|Year : 2013 | Volume
| Issue : 3 | Page : 169-171
Management of a case of misadventure with lasers
Rajendra B Metgudmath1, Vinita V Metgudmath1, Anjali R Metgudmath2, Amal Das1
1 Department of Otorhinolaryngology, Head and Neck Surgery, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India
2 Department of General Medicine, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India
|Date of Web Publication||19-Oct-2013|
Rajendra B Metgudmath
95/c, Anugraha, Shanti-Nagar, M. G. Road, Tilakwadi, Belgaum - 590 006, Karnataka
Source of Support: None, Conflict of Interest: None
Transoral laser microsurgery in the management of primary as well as recurrent laryngeal carcinoma has been well-established throughout the world as an organ-preserving surgical procedure. We present a patient with early glottic carcinoma who inadvertently underwent several laser excisions and finally ended up with a total laryngectomy.
Keywords: Glottic carcinoma, laryngectomy, laser microsurgery, radiotherapy
|How to cite this article:|
Metgudmath RB, Metgudmath VV, Metgudmath AR, Das A. Management of a case of misadventure with lasers. J Sci Soc 2013;40:169-71
| Introduction|| |
Laser has been used in the management of both benign and malignant lesions of various organs of the body. In recent years, the role of laser in the treatment of laryngeal tumor has increased many folds. Adequate training, proper selection of cases and appropriate instrumentation are of paramount importance in accomplishing superior outcome.
| Case Report|| |
A 45-year-old male patient attended Head and Neck surgical oncology out-patient department with the complaints of hoarseness of voice along with breathing difficulty since 6 months. Patient had undergone treatment for the same in the hands of reputed laser surgeon at a leading tertiary referral center in the country. The documents regarding the previous treatment received at the tertiary center was analyzed. The initial video laryngoscopy carried out revealed a right vocal cord growth and the video stroboscopy revealed decreased mobility of the right vocal cord [Figure 1]a, [Table 1]. Frozen section report of the right vocal cord biopsy showed squamous carcinoma, following which the patient underwent right vocal cord laser cordectomy. Histopathology sections from the right true cord, anterior part of true cord, postero-inferior part of cord, and tissue lateral to right cord showed moderately differentiated invasive squamous cell carcinoma and the mentioned margins of excision were positive for tumor. Subsequently after one week, the patient underwent second surgery in the form of a right extended cordectomy using diode laser and the histopathology report mentions revised lateral margin positive for tumor. Video laryngoscopy carried out a week after surgery showed slough at the operated site [Figure 1]b and the patient underwent removal of slough along with excision of the positive lateral margin and right false cord the very next day. The histopathology report suggested that the surgically excised margins were free of tumor.
|Figure 1: (a) Initial video laryngoscopy showing right vocal cord growth; (b) Videolaryngoscopy showing slough at the operated site|
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The patient again presented with complaints of breathlessness at the same center after one and a half months. The video laryngoscopy carried out at that time revealed anterior glottic web, [Figure 2]a which was excised using carbon dioxide laser and the histopathology report mentioned that the margins were free of tumor.
|Figure 2: (a) Video laryngoscopy showing anterior glottic web; (b) Videolaryngoscopy showing slough at the operated site|
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After another 3 months, the patient returned with persisting complaints and video laryngoscopy carried out showed slough at the operated site, [Figure 2]b and the same was excised the very next day. The computed tomography (CT) scan of the neck carried out a day after slough excision revealed significant narrowing of the supra-glottic and glottic airway for a length of 2.8 cm with airway measuring 2 mm in maximum width. It also revealed that the right paraglottic fat was obliterated and there was no documentation of recurrence and a decision to observe was taken at that center. One month later, the patient again presented with breathing difficulty for which he underwent left complete cordectomy and arytenoidectomy using carbon dioxide laser, which happened to be the sixth surgery that the patient underwent [Figure 3]a. As per the radiotherapist opinion, no radiotherapy (RT) was given.
|Figure 3: (a) Video laryngoscopy showing operated field after left complete cordectomy and arytenoidectomy; (b) Video laryngoscopy showing narrowed glottis space|
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When the patient presented again with similar complaints after two and a half months, video laryngoscopy revealed narrowed glottis space, [Figure 3]b and he was advised to undergo another surgery. As the patient was unhappy with the treatment, he visited our center for consultation with all the above medical reports.
The patient was subjected for CT scan of neck with contrast at our center, which showed the lesion involving bilateral vocal cords, anterior commissure, posterior commissure, and with involvement of the paraglottic space [Figure 4]a. The biopsy of the lesion confirmed squamous cell carcinoma, and the patient underwent total laryngectomy [Figure 4]b along with post-operative adjuvant RT.
|Figure 4: (a) Computed tomography scan showing growth involving the anterior commissure, both vocal cords along with involvement of paraglottic space; (b) Total laryngectomy specimen|
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| Discussion|| |
Early glottic cancer (that is stage 1 and stage 2) is a curable disease. ,, Hence, the treatment goal should offer the best possibility for cure, preserving best possible laryngeal voice quality, without inducing serious acute or late complications and must be cost effective. ,, Currently available treatment options include RT, transoral laser microsurgery (TLM) and open partial laryngectomy. , Generally radiation therapy has been the preferred initial therapy and has been the treatment of choice in the management of early glottic carcinoma. 
In recent years, with introduction of laser in the management of laryngeal malignancy, it has been used successfully for early as well as advanced-staged laryngeal cancers, both as primary modality and in recurrent glottic carcinomas after radiation failure.  Hence currently; there is a discrepancy regarding the choice of primary modality of treatment especially, for early laryngeal cancer. Both RT and TLM can offer high-cure rates, satisfactory post treatment voice quality along with acceptable short- and long-term morbidities for early glottic cancers.  The currently available literature shows that the overall survival and local control by radiation therapy and laser microsurgery are equally effective. ,,,,,,,
The advantages of TLM are it can be carried out as a single sitting out-patient procedure, cost- effective, does not require tracheostomy and it may be repeated. However, patients with trismus, dental arch abnormality, bulky tongue or anteriorly placed larynx might lead to an inadequate exposure of the entire lesion endoscopically, which could result in difficulty to excise the entire lesion safely. 
Thus, the decision to choose the modality of treatment could finally depend on the skill of the surgeon, availability of various endoscopic instruments, type of RT treatment, and treatment planning equipment.  Besides great expertise is required, especially, in resections of advanced-stage or recurrent carcinomas.  Careful and appropriate case selection for TLM would possibly result in lower recurrence rates and prevent such complications as mentioned in this case report.
This is a case report of patient who underwent total laryngectomy and had to sacrifice his natural voice, which could have been prevented. Lesson to be learnt from this case is that, laser has a steep learning curve and even after mastering one need to select the cases appropriately. Any newer modality should be used cautiously. No harm should be caused to the patients just for sake of using newer modality. This case should be an eye opener for the budding as well as senior laser surgeons alike.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]