Bilateral Eustachian Tuboplasty Utilizing AcuPulse™ 40WG CO2 Laser and FiberLase™ Flexible CO2 Laser Fiber Case by Stuart Ort, M.D. | California Ear Institute, Palo Alto, CA, U.S.A.

ENT Technique Guide Series Volume 12, No. 1, April 2012 PB-1125190_A

The FiberLase™ flexible CO2 laser fiber was easily delivered to the nasopharynx in conjunction with an endoscopic telescope for this outpatient procedure. The CO2 laser allowed for efficient and precise tissue removal at the Eustachian tube orifice, and also assisted with hemostasis. At one and three months post op, presenting symptoms were reportedly improved and endoscopic exam revealed improved dilation of the Eustachian tube lumen.

Preoperative

Past Medical History and Presenting Complaint

60-year-old female with approximate 10-year history of frequent ear fullness and otalgia due to eustachian tube dysfunction.

Chronic ear popping and significant difficulty with airplane flights.

Frequent bilateral serous otitis media.

Significant perennial environmental allergies treated with immunotherapy and maximal medical therapy.

Previous bilateral myringotomy with tube placement, resulting in worse fullness symptoms. Both tubes extruded and were not replaced.

Relevant Physical Findings and Diagnostics

Right tympanic membrane showed a small pars flaccida retraction pocket. Left tympanic membrane showed deep posterior inferior retraction.

Tympanograms found negative pressure bilaterally.

Eustachian tube endoscopic exam:

- Nasal mucosa moderately edematous, right greater than left, with mild right septal deviation.

- Nasopharyngeal mucosa grossly normal with no residual adenoid.

- Mucosal tissue of torus tubarius mildly edematous bilaterally.

- Significant redundant tissue on luminal surface of medial cushion bilaterally, partially obstructing tube lumen. Only moderate Eustachian tube dilation noted with swallowing and mastication.

- Lateral nasopharyngeal wall motion grossly normal.

Diagnosis Bilateral eustachian tube dysfunction

CO2 Laser-Assisted Eustachian Tuboplasty Using AcuPulse™ 40WG and FiberLase™ CO2 Laser Fiber

Stuart Ort, M.D.

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Operative

Surgical Procedure

CO2 Laser-Assisted Bilateral Eustachian Tuboplasty

Anesthesia General anesthesia with LMA was induced.

Nose and nasopharynx treated with topical 2% lidocaine and oxymetazoline on pledgets.

Laser Accessories

FiberLase flexible CO2 laser fiber

FiberLase M Handpiece (malleable), 140mm. Shaft shaped by hand to accommodate nasal anatomy.

Smoke Evacuation

Suction cannula inserted into contralateral nares and connected to wall suction

Laser and Parameters

Laser System: AcuPulse 40WG with FiberLase Flexible CO2 Laser Fiber

Laser Operation Mode and Power: Pulser at 5-6 Watts

Exposure Mode and Time: Repeat, Time ON- 0.1 sec. Time OFF- 0.1 sec. Air Flow: Internal low-flow pump utilized with continuous air through fiber

Laser Technique

Under endoscopic guidance, laser advanced through right nasal cavity to nasopharynx. Laser first applied to the mucosa at the center of the medial cushion of Eustachian tube. Tissue vaporized extending outward to encompass entire luminal surface of medial cushion.

Tissue removed in layers until underlying cartilage could be identified by sight and/or palpation.

Left Eustachian tube treated in similar manner.

Hemostasis Minimal bleeding. Hemostasis primarily controlled by laser.

Supplemental hemostasis achieved with oxymetazoline coated pledgets.

Technique Tips

Avoid Treatment to Lateral Cushion

Care must be taken to avoid any mucosal injury to the lateral cushion. If injured, scarring may occur resulting in increased Eustachian tube obstruction.

Palpation to Dissection Plane

Occasional palpation of the dissection plane with a blunt instrument can allow for identification of the cartilage layer, indicating the deepest extent of tissue removal.

CO2 Laser-Assisted Eustachian Tuboplasty Using AcuPulse 40WG CO2 Laser and FiberLase CO2 Fiber

Stuart Ort, M.D.

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Operative Photos

Fig. 1 Preoperative – right eustachian tube

Fig. 2 Preoperative - dilitation

Fig. 3 Intraoperative CO2 laser application

Fig. 5 3 month postoperative – right eustachian tube

Fig. 6 3 month postoperative - dilitation

Fig. 4 Laser Application Complete

CO2 Laser-Assisted Eustachian Tuboplasty Using AcuPulse™ 40WG and FiberLase™ CO2 Laser Fiber

Stuart Ort, M.D.

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Post Operative

Discharge and Postoperative Instructions

Same day discharge roughly 1 hour post procedure completion.

Saline nasal rinse at least once daily, starting post-op day one until 1-week post-op visit.

Hold nasal steroid sprays for one week post-op; then may be restarted.

No heavy lifting (>20 lbs) or other heavy physical exertion for 2 weeks.

Recovery and Outcome

At 1 week post-op visit, pain and nasal discharge noted to be minimal. Ear fullness was increased compared to pre-op. Endosscopy noted a fiberous scab at the operative site.

At 1 month post-op, significant improvement in ear clearing ability. She was able to tolerate airplane flights with much less discomfort.

At 3 months post-op, further improvement in symptoms. The patient reported minimal fullness. Endoscopy noted significant improvement in Eustachian tube dilation.

Discussion Eustachian tuboplasty appears to offer a low risk and low complexity treatment for select cases of recalcitrant Eustachian tube dysfunction. The FiberLase CO2 laser serves as a successful tool, allowing easy access to the nasopharynx, and allows precise tissue removal and effective hemostasis.