On the basis of the authors' experience with 20 patients, CO2 laser resection of palatal tumours has proved to be a good alternative to conventional surgical resection. The CO2 laser beam permits precise resection, due to only slight intra-operative bleeding coupled with use of the operating microscope. Wound healing is good and post-operative pain remarkably littl

Grossenbacher, R.

Sutter, R.

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The Journal of Laryngology and OtologyJanuary 1990, Vol. 104, pp. 20-23Resection of palatal tumours with the CO2 laserR. SUTTER and R. GROSSENBACHER, (St Gallen, Switzerland)AbstractOn the basis of the authors' experience with 20 patients, CO2 laser resection of palatal tumours has provedto be a good alternative to conventional surgical resection. The CO2 laser beam permits precise resection,due to only slight intra-operative bleeding coupled with use of the operating microscope. Wound healing isgood and post-operative pain remarkably little.IntroductionThe CO2 laser beam has acquired increasing importancein recent years as a surgical cutting instrument in variousspecialist fields of medicine. It is particularly suited tooperations on the upper respiratory and digestive tractsbecause its energy output is confined to the surface andunaffected by pigmentation, and because it can conse-quently be well controlled (Grossenbacher, 1979,1985).As early as the end of the 1970's, the advantages of CO2laser surgery were recognized for the treatment of local-ized tumours of the tongue and floor of the mouth, sinceit facilitated precise resection with minimal intra-oper-ative bleeding, slight post operative oedema and pain,and good preservation of function (Strong et al., 1979,Rhys Evans and Frame, 1988).More recently, we have also employed the CO2 laserbeam increasingly for tumours of the hard and softpalate, and report our experience below.Materials and methodsDuring the period from May 1985 to December 1988,a total of 21 laser surgical procedures were performed on20 patients with palatal tumours at the Department ofOto-Rhino-Laryngology, Head and Neck Surgery, Can-tonal Hospital, St Gallen. The treated cases were retro-spectively analysed with regard to age, sex, histology,tumour localization, complications, healing period andrecurrence rate.The apparatus employed is a CO2 laser system(Cooper, model 250Z) coupled with an operating micro-scope (Zeiss OP Mi 1) (Fig. 1). For easily accessiblepalatal tumours, it is also suitable for direct incisionusing the handpiece, with which the microscope is alsoemployed. The smallest possible focus (0.8 mm dia-meter) is used for continuous working with a power out-put between 10 and 20 watts. Most operations take placeunder general anaesthesia with nasotracheal intubation.After exposing the operative field (Fig. 2a) withAccepted for publication: 4 October 1989.Mclvor's tonsillar spatula, the nasotracheal tube and allexposed skin and mucosal sites are covered with moisttowels to protect from stray radiation. For protection ofthe cornea, the operation room personnel wear pro-tective spectacles.The line of incision is first marked with the CO, laserFIG. 1The CO, laser system employed, with operating microscopeattached.beam 5-10 mm peripheral to the microscopically-visibletumour boundary (Fig. 2b). The margin of the tumourspecimen is now grasped at one point with a clamp and,under continuous tension, the tumour can be cut aroundstep by step in healthy tissue, working with the CO, laserbeam in the gaping incisional fissure. The tissue struc-tures can be readily differentiated because of the virtualabsence of bleeding. Larger vessels with a diameter over0.5 mm must occasionally be coagulated with bipolarforceps. The periosteum of the hard palate is left intact ifthis permits sufficiently radical excision. The wound sur-face is left uncovered to heal by secondary granulation20https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100111685Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:23:17, subject to the Cambridge Core terms of use, available atRESECTION OF PALATAL TUMOURS WITH THE CO2 LASER 21a. Operation site defined. b. Incision line marked with CO, laser beam.c. Wound surface after tumour removal by CO, laser surgery. d. Resected tumour with typical cut surface.FIG. 2a-dResection of a pleomorphic adenoma.and epithelization (Fig. 2c). The pathologist can assessthe cut edges of the resected tumour without difficulty,as with the conventional procedure (Fig. 2d).ResultsWith the technique described above, a total of 21 lasersurgery operations on the palate were performed on 20patients. The 12 female and eight male patients wereaged between 16 and 78. The distribution of the histolog-ical morphology of the treated lesions is shown in Table1. Among the 12 benign tumours most commonly repre-sented are pleomorphic adenomata, and among theeight malignant tumours squamous cell carcinomata. Inall, seven tumours can be traced by their fine structure tothe small salivary glands. One-third of the tumours werelocalized on the hard palate, one-third on the soft palateand one-third in the transitional zone.A further example is presented to illustrate themethod described (Fig. 3a-c).TABLE IHISTOLOGY OF THE 2 0 PALATAL TUMOURSSquamous cell carcinomaPleomorphic adenomaSquamous cell papillomaAcantho-hyperkeratosisHaemangiomaMonomorphic adenomaMucoepidermoid tumourAdenoidcystic carcinomaMalignant mesenchymal tumourFibromahttps:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100111685Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:23:17, subject to the Cambridge Core terms of use, available at22 R. SUTTER AND R. GROSSENBACHERAfter resection of a large, superficially ulceratedmonomorphic adenoma from a 35-year-old woman, thewound measured over 4 cm in diameter, with exposureof bone. Even this resection defect healed without prob-lems within 2J months.A striking feature was the slight post-operative paineven among patients with such extensive resections.Neither wound infection nor post-operative bleedingwas observed. According to the size of the defect, com-plete epithelialization took between three weeks and 2£months. Exposed bone, in particular, delayed granu-loma formation but, astonishingly, this caused thepatients scarcely any discomfort. In two patients theoperation produced a small perforation in the softpalate, which however closed spontaneously within ashort time. Two further patients with extensive resec-tions of the soft palate for squamous cell carcinomataFIG. 3a-cMonomorphic adenoma of palate:a. Superficially ulcerated tumour of palate, before operation.b. Large resected area, over 4 cm in diameter, with exposed bone.c. Condition one year post-operatively.had post-operative problems with eating because ofvelo-pharyngeal deficiency, which could be improvedwith an obturator prosthesis. During the follow-upperiod between five months and four years, one of the 20patients developed a tumour recurrence, and two casestreated palliatively had persistent tumours.DiscussionIn the light of our experience, CO2 laser surgeryappears to be as valuable for palatal tumours as repeat-edly reported for other sites in the oral cavity (Duncav-age and Ossoff, 1986; Flynn etal, 1988; Grossenbacher,1985; Guerry etal, 1986; Nagorsky and Sessions, 1987;Rhys Evans and Frame, 1988). The main advantage ofthe method is the excellent visualization due to onlyslight intraoperative bleeding, especially when using thehttps:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100111685Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:23:17, subject to the Cambridge Core terms of use, available atRESECTION OF PALATAL TUMOURS WITH THE CO2 LASER 23operating microscope. With the relatively common sal-ivary gland tumours, primary radical resection withoutinjuring the tumour capsule is known to be particularlyimportant. In comparison to electrosurgical resection,the significantly smaller depth of damage at the marginof the incision with CO2 laser-surgical resection leads tobetter wound healing and improved histological assess-ment of the cut edge (Duncavage and Ossoff, 1986;Guerry et ai, 1986). Even larger defects with exposedbone healed without problems in all our cases with mini-mal post-operative complaints. The method describeddoes not consist of uncontrolled tumour vaporization,but tumour resection with consistent histological assess-ment of the cut edge. In no case should the employmentof the CO2 laser for treating malignancy lead to neglectthe generally recognized oncological principles of tum-our resection. The uncontrolled vaporization of malig-nant tumours performed elsewhere should, in our view,be decisively rejected. Among squamous cell carcino-mata, only tumours with minimal deep spread and nolymph-node metastases are suitable for curative ther-apy. For palliation, the CO2 laser can occasionally beemployed in incurable conditions for tumour resection.Whether local recurrence, or with malignant tumoursmetastasis formation, occurs less commonly after CO2laser-surgical resection are speculative questions thatneed to be settled by large controlled studies.ConclusionCO2 laser-surgery for palatal tumours offers a goodalternative in comparison to conventional resection withthe scalpel or electrotome. The main advantage of themethod is that it facilitates precise resection with opti-mal visibility. Striking features are minimal post-oper-ative complaints with good wound healing.ReferencesDuncavage, J. A., Ossoff, R. H. (1986). Use of the CO2 laser formalignant disease of the oral cavity. Lasers in Surgery and Medi-cine, 6: 442^44.Flynn, M. B., White, M., Tabah, R. J. (1988). Use of the carbondioxide laser for the treatment of premalignant lesions of the oralmucosa. Journal of Surgical Oncology, 37: 232-234.Grossenbacher, R. (1979). Erfahrungen mit der CO2-Laser-chi-rurgie in der Otorhinolaryngologie. HNO, 27: 403.Grossenbacher, R. (1985). Laserchirurgie in der Oto-Rhino-Laryngologie. Georg Thieme Verlag, Stuttgart.Guerry, T. L., Silverman, S., Dedo, H. H. (1986). Carbon dioxidelaser resection of superficial oral carcinoma: Indications, tech-nique and results. Annals of Otology, Rhinology and Laryngol-ogy, 95: 547-555.Nagorsky, M. J., Sessions, D. G. (1987). Laser resection for earlyoral cavity cancer: Results and complications. Annals of Otol-ogy, Rhinology and Laryngology, 96: 556-560.Rhys Evans, P. H., Frame, J. W. (1988). CO2 Laser surgery in theoral cavity. In Lasers in Otolaryngology (Carruth, J. A. S. andSimpson, G. T., eds) pp. 101-132. Chapman and Hall Ltd.,London.Strong, M. S., Vaughan, C. W., Healy, G. B., Shapshay, S. M.,Jako, G. J. (1979). Transoral management of localized car-cinoma of the oral cavity using the CO2 laser. Laryngoscope, 89:897-905.Address for correspondence:PD Dr R. Grossenbacher,Department of Otorhinolaryngology, Head and Neck Surgery,Cantonal Hospital,CH-9007, St Gallen (Switzerland).https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0022215100111685Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 08:23:17, subject to the Cambridge Core terms of use, available at

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