Marc Rubinstein

Transoral laser microsurgery for laryngeal cancer: a primer and review of laser dosimetry.

Transoral laser microsurgery (TLM) is an emerging technique for the management of laryngeal and other head and neck malignancies. It is increasingly being used in place of traditional open surgery because of lower morbidity and improved organ preservation. Since the surgery is performed from the inside working outward as opposed to working from the outside in, there is less damage to the supporting structures that lie external to the tumor. Coupling the laser to a micromanipulator and a microscope allows precise tissue cutting and hemostasis; thereby improving visualization and precise ablation. The basic approach and principles of performing TLM, the devices currently in use, and the associated dosimetry parameters will be discussed. The benefits of using TLM over conventional surgery, common complications and the different settings used depending on the location of the tumor will also be discussed. Although the CO2 laser is the most versatile and the best-suited laser for TLM applications, a variety of lasers and different parameters are used in the treatment of laryngeal cancer. Improved instrumentation has lead to an increased utilization of TLM by head and neck cancer surgeons and has resulted in improved outcomes. Laser energy levels and spot size are adjusted to vary the precision of cutting and amount of hemostasis obtained.

Semi-resonant operation of a fiber-cantilever piezotube scanner for stable optical coherence tomography endoscope imaging

A forward-view optical coherence tomography (OCT) scanning catheter has been developed based on a fiber-cantilever piezotube scanner by using a semi-resonant scan strategy for a better scan performance. A compact endoscope catheter was fabricated by using a tubular piezoelectric actuator with quartered electrodes in combination with a resonant fiber cantilever. A cantilever weight was attached to the fiber cantilever to reduce the resonance frequency down to 63 Hz, well in the desirable range for Fourier-domain OCT. The resonant-cantilever scanner was driven at semi-resonance frequencies that were well out of the resonance peak but within a range of partial resonance. This driving strategy has been found to minimize the phase difference between the two scan axes for a better scan stability against environmental perturbations as well as for a driving simplicity. By driving the two axes at slightly different frequencies, a low-order Lissajous pattern has been obtained for a 2D area scan. 3D OCT images have been successfully acquired in an acquisition time of 1.56 seconds for a tomogram volume of 2.2 × 2.2 × 2.1 mm3. They were reconstructed without any scan calibration by extracting the scan timing from the image data. In addition, it has been found that the Lissajous scan strategy provides a means to compensate the relative axial motion of a sample for a correct imaged morphology.

Office-based dynamic imaging of vocal cords in awake patients with swept-source optical coherence tomography

Optical coherence tomography (OCT) is an evolving noninvasive imaging modality that has been used to image the human larynx during surgical endoscopy. The design of a long gradient index (GRIN) lens-based probe capable of capturing images of the human larynx by use of swept-source OCT during a typical office-based laryngoscopy examination is presented. In vivo OCT imaging of the human larynx is demonstrated with a rate of 40 frames per second. Dynamic vibration of the vocal folds is recorded to provide not only high-resolution cross-sectional tissue structures but also vibration parameters, such as the vibration frequency and magnitude of the vocal cords, which provides important information for clinical diagnosis and treatment, as well as fundamental research of the voice itself. Office-based OCT is a promising imaging modality to study the larynx for physicians in otolaryngology.

Laryngeal epithelial thickness: a comparison between optical coherence tomography and histology

Objectives:  Optical coherence tomography, an imaging modality using near‐infrared light, produces cross‐sectional tissue images with a lateral pixel resolution of 10 μm. However, normative data is first needed on epithelial thickness for lesion characterisation, and, to date, little exists. The purpose of our study is to measure normal laryngeal epithelial thickness by in vivo optical coherence tomography, and compare these values to those obtained from fixed ex‐vivo laryngectomy specimens.

Imaging vibrating vocal folds with a high speed 1050 nm swept source OCT and ODT

Vocal fold vibration is vital in voice production and the correct pitch of speech. We have developed a high speed functional optical coherence tomography (OCT) system with a center wavelength of 1050 nm and an imaging speed of 100,000 A-lines per second. We imaged the vibration of an ex-vivo swine vocal fold. At an imaging speed of 100 frames per second, we demonstrated high quality vocal fold images during vibration. Functional information, such as vibration frequency and vibration amplitude, was obtained by analyzing the tissue surface during vibration. The axial direction velocity distribution in the cross-sectional images of the vibrating vocal folds was obtained with the Doppler OCT. The quantitative transverse direction velocity distribution in the cross-sectional images was obtained with the Doppler variance images.

Optical coherence tomography of cholesteatoma.

Objectives: To image cholesteatoma using optical coherence tomography (OCT) and correlate the results with clinical findings and conventional observations obtained using binocular microscopy and histology. OCT is a high-resolution optical imaging modality that generates cross-sectional images of turbid media, such as tissue with resolution approaching that of light microscopy. OCT relies on intrinsic differences in tissue optical properties for image contrast. Study Design: In vivo prospective clinical study. Setting: University Medical Center. Patients: Patients with cholesteatoma undergoing otologic surgery. Intervention: Using a commercial OCT imaging system, we obtained cross-sectional images (resolution, ∼10 &mgr;m; depth penetration, ∼1 mm) of cholesteatomas. Main Outcome Measures: Images are obtained by raster scanning a single mode fiber across the interior of the probe. The imaging probe is sterilized and inserted into the middle ear or mastoid under microscopic guidance, and still images of the middle ear or mastoid mucosa and cholesteatoma when present were obtained. Results: OCT images of cholesteatomas demonstrate differences in signal intensity, which are distinct from those of normal or inflamed middle ear/mastoid mucosa. Identification of keratin in cholesteatoma, even if very thin, distinguished it from inflamed mucosa. Conclusion: This is the first study that systematically used OCT to image cholesteatoma during otologic surgery. Cholesteatomas can be distinguished from normal or inflamed adjacent mucosa.

Optical coherence tomography applications in otolaryngology

Optical coherence tomography is a novel imaging technique providing high-resolution bidimensional images of tissue microstructures. Several studies have been published on the use of this technique in different fields of medicine, particularly ophthalmology. There are very few studies in the field of otolaryngology. This paper presents various applications of optical coherence tomography in the different sub-specialties of otolaryngology, as well as the benefits of this technique over traditional diagnostic methods.

Emerging applications for OCT in the head and neck

Objectives: To describe the current and promising new applications of Optical Coherence Tomography (OCT) as a helpful tool when imaging the different sites in the head and neck. We used the OCT Niris system, which is the first commercially available OCT device for applications outside the field of ophthalmology. Methods: OCT images were obtained of normal, benign, premalignant and malignant lesions in different areas of the head and neck. The OCT imaging system has a tissue penetration depth of approximately 1-2mm, a scanning range of 2mm and a spatial depth resolution of approximately 10-20μm. Imaging was performed using a flexible probe in two different settings, the outpatient clinic and the operating room. Results: High-resolution cross-sectional images from the larynx were obtained with the patient awake, without the need for general anesthesia, under direct visualization with a flexible fiberoptic endoscope. The OCT probe was inserted through the nasal cavity and placed in slight contact with the laryngeal tissue. In the ears, cholesteatoma was differentiated from inflamed middle ear mucosa by the different hyperintensity. In the neck, normal as well as different pathologies of the thyroid were identified. Conclusions: This system is non invasive and easy to incorporate into the operating room setting as well as the outpatient clinic. It requires minimal set-up and only one person is required to operate the system. OCT has the distinctive capability to obtain highresolution images, and the microanatomy of different sites can be observed. OCT technology has the potential to offer a quick, efficient and reliable imaging method to help the surgeon not only in the operating room but also in the clinical setting to guide surgical biopsies and aid in clinical decision making of different head and neck pathologies, especially those arising form the larynx.

Aplicaciones de la tomografía de coherencia óptica en otorrinolaringología

Optical coherence tomography is a novel imaging technique providing high-resolution bidimensional images of tissue microstructures. Several studies have been published on the use of this technique in different fields of medicine, particularly ophthalmology. There are very few studies in the field of otolaryngology. This paper presents various applications of optical coherence tomography in the different sub-specialties of otolaryngology, as well as the benefits of this technique over traditional diagnostic methods.

Optical coherence tomography using the Niris system in otolaryngology

Objectives: To determine the feasibility and accuracy of the Niris Optical Coherence Tomography (OCT) system in imaging of the mucosal abnormalities of the head and neck. The Niris system is the first commercially available OCT device for applications outside ophthalmology. Methods: We obtained OCT images of benign, premalignant and malignant lesions throughout the head and neck, using the Niris OCT imaging system (Imalux, Cleveland, OH). This imaging system has a tissue penetration depth of approximately 1-2mm, a scanning range of 2mm and a spatial depth resolution of approximately 10-20μm. Imaging was performed in the outpatient setting and in the operating room using a flexible probe. Results: High-resolution cross-sectional images from the oral cavity, nasal cavity, ears and larynx showed distinct layers and structures such as mucosa layer, basal membrane and lamina propria, were clearly identified. In the pathology images disruption of the basal membrane was clearly shown. Device set-up took approximately 5 minutes and the image acquisition was rapid. The system can be operated by the person performing the exam. Conclusions: The Niris system is non invasive and easy to incorporate into the operating room and the clinic. It requires minimal set-up and requires only one person to operate. The unique ability of the OCT offers high-resolution images showing the microanatomy of different sites. OCT imaging with the Niris device potentially offers an efficient, quick and reliable imaging modality in guiding surgical biopsies, intra-operative decision making, and therapeutic options for different otolaryngologic pathologies and premalignant disease.