Image guided surgery is one of the most significant advances in endoscopic sinus surgery since its beginning. This technology enables the surgeon to follow the anatomic dissection of the sinuses on a computer monitor in the operating room in real time. As the normal anatomy is often distorted by disease, trauma or previous surgery, and as minimally invasive surgical techniques have been developed, Intraoperative image guidance has become an invaluable tool.
Image guidance is a near-three-dimensional mapping system that combines computed tomography (CT) scans and real-time information about the exact position of surgical instruments using infrared signals. In this way, surgeons can navigate their surgical instruments through complex sinus passages and provide surgical relief more precisely and safely.
Even after obtaining a detailed knowledge of the anatomy and surgical skills, motor nerves can be difficult to identify during surgery due to a disease, a previous operation, or normal anatomical variations, which can lead to a temporary or permanent damage if nerve is irritated or injured.
For e.g., During skull base surgery and various ear surgeries, the facial nerve is commonly exposed and at a risk for injury. This nerve controls all movements and expressions of the face and damaging this nerve can have devastating physical and emotional results.
Similarly, the recurrent laryngeal nerve, is one of the nerves at risk during neck dissections including thyroid surgery. Damaging this nerve can severely affect patient’s ability to speak and swallow. Intraoperative Nerve monitoring system enable the surgeon to identify, confirm and monitor nerve function to help reduce the risk of nerve damage during various procedures. Research confirms the benefits of intraoperative nerve monitoring for nerve preservation and as a risk – minimizing tool.
The term coblation is derived from “Controlled ablation”. The procedure involves non-heat driven process of soft tissue dissolution using bipolar radiofrequency energy under a conductive medium like normal saline. When current from radiofrequency probe pass through saline medium it breaks saline into sodium and chloride ions. These highly energized ions form a plasma field which is sufficiently strong to break organic molecular bonds within soft tissue causing its dissolution.
Coblation tonsillectomy has evolved as a very effective method of treatment due to the face that, contrary to laser method, little heat is used causing little or no damage to neighbouring structures. Additionally, this method is more advantageous because it causes little to almost no pain and reduces subsequent bleeding.
Radiofrequency is high frequency alternating current used in ablative treatment of tongue base, palate, tonsil, and nasal turbinates in obstructive sleep apnoea. It entails giving high frequency energy to these structures causing ablation, inflammation and subsequent healing with fibrosis. Radiofrequency has many applications in ENT but the main are for obstructive sleep apnoea.
Surgeries for snoring – Snoring is mostly caused by relaxed soft palate tissues. Radiofrequency can be used to contract and stiffen lax tissues, thus eliminating snoring.
Tonsillar hypertrophy – Reduces the size of tonsils without compromising on lymphatic function.
Turbinate hypertrophy – The most common reason for nasal obstruction is mucosal hypertrophy of the inferior turbinate, followed by structural deformity of the nasal airway (septal deviation, bony inferior turbinate hypertrophy). Numerous interventions are available for the treatment of nasal obstruction secondary to inferior turbinate hypertrophy including medical treatments (immunotherapy, antihistamines, intranasal corticosteroid sprays, decongestants) and surgical options (corticosteroid turbinate injections, cryosurgery, electrocautery, turbinate out-fracture, microdebrider-assisted turbinoplasty, excision and submucous resection). The goals of inferior turbinate surgery include volume reduction, a reduction in nasal obstruction, and maintenance of nasal function while minimizing complications. There is currently no consensus on the most effective technique.
Radiofrequency turbinate reduction (RFTR) is a minimally invasive surgical option that can reduce tissue volume in a precise, targeted manner. This technique uses radiofrequency to create lesions within the submucosal tissue of the turbinate, reducing tissue volume with minimal impact on surrounding tissues. Radiofrequency turbinate reduction differs fundamentally from traditional methods by using low-power radiofrequency energy to provide a relatively quick and painless procedure for tissue coagulation.
Obstructive sleep apnoea syndrome
Advantages of Radiofrequency Low temperature
Cosmetic results superior
Laser surgery is widely applied in a variety of human surgical specialities such as otolaryngology, gynaecology, neurosurgery, plastic surgery, dermatology and oral & maxillofacial surgery. Out of several laser types available, the CO2 laser is considered the “workhorse” of laser surgery due to its unique capabilities in performing precise, hemostatic incisions, excisions and ablations of tissue. The CO2 laser emits continuous or pulsed infrared radiation which is highly absorbed in water. Since any soft tissue is composed mainly of water, tissue at the focal point of the laser beam is instantaneously vaporized, leaving behind a thin necrotic layer of tissue which assures hemostasis.
How does it work?
The wavelength emitted by a CO2 laser is 10,600 nanometers (nm). This wavelength is in the far infrared spectrum and is invisible to the human eye. Water has extremely high absorption at this wavelength. A 30-micron thin layer of water will absorb 90% of CO2 laser radiation, and only 10% will pass through. Since 75-95% of soft tissue is composed of water, this wavelength is highly absorbed in soft tissue and therefore highly effective in vaporizing soft tissue, regardless of colour. Tissue vaporization is instantaneous with very minimal surrounding thermal necrosis which aids in hemostasis. The spectral absorption of water also provides the CO2 laser with the ability to coagulate, cut, or char, tissue depending on the power density and the energy level applied by the surgeon. When the laser beam is focused, the laser can cut like a scalpel, but when the laser is defocused the laser vaporizes the soft tissue. The surgeon can control the extent by which the laser beam is absorbed into surrounding tissue, resulting in an extremely precise tissue incision. To minimize heat transfer to surrounding tissue and reduce collateral heat damage, the duration of the laser beam on the tissue can be controlled (usually less than 1 millisecond). To allow precise positioning of the surgical laser beam, an additional red, low power laser beam is incorporated in the system so that both beams are coincident at the surgical site.
BENEFITS
1. Pain Reduction
Patients will experience considerably less postoperative pain in almost every instance. This reduction in pain is a result of the unique characteristics of the laser beam as it cuts nerve endings, preventing the raw ends typical to scalpel incisions.
2. Swelling Reduction
Whenever an incision is made in the tissue with either a scalpel blade or scissors, inflammation begins in the affected tissue. This inflammation is a result of interaction with the circulatory and lymphatic systems. Because the laser beam effectively cauterizes the lymphatic system, there is much less postoperative swelling. In addition, laser energy does not crush, tear, or bruise tissue since there is no physical contact with the tissue. Postoperative Recovery is faster and the patient experiences more comfortable.
3. Control of Infection
Since laser beam operates at a temperature of over 200 degrees Fahrenheit; it is highly effective at killing bacteria that have the potential to cause an infection. In fact, this is particularly important in areas in which it is difficult to prevent contamination of the surgical site. The CO2 laser sterilizes the infected area as it removes diseased tissue, leaving healthy tissue undamaged. Because the sterilization process is so effective, the use of antibiotics is substantially reduced.
4. Minimal Surgical Bleeding
When an incision is made with a scalpel blade, blood vessels in the area are severed and can ooze during and after the surgery. The laser seals small blood vessels as it cuts, reducing or eliminating the need for any other bleeding control measures.
5. Hospitalization and Healing Time
With laser surgery, healing is rapid and there is less postoperative discomfort. Laser procedures provide reduced trauma and less invasive surgeries for patients, improve recovery time, and shorten time spent in the hospital. No tissue reaction (edema) is usually noted. The laser allows the destruction of diseased tissue while preserving normal tissue. Post-surgical scarring is also reduced.
6. Greater Accuracy & Precision
The laser can remove diseased tissue without affecting surrounding healthy tissue. Not only does the blood-free cutting benefit the patient, but it also provides a clear, dry surgical field for the surgeon.
However, the used of the laser in the field of otorhinolaryngology is limited. The described indications for the use of laser in E.N.T surgery are:
Middle Ear Surgery : Stapedotomies and myringotomies
Nasal, Endonasal & Endoscopic Sinus Surgery: Turbinate reduction | removal of nasal obstructions/synechiae | rhinophyma | keloids and hypertrophic scars
Oral Surgery: Leukoplakia | Erythroplakia | Papilloma | Hemangioma | Tumours | Zenker’s diverticulum | | LAUP (Laser Assisted Uvulo Palatoplasty) | Tonsillotomy & tonsillectomy
Transoral Laryngeal Microsurgery: Cordectomies and cordotomies | polyps and laryngeal papilloma | Reinke’s edema | laryngocele | hyperkeratosis laryngitis | scar tissue | granulomas | congenital web | primary laryngeal tumours | laryngotracheal stenosis | laryngeal amyloidosis
Tracheobronchial Tree:Stenosis, nodules, polyps, tumour
Head & Neck: Resection of tumours