Giotakis and Pototschnig World Journal of Surgical Oncology (2018) 16:176

https://doi.org/10.1186/s12957-018-1480-9

CASE REPORT Open Access

Use of erbium laser in the treatment of

persistent post-radiotherapy laryngeal
edema: a case report and review of the
literature
Aris I. Giotakis* and Claus Pototschnig

Abstract
Background: Post-radiotherapy laryngeal edema may affect the patients’ quality of life, leading to repeated treatment
attempts, which include massage/physical therapy, inhalations, and/or tracheostomy.
Case presentation: We report the surgical treatment approach of a 69-year-old patient with severe persistent post-
radiotherapy laryngeal edema. After multiple inpatient admissions and failed conservative therapy, we used the erbium
laser to treat the arytenoid edema. After repeated procedures, no complications were observed. The patient remained
free of symptoms after 30 months of follow-up.
Conclusions: The authors provide an easy-to-perform, safe, and quick surgical technique without non-severe or severe
complications. Using this technique repeatedly, complications from excessive thermal damage with CO2 laser
or unpleasant solutions such as tracheostomy can be avoided.
Keywords: Erbium, Laser microsurgery, Post-radiotherapy, Laryngeal, Edema

Background acute dyspnea. The endoscopic findings of the larynx al-

Post-radiotherapy laryngeal edema may result in hoarse- ways revealed a massive edema of the arytenoid area
ness, airway compromise, and dysphagia. It may also affect (Fig. 1, upper). Treatment included corticosteroid/adren-
the long-term patients’ quality of life, leading to repeated alin inhalation with systemic corticosteroids. Each time,
treatment attempts, which include massage/physical ther- subjective and objective recovery were transient. The
apy, inhalations, and/or tracheostomy. In order to provide endoscopic and radiologic findings revealed no indica-
alternative methods to confront this condition, we report tions of tumor recurrence. As an outpatient, the patient
the use of erbium laser in the treatment of post-radiother- underwent multiple sessions of lymphatic massage
apy laryngeal edema of a 69-year-old male patient. drainage without improvement. Treatment with proton
pump inhibitors also showed neither subjective nor ob-
jective benefits.
Case presentation Two and a half years after radiotherapy, the patient
We report a case of a 69-year-old male patient with underwent transoral laser microsurgery of the arytenoid
post-radiotherapy laryngeal edema. The patient was area. An erbium laser was used. The laser was set at
treated with tumor resection, right selective neck dissec- 103 J/cm2 and 10 Hz. To prevent postoperative synechia
tion of levels II to IV, and adjuvant radiotherapy due to and/or webs, only the right arytenoid was assessed. This
a pT2N1M0R0 oropharyngeal squamous cell carcinoma intervention aimed to minimize the edema without caus-
of the right tonsil. In the 2 years following radiotherapy, ing severe thermal tissue damage, which could lead to
the patient was treated six times as an inpatient due to additional edema. Therefore, the cranial surface of the
* Correspondence: [email protected]
right arytenoid was pulse targeted to achieve a shrinking
Department of Otorhinolaryngology, Medical University of Innsbruck, effect. Subsequently, multiple targeted holes were made
Anichstrasse 35, 6020 Innsbruck, Austria

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Giotakis and Pototschnig World Journal of Surgical Oncology (2018) 16:176 Page 2 of 4

Fig. 2 Pictures during surgery of the right arytenoid area with an

erbium laser. Left upper: before the initiation of the procedure. The
position of the microlaryngoscopy tube exposes the right arytenoid
area; right upper: during “bombardment” of the cranial surface of
the right arytenoid area with erbium laser to achieve a shrinking
effect; left bottom: post-treatment picture. “Bombardment” of the
cranial surface of the right arytenoid results in the production of
white areas. The red points represent the holes created to empty
the edema fluids; right bottom: after releasing the tension

The patient was admitted 2 weeks later to our depart-

ment due to acute dyspnea. However, endoscopic
examination of the larynx revealed a slight edema re-
duction of the right arytenoid. After conservative treat-
ment with inhalation and systemic corticosteroids, the
same procedure was performed for the left arytenoid,
resulting in similar intraoperative edema reduction
(Fig. 3). In January 2015, 2 months later, endoscopic
findings revealed a slight edema reduction of the left
arytenoid area, whereas the postoperative status of the
right arytenoid remained stable. No synechiae, webs, or
local swelling were observed. The patient also noted a
slight improvement of the dyspnea. Thus, a new pro-
Fig. 1 Upper: pictures before any interventions. Massive bilateral cedure was performed using the same surgical tech-
similar arytenoid edema (in respiratory position) causing dyspnea.
Bottom: 30 months after the last surgery with erbium laser (in same
nique, this time in both arytenoids, with the same
respiratory position as preoperatively). No contact between anterior intraoperative findings. Again, no synechiae or webs
parts of the arytenoid area (in comparison to preoperatively) after were observed postoperatively.
treatment of both arytenoid areas with the erbium laser. Obvious During the next 6 months, the patient underwent
difference in the edema of the anterior-posterior axis of the arytenoid three procedures in both arytenoids using the same
area in comparison to preoperatively
surgical technique, with the same intraoperative find-
ings. The erbium laser settings varied between 100
and 200 J/cm2 and 3 and 10 Hz, depending on the
in the tissue. Edema fluid was emptied from the chan- precise exposure of the cranial surface of the aryten-
nels. The intraoperative effect was slightly obvious oid area. No complications were observed. Endoscopic
(Fig. 2). The patient remained under general anesthesia. findings of the larynx at 2 months after the final pro-
The day after the procedure, microlaryngoscopy was cedure revealed a massive improvement. The patient
performed. No additional edema was observed. The experienced no symptoms. Thirty months after the
right arytenoid was still shrunken, and the patient was final procedure, no additional edema was observed
extubated. (Fig. 1, bottom).
Giotakis and Pototschnig World Journal of Surgical Oncology (2018) 16:176 Page 3 of 4

lasers in the fenestration of the inner ear. The three

remaining publications were considered relevant. Ex-
cluding the German article, two of these studies com-
pared the thermal damage of carbon dioxide (CO2) and
erbium:YAG lasers in non-living animal and human la-
ryngeal tissue [5–7].
The first study by Herdman and coauthors, conducted
in 1993, examined the human vocal fold in vitro [5]. In
this study, a continuous mode was used for the CO2
laser. The authors reported that charring is eliminated
when using the erbium:YAG laser. Specifically, the depth
of coagulated necrosis near the incision was reduced
from 510 μm (± 75) with the CO2 laser to 23 μm (± 12)
with the erbium:YAG laser. At the base of the incision,
the same values were 125 μm (± 45) with the CO2 laser
and 12 μm (± 8) with the erbium:YAG laser. The second
study by Böttcher and coauthors, performed in 1994,
used ex vivo porcine vocal folds [7]. In this study, the
super-pulse mode was used for the CO2 laser. With the
super-pulse mode, less thermal damage should occur
compared to the continuous mode [8]. The authors
reported that erbium:YAG incisions produced signifi-
cantly decreased epithelial (236.44 μm) and subepithelial
(72.91 μm) damage zones (p < 0.001) compared to the
CO2 laser. Cutting gaps were significantly narrowed
when using the CO2 laser (878.72 μm) compared to the
erbium:YAG laser (1090.78 μm; p < 0.027). Collagen fi-
bers along the erbium:YAG laser cutting edges were in-
tact, without obvious carbonization, in contrast to the
diffuse carbonization and tissue melting observed along
Fig. 3 Pictures during surgery of the left arytenoid area with an the CO2 laser cutting edges. Both studies concluded that
erbium laser. Upper: before the initiation of the procedure. the erbium:YAG laser produces less thermal damage
Obvious difference in the edema of the left non-treated swollen than the CO2 laser when used on the laryngeal tissue.
arytenoid in comparison to the already treated right arytenoid area. This physical ability originates from the ability of the
The right arytenoid area is healed after surgery 3 weeks ago. No
scarring, synechiae, or webs are observed; Bottom: post-treatment
erbium:YAG laser to emit light at 2.94 μm, which corre-
picture. “Bombardment” of the cranial surface of the right arytenoid sponds to the peak absorption of water for non-ionizing
results in white areas. The red points represent the holes created to wavelengths. This absorption is approximately ten times
empty the edema fluids greater than the absorption that occurs at a wavelength
of 10.6 μm, which is emitted by the CO2 laser [7].
Discussion and conclusions Therefore, in hydrated tissue, photon absorption from
The erbium:yttrium-aluminum-garnet (erbium:YAG) the erbium:YAG laser occurs over a shorter distance
laser has been in medical use for decades. While its clin- than that of a CO2 laser. Another study reported that
ical application in dermatology and dentistry is well doc- the mean surface temperature increased only approxi-
umented [1–4], its use in laryngeal surgery has not been mately 19 °C during the ablation of porcine skin with an
described. The authors of the current article performed erbium:YAG laser [8]. Both studies concluded that the
a search of the data in the PubMed database using all thermal spread and temperature increases are limited
possible combinations of the following keywords: “er- when using an erbium:YAG laser.
bium,” “erbium:YAG,” “er:YAG,” “laryngeal,” “larynx,” Post-radiotherapy laryngeal edema occurs in 5 to 50% of
and “arytenoid.” Five of the 8 publications retrieved were patients treated with 45 and 80 Gy doses of radiotherapy,
considered irrelevant. These publications concerned the respectively, in the head and neck region [9]. Fu and coau-
use of erbium lasers and snoring, the use of a picosec- thors reported that post-radiotherapy laryngeal edema
ond infrared laser in laryngeal tissue, the susceptibility without persistent or recurrent disease developed in 21/
of the laryngeal airway mask, laser reshaping of the cos- 247 (8.5%) patients irradiated due to carcinoma of the
tal cartilage transplantation, and the influence of erbium vocal cord [10]. The addition of concurrent chemotherapy
Giotakis and Pototschnig World Journal of Surgical Oncology (2018) 16:176 Page 4 of 4

can double the risk of laryngeal edema [11]. Post-radio- Abbreviations

therapy laryngeal edema can be treated conservatively CO2: Carbon dioxide; Erbium:YAG: Erbium:yttrium-aluminum-garnet

and/or surgically. Conservative management includes Funding

adrenalin-corticosteroid inhalation, systemic corticoste- This research received no specific grant from any funding agency in the
roids, and/or massage/physical therapy. Surgical man- public, commercial, or not-for-profit sectors.

agement includes tracheostomy or, in selected cases, Authors’ contributions

functional laryngectomy, if aspiration is present. Re- CP was the treating physician. AIG and CP were the major contributors in
cently, Lee and coauthors provided an alternative surgi- writing the manuscript. Both authors read and approved the final manuscript.

cal approach to treat post-radiotherapy laryngeal edema Ethics approval and consent to participate
[12]. Specifically, the authors reported four such cases Not applicable
treated with arytenoid resection with a CO2 laser. Air-
Consent for publication
way widening was more than sufficient in all four cases Obtained
and remained stable in follow-up evaluations. No per-
manent complications were observed. However, one pa- Competing interests
Both authors declare that they do have no competing interests.
tient experienced temporary vocal fold fixation for
6 months. The authors presumed that mucosal inflam-
Publisher’s Note
mation from the CO2 laser injury extending to the cri- Springer Nature remains neutral with regard to jurisdictional claims in
coarytenoid joint caused the fixation. They concluded published maps and institutional affiliations.
that excessive CO2 laser injury to the cartilage can
Received: 30 May 2018 Accepted: 21 August 2018
cause mucosal stenosis, stricture, and perichondritis.
Crumley also reported that excessive laser injury to the
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