Powered laryngeal shavers and laryngeal papillomatosis: a preliminary report

Low-temperature radiofrequency coblation reduces treatment interval and post-operative pain of laryngotracheal recurrent respiratory papillomatosis

Laryngeal papillomatosis is a benign disease in the larynx but with the potential to develop into significant complications as a result of its high recurrence rate. CO₂ laser and radiofrequency controlled ablation (coblation) have been used to treat recurrent respiratory papillomatosis, but detailed comparisons of their respective treatment outcomes are not fully investigated. This retrospective study examines the procedure time, time interval between interventions, blood loss during operation, post-operative complications and pain scores among patients who received either CO₂ laser or radiofrequency coblation interventions for laryngotracheal recurrent respiratory papillomatosis. Compared with CO₂ laser intervention, radiofrequency coblation significantly reduced operation time, time interval between interventions, blood loss during operation and number of times bipolar electrocoagulation needed in each procedure. Post-operatively, pain scores after radiofrequency coblation were significantly lower than those after CO₂ laser intervention. Incidence rates of post-operative complications, in terms of palate pharyngeal mucosa damage, bleeding and subcutaneous emphysema, were also significantly reduced after radiofrequency coblation. Low-temperature radiofrequency coblation is a superior intervention compared with CO₂ laser against laryngotracheal recurrent respiratory papillomatosis.

Expanding Applications for the Microdebrider in Pediatric Endoscopic Airway Surgery

OBJECTIVE: The microdebrider has been described for treating laryngeal papillomas, but there are no reports of other uses for this instrument in the pediatric airway. The objective of this article is to describe expanding applications for the microdebrider in pediatric airway surgery.

STUDY DESIGN AND SETTING: Retrospective review, tertiary care academic institution.

RESULTS: The microdebrider was used in 75 pediatric airway procedures. Twenty-two of these cases involved novel, previously unreported applications of the microdebrider.

CONCLUSIONS: The microdebrider can be used safely and effectively for a variety of pediatric airway pathologies, including papillomas, granulations, and stenoses from the larynx to the distal trachea.

SIGNIFICANCE: Correct usage of the various tip configurations on the microdebrider has made management of many airway lesions commonly encountered by pediatric otolaryngologists safer, more expedient, and simpler than management by other methods. In our practice, this instrument largely has supplanted the use of the CO2 laser and some open approaches for pediatric airway lesions.

Management of complex glottic stenosis in children with recurrent respiratory papillomatosis

OBJECTIVES

To describe our management of complex glottic stenosis in tracheotomy dependent children with severe recurrent respiratory papillomatosis.

METHODS

Retrospective chart review at a tertiary care children's hospital.

RESULTS

Three children with complex glottic stenosis secondary to severe recurrent respiratory papillomatosis were treated at our institution since 2011. Two patients had complete stenosis, and the third had near-complete stenosis. Two patients were managed using balloon dilation alone, and the third also underwent laryngotracheal reconstruction with posterior costal cartilage grafting. Two patients have been successfully decannulated and the third has been tolerating continuous tracheotomy capping for greater than twelve months. All three patients underwent aggressive debridement of papillomatosis and balloon dilation every 4-6 weeks until their burden of disease was controlled. In two patients, the glottic airway was patent, and the third continued to have complete restenosis between procedures and required laryngotracheoplasty with multiple post-operative dilation procedures to establish an adequate glottic airway.

CONCLUSIONS

Severe laryngeal stenosis is a well-described complication of recurrent respiratory papillomatosis, but its management is not well-defined. Aggressive management of papillomatosis with frequent debridement is critical in successfully managing laryngeal stenosis. Balloon dilation alone may be surprisingly effective in these patients, and laryngotracheoplasty can be used as an adjunct procedure in those patients who fail balloon dilation. Given the quality of life issues and concerns regarding distal spread of disease with tracheotomies in these patients, we feel that aggressive management and early decannulation is in the patient's best interest.

Radiofrequency coblation for treatment of advanced laryngotracheal recurrent respiratory papillomatosis

Background:

A variety of treatment modalities are currently used to treat recurrent respiratory papillomatosis. We aimed to study the efficacy of radiofrequency cold ablation (coblation) for the treatment of laryngotracheal recurrent respiratory papillomatosis, by comparing treatment intervals for coblation and CO2 laser vaporisation.

Method:

Retrospective case series of adult patients with advanced laryngotracheal recurrent respiratory papillomatosis.

Results:

Six patients were treated for at least two years by CO2 laser vaporisation with or without intralesional cidofovir. All six subsequently underwent treatment with radiofrequency coblation with or without intralesional cidofovir. Coblation resulted in longer periods between interventions, compared with CO2 laser (p = 0.03).

Conclusion:

Radiofrequency coblation appears to be an attractive alternative technique to CO2 laser for the surgical treatment of advanced laryngotracheal papillomata.

Juvenile recurrent respiratory papillomatosis: still a mystery disease with difficult management

Juvenile recurrent respiratory papillomatosis (RRP) is the most common benign neoplastic disease of the larynx in children and adolescents and has a significant impact on patients and the health care system with a cost ranging from $60,000 to $470,000 per patient. The aim of this paper is to review the current literature on RRP and summarize the recent advances. RRP is caused by human papillomavirus (HPV; mainly by types 6 and 11). Patients suffer from wart-like growths in the aerodigestive tract. The course of the disease is unpredictable. Although spontaneous remission is possible, pulmonary spread and malignant transformation have been reported. Surgical excision, including new methods like the microdebrider, aims to secure an adequate airway and improve and maintain an acceptable voice. Repeated recurrences are common and thus overenthusiastic attempts to eradicate the disease may cause serious complications. When papillomas recur, old and new adjuvant methods may be tried. In addition, recent advances in immune system research may allow us to improve our treatment modalities and prevention strategies. A new vaccine is under trial to prevent HPV infection in women; the strongest risk factor for juvenile RRP is a maternal history of genital warts (transmitted from mother to child during delivery). Better understanding of the etiology of the disease and the knowledge of all available therapies is crucial for the best management of the affected patients.

Microdebrider removal of tracheal papilloma via tracheostomy in the child with an obliterated larynx

In children, recurrent respiratory papillomatosis is the most common benign neoplasm of the airway. The disease frequently involves the larynx and may spread to extralaryngeal sites. Use of a microdebrider has been suggested as a safe and low-cost technique which reduces operating time, compared with laser removal of laryngeal lesions.

We describe a technique for using a microdebrider to remove tracheal papillomas when the larynx is obliterated with the disease.

Treatment of recurrent respiratory papillomatosis in children with the microdebrider

The mainstay of treatment of children with recurrent respiratory papillomatosis has been CO2 laser laryngoscopy. Powered microdebriders allow precise removal of laryngeal lesions without thermal damage. The microdebrider may reduce costs by reducing operative time and limiting the need for expensive laser-related equipment. To compare the use of the microdebrider with that of the CO2 laser in children undergoing surgery for recurrent respiratory papillomatosis, we retrospectively reviewed the charts of 18 patients from 2 institutions covering a treatment period between December 1998 and October 2001. These patients were initially treated with the CO2 laser, but were switched to microdebrider resection during the review period. We recorded the number of procedures, the technique(s) of resection used, and the operative time for each procedure. We identified 18 patients, 11 male and 7 female, ages 18 months to 14 years. A total of 127 procedures were performed with the CO2 laser, and a total of 50 procedures were performed with the microdebrider. The mean number of procedures per patient was 10 (range, 2 to 17 procedures). The mean surgical time per procedure using the CO2 laser was 59.2 minutes (range, 8 to 130 minutes). The mean time per procedure with the microdebrider was 32.4 minutes (range, 12 to 47 minutes). This reduction in operative time was clinically and statistically significant (p = .0001, unpaired Student's t-test). We concluded that microdebrider resection of laryngeal papilloma in children allowed more rapid surgery with potentially reduced treatment costs. Other advantages of this technique include precise excision without thermal injury. Our report details useful refinements of technique with the microdebrider.

Microdebrider versus CO2 laser removal of recurrent respiratory papillomas: a prospective analysis

OBJECTIVE

To compare postoperative patient discomfort, voice quality, and procedure time and cost for removal of recurrent respiratory papillomas using the microdebrider versus the CO2 laser.

STUDY DESIGN

A randomized prospective study comparing children undergoing excision of recurrent respiratory papillomas by CO2 laser versus excision by microdebrider.

METHODS

For the 6-month study, patients for whom removal of recurrent respiratory papillomas was indicated were randomly assigned by birth year to microdebrider or CO2 laser therapy. Disease severity was scored as the sum of ratings of 1+ (minimal), 2+ (moderate), or 3+ (severe) for involvement of 27 areas of the aerodigestive tract by direct microlaryngoscopy immediately before treatment. Parents scored patient discomfort and improvement in voice quality 24 hours after surgery, using a 5-point (0 = no pain; 4 = worst pain) and a 10-point (1 = minimal change; 10 = significant improvement) scale, respectively.

RESULTS

Nineteen patients ranging in age from 2.5 to 20 years underwent 32 procedures in all. Groups did not differ significantly in age, sex, or severity of disease. For disease of equivalent severity, microdebrider treatment was associated with equivalent 24-hour-postoperative pain scores, greater improvement in voice quality, shorter procedure times, and lower overall procedure cost.

CONCLUSIONS

Immediate postoperative results indicate that the microdebrider may be as safe as and, at some institutions, might be more cost-effective than the CO2 laser for removal of recurrent respiratory papillomas.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is a relatively rare disease caused by members of the human papilloma virus family. Lesions may occur anywhere throughout the respiratory tract but show a predilection for squamo-columnar epithelial junctions, frequently leading to hoarseness and upper airway obstruction. Rarely, it can progress to squamous cell carcinoma. The impact of recurrent respiratory papillomatosis on patients, their families, and the health care system is considerable. Unfortunately, despite extensive investigational studies, no cure is available for the disease. This article reviews the aetiology of and therapeutic options for recurrent respiratory papillomatosis.