CO₂ laser has been a traditional treatment for RRP. It has an emission wavelength of 10,600 nm and is absorbed by intracellular water. Therefore CO₂ laser , when coupled to an operating microscope, can effectively vaporize RRP lesions with precision, resulting in minimal bleeding. Dedo reported a series of 244 patients with RRP treated with CO₂ laser every 2 months (Dedo and Yu 2001). He achieved disease remission in 37% of his patients, disease clearance (no recurrence in 3 years) in 6%, and cure of disease (no recurrence in 5 years) in 17%.

Laser safety precautions are paramount in the OR. The laser beam can reflect off metal from the laryngoscope and injure eyes or skin in it’s path. A misfire may also hit patient tissue(s) that are not protected by a wet towel to absorb the laser energy. In addition, laser smoke, or plume, has been found to contain active viral DNA, which is a potential source of infection (Kashima et al. 1991). In the oxygen-rich environment provided by anesthetic gases, airway fire can be a possibility. Low FiO₂ setting (<30%) should be utilized when at all possible. Saline pledgets are placed in the airway to protect the endotracheal tube. The patient’s face is wrapped with wet towels. All OR personnel should wear laser safety goggles. Smoke evacuators are necessary to further reduce laser plume. Laser warning signs are posted outside the OR door. Disadvantage of the CO₂ laser includes thermal injury to the surrounding normal tissue, with a theoretical risk of implanting viral particles into those areas. CO₂ laser has long been considered a workhorse in otolaryngology. Recent advances in technology including micromanipulators and scanning laser delivery systems have made it into a more powerful operative tool in laryngologic procedures. The use of a CO₂ laser requires the laser to be used frequently by the surgeon and well maintained by the laser team at its facility.

Photoangiolytic lasers such as the KTP selectively ablate the papilloma microvasculature with limited thermal injury to the surrounding tissue due to their selective absorption by oxyhemoglobin. KTP was first reported as a treatment modality for RRP during microlaryngoscopy under general anesthesia in 2007 (Burns et al. 2007). This study described 35 procedures performed on 23 patients. Approximately 80% of the cohort achieved more than 90% disease regression with no new laryngeal webbing. Typically KTP laser settings in the OR are the same as office-based settings as described previously. Standard laser safety precautions should apply (see above). KTP end-tissue effects are recorded as described in office-based procedures.

Powered instrumentation for RRP removal first came into use in the early 2000s. Two studies have shown that the microdebrider reduced operative time and caused minimal soft tissue effects (El-Bitar and Zalzal 2002; Patel et al. 2003). Microdebriders allow removal of laryngeal RRP lesions without causing thermal damage. Collection of specimens is available if the tissues are captured in a filtration sock placed on the suction apparatus. The specimens are collected piecemeal rather than en bloc. Nonetheless the tissues obtained through a microdebrider have been shown to be suitable for pathological diagnosis (McGarry et al. 1997), and it is routinely done in endoscopic sinus surgery. There is no plume exposure compared to CO₂ laser treatment. In addition, microdebrider has been associated with equivalent postoperative pain and improved voice quality compared to CO₂ laser (Pasquale et al. 2003). It may also result in cost savings as expensive laser equipment and personnel are not required. Bleeding intraoperatively can be controlled by submucosal infusion of epinephrine prior to surgical excision or application of epinephrine-soaked pledgets on the surgical site post lesion removal. The smallest microdebrider blade should be used first. The authors typically use a 2.9-mm Skimmer blade (Medtronic^®, Minneapolis, Minnesota). The microdebrider should have a starting setting of 500 rpm and can be adjusted accordingly. The microdebrider blade should be held approximately 1–2 mm over the RRP lesion, allowing the suction from the microdebrider to draw the RRP tissue toward the blade and therefore away from the underlying deep tissue. This technique is great for bulky, pedunculated RRP lesions. Its main disadvantage is that the instrument is large in size and sometimes it may obstruct the operative view. When used with great control and good visualization, precision RRP removal can be achieved.