Principles and Practice of Lasers in Otorhinolaryngology and Head and Neck Surgery

Review by L Flood
Middlesborough, UK

I must declare an interest here. In 1985, I sat in my consultant appointment committee, facing the lead editor of this work, Vasant Oswal. I well recall him warning me not to expect in Middlesbrough the facilities that I must have grown used to in a London teaching hospital. Having visited Middlesbrough twice, and knowing its developing reputation for laser surgery, I assured him that the North (back then, anyway) was far healthier than the capital for funding.

Oswal was the driving force behind the acquisition of the first Middlesbrough laser, which was achieved entirely through community fundraising. Our new mega hospital still has a mural showing some very young, slimmer and more hirsute members of our current staff pushing a barrow through the town in the 1980s. It carried a sign saying ‘Florence Nightingale had a lamp; we want a laser’. Oswal is not the sort to then sit back; instead, he ran a series of annual international instructional courses (over 25 are now held). In 1988, he published a book on carbon dioxide (CO₂) lasers, which I played a very small part in co-editing.¹

He went on to edit the first edition of this textbook, published in 2002, which covers the whole range of surgical lasers. He is said to have been ‘retired’ from clinical practice for over a decade, but, if anything, his academic output has increased. Only last year, sitting in the Royal Society of Medicine lecture theatre, I watched a live video link from India, and who should be sitting in the centre of the trio addressing us from across the globe?

Dr Remacle, from Belgium, again joins Oswal in editing this second edition, but he has clearly been a busy author as well, most notably in his specialties of laryngology and robotic surgery. The four co-editors are household names in the field of laser surgery and the list of authors really is a Who’s Who exercise.

The scope, the scale, even the weight of this two-volume set does impress. Until I saw it, I did question the price, especially in this cash-strapped era, but, to quote the Cold War phrase, you do get ‘more bang for your buck’. There are 67 chapters from 59 international authors, and to have gathered updated work from so many busy and eminent contributors is quite an editorial achievement. To name but a few, I was glad to see Bik Kotecha on snoring surgery, as that still forms a major part of my own work. John Hamilton on lasers in cholesteatoma surgery reminded me of the many laser course dinners my wife and I enjoyed with him. We were always seated on the same table and usually stayed very late into the evening indeed! Vinidh Paleri has helped me greatly with National Institute for Health and Care Excellence (NICE) guidance and, here, writes on obstructive laryngeal malignancy. Paul O’Flynn is a very old friend; he describes his work in developing a flexible CO₂ laser for head and neck surgery, having reported on the first UK applications in Clinical Otolaryngology.² Equally memorably, in an earlier paper in The Journal of Laryngology & Otology, he and his co-authors described removal of a foreign body from the ear canal which exhibited ‘the characteristic smell of cannabis’.³ I have often wondered.

Volume 1 does take some lifting at 509 pages. The six opening chapters cover basic laser science, including risk management, anaesthesia and biophysics of the various wavelengths employed. In any textbook claiming to be updated, it is worth checking the dates of references and, throughout, they do confirm that the authors have met the challenge. You would expect good coverage of lasers for benign and malignant laryngeal disease, and for the obstructed airway, but indications have clearly increased dramatically for endonasal and otological surgery. I will not touch a turbinate now without my holmium laser, but I did find the chapters on laser-assisted endoscopic sinus surgery and usage with balloon dilatation thought-provoking (and very photogenic).

The second volume shows more novelty, with updated applications in some unexpected territories. Laser cartilaginous eustachian tuboplasty, palatal stiffening (working on the upper surface; less painful and I never thought of that!) and laser cartilage reshaping for pinnaplasty (no skin incision!) are just three inspiring chapters. My favourite had to be Chapter 66 ‘Optical diagnostics’. This has a huge bibliography and is highly topical. It proved a godsend source to me when pretending to NICE that I am an expert on the subject.

There are high quality and new illustrations throughout. Instead of the compact disc read-only memory of the first edition, there is soon to be a website demonstrating surgery, which of course allows for further updating. It is still under construction, as of April 2014. Finally, each chapter closes with multiple-choice questions, which vary in value. They are especially good at the end of the excellent chapter on recurrent respiratory papillomatosis. Multiple-choice question writing is difficult, as little in medicine is absolutely yes or no, or true or false.

One might be forgiven for thinking that lasers are so established in surgical practice that there is little new to say. Conversely, I do recall a sceptic, addressing us at the Royal Society of Medicine in the early 1980s, stating that ‘If you give a child a hammer, it will hit everything with it, until it finds a use for it’. This massive textbook addresses the limitations as well as the values of the full range of surgical lasers, and hints at the prospects for further developments. It is a must for any unit undertaking such work, but is also an excellent reference for the trainee facing final examinations.

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