EXPERIMENTAL AND THERAPEUTIC MEDICINE 25: 108, 2023

Laser nasal surgery (Review)

1
Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj‑Napoca;
2
Department of Clinical Surgery, Dunărea de Jos University, Faculty of Medicine and Pharmacy, 800008 Galați, Romania

Received March 9, 2022; Accepted January 5, 2023

DOI: 10.3892/etm.2023.11807

Abstract. Laser nasal surgery has been an elusive subject in 4. Comparing laser types
the last 10 to 15 years It was considered as a potential surgical 5. Novel techniques for nasal polyposis treatment
staple for nasal surgery in the 1980s; however, it did not 6. Lasers and biofilms
become one due to technical difficulties. Laser therapy has 7. Laser surgery technique and precautions
reemerged as an alternative to classical endoscopic surgery, 8. Advantages and disadvantages of laser treatment
and otorhinolaryngology surgeons are considering the benefits 9. Current use of lasers
that it can offer. The advantages of this procedure are shorter 10. Conclusion
hospitalization time, lack of nasal packing, high procedural
precision with tissue sparing, and the unique capability of
reducing both bacterial and fungal colonization at the level of 1. Introduction
the paranasal sinus. Therefore, laser therapy appears to be an
invaluable tool for clinical practice. Due to the absence of a Despite the improved outcomes of endoscopic sinus surgery
guaranteed cure for reoccurring nasal polyposis, laser therapy (ESS) and biological therapy, numerous shortcomings
is worth investigating. For this therapy to evolve, an improved remain (1). Nasal laser surgery was first proposed in 1982
understanding of laser types and the effects that they produce with promising results (2). In the early 2000s, it continued to
is required. By investing in further developments of the equip‑ improve, consolidating into a modern technique (3). However,
ment, the technique may become more widely used. With the due to the lack of proper directional aiming of the laser beam,
current accelerated rate of technological evolution and robotic it entered a period of decline. At present, nasal laser use is
capabilities, laser nasal surgery may become a gold standard reappearing as a treatment option along with improvements in
in future years. The aim of the present review is to evaluate technology (4).
whether it is worth investing in nasal laser surgery as a future Laser is an acronym for light amplification by stimulated
alternative to current treatment standards. emission of radiation, which originally described the process;
however, it is currently used to describe both the light fascicle
and the apparatus (5).
Contents Chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP)
is presented in ancient texts dating back almost 4,000 years;
1. Introduction however, it is still a pathology that is not fully understood and
2. Methods does not have a definitive therapeutic option (5). Currently, the
3. Laser types used in surgery most used treatment options are intranasal corticosteroids and
ESS, with a high recurrence rate due to the preponderance of
atopic origin in the majority of nasal polyp cases (1). With the
advances in understanding CRS endotypes, type 2 (which is
based on eosinophil activity) has been demonstrated to be the
Correspondence to: Dr Rădeanu Gheorghe Doinel, Department of most common cause of nasal polyposis (6). Almost 80% of
Otorhinolaryngology, Iuliu Haţieganu University of Medicine and these cases present a high degree of recurrence due to ongoing
Pharmacy, 8 Victor Babes Street, 400012 Cluj‑Napoca, Romania
immunological processes (6).
E‑mail: [email protected]
Nasal laser surgery may be useful in certain cases due to
Abbreviations: ESS, endoscopic sinus surgery; CRS, chronic the added benefit of cauterizing and cutting at the same time,
rhinosinusitis; CRSwNP, chronic rhinosinusitis with nasal polyps; aiding in hemostasis. Due to these properties, day surgery
YAG, yttrium aluminum garnet; Nd:YAG, neodymium‑doped YAG; may be achieved for patients who would normally undergo
Er:YAG, erbium‑doped YAG continuous hospitalization, thus reducing the hospital stay
considerably, and also providing a financial gain for both the
Key words: laser, CRS, nasal polyps, quality of life, surgery patient and the healthcare system (7).
A unique aspect of laser surgery is the ability to sterilize the
exposed area. This quality is useful in a confined space such
2 TĂNASE et al: LASER NASAL SURGERY (REVIEW)

as the nasal sinus pathway, which is covered with a mucosa spectra, with the YAG laser having a wavelength between
colonized with bacteria and fungi (8). These microorganisms 1,000 and 3,000 nm, and the CO2 laser having a wavelength of
can inhibit healing and maintain a blockage of the nasal 10,600 nm. The most important properties of a laser are that
drainage system by sustaining inflammation and affecting the emitted light is monochromatic, coherent and collimated.
cilia movement (8). These characteristics help lasers perform with a high grade
The aim of the present review is to evaluate if laser of precision and high energy delivery (10). Currently, laser
technology is a viable option for nasal surgery and whether technologies with shorter wavelengths are less used in clinical
it is associated with improved patient outcomes in order to practice due to the lesser penetration power and dispersed
determine if future investments in equipment are worth the energy delivery (10).
financial and research effort. Although laser treatment options When the laser interacts with the tissue, there are four
for nasal pathologies have not seen major advancements in the scenarios that can occur: i) Through reflection, the incident
last two decades, with the aid of certain technical improve‑ laser light returns to the same medium; ii) by transmission, the
ments, they may still emerge as superior to the currently used incident light passes through the tissue; iii) by scattering, the
techniques in treating various nasal pathologies. laser penetrates the surface of the tissue following different
paths in a nonlinear manner; or iv) absorption, where the laser
2. Methods transfers the energy that it carries to the tissue, which becomes
hot (11). The interaction of a tissue with the laser light during
A non‑systematic search was performed using the PubMed absorption produces three distinct effects: i) Photothermal
(MEDLINE) (https://pubmed.ncbi.nlm.nih.gov/) and Embase effect, in which the energy is converted to heat (as aforemen‑
(https://www.embase.com/) databases with the following tioned); ii) photomechanical effect, which produces expansion
medical subject headings terms: ‘Nasal polyp’, ‘polyposis’, of the targeted tissue due to high temperature; and iii) photo‑
‘laser’, ‘surgery’ and ‘endoscopic’. chemical effect, where different chemicals and molecules
The search results yielded 130 original and review articles subjected to the energy of the laser react (10).
in the PubMed database, and 77 in the Embase database. To achieve the best results, the apparatus settings should
Duplicates were removed, resulting in 131 original and review be specifically adjusted for the purpose and use. In a clinical
articles. setting, the wavelength should be selected according to the
The selection process was performed by two independent target tissue. The pulse duration should be equal to or shorter
authors based on the inclusion and exclusion criteria. For than the thermal relaxation time, which is the time needed for
the inclusion criteria to be met, articles needed to define and the target to dissipate 63% of the heat of the peak temperature.
mention at least one of the following surgical procedures: The energy density should be measured in J/cm 2. During
Sinus surgery, nasal septum surgery, turbinate procedures or surgical use, setting the correct pulse duration influences the
lacrimal sac procedures. In addition, articles needed to define outcomes, as the energy also interacts with blood vessels (12).
how the procedural benefits were evaluated, if the impact of the Small blood vessels, with a diameter ≤50 µm, have a thermal
surgical procedure on the quality of life had been surveyed and relaxation time of <1 msec, while large blood vessels,
for the results of the surveys to be clearly explained. Articles with a diameter >50 µm, have a thermal relaxation time of
referring to other pathologies or those presenting irrelevant 20 msec (12).
techniques for the subject were eliminated throughout the A solid‑state laser uses a solid component as the laser
selection process. As a first step, article and review titles and medium. The solid component is usually made from glass
abstracts were screened. If no information on the topic was and crystalline materials, which can be doped with diverse
mentioned, the article was discarded. Full‑text analysis was impurities. Through this process, the power of the laser can
performed for the remaining articles. Finally, 49 articles were be controlled either by amplifying or lowering the wave‑
included in the present review. length. Some of these impurities are rare earth elements
Articles selected for the present review described the effect such as terbium, cerium, erbium and neodymium. The
of surgical laser, implementation in otorhinolaryngology, most used and researched is the neodymium‑doped YAG
quality of life assessment, endoscopic and robotic surgery, and (Nd:YAG); however, alternatives such as erbium‑doped YAG
CRSwNP. The surgical and scholarly expertise of the authors (Er:YAG), holmium‑doped YAG, thulium‑doped YAG and
was used to compile and create a comprehensive review. ytterbium‑doped YAG are also utilized in various industries
such as research or automotive. All the aforementioned lasers
3. Laser types used in surgery operate at wavelengths between 1.00 and 2.94 µm and have the
potential to create diverse effects depending on the settings
Laser technologies are used in a wide spectrum of patholo‑ and the targeted tissue (13). In the future, these variations
gies. Continuous wave argon, CO2 and yttrium aluminum may be associated with different uses in rhinology and nasal
garnet (YAG) lasers are paving the way for improved surgery.
surgical outcomes. Their main usage in surgery is due to
their unique properties of being able to cut and coagulate at 4. Comparing laser types
the same time (9). Further advancements are now aiding the
technology to become more selective in differentiating tissue Lasers produce different effects depending on the type of
absorption and minimizing thermal damage while targeting laser. The most common types currently used are diode,
only the desired structures (9). The lasers used in the medical Nd:YAG, CO2 and Er:YAG. All of them are used with two
field have a wavelength between the ultraviolet and infrared main functions, namely to cut and/or to coagulate (14). This
 EXPERIMENTAL AND THERAPEUTIC MEDICINE 25: 108, 2023 3

duality may offer an advantage in nasal polyposis surgery due good results in a study including 250 surgical procedures,
to the confined space and the limited surgical instruments that with only 1 case having the undesired effect of postoperative
are in use at present. Cold instruments primarily grasp and bleeding, a few having small incidents, and the majority of
pull the tissue but do not cauterize or cut; thus, a more versatile patients having no postoperative bleeding or synechia.
instrument is required. Monteiro et al (15) compared the effect Two main problems that arise from this form of treatment
of different laser technologies on nasal mucosa and revealed are the necessity of a lifelong administration and the high cost
that the least destructive laser was the Er:YAG laser, followed of treatment. Cases for biological treatment should be care‑
by the Nd:YAG laser. The results of the CO2 laser were similar fully selected considering that the results were only obtained
to the thermal damage caused by electrosurgical scalpels, for a type 2 endotype. Until lower treatment costs and a more
yielding the worst overall results. permanent medical solution are found, the need for improved
Another factor to consider for preferential use is the speed surgical options remains (25).
at which the laser performs, with the CO2 laser being the best A novel technique used in recurring nasal polyposis is
option (16). Keane and Atkins (17) suggested that the CO2 reboot surgery. The principle is focused on the removal of the
laser could be considered for endonasal application, with the whole mucosal lining from the sinuses during classical ESS.
generated energy being absorbed by water, producing the This procedure permits the normal mucosa from the turbinate
thermal cutting and coagulating effects that are required in processes to form and grow the new epithelial lining in the
surgery. It also had a shallow penetration; thus, it could be sinuses, thus preventing the recurrence of polypoid structures.
used efficiently in nasal surgery without producing deep tissue The principles of laser surgeries have the advantage of
trauma. Its biggest disadvantage was the inability to curve the generating both a focused and a dispersed beam that can
beam. Mirrors had to be used for execution, thus complicating quickly cauterize and remove the mucosa, and let it redevelop
the technical implementation and raising the end cost. without the need of physically scraping and detaching the
The YAG laser has been demonstrated to be a superior old mucosa using blunt instruments. This technique is not
option for endonasal surgeries, providing good postprocedural currently in use; however, with further research, it has the
healing and superior cauterization compared with the CO2 potential of becoming a viable surgical option (26).
laser. With these advantages, applications range from nasal
turbinate reduction to dacryocystorhinostomy. Due to these 6. Lasers and biofilms
properties, the YAG laser is widely used in endoral tumor
resections, where faster healing and good cauterization are One of the advantages when using laser technology as an alter‑
paramount. However, the disadvantage of the YAG laser type native to cold instruments in performing endonasal surgery is
is the time needed for efficient tissue obliteration (18). the non‑requirement of nasal packing after surgery (27).
Laser equipment involves a great financial cost, not only for Zernotti et al (27) suggested that the presence of biofilms
acquisition but also for maintenance. Due to the hard‑to‑reach may contribute to mucosal damage, increase inflammation and
spaces in the paranasal sinuses, different adaptors must be used initiate hyperplasic processes.
to guide the laser beam, which generates further expenses (19). With the use of nasal packing, the avoidance of the
With time and advancements in technology, improved, smaller formation of Staphylococcus aureus biofilms is a difficult
and more precise laser devices should be used, helping these task. Biofilms have been identified at 3, 7 and 15 days
techniques to spread faster and to be implemented into clinical post‑surgery in patients with nasal packing (28). In addi‑
practice (20). tion, the discomfort that arises from a packed nose and the
minimal risk of packing dislodgement towards the naso‑
5. Novel techniques for nasal polyposis treatment pharynx must be taken into consideration (29). By using a
laser, both inconveniences can be avoided, with less need for
In the European Position Paper on Rhinosinusitis and Nasal packing after surgery and a higher degree of sterilization of
Polyps 2020, CRS was classified as type 2 or non‑type 2 the nose (30,31).
polyposis. Type 2 is the most common variant and also the Staphylococcus aureus is present in the nasal and para‑
most difficult to treat due to its high recurrence rate and high nasal cavities as a commensal bacterium. Its presence and
morbidity (21). quantity can amplify the immune‑mediated response in
Emerging techniques in the field of biomodulation therapy pathologies such as CRS. By sterilizing and eradicating
are achieving full remission of the pathology in certain recur‑ biofilms containing Staphylococcus aureus from the para‑
ring nasal polyps cases (22). By regularly administrating nasal spaces, patients suffering from CRS had improved
biological therapies, usually months apart, the underlying outcomes (32). In CRSwNP, bacterial biofilms have been
immunological disease can be temporarily controlled (23). demonstrated to be internalized by mast cells through the
Some of the approved treatment options are dupilumab, omali‑ process of phagocytosis. After multiplication within the
zumab and benralizumab, which have been demonstrated to mast cells, the rupture of the cell wall occurred, and viable
be effective and have been approved by the USA Food and bacteria spread back into the extracellular space, leading to
Drug Administration (23). biofilm growth (33). Localization of bacteria is determined in
In a study by Levine (7), 128 patients underwent laser both levels of the epidermis, in which the laser fascicle can
surgery for various endonasal pathologies, varying from turbi‑ penetrate, thus achieving its desired effect (34).
nate hypertrophy to inverted papillomas. No postoperative Sun et al (35) has demonstrated that Staphylococcus aureus
hemorrhage or synechia were found after using a potassium is not the only pathogen that can cause disease activity, and the
titanyl phosphate/Nd:YAG laser. Selkin (24) also reported presence of coagulase‑negative Staphylococci, Streptococcus
4 TĂNASE et al: LASER NASAL SURGERY (REVIEW)

pneumoniae, Moraxella catarrhalis, Hemophilus influenzae, improvements. The quality of care offered by the health
Pseudomonas aeruginosa, Escherichia coli or Klebsiella system and the advantage of ending the surgery without nasal
pneumoniae as commensal and pathogenic bacteria has been packing (41), thus reducing the psychological trauma of the
proposed as a possible cause of treatment‑resistant disease. patient, offering instant results and preventing bacterial growth
Laser surgery may become a compelling treatment option, should become a future target (42).
improving results by sterilizing colonies, and clearing the The major shortcomings of laser surgery in rhinology are
nasal and paranasal mucosa (35). primarily associated with high costs and technical ineffective‑
A study performed by Krespi and Kizhner (36) on ness due to poor guiding technology (43). Due to past failures,
25 patients compared laser alone and laser combined with doctors can be reserved in re‑adapting technologies that did
antibiotics (erythromycin). The laser used was a low‑powered, not pass the Gartner hype cycle (43). The costs of purchase
dual‑wavelength 870/930 nm, and it had the potential to eradi‑ can be relatively high, which can be a challenge for numerous
cate MRSA or even reverse the resistance level and re‑sensitize hospitals. Besides the laser itself, the specialized equipment
the bacterium to erythromycin. and protective gear needed, and the maintenance fees are
Biener et al (37) discussed that laser therapy has shown costly (44).
great potential for inactivating MRSA by altering the trans‑ Due to the tight spaces in which the surgeon needs to
membrane potential by using 121 J/cm2, which is a relatively manipulate the laser, guiding technologies need to evolve to
low dose of energy that can be targeted at the human body achieve the level of precision needed to avoid injuries (45).
without creating other undesired negative effects. The CO2 laser tends to be ~5‑fold cheaper than a YAG
A study on conjunctival and lacrimal sac specimens before laser, helping the odds of implementation and experimenta‑
and after dacryocystorhinostomy, with Staphylococcus aureus tion in diverse surgical fields, with proven advantages and
being the primarily isolated bacterium, revealed a decreased disadvantages for different tissues. In the case of nasal
growth rate and a change in antibiotic sensitivity following surgery, experience from dacryocystorhinostomies and partial
external, endoscopic and trans‑canalicular multidiode laser resections of the inferior turbinate processes may be a useful
surgery. These findings may be extrapolated to show the starting point for nasal polyp surgeries. However, the need to
benefits of laser surgery in other nasal and paranasal cavity use different surgical approaches and angles can challenge the
disorders (38). surgical team, thus lowering the rate of implementation of this
technology (46).
7. Laser surgery technique and precautions
9. Current use of lasers
Due to the specific nature of the laser as having an open‑ended
energy source, special care must be taken when using it in The usage of a laser with a power between 3 and 7 W has been
an enclosed environment. Specifically, protection of the alar demonstrated to be a great option for sterilizing intranasal
rims and septum should always be considered regarding the mucosa, resecting tumors and cutting diverse lesions. Due to
patient. Facial and ocular protection is mandatory, and wet these advantages, lasers are now used more frequently without
towels can be used for this purpose. Wet cotton should also be traumatizing the underlying tissues, and with improved results
placed in the nasopharynx, and the intubation tube should be in healing and surgical scar forming. Due to the capability of
draped with wet towels, so it can be protected from accidental adapting the power of the laser, necrosis of the periosteum and
misuse (39). During procedures that use any form of laser in bone can be prevented. Another added benefit of laser surgery
a cavity, suction should always be used to clear the smoke is that it only targets the connective tissue, while sparing the
generated and to cool the tissues to prevent further thermal epithelial glands (47).
trauma (39). Olszewska et al (48) evaluated the effect of the CO2 laser
As a preferred position for endonasal laser surgery, the as a means of producing mucotomy. The evaluation was
surgeon should sit at the head of the patient, with the patient performed using rhinomanometry and olfactory measure‑
in the Trendelenburg position (33). The energy emitted by ments, and by comparing cytological exams before and
the laser can cause deeper lesions, thus causing thermal 3 months after the procedure. At 3 months following the
damage to bony structures and leading to osteonecrosis or procedure, histologically, there was a reduction of goblet
sequestration of bone fragments (24). When dealing with cells, which were predominant in the cytograms of the patient
a potentially malignant tumor, pulse mode should be used before the surgery. There was also a reduction in nasal airway
rather than the continuous one, so that the specimen is not resistance and a slight increase in olfactory function after the
carbonized (24). procedure.
Allergies are the predominant cause of CRSwNP and
8. Advantages and disadvantages of laser treatment have become a target for surgical and medical treatments (49).
Diode laser surgery has been demonstrated to improve subjec‑
The benefits of laser surgery in conditions such as CRSwNP tive symptoms such as nasal obstruction, rhinorrhea, sneezing,
remain to be demonstrated along with future advances in itching and overall satisfaction. Notably, improvements were
technology. In certain situations, the use of laser on the nasal higher in cases of perennial allergic rhinitis at the beginning
mucosa may be able to eradicate bacterial biofilms, thus ending of the treatment, but they were more sustained in seasonal
a vicious cycle of recurring nasal afflictions (40). allergic cases (43).
Shorter hospitalization time, and possibly enhancing In cases of aggressive recurring nasal polyposis, surgical
the quality of life of patients, can be considered as key treatment is repeated multiple times during the lifetime of the
 EXPERIMENTAL AND THERAPEUTIC MEDICINE 25: 108, 2023 5

patient, and the underlying problem is that even in the best References
conditions, accidental removal of healthy tissue or even whole
structures such as the middle and inferior turbinate processes 1. Ceballos Cantu JC, Alobid I and Mullol J: Current evaluation
and management of patients with chronic rhinosinusitis and nasal
can occur. The most dreaded morbidity that can occur is polyps. Expert Rev Clin Immunol 18: 1253‑1263, 2022.
empty nose syndrome, which does not only alter the flow of 2. Simpson GT, Shapshay SM, Vaughn CW and Strong MS:
air through the nose but is also associated with mental health R h i nologic su rger y wit h t he ca rbon diox ide laser.
Laryngoscope 92: 412‑415, 1982.
disorders. Laser surgery can aid in this matter by reducing 3. Sato K and Nakashima T: Endoscopic sinus surgery for antrocho‑
the number of surgeries due to its longer‑lasting effects, and anal polyp using CO2 laser and/or microresector: A long‑term
by promoting a more targeted approach with a lower risk of result. J Laryngol Otol 119: 362‑365, 2005.
4. Bottero E, Mussi E, Raponi F, de Lorenzi D and Ruggiero P:
harming normal tissue (50). Diagnosis and outcome of nasal polyposis in 23 dogs treated
medically or by endoscopic debridement. Can Vet J 62: 736‑742,
10. Conclusion 2021.
5. Di Cicco ME, Bizzoco F, Morelli E, Seccia V, Ragazzo V,
Peroni DG and Comberiati P: Nasal polyps in children: The early
Laser surgery may be adapted for nasal surgery, including origins of a challenging adulthood condition. Children (Basel) 8:
turbinate resections, dacryocystorhinostomies and nasal 997, 2021.
6. Metin Önerci T and Ferguson BJ (eds): Nasal polyposis:
polyp surgeries, and can improve sinus surgery outcomes. Pathogenesis, medical and surgical treatment. Springer Berlin
Laser surgery can reduce hospitalization, limit postoperative Heidelberg, pp 1‑311, 2010.
bleeding and provide an improved quality of life for patients. 7. Levine HL: Endoscopy and the KTP/532 laser for nasal sinus
disease. Ann Otol Rhinol Laryngol 98 (1 Pt 1): 46‑51, 1989.
If further researched, laser surgery may be demonstrated to 8. Feng F, Zhou Y, Hong W, Li K and Xie L: Development and
be beneficial in modulating nasal biofilms, thus potentially experiments of a continuum robotic system for transoral laryn‑
benefiting patients with nasal polyposis. The costs of acqui‑ geal surgery. Int J Comput Assist Radiol Surg 17: 497‑505,
2022.
sition and maintenance can be a burden for certain medical 9. Herd RM, Dover JS and Arndt KA: Basic laser principles.
providers. Therefore, more detailed guidance of the laser beam Dermatol Clin 15: 355‑372, 1997.
is necessary to use lasers efficiently and safely in nasal surgery 10. Bogdan Allemann I and Kaufman J: Laser principles. Curr Probl
Dermatol 42: 7‑23. 2011.
as an alternative to the currently existing technology. 11. Chung H, Dai T, Sharma SK, Huang YY, Carroll JD and
Hamblin MR: The nuts and bolts of low‑level laser (Light)
Acknowledgements therapy. Ann Biomed Eng 40: 516‑533, 2012.
12. Archer KA and Carniol P: Diode Laser and Fractional Laser
Innovations. Facial Plast Surg 35: 248‑255, 2019.
Not applicable. 13. Neruntarat C, Khuancharee K and Shoowit P: Er:YAG laser
for snoring: A systemic review and meta‑analysis. Lasers Med
Sci 35: 1231‑1238, 2020.
Funding 14. Sieśkiewicz A, Rogowski M and Olszewska E: Selected appli‑
cations of diode laser in laryngological surgery. Otolaryngol
No funding was received. Pol 62: 549‑552, 2008 (InPolish).
15. Monteiro L, Delgado ML, Garcês F, Machado M, Ferreira F,
Martins M, Salazar F and Pacheco JJ: A histological evaluation of
Availability of data and materials the surgical margins from human oral fibrous‑epithelial lesions
excised with CO2 laser, Diode laser, Er:YAG laser, Nd:YAG
Not applicable. laser, electrosurgical scalpel and cold scalpel. Med Oral Patol
Oral Cir Bucal 24: e271‑e280, 2019.
16. Liu R, Sun K, Wang Y, Jiang Y, Kang J and Ma H: Clinical
Authors' contributions comparison between Er: YAG and CO2 laser in treatment of oral
tumorous lesions: A meta‑analysis. Medicine (Baltimore) 99:
e20942, 2020.
MIT, RGD and MC contributed to the analysis and interpreta‑ 17. Keane WM and Atkins JP Jr: CO2 laser surgery of the upper
tion of data and made substantial contributions to the design of airway. Surg Clin North Am 64: 955‑971, 1984.
the study. MIT, AAM, RGD and SSP performed the literature 18. Sroka R, Janda P, Killian T, Vaz F, Betz CS and Leunig A:
Comparison of long term results after Ho:YAG and diode laser
review. MB, CS, AAM and SSP made substantial contributions treatment of hyperplastic inferior nasal turbinates. Lasers Surg
to the conception and design of the study. AAM, RGD, MC and Med 39: 324‑331, 2007.
SSP supervised the present study and revised the manuscript for 19. Sato K: Endoscopic sinus surgery for the anterior maxillary
sinus, using a 135 degrees reflective CO 2 laser. J Laryngol
important intellectual content. Data authentication is not appli‑ Otol 122: 918‑920, 2008.
cable. All authors have read and approved the final manuscript. 20. Levine HL: Endonasal laser surgery: An update. Otolaryngol
Clin North Am 39: 493‑501, viii, 2006.
21. Fokkens WJ, Lund VJ, Hopkins C, Hellings PW, Kern R,
Ethics approval and consent to participate Reitsma S, Toppila‑Salmi S, Bernal‑Sprekelsen M, Mullol J,
Alobid I, et al: European position paper on rhinosinusitis and
Not applicable. nasal polyps 2020. Rhinology 58 (Suppl S29): S1‑S464, 2020.
22. Bachert C, Zhang N, Cavaliere C, Weiping W, Gevaert E and
Krysko O: Biologics for chronic rhinosinusitis with nasal polyps.
Patient consent for publication J Allergy Clin Immunol 145: 725‑739, 2020.
23. Cuevas M and Zahnert T: Biologics: A new option in treat‑
ment of severe chronic rhinosinusits with nasal polyps.
Not applicable. Laryngorhinootologie 100: 134‑145, 2021 (In German).
24. Selkin SG: Pitfalls in intranasal laser surgery and how to avoid
Competing interests them. Arch Otolaryngol Head Neck Surg 112: 285‑289, 1986.
25. Chong LY, Piromchai P, Sharp S, Snidvongs K, Philpott C,
Hopkins C and Burton MJ: Biologics for chronic rhinosinusitis.
The authors declare that they have no competing interests. Cochrane Database Syst Rev 2: CD013513, 2020.
6 TĂNASE et al: LASER NASAL SURGERY (REVIEW)

26. Malvezzi L, Pirola F, De Virgilio A and Heffler E: Long‑lasting 39. Scherer H, Reichert K and Schildhauer S: Laser surgery
clinical, radiological and immunological remission of severe of t he m iddle nasa l meat us i n recu r rent si nusitis.
nasal polyposis by means of ‘reboot’ surgery. BMJ Case Rep 13: Laryngorhinootologie 78: 50‑53, 1999 (In German).
e233726, 2020. 40. Herbert S, Worlitzsch D, Dassy B, Boutonnier A, Fournier JM,
27. Z er not ti M E, A ngel Vi llegas N, Roques Revol M, Bellon G, Dalhoff A and Döring G: Regulation of Staphylococcus
Baena‑Cagnani CE, Arce Miranda JE, Paredes ME, Albesa I and aureus capsular polysaccharide type 5: CO2 inhibition in vitro
Paraje MG : Evidence of bacterial biofilms in nasal polyposis. and in vivo. J Infect Dis 176: 431‑438, 1997.
J Investig Allergol Clin Immunol 20: 380‑385, 2010. 41. Abstracts of the American Society for Laser Medicine and
28. Wang Y, Chen S, Chen J, Zhang W, Gong G, Zhou T and Surgery 30th Annual Conference Phoenix, Arizona, USA April
Kong W: Bacterial biofilm formation after nasal packing in 16‑April 18, 2010. Lasers Surg Med (Suppl 22): 1‑125, 2010.
nasal mucosa‑wounded mice. Am J Rhinol Allergy 27: e91‑e95, 42. Bacher t C, Zhang N, Hellings PW and Bousquet J:
2013. Endotype‑driven care pathways in patients with chronic rhinosi‑
29. Zaha DC, Bungau S, Aleya S, Tit DM, Vesa CM, Popa AR, nusitis. J Allergy Clin Immunol 141: 1543‑1551, 2018.
Pantis C, Maghiar OA, Bratu OG, Furau C, et al: What antibi‑ 43. Caffier PP, Neumann K, Enzmann H, Paschen C, Scherer H and
otics for what pathogens? The sensitivity spectrum of isolated Göktas O: Endoscopic diode laser polypectomy and high‑dose
strains in an intensive care unit. Sci Total Environ 687: 118‑127, intranasal steroids in recurrent nasal polyposis. Am J Rhinol
2019. Allergy 24: 143‑149, 2010.
30. Dag I, Acar M, Sakallioglu O, Catli T, San T and Cingi C: 44. Alsharif S, Jonstam K, van Zele T, Gevaert P, Holtappels G
Influence of surface properties of Merocel® (polyvinyl acetal) and Bachert C: Endoscopic sinus surgery for type‑2 CRS wNP:
and silicone nasal splints on biofilm formation. Eur Arch An endotype‑based retrospective study. Laryngoscope 129:
Otorhinolaryngol 271: 1519‑1524, 2014. 1286‑1292, 2019.
31. Acar M, Catli T, Dag I, San T and Cingi C: Microbial biofilm 45. Wang HK, Wang PC, Tsai YH, Huang TC and Hsu SY:
formation on silicone nasal splints: Optimal time for splint Endoscope‑assisted KTP laser sinus clear‑out procedure for recur‑
removal. Rhinology 52: 371‑375, 2014. rent ethmoid polyposis. J Clin Laser Med Surg 21: 93‑98, 2003.
32. Cantero D, Cooksley C, Jardeleza C, Bassiouni A, Jones D, 46. Parimbelli E, Simon C, Soldati F, Duchoud L, Armas GL,
Wormald PJ and Vreugde S: A human nasal explant model to de Almeida JR and Quaglini S: Quality of life and health‑related
study Staphylococcus aureus biofilm in vitro. Int Forum Allergy utility after trans‑oral surgery for head and neck cancers. Health
Rhinol 3: 556‑562, 2013. Qual Life Outcomes 19: 250, 2021.
33. Leong SC, Mogre D, Andrews P and Davies E: Reducing the 47. Chhabra N and Houser SM: Surgical options for the allergic
risks of endoscopic sinonasal surgery in the Covid‑19 era. Clin rhinitis patient. Curr Opin Otolaryngol Head Neck Surg 20:
Otolaryngol 46: 809‑815, 2021. 199‑204, 2012.
34. Hanssen AM, Kindlund B, Stenklev NC, Furberg AS, 48. Olszewska E, Sieskiewicz A, Kasacka I, Rogowski M,
Fismen S, Olsen RS, Johannessen M and Sollid J U: Zukowska M, Soroczyńska J and Rutkowska J: Cytology of nasal
Localization of Staphylococcus aureus in tissue from the mucosa, olfactometry and rhinomanometry in patients after
nasal vestibule in healthy carriers. BMC Microbiol 17: 89, CO2 laser mucotomy in inferior turbinate hypertrophy. Folia
2017. Histochem Cytobiol 48: 217‑221, 2010.
35. Sun F, Zhou K, Chen XD, Xu XL and Zha DJ: Screening and 49. Wallace DV: Treatment options for chronic rhinosinusitis with
antibiotic resistance analysis of nasal colonized bacteria in nasal polyps. Allergy Asthma Proc 42: 450‑460, 2021.
patients with chronic rhinosinusitis. Lin Chung Er Bi Yan Hou 50. Kanjanawasee D, Campbell RG, Rimmer J, Alvarado R,
Tou Jing Wai Ke Za Zhi 33: 736‑741, 2019 (In Chinese). Kanjanaumporn J, Snidvongs K, Kalish L, Harvey RJ and
36. Krespi YP and Kizhner V: Laser‑assisted nasal decoloniza‑ Sacks R: Empty nose syndrome pathophysiology: A systematic
tion of Staphylococcus aureus, including methicillin‑resistant review. Otolaryngol Head Neck Surg 167: 434‑451, 2022.
Staphylococcus aureus. Am J Otolaryngol 33: 572‑575, 2012.
37. Biener G, Masson‑Meyers DS, Bumah VV, Hussey G, This work is licensed under a Creative Commons
Stoneman MR, Enwemeka CS and Raicu V: Blue/violet laser Attribution-NonCommercial-NoDerivatives 4.0
inactivates methicillin‑resistant Staphylococcus aureus by International (CC BY-NC-ND 4.0) License.
altering its transmembrane potential. J Photochem Photobiol
B 170: 118‑124, 2017.
38. Balikoglu‑Yilmaz M, Esen AB, Yilmaz T, Taskin U, Taskapili M,
Oktay MF, Sen E and Kose T: Bacteriological profile in conjunc‑
tival, lacrimal sac, and nasal specimens and conjunctival
normalization time following external, endoscopic, and trans‑
canalicular multidiode laser dacryocystorhinostomy. Arq Bras
Oftalmol 79: 163‑170, 2016.