Laser technology, a mainstay in many medical disciplines, has long been perceived by the public as a harbinger of advanced treatment, often resulting in heightened expectations of revolutionary outcomes. Such misconceptions, fueled by the futuristic allure of lasers, lead patients to believe that laser treatments are synonymous with complete recovery. In the nuanced field of rhinology, while lasers have indeed made notable contributions, the results more often reflect symptomatic improvement rather than total cure.

The panorama of laser applications in rhinologic diseases is broad and varied. However, in Republic of Korea, an interesting shift can be observed. Historically open to technological adoptions, Republic of Korea’s medical fraternity has in recent times shown a tendency to rely less on lasers for rhinologic treatments. This change, not a dismissal of laser efficacy, but rather an evolution, has been influenced by the emergence of alternative treatments and methodologies which promise comparable, if not better, outcomes with fewer complications.

This review seeks to delve into the intricacies of laser applications in rhinology, with a specific focus on trends, challenges, and evolving preferences within the Korean medical landscape.

The diversity of lasers available for medical applications has opened new doors for the treatment of rhinologic diseases. Nevertheless, the intricate and constrained anatomy of the nasal cavity poses significant challenges in the application of these lasers. Commonly used lasers in the rhinologic field and their specifics are summarized in Table 1.

Table 1 . Summary of lasers and their properties

	Type	Continuous/pulsed	Color	Wavelength (nm)	Depth of penetration (mm)	Delivery system	Absorption	Absorber	Scattering	Common applications
CO2	Gas molecule	Continuous/pulsed	Mid infrared	10,600	0.01	Coupler and waveguide	Very strong	Water	Neglible	Septal surgery, turbinoplasty
Argon	Gas ions	Continuous	Blue, green	488 (blue) 514 (green)	0.44	Quartz fiber	Medium	Hemoglobin	Low	HHT
KTP	Solid state	Quasi-continuous/pulsed	Green	532	0.39	Quartz fiber	Medium	Hemoglobin	Low	HHT Choanal atresia DCR Turbinoplasty
Diode	Semiconductor	Continuous	Near infrared	800-1,000	3.5	Quartz fiber	Low	Cell material	Medium/strong	Choanal atresia DCR Turbinoplasty Vidian neurectomy SPA ligation
Nd:YAG	Solid state	Continuous	Near infrared	1,064	4.6	Quartz fiber	Low	Water	Strong	HHT
Ho:YAG	Solid state	Quasi-continuous/pulsed	Near infrared	2,100	0.2	Quartz fiber	Strong	Water	Neglible	Septal surgery

CO₂, carbon dioxide; HHT, hereditary hemorrhagic telangiectasia; KTP, potassium titanyl phosphate; DCR, dacryosystorhinostomy; SPA, sphenopalatine artery; Nd, neodymium; Ho, holmium.

One of the primary reasons for the popularity of carbon-dioxide (CO₂) lasers is their cost-effectiveness. Their wavelengths allow for precision cutting and vaporization of tissue, making them highly effective in specific procedures [1]. However, CO₂ lasers come with inherent drawbacks such as reduced hemostatic properties, which makes controlling bleeding during procedures a challenge. Additionally, their inability to be efficiently delivered through flexible fibers limits their versatility in navigating the complex nasal anatomy.

Diode lasers operate at wavelengths that permit deeper tissue penetration [2]. Their compatibility with flexible fibers makes them an excellent choice for procedures within the sinuous nasal cavity. Their depth of penetration can sometimes risk damage to deeper structures if not used cautiously.

The potassium titanyl phosphate (KTP) laser provides the dual benefit of precise cutting with hemostatic capabilities [3]. Furthermore, its compatibility with flexible fibers makes it well-suited for the intricacies of rhinologic procedures. However, it might not be as effective in ablating denser tissues compared to the CO₂ laser.

The challenge of the nasal cavity’s architecture has prompted the development of specialized handpieces for laser delivery. These adaptations, especially those with smaller diameters, enhance maneuverability and precision during nasal procedures. Innovations in fiber design and handpiece ergonomics have expanded the potential of lasers in rhinology.

While various lasers offer their unique advantages in treating rhinologic conditions, understanding their limitations and advancements in delivery mechanisms is crucial to harness their full potential.

Allergic rhinitis, a condition marked by an IgE-mediated immune response to environmental allergens, manifests symptoms like rhinorrhea (runny nose), sneezing, nasal pruritus (itching), and congestion [4]. These symptoms invariably affect a patient’s quality of life, prompting a search for effective treatments. Beyond conventional treatment modalities, lasers, especially low-level laser therapy (LLLT) and laser-assisted turbinate surgery, have emerged as potential therapeutic avenues.

LLLT has been explored for its potential anti-inflammatory and immunomodulatory effects, which can be particularly beneficial for allergic rhinitis patients [5].

In a notable study, the efficacy of a multi-wavelength laser was investigated in a double-blind, placebo-controlled trial. This laser device combined wavelengths of 670 nm (AlGaInP, 3 mW) and 830 nm (GaAs, 20 mW) and was developed by Optowell Co., Ltd.. The trial reported a positive therapeutic effect, demonstrating symptom relief in patients with moderate-to-mild allergic rhinitis [6].

Furthermore, a meta-analysis evaluating various phototherapy techniques, inclusive of laser therapy, corroborated the findings, indicating an improvement in allergic rhinitis symptoms following the interventions [7,8].

However, the field is not without challenges. The heterogeneity in the types of lasers used across different studies and the diverse methodologies to assess therapeutic outcomes make it challenging to draw universal conclusions. This calls for more structured and standardized research approaches to better understand and harness the potential of lasers in allergic rhinitis treatment.

Encouragingly, the medical devices industry seems poised to support this shift. Several laser treatment devices have already obtained the green light from regulatory authorities for commercial distribution. Concurrently, there are multiple devices that are in the pipeline, undergoing rigorous clinical trials to ascertain their safety and efficacy.

The nasal turbinates, especially the inferior ones, play a crucial role in the dynamics of nasal airflow and filtration [9]. However, hypertrophy or enlargement of these structures, often seen in conditions like allergic rhinitis, can lead to bothersome symptoms such as nasal congestion and rhinorrhea [10]. In recent years, lasers have been harnessed for turbinate surgery, aiming to reduce turbinate size and ameliorate the associated symptoms (Table 2) [11-16].

Table 2 . Studies using laser in turbine surgery

Study	Country	No. of patients	Mean age at diagnosis (yr)	Follow-up period	Methods	Surgical instruments	Disease	Results
Hussain and Ahmad, 2022 [11]	India	53		3 mon	CO2 laser		AR, NAR	Improved nasal obstruction
Lee and Kim, 2010 [12]	Republic of Korea	37	28.8	3 mon	MAIT, laser	Microdebrider Laser	HR	VAS symptom and nasal endoscopic score both improved after surgery MAIT is superior than laser-assisted turbinoplasty
Min et al., 1996 [13]	Republic of Korea	53	31.2	6 mon	Laser	Diode laser	NAR	Both nasal obstruction and rhinomanometry improved
Supiyaphun et al., 2003 [14]	Thailand	28	33.29	2 mon	Laser	KTP laser	AR (85%), VMR (10%), HR (5%)	Both nasal obstruction and rhinomanometry improved
Testa et al., 2006 [15]	Italy	308	31.4	7.8 yr	Laser	CO2 laser	AR (55%), HR (45%),	Improved symptoms and quality of life after 7.8 years of surgery
Volk et al., 2010 [16]	Germany	41	42.4	2 mon	Laser	Diode laser	VMR	Improved nasal airflow postoperatively

CO₂, carbon dioxide; AR, allergic rhinitis; NAR, non-allergic rhinitis; MAIT, microdebrider-assisted inferior turbinoplasty; HR, hypertrophic rhinitis; VAS, visual analogue scale; KTP, potassium titanyl phosphate; VMR, vasomotor rhinitis.

Lasers in turbinate surgery act by causing controlled thermal injury to the turbinate mucosa [17]. This injury instigates a healing process characterized by the shrinkage of the turbinate and the formation of scar tissue or fibrosis. The end result is a reduced turbinate volume and alleviated symptoms, especially nasal congestion.

Different lasers have distinct modes of application. Diode lasers and KTP lasers are used in contact mode, where they directly contact the mucosa before operation, while CO₂ lasers are applied by scanning the mucosa with the laser beam. Typically, 3-4 lines of parallel scanning are performed parallel to the inferior turbinate, moving from the posterior to the anterior aspect.

Numerous studies have been conducted, targeting conditions such as allergic rhinitis, hypertrophic rhinitis, and vasomotor rhinitis. A meta-analysis of six clinical studies showed a significant improvement in visual analogue scale scores for nasal congestion, with a value of 4.54 (95% confidence interval, 3.32-6.05), indicating symptom improvement [18].

Testa and colleagues reported significant long-term symptom improvement in a study of 308 patients undergoing CO₂ laser-assisted turbinate surgery at 2, 4.5, and 7.8 years postsurgery [19]. This study provided evidence for the long-term symptomatic improvement effects of turbinate surgery using lasers. Apart from the mentioned studies, there are also reports involving the use of holmium lasers.

Laser-assisted turbinate surgery has undoubtedly etched a spot for itself in the management of conditions like allergic rhinitis and turbinate hypertrophy. The evidence underscores its potential for both immediate and long-term symptom relief. As with all medical interventions, the decision to undergo laser turbinate surgery should be a judicious one, made in consultation with a skilled otolaryngologist, considering the patient’s unique clinical profile.

Dacryocystorhinostomy (DCR) remains the gold standard for surgical intervention in nasolacrimal duct obstructions. Over the years, the shift from traditional external DCR to endoscopic approaches has been evident. One innovation in this domain is the incorporation of lasers in the DCR procedure.

In endoscopic DCR, lasers play a dual role. Lasers, such as diode, holmium YAG, CO₂, and neodymium (Nd):YAG, are employed to remove the bone surrounding the lacrimal sac to create a new ostium. Prior to forming the ostium, the exact location of the lacrimal sac needs confirmation. By introducing a laser fiber into the lacrimal puncta and advancing it through the canaliculi and sac, the emanating light can be observed from the upper part of the middle turbinate, providing a beacon for the correct surgical site.

Although laser DCR is promising, the reported success rates hover between 64%-90%, a notch lower than the 70%-96% observed with non-laser DCR techniques. Several factors contribute to this differential. The heat generated by lasers can cause local tissue damage, potentially impairing optimal healing. Laser-assisted DCR often results in a smaller ostium, which may be more prone to restenosis. In addition, an undeniable advantage of laser DCR is its hemostatic properties. This minimizes bleeding, making the procedure suitable under local anesthesia.

In a comprehensive study in 2018, spanning 423 patients and comparing different DCR methodologies, the results after six months showcased an 86.3% success rate for standard endoscopic DCR vs. a 69% success rate for laser-assisted DCR [20]. Interestingly, statistical analysis found this difference to be non-significant. This study emphasized the limited ostium size and reduced bone removal observed in laser DCRs, further noting the possible implications of excessive eschar formation in the postoperative period [21].

While laser-assisted DCR introduces precision and the benefit of local anesthesia due to effective hemostasis, it presents its own set of challenges. The balance between the advantages and potential complications must be judiciously weighed. As with all surgical interventions, patient selection remains paramount. A comprehensive preoperative assessment combined with a discussion of potential benefits and risks is crucial to ensure optimal outcomes.

Choanal atresia, a congenital obstruction in the posterior nasal passages, has been recognized and addressed surgically for centuries. While multiple surgical techniques have evolved over time, the use of lasers has emerged as a modern intervention method. The history of identifying and addressing choanal atresia dates back to the mid-18th century [22]. Over the years, surgical techniques have diversified, spanning interventions through the nasal cavity, palate, maxillary sinus, and nasal septum. The introduction of laser-assisted methods signifies the advancement and innovation in this surgical realm. The severity of symptoms in patients with choanal atresia largely depends on whether the condition is unilateral or bilateral. In cases of bilateral atresia, neonates might present with immediate respiratory distress due to their obligatory nasal breathing pattern, making urgent intervention indispensable.

The modern-day application of lasers in treating choanal atresia traces its origins to Healy et al.’s [23] pioneering work in 1978, where a CO₂ laser was employed. Following this groundbreaking approach, a multitude of lasers, including Nd:YAG, holmium YAG, KTP, and contact diode lasers, have found their place in the surgical armamentarium [22].

The advantages of laser treatment include the ability to deliver the laser through the narrow nasal passage using endoscopy and ease of manipulation. However, similar success rates as other methods, concerns about restenosis due to thermal damage from heat, and potential complications are issues to consider when comparing it with alternative techniques.

While laser-assisted techniques offer a sophisticated approach to treating choanal atresia, they come with their own set of challenges. Surgeons must weigh the benefits against potential complications, ensuring patient safety and optimal postoperative outcomes. The selection of an appropriate surgical method should be based on individual patient presentation, surgeon expertise, and available resources.

Lasers have long been recognized in medical surgery for their precision and versatility. While their use is entrenched in head and neck surgery, the adaptation of lasers in rhinology, specifically for sinonasal tumor removal, remains relatively underutilized. This is primarily due to the ease of access and availability of alternative tools in the nasal cavity. However, emerging literature suggests potential roles for lasers in the management of sinonasal tumors.

A recent literature has reported the use of CO₂ lasers in sinonasal tumors [24]. Their benefits lie in their precision cutting and efficient hemostasis in small vessels. Although more time-consuming and pricier, recent studies suggest CO₂ lasers to be effective in tumor debulking and margin excision in cases of inverted papilloma and certain malignancies.

Diode lasers produce more heat, rendering them advantageous for achieving hemostasis. While they lack the sharp dissection prowess of the CO₂ lasers, their coagulative properties might be beneficial in some scenarios.

In another report, nine cases of sinonasal inverted papilloma were treated with KTP lasers [25]. Only one case experienced recurrence at 12 months and was successfully treated with the same method, with no further recurrence reported over an extended period.

There was an interesting application of laser in clival chordoma [26]. Authors introduced magnetic resonance imaging (MRI)-guided laser-induced thermal therapy and clival chordoma was completely treated. Under general anesthesia, a laser applicator was inserted into the tumor, and the patient was transferred to MRI room, where the laser ablation procedure was monitored in real-time via MRI. Four months after the procedure, the tumor had completely regressed.

While the use of lasers in sinonasal tumor management is still budding, initial findings underscore their potential. Their precise nature and minimal invasiveness make them an attractive option for specific cases. However, as with any emerging technology, further rigorous research is indispensable to establish their efficacy and safety fully and to broaden their scope in rhinology.

In conclusion, laser technology has etched a transformative path within the domain of rhinology, bringing forth enhanced precision, minimal invasiveness, and improved patient outcomes. Rhinologic disorders, ranging from allergic rhinitis to sinonasal tumors, have witnessed some benefits of laser-assisted interventions. While lasers have expanded the horizons of treatment options, they also pose unique challenges, including restenosis and varying success rates due to high thermal damage. Therefore, further research and innovation are imperative to harness the full potential of lasers in rhinology. With ongoing advancements, lasers can be poised to continue reshaping the landscape of rhinologic disease care, promising more effective, patient-centered, and minimally invasive solutions.

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Conceptualization: JHM. Data curation: SHY. Formal analysis: JHM. Funding acquisition: all authors. Investigation: all authors. Methodology: all authors. Project administration: all authors. Software: all authors. Validation: all authors. Visualization: all authors. Writing–original draft: all authors. Writing–review & editing: all authors.

No potential conflict of interest relevant to this article was reported.

This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Education [2021R1I1A1A01052298]. This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI22C0612).

This research was supported by the Bio&Medical Technology Development Program of the National Research Foundation (NRF) funded by the Korean government (MSIT) (RS-2023-00220408). This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (2020R1A2C1012105). This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2020R1A6A1A03043283).

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