Case study
Resection of left tympanic paraganglioma using blue photoangiolytic laser
Resección de paraganglioma timpánico izquierdo mediante láser fotoangiolítico azul
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Hypertensive signal is observed in the T2-weighted medullary cystic cavity. B) Sagittal 2-weighted MRI. Syringomyelia up to T12. C) Nasofibroscopy: right vocal cord in paramedian position. D and E) Sagittal T1-weighted MRI, cervical, thoracic and lumbar medullary sections. Hypointense signal is observed in the syringomyelia cystic cavity.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alejandro Klein-Rodríguez" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Klein-Rodríguez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001651924000979" "doi" => "10.1016/j.otorri.2024.07.002" "estado" => "S200" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001651924000979?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173573524000826?idApp=UINPBA00004N" "url" => "/21735735/unassign/S2173573524000826/v1_202409230427/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "S217357352400036X" "issn" => "21735735" "doi" => 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[ 0 => array:4 [ "nombre" => "María del Mar" "apellidos" => "Martínez Ruiz-Coello" "email" => array:2 [ 0 => "marmruizcoello@hotmail.com" 1 => "mariadelmar.martinez@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Victoria" "apellidos" => "García Peces" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ramón" "apellidos" => "González Herranz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Guillermo" "apellidos" => "Plaza Mayor" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario de Fuenlabrada, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario Sanitas La Zarzuela, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario de La Zarzuela, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resección de paraganglioma timpánico izquierdo mediante láser fotoangiolítico azul" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1187 "Ancho" => 1780 "Tamanyo" => 204519 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Otoscopy image 3 months after placement of a TTD in the left ear. B) Audiometry of the patient, with transmissive gap in the pantonal left ear. C) MRI image of axial section showing Fisch's type A2 paraganglioma in the left ear (blue arrow). D) MRI image of coronal section, Fisch’s type A2 paraganglioma (red arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical case</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 46-year-old woman who attended ENT surgeries due to a left ear tamponade of several months’ evolution. Her general practitioner diagnosed her with serous otitis media and prescribed treatment with nasal corticosteroids but without any improvement. At the ENT outpatient visit, seromucosal otitis was first diagnosed with audiometry, acoumetry, tympanogram and congruent otoscopy, due to the clinical symptoms of persistent ear tamponade.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Audiometry showed transmissive hearing loss in the left ear with a tonal threshold of 35 dB and a pantonal gap of 15 dB. The tympanogram showed a type B curve in the left ear and the acoumetry was consistent with transmissive hearing loss. Otoscopy suggested an amber, domed eardrum. With all these findings, a transtympanic drain (TTD) was inserted under local anaesthesia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">After 3 postoperative months, at follow-up surgery visits, an erythematous pulsatile mass was observed in the anterior tympanic area, with a TTD inserted in the lower area, sparing the lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A CT scan of the petrous bone with contrast was run, showing a tumour of 7 × 8 × 4 mm in the left middle ear, in the mesotympanum: suspected tympanic paraganglioma. This tumour was related to the cochlear promontory and involved the handle of the malleus and the incudostapedial joint. The study was supplemented with an MRI that confirmed the diagnosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C).</p><p id="par0025" class="elsevierStylePara elsevierViewall">After the analysis of the CT scan and MRI images, it was concluded that the paraganglioma corresponded to Fisch’s A2, since it occupied the middle ear exclusively, however the tumour margins were not observed in otoscopy, extending anteriorly, reaching the Eustachian tube, towards the mesotympanum.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Surgery was scheduled for excision of the tympanic paraganglioma with blue photoangiolytic laser, and interdepartmental consultation was requested with the Endocrinology unit to expand the hormonal and genetic study on their part.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Surgery</span><p id="par0035" class="elsevierStylePara elsevierViewall">Under general anaesthesia and nasotracheal intubation, a retroauricular approach was performed, lifting the tympanomeatal flap under prior infiltration of local anaesthesia. The middle ear was accessed, exploring the cavity and revealing the angiomatous lesion described. The paraganglioma was closely related to the cochlear promontory and the handle of the malleus, involving the incudomalleolar joint. Excision began with dissection with spatula and cottonwool soaked in adrenaline. Once the lesion had been located and individualised, it was excised using a 300 nm blue laser fibre. During the procedure, the manubrium of the malleus was amputated to facilitate the excision of the lesion, respecting the incudomalleolar joint, which was released and individualised from the paraganglioma (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A–F). A complete resection of the pathology was obtained.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The laser parameters used were as follows: 80 ms pulse, a pause of 300 ms and 2 W power. The surgical time was 42 min and blood loss was minimal. The procedure was completed without any relevant complications.</p><p id="par0045" class="elsevierStylePara elsevierViewall">During follow-up, the patient evolved favourably, improving the transmissive component of the hearing loss and presenting a normal otoscopy. After 12 months of follow-up, there were no complications or recurrences of the lesion.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Photoangiolytic lasers, such as the blue laser, have emerged in recent years, improving the therapeutic practice of otolaryngology surgeons. The angiolytic characteristics of the blue laser and its particular absorption by tissues result in a reduction of mucosal lesions. Thanks to this fact, it can be used to perform tissue resections, greatly limiting the affected neighbouring tissue.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Among other features, a very beneficial property of photoangiolytic lasers is their ability to coagulate superficial and subepithelial blood vessels with minimal damage to the epithelium between the laser and the lesion, thus reducing the absorption of energy from surrounding tissue. Photoangiolytic lasers applied using very small gauge fibres (300 or 400 μm) enable very selective application of laser pulses. Until the advent of the blue laser, we were forced to choose between cutting lasers (prototypically a CO2 laser) or a photoangiolytic laser (PDL, KTP), however in the case of the blue laser, this combines these two characteristics.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">These characteristics have generalised the use of photoangiolytic lasers in the treatment of vascular and mucosal lesions, with more experience in the field of laryngology.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> The blue laser has been proven to be a safe and effective alternative in the treatment of laryngeal lesions.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Their easy portability, the small size of the laser fibres and their properties have facilitated their use, even in outpatient surgeries, enabling lesion resection procedures to be performed under local anaesthesia.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> Other vascular and mucosal lesions at the nasal and ear level may be suitable for treatment with blue photoangiolytic laser, although these procedures are much less documented in the literature.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Our clinical case details a resection of a Fisch’s type A2 tympanic paraganglioma by blue laser in theatre, demonstrating the usefulness, safety and efficacy of this laser in the treatment of vascular ear lesions. To date, we have found only one recent bibliographical reference that describes the excision of a tympanic paraganglioma by blue laser.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The Spanish group has concluded that the blue laser is safe and effective in the minimally invasive treatment of paragangliomas in the early stages. In our study we have proposed Fisch's type A1 and A2 paragangliomas as the most suitable lesions to be resected by blue laser.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Noel et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> present a case series with 5 patients who underwent surgery for tympanic paraganglioma by endoscopic approach and the use of KTP laser. The authors emphasize the advantages of the endoscopic approach to visualise and completely resect the lesion, as well as the advantages of the KTP laser when performing glomus excision with less intraoperative bleeding. Molony et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> describe a clinical case in which they present a 39-year-old woman who underwent surgery for a type A2 tympanic paraganglioma that occupied the mesotympanum and hypotympanum. The use of the KTP laser to coagulate this vascular lesion enabled safe removal of the tumour and avoided the need for an extended facial recess or hypotympanotomy surgery.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Alkhelder et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> summarise that Fisch's type A tympanic glomus is the most recommended for laser treatment, in line with our experience. In addition, they emphasize the importance of adequate knowledge of ear anatomy and sufficient experience in the use of lasers to guarantee a good post-surgical result. Durvarsula et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> present 9 cases of tympanic paragangliomas treated with KTP and Diode lasers and can conclude, after 3.18 months of mean post-surgical follow-up, that both lasers are effective and safe in the management of these lesions. The morbidity observed with this laser technique is lower, although this emphasizes the need for more literature to support this statement, as well as comparisons between different lasers. The NdYAG laser can also be useful when resecting tympanic paragangliomas using low levels of power to avoid energy transmission at the level of the cochlea.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Photoangiolytic lasers have been shown to be useful in the treatment of vascular and mucosal lesions due to their combined cutting and coagulation properties. In the field of otology, more studies are needed to support these lasers, in order to guarantee their efficacy and safety, thus generalising their use. In our clinical case, the blue photoangiolytic laser turned out to be a useful tool in the treatment of type A tympanic paragangliomas, presenting no intra- or postoperative complications, facilitating the resection of the lesion by reducing bleeding, as well as reducing surgery time. More studies are needed to confirm these claims and compare the different laser techniques that exist.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Surgery" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-01-10" "fechaAceptado" => "2024-05-19" "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1187 "Ancho" => 1780 "Tamanyo" => 204519 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Otoscopy image 3 months after placement of a TTD in the left ear. B) Audiometry of the patient, with transmissive gap in the pantonal left ear. C) MRI image of axial section showing Fisch's type A2 paraganglioma in the left ear (blue arrow). D) MRI image of coronal section, Fisch’s type A2 paraganglioma (red arrow).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1055 "Ancho" => 1650 "Tamanyo" => 208802 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Surgical intervention of Fisch’s type A2 left paraganglioma with blue laser: QR code where full video is shown. A) The paraganglioma is visualised occupying the mesotypanum. B) Resection was then begun with blue photoangiolytic laser. C) Partially resected lesion. D) Cauterisation of venous pedicles that adhered the paraganglioma to the promontory. E) Removal of the completely resected lesion. F) Cochlear promontory without visible lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New 445 nm blue laser for laryngeal surgery combines photoangiolytic and cutting properties" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.M. Hess" 1 => "S. Fleischer" 2 => "M. Ernstberger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00405-018-4974-8" "Revista" => array:6 [ "tituloSerie" => "Eur Arch Otorhinolaryngol." 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