| |
An MEDLINE search was made of the pertinent medical literature confined to English language from 1966 to September, 2015. Broad search terms such as "Pulsed dye laser," "microlaryngeal surgery," "KTP laser," "laryngeal papillomatosis," and "laser" in various combinations were used for the search. Reference lists from relevant articles were cross-searched. The studies included for analysis were in vivo observational and comparative studies.
| Results|| |
We identified 31 studies in our initial studies. However, only 16 out of those met our inclusion criteria and were, thus, included in our study. Of these, 12 were prospective studies and 4 were retrospective. There were 2 studies that made a comparative analysis with other lasers such as CO 2 and KTP 432 [Table 1].
|Table 1: Summary of studies included for review of efficacy and safety of pulsed dye laser for laryngeal application |
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Most of the earlier studies have assessed the role of this laser in recurrent respiratory papillomatosis. However, the later studies have reported its successful use for varying laryngeal pathologies including vascular lesions, vocal scars, sulcus vocalis, Reinke's edema, leukoplakia, laryngeal keratosis, vocal polyps, and early glottis carcinoma. On comparative analysis, PDL was found to be better as compared to CO 2 laser in terms of voice outcomes for treatment of leukoplakia.  However, pulsed KTP 432 laser was found to be better in the management of vascular lesions of the larynx. ,
| Discussion|| |
Selective properties of pulsed dye laser
There are certain properties of PDL that make it an ideal choice in the management of various laryngeal pathologies. First, this laser works at a wavelength of 585 nm. As a result, it is selective absorbed by hemoglobin which makes it an ideal angiolytic tool.  Second, when delivered in a pulsed format rather than in a continuous manner, the heat build-up in the surrounding tissues is much less resulting in a less collateral thermal damage.  Third, this laser can be transmitted although fiber making it useful for both in the office and operating room surgeries. Furthermore, a fiberoptic transmission gives the choice of using them in contact or noncontact mode.  Besides, office-based laser surgery of larynx has been reported to be significantly cost-effective and better tolerated by patients. , All these factors make PDL a desirable treatment modality for laryngeal pathologies.
Evidence for pulsed dye laser efficacy and safety
PDL has been used for the management of cutaneous lesions in the past.  The first in vivo application of PDL for laryngeal lesions was reported in 1998 by McMillan et al.  They used PDL in the management of 3 patients with laryngeal papillomatosis. The principle behind using PDL in their study was to cause regression of papillomas by selective eradication of the tumor microvasculature. They reported a successful treatment outcome with PDL and also stated that the epithelial surface of the larynx in these treated patients was well-preserved as compared to those treated with CO 2 laser. Centric et al. also reported a successful outcome with PDL for the management of laryngeal papillomatosis.  However, some of his patients required the use of other treatment modalities in conjunction with PDL in these patients. Hartnick et al. reported the use of PDL in the management of laryngeal papillomatosis of vocal folds and anterior commissure in 23 pediatric patients. This prospective cohort study concluded that PDL is an extremely efficient and safe instrument of managing this condition as evidenced by a lack of any anterior commissure webbing or vocal fold scarring in the study subjects.  Zeitels et al. ( 2007) also concluded the office-based PDL is a safe and effective instrument for managing laryngeal papillomatosis.  They reported a significant disease involution and regression with better voice outcomes in their patients. The safety and efficacy of PDL have also been concluded by Franco et al. in their study on 41 patients with laryngeal papillomatosis in 2002.  They reported that PDL also makes excision with cold knife easy and bloodless in patients requiring surgery after PDL application. However, they reported PDL to be ineffective for exophytic lesions as the depth of penetration of PDL was limited to 2 mm. Mouadeb and Belafsky and Valdez et al. have also reported similar results with significant disease regression and absence of complications such as vocal fold scarring or web formation in treated subjects. ,
Other benign laryngeal pathologies
Besides laryngeal papillomatosis, there are reports of PDL being used in a wide range of laryngeal pathologies. Zeitels et al. reported its used for the management of ectasias and varices of true vocal folds in singers.  They reported that noncontact selective angiolysis of the aberrant vessels using PDL and pulsed KTP-532 in these patients prevented future bleeding without any significant photothermal injury to the epithelium and superficial lamina propria. This allowed for optimal postoperative mucosal pliability and better perceptual sound production. Mouadeb and Belafsky reported the successful use of PDL in management of Reinke's edema and vocal polyps without any complications. 
Mortensen et al. reported the application of PDL for treatment of vocal fold scarring.  They carried out a prospective cohort study involving 11 patients with vocal fold scarring due to phonosurgery, radiation, or partial laryngectomy. The patients underwent a preoperative VHI, stroboscopic analysis, acoustic analysis, aerodynamic analysis, and self-evaluation. Three applications of PDL were done 1 month apart as an office-based procedure. Postoperative assessment showed a statistically significant improvement in all the parameters without any complications.
Centric et al. reported successful treatment of benign pathologies such as vascular lesions, granulomas, benign neoplasms, amyloidosis, and anterior glottis web, besides laryngeal papillomatosis with PDL.  The advantages reported by them included avoidance of general anesthesia, improved efficiency, lowered overall cost, and minimal anterior commissure web formation. They also advocated PDL to be used as monotherapy in selected laryngeal pathologies.
Kim and Auo reported a retrospective analysis of 75 patients who underwent PDL-assisted vocal cord polypectomy.  The mean follow-up was 5.2 months and all the patients showed statistically significant improvement in terms of acoustic, aerodynamic, and perceptual parameters. There were no reported complications. Hwang et al. reported a prospective cohort study of application of PDL in the management of 25 patients with sulcus vocalis.  Their results indicated a decreased stiffness and increased mucosal wave properties of the vocal folds treated with PDL. Aerodynamic, stroboscopic, and acoustic voice analyses also showed significant improvement in these patients.
Premalignant and malignant laryngeal lesions
Franco et al. were the earliest to report the use of PDL in the management of glottis dysplasia.  In their prospective cohort study on 57 patients (including 1 case of glottis carcinoma), they reported a significant reduction in lesion size in 80% of the patients. They also found an enhanced epithelial excision as a result of improvement in hemostasis and creation of an optimal dissection plane between the basement membrane and the underlying superficial lamina propria in patients treated with PDL. There was no anterior glottis web formation in spite of simultaneous bilateral anterior vocal cord treatment. Zeitels et al. also reported a significant disease involution in a prospective cohort study comprising 52 cases.  Ayala et al. performed a prospective cohort study on 9 patients with glottic dysplasia.  The lesions were partly subjected to PDL and biopsies for ultrastructural evaluation were taken from PDL- and non-PDL-treated areas. The evaluation revealed that the intraepithelial desmosome junctions were preferentially destroyed, and regional blood vessels were coagulated in PDL-treated areas. The PDL consistently caused a separation of epithelial cells away from the basement membrane. They also reported that the vocal fold appearance returned to normal 3-4 weeks following treatment.
An interesting and novel application of PDL was reported by Franco in 2007.  He reported a 5 years prospective cohort study in 8 individuals with laryngeal keratosis in which PDL was used as an activating agent in photodynamic therapy using aminolevulinic acid (ALA-PDT). The mean follow-up in this study was around 3 years with a 78% reduction in keratosis. There were no side effects reported. The voice-preserving advantage of PDL in premalignant lesions was reported in 2014 by Park et al.  They subjected 19 patients of leukoplakia to PDL treatment. They reported a significant improvement in terms of acoustic analysis, electroglottography, and VHI.
Comparative analysis and complications
Although the safety and efficacy of PDL have been well-established in a majority of reported studies, the literature on its comparative analysis with the other commonly used lasers is scarce. We could identify only one study comparing its application with that of CO 2 laser. This study carried out by Park et al. reported PDL to be distinctly advantageous over CO 2 laser in terms of voice outcomes when used in the management of glottis leukoplakia.  PDL also has a distinct advantage of being transmitted through fiberoptic that makes it suitable for in-office application as compared to the traditional CO 2 laser. However, the recent invention of the flexible CO 2 laser delivery system has expanded its use to the office as well, thereby overcoming this limitation of CO 2 laser.  More such comparative analyses are required for different laryngeal pathologies to reach a conclusion as to the relative efficacy of the two lasers. Similarly, we could identify only one study that compares the efficacy of PDL with a recently developed pulsed KTP-432 laser. Zeitels et al. reported the pulsed KTP laser to be better as compared to PDL when used for management of vocal fold ectasias and varices.  The reported the pulsed KTP laser to be substantially easier to use due to its enhanced hemostasis owing to its longer pulse width. They also reported a significantly lesser incidence of vessel wall rupture with KTP laser as compared to PDL. Zeitels et al. in their review also reported pulsed KTP to be clinically more effective, structurally more reliable, and less expensive as compared to PDL.  Again, more structured comparative analyses are required to reach a conclusion regarding the relative efficacy of these two lasers.
None of the reviewed studies have reported any significant complication with the use of PDL. Procedure related complication in the form of anxiety attack in one patient was reported by Centric et al.  Similarly, Zeitels et al. also reported inadequate exposure and discomfort in few of the patients.  The only significant complication that may be laser related was reported by Mouadeb and Belafsky in the form of stridor in one patient requiring hospitalization of the patient.  Thus, the safety of PDL is well-established for both in-office as well as operative room application.
| Conclusion|| |
There is a good deal of evidence to support the efficacy and safety of PDL in the management of a wide range of benign, premalignant, and early malignant lesions of the larynx. However, the limited depth of penetration does not make it an ideal tool for managing exophytic lesions at present. It is cost effective and relatively easy to use. Although there are reports of the pulsed KTP laser to be better than PDL in the management of certain laryngeal lesions, the data are currently inadequate to conclude this comparison. We recommend the use of PDL in the management of selective laryngeal pathologies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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