CO · absence of bleeding, the boundaries between tumor and healthy tissue can ... Today, then, we can remove resectable carcinomas of the supraglottis and

CO2 LASER SURGERY OFBENIGN AND MALIGNANT LESIONS

OF THE ORAL CAVITY,PHARYNX AND LARYNX

Prof. emeritus Heinrich RUDERT, M.D.and Prof. Jochen A. WERNER, M.D.

CO2 Laser Surgery of Benign and Malignant Lesions of the Oral Cavity, Pharynx and Larynx4

Some of the product names, patents, and registered designs referred to in this booklet are in fact registered trademarks or proprietary names even though specifi c reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

Important notice:

Medical knowledge is ever changing. As new research and clinical experience broaden our knowledge, changes in treatment and therapy may be required. The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publi-cation. However, in view of the possibility of human error by the authors, editors, or pub-lisher of the work herein, or changes in medi-cal knowledge, neither the authors, editors, publisher, nor any other party who has been involved in the preparation of this work, war-rants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omis-sions or for the results obtained from use of such information. The information contained within this brochure is intended for use by doc-tors and other health care professio nals. This material is not intended for use as a basis for treatment decisions, and is not a substitute for professional consultation and/or use of peer-reviewed medical literature.

CO2 Laser Surgery of Benign and Malignant Lesionsof the Oral Cavity, Pharynx and LarynxProf. emeritus Heinrich RUDERT, M.D.and Prof. Jochen A. WERNER, M.D.

Addresses for correspondence:Prof. emeritus Dr. med. Heinrich RUDERTder Klinik für Hals-, Nasen-, Ohrenheilkunde,Kopf- und Halschirurgie der Christian-Albrechts-Universität zu KielLamontstr. 1, D-81679 München, GermanyPhone: +49 (0) 89/4 1 07 48 88Fax: +49 (0) 89/4 10 49 18E-mail: [email protected]

Prof. Dr. med. Jochen A. WERNERDirektor der Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde,Philipps-Universität MarburgDeutschhausstr. 3, D-35037 Marburg, GermanyPhone: +49 (0) 64 21-5 86 64 78Fax: +49 (0) 64 21-5 86 63 67E-mail: [email protected]

© 2011 ™ TuttlingenISBN 978-3-89756-048-2, Printed in GermanyP.O. Box D-78503 Tuttlingen, GermanyPhone: +49 (0) 74 61/1 45 90Fax: +49 (0) 74 61/7 08-5 29E-mail: [email protected]

Editions in languages other than English and German are in preparation. For up-to-date information, please contact TM

Tuttlingen, Germany, at the address indicated above.

Layout and illustrations:™ Tuttlingen, Germany

Printed by:Straub Druck + Medien AGD-78713 Schramberg, Germany04.11-2

5CO2 Laser Surgery of Benign and Malignant Lesions of the Oral Cavity, Pharynx and Larynx

Content1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.0 Basic Principles of Laser Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.0 Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

4.0 Preoperative Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

5.0 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

6.0 Safety Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166.1 Immediate Management of an Endotracheal Tube Fire. . . . . . 16

7.0 Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177.1 Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

7.1.1 Recurrent Respiratory Laryngeal Papillomatosis. . . 177.1.2 Laryngotracheal Stenosis . . . . . . . . . . . . . . . . . . . . . . 197.1.3 Bilateral Recurrent Laryngeal Nerve Palsy . . . . . . . . 227.1.4 Benign Neoplasms of the Larynx and Hypo-

pharynx (Cysts, Polyps, Reinke Edema, Vocal Cord Nodules, Hemangiomas, Pheochromocytomas) . . . 25

7.1.5 Hypopharyngeal Diverticula (Zenker Diverticula) . . . 277.1.6 Laryngeal and Hypopharyngeal Carcinoma . . . . . . . 297.1.6.1 Glottic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297.1.6.1.1 Limited Glottic Carcinoma . . . . . . . . . . . . . . . . . . . . . 297.1.6.1.2 Advanced Glottic Carcinoma . . . . . . . . . . . . . . . . . . . 307.1.6.1.3 Limits of the Transoral Resection of Glottic

Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347.1.6.2 Supraglottic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . 357.1.6.2.1 Small Carcinomas of the Epiglottic Margin. . . . . . . . 357.1.6.2.2 Carcinomas of the Suprahyoid and Infrahyoid

Epiglottis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367.1.6.2.3 Carcinomas of the Ventricular Fold . . . . . . . . . . . . . . 417.1.6.2.4 Treatment Concept for the Lymphatic Drainage of

Supraglottic Cancers. . . . . . . . . . . . . . . . . . . . . . . . . . 427.1.6.3 Hypopharyngeal Carcinoma . . . . . . . . . . . . . . . . . . . . 44

7.2 Lesions of the Oral Cavity and Oropharynx . . . . . . . . . . . . . . . 497.2.1 Intraoral and Oropharyngeal Carcinomas . . . . . . . . . 49

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Rigid and Flexible Endoscopes, Operating Instruments, and Accessories for CO2 Laser Surgery – KARL STORZ EndovisionCamera System and Accessories for Illumination, Video Documentation, and Data Storage . . . . . . . . . . . . . . . . . . . . . . . 56


1.0 IntroductionJako introduced the CO2 laser to endolaryngeal surgery in the early 1970s by coupling the laser to an operating microscope. One of the earliest applications of CO2 laser surgery was for the vaporization of laryngeal papillomas. Initial hopes that the new technology could solve the problem of recurrent laryngeal papillomatosis were not fulfi lled, although CO2 laser surgery was able to minimize the need for tracheostomy. Initially, surgeons also tended to overestimate the role of laser surgery in the treat-ment of laryngotracheal stenosis.

On the other hand, the potential of lasers in treating carcinomas of the larynx and hypopharynx, oral cavity, and oropharynx was underestimated for many years. As early as 1972, Strong and Jako performed the laser resection of small glottic cancers limited to the middle third of the vocal cords. But even today in the U.S. and many other countries, small, easily resectable laryngeal and hypopharyngeal cancers are managed by radiotherapy rather than laser surgery, despite the signifi cant risks of radiogenic mucosal damage and voice impairment. This trend has been encouraged by the successful use of chemoradiation in the treatment of advanced tumors. Surgical techniques for partial laryngectomy have become a lost art at many centers. In Europe and especially in Germany, surgeons at selected centers have systematically tested and refi ned CO2 laser techniques for the treatment of malignant tumors, including larger laryngeal cancers, since the late 1970s. Wolfgang Steiner and surgeons at hospitals in Erlangen and Göttingen, Germany, have been particularly instrumental in this regard. Another center in Northern Germany was and is the Department of Otorhinolaryngology, Head and Neck Surgery at Christian Albrecht University Hospital in Kiel, where laser surgical techniques have been performed and developed under the senior author of this booklet, Heinrich Rudert, since the 1980s. The junior author, Jochen A. Werner, has also been instrumental through his contribu-tions to international tumor conferences and courses on laser surgery in Kiel. Since 1998, these techniques have been advanced by Prof. Werner and his school in Marburg and have been taught at the international level.

Initially, many surgeons rejected CO2 laser surgery because the earliest micromanipulators offered by industry could coagulate tissue but could not produce fi ne surgical incisions. As a result, surgeons could not obtain histologic confi rmation of negative margins. Another disadvantage was that the removal of small glottic cancers left extensive scars that compromised vocal function.


This changed with the advent of modern microspot manipulators, which could produce a fi ne incision similar to that made by a sharp surgical scalpel. Now it was possible to remove even small, superfi cial glottic cancers with-out causing signifi cant submucosal injury. The good functional results are comparable to the results of conventional microsurgery using Kleinsasser-type microscissors and scalpels. Additionally, the functional results in most patients are signifi cantly better than the results of radiotherapy.

One advantage of the CO2 laser over conventional microsurgery of the larynx is the excellent cutting properties of the CO2 laser, which make it possible to excise tissue specimens larger than those removable with conventional microsurgical scissors and scalpels.

Large, oncologically resectable tumors that cannot be removed in one piece by the transoral route must be divided into smaller portions with the laser beam. This method, which is unconventional in oncologic surgery, is made practical by the cutting characteristics of the CO2 laser. Due to the absence of bleeding, the boundaries between tumor and healthy tissue can be accurately identifi ed by examining the cut surface under the operating microscope. This allows for a piecemeal tumor resection while still obtaining clear surgical margins.Another advantage of the CO2 laser is that the dysphagia which usually follows a conventional open partial laryngectomy is either absent or much less severe after an endolaryngeal partial laryngectomy with the CO2 laser. Today, then, we can remove resectable carcinomas of the supraglottis and hypopharynx transorally that would otherwise be referred for radiotherapy – a modality that yields demonstrably poorer oncologic results than surgical resection.

In this new edition of our 2002 booklet on CO2 laser surgery, we confi ne our attention to the treatment of benign and malignant neoplasms of the oral cavity, larynx, oropharynx, and hypopharynx. Use of the laser in the nose and auditory canal is no longer addressed.


2.0 Basic Principles of Laser SurgeryThe CO2 laser emits coherent, monochromatic, invisible light at a wavelength of 10,600 nm (Fig. 2.1). The laser beam is directed into the optical path of an operating microscope along with a visible, coaxial aiming beam produced by a helium-neon laser (Fig. 2.2). The microscope is adjusted so that the focal spots of the aiming beam, CO2 laser beam, and operating microscope all coincide.

The invisible CO2 laser beam with coaxial visible aiming beam is directed into the optical path of the operating microscope with a micromanipulator.

2.2

Difference between laser light and non-laser light. The rays of laser light are monochromatic, coherent, and parallel to one another. The CO2 laser emits light at a wavelength of 10,600 nm.

2.1

Laser light Lens

Non-laser light


The surgeon uses the joystick of a micromanipulator (Fig. 2.3) to move the laser beam into the target area where it will exert its effect.

The laser has several operating modes. We prefer the continuous-wave (CW) mode, which delivers laser energy continuously to the targeted site (Fig. 2.4a). The CW mode produces a bloodless cut surface at the capillary level. Pulsed lasers are less suitable for working on soft tissue. The applied laser energy is measured in watts. Energy density is expressed as watts/cm2, power density as joules/cm2. There are also other operating modes like the superpulse and ultrapulse modes whose designations vary from one manufacturer to the next (Fig. 2.4b). The laser pulse shape, or pulsed laser energy plotted over time, is a more important consideration than mode designations. Armed with this information, the surgeon can more accurately assess whether a given pulse shape can remove tissue with little collateral thermal injury – e.g., for ablating minimal lesions on the free edge of the vocal cord – or whether it can divide bone or even cartilage more effectively than a continuous beam.

Operating room setup. The patient is under general endotracheal anesthesia. The laryngoscope, which has been passed into the larynx, is connected to a lateral suction system. The surgeon controls the joystick of the micromanipulator with the left hand. The right hand controls an additional instrument at the operating site.

2.3

2.4a

P

P

t

t

CW mode

Single pulse

a + b: Different operating modes of the CO2 laser. We prefer the continuous-wave (CW) mode for most applications.

2.4b

P

P

t

t

Superpulse (Sharplan)

Ultrapulse (Coherent)Ultrapulse (Coherent)

Pmax =150 W

Pmax =550 W


Surgical applications of the CO2 laser make use of its photothermal properties. The CO2 laser beam is completely absorbed at tissue surfaces and is transformed into heat. Thus as the laser beam enters the tissue, it generates temperatures on the order of several hundred degrees Celsius. This is suffi cient to vaporize the tissue, producing a crater whose walls exhibit three zones of tissue damage (Fig. 2.5).

The penetration depth of the laser beam depends on the applied energy.1. Carbonized zone2. Necrotic zone3. Zone of reversible edema

2.5

1

23

High energy

Moderate energy

Low energy


The carbonized zone is a charred area that lines the laser crater. It consists of carbon particles that are visible under the operating microscope. These particles should be wiped away with a moist brush at the end of the proce-dure to prevent foreign body reactions.

The carbonized zone is bordered by the necrotic zone. This is an area of coagulation necrosis caused by thermal effects below the boiling point. The necrotic zone is bordered by a zone of reversible edema caused by temperatures below 45° C.

Because of the steep temperature gradient, the three damage zones have a cumulative thickness of no more than 0.5 to 0.8 mm. The necrotic zone includes small vessels up to 0.5 mm in diameter that have been sealed by the beam. This is a desirable effect which provides an almost bloodless fi eld and makes it easier to evaluate the cut surface through the operating microscope.The smaller the spot size of the CO2 laser beam, the lower the beam energy that can be used and the better the quality of the laser incision. For example, modern microspot manipulators can produce a spot size of 0.25 mm at a focal length of 400 mm. In this situation a power setting of 2 W will produce an energy density of approximately 8000 J/cm2, which ensures a clean incision (Fig. 2.6b). Older micromanipulators often have a spot size larger than 0.6 mm, requiring a power setting of 10–13 W to achieve the same energy density (Fig. 2.6a).

Figures 2.6a, b and 2.7 show that the surface of the cut is signifi cantly less traumatized when a modern microspot manipulator is used. This also facilitates histologic evaluation of the cut edges (Fig. 2.7).

It should be noted, however, that wound healing takes approximately 10 days longer with a CO2 laser than with cold-cutting instruments. This greatly limits the use of the CO2 laser in phonosurgery.The cutting mode is the most commonly used operating mode for the CO2 laser. Vaporization is limited to a few indications such as the debulking of extensive laryngeal papillomatosis.

Relationship between laser power, spot size, and exposure time. 13 W, 0.64 mm, 2 seconds => 8148 J/cm2.

2.6a

2 W, 0.25 mm, 2 seconds => 8148 J/cm2.

2.6b

Quality of the incision obtained with a spot size of 0.25 mm and a low-power beam (2 W).

2.7


3.0 InstrumentationThe CO2 laser is usually coupled to an operating microscope in otolaryn-go logy. For laryngeal surgery, the microscope and laser beam are used at a focal length of 400 mm. A focal length of 300 mm is appropriate for laser surgery in the oral cavity, pharynx, and nose. Tracheal surgery employs a ventilation bronchoscope and optical adapters with longer focal lengths.The structures of interest are exposed with retractor blades and endoscopic tubes that have at least one smoke evacuation channel. We have modifi ed the Kleinsasser laryngoscope by adding two side channels that can alternately accommodate fi beroptic light cables and suction tubes (Figs. 3.1a, b).

A laryngoscope with a triangular distal aperture can improve visualization of the anterior commissure (Figs. 3.2a–c). The triangular opening conforms better to the anatomy of the glottic plane than a standard tube.

Triangular laryngoscope for visualization of the anterior commissure.

3.2a

View from the proximal to distal end.

3.2b

The glottic plane viewed through the triangular laryngoscope. The anterior commissure is clearly visualized.

3.2c

View through the laryngoscope from the proximal end. A fi beroptic cable has been inserted into the left channel and a suction tube into the right channel. Each channel opens distally into the laryngoscope lumen.

3.1b

Modifi ed Kleinsasser laryngoscope with side channels for introducing fi beroptic cables and smoke evacuation tubes. The proximal ends of the channels open externally. Their distal ends open into the laryngoscope lumen for evacuating the vaporization fumes.

3.1a


Exposure of the lesion depends critically on anatomical factors. Visualization may be hampered by factors such as a stiff cervical spine, a very short neck, or even protruding maxillary teeth. In the latter case it may be helpful to introduce the tube at an edentulous area of the jaw (Fig. 3.3).

The Weerda bivalved laryngoscope has been modifi ed for surgery of the oropharynx, supraglottis, and hypopharynx by adding suction tubes and shortening the blades.

A special supraglottiscope (Figs. 3.4a, b) and an oropharyngoscope (Figs. 3.5a, b) were developed by shortening and widening the blades. We use the Weerda diverticuloscope when performing an endoscopic Zenker diverticulotomy (Figs. 3.6a, b).

The familiar bivalved instruments of Negus, Whitehead, etc. are suitable for intraoral surgery. Several suction pumps should be on hand (see Fig. 4.1, page 15), three being a practical number for most operating room setups.

Very prominent maxillary teeth may prevent adequate exposure of the larynx in cases where a mouth guard also must be used. This problem is solved by utilizing a broad edentulous area in the left maxilla.

3.3

Bivalved supraglottiscope with a fi beroptic cable (above) and two lateral suction tubes for evacuating vaporization fumes. View from the proximal to distal end.

3.4a

Bivalved oropharyngoscope with a fi beroptic cable at the top and two suction tubesat the sides (lateral view). This instrumenthas shorter blades than the bivalvedsupraglottiscope.

3.5a

WEERDA bivalve diverticuloscope with fi beroptic cable and two suction tubes.

3.6a

Lateral view of the supraglottiscope. The two blades have already been opened distally. The proximal end is still closed.

3.4b


3.5b


3.6b


The evacuation of hot vaporization fumes not only relies on the laryngoscope suction tubes, which are not always adequate for the task, but also on suction tips with a grip plate and hole that are part of the standard Kleinsasser instru-ment set. One hand holds the suction while the other hand works the micro-manipulator. When it is necessary to grasp tissue, the suction tip is replaced by tissue forceps fi tted with a parallel suction tube soldered to the shaft (Fig. 3.7a). Larger graspers have proven useful in addition to fi ne microcup forceps (Fig. 3.7b).

The suction tubes and alligator microforceps are electrically insulated along their shafts and have a noninsulated working end (Figs. 3.7a, 3.8). The instrument set includes various protectors, also fi tted with suction tubes, that protect adjacent tissues from the laser (Fig. 3.9).

Extensive resections in the pharynx and larynx will occasionally cause bleed-ing that cannot be adequately managed with monopolar current. Titanium clips placed with specially designed instruments have proven very effective for situations of this kind (Fig. 3.10).Modifi ed graspers and protectors have been

fi tted with suction tubes. The suction tubes and alligator forceps are electrically insulated except at their tips.

3.7a

Small and large graspers, both with integrated suction tubes.

3.7b

Alligator microforceps and suction tube with insulated shafts.

3.8

Tissue protectors with integrated suction tubes.

3.9

Two titanium clips have been placed forhemostasis during the endolaryngealresection of a supraglottic carcinoma.

3.10


4.0 Preoperative PreparationsThe surgery is performed under general endotracheal anesthesia. The patient is positioned supine on the operating table (Fig. 4.1). The anesthesiologist and anesthesia machine are at one side of the operating table at the level of the patient’s thigh. The surgeon and operating microscope are at the head of the table, and two scrub nurses/assistants are stationed to the right and left of the patient’s head (see Fig. 4.1). Next to the patient’s head is the laser unit, which is coupled to the operating microscope. The setup includes three suction pumps – one connected to the endoscope suction, one to the suction tip held by the surgeon, and one to the graspers with integrated suction tubes (Figs. 4.1, 4.2).

The surgeon at work.

4.2

Operating room setup.

4.1

1

8

2

3

4

5

6

7

3

a

b d

c

1 Operating microscope 2 Laser unit3 Chest support4 Suction pump5 Anesthesia machine6 Suction pump7 Suction pump8 Instrument tablea Surgeonb Scrub nursec Anesthesiologistd Scrub nurse


5.0 AnesthesiaLaser operations, like all microlaryngoscopic procedures, are most safely performed under general endotracheal anesthesia. “Laser tubes” made of a nonfl ammable material are recommended for less experienced surgeons and in operations on large tumors. But a comprehensive survey of centers that perform laser surgery (Sesterhenn et al. 2003) has shown that even specially designed laser-resistant endotracheal tubes do not give absolute protection from a potentially lethal tube fi re. We very often use thin-walled polyvinyl tubes that are protected with wet neurosurgical cotton. In prolonged opera-tions the cotton should be changed frequently and cooled with ice water to prevent thermal injury to healthy tissue from vaporization fumes. The tube cuff is infl ated with Ringer solution instead of air. This must be done care-fully and without introducing air bubbles, since an air bubble forming in the top of the fl uid-fi lled cuff may create a nidus for ignition. We recommend that beginners use special laser tubes, despite their high cost. Alternative anesthesia techniques such as jet ventilation and intermittent apnea are occasionally indicated in the pediatric larynx or for lesions at the posterior commissure. General endotracheal anesthesia is possible in most cases, however. Intermittent apnea is an option for benign lesions that can likely be resected by laser surgery without signifi cant bleeding. With adequate preoxygenation, the surgeon can sometimes work for more than 5 minutes with the endotracheal tube removed.

6.0 Safety MeasuresThe face and eyes of the patient are covered with moist compresses, and the operating room personnel wear laser safety glasses. Tube safety issues were addressed above.

6.1 Immediate Management of an Endotracheal Tube FireWhile this complication has been reported elsewhere, we have not experi-enced a single tube fi re in several thousand CO2 laser operations performed over a period of more than 20 years. If an airway fi re should occur, the most immediate measure is to disconnect the ventilation hose and tracheal tube. Next the tube is removed and saline or Ringer solution is sprayed into the airway. Once the fi re is extinguished, the patient is immediately reintubated. This is followed by tracheobronchoscopy and any critical care measures that may be required.


7.0 Applications

7.1 Larynx

7.1.1 Recurrent Respiratory Laryngeal Papillomatosis

To date, all attempts to treat papillomatosis caused by HPV 6 and HPV 11 through medical or surgical means, including CO2 laser surgery, have failed to produce a permanent cure. Moreover, it is uncertain whether the disease-free intervals achieved with CO2 laser surgery are greater than those obtained with other ablative techniques.

The advantage of laser surgery over other techniques is that use of the CO2

laser does not cause bleeding as long as the papillomas are not grasped with instruments and the CO2 laser is not used to ablate the lesions. Papillo-matosis is one of the few indications in which the laser is used for tissue vaporization rather than cutting. Nevertheless, the rule still applies that histologic evaluation is essential, and today the workup should include HPV typing.

The lesions are progressively vaporized using a low-energy beam (1–2 W) and small spot size (0.25 mm) until the papilloma-free submucosa, or the muscular tissue of the vocal cords, is visualized under the operating microscope. Carbonization particles are removed with a moist cotton brush if necessary, or they may be aspirated from the site with a fi ne suction tip. This technique will prevent signifi cant damage to the vocal cord musculature. An effort should be made to remove all the papillomas from the larynx in one sitting. It is occasionally necessary in small children to withdraw the tracheal tube for a brief time and work during periods of intermittent apnea. When working in the glottic plane, the surgeon should take meticulous care that opposing raw surfaces at the anterior commissure are not in contact with each other, as this would cause synechia formation. In dealing with bilateral papillomas, therefore, the surgeon should initially leave one vocal cord untreated at the commissure and wait several weeks until the treated surface is covered by healthy mucosa before removing the contralateral lesions in a second sitting (Fig. 7.1).

CO2 laser surgery of laryngeal papillomas. The surgery is staged to prevent synechia formation.

7.1

First operation Second operation (6 weeks later)


Follow-ups consist of fl exible transnasal nasopharyngolaryngoscopy or microlaryngoscopy performed under general anesthesia. The laser treat-ments are repeated at close intervals whenever new papillomas are found. Generally we do not wait until the papillomas have caused vocal or respiratory impairment or the disease has entered a quieter phase, except in patients who develop a very rapid recurrence. Figures 7.2a, b and 7.3a, b show illustrative cases before and after papilloma removal. Interferon therapy may be tried in patients with massive, rapidly recurring lesions.

Evaluation of response is based on the quality of the voice, which suffers considerably less than with other treatment modalities. A permanent cure cannot be predicted with certainty because papillomatosis is an episodic disease that may recur even after a period of decades.

Appearance before (a) and immediately after (b) the removal ofjuvenile papillomas.

7.2a 7.2b

Juvenile papillomas before (a) and 8 days after (b) removal with the CO2 laser.

7.3a 7.3b


7.1.2 Laryngotracheal Stenosis

Initial enthusiasm over the laser treatment of laryngeal and tracheal stenoses has given way to a more sober attitude. Today it is recognized that the CO2 laser is best suited for treating synechiae involving the middle third of the vocal cords (Figs. 7.4a, b) as well as subglottic webs with a small hole (Fig. 7.5a). The stenosis is not treated by cutting around its circumference but by making a radial stellate or cruciform incision with the laser beam (Fig. 7.5b). This technique leaves islands of intact epithelium that can reepithelialize the surfaces of the enlarged opening.

Appearance before (a) and immediately after (b) division of a synechiainvolving the middle third of the vocal cords.

7.4a 7.4b

Subglottic web with a small hole before (a) and after (b) laser treatment. Cruciform incision avoids the creation of a circumferential wound surface.

7.5a 7.5b


Long stenoses with or without involvement of the cartilaginous skeleton of the larynx or trachea (Fig. 7.6a) are unsuitable for laser surgery. The CO2 laser can be used to divide laryngeal and even tracheal webs or strictures with a central hole (Fig. 7.6b), which may be secondary to healed Wegener granulomatosis, for example.

A long stenosis with involvement of the tracheal or laryngeal skeleton is unsuitable for laser treatment (a). Laser surgery is appropriate for localized webs in the trachea or larynx that do not involve the laryngeal skeleton (b).

7.6b

Unsuitable for laser surgery

Suitable for laser surgery

7.6a


Long tracheal stenoses are treated through a classic external (transcervical) approach by performing a sleeve resection of the stenotic area, followed by an end-to-end anastomosis of the tracheal and laryngeal stumps. The stumps should be outside the stenotic area and should be free of infl amma-tory changes. The Réthi operation is still an option for stenosis of the cricoid cartilage (Rudert 1976).

Florid granulating subglottic Wegener stenosis can be effectively treated by dilatation or by laser resection of the granulomas combined with the submu-cous injection of Decortin® (prenisolone) crystal suspension. Not infrequently, a several-week course of adjuvant systemic corticosteroids is advised.

Occasional supraglottic stenoses are also amenable to laser treatment. Panels a–d in Fig. 7.7 illustrate a supraglottic stenosis that had been present for decades following childhood diphtheria and was successfully treated by making a stellate incision with the CO2 laser and placing a stent in the anterior commissure. Airway restoration permitted the removal of a tracheo-stomy tube that the woman had worn for decades.

Supraglottic soft-tissue stenosis secondary to diphtheria during childhood.

7.7a

Appearance after stellate incision of the stenosis …

7.7b

… and stent insertion into the anterior commissure.

7.7c

Appearance after healing. The patient was decannulated after living for decades with a tracheostomy.

7.7d


Synechiae of the anterior commissure can sometimes be divided with the laser more easily than with cold instruments (microscissors and knives), but the wound surfaces produced by the laser have a tendency to fuse together again. On occasion, epithelialization of the vocal cords can be induced by conscientious postoperative brushing via indirect laryngoscopy. But even today in many cases, division of the synechiae should be followed by trans-oral stent insertion as shown in Fig. 7.7c or by introducing and securing the stent through a laryngotomy. Even with successful removal of the synechiae, postoperative voice function may be unsatisfactory if too much vocal cord musculature has been lost as a result of infl ammatory adhesions.

7.1.3 Bilateral Recurrent Laryngeal Nerve Palsy

Most cases of bilateral recurrent laryngeal nerve palsy are observed in patients who have undergone a strumectomy. When the vocal cords become fi xed in a median or paramedian position, the glottic aperture is inadequate for respiration even though vocal function is still relatively good. Before the advent of endoscopic techniques, the glottic aperture was widened either by translaryngeal splitting of the cricoid lamina (Réthi laminotomy) or by lateral fi xation of the vocal cord through a lateral approach without opening the laryngeal lumen, with or without resection of the arytenoid cartilage (De Graaf Woodman procedure). After the introduction of laryngeal microsurgery by Kleinsasser, these older operations were replaced by microlaryngoscopic techniques for widening the glottis.

We perform either an arytenoidectomy with the CO2 laser or a posterior cordectomy as modifi ed by Kashima.The arytenoidectomy basically follows the Kleinsasser technique, but we use the CO2 laser as it causes much less bleeding and postoperative edema than conventional cutting instruments. One disadvantage of arytenoidectomy is that the patient occasionally requires a tracheostomy due to postoperative edema. The tracheostomy tube is removed after swelling has subsided. This complication can be prevented by additionally using the endo-extralaryngeal suturing technique described by Lichtenberger, which widens the glottic plane.


Posterior cordectomy. A wedge of muscle tissue is excised from one vocal cord just anterior to the vocal process. Muscle is also removed from the anterolateral portion of the residual vocal cord.

7.8

Posterior cordectomy

For several years we have preferred the Kashima modifi cation of the poste-rior cordectomy. In this technique a tissue wedge is excised from the vocal cord just anterior to the vocal process, leaving the arytenoid cartilage intact. The wedge excision of the thyroarytenoid muscle should be supplemented by an additional, anteriorly directed submucous excision of the vocal cord muscle (Fig. 7.8). Generally this widens the glottis to a degree that eliminates the need for a tracheostomy. Subsequent scarring and tissue contraction result in an approximately elliptical glottic aperture. If the opening is still inadequate, the procedure should be repeated in a second sitting or the opposite vocal cord should be treated in the same way. Panels a–c in Fig. 7.9 illustrate various phases of wound healing after a posterior cordectomy.

One advantage of the posterior cordectomy over an arytenoidectomy is that it preserves the laryngeal sphincter mechanism formed by the supraglottic muscles. This eliminates the postoperative risk of latent aspiration.

Appearance following posterior cordectomy.

7.9a

Appearance one week after surgery.

7.9b

Appearance four weeks after the posterior cordectomy.

7.9c


Since the function of the laryngeal sphincter is preserved, adduction of the paretic vocal cords occurs during phonation (Figs. 7.10a, b). This results in better voice quality than after an arytenoidectomy.

Between 1993 and 1996, we performed the posterior cordectomy in 23 patients with bilateral recurrent laryngeal nerve palsy at our hospital in Kiel (Reker and Rudert 1998). In fi ve cases the procedure had to be repeated. Two of the patients required a temporary tracheostomy and arytenoidectomy. Later, however, we observed cases in which neither the cordectomy nor the transoral arytenoidectomy could establish an adequate airway. These pa-tients were women who had a very small larynx. They will continue to require a tracheostomy tube unless they undergo one of the major extralaryngeal operations noted above.

View after posterior cordectomy with the larynx in the respiratory position.

7.10a

View in the phonatory position. The vocal cords are adducted owing to the intact function of the laryngeal sphincter.

7.10b


7.1.4 Benign Neoplasms of the Larynx and Hypopharynx(Cysts, Polyps, Reinke Edema, Vocal Cord Nodules,Hemangiomas, Pheochromocytomas)

In principle, benign lesions of the vocal cords can be removed with the CO2

laser. But because wound healing is delayed for up to 10 days relative to an incised wound, we see little advantage in the laser treatment of benign vocal cord lesions such as polyps, cysts, Reinke edema, and singer’s nodules, and we still prefer to use conventional sharp cutting instruments. This particularly applies to phonosurgical procedures.An essential prerequisite for using the CO2 laser is the use of a microspot manipulator with a spot size of 0.25 mm. A 0.5 to 1 W power setting allows for bloodless, atraumatic surgery.

Large supraglottic laryngeal cysts and mucoceles are a valid and important indication for laser therapy (Figs. 7.11a–e). Conventional microlaryngoscopic instruments are not sturdy enough for this type of dissection.

Ventricular cyst prior to excision.

7.11a

Preoperative CT scan.

7.11b

Appearance immediately after excision.

7.11c

Post-healing view during respiration.

7.11d

View during phonation.

7.11e


The CO2 laser is easier, faster, and provokes less bleeding, especially when removing large cysts of the false vocal cords and aryepiglottic folds. Figures 7.12a–c shows a large cyst of the aryepiglottic fold that was removed by laser surgery.

Very large, hypervascular tumors stand at the limits of transoral surgery. Yet so far we have successfully removed four glomus tumors of the larynx by transoral laser surgery. One patient was advised elsewhere to undergo a laryngectomy after several failed transoral attempts (Figs. 7.13a–d). The glomus tumor was successfully removed by the transoral route. Preoperative embolization is recommended for large, hypervascular tumors of this kind.

Large mucocele of the aryepiglottic fold before …

7.12a

… and immediately after removal. Tracheotomy is not required.

7.12b

CT scan of the mucocele.

7.12c

Giant glomus tumor of the larynx before endolaryngeal removal.

7.13a 7.13b

Preoperative CT scan of the neoplasm.

7.13c

View of the larynx after transoral excision of the glomus tumor. The patient has good respiratory function and deglutition.(�) Remaining portion of the epiglottis.

7.13d

�


View of the septum of a Zenker diverticulum after insertion of the diverticuloscope.

7.14

Appearance immediately before …

7.15a

... and after division of the septum. The green thread, swallowed two days before the operation, marks the entrance to the esophagus.

7.15b

7.1.5 Hypopharyngeal Diverticula (Zenker Diverticula)

The transoral treatment of Zenker diverticula by dividing the septum between the diverticulum and esophageal lumen dates back to Mosher (1917), Seiffert (1936), and Dohlmann (1949). Seiffert initially performed the diverticulotomy in the sitting patient under local anesthesia, changing later to general endo-tracheal anesthesia. Dohlmann grasped the septum with an alligator forceps, coagulated it, and divided it with a special knife. The endoscopic technique was long rejected in favor of an external diverticulectomy due to the risk of bleeding. It was not until the 1970s that surgeons at Groningen University Hospital revived the endoscopic approach and performed the diverticulo-tomy under an operating microscope. Van Overbeck and Hoeksema (1982) were the fi rst surgeons to divide the septum with the CO2 laser.To date, more than 150 patients with Zenker diverticula have been treated by transoral endoscopic diverticulotomy with the CO2 laser at the Kiel and Marburg University Hospitals in Germany. Suitable endoscopes are the Dohlmann endoscope and the Weerda bivalved diverticuloscope (see Fig. 3.4a, b). The procedure is facilitated by having the patient swallow a thread weighted with a lead bead several days before the operation. When the distal end of the thread has passed through the gastrointestinal tract, it is certain that the proximal portion marks the entrance to the esophagus (Fig. 7.15a). This is particularly helpful in revision cases and in patients with very large diverticula. Occasionally the bead is retained in a large diverticulum, so this technique is not always successful. The bivalved diverticuloscope is introduced under general endotracheal anesthesia, positioning the upper blade in the esophagus and the lower blade in the diverticulum (Fig. 7.14). The septum is progressively divided with the CO2 laser (1–2 W), continuing the cut until the fundiform part of the cricopharyngeus muscle has been completely divided. The separation of the severed cricopharyngeus fi bers is clearly visible under the operating microscope (Fig. 7.15b). We have never encountered any bleeding that could not be controlled by coagulation. Some fever may occur during the fi rst night after the operation but should subside the following day. As a precaution, we administer a broad-spectrum anti-biotic and dipyrone (Novalgin®) and place a feeding tube for several days. As of 1997, 70 Zenker diverticula had been treated endoscopically without serious complications (Lippert et al. 1997, 1999). The procedure had to be repeated in three cases. Sixty-nine of the patients were free of complaints. One case of mild mediastinitis resolved completely with antibiotic therapy.


Oral contrast study after the diverticulotomy.

7.16b 7.16c

Contrast radiograph of the diverticulum before the diverticulotomy.

7.16a

Stapling has proven to be an effective alternative to the transoral crico-pharyngotomy. Its main advantages are a reduced incidence of the fever that may occur after CO2 laser surgery and a lower incidence of pain radiating to the back. It is clear, however, that stapling is not appropriate for all diverticula. This particularly applies to small diverticula and to septa that are diffi cult to expose due to space limitations. The CO2 laser is a much better option for these two situations.

It should be added that the transoral diverticulotomy is not always possible, especially when the septum is diffi cult to expose (e.g., in patients with ankylosing spondylitis). This underscores the fact that a conscientious head and neck surgeon should not only be trained in laser surgery but must also be profi cient in conventional neck surgery. Diverticulectomy through an external approach is still a viable surgical option that is reserved for special situations.

Setup for a transoral laser diverticulotomy. The septum between the pouch and esophagus is visualized with the diverticuloscope. The laser beam (shown in red) is refl ected into the optical pathway of the operating microscope.

7.17


7.1.6 Laryngeal and Hypopharyngeal Carcinoma

The CO2 laser has opened a new dimension in the treatment of laryngeal and hypopharyngeal cancers. It is now possible to perform partial laryngecto-mies by the transoral route that yield signifi cantly better functional results for supraglottic and hypopharyngeal tumors than operations through an external approach. It is little wonder that this indication is not widely recognized when we consider that it took almost 20 years for the classic Kleinsasser technique of microlaryngoscopy to gain international acceptance. Recall that Kleinsasser was still being attacked in the early 1970s for removing microcarcinomas of the vocal cords through a transoral approach. Logically, however, anyone who accepts the concept of the open partial laryngec-tomy must also accept the transoral concept if it can accomplish tumor removal with adequate margins. The key issue is patient selection. Once the decision for a partial laryngectomy has been made, deciding between the classic external approach or a transoral CO2 laser resection is a secondary concern. The advantage of the transoral method is its signifi cantly lower morbidity. As a general rule, patients who undergo the transoral laser resec-tion of supraglottic tumors and hypopharyngeal carcinomas will not require a tracheostomy. Most patients are already able to swallow without aspirating during the immediate postoperative period. Hence there is no age limit as there is with external operations.

7.1.6.1 Glottic Carcinoma7.1.6.1.1 Limited Glottic CarcinomaSuperfi cial keratotic lesions confi ned to the middle third of the vocal cord mucosa are resected in one piece during excisional biopsy (Fig. 7.18). The specimen is mounted on cork and sent to pathology. As it is easily determined under the operating microscope whether the tumor extends beyond Reinke’s space into the vocal cord and muscle, the individual depth of the resection can be determined with much greater accuracy than in an external cordectomy. As a result, voice quality is generally better after this procedure than after an external partial laryngectomy (Figs. 7.19a–d). The submucous injection of Ringer solution in the tumor area has proven helpful for assessing the depth of tumor invasion. Often this will reveal the limits of tumor demarcation, allowing the surgeon to better tailor the depth of the resection.

A small, superfi cial glottic carcinoma is removed by excisional biopsy.

7.18

Superfi cial T1a glottic carcinoma before …

7.19a

… and immediately after a muscle-sparing excision.

7.19b

Result at 2 months. The patient has good respiratory and phonatory function.

7.19c 7.19d


If the overhanging ventricular fold hides the lateral boundary of the glottic carcinoma in the sinus of Morgagni, it can be resected to expose the lateral extent of vocal cord involvement without compromising voice function (Figs. 7.20a–d). While this technique has been attributed to Kashima for several years in the English-language literature, we fi rst described it in 1983. The surgical defect in the ventricular fold will resolve spontaneously during the healing period and is no longer visible after a few weeks.

7.1.6.1.2 Advanced Glottic CarcinomaLarge tumors that have invaded the musculature or crossed the commis-sure often cannot be endoscopically resected in one piece with the CO2

laser. They must be divided into smaller fragments with the laser beam (Figs. 7.21a, b).

This affords a clear view of the lateral tumor margin.

7.20c

The tumor is removed with a margin of healthy tissue.

7.20d

7.20b

An overhanging ventricular fold is removed prior to resecting the glottic carcinoma.

7.20a

Large glottic carcinomas are removed piecemeal.

7.21a

The posterior part of the glottic carcinoma has been resected. The boundary between the tumor and healthy tissue is clearly visible with the operating microscope. The rest of the tumor is removed with generous margins.

7.21b


This technique, which is unconventional in oncologic surgery, is made prac-tical by the cutting characteristics of the CO2 laser. Due to the absence of bleeding, the boundaries between tumor and healthy tissue can be precisely identifi ed by examining the cut surface under the operating microscope. This allows for a piecemeal tumor resection while still obtaining clear margins. If the tumor has crossed the commissure, the thyroid cartilage should be com-pletely exposed at the anterior commissure due to the absence of muscle and perichondrium in that area.

Examples of the laser resection of glottic carcinoma are shown in Figs. 7.22–7.27.

7.22b

Appearance before (a) and after laser resection (b) of a carcinoma of the left vocal cord in a 41-year-old school teacher. Later the patient was able to return to her job.

7.22a

T1a carcinoma of the left vocal cord extending into the anterior commissure, before (a) and immediately after laser resection (b). The right vocal cord exhibits leukoplakia without aplasia. These lesions were excised 10 weeks later to prevent synechia formation (c, d).

7.23a

7.23b 7.23c 7.23d


Large glottic carcinoma before …

7.24a

… and 1 week after laser resection.

7.24b

Result at 2 years.

7.24c

T2a carcinoma of the left vocal cord (a),

7.25a

initially circumscribed with the laser beam (b)

7.25b

and then resected in the anteroposterior direction (c–f).

A glottic spreader was used fi rst to help defi ne tumor extent (b–d),

7.25d

then the tube was advanced (e).

7.25e

View after complete resection of the tumor (f).

7.25f

7.25c


Appearance before …

7.26a

… and 1 year after the resection of a large glottic carcinoma.

7.26b

Recurrence of a carcinoma of the left vocal cord treated 20 years earlier by radiotherapy.

7.27a

Transoral hemilaryngectomy specimen (same patient).

7.27b


7.1.6.1.3 Limits of the Transoral Resection of Glottic Carcinoma

Laser resection yields good oncologic results for localized glottic cancers. Outcomes comparable to those of an external partial laryngectomy can be achieved. The recurrence rate is lower than after primary radiotherapy. Signifi cantly fewer larynges must be extirpated as a salvage measure. The anterior commissure is the main problem area for radiotherapy and all other treatment modalities.

As Table 1 shows, we performed laser resections of 114 glottic cancers with curative intent from 1979 to 1992 (Rudert and Werner 1995). Only 3 of 10 recurrences necessitated laryngectomy. The rest were successfully managed by another laser resection, external partial laryngectomy, or irradiation. Since 1992, one patient has died from recurrent disease. That patient refused laryngectomy, which might have been curative.

Table 1* Patient refused salvage surgery.

Table 1: Results of Laser Surgery of Glottic Carcinomas from 1979 to 1992, (Rudert and Werner 1995)(at least 48 months’ follow-up, with an average of 70 months)

Treatment for Recurrence

T stage Number of patients

Norecurrence Recurrence Radiation Laser Laryngectomy None Died from

tumor Tumorfree

Tis 8 8 – – – – – – 8Tla 88 81 7 2 2 2 1 1* 87Tib 10 8 2 1 – 1 – – 10T2 8 7 1 – 1 – – – 8

Total 114 104 10 3 3 3 1 1 113

� Carcinoma of the Anterior CommissureHistology cannot confi rm clear margins with full confi dence due tothe absence of muscle tissue and perichondrium. This fact, plus thetendency of cancers to grow along blood vessels in the ossifi ed thyroid cartilage and the occasional diffi culty of visualizing the anterior commissure, account for the poorer results of laser surgery in this region.

� Subglottic CarcinomaThe limits of resectability are reached by subglottic tumors that have spread more than 7 mm distal to the glottic margin. These tumors quickly leave the larynx in the area of the cricothyroid ligament, undergoing peritracheal spread and metastasizing along the trachea into the mediastinum.

� Carcinoma of the Posterior Third of the Vocal CordWith tumors at this location, portions of the arytenoid cartilage must be included in the resection. It is diffi cult to elect transoral laser surgery for tumors that have grown between the arytenoid cartilage and thyroid cartilage toward the piriform sinus, because these tumors quickly leave the glottic plane and spread in the paraglottic space, which communicates laterally with the preepiglottic space. If the tumor is at all resectable, it should be approached from above as ina supraglottic partial laryngectomy.


7.1.6.2 Supraglottic Carcinoma

Limited supraglottic cancers are even better suited for laser surgery than glottic cancers because the upper portions of the supraglottis are not narrowed by the laryngeal skeleton as in the glottic plane. The tumor can be encompassed with wide margins unless it is resectable by a simple marginal excision. Technical problems may arise if the tumor has spread deeper into the larynx funnel, establishing contact anteriorly with the petiole, laterally with the thyroid cartilage, and posteriorly with the arytenoid cartilages. In this case the prospects for a transoral resection become less favorable.

7.1.6.2.1 Small Carcinomas of the Epiglottic MarginThese tumors, like limited glottic cancers, can be removed by excisional biopsy. They are resected in one piece with healthy margins along with the involved portion of the epiglottis (Figs. 7.28, 7.29a, b). Patients do not require a tracheostomy or feeding tube.

Excisional biopsy of a small epiglotticcarcinoma.

7.28

Appearance before …

7.29a

… and after the laser resection of a small-based carcinoma of the epiglottic margin.

7.29b


7.1.6.2.2 Carcinomas of the Suprahyoid and Infrahyoid EpiglottisThe more extensive the tumor base along the epiglottic margin, valleculae, and laryngeal surface of the epiglottis, the more diffi cult it is to encompass the tumor in accordance with classic oncologic principles.

As with advanced glottic cancers, it is best to divide the epiglottis and pos-sibly the tumor with the laser, removing the specimen in two or more pieces (Figs. 7.30a, b, 7.31, 7.32). With infrahyoid involvement, the resection should include the preepiglottic space. This can be done as long as the boundaries between the tumor and healthy tissue can be identifi ed under the operating microscope.

The lines of resection for supraglottic cancers depend on tumor extent.

7.30a

With infrahyoid tumors and tumors of the ventricular fold, the resection should include the preepiglottic space.

7.30b

Lines of resection for suprahyoid tumors of the epiglottis. The epiglottis and tumor are split in the midline and resected in two pieces.

7.31

Lines of resection for epiglottic tumors that extend to the ventricular fold.

7.32


The operative technique for supraglottic tumors is learned most effi ciently by practicing on cadaveric larynges (Figs. 7.33a–d). First the suprahyoid epiglottis is divided in the midline. Then the infrahyoid epiglottis can also be divided with the laser. Next the preepiglottic space, with its copious fatty tissue, is exposed (Fig. 7.33b). At this point the entire supraglottis, epiglottis, and ventricular fold can be resected in accordance with the pattern lines shown in Figs. 7.30a, b. Figure 7.33d shows the appearance of the operative site following complete removal of the supraglottis. It is important to remove the soft tissue as far as the thyroid cartilage.

Dissection of a cadaveric larynx. The suprahyoid epiglottis is divided in the midline.

7.33a

Appearance after resection of the left portion of the epiglottis and the left ventricular fold.

7.33c

Appearance after bilateral resection of the epiglottis and ventricular folds. View of the inner surface of the thyroid cartilage (�), (•) Vocal cords.

7.33d

The infrahyoid epiglottis is also divided in the midline along with the preepiglottic fat (�) on each side.

7.33b

��

•

�

�•


Panels a–d in Fig. 7.34 show a carcinoma of the suprahyoid epiglottis before laser resection (a), the surgical specimen (b), and a magnifi ed laryngoscopic view 8 days after surgery in the respiratory position (c) and phonatory position (d).

Figures 7.35a–c illustrates a patient with a carcinoma of the infrahyoid epiglottis and ventricular fold.

Figures 7.36a–f illustrates the occasional need to lift the tube intermittently to help access and resect the posterior portions of supraglottic cancers.

Carcinoma of the suprahyoid epiglottis before laser resection.

7.34a

The resected specimen.

7.34b

Larynx in the respiratory position 8 days after laser resection.

7.34c

Larynx in the phonatory position. The patient has no aspiration and did not require a tracheostomy.

7.34d

Carcinoma of the infrahyoid epiglottis and ventricular fold before …

7.35a

… immediately after …

7.35b

… and one year after the operation.

7.35c


7.36a 7.36b

7.36c 7.36d

7.36e 7.36f

Stepwise resection of a supraglottic carcinoma located chiefl y on the lateral surface of the epiglottis with extension into the left ventricle (a). Initially the left portion of the tumor was resected through a right paramedian incision in the epiglottis, carrying the resection across the midline to the ventricular plane (b).Next, left posterior access was established (c). The tube was lifted and the posterior line of resection was determined (d, e).This stepwise technique allowed for a complete tumor resection (f).


Figures 7.37a–d shows a carcinoma of the lingual epiglottis. Postresection radiotherapy caused edema of the arytenoid region, which was ablated in a second laser operation.

Figure 7.38 a shows a large epiglottic carcinoma in an 89-year-old man. This tumor had spread downward from the epiglottis to the piriform sinus. One year after palliative removal of the carcinoma, the patient was free of primary tumor (Fig. 7.38 b).

Tumor of the glossoepiglottic vallecula before …

7.37a

… and immediately after laser resection.

7.37b

Edema of the arytenoid region following subsequent radiotherapy.

7.37c

Appearance after edema ablation with the CO2 laser.

7.37d


7.1.6.2.3 Carcinomas of the Ventricular FoldCarcinomas of the ventricular folds (false vocal cords) are more diffi cult to resect than epiglottic cancers because the laryngeal skeleton begins to narrow at the level of the ventricular folds. Like tumors of the infrahyoid epiglottis, they are best approached from above (Fig. 7.30b). Suffi cient anterior and lateral clearance can be obtained by dividing the epiglottis and dissecting to the superior border of the thyroid cartilage, then proceeding from there along the inner surface of the thyroid cartilage to the vocal cord. The tumor can be widely encompassed and removed, including if necessary the cricoarytenoid joint and even the mucosa of the medial piriform sinus wall in the excision (Fig. 7.32). The resection of a ventricular fold carcinoma is illustrated in Figs. 7.39a–d.

Extensive carcinoma of the epiglottis in an 89-year-old man.

7.38a

Appearance one year after surgery.The patient is free of primary tumor.

7.38b

Carcinoma of the right ventricular foldbefore …

7.39a

Laryngoscopic view of the healed surgical site.

7.39d

… and immediately after laser resection. (�) marks the inner surface of the right thyroid cartilage.

7.39b

�

The surgical specimen. Half of the epiglottis was resected.(�) Ventricular fold tumor(•) Resected half of the epiglottis.

7.39c

�

•


7.1.6.2.4 Treatment Concept for the Lymphatic Drainageof Supraglottic Cancers

Lymphatic drainage is an important consideration in the evaluation and treatment of supraglottic cancers and is essential for conscientious man-a gement. This applies not only to the supraglottic region but to cancers occurring anywhere in the upper aerodigestive tract.

Treatment planning should always be preceded by a detailed imaging eva-luation of cervical lymphatic drainage. If extensive metastasis is found, it is essential to prescribe chemoradiation. The indication for laser surgery is highly questionable in these cases, as the chemoradiation will control the primary tumor in the great majority of cases. Exceptions are extensive invasion of the laryngeal skeleton and carcinomas of the oral cavity. With extensive infi ltra-tion of the laryngeal skeleton, laryngectomy is still unavoidable despite the availability of “organ conserving” protocols.If imaging modalities suggest the absence of metastatic disease in regional lymph nodes or the presence of one metastatic node, this should not only be considered an appropriate indication for laser surgery, but rather seen as suffi cient cause to advocate this treatment option, because such patients can be spared the discomfort of bothersome sideeffects and sequelas inevitably associated with intensity-modulated radiotherapy.

These considerations explain our frequent recommendations for neck dis-section, with or without a sentinel node biopsy, to achieve the gold standard of cervical lymph node staging. If histology is negative for metastasis or if metastasis is found without extracapsular spread, we withhold postoperative radiotherapy or chemoradiation. If the laser resection of a laryngeal cancer yields negative margins but multiple metastases are detected histologically, we recommend largely excluding the larynx from the radiation portal as this will signifi cantly reduce the risk of postirradiation laryngeal dysfunction. Modern radiotherapy techniques allow for a differentiated treatment strategy of this kind. This example illustrates the great importance of interdisciplinary tumor conferences in which these issues are fully explored.

The great advantage of laser surgery in performing a transoral supraglottic partial laryngectomy is its signifi cantly lower morbidity compared with conventional external operations. Tracheostomies are rarely necessary and, when performed, are usually temporary.The prognosis depends far more on tumor stage than on primary tumor recurrence. Patients with a stage I or II lesion (no lymph node metastasis) have a signifi cantly better prognosis than patients with stage III or IV disease (presence of nodal metastases) (Fig. 7.40).


Survival rates after laser resection of supraglottic cancers(N0 + N1 versus N2 + N3; p < 0.02641).

Survival Rates of 34 Patients with Supraglottic Cancers Treated byLaser Surgery between 1981 and 1994 as a Function of Lymph Node Involvement

(N0 and N1 versus N2 and N3)1

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

00 12 24 36 48 60 72

Survival Time (Months)7.40

Results of the Laser Resection of Supraglottic CancersFrom 1981 to 1994, 34 previously untreated patients with supraglottic cancer were treated by laser surgery at our hospital in Kiel (Rudert, Werner, Höft 1999). Seven of the operations were palliative. Only six of the patients required a temporary tracheostomy. The fi ve patients with T1 lesions did not have a local recurrence. Three of the 12 patients with T2 lesions suffered a local recurrence. One of these patients was free of tumor after a second transoral laser resection. Two (22%) of the nine patients with T3 cancers and fi ve (63%) of the eight patients with T4 cancers developed a local recur-rence.

Twelve patients (35%) developed a second carcinoma, six cases occurring in the lung. The oncologic outcomes were signifi cantly better with T1 and T2 lesions than with T3 and T4 tumors. The same applied to lymph node involvement. N0 and N1 patients had a better than 55% 5-year survival rate, whereas all N3 and N4 patients had died from their tumor by 3 years after surgery.The poor prognosis of advanced supraglottic cancers is based mainly on the development of regional and distant metastases and secondary primary cancers rather than local recurrence. Tumor debulking may be appropriate in advanced stages and in elderly patients, as it can eliminate the need for tracheostomy in many cases.


7.1.6.3 Hypopharyngeal Carcinoma

To date, the treatment results for hypopharyngeal cancers have been unsatis-factory regardless of the treatment modality employed. This is due largely to the early involvement of regional lymph nodes. Radiotherapy alone gives the poorest results. Chemoradiation yields better results in advanced stages and may be followed if necessary by salvage surgery.The external partial laryngopharyngectomy techniques described by Alonso, Ogura, André, and Lacourraye are technically diffi cult to perform and are not widely accepted due to severe postoperative aspiration problems. The same applies to the near-total laryngectomy of Pearson and Krespi. Issues of lymphogenous metastasis described above need to be considered as well. In patients with advanced lymph node metastasis, the good treatment results with chemoradiation make it diffi cult to fi nd a rationale for performing an open partial resection with all its attendant problems.

Of all treatment modalities, transoral laser resection has become the least established method despite the fact that no other treatments can provide comparable preservation of swallowing function.

The transoral CO2 laser resection of hypopharyngeal cancers offers several advantages:

Surgical Anatomy of the HypopharynxThe UICC classifi cation of the hypopharynx into three subregions – the piriform sinus, postcricoid region, and posterior hypopharyngeal wall – is not optimum because it disregards the existence of the lateral walls cranial to the superior border of the thyroid cartilage at the level of the hyothyroid membrane. Like Clayman and Weber (1996), we apply the term “lateral wall of the superior piriform sinus” to this important surgical region that borders directly on the parapharyngeal space. It is continuous inferiorly with the “lateral wall of the inferior piriform sinus,” which is bounded laterally by the thyroid lamina (Figs. 7.41a–c).

The lateral walls can be clearly distinguished from the posterior wall during endoscopic visualization of the larynx and hypopharynx with the bivalved laryngoscope. The posterior wall is fi rmly adherent to the prevertebral fascia, while the lateral walls are closely related to the large cervical vessels and nerves of the parapharyngeal space.

� The wound created by transoral laser resection of the affected portion of the hypopharyngeal wall can heal by second intention, eliminating the need to close the mucosal defects as in open surgery.

� Patients generally do not experience serious postoperative swallowing diffi culties.

� Most patients do not even require a temporary tracheostomy.

Lateral wall of the hypopharynx. The yellow area bordering the parapharyngeal space is the superior piriform sinus. The green area of the hypopharynx O bordering the thyroid cartilage is the inferior piriform sinus.The upper line marks the cross section at the level of the superior piriform sinus and parapharyngeal space (Fig. 7.41b).The lower line marks the cross section at the level of the inferior piriform sinus (inner surface of the thyroid lamina) (Fig. 7.41c).

7.41a

O

7.41 b

7.41 c


Defi ning the lateral walls as a separate subregion is justifi ed not only from an anatomic and surgical standpoint but also by the better prognosis of lateral wall lesions compared with tumors in other regions of the hypopharynx.

Thus, hypopharyngeal tumors are classifi ed as follows from the standpoint of endoscopic laser surgery:

Resection of Tumors of the Posterior Hypopharyngeal Wall After the larynx and hypopharynx have been visualized with the bivalved supraglottiscope, the laser beam marks a line of resection around the tumor ulcer in the posterior wall, outlining it at a distance of 1 cm. This line is then divided cranial to the tumor with a low-energy CO2 laser beam (2 W) using the smallest spot size (0.25 mm), dividing the line to the prevertebral fascia. The entire tumor, together with all tissue layers of the posterior wall, is progressively freed from the prevertebral fascia with the laser, much as with a scissors or scalpel, and is fi nally removed en bloc. In contrast to open surgery, in which the defect must be reconstructed with free, pedicled or vascularized fl aps or a jejunal graft, the transoral laser wound should heal well by second intention. There is no need to reconstruct the mucosal defect. Patients do not have signifi cant postoperative swallowing diffi culties when the feeding tube is removed a few days later.

� Tumors of the posterior wall of the hypopharynx, � Tumors of the postcricoid region, � Tumors of the medial wall of the piriform sinus, � Tumors of the upper lateral wall of the piriform sinus, � Tumors of the lower lateral wall of the piriform sinus.

The lateral wall of the hypopharynx in the area of the hyothyroid membrane (superior piriform sinus ) borders on the parapharyngeal space.

7.41b

The lateral wall of the inferior piriform sinus (shown in green) borders on the inner surface of the thyroid cartilage.

7.41c


Resection of Lateral-Wall Hypopharyngeal TumorsTumors of the upper lateral wall of the piriform sinus (Figs. 7.41a, b) that have not yet penetrated the muscular pharyngeal tube and invaded the vascular sheath can often be resected transorally like posterior wall tumors. The parapharyngeal space is opened during the procedure. Dissection with the laser beam proceeds fi ber by fi ber within the loose connective tissue of the vascular sheath, aided in part by long blunt suction tips and forceps. This can be done with almost no bleeding owing to the coagulating effect of the CO2 laser at the capillary level. Larger vessels in the fi ne network of connective-tissue fi bers are identifi ed under the operating microscope and either coagulated or clipped. On the lower sidewall of the piriform sinus (Figs. 7.41a, c), the involved portion of the pharyngeal wall is resected to the inner surface of the thyroid lamina. Invasion of the laryngeal skeleton represents the limit of any partial resection.

Resection of Tumors of the Medial Walland Fornix of the Piriform SinusCarcinomas that have invaded the fornix of the piriform sinus are the most technically diffi cult to resect. In this case the operative fi eld is restricted medially by the cricoid cartilage and laterally by the thyroid lamina. Often, however, the resection may go surprisingly well by starting at a proximal level and splitting and resecting the epiglottis on the affected side, as in the treat-ment of supraglottic lesions (Fig. 7.42). The resection then proceeds from the vallecula along the greater horn of the hyoid bone and inner surface of the thyroid cartilage on the affected side. Medially, the piriform sinus mucosa is separated from the cricoid cartilage while also removing the ipsilateral arytenoid cartilage in some cases. Even larger piriform sinus carcinomas can be dissected and removed from the piriform sinus funnel in one piece like a “fi nger cot" by using this technique. Again, involvement of the laryngeal skeleton represents the limit of a laser resection.

Resection of Postcricoid TumorsTumors of the postcricoid region can be resected with the CO2 laser if they have not invaded the cricoid and if only one arytenoid cartilage must be removed.

Neck DissectionA unilateral neck dissection is indicated for unilateral hypopharyngeal carcinomas, and a bilateral neck dissection is necessary for midline lesions. Postoperative radiotherapy that includes radiation to the larynx is also mandatory. Possible exceptions are small lesions in which histology con-fi rms clear margins and the neck dissection is negative for lymphogenous metastasis. Withholding postoperative radiotherapy may be an option in cases of this kind.

Hypopharyngeal carcinomas of the posterior wall, lateral walls, and aryepiglottic folds can usually be resected en bloc. With piriform sinus cancers, the resection should include the epiglottis and supraglottis on the affected side.

7.42


Results of the Transoral Laser Resection of Hypopharyngeal CarcinomasFrom 1991 to 1995, a total of 130 previously untreated patients with hypopharyngeal cancer were treated at the Kiel University Hospital. In 29 of the 130 patients, the primary tumor was treated by laser surgery (Rudert and Höft 2003). Twenty-seven of the patients had stage I or II lesions while two had stage III or IV disease. None of the patients required a primary tracheostomy. Two patients required a postoperative tracheostomy for aspiration, which was temporary in both cases. Nasogastric feeding tubes placed at operation were removed within a few days. Only one patient with a synchronous carcinoma of the oral fl oor required long-term alimentation through a percutaneous epigastric tube.

Eight of the 29 patients (27.6%) developed a local recurrence. Only seven patients died from their cancer. One patient underwent a curative laryngo-pharyngectomy. Local recurrence rates were lowest in patients with tumors of the lateral walls (2 of 12) or posterior wall (0 of 3), while 6 of the 12 patients with tumors of the medial wall and fornix of the piriform sinus developed a local recurrence.

Eleven of the 29 patients (62%) had cervical lymph node metastases at the start of treatment. Eight patients (27.6%) developed distant metastases after primary treatment, and 12 patients (41%) developed secondary primary tumors.

Thus, the prognosis depended far less on the primary tumor than on cervical lymph node involvement, the presence of distant metastases, and second-ary primary tumors (Fig. 7.43).

Overall survival rates of treated patients (N0 and N+, P < 0.048).

Survival rates of 29 patients with hypopharyngeal cancerstreated by laser surgery between 1991 and 1995

as a function of lymph node involvement

Survival time (months)

1

0.8

0.6

0.4

0.2

00 12 24 36 48 60 72 84 96 108 120

7.43


Carcinoma of the left aryepiglottic fold before …

7.44a

… and after resection.

7.44b

Carcinoma of the left piriform sinus before …

7.45a

… and after resection.

7.45b

These observations support the use of laser surgery for hypopharyngeal can-cers. While laser surgery has not improved the prognosis of these patients, its great advantage over other treatment modalities is its lower morbidity and the frequent preservation of the larynx. Even fewer patients required tracheostomy or tube feeding than after supraglottic tumor resections.

Figures 7.44 and 7.45 illustrate carcinomas of the piriform sinus before and after removal by laser surgery.


7.2 Lesions of the Oral Cavity and OropharynxBenign lesions of the oral and oropharyngeal mucosa can easily be removed with the CO2 laser. This device offers major advantages over conventional instruments in the removal of hypertrophic lingual tonsils. It can be of particular benefi t in patients with recurrent lingual tonsillitis. This is why, in the early years, we received wide-ranging patient referrals since a lingual tonsillectomy by conventional means was practically unavailable before the advent of the CO2 laser. The tongue base is visualized with a tonsillar spatula or oropharygoscope. We perform the tonsillectomy with a defocused beam at a relatively high power setting (> 10 W in some cases). Intraoperative bleeding is slight. There have been reports of heavy postope-rative bleeding, however, and therefore we recommend one week of inpatient observation.

7.2.1 Intraoral and Oropharyngeal Carcinomas

En plaque carcinomas of the oral cavity are an ideal indication for laser surgery, as are leukoplakic lesions. The lesions are excised and mounted for histologic evaluation. The wounds are left open to epithelialize by second intention (Figs. 7.46a–c). Exceptions are tumors that have spread from the fl oor of the mouth to the undersurface of the tongue. In this case the wounds should be resurfaced with split-thickness grafts to prevent adhesions that would compromise lingual function.

Carcinoma on the undersurface of the tongue before …

7.46a

… immediately after …

7.46b

… and 6 months after laser resection.

7.46c


Figures 7.47 a–d shows a superfi cial squamous cell carcinoma of the palate that was removed in several sittings.

Plaquelike squamous cell carcinoma of the palate before …

7.47a

… and after laser therapy.

7.47b

Residual tumor was removed in a second sitting.

7.47c

End result: complete local clearance.

7.47d


Figures 7.48a, b and 7.49a, b illustrate the laser treatment of carcinomas of the oral fl oor.

Preoperative appearance of an oral fl oor carcinoma …

7.48a

… and appearance after healing.

7.48b

Oral fl oor carcinoma before laser surgery …

7.49a

… and after healing.

7.49b


T2 carcinoma of the left tonsil before …

7.51a

… and after laser resection.

7.51b

Figures 7.50a–c illustrates a hemiglossectomy.

Stage I and II tonsillar carcinomas can also be resected with healthy margins by laser microsurgery (Figs. 7.51a, b). This is more diffi cult with tumors of the tongue base, where the boundaries between tumor and lingual muscle are diffi cult to discern even under the operating microscope. The regional lymph nodes are managed by curative or elective neck dissection. In the absence of contiguous spread, there is no need to perform an en-bloc resection of the tumor and its lymphatic drainage. The laser resection of oropharyngeal cancers is most appropriate in cases where (1) the tumor defi nitely appears to be resectable and (2) there is no clinical evidence of lymphogenous metastasis. If this impression is confi rmed, postoperative radiotherapy may be withheld, sparing the patient its poten-tially signifi cant long-term effects. On the other hand, if locally extensive oropharyngeal cancer is present, the laser can be used as a surgical cutting instrument prior to a vascularized fl ap reconstruction. Postoperative radio-therapy is mandatory in these cases, and most patients will require chemo-radiation.

Surgical specimen after a left hemiglossectomy.

7.50a

Appearance of the surgical site immediately after the hemiglossectomy …

7.50b

… and after healing.

7.50c


ReferencesAMBROSCH P, KRON M, STEINER W: Carbon dioxide laser microsurgery for early supraglottic carcinoma. Ann Otol Rhinol Laryngol 107: 680–688 (1998)

BRADLEY PJ, FERLITO A, SUÁREZ C, WERNER JA, GENDEN EM,SHAHA AR, LEEMANS CR, LANGENDIJK JA, RINALDO A: Options forsalvage after failed initial treatment of anterior vocal commissure squamous carcinoma. Eur Arch Otorhinolaryngol. 263: 889–894 (2006)

CLAYMAN GL, WEBER RS: Cancer of the hypoharynx and the cervical esophagus, In: Meyers EN, Suen JY (ed.) Cancer of the head and neck. Saunders, Philadelphia, pp 423–438 (1996)

FOLZ BJ, LIPPERT BM, KUELKENS C, WERNER JA: The infl uence of laser surgery on the assessment of „molecular margins“ in carcinomas and mucous membranes of the upper aerodigestive tract.Otolaryngol Pol. 53: 377–85 (1999)

GENDEN EM, FERLITO A, SILVER CE, JACOBSON AS, WERNER JA, SUÁREZ C, LEEMANS CR, BRADLEY PJ, RINALDO A: Evolution of the management of laryngeal cancer. Oral Oncol. 43: 431–439 (2007)

LIPPERT BM, FOLZ BJ, GOTTSCHLICH S, WERNER JA: Microendoscopic Treatment of the Hypopharyngeal Diverticulum with the CO2-Laser.Lasers in Surgery and Medicine, 20: 394–401 (1997)

LIPPERT BM, FOLZ BJ, RUDERT H, WERNER JA: Management ofZenker’s diverticulum and postlaryngectomy pseudodiverticulum with the CO2-laser. Otolaryngology – Head and Neck Surgery 121, 809–814 (1999)

LIPPERT BM, TEYMOORTASH A, FOLZ BJ, WERNER JA: Wound healing after laser treatment of oral and oropharyngeal cancer.Lasers Med Sci. 18: 36–42 (2003)

MAHNKE CG, FRÖHLICH O, LIPPERT BM, WERNER JA: Recurrentlaryngeal papillomatosis. Retrospective analysis of 95 patients and review of the literature. Otolaryngol Pol. 50: 567–578 (1996)

REKER U, RUDERT H: Die modifi zierte posteriore Chordektomie nach Dennis und Kashima bei der Behandlung beidseitiger Rekurrensparesen. Laryngo-Rhino-Otol 77, 213–218 (1998)

RUDERT H: Die Laminotomie nach Réthi (Erfahrungsbericht über dieBehandlung von 8 Larynxstenosen und 3 Larynxatresien).Z Laryngol Rhinol 55: 138–144 (1976)

RUDERT H: Erfahrungen mit dem CO2-Laser unter besonderer Berücksichtigung der Therapie von Stimmbandcarcinomen.Laryngo-Rhino-Otol. 62: 493–498 (1983)

RUDERT H: Transoral CO2-laser surgery of early glottic cancer (Cis-T2):in SMEE R, BRIDGER GP (Eds.): Laryngeal cancer.Amsterdam, the Netherlands: Elsevier: 389–392 (1994)

RUDERT H. Transoral CO2-laser surgery in advanced supraglottic cancer:in SMEE R, BRIDGER GP (Eds.): Laryngeal cancer.Amsterdam, the Netherlands: Elsevier: 457–461 (1994)

RUDERT H, WERNER JA: Endoskopische Teilresektionen mit demCO2-Laser bei Larynxkarzinomen. I. Resektionstechniken.Laryngo-Rhino-Otol. 74: 71–77 (1994)


RUDERT H, WERNER JA: Endoskopische Teilresektionen mit dem CO2-Laser bei Larynxkarzinomen. II. Ergebnisse.Laryngo-Rhino-Otol. 74: 294–299 (1995)

RUDERT H, WERNER JA: Endoscopic resections of glottic and supraglottic carcinomas with the CO2 laser. Eur Arch Otorhinolaryngolgoy 252:146–148 (1995)

RUDERT H: Technique and results of transoral laser surgery of supraglottic carcinoma. Adv otorhinolaryngol (Basel, Karger) 49: 227–230 (1995)

RUDERT H, WERNER JA: Lasers in otorhinolaryngology, and in head and neck surgery Advances in otorhinolaryngology, Vol 49, Karger, Basel (1995)

RUDERT H: Laser surgery in the management of carcinoma of thesupraglottic larynx and hypopharynx. In: MYERS EN, BLUESTONE CD, BRACKMANN DE, KRAUSE CJ (Eds.): Advances in otolaryngology –head and neck surgery. Vol. 12, St. Louis, Mosby: 61–80 (1998)

RUDERT H: Laser surgery for carcinomas of the larynx and hypopharynx, in: NAUMANN HH, HELMS J, HERBERHOLD C, JAHRSDOERFER RA, KASTENBAUER ER, PANJE WR, TARDY Jr. ME (Eds.): Head and NeckSurgery, Vol. 3, Stuttgart, New York, Thieme 1998: 355–370

RUDERT H: Endoscopic Management of Early Supraglottic Carcinomas, in: WEINSTEIN GS, LACCOURREYE O, BRASNU D, LACCOURREYE H:Organ Preservation Surgery for Laryngeal Cancer.Singular Publishing Group, San Diego: 97–105 (1999)

RUDERT H: CO2-Laserchirurgie in der Otorhinolaryngologie, Kopf und Halschirurgie Endopress, Tuttlingen 2002

RUDERT H, WERNER JA, HÖFT S: Transoral carbon dioxide laser resection of supraglottic carcinoma. Ann. Otol. Rhinol. Laryngol. 108: 819–827 (1999)

RUDERT H, HÖFT S: Transoral carbon-dioxide laser resection of hypo-pharyngeal carcinoma. Eur Arch Otorhinolaryngol 260: 198–206 (2003)

SAPUNDZHIEV NR, DÜNNE AA, RAMASWAMY A, SITTER H, DAVIS RK, WERNER JA: Lymph node metastasis in an animal model: effect ofpiecemeal laser surgical resection. Lasers Surg Med. 36: 371–376 (2005)

SAPUNDZHIEV N, LICHTENBERGER G, ECKEL HE, FRIEDRICH G, ZENEV I, TOOHILL RJ, WERNER JA: Surgery of adult bilateral vocal fold paralysis in adduction: history and trends. Eur Arch Otorhinolaryngol. 265: 1501–1514 (2008)

SCHÜNKE M, KRÜSS C, MECKE H, WERNER JA: Characteristic features of wound healing in laser-induced incisions. Adv Otorhinolaryngol. 49: 8–14 (1995)

SESTERHENN AM, DÜNNE AA, BRAULKE D, LIPPERT BM, FOLZ BJ, WERNER JA: Value of endotracheal tube safety in laryngeal laser surgery. Lasers Surg Med. 32: 384–390 (2003)

SESTERHENN AM, FOLZ BJ, LIPPERT BM, JÄNIG U, WERNER JA: Laser surgical treatment of laryngeal paraganglioma. J Laryngol Otol. 117:641–646 (2003)

SESTERHENN AM, DÜNNE AA, WERNER JA. Complications after CO2 laser surgery of laryngeal cancer in the elderly. Acta Otolaryngol. 126:530–535 (2006)

STEINER W, AMBROSCH P: Endoscopic Laser Surgery of the upper aerodigestive tract. Thieme Stuttgart, New York (2000)


THEISSING J, RETTINGER G, WERNER JA: HNO-Operationslehre,4. Aufl age, Thieme, Stuttgart (2006)

WERNER JA, LIPPERT BM, SCHÜNKE M, RUDERT H: Tierexperimentelle Untersuchungen zur Laserwirkung auf Lymphgefäße. Ein Beitrag zurDiskussion um die laserchirurgische Resektion von Karzinomen inmehreren Teilen. Laryngorhinootologie 74: 748–755 (1995)

WERNER JA, DUNNE AA, FOLZ BJ, LIPPERT BM: Transoral laser micro-surgery in carcinomas of the oral cavity, pharynx, and larynx.Cancer Control. 9: 379–86 (2002)

WERNER JA: Transoral Laryngeal Surgery. Endo-PressTM, Tuttlingen (2004)

WERNER JA: Lasers in Otorhinolaryngology. Part I: Benign Diseases.Endo-PressTM, Tuttlingen (2009)

WERNER JA: Lasers in Otorhinolaryngology. Part II: Malignant Diseases. Endo-PressTM, Tuttlingen (2010)


HOPKINS® Telescopesfor Direct Laryngoscopy

8710 AA

8710 AA h® Straight Forward Telescope 0°,enlarged view, diameter 5.8 mm, length 19 cm,autoclavable, fi ber optic light transmission incorporated,color code: green

8711 AA

8711 AA h® Straight Forward Telescope 0°,enlarged view, diameter 10 mm, length 20 cm,autoclavable,fi ber optic light transmission incorporated,color code: green

8714 AA

8714 AA h® Straight Forward Telescope 0º,enlarged view, diameter 6.5 mm, length 35 cm,autoclavable,fi ber optic light transmission incorporated,color code: green


HOPKINS® Telescopesfor Direct Laryngoscopy

8712 CA H® Lateral Telescope 70°,enlarged view, diameter 5 mm, length 24 cm, autoclavable,fi ber optic light transmission incorporated,color code: yellow

8712 BA H® Forward-Oblique Telescope 30°,enlarged view, diameter 5 mm, length 24 cm,autoclavable,fi ber optic light transmission incorporated,color code: red

8712 AA

8712 AA H® Straight Forward Telescope 0°,enlarged view, diameter 5 mm, length 24 cm,autoclavable,fi ber optic light transmission incorporated,color code: green


CCD Video-Rhino-Laryngoscopefor use with IMAGE 1™, TELECAM® SL II, TELECAM® DX II, TELE PACK and TELE PACK X

Special features: � Large viewing angle and defl ectable distal tipfacilitates orientation

� Waterproof, fully immersible for cleaningand disinfection

� Sterilizable with EtO gas, Steris® and Sterrad®

� Excellent optical quality – of both lens systemand video chip

� Superior life span due to robust mechanical design � Sensitive and stable control via ergonomic handle � Short insertion tip with smooth-running and non-twisting angle mechanism

� Optimally matched, non-rotational insertion sheath


11101 VP CCD Video-Rhino-Laryngoscope, PAL, for use with IMAGE 1™, TELECAM® SL II, TELECAM® DX II, TELE PACK and TELE PACK X

Direction of view: 0°Angle of view: 85°Defl ection: up 180°, down 90°Working length: 30 cmOuter diameter: 3.7 mm

Following accessories are included:

27677 VC Case13242 XL Leakage Tester, with bulb and manometer11025 E Pressure Compensation Cap,

for ventilation during gas sterilization

11101 VP

Note: The video connecting cables are not included in the set and must be ordered separately!

22 2000 77 IMAGE 1™ Video Connecting Cable, for video endoscopes, color system PAL, length 90 cm, for use with all KARL STORZ video endoscopes

or22 200177 IMAGE 1™ Video Connecting Cable,

for video endoscopes, color system NTSC, length 90 cm,for use with all KARL STORZ video endoscopesor

20 2130 70 Video Connecting Cable,for all KARL STORZ video endoscopes and TELECAM® SL II, TELECAM® DX II, TELE PACK and TELE PACK X, length 60 cm

CCD Video-Rhino-Laryngoscopefor use with IMAGE 1™, TELECAM® SL II, TELECAM® DX II, TELE PACK and TELE PACK X

11101 VN CCD Video-Rhino-Laryngoscope, NTSC, for use with IMAGE 1™, TELECAM® SL II, TELECAM® DX II, TELE PACK and TELE PACK X

Direction of view: 0°Angle of view: 85°Defl ection: up 180°, down 90°Working length: 30 cmOuter diameter: 3.7 mm


Rhino-Pharyngo-Laryngo-Fiberscope

Special features: � Large viewing angle and defl ectable distal tipfor better orientation

� Waterproof, fully immersible for cleaning anddisinfection

� Simple leakage test takes only a few minutesand requires no additional accessories

� Sterilizable with EtO gas, Steris® and Sterrad®

� Recommended for use in combination withKARL STORZ Endovision® TELECAM® System

� Exceptional optical quality of both lens and fi ber optic image transmission bundle

� Resistant construction and robust mechanics

11101 RP Rhino-Pharyngo-Laryngo-FiberscopeDirection of view: 0°Angle of view: 70°Working length: 30 cmOuter diameter: 3.5 mm

Following accessories are included: Case Pressure Compensation Cap Leakage Tester


Triangle Anterior Commissure Laryngoscopes

8574 LF

8574 LM

34.5

8589 B

19.5

14.5 x 19.5

29.5

8589 C

16 13 x 16

8574 LF

8574 LM

8589 B

Fig. 1. Focus of distal laryngoscope on the glottis: the oval or round laryngoscope (left); the triangular-shaped laryngoscope for the anterior commisure (right).

Fig. 2. The upturned distal end of the so-called “anterior commissure tube” impedes the view of the anterior commissure.

8589 B RUDERT Anterior Commissure Laryngoscope,large, triangular spatula-shaped, with lateral outer channels for Fiber Optic Light Carrier 8574 LF or Suction Tube to remove vapor 8574 LM, length 17 cm, (version with wide lumen for special cases)

8589 C Same, medium, universal size, (most commonly used model)

8574 LF Fiber Optic Light Carrier, for distal illumination, length 16 cm, for use with Laryngoscopes8590 AL/BL/C/CL/DL/JA and 8589 B/C

8574 LM Suction Tube to remove vapor,for LASER treatment, length 16 cm, for use with Laryngoscopes8590 AL/BL/CL/DL/JA and 8589 B/C

Most laryngoscopes have a round or oval distal opening, which is not optimally suited to the triangular shaped glottis (Fig. 1, left). It is therefore frequently not possible to focus on the anterior commissure with these laryngoscopes. The so-called “anterior commissure tubes” with upturned distal end shift the larynx and thus the anterior third of the glottis forwards out of the field of view. In addition to this, the curve of the tube end impedes the view of the anterior commissure (Fig. 2).

Taking up the idea of Vaughan, we developed a laryngoscope for examining the anterior commissure. Its

distal end is not upturned, but is shaped like the ridge of a roof. The triangular shape means that the distal opening exactly fits into the similarly triangular shape of the glottis (Fig. 1, right). The laryngoscope offers a good view of the glottis from the anterior commisure right to the arytenoid region.

The laryngoscope is available in 2 sizes. The smaller one is the universal tube. The larger one is suitable for large larynxes in adults with edentulous upper jaws.

Prof. emeritus H. RUDERT, M.D.Universitätsklinik Kiel, Germany


Special features: � Proven conical KLEINSASSER design � Modifi ed by RUDERT with right and left lateral outer channels used for smoke evacuationand/or for fi ber optic light carrier

� Full lumen working capacity, unobstructed view,operating instruments cannot get caught

8590 JA

8574 LM

8574 LF

31.5

8590 AL

21.5

19

28.5

8590 BL

18.5

15

21

8590 DL

13.5

11.5

25

8590 JA

16 12 x 18

19.5

8590 LL

12 10.5

Full size illustration: inner diameter in mm proximal and distal

8574 JH/LF/LG

8574 JK/LM/LN

8590 AL KLEINSASSER Laryngoscope, extra large, modifi ed by RUDERT for CO2 LASER surgery, for adults, with lateral outer channels forsuction tube to remove vapor and/or forfi ber optic light carrier, length 17 cm

8590 BL Same, large8590 CL Same, medium8590 DL Same, small, length 18 cm8590 JA Same, medium, length 18 cm,

for anterior commissure8590 KL Same, for children, length 15 cm8590 LL Same, for infants, length 13 cm

8574 JH Fiber Optic Light Carrier, for distal illumination, length 12 cm, for use with Laryngoscopes8574 J/JP and 8590 LL

8574 LF Same, length 16 cm, for use with Laryngoscopes 8590 AL/BL/CL/DL/JA and 8589 B/C

8574 LG Same, length 14 cm,for use with Laryngoscope 8590 KL

8574 JK Suction Tube to remove vapor, length 12 cm,for use with Laryngoscopes 8574 J/JP and 8690 LL

8574 LM Same, length 16 cm, for use with Laryngoscopes 8590 AL/BL/CL/DL/JA and 8589 B/C

8574 LN Same, length 14 cm,for use with Laryngoscope 8590 KL

26

15.5

13.5

8590 CL

20.5

13 10.5

8590 KL

KLEINSASSER Operating Laryngoscopesmodifi ed by RUDERT


WEERDA Distending Diverticuloscopefor CO2 LASER Technique

Outer dimensions in mm:proximal:

Spread: max. 40min. 29

12067 A WEERDA Distending Diverticuloscope,length 24 cm, with adaption for Suction Tube 12067 M

Proximal size open: max. 40 x 27 mm min. 29 x 27 mm Distal size open: max. 65 x 18 mm min. 7 x 18 mm

8590 GF Fiber Optic Light Carrier, for distal illumination, working length 14 cm

8590 ML Suction Tube, to remove vapor, for LASER treatment, outer diameter 3 mm

12067 M Suction Tube, to remove vapor, fl at, size 6 x 3 mm

Spread: max. 65min. 7

distal:

12067 A

18

12067 A

27

12067 A 12067 M

8590 GF

8575 K

8590 ML


8575 K Laryngoscope Holder and Chest Support, GÖTTINGEN model including: Laryngoscope Holder, GÖTTINGEN model,

with adjustment wheel Support Rod, movable, with metal ring,

diameter 9 cm, length 34 cm

8575 K

Laryngoscope Holdersfor Operating Laryngoscopes


Chest Supportfor Laryngoscope Holders

Chest Support, GÖTTINGEN model

A special chest support system has been designed to meet the requirements of transoral tumor surgery in the pharynx and larynx, together with an adjustable platform that can be secured in any of three dimen sional positions, allowing effortless changes in the position

8575 L

8575 L Support Table, GÖTTINGEN model,for Laryngoscope Holders 8575 K/KC, 8574 KT/KW,autoclavable

including: Swivel Arm, with moveable plate Holding Rod, for height adjustment Attachment Blocks, can be mounted on operation table

equipped with standard sliding rail 25 x 10 mm

of the laryngo-pharyngo scope during tumor surgery. Extremely lateral angles, as are often neces sary for work in the pharynx, are easily achieved and maintained.

Prof. emeritus W. STEINER, M.D.Universitäts-Hals-Nasen-Ohrenklinik, Göttingen, Germany


KLEINSASSER LASER Additional Instrumentsmodifi ed by RUDERTfor Laryngoscopy during CO2 LASER Treatment

Special features: � All instruments are equipped with a channelfor evacuation of LASER vapors

� Special matt fi nish for use with CO2 LASER

� Distal end thinner than proximal end to providebetter viewing

� Sheath conically reinforced from distal to proximal end to increase mechanical stability

Working length 18 and 23 cm

8591 AL/AKL

8591 BL Cutting Forceps, curved upwards,diameter 2 mm, working length 23 cm,with suction channel to remove LASER vapors

8591 BKL Same, working length 18 cm

8591 RL Cutting Forceps, opens horizontally to right,diameter 2 mm, working length 23 cm,with suction channel to remove LASER vapors

8591 SL Same, opens horizontally to left

8591 BL/BKL/RL/SL

8591 AL Cutting Forceps, straight, with 2 mm cupped jaws, working length 23 cm,with suction channel to remove LASER vapors

8591 AKL Same, working length 18 cm


Additional LASER Instruments for use with CO2 LASERRecommended by Prof. RUDERT, M.D.

8662 G LARYNGOFORCE®II Grasping Forceps, with oval,fenestrated alligator jaws, large,special matt fi nish, working length 22 cm

8662 GL Same, with suction channel to remove LASER vapors

8662 GLR Same, with suction channel to remove LASER vapors, with ratchet

8662 H LARYNGOFORCE®II Grasping Forceps, with triangular,fenestrated alligator jaws, extra large,special matt fi nish, working length 22 cm

8662 HL Same, with suction tube for LASER vapors

Working length 22 cm

8662 G/H

8662 GL/HL

8662 HLR Same, with suction channel to remove LASER vapors, with ratchet


8591 TL

8591 TL KLEINSASSER Cutting Forceps,4 mm round cupped jaws,special matt fi nish,with suction channel to remove vapor,working length 22 cm, straight

8591 UL Same, curved upwards

8591 VL Same, curved right

8591 WL Same, cuved left


8663 AH

8663 AH Grasping Forceps, straight, serrated,sheath insulated, working length 23 cm

8663 BH Same, curved to right

8663 CH Same, curved to left


8605 N/P

8605 N Insulated Cannula,for suction and coagulation, outer diameter 3 mm,working length 26 cm,for use with unipolar High Frequency Cords 26005 Mor 26002 M/26004 M/26006 M

8605 P Same, outer diameter 5 mm

8602 – 8604

8602 Suction Tube, outer diameter 2 mm,working length 23 cm

8603 Same, outer diameter 2.5 mm8604 Same, outer diameter 3 mm




Please note:Simultaneous use of insulated instruments and LASER is prohibited.

8602 KA / 8603 KA

8602 KA Suction Tube, insulated, distal end ball-shaped, outer diameter 2 mm, working length 23 cm, for suction of carbonized tissue after LASER treatment

8603 KA Same, outer diameter 3 mm

Special features: � All instruments are equipped with a channel for evacuationof LASER vapors

� Special matt fi nish for use with CO2 LASER

8596 JL

8596 JL RUDERT Protector, to protect tissue against laser beam,with suction channel to remove vapor, working length 23 cm, straight,plate shape,distal suction hole left side

8596 JR Same, distal suction hole right side

8596 N Same, round, curved upwards,diameter 3 mm

8596 O Same, diameter 4 mm

8596 P Same, diameter 5 mm


IMAGE 1 HUBTM HDIMAGE 1 HUBTM HD Camera Control Unit

� Genuine FULL HD (High Defi nition) is guaranteed by a maximum resolution and the consistent use of the native 16:9 aspect ratio throughout the entire image chain, from image capture, signal transmission to display

� HD-compatible endoscopic video camera systems must be equipped with three-CCD chips supporting the 16:9 input format and require that image capture is performed at a resolution of 1920 x 1080 pixels

The benefi ts of FULL HD (High Defi nition)for medical applications are:

� 6 times higher input resolution of the cameradelivers more detail and depth of fi eld

� Using 16:9 format during image acquisitionenlarges the fi eld of view

� The 16:9/16:10 format of the widescreen monitorsupports ergonomic viewing

� Enhanced color brilliance for optimal diagnosis � Progressive scan technology provides a steady, fl icker-free display and helps eliminate eyestrainand fatigue

22 201020-1xx

22 2010 11U102 IMAGE 1 HUBTM HD Camera Control Unit SCB®,with SDI module

for use with IMAGE 1™ HD and standard one- and three-chip camera heads,max. resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB® and integrated digital Image Processing Module, color systems PAL/NTSC,power supply 100 – 240 VAC, 50/60 Hzincluding:Mains CordMains Cord, US-version3x BNC/BNC Video Cable, length 180 cmS-Video (Y/C) Connecting Cable, length 180 cmSpecial RGBS Connecting Cable, length 180 cm2x Connecting Cable, for controlling peripheral units, length 180 cmDVI-D Connecting Cable, length 300 cmSCB® Connecting Cable, length 100 cmKeyboard, with US English character set

22 2010 11U1 IMAGE 1 HUB™ HD Camera Control Unit SCB®

for use with IMAGE 1™ HD and standard one- and three-chip camera heads, max. resolution 1920 x 1080 pixels, with integrated KARL STORZ SCB® and integrated digital Image Processing Module, color systems PAL/NTSC, power supply 100 – 240 VAC, 50/60 Hzincluding:Mains CordBNC/BNC Video Cable, length 180 cmS-Video (Y/C) Connecting Cable, length 180 cmSpecial RGBS Connecting Cable, length 180 cm2x Connecting Cable, for controlling peripheral units, length 180 cmDVI-D Connecting Cable, length 300 cmSCB® Connecting Cable, length 100 cmKeyboard, with US English character set


IMAGE 1 HUBTM HDHD Camera Control Unit

22 2010 20-11x

22 2010 11U110 IMAGE 1 HUB™ HD Camera Control Unit SCB®,with ICM module

for use with IMAGE 1™ HD and standard one- and three-chip camera heads, max. resolution 1920 x 1080 pixels, with integrated KARL STORZ SCB® and integrated digital Image Processing Module, color systems PAL/NTSC, power supply 100 – 240 VAC, 50/60 Hzincluding:Mains Cord3x BNC/BNC Video Cable, length 180 cmS-Video (Y/C) Connecting Cable, length 180 cmSpecial RGBS Connecting Cable, length 180 cm2x Connecting Cable, for controlling peripheral units, length 180 cmDVI-D Connecting Cable, length 300 cmSCB® Connecting Cable, length 100 cmKeyboard, with US English character set

22 2010 11U112 IMAGE 1 HUB™ HD Camera Control Unit SCB®, with SDI/ICM module

for use with IMAGE 1™ HD and standard one- and three-chip camera heads, max. resolution 1920 x 1080 pixels, with integrated KARL STORZ SCB® and integrated digital Image Processing Module, color systems PAL/NTSC, power supply 100 – 240 VAC, 50/60 Hzincluding:Mains Cord3x BNC/BNC Video Cable, length 180 cmS-Video (Y/C) Connecting Cable, length 180 cmSpecial RGBS Connecting Cable, length 180 cm2x Connecting Cable, for controlling peripheral units, length 180 cmDVI-D Connecting Cable, length 300 cmSCB® Connecting Cable, length 100 cmKeyboard, with US English character set

IMAGE 1 HUB™ HDthree-chip camera systems � 60 dB

Signal-to-noise Ratio AGC Video Output Input

Microprocessor-controlled

- Composite signal to BNC socket- S-Video signal to 4-pin Mini-DIN socket (2x)- RGBS signal to D-Sub socket- SDI signal to BNC socket (only IMAGE 1 HUB™ HD with SDI module) (2x)- HD signal to DVI-D socket (2x)

Keyboard for title generator, 5-pin DIN socket

Specifications:

Control Output /InputDimensions

w x h x d (mm) Weight (kg) Power supply Certified to:

- KARL STORZ-SCB® at 6-pin Mini-DIN socket (2x)- 3.5 mm stereo jack plug (ACC 1, ACC 2),- Serial port at RJ-11

305 x 89 x 335 2.95 100-240 VAC, 50/60 Hz

IEC 601-1, 601-2-18, CSA 22.2 No. 601, UL 2601-1 and CE acc. to MDD, protection class 1/CF


H3-M Microscope Camera Head

With the new H3-M microscopic camera head KARL STORZ brings all benefits of FULL HD in the field of microscopy.A range of unique features that have been optimized for microscopy include:

� 3-CCD HD progressive scan generates 1920x1080p FULL HD resolution

� Lightweight small-profi le camera head does not affect microscope balance

� 9 meter-removable head cable can be routed through the microscope swing arm or ceiling tiles

� True C-MOUNT interface provides parfocal image on any microscope

� Manual and automatic white balance maintains color accuracy

� User-defi ned specialty presets allow up to eight custom camera settings

� Exclusive exposure control provides four gain settings for optimized camera sensitivity in low-lightconditions, and brightness controls adapt to various operative environments

� C-MOUNT adaptors for surgical microscopes provide user-adjustable focus and iris control,and horizontal/vertical controls adjust centering of the microscope image

222200 54-322220 154-3

301513 Optical Beamsplitter 50/50, for use with ZEISS operating micro scope or colposcope

20 9230 55 QUINTUS Z 55 TV-Adapter for CARL ZEISSMEDITEC surgical microscope and colposcope,f = 55 mm, for use with optical beam splitter andIMAGE 1™ H3-M microscope camera head(22220 x 54-3) or C-MOUNT Adapter (2010 Z)

20 9230 55

n

IMAGE 1™ HD Camera Heads

50 Hz

60 Hz

Image Sensor

Pixel Output Signal H x V

Dimensions

Weight

Min. Sensitivity

Lens

Grip Mechanism

Cable

Cable Length

H3-M

22 2200 54-3 (PAL)

22 2201 54-3 (NTSC)

3x 1/3“ CCD chip

1920 x 1080

44.7 x 47.2 mm, length 87 mm

260 g

F 1.4/1.9 Lux

C-MOUNT connection

C-MOUNT connection

detachable

900 cm

Specifications:

n 22 2201 54-3 60 Hz IMAGE 1™ H3-M Three-ChipHD Microscope Camera Head

max. resolution 1920 x 1080 pixels, progressive scan, with C-MOUNT thread for coupling to microscopes, 2 freely programmable camera head buttons,with detachable camera head cable, length 900 cm, for use with color system NTSC

301513

22 2200 54-3 50 Hz IMAGE 1™ H3-M Three-ChipHD Microscope Camera Head

max. resolution 1920 x 1080 pixels, progressive scan,with C-MOUNT thread for coupling to microscopes, 2 freely programmable camera head buttons,with detachable camera head cable, length 900 cm, for use with color system PAL


IMAGE 1 HUB™ HDFULL HD Camera Head

Standard IMAGE 1TM camera heads may also be used with the IMAGE 1 HUBTM HD camera control unit.

22 2200 55-3

IMAGE 1™ HD Camera Heads

50 Hz/60 Hz

Image Sensor

Pixel Output Signal H x V

Dimensions

Weight

Min. Sensitivity

Lens

Grip Mechanism

Cable

Cable Length

H3-Z

22 2200 55-3 (PAL/NTSC) (50/60 Hz)

3x 1/3“ CCD chip

1920 x 1080

Diameter 32-44 mm, length 114 mm

246 g

F 1.4/1.17 Lux

Integrated Parfocal Zoom Lens,f = 15-31 mm

Standard eyepiece adaptor

non-detachable

300 cm

Specifications:

22 2200 55-3 50 Hz IMAGE 1™ H3-Z60 Hz Three-Chip HD Camera Head

max. resolution 1920 x 1080 pixels, progressive scan, soakable,gas-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x),2 freely programmable camera head buttons


9619 NB 9626 NB/NB-2

KARL STORZ FULL HD Monitors

19"

9619 NB

1x

optional

1x

1x

1x

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26"

9626 NB

1x

optional

1x 1x

1x

��

��

KARL STORZ HD and FULL HD Monitors

Wall-mounted with VESA 100 adaption

Inputs:

DVI-D

Fiber Optic

RGBS/VGA

S-Video

Composite

Outputs:

DVI-D

S-Video

Composite

Displayable signal formats:

4:3

5:4

16:9

Picture-in-Picture

PAL/NTSC compatible

26"

9626 NB-2

2x

optional

2x

2x

2x

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Mains CordFollowing accessories included:

External 24VDC Power SupplySignal cables: DVI-D, VGA, S-Video, BNC

Optional accessories:9626 SF Pedestal, suitable for monitors of

the 96xx series

n

19"

optional

9619 NB

280 cd/m2

178° vertical

0.29 mm

≤ 12 ms

700:1

100 mm VESA

10 kg

120 W

0-40°C

-20-60°C

max. 80%

469.5 x 416 x 75.5 mm

85-264 VAC

26"

optional

9626 NB/NB-2

400 cd/m2

178° vertical

0.30 mm

≤ 12 ms

700:1

100 mm VESA

14 kg

120 W

0-40°C

-20-60°C

max. 80%

699 x 645.6 x 87.5 mm

85-264 VAC

KARL STORZ HD and FULL HD Monitors

Pedestal


Brightness

Max. Viewing Angle

Pixel Distance

Reaction Time

Contrast Ratio

Mounting

Weight

Rated Power

Operating Conditions

Storage

Rel. Humidity

Dimensions w x h x d

Power Supply

Specifications:


KARL STORZ HD and HD WideView™ Monitors

9515 NB, 9519 NB9524 NB/NBO, 9526 NB/NBO

15"

9515 NB

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19"

9519 NB

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Inputs:

SDI

HD-SDI

RGBS

S-Video

Composite

SOG

DVI-D

Fiber Optic

VGA

Outputs:

SDI

HD-SDI

RGBS

S-Video

Composite

DVI-D

Displayable signal formats:

4:3

5:4

16:9

16:10

Picture-in-Picture

PAL/NTSC compatible

9526 NB

–

��–

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9526 NBO

–

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9524 NB

–

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24" 26"

TFT Flat Screens HD WideView™ Monitors

Optional accessories:9626 SF Pedestal, suitable for monitors of

the 94xx-, 95xx- and 97xx seriesMains CordExternal 24VDC Power Supply

Following accessories included:

Signal Cables: DVI-D, BNC


KARL STORZ HD and HD WideView™ Monitors

9515 NB 15" HD Monitor

Wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1024 x 768, pow-er supply 100 – 240 VAC, 50/60 Hzincluding:Power SupplyMains CordSignal cables: DVI-D, BNC

9519 NB 19" HD Monitor

Wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1280 x 1024, power supply 100 – 240 VAC, 50/60 Hzincluding:Power SupplyMains CordSignal cables: DVI-D, BNC

9524 NB 24" HD WideView™ Monitor

Wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1920 x 1200, im-age format 16:10, power supply 100 – 240 VAC, 50/60 Hzincluding:Power SupplyMains CordSignal cables: DVI-D, BNC

9524 NBO 24" HD WideView™ Monitor (Fiber)

Wall-mounted with VESA 100 adaption, optical input, color systems PAL/NTSC, max. screen resolution 1920 x 1200, image format 16:10, power supply 100 – 240 VAC, 50/60 Hzincluding:Power SupplyMains CordSignal cables: DVI-D, BNC

9526 NB 26" HD WideView™ Monitor

Wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1920 x 1200, im-age format 16:10, power supply 100 – 240 VAC, 50/60 Hzincluding:Power SupplyMains CordSignal cables: DVI-D, BNC

9526 NBO 26" HD WideView™ Monitor (Fiber)

Wall-mounted with VESA 100 adaption, optical input, color systems PAL/NTSC, max. screen resolution1920 x 1200, image format 16:10, power supply 100 – 240 VAC, 50/60 Hzincluding:Power SupplyMains CordSignal cables: DVI-D, BNC

15"

9515 NB

430 cd/m2

178° vertical

0.297 mm

10-16 ms

500:1

100 mm VESA

4.8 kg

40 Watt

0-40 °C

-20-60 °C

5-85 %,non-condensing

385 x 301 x 81 mm

100-240 VAC

19"

9519 NB

300 cd/m2

178° vertical

0.294 mm

10-16 ms

600:1

100 mm VESA

6.8 kg

65 Watt

0-38 °C

-20-60 °C

5-85%, non-condensing

465 x 400 x 98 mm

100-240 VAC

24"

9524 NB/NBO

400 cd/m2

178° vertical

0.270 mm

5-12 ms

1000:1

100 mm VESA

7.3 kg

115 Watt

0-40 °C

-20-60 °C


597 x 401 x 100 mm

100-240 VAC

26"

9526 NB/NBO

500 cd/m2

178° vertical

0.287 mm

5-12 ms

800:1

100 mm VESA

8.2 kg

115 Watt

0-40 °C

-20-60 °C


627 x 427 x 100 mm

100-240 VAC


Brightness

Max. Viewing Angle

Pixel Distance

Reaction Time

Contrast Ratio

Mount

Weight

Rated Power

Operating Conditions

Storage

Rel. Humidity

Dimensions w x h x d

Power Supply

Specifications:


Data Management and DocumentationKARL STORZ AIDA® compact NEO (HD/SD)Brilliance in documentation continues!

AIDA compact NEO from KARL STORZ combines all the required functions for integrated and precise documentation of endoscopic procedures and open surgeries in a single system.

Data Acquisition

Still images, video sequences and audio comments can be recordedeasily during an examination or intervention on command by either pressing the on screen button, voice control, foot switch or pressing the camera head button. All captured images will be displayed on the right hand side as a “thumbnail” preview to ensure the still image has been generated.

The patient data can be entered by the on-screen keyboard or by astandard keyboard.

Flexible post editing and data storage

Captured still images or video fi les can be previewed before fi nal storageor can be edited and deleted easily in the edit screen.

Reliable storage of data

� Digital saving of all image, video and audio fi les on DVD, CD-ROM, USB stick, external/internal hard-drive or to the central hospital storage possibilities over DICOM/HL7

� Buffering ensures data backup if saving is temporarily not possible

� Continuous availability of created image, video and sound material forprocedure documentation and for research and teaching purposes.

Effi cient data archiving

After a procedure has been completed, KARL STORZ AIDA® compact HD/SD saves all captured data effi ciently on DVD, CD-ROM, USB stick,external hard-drive, internal hard-drive and/or the respective network onthe FTP server. Furthermore the possibility exists to store the data directlyon the PACS respective HIS server, over the interface package AIDAcommunication HL7/DICOM.

Data that could not be archived successfully remains in a special buffered procedure until it is fi nally saved. A two-line report header and a logo can be used by the user to meet his or her needs.

Multisession and Multipatient

Effi cient data archiving is assured as several treatments can be saved on a DVD, CD-ROM or a USB stick.

AIDA compact NEO: Automatic creation of standard reports

AIDA compact NEO: Effi cient archiving

AIDA compact NEO: Voice control

AIDA compact NEO: Review screen


Specifications:

Video Systems

Signal Inputs

Image Formats

- PAL- NTSC

- S-Video (Y/C)- Composite- RGBS- SDI- HD-SDI- DVI

- JPG- BMP

Video Formats

Audio Formats

Storage Media

- MPEG2

- WAV

- DVD+R- DVD+RW- DVD-R- DVD-RW- CD-R- CD-RW- USB stick

20 0409 10 KARL STORZ AIDA® compact NEO SDCommunication, documentation systemfor digital storage of still images, video sequences and audio files, power supply 115/230 VAC, 50/60 Hz

20 0409 11 KARL STORZ AIDA® compact NEO HDCommunication, documentation systemfor digital storage of still images,video sequences and audio files,power supply 115/230 VAC, 50/60 Hz

20 0406 10 KARL STORZ AIDA® compact NEO SD,documentation system for digital storage of still images, video sequences and audio files,power supply 115/230 VAC, 50/60 Hz

20 0406 11 KARL STORZ AIDA® compact NEO HD,documentation system for digital storage of still images, video sequences and audio files,power supply 115/230 VAC, 50/60 Hz

Features and Benefi ts

� Digital storage of still images with a resolution of 1920 x 1080 pixels,video sequences in 720p and audio fi les with AIDA compact NEO HD

� Optional interface package DICOM/HL7

� Sterile, ergonomic operation via touch screen, voice control,camera head buttons and/or foot switches

� Auto detection of the connected camera system on HD-SDI/SD-SDI input

� Effi cient archiving on DVD, CD-ROM or USB stick,multi-session and multi-patient

� Network saving

� Automatic generation of standard reports

� Approved use of computers and monitors in the OR environmentas per EN 60601-1

� Compatibility with the KARL STORZ Communication Bus (SCB®)and with the KARL STORZ OR1™ AV NEO

� KARL STORZ AIDA® compact NEO HD/SD is an attractive, digital alternative to video printers, video recorders and dictaphones.


Fiber Optic Light Cable

495 NCS Fiber Optic Light Cable,with straight connector, extremely heat-resistant, diameter 4.8 mm, length 250 cm

495 NA Fiber Optic Light Cable,with straight connector, diameter 3.5 mm, length 230 cm

Cold Light Fountain XENON 300 ®

20 133101-1 Cold Light Fountain XENON 300 ®

with built-in antifog air-pump, and integrated KARL STORZ Communication Bus System ®

power supply:100 –125 VAC/220 –240 VAC, 50/60 Hz

including: Mains Cord Silicone Tubing Set, autoclavable, length 250 cm ® Connecting Cord, length 100 cm20133027 Spare Lamp Module XENON

with heat sink, 300 watt, 15 volt20133028 XENON Spare Lamp, only,

300 watt, 15 volt

Cold Light Fountain XENON NOVA® 300

20134001 Cold Light Fountain XENON NOVA® 300,power supply:100–125 VCA/220–240 VAC, 50/60 Hz

including: Mains Cord20132028 XENON Spare Lamp, only,

300 watt, 15 volt


29005 LAP Equipment Cart, rides on 4 antistatic dual wheels,2 equipped with locking brakes, 3 fi xed shelfs, one with handles,main switch at vertical beam,integrated cable conduits in vertical beams, drawer unit with lock,3 horizontal cable conduits,one with cable winding,two with 4-times electrical sub-distributer,1 set of non-sliding stands for units,1 TFT-Monitor arm (VESA 75/100),1 camera holder,8 power cords (50 cm), 2 power cords (2 m),2 equipment rails,1 CO2-bottle holder, max. diameter 155 mm, Isolation transformer 230 VAC (50/60 Hz) with 8 sockets and earth potentialand earth leakage monitor (2000 VA),

Dimensions: Videocart 730 x 1470 x 716 mm (w x h x d),shelf: 630 x 480 mm (w x d),caster diameter: 150 mm

Equipment Cart

29005 LAP

29005 SZ TFT- Monitor arm, height- and side-adjustable, can be positioned at left/right side, rotatable and inclinable,turning radius approx. 180°, load capacity max. 14 kg, swivel length 600 mm, VESA 75/100-adaption, for mobile videocart,model 29005 LAP/GU and 29003 NE/NA

29005 SZ


Notes:

WITH COMPLIMENTS OFKARL STORZ––ENDOSKOPE

Documents

CO · absence of bleeding, the boundaries between tumor and healthy tissue can ... Today, then, we can remove resectable carcinomas of the supraglottis and