- Email: [email protected]
Laser treatment of laryngeal polyps
Betty L Carrell, RN
Laser treatment of laryngeal polyps
Removal of benign laryngeal polyps is a common application of the COz laser. The polyps, which form where the cords come together, are chronic subepithelial edematous masses usually caused by abusing the voice. Since the polyps prevent the cords from closing properly during phonation, the patient has a hoarse voice, which is the major symptom. The growths aren’t painful, and removal is generally successful in treating the condition. Usually, with the laser the procedure can be done on a n outpatient basis under general anesthesia. The patient recovers quickly and often can return to work within a few days, although he must be careful not to strain his voice. Polyp removal is an example of how the laser has made surgery faster. The conventional method is vocal cord stripping, in which the polyp is grasped and removed. This procedure takes about 1%hours, compared to laser surgery, which takes about % hour. The laser beam, aimed at the lesions through a laryngoscope, vaporizes the polyps. The COz laser works by raising water in cells to the flash-boiling point, ~~
Betty L Carrell, RN, BS, is office and private scrub nurse for A D Meyers, MD, and administrative assistant for the Institute of Laser Medicine at Saint Joseph Hospital, Denver. She received an associate degree in nursing from Arapahoe Community College, Littleton,Colo, and a bachelot‘s degree from St Louis University.
so the cells are destroyed. It is difficult to generalize about the procedure’s success, because recurrence depends on complex factors, including the nature and severity of the underlying pathol-
om. Because of careful and thorough preoperative teaching, most of our patients do not seem anxious about laser surgery when they come to the operating room. The teaching is usually done one or two days before surgery. On the day of surgery, the nurse meets the patient in the holding area to reinforce the teaching, reassuring him or her, and answering last-minute questions. A phone call one or two days after surgery provides the nurse an opportunity to do an evaluation and check on the patient’s status. We wait to do the preoperative teaching until a day or two before surgery, because patients seem more receptive and less anxious than when surgery is first scheduled. At this preoperative office visit, the patient fills out a preanesthesia surgery questionnaire, which provides a standard medical and surgical history. We schedule laboratory tests so they will be completed before the day of surgery, avoiding added anx iety that might be caused by having tests and surgery done the same day. All patients have a complete blood count and urinalysis. Those over 40 also have an electrocardiogram and chest x-ray. From our experience, the majority of patients view laser surgery more with
AORN Journal, August 1983, Vol38, No 2
curiosity than fear. We explain that a high-energy light beam will be aimed a t a very small target area of the polyp. The precise beam destroys the diseased tissue, causing little damage to the surrounding area. If there are large lesions on both sides of the cords, we usually treat one side a t a time. There is minimal edema with the laser, and little tissue trauma and scar formation, contributing to a smooth recovery. Healing is normally rapid. Pain seems to be minimal after larnygeal surgery, and most patients are discharged the same day. Although we prescribe an analgesic, most patients report they don’t need to take it. Patients’ most common questions about the laser are, “Will it miss and hit something else?” and “Does i t cause cancer?’ We explain that although the laser beam is invisible, the machine has a red helium-neon light used to aim it. Both the nurse and the physician test the beam before surgery to make sure it is properly aligned. We also reassure them that follow-up studies with patients treated with the laser as long as 20 years ago show no relationship between laser surgery and cancer. Unlike ionizing radiation (x-ray),the laser does not cause genetic mutation. Risks and possible complications are
A common question is: “Will it miss and hit something else?” reviewed in the process of obtaining the patient’s consent for surgery. They include: 0 Tooth fracture. This may occur when the laryngoscope is inserted over the teeth, so a tooth guard is used. We
tell the patient that with proper technique, damage is unlikely. 0 Tracheal fire. This rare complication of laser surgery may occur when the laser beam reflects off a shiny object, igniting anesthetic gases in the patient’s trachea. We tell patients that we prevent reflection by using a rubber endotracheal tube covered with cloth tape. We show them the equipment. We also explain that we have emergency equipment available in the unlikely event a fire happens. 0 No improvement i n polyps. Depending on how many polyps a patient has, we tell them that more than one procedure may be needed to clear them. In a few cases, patients will not show improvement. Polyps may recurr. Before the patient enters the operating room, the laser is tested, and the instrument setup is prepared. For the protection of hospital personnel, signs are posted on the operating room door saying that a laser is in use. Operating room personnel wear protective eyewear. During the procedure, the patient’s eyes are protected with moistened eye pads taped securely in place. Eyes are especially vulnerable to the COz laser because of their high fluid content. Moistened pads protect them because water will completely absorb the COz laser beam. Compared with conventional surgery, the instrument setup for a laser laryngoscopy is simple. Since the laser is the main surgical instrument, few others are needed. Most of the items are for emergencies. Instruments and equipment in the setup are: 0 a tracheostomy set and tracheostomy tubes in case of a spasm or burn to the larynx 0 a bronchosocpe connected to a fiberoptic light source to be used in looking for burned cottonoid particles in case of a tracheal fire
AORN Journal, August 1983, Val 38, No 2
233
alligator forcep for use in retrieving burned cottonoid particles from the bronchial trees in case of a fire alligator forcep with cottonoid attached used to cover balloon on end of endotracheal tube, which is kept moistened with saline bowl for specimen bowl with saline for irrigation 20 cc syringe with K-52extension tubing used for irrigating. Although we have never had an endotracheal fire in our practice, we have simulated one in the laboratory so we could plan how to respond. Some hospitals have a laser tray, with such items as: tracheostomy instruments vocal cord retractor laryngeal mirrors used to reflect the laser beam t o inaccessible places such as the dorsum of the soft palate or the larnygeal surface of the epiglottis laryngoscope and light source 0 alligator forcep right, left, and upper biopsy forcep. The back table is always set up in the same order so the nurse will know where everything is in case of a n emergency. After the patient is placed in the supine position, he is entubated with a soft, red rubber endotracheal tube that has been wrapped with white cloth tape. Then he is anesthetized. The laser microscope unit is swung into place. The surgeon introduces the laryngoscope into the mouth over the tooth guard and places i t through the laryngeal opening. It is locked into place in suspension fashion. He examines the entire larynx for polyps. A biopsy specimen is taken of the polypoid tissue and sent to the pathology department. Before turning on the laser beam, the surgeon places a cottonoid over the endotracheal tube to further protect the 234
area. A foot pedal turns on the laser beam, which vaporizes the polyp. The surgeon will decide how much of the area to treat in this one procedure. After the laser treatment is finished, the laryngoscope is removed, and the patient is extubated. In our phone call the first or second day after surgery, our objective is to find out if the patient is having any problems and any pain. Usually, someone is with him who can talk to us on the phone so the patient does not have to use his or her voice. By the third day, most patients can talk briefly. Most are able to go back to work by then if their job does not involve a great deal of speaking. During their preoperative teaching session, patients have many questions about their postoperative care. The most common ones are: How soon can I eat? What can I have? For the first 24 hours, they eat primarily a soft diet, expecially avoiding fried foods and anything scratchy. They must drink fluids to help lubricate the vocal cords. In excising the tissues, the laser vaporizes fluids from the cells, which drinking fluids helps restore. When can I talk? Patients may be hoarse for two or three months after surgery. We emphasizethat they should not abuse their voice. They must rest
By the third day, most patients can talk briefly. their voice for the first five or six postoperative days. Whispering is especially hard on the cords, even worse than yelling or shouting. By drinking water before speaking, they can ease strain on the surgical area.
AORN Journal, August 1983, Vol38, No 2
0 Can I smoke or drink? Smoking and drinking alcohol are out, at least for the first several days, because both irritate the burned area of the larynx and may delay healing. 0 Will my throat swell up? With the laser, swelling is minimal, so the patient should not have breathing problems. Breathing through the mouth while asleep may irritate the tissues, so it helps to have a glass of water a t the bedside. In other postoperative instructions, we explain that the patient may feel tired and have achy muscles immediately after surgery due to muscle relax-
ants used with the general anesthetic. Likewise, there may be some pain in the temporomandibular joint, radiating out to the ears, caused by having the mouth held open during the procedure. The laser has considerably simplified removal of polyps. Patients do not have to undergo the trauma involved in other types of surgical removal. With less area affected and less swelling, they are able to return to normal functioning faster. Preoperative teaching plays an important part in helping alleviate the apprehension that may accompany a procedure that will be performed with a relatively new surgical instrument. 0
Breast cancer victims have new alternative Women who have early detection of breast cancer may no longer have to undergo a radical mastectomy. Results of a large-scale study published in the May 1983 Archives of Surgery show that conservative surgery with irradiation may be as effective in curing the cancer as a radical mastectomy. Marvin M Romsdahl, MD, and colleagues from the M D Anderson Hospital, Houston, studied 922 patients from 1955 through 1979. They compared conservative surgery and irradiation with radical or modified radical mastectomy for treating breast cancer at three stages (minimal, stage I, and stage 11). The researchers report that “disease-free survival rates at five and ten years for patients having radical mastectomy or conservative surgery with irradiation are similar. Patients having conservative surgery and irradiation, in our study, had virtually similar survival rates to radical mastectomy for each of the stages represented.” The researchers caution, however, that “in different persons, carcinoma of the breast has a wide spectrum of biologic behavior, and clinical outcomes are perhaps as much related to this variable as to specific management.” They recommend
236
conservative surgery with irradiation for selected patients with either no axillary lymph node involvement or a movable node in the lateral axillary compartment. The researchers report that patients are enthusiastic about the alternative surgery and are pleased with the cosmetic result.
Chest x-rays not justified, panel says A panel of physicians, supported by the National Center for Devices and Radiological Health (NCDRH), is recommending limiting routine chest x-rays, according to an article in Hospitals. The yield of unsuspected disease found by routine, mandated, chest x-ray examinations has not been of sufficient clinical value to justify the cost, added radiation exposure, and subject inconvenience of the examination, the panel reported. The panel would limit mandated, routine chest x-ray screening examinations; routine prenatal chest x-ray exams; routine hospital admission chest x-ray exams; chest x-ray exams for tuberculosis detection and control; and routine chest x-ray exams for occupational medicine.
AORN Journal, August 1983, Vol38, No 2
Laser treatment of laryngeal polyps
Removal of benign laryngeal polyps is a common application of the COz laser. The polyps, which form where the cords come together, are chronic subepithelial edematous masses usually caused by abusing the voice. Since the polyps prevent the cords from closing properly during phonation, the patient has a hoarse voice, which is the major symptom. The growths aren’t painful, and removal is generally successful in treating the condition. Usually, with the laser the procedure can be done on a n outpatient basis under general anesthesia. The patient recovers quickly and often can return to work within a few days, although he must be careful not to strain his voice. Polyp removal is an example of how the laser has made surgery faster. The conventional method is vocal cord stripping, in which the polyp is grasped and removed. This procedure takes about 1%hours, compared to laser surgery, which takes about % hour. The laser beam, aimed at the lesions through a laryngoscope, vaporizes the polyps. The COz laser works by raising water in cells to the flash-boiling point, ~~
Betty L Carrell, RN, BS, is office and private scrub nurse for A D Meyers, MD, and administrative assistant for the Institute of Laser Medicine at Saint Joseph Hospital, Denver. She received an associate degree in nursing from Arapahoe Community College, Littleton,Colo, and a bachelot‘s degree from St Louis University.
so the cells are destroyed. It is difficult to generalize about the procedure’s success, because recurrence depends on complex factors, including the nature and severity of the underlying pathol-
om. Because of careful and thorough preoperative teaching, most of our patients do not seem anxious about laser surgery when they come to the operating room. The teaching is usually done one or two days before surgery. On the day of surgery, the nurse meets the patient in the holding area to reinforce the teaching, reassuring him or her, and answering last-minute questions. A phone call one or two days after surgery provides the nurse an opportunity to do an evaluation and check on the patient’s status. We wait to do the preoperative teaching until a day or two before surgery, because patients seem more receptive and less anxious than when surgery is first scheduled. At this preoperative office visit, the patient fills out a preanesthesia surgery questionnaire, which provides a standard medical and surgical history. We schedule laboratory tests so they will be completed before the day of surgery, avoiding added anx iety that might be caused by having tests and surgery done the same day. All patients have a complete blood count and urinalysis. Those over 40 also have an electrocardiogram and chest x-ray. From our experience, the majority of patients view laser surgery more with
AORN Journal, August 1983, Vol38, No 2
curiosity than fear. We explain that a high-energy light beam will be aimed a t a very small target area of the polyp. The precise beam destroys the diseased tissue, causing little damage to the surrounding area. If there are large lesions on both sides of the cords, we usually treat one side a t a time. There is minimal edema with the laser, and little tissue trauma and scar formation, contributing to a smooth recovery. Healing is normally rapid. Pain seems to be minimal after larnygeal surgery, and most patients are discharged the same day. Although we prescribe an analgesic, most patients report they don’t need to take it. Patients’ most common questions about the laser are, “Will it miss and hit something else?” and “Does i t cause cancer?’ We explain that although the laser beam is invisible, the machine has a red helium-neon light used to aim it. Both the nurse and the physician test the beam before surgery to make sure it is properly aligned. We also reassure them that follow-up studies with patients treated with the laser as long as 20 years ago show no relationship between laser surgery and cancer. Unlike ionizing radiation (x-ray),the laser does not cause genetic mutation. Risks and possible complications are
A common question is: “Will it miss and hit something else?” reviewed in the process of obtaining the patient’s consent for surgery. They include: 0 Tooth fracture. This may occur when the laryngoscope is inserted over the teeth, so a tooth guard is used. We
tell the patient that with proper technique, damage is unlikely. 0 Tracheal fire. This rare complication of laser surgery may occur when the laser beam reflects off a shiny object, igniting anesthetic gases in the patient’s trachea. We tell patients that we prevent reflection by using a rubber endotracheal tube covered with cloth tape. We show them the equipment. We also explain that we have emergency equipment available in the unlikely event a fire happens. 0 No improvement i n polyps. Depending on how many polyps a patient has, we tell them that more than one procedure may be needed to clear them. In a few cases, patients will not show improvement. Polyps may recurr. Before the patient enters the operating room, the laser is tested, and the instrument setup is prepared. For the protection of hospital personnel, signs are posted on the operating room door saying that a laser is in use. Operating room personnel wear protective eyewear. During the procedure, the patient’s eyes are protected with moistened eye pads taped securely in place. Eyes are especially vulnerable to the COz laser because of their high fluid content. Moistened pads protect them because water will completely absorb the COz laser beam. Compared with conventional surgery, the instrument setup for a laser laryngoscopy is simple. Since the laser is the main surgical instrument, few others are needed. Most of the items are for emergencies. Instruments and equipment in the setup are: 0 a tracheostomy set and tracheostomy tubes in case of a spasm or burn to the larynx 0 a bronchosocpe connected to a fiberoptic light source to be used in looking for burned cottonoid particles in case of a tracheal fire
AORN Journal, August 1983, Val 38, No 2
233
alligator forcep for use in retrieving burned cottonoid particles from the bronchial trees in case of a fire alligator forcep with cottonoid attached used to cover balloon on end of endotracheal tube, which is kept moistened with saline bowl for specimen bowl with saline for irrigation 20 cc syringe with K-52extension tubing used for irrigating. Although we have never had an endotracheal fire in our practice, we have simulated one in the laboratory so we could plan how to respond. Some hospitals have a laser tray, with such items as: tracheostomy instruments vocal cord retractor laryngeal mirrors used to reflect the laser beam t o inaccessible places such as the dorsum of the soft palate or the larnygeal surface of the epiglottis laryngoscope and light source 0 alligator forcep right, left, and upper biopsy forcep. The back table is always set up in the same order so the nurse will know where everything is in case of a n emergency. After the patient is placed in the supine position, he is entubated with a soft, red rubber endotracheal tube that has been wrapped with white cloth tape. Then he is anesthetized. The laser microscope unit is swung into place. The surgeon introduces the laryngoscope into the mouth over the tooth guard and places i t through the laryngeal opening. It is locked into place in suspension fashion. He examines the entire larynx for polyps. A biopsy specimen is taken of the polypoid tissue and sent to the pathology department. Before turning on the laser beam, the surgeon places a cottonoid over the endotracheal tube to further protect the 234
area. A foot pedal turns on the laser beam, which vaporizes the polyp. The surgeon will decide how much of the area to treat in this one procedure. After the laser treatment is finished, the laryngoscope is removed, and the patient is extubated. In our phone call the first or second day after surgery, our objective is to find out if the patient is having any problems and any pain. Usually, someone is with him who can talk to us on the phone so the patient does not have to use his or her voice. By the third day, most patients can talk briefly. Most are able to go back to work by then if their job does not involve a great deal of speaking. During their preoperative teaching session, patients have many questions about their postoperative care. The most common ones are: How soon can I eat? What can I have? For the first 24 hours, they eat primarily a soft diet, expecially avoiding fried foods and anything scratchy. They must drink fluids to help lubricate the vocal cords. In excising the tissues, the laser vaporizes fluids from the cells, which drinking fluids helps restore. When can I talk? Patients may be hoarse for two or three months after surgery. We emphasizethat they should not abuse their voice. They must rest
By the third day, most patients can talk briefly. their voice for the first five or six postoperative days. Whispering is especially hard on the cords, even worse than yelling or shouting. By drinking water before speaking, they can ease strain on the surgical area.
AORN Journal, August 1983, Vol38, No 2
0 Can I smoke or drink? Smoking and drinking alcohol are out, at least for the first several days, because both irritate the burned area of the larynx and may delay healing. 0 Will my throat swell up? With the laser, swelling is minimal, so the patient should not have breathing problems. Breathing through the mouth while asleep may irritate the tissues, so it helps to have a glass of water a t the bedside. In other postoperative instructions, we explain that the patient may feel tired and have achy muscles immediately after surgery due to muscle relax-
ants used with the general anesthetic. Likewise, there may be some pain in the temporomandibular joint, radiating out to the ears, caused by having the mouth held open during the procedure. The laser has considerably simplified removal of polyps. Patients do not have to undergo the trauma involved in other types of surgical removal. With less area affected and less swelling, they are able to return to normal functioning faster. Preoperative teaching plays an important part in helping alleviate the apprehension that may accompany a procedure that will be performed with a relatively new surgical instrument. 0
Breast cancer victims have new alternative Women who have early detection of breast cancer may no longer have to undergo a radical mastectomy. Results of a large-scale study published in the May 1983 Archives of Surgery show that conservative surgery with irradiation may be as effective in curing the cancer as a radical mastectomy. Marvin M Romsdahl, MD, and colleagues from the M D Anderson Hospital, Houston, studied 922 patients from 1955 through 1979. They compared conservative surgery and irradiation with radical or modified radical mastectomy for treating breast cancer at three stages (minimal, stage I, and stage 11). The researchers report that “disease-free survival rates at five and ten years for patients having radical mastectomy or conservative surgery with irradiation are similar. Patients having conservative surgery and irradiation, in our study, had virtually similar survival rates to radical mastectomy for each of the stages represented.” The researchers caution, however, that “in different persons, carcinoma of the breast has a wide spectrum of biologic behavior, and clinical outcomes are perhaps as much related to this variable as to specific management.” They recommend
236
conservative surgery with irradiation for selected patients with either no axillary lymph node involvement or a movable node in the lateral axillary compartment. The researchers report that patients are enthusiastic about the alternative surgery and are pleased with the cosmetic result.
Chest x-rays not justified, panel says A panel of physicians, supported by the National Center for Devices and Radiological Health (NCDRH), is recommending limiting routine chest x-rays, according to an article in Hospitals. The yield of unsuspected disease found by routine, mandated, chest x-ray examinations has not been of sufficient clinical value to justify the cost, added radiation exposure, and subject inconvenience of the examination, the panel reported. The panel would limit mandated, routine chest x-ray screening examinations; routine prenatal chest x-ray exams; routine hospital admission chest x-ray exams; chest x-ray exams for tuberculosis detection and control; and routine chest x-ray exams for occupational medicine.
AORN Journal, August 1983, Vol38, No 2