Laser versus cold instruments for microlaryngoscopic surgery

Controversy has arisen concerning the merits of the CO2 laser in microlaryngoscopic surgery because of the potentially harmful effects that the injudicious application of the laser could have on voice production. In an effort to develop a logical approach to instrument selection, the author examined the use of both cold instruments and the CO2 laser in the treatment of various benign and malignant lesions. A retrospective review of 307 microlaryngeal procedures performed over a 3-year period revealed that 263 (86%) were glottal and 44 (14%) were supraglottal. Of the 263 glottal procedures, 203 (77%) employed cold instruments alone and 60 (23%) used both cold instruments and the CO2 laser. The laser was used to assist in all 44 supraglottal procedures. Therefore, 203 (66%) of 307 procedures were done with cold instruments alone, and 104 (34%) of 307 procedures were performed using the CO2 laser with cold instruments. Lesions were stratified on the basis of pathology and size, as well as surgical approach. A primary phonomicrosurgical principle in glottal surgery is to maximally preserve the vocal fold's layered microstructure (laminae propria and epithelium). Precise tangential dissection was necessary for achieving this goal. For limited lesions, this dissection was best accomplished with cold instruments alone. The CO2 laser facilitated hemostatic surgical dissection for all supraglottal lesions and for selected larger glottal lesions in which bleeding would obscure visualization of the microanatomy of the musculomembranous vocal fold.