Nasal AllergyNasal AllergySurgical TreatmentSurgical Treatment

Dr.K.O.Paulose FRCS DLODr.K.O.Paulose FRCS DLOConsultant ENT SurgeonConsultant ENT Surgeon

Jubilee Hospital, TrivandrumJubilee Hospital, TrivandrumSouth IndiaSouth India

www.drpaulose.comwww.drpaulose.com, , www.snorefreesleep.comwww.snorefreesleep.com

Fed up with Sneezing?Fed up with Sneezing?

Achooo… in KidsAchooo… in Kids

Medical ManagementMedical Management

Medical treatment of Nasal Medical treatment of Nasal allergyallergy

Topical steroidTopical steroid Antihistamine Antihistamine

tabletstablets Decongestants Decongestants Systemic SteroidSystemic Steroid ImmunotherapyImmunotherapy

Anatomy of Nose and Anatomy of Nose and SinusSinus

The TurbinatesThe Turbinates

What is Laser?What is Laser?

INTRODUCTION OF INTRODUCTION OF LASERLASER

Laser is an acronym that Laser is an acronym that stands for Light stands for Light Amplification by Amplification by Stimulated Emission of Stimulated Emission of Radiation. Radiation. The first concept of the The first concept of the laser was initiated by laser was initiated by Albert Einstein in 1917.Albert Einstein in 1917.

Types of LasersTypes of Lasers

CO2 Laser

Argon laser

The Nd:YAG (Neodymium:Yttrium-aluminum-Garnet)

The Potassium-Titanyl-Phosphate (KTP)

CO2 LaserCO2 Laser

The CO2 laser is the most versatile laser in The CO2 laser is the most versatile laser in otolaryngology. otolaryngology.

The carbon dioxide (CO2) laser emits a colorless, The carbon dioxide (CO2) laser emits a colorless, infrared light infrared light

wavelength 10,600 nano microns wavelength 10,600 nano microns

Principle: The radiant energy produced by the CO2 laser Principle: The radiant energy produced by the CO2 laser is strongly absorbed by pure, homogeneous water is strongly absorbed by pure, homogeneous water and by all biological tissues high in water content. and by all biological tissues high in water content.

coaxial helium neon laser as aiming beam- red in colourcoaxial helium neon laser as aiming beam- red in colour

How does a CO2 Laser work?

Ability to coagulate, cut, Ability to coagulate, cut, vaporize vaporize

The main constituent of The main constituent of cells-water, readily absorbs cells-water, readily absorbs the wavelength of light the wavelength of light produced by the CO2 produced by the CO2 surgical laser. surgical laser.

The surgeon can control the The surgeon can control the extent by which the laser extent by which the laser beam is absorbed into beam is absorbed into surrounding tissue, surrounding tissue, resulting in an extremely resulting in an extremely precise tissue incision. precise tissue incision.

Indications of Co2 Laser in ENTIndications of Co2 Laser in ENT

Operations for snoring and sleep apneaOperations for snoring and sleep apnea Operations for Allergic Rhinitis,Correcting deviated Operations for Allergic Rhinitis,Correcting deviated

Nasal septum, Partial turbinectomy (LAPT), Choanal Nasal septum, Partial turbinectomy (LAPT), Choanal atresia, excision of Rhinophymaatresia, excision of Rhinophyma

Operations for voice disorders, the addition of the Operations for voice disorders, the addition of the microspot micromanipulator to the operating microspot micromanipulator to the operating microscope allows-arytenoidectomy, vocal nodules, microscope allows-arytenoidectomy, vocal nodules, early ca lesionsearly ca lesions

Operations for nose bleeds, nasal polyps, Operations for nose bleeds, nasal polyps, Rhinosporidiosis, HaemangiomasRhinosporidiosis, Haemangiomas

Excision of Facial Moles, Keloid, ScarsExcision of Facial Moles, Keloid, Scars

Indications of Co2 Laser_contdIndications of Co2 Laser_contd

Ulcers on tongue, check, multiple areas of leukoplakia Ulcers on tongue, check, multiple areas of leukoplakia can be precisely excisedcan be precisely excised

Skin lesions on head, Face and NeckSkin lesions on head, Face and Neck

TonsillectomyTonsillectomy

Tympanotomy, Myringotomy,StapedectomyTympanotomy, Myringotomy,Stapedectomy

(Bronchoscopic indications -management of recurrent (Bronchoscopic indications -management of recurrent respiratory papillomatosis or granulation tissue within the respiratory papillomatosis or granulation tissue within the tracheobronchial tree, excision of selected subglottic or tracheobronchial tree, excision of selected subglottic or tracheal strictures, excisions of bronchial adenomas.).tracheal strictures, excisions of bronchial adenomas.).

How It Works?How It Works? • • The excitability of anterior The excitability of anterior

ethmoidal nerve is ethmoidal nerve is decreased, and thereby decreased, and thereby vascular permeability and vascular permeability and nasal secretion are also nasal secretion are also decreased.decreased.

• • Some of sensory nerves Some of sensory nerves have been cut, the sensory-have been cut, the sensory-parasympathetic nerve parasympathetic nerve reflex is weakened, and at reflex is weakened, and at the meantime release of the meantime release of vascular-origin intestinal vascular-origin intestinal peptide as well as substance peptide as well as substance P is also decreased.P is also decreased.

• • Scar formation of nasal Scar formation of nasal mucosa will prevent mucosa will prevent hypersensitivity.hypersensitivity.

Advantages of Laser SurgeryAdvantages of Laser Surgery

Minimal operative bleeding due to coagulation of Minimal operative bleeding due to coagulation of blood vessels minor to 2 mm of diameter. blood vessels minor to 2 mm of diameter.

Reduced post operative pain due to minimal thermal Reduced post operative pain due to minimal thermal effect. effect.

Increased accuracy of the surgical wound Increased accuracy of the surgical wound Possibility of ambulatory surgery Possibility of ambulatory surgery Quick post op. healing Quick post op. healing Better plastic result of surgical wounds due to Better plastic result of surgical wounds due to

minimal scarring (that effect is very obvious in the minimal scarring (that effect is very obvious in the post tonsillectomy preservation of the tonsillar post tonsillectomy preservation of the tonsillar pillars). pillars).

Disadvantages of LaserDisadvantages of Laser

Cost of equipment and maintenance . Cost of equipment and maintenance . (around USD 4000=Rs 4Lakh)(around USD 4000=Rs 4Lakh)

Special surgical skills Special surgical skills Increased setup time of equipment Increased setup time of equipment Need of safety eyewear Need of safety eyewear Increased care for patient safety - explosion Increased care for patient safety - explosion

or fire hazard.or fire hazard. Smoke Smoke

How Laser work?How Laser work?

Laser surgery is the most preferred Laser surgery is the most preferred technique in removing moles. Laser removal technique in removing moles. Laser removal of moles is by far the most simple for of moles is by far the most simple for eliminating moles on the skin. In most cases eliminating moles on the skin. In most cases of laser removal anesthesia may not be of laser removal anesthesia may not be necessary.necessary.

The laser beam will also burn away the mole. The laser beam will also burn away the mole. Depending on the size of your mole, you may Depending on the size of your mole, you may need multiple sessions to completely remove need multiple sessions to completely remove it. No scarring , no bleeding, no pain and can it. No scarring , no bleeding, no pain and can be done in OPD set up with surface be done in OPD set up with surface anesthesia.anesthesia.

How LAPT Done?How LAPT Done? Patient is kept semi Patient is kept semi

sitting in an ENT chair sitting in an ENT chair (as seen in picture) and (as seen in picture) and Co2 CW at 6 watts Co2 CW at 6 watts setting, the turbinates setting, the turbinates are cauterized. The are cauterized. The procedure takes 10-15 procedure takes 10-15 mnts on each side. mnts on each side. There is hardly any There is hardly any bleeding and patient bleeding and patient goes home after few goes home after few hours. This gives very hours. This gives very good resultsgood results

Laser SurgeonLaser Surgeon

Testing Laser Testing Laser

LOCAL ANESTHESIALOCAL ANESTHESIA

The anesthesia parameters used in The anesthesia parameters used in all patients were for premedication , all patients were for premedication , diazepam 5mg + atropine 0,5 diazepam 5mg + atropine 0,5 mg .For local superficial anesthesia mg .For local superficial anesthesia xylocaine spray 10 % + For xylocaine spray 10 % + For infiltration anesthesia xylocaine 2 % infiltration anesthesia xylocaine 2 % + 1: 100.000 adrenaline solution.+ 1: 100.000 adrenaline solution.

General AnesthesiaGeneral Anesthesia

These include wrapping aluminum tape These include wrapping aluminum tape around the tube, placing wet cottonoids around the tube, placing wet cottonoids around the endotracheal tube cuff, placing around the endotracheal tube cuff, placing saline within the cuff using a metal or xomed saline within the cuff using a metal or xomed endotracheal tube. endotracheal tube.

Flexible stainless steel corrugated tubes are Flexible stainless steel corrugated tubes are availableavailable

The most morbid complication of laryngeal The most morbid complication of laryngeal laser surgery is airway fire.Various methods laser surgery is airway fire.Various methods have been suggested for protecting the have been suggested for protecting the endotracheal tube and larynx.endotracheal tube and larynx.

Advantages of LAPTAdvantages of LAPT

FastFastPainlessPainlessIn OfficeIn OfficeNo SuturesNo SuturesNo BleedingNo BleedingFast RecoveryFast RecoveryNo HospitalizationNo HospitalizationNo General AnesthesiaNo General AnesthesiaImmediate Return To WorkImmediate Return To Work

Laser SafetyLaser Safety

Eye wearEye wear Smoke evacuatorSmoke evacuator Fire HazardsFire Hazards

Laser SafetyLaser Safety

Allergic RhintisAllergic Rhintis Allergic RhinitisAllergic Rhinitis is an is an

inflammation of the nasal inflammation of the nasal passages, usually passages, usually associated with watery associated with watery nasal discharge and nasal discharge and itching of the nose and itching of the nose and eyes. eyes.

  Allergic Rhinitis affects Allergic Rhinitis affects about 20-30 percent of the about 20-30 percent of the population. The symptoms population. The symptoms occur in the nose and eyes occur in the nose and eyes and usually occur after and usually occur after exposure to dust, danders, exposure to dust, danders, or certain seasonal pollens or certain seasonal pollens in people that are allergic in people that are allergic to these substances. to these substances.

Causes of Nasal AllergyCauses of Nasal Allergy House Dust mites, House Dust mites,

cockroaches, molds and cockroaches, molds and animal dander, are animal dander, are examples of year-around examples of year-around allergens. allergens.

Tree, grass and ragweed Tree, grass and ragweed pollens are primarily pollens are primarily seasonal outdoor seasonal outdoor allergens. allergens.

Animal allergens are also Animal allergens are also important indoor important indoor allergens. The major cat allergens. The major cat allergen is secreted allergen is secreted through the sebaceous through the sebaceous glands of the animal's glands of the animal's skin. skin.

Symptoms of Nasal Symptoms of Nasal AllergyAllergy

Repetitive sneezing; Repetitive sneezing; runny nose, post-nasal runny nose, post-nasal drip; nasal congestion, drip; nasal congestion, itchy eyes, ears, nose or itchy eyes, ears, nose or throat; and generalized throat; and generalized fatigue. fatigue.

wheezing, eye tearing, wheezing, eye tearing, sore throat, and impaired sore throat, and impaired smell. smell.

chronic cough may be chronic cough may be secondary to postnasal secondary to postnasal drip drip

Sinus headaches and ear Sinus headaches and ear ache, and itching are also ache, and itching are also common common

ENT Evaluation in OPDENT Evaluation in OPD

Nasal ExaminationNasal Examination

InvestigationsInvestigations

CT ImagingCT Imaging

Enlarged pale Enlarged pale turbinatesturbinates

Nasal PolypsNasal Polyps Congested nasal Congested nasal

mucosamucosa Mucopus if sinusitisMucopus if sinusitis Septal spur,DNSSeptal spur,DNS Concha bullosaConcha bullosa Sinus pathologySinus pathology

Diagnosis of Allergic Diagnosis of Allergic RhinitisRhinitis

Medical history Medical history ENT ExaminationENT Examination RAST-Radio RAST-Radio

immunoassay immunoassay CT ImagingCT Imaging

Self CareSelf Care

Avoidance Avoidance measuresmeasures

Air purifiers and Air purifiers and dust filters may dust filters may help. help.

Jel Neti , saline Jel Neti , saline Nasal WashNasal Wash

Spraying Local Spraying Local AnestheticAnesthetic

Injecting Local Injecting Local AnestheticAnesthetic

Peter Malakkof: Packing Peter Malakkof: Packing NoseNose

Peter Malakkof: Peter Malakkof: SeptoplastySeptoplasty

Peter Malakoff:LAPTPeter Malakoff:LAPT

Patient #027Patient #027

Patient #009Patient #009

Dr Senthil Gets LAPTDr Senthil Gets LAPT

Patient #021Patient #021

Patient#009Patient#009

Patient #046Patient #046

Laser Nasal Allergy in Laser Nasal Allergy in OPDOPD

Patient#019Patient#019

LAPTLAPT

Patient #018Patient #018

Vasomotor Rhintis:LaserVasomotor Rhintis:Laser

Patient #016Patient #016

Patient #011Patient #011

Diode LaserDiode Laser

Post op Laser NosePost op Laser Nose

Post op Laser AshishPost op Laser Ashish

Ashish Gets Laser Ashish Gets Laser Treatment 2Treatment 2

Ashish Gets Laser Ashish Gets Laser TreatmentTreatment

Patient #037Patient #037

Sr.Anjelina gets Laser Sr.Anjelina gets Laser treatmenttreatment

Laser Treatment in a Laser Treatment in a little girllittle girl

Post Op after 6 monthsPost Op after 6 months

CT Scan of a CT Scan of a patient who patient who underwent Laser underwent Laser surgery to the surgery to the TurbinatesTurbinates

The turbinates are The turbinates are reduced in sizereduced in size

Patient symptom Patient symptom freefree

Antral Lavage before Antral Lavage before LaserLaser

Fr.Sony Gets Laser Fr.Sony Gets Laser TreatmentTreatment

Patient #036Patient #036

LAPT in JubileeLAPT in Jubilee

Giving Local AnestheticGiving Local Anesthetic

Doubting “Thomas”Doubting “Thomas”

After LaserAfter Laser

Patient #012Patient #012

Laser Treatment as Day Laser Treatment as Day CaseCase

Laser TherapyLaser Therapy

LAPT #034LAPT #034

Patient #016Patient #016

LAPT GALAPT GA

LAPT GALAPT GA

Laser Surgery Under GALaser Surgery Under GA

LAPT Under GALAPT Under GA

Patient #011Patient #011

Patient No #022Patient No #022

Patient No #019Patient No #019

Patient No #018Patient No #018

Patient No #015Patient No #015

Coblator TurbinoplastyCoblator Turbinoplasty

Coblation TurbinoplastyCoblation Turbinoplasty

Coblator Nose: CAPTCoblator Nose: CAPT

Coblator Surgery of NoseCoblator Surgery of Nose

SMD:Submucus SMD:Submucus Diathermy GADiathermy GA

SMD GASMD GA

Laser Team in Jubilee Hospital, Laser Team in Jubilee Hospital, TrivandrumTrivandrum

Laser Therapy #018Laser Therapy #018

All Healing Comes From GodAll Healing Comes From God

All healing comes All healing comes from Godfrom God whether whether it is supernatural it is supernatural or through a or through a surgeon or a surgeon or a physician. He is physician. He is still the source of still the source of our healing. our healing.

I am the LORD who heals you, says God

THANK YOUTHANK YOU

Dr.K.O.Paulose FRCS DLODr.K.O.Paulose FRCS DLOConsultant ENT SurgeonConsultant ENT Surgeon

Jubilee Hospital, Jubilee Hospital, Trivandrum, kerala, South IndiaTrivandrum, kerala, South India

www.drpaulose.comwww.drpaulose.com www.snorefreesleep.comwww.snorefreesleep.com