34.tabish maqbool.cdr INTRODUCTION: the word LASER is an acronym for light amplication by stimulated emission of radiation. The main stay of lasers in otorhinology and head and neck surgeries is CO2 laser. Co2 1laser was rst developed by patel et all in 1964 , and was 2,3,5introduced for medical use in early 1970's . it was the rst laser to be used clinically in otorhinology by Strong and 4,5Jako . CO2 lasers produce light with a wavelength of 10.6 microm in the infrared (invisible) range of the electromagnetic spectrum. A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the site where the invisible CO2 laser beam will impact the target tissue. This laser, then, acts as an aiming beam for the invisible CO2 laser beam. The radiant energy produced by the CO2 laser is strongly absorbed by pure, homogeneous water and by all biological tissues high in water content. The extinction length of this wavelength is about 0.03 mm in water and in soft tissue; reection and scattering are negligible. Because absorption of the radiant energy produced by the CO2 laser is independent of tissue color and because the thermal effects produced by this wavelength on adjacent nontarget tissues are minimal, the CO2 laser has become extremely versatile for use in otolaryngology - head and neck surgery. CO transoral 2 laser microsurgery (TLM) is an emerging technique for the management of laryngeal cancer and other head and neck malignancies. The CO laser is coupled to a micromanipulator 2 and microscope, which provides enhanced tumor visualization and the ability to perform precise tissue cuts, obtain excellent hemostasis, and avoid damaging the surrounding tissues and structures that are transected during open surgical procedures.This study was done in department of Otorhinolaryngology and head and neck surgery GMC Srinagar, to check efcacy of transoral CO2laser in treatment of early head and neck cancers. MATERIAL AND METHODS: T h i s s t u d y w a s c o n d u c t e d i n d e p a r t m e n t o f Otorhinolaryngology and head and neck surgery GMC Srinagar for 2 years ( 2016, 2017). 34 patients who had early Head and Neck cancers(18 laryngeal cancers,4tongue cancers )were treated with CO2 laser.In all patients relevant history was taken. Personal history about any addiction( smoking,tobacco chewing,alcohol) was taken. Proper examination was done in all patients. oral cavity and oropharynx were examined. Site of lesion was palpated for any induration in tongue . Indirect laryngoscopy was done. FOL was done in all patients of laryngeal lesions. Excision biopsy of all lesions was taken and sent for HPE. Neck was examined for any cervical lympadenopathy.all baseline investigations were done. MRI tongue was done in patients with CA tongue , and CECT neck was done in all patients with CA larynx. MRI tongue and CECT neck was done before taking the biopsy. During the procedure all laser precautions were taken.Recommended power settings were kept . In laryngeal surgeries power of 3 to 5 W, depth of 1mm was taken, while in oral surgeries Power of 4 to 8 Watts was used , depth of 1 mm. spot size was kept between 0.3 to 0.7 mm. Mode was kept repeat superpulse in all surgeries. RESULTS: from January 2016 to December 2017, 22 patients with early head and neck cancers ( T1 and T2) were treated in our department with CO2 laser . . Among 22 patients ,18 were having laryngeal cancers,4 were having tongue cancers.All patients were above 45 years of age. All 18 patients with laryngeal ca were males while all 4 patients with ca tongue were females. Majority of patients were from rural areas ( 64%).All patients with Ca larynx presented with change of voice. On FOL , vocal cord mass was present in all patients . Table 1; Stage wise Distribution of Malignant lesion in Larynx TREATMENT OF EARLY HEAD AND NECK MALIGNANCIES USING CO2 LASER : OUR EXPERIENCE Original Research Paper Prof Rauf Ahmed MS ENT and HNS GMC Srinagar (Professor and Head) X 37GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS ENT Introduction: Since 1970s,CO2laser has been an effective method of treatment of several types of Head and Neck lesions. Because of the precise cutting and supercial well delineated effect of the CO2 laser, it is widely used in laryngology for delicate phonatory surgery,benign lesions, precise excision of carcinoma in situ or early (T1) tumors, and vaporization of bulky obstructing carcinoma of the upper airway. Objective: To check efcacy of transoral CO2laser in treatment of early head and neck cancers. Material and method: Total of 197 patients with both malignant and non malignant lesions were treated with CO2 laser from January 2016 to December 2017 .Out of these, 22 patients who had early HNcancers(18laryngeal cancers,4tongue cancers were treated with CO2 laser.In all patients history,examination and relevant investigations were done for TNM Staging of the tumor and were treated with transoral CO2laser .Type of procedure,any intraoperative or postoperative complication was documented. Result: Out of 18 patients of carcinoma larynx,4 underwent type1 cordectomy,9 underwent type2 cordectomy and 4 underwent type3 cordectomy and 1 patient underwent type 4 cordectomy depending on depth of lesion. All 4 patients of carcinoma tongue underwent wide local excision with supra omohyoid neck dissection. HPE of all cases showed tumor free margins..All patients are under regular followup . 2 patients with Ca larynx had reccurence. Conclusion: Our study showed that CO2laser is treatment of choice for early HNcancers. ABSTRACT KEYWORDS : CO2 Laser , early head and neck cancers. VOLUME-9, ISSUE-3, MARCH-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Dr Tabish Maqbool* MS ENT and HNS GMC Srinagar *Corresponding Author T Stage Number of patients n=18 Percentage T1 8 44.4% T2 10 55.6% Total 18 100% Dr Ihsan Ali MS ENT and HNS GMC Srinagar (Associate Professor) 38 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Table 2; Type of Malignancy in Larynx Table 3; Type of Laser Cordectomy Patients with ca tongue presented with lesion on border of tongue . On examination all patients with ca tongue were having tongue ulcer with induration. Neck nodes were absent in all patients. Table 4; Stage of malignant Lesions in Oral cavity (tongue) All 4 patients underwent wide local excision of tongue using CO2 laser with supraomohyoid neck dissection. Table 5, Recurrence: Recurrence was seen in two patients of Ca larynx (1.68%). In both the patients the recurrence site was Subglottis. One patient among these underwent Salvage laryngectomy while another patient underwent Palliative Chemotherapy, due to comorbid conditions. No recurrence was seen in patients who were operated for Ca tongue. There was not any laser related Intraoperative or postoperative complication. DISCUSSION: This prospective study was conducted rst time in the department of Otorhinolaryngology Head and Neck Surgery, Government Medical College and Associated SMHS Hospital Srinagar. The study included 22 patients with head and neck malignancies. Among the patients studied 18 patients were having laryngeal malignancy while 4 patients were having tongue malignancy. T1 laryngeal Ca was seen in 44.4% of pts while T2 lesions was present in 55.6%(table 1). Moderately differentiated Ca was seen in majority of patients with laryngeal Ca(table 2). Cordectomy was done in 18 patients with Ca larynx. As shown in Table 3 Among these 4 patients underwent type 1 cordectomy all of which were having T1 lesions, 9 patients underwent type II cordectomy, 4 underwent type III and 1 patient underwent type IV codectomy. Patients who underwent type II cordectomy either had T1 or T2 lesions while all patients who underwent type III or type IV cordectomy were having T2 lesions while all patients with Ca tongue underwent wide local excision with supraomohyois neck dissection. According 6to study by C Bocciolini et al, A cohort of 79 patients with previously untreated early glottic carcinoma, subjected to endoscopic CO laser excision between January 1993 and 2 October 2000, was retrospectively examined . The population comprised 75 males (95%) and 4 females (5%), age range 40- 93 years (mean 66.5). . Eight (10.1%) patients experienced local recurrence within periods varying from 4 to 55 months (mean 14.5). According to another the study by Vijay K 7Sharma et al on evaluation of CO2 laser surgery for early carcinoma larynx where (n=40) Patients underwent trans oral laser surgery or radiotherapy as primary modality of treatment . This study revealed local recurrence rate 10% in CO2 laser treated arm which was not statistically signicant. In our study ,2 patients had recurrence (4.44%). In one patient recurrence was seen after 9 months of surgery , in another patient it was seen after 11 months of TOLE. Rest all patients are disease free. The recurrence rate in our study is less than the above mentioned studies, which may be due to the short study period.(table 5) 4 patients in our study were having Ca tongue. Among these 3 patients were having T2 lesion while 1 was haiving T1 lesion (table 4). HPE results showed squamous cell carcinoma in all patients.Thirty-seven consecutive patients with cancer of the anterior two-thirds of the tongue without clinical neck lymph nodes or distant metastasis were treated with transoral CO 2 [8]laser microsurgery. Wang et al. resected the tumour under surgical microscope. Of the 28 patients in the T1/T2 group, 26 patients did not receive postoperative radiotherapy. The local control rate in all 37 patients at 5 years was 93.6 %. No local recurrence occurred in the T1 or T2 cases. In our study , none of the patients had recurrence which may be due to the less number of patients studied (table 5). CONCLUSION: It is concluded that CO2 laser surgery is a preferable surgery for early head and neck cancers. REFERENCES 1. Patel CKN,Tien PK, Mc Fee JH(1965): CW high power CO2-N2-He laser.Appl phys Lett 7:290-292 2. TG, Laser physics, otolaryngo Clinic of North America 1983; 16: 753- 774 3. matschke RG, Experiences with laser surgery in bening and malignant ndings of the oro and hypopharynx. Adv otorhinolaryngol 1995; 49: 153-157 4. Jako FG. Laser surgery of the vocal cord; an experimental study with carbondioxide laser on dogs. Laryngoscope 1972; 82: 204-211 5. Strong MS, Jako GJ (1972): Laser surgery in the larynx. Ann otorhinolaryngol 81:791-798 6. C bocciolini, l presutti,1 and p laudadio . Oncological outcome after co2 laser cordectomy for early stage glottic carcinoma acta otorhinolaryngol ital. 2005 apr; 25(2): 86–93 7. Chiesa f, sala l, costa l, iglo k. Excision of oral leukoplakias by co2 laser on an outpatient: a useful procedure for prevention and early detection of oral carcinomas. Tumori 1986; 72: 307–312. 8. Wang cp, chang sy, wu jd, tai sk. Carbon dioxide laser microsurgery for tongue cancer: surgical techniques and long-term results. J otolaryngol. 2001;30(1):19–23. Doi: 10.2310/7070.2001.20897.[pubmed] [cross ref] VOLUME-9, ISSUE-3, MARCH-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Type of Malignancy in larynx Number of patients n=18 Percentage Well differentiated sq.cell carcinoma 7 38.88% Moderately differentiated sq.cell carcinoma 11 61.11% Total 18 100% Type Number of patients(n=18) Percentage Type I 4 22.2% Type II 9 50% TypeIII 4 22.2% Type IV 1 5.5% Stage of malignant Lesions Number of patients n=4 Percentage T1 1 25% T2 3 75% Total 4 100% Site of recurrence No. of patients Percentage (n= 119) Procedure done post recurrence. Subglottis 2 1.68% Patient 1) Salvage laryngectomy Patient 2)Palliative chemotherapy Total 2 1.68%