Use of a laryngeal micro resector system

Safety of different surgical modalities for recurrent respiratory papillomatosis resection: A systematic review and meta-analysis

BACKGROUND

Currently, the most common surgical modalities used for recurrent respiratory papillomatosis (RRP) resection are microdebrider, carbon dioxide (CO₂ ) laser and potassium-titanyl-phosphate (KTP) laser. However, complication rates vary among different surgical modalities and have been controversial in different studies.

OBJECTIVE OF REVIEW

This study systematically reviews the available studies which reported intra-operative and post-operative complications, aiming to compare the safety of microdebrider, CO₂ laser and KTP laser.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

Seven electronic databases (PubMed/MEDLINE, EMBASE[Ovid], Scopus, Cochrane Library and Web of Science) were searched from inception through 28 April 2022. Randomised controlled, prospective or retrospective observational studies that recorded the complications of three different surgical modalities for RRP resection were included in the meta-analysis.

EVALUATION METHOD

Outcomes of interest were intra-operative and post-operative complications, and complication rate was calculated to evaluate the safety of surgical methods.

RESULTS

Twenty different studies were included in quantitative synthesis. Only one study compared outcomes of those three kinds of treatment modalities simultaneously, two studies compared microdebrider and CO₂ laser, and the remaining studies focussed on only one of three treatments. The weighted average complication rate for microdebrider was 0.03 (95% confidence interval [CI] 0.00-0.21), n = 6, for CO₂ laser treatment was 0.16 (95% CI 0.09-0.25), n = 14 and for KTP laser treatment was 0.04 (95% CI 0.00-0.14), n = 4.

CONCLUSION

The limited evidence demonstrated that CO₂ lasers in the surgical treatment of RRP may lead to more surgical complications, and microdebrider and KTP lasers may be safer. However, the heterogeneous data limit any strong comparison of outcomes of different treatment of laryngeal papillomas. Future randomised controlled trials that directly compare the safety of different surgical modalities are needed.

Pediatric bronchoscopy: recent advances and clinical challenges

Introduction: During the last 40 years equipment has been improved with smaller instruments and sufficient size working channels. This has ensured that bronchoscopy offers therapeutic and interventional options.Areas covered: We provide a review of recent advances and clinical challenges in pediatric bronchoscopy. This includes single-use bronchoscopes, endobronchial ultrasound, and cryoprobe. Bronchoscopy in persistent preschool wheezing and asthma is included. The indications for interventional bronchoscopy have amplified and included balloon dilatation, endoscopic intubation, the use of airway stents, whole lung lavage, closing of fistulas and air leak, as well as an update on removal of foreign bodies. Others include the use of laser and microdebrider in airway surgery. Experience with bronchoscope during the COVID-19 pandemic has been included in this review. PubMed was searched for articles on pediatric bronchoscopy, including rigid bronchoscopy as well as interventional bronchoscopy with a focus on reviewing literature in the past 5 years.Expert opinion: As the proficiency of pediatric interventional pulmonologists continues to grow more interventions are being performed. There is a scarcity of published evidence in this field. Courses for pediatric interventional bronchoscopy need to be developed. The COVID-19 experience resulted in safer bronchoscopy practice for all involved.

High Radiofrequency Surgery and Chromoendoscopy: A Novel Surgical Technique for the Treatment of Respiratory Papillomatosis

Recurrent Respiratory Papillomatosis is a highly recurrent and residual disease. The use of indigo-carmine chromoendoscopy increases the early detection of nonvisible disease and reduces the possibility of leaving residual lesions. The best chances of papillomatosis being eradicated depend upon a surgical shallow epitheliolysis approach applied to patients who have never been surgically damaged before. We developed a novel surgical technique based upon the use of a time controlled High Radiofrequency (HRF) energy output. We applied a three-step bloodless HRF-surgical technique, that is, epitheliolysis, angiolysis and peeling without the aid of adjunct therapies. It acts according to differences in the water density of the tissues. We use it to remove the epithelial viral reservoir thus preserving subepithelial layers. For this purpose, we designed and manufactured a custom-made HRF electrodes set for office and O.R. use. From 2005 to 2018, 39 patients (100%) with recurrent respiratory papillomatosis participated in the present prospective work. Twenty-five (64,10%) achieved complete postsurgical remission, 6 (15,38%) were lost to follow up, and 8 (20,51%) present partial remissions. Thirty-six patients had laryngeal papillomatosis. Follow-up was possible in 30 of the 36 patients with laryngeal papillomatosis with a success remission rate of 83,33% (25 of 30). Eleven of those 36 (30,55%) entered this study without previous surgical treatment and 9 of 11 (81,81%) were cured. Indigo-carmine chromoendoscopy, a visualization solution for papillomatosis detection, together with a bloodless HRF-surgical technique proved to be effective tools to eradicate papillomatosis. Voice restoration to normal or near normal levels was achieved in all patients.

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.

Powered Instrumentation in the Treatment of Tracheal Granulation Tissue for Decannulation

OBJECTIVE: To evaluate the outcomes of powered instrumentation tracheal surgery (PITS) in patients with tracheal granulation tissue following tracheostomy that caused or exacerbated airway obstruction and impeded decannulation.

STUDY DESIGN: Retrospective case review.

METHODS: Sixteen patients that accepted PITS for decannulation from tracheal granulation tissue were reviewed. The surgical procedure was performed with the assistance telescope connected to a television monitoring system. The success of PITS was defined as a decannulation for 3 months without a recurrence of airway obstruction.

RESULTS: The average operation time was 34 minutes. No complication was met in the perioperative period. Fourteen cases (87.5%) were successfully decannulated within 3 days following PITS. The 2 cases that failed successful decannulation had undergone insertion of a tracheal stent for their hindered tracheal stenosis.

CONCLUSIONS: The preliminary results reveal that the new operation modality, PITS, is a safe and simple method for the treatment of tracheal granulation tissue and could be a useful alternative for benign tracheal lesions.

Voice outcomes following endolaryngeal surgery; are we achieving our aims?

OBJECTIVE

To determine voice outcomes in endolaryngeal surgery.

METHODS

Prospective assessment of patients undergoing endolaryngeal surgery in one head and neck team in North Glasgow from 2007 to 2014. Each patient completed a VoiSS (the Voice Symptom Scale) questionnaire at pre-assessment and post-endolaryngeal surgery. Per-operatively, the aim of the procedure was recorded from a choice of seven options in addition to the clinical conditions and the procedure.

RESULTS

One thousand and sixty-six patient episodes were recorded. Thirty-two had incomplete data at pre-assessment and were excluded. Of the remainder, 703 (68%) had complete paired data sets. 'To improve voice' (n = 169, 24%) and 'to achieve a biopsy with no deterioration in voice' (n = 185, 26%) categories had significant outcomes in keeping with the operative aims.

CONCLUSION

This study demonstrated that it is possible to assess patient reported voice outcomes in universal heterogeneous endolaryngeal surgery cohort over a prolonged period. The voice outcomes were in keeping with the stated aims of the endolaryngeal surgical procedures.

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.

Microdebrider removal under suspension laryngoscopy: an alternative surgical technique for subglottic hemangioma

OBJECTIVE

To describe microdebrider removal of subglottic hemangiomas and evaluate the efficacy of this procedure.

METHODS

This retrospective study was conducted at an otorhinolaryngology department. Seven consecutive patients with subglottic hemangiomas who failed to respond to pharmacologic treatment were treated by microdebrider removal under suspension laryngoscopy. Respiratory symptoms and hemangioma status were assessed preoperatively and postoperatively.

RESULTS

The mean age of patients at disease onset was 68 days (range, 24-120 days), and their mean age at the time of surgical treatment was 132 days (range, 55-195 days). Their initial pharmacologic treatment included steroids, propranolol, and/or antibiotics. The mean percentage of airway obstruction was initially 36% (range, 30-50%), and this value changed to 61% (50-80) before surgery. Microdebrider removal of hemangiomas was successful in all patients without any intraoperative or postoperative complication. The mean operative time was 30 min (range, 21-47 min). Three patients required orotracheal intubation for 12 or 24h after surgery, and no reintubation or tracheotomy was required in this series. Symptoms such as stridor and inspiratory retraction were resolved approximately 72 h after surgery, but wheezing was generally resolved at a later time point. One year later, no respiratory symptom was noted in these patients, and endoscopic examination revealed a sufficient glottis opening.

CONCLUSIONS

Surgical removal with a microdebrider is advantageous as a routine surgical technique for small and moderate pediatric subglottic hemangioma.

Management of a rare case of arytenoid mucosa oedema inducing stridor and cough

OBJECTIVE

Current guidelines recommend a multidisciplinary systematic integrated approach to patient with chronic cough in which nowadays otolaryngologists play an increasingly valuable role as new procedures are used for evaluation and treatment. Surgery has been never taken into consideration to treat refractory chronic cough.

METHOD

We present a rare case of arytenoid mucosa oedema inducing stridor and cough, lasting 8 months, that critically affected the quality of life of a 15-year-old adolescent arrived to our emergency department with prominent arytenoid oedema causing paroxysmal cough and laryngeal stridor and that was successfully treated by laryngeal debridement.

RESULTS

In this case report we observed that prominent swelling of arytenoid mucosa might sustain a vicious cycle of cough persistence and that laryngeal surgical debridement might interrupt it resolving the particular clinical condition.

CONCLUSION

The description of this case could be of some help for clinicians to draw new insight about diagnosis and therapy of rare selected cases of chronic refractory cough.

Powered debridement of suprastomal granulation tissue to facilitate pediatric tracheotomy decannulation

OBJECTIVE

To compare suprastomal granulation tissue (SSGT) removal using the microdebrider with other common methods of excision.

METHODS

Retrospective review (n=21) of SSGT excision at a tertiary care pediatric hospital (2004-10). Outcome measures included intraoperative blood loss, operative time, decannulation rates, and complications.

RESULTS

10 children underwent excision of SSGT via powered SSGT debridement and 8 were decannulated (80% success rate). Of the other 11 patients who had manually non-powered techniques (kerrison rongeur, laryngeal microinstruments, or optical forceps), 7 were decannulated (63% success rate). Operative time was on average shorter than all other procedures, but not significantly (p=0.101). There was no significant difference in blood loss when powered debridement was compared to other techniques (p=0.872). There were no significant complications encountered in our patients who received SSGT powered debridement.

CONCLUSIONS

Endoscopic powered SSGT debridement is a simple and useful tool in the process of pediatric tracheotomy decannulation with superior decannulation rate, shorter operative time, and comparable blood loss to other techniques.

Trends in paediatric airway surgery: a move towards endoscopic techniques

The endoscope has long been an invaluable tool in assessment of the paediatric airway. Recently, its applications for definitive surgery of the airway have greatly increased, due to innovative surgical techniques, development of new instruments, improvements in anaesthesia and availability of new medications for endoscopic use. This review discusses the move towards endoscopic techniques in the management of paediatric airway disorders.

Design and Integration of a Telerobotic System for Minimally Invasive Surgery of the Throat

This paper presents the clinical motivation, design specifications, kinematics, statics, and actuation compensation for a newly constructed telerobotic system for Minimally Invasive Surgery (MIS) of the throat. A hybrid dual-arm telesurgical slave, with twenty joint-space Degrees of Freedom (DoF), is used in this telerobotic system to provide the necessary dexterity in deep surgical fields such as the throat. The telerobotic slave uses novel continuum robots that use multiple super-elastic backbones for actuation and structural integrity. The paper presents the kinematics of the telesurgical slave and methods for actuation compensation to cancel the effects of backlash, friction, and flexibility of the actuation lines. A method for actuation compensation is presented in order to overcome uncertainties of modeling, friction, and backlash. This method uses a tiered hierarchy of two novel approaches of actuation compensation for remotely actuated snake-like robots. The tiered approach for actuation compensation uses compensation in both joint space and configuration space of the continuum robots. These actuation hybrid compensation schemes use intrinsic model information and external data through a recursive linear estimation algorithm and involve compensation using configuration space and joint space variables. Experimental results validate the ability of our integrated telemanipulation system through experiments of suturing and knot tying in confined spaces.

Recurrent Respiratory Papillomatosis: A Longitudinal Study Comparing Severity Associated With Human Papilloma Viral Types 6 and 11 and Other Risk Factors in a Large Pediatric Population

OBJECTIVES/HYPOTHESIS

A database was developed for prospective, longitudinal study of recurrent respiratory papillomatosis (RRP) in a large population of pediatric patients. Data recorded for each patient included epidemiological factors, human papilloma virus (HPV) type, clinical course, staged severity of disease at each surgical intervention, and frequency of surgical intervention. The study hypothesizes that patients with HPV type 11 (HPV-11) and patients younger than 3 years of age at diagnosis are at risk for more aggressive and extensive disease.

STUDY DESIGN

The 10-year prospective epidemiological study used disease staging for each patient with an original scoring system. Severity scores were updated at each surgical procedure.

METHODS

Parents of children with RRP referred to the authors' hospital completed a detailed epidemiological questionnaire at the initial visit or at the first return visit after the study began. At the first endoscopic debridement after study enrollment, tissue was obtained and submitted for HPV typing using polymerase chain reaction techniques and in situ hybridization. Staging of disease severity was performed in real time at each endoscopic procedure using an RRP scoring system developed by one of the authors (B.J.W.). The frequency of endoscopic operative debridement was recorded for each patient. Information in the database was analyzed to identify statistically significant relationships between extent of disease and/or HPV type, patient age at diagnosis, and selected epidemiological factors.

RESULTS

The study may represent the first longitudinal prospective analysis of a large pediatric RRP population. Fifty-eight of the 73 patients in the study underwent HPV typing. Patients infected with HPV-11 were significantly more likely to have higher severity scores, require more frequent surgical intervention, and require adjuvant therapy to control disease progression. In addition, patients with HPV-11 RRP were significantly more likely to develop tracheal disease, to require tracheotomy, and to develop pulmonary disease. Patients receiving a diagnosis of RRP before 3 years of age had significantly higher severity scores, higher frequencies of surgical intervention, and greater likelihood of requiring adjuvant medical therapy. Patients with Medicaid insurance had significantly higher severity scores and required more frequent surgical debridement. Birth by cesarean section appeared to be a significant risk factor for more severe disease and necessity of more frequent surgical intervention.

CONCLUSION

Statistical analysis of the relationships among epidemiological factors, HPV type, and clinical course revealed that patients with HPV-11 and patients younger than 3 years of age at RRP diagnosis are prone to develop more aggressive disease as represented by higher severity scores at endoscopic debridement, more frequent operative debridement procedures per year, a greater requirement for adjuvant therapy, and greater likelihood of tracheal disease with tracheotomy.

Applications of robotics for laryngeal surgery

The authors present the clinical application of robotics to laryngeal surgery in terms of enhancement of surgical precision and performance of other minimally invasive procedures not feasible with current instrumentation. Presented in this article are comparisons of human arm with robotic arm in terms of degrees of freedom and discussion of surgeries and outcomes with use of the robotic arm. Robotic equipment for laryngeal surgery has the potential to overcome many of the limitations of endolaryngeal procedures by improving optics, increasing instrument degrees of freedom, and modulating tremor. Outside of laryngology, a multi-armed robotic system would have utility in microvascular surgery, procedures at the base of the skull, sinus surgery, and single-port gastrointestinal and thoracic access surgery.

Cidofovir efficacy in recurrent respiratory papillomatosis: a randomized, double-blind, placebo-controlled study

OBJECTIVES

We performed a prospective, double-blind, placebo-controlled, longitudinal adjuvant therapy trial to determine the efficacy of cidofovir in the treatment of severe recurrent respiratory papillomatosis (RRP). Although results of case series suggest that cidofovir may decrease the frequency and rapidity of papilloma regrowth, no blinded placebo-controlled studies have demonstrated efficacy.

METHODS

Adults and children (n = 19) with aggressive RRP received either active drug (cidofovir) or placebo. When surgical intervention was needed, drug or placebo was injected into affected areas after surgical removal of disease. The following measures were made at baseline and at 2-month intervals for the course of 12 months: Derkay papilloma severity grading scale, Voice Handicap Index, Health-Related Quality of Life, and total number of procedures performed over 12 months.

RESULTS

At 2- and 12-month follow-ups, there was a significant (p < .05) improvement in the Derkay Severity Score within the cidofovir and placebo groups, but no difference between groups, and no difference between groups in the number of procedures performed. Significant improvement was found in Voice Handicap Index scores in the cidofovir group at the 12-month follow-up. No differences were seen in Health-Related Quality of Life.

CONCLUSIONS

A randomized, blinded, placebo-controlled trial is necessary in the study of RRP, because the natural history of the disease can include remissions and reactivations. We found a significant improvement in the Derkay Severity Score 12 months after the baseline assessment in patients treated with cidofovir. This effect, however, was also seen in the placebo group. Accordingly, we were unable to provide proof of efficacy of cidofovir in the treatment of RRP.

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.

Endoscopic resection of laryngeal and tracheal lesions using the microdebrider

CONCLUSION

Endoscopic resection of laryngeal and tracheal lesions using the microdebrider is a safe, accurate and reliable method.

OBJECTIVE

The microdebrider is an important tool for endoscopic nasal and sinus surgery and over the last few years a powered blade with a long shaft has been developed for endoscopic laryngeal and tracheal surgery. The aim of this non-randomized prospective study was to determine the advantages and disadvantages of the microdebrider for treating patients with different laryngeal and tracheal pathologies.

MATERIAL AND METHODS

The laryngeal microdebrider was used under endoscopic control in 37 patients. In 29 cases a benign laryngeal lesion was removed endoscopically. In four patients debulking of a malignant obstructive endolaryngeal tumor was performed in order to avoid a tracheotomy. In four cases a bulky obstructing endotracheal lesion was removed.

RESULTS

All laryngotracheal lesions could be removed, and this was facilitated by the use of angled rigid telescopes and the laryngeal blade. No traumatic lesions to normal laryngeal tissue occurred as a result of use of the microdebrider and no postoperative endolaryngeal bleeding was observed. The histological diagnosis of the biopsies taken with the microdebrider was accurate in every case. In three of the four cases with obstructive laryngeal malignancies, a tracheotomy was avoided until definitive therapy was undertaken. Normal breathing was restored in all patients with endotracheal lesions.

Central Airway Obstruction

Central airway obstruction is a problem facing all medical and surgical subspecialists caring for patients with chest diseases. The incidence of this disorder appears to be rising because of the epidemic of lung cancer; however, benign causes of central airway obstruction are being seen more frequently as well. The morbidity is significant and if left untreated, death from suffocation is a frequent outcome. Management of these patients is difficult, but therapeutic and diagnostic tools are now available that are beneficial to most patients and almost all airway obstruction can be relieved expeditiously. This review examines current approaches in the workup and treatment of patients suffering from airway impairment. Although large, randomized, comparative studies are not available, data show significant improvement in patient outcomes and quality of life with treatment of central airway obstruction. Clearly, more studies assessing the relative utility of specific airway interventions and their impact on morbidity and mortality are needed. Currently, the most comprehensive approach can be offered at centers with expertise in the management of complex airway disorders and availability of all endoscopic and surgical options.

Overview of recurrent respiratory papillomatosis

PURPOSE OF REVIEW

The purpose of this article is to review recent literature regarding pediatric recurrent respiratory papillomatosis (RRP) published within the last year. By reviewing and assessing these articles, a more clear understanding regarding the etiology and management of pediatric RRP can be obtained, allowing physicians to better care for their pediatric RRP patients.

RECENT FINDINGS

Pediatric RRP continues to be an extremely difficult management problem for otolaryngologists. This disease process continues to be a significant burden on the health care system and is a significant cause of morbidity in affected patients and their families. The incidence of RRP continues to be approximately 3.96 per 100,000 in the pediatric population. It has been noted recently that approximately 7 of every 1000 children born to mothers with vaginal condyloma develop pediatric RRP. Although the mainstay of surgical management has traditionally been the CO2 laser, newer surgical techniques have demonstrated efficacy in the management of pediatric RRP patients, including powered instrumentation and the pulse-dye laser. The traditional adjuvant medical therapies used for pediatric RRP continue to be commonly used, including interferon-alpha2a, retinoic acid, and indol-3-carbinol/diindolylmethane (I3C/DIM). Recently cidofovir has demonstrated efficacy in selected patients. In addition, current research regarding vaccine therapy for pediatric RRP has shown promise. Basic science research in the field of immunology has demonstrated multiple defects in cell-mediated immunity, which has shed further light on the etiology of pediatric RRP.

SUMMARY

Pediatric RRP continues to be a highly morbid disease process. New surgical and medical therapies offer hope for better control of this disease in affected patients. Recent advances in immunologic research offer the hope of immune system modulation and augmentation as potential future treatment modalities to better control this disease process.

Intralesional cidofovir and surgical excision for laryngeal papillomatosis

OBJECTIVE

To evaluate the efficacy of cidofovir intralesional therapy in recurrent respiratory papillomatosis and the role of surgical excision as an associated treatment.

STUDY DESIGN

Prospective study and case series.

METHOD

Twenty-six patients received intralesional cidofovir. Three endoscopies were performed at monthly intervals, with intralesion injections of cidofovir at 5 mg/mL. Further endoscopic evaluation was made at 3 or 6 months depending on whether there was persistent papillomatosis. Cidofovir was again injected in the case of persistent papillomas, and treatment was repeated as long as papillomas were observed. Surgical excision of the papilloma was only performed in cases of airway obstruction or in cases proving resistant to cidofovir.

RESULTS

Complete remission was obtained in 8 (31%) patients after an average of 2.6 endoscopic treatment. Seventeen (65%) patients presented slight or mild disease at endpoint (final severity score 1-4). Significant results were obtained in both adults and children. A greater response was obtained in the supraglottis and glottis subsites than in subglottis, tracheal, and other sites. Patients conforming to the 1 month interinjection schedule showed better responses in supraglottis subsite than those receiving their injections with intervals longer than 1 month. Combined therapy (cidofovir plus excision) was necessary in persistent papillomas. No patients presented with any systemic or local side effects.

CONCLUSIONS

Cidofovir therapy was an effective treatment in adults and in children, allowing papillomatosis to be controlled without observed side effects. Surgical excision associated with cidofovir injections remained necessary in persistent papillomatosis after cidofovir treatment.

Disorders of phonation in children

Vocal disturbances in children are surprisingly common. Typical pathologic conditions differ, however, from those that are seen commonly in adults. Disturbances in the vibratory characteristic of the vocal folds cause dysphonia. The most common causes for dysphonia are infectious, anatomic, congenital, inflammatory, neoplastic, neurologic, or iatrogenic in nature. A child who presents with hoarseness demands a rapid and thorough assessment. Fine points during the history may provide the clinician with clues as to the correct etiologic category. Proper treatment requires an accurate diagnosis. Although some conditions are similar in the adult larynx, treatment of the pediatric larynx often differs. An understanding of the changing and growing pediatric larynx is necessary for treatment and satisfactory results.

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.

Pharmacotherapy of recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is a disease which affects both children (juvenile-onset RRP) and adults (adult-onset RRP). While a greater amount of information is known about the epidemiology of juvenile-onset than adult-onset RRP, fundamental work is still needed to more fully describe areas such as the mode of transmission. The primary management approach focuses on the removal of the papillomas by surgical debulking, although persistence of the human papillomavirus genome and subsequent recurrence of disease is the typical outcome. In a minority of patients, surgical management must be supplemented with adjuvant medical therapy, with IFN being the best studied and most commonly used. Other adjuvant treatments being employed include photodynamic therapy, indole-3-carbinol, ribavirin and cidofovir. Large controlled trials are lacking for all but IFN, making it extremely difficult to assess clinical benefit and risk in a systematic fashion at the current time. As with surgical management, viral persistence occurs following treatment with these adjuvant modalities, further contributing to the challenge of managing patients with this potentially devastating disease.

Recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is the most common benign neoplasm of the larynx in children. Despite its benign histology, RRP has potentially morbid consequences and is often difficult to treat because of its tendency to recur and spread throughout the respiratory tract. Long neglected from an epidemiological standpoint, recent initiatives to better understand this disease process have been launched through coordination between the Centers for Disease Control and Prevention and the American Society of Pediatric Otolaryngology. In this clinical review, I discuss what we currently know regarding the etiology, epidemiology, and transmission of this disease. Clinical features including pertinent aspects of the history, physical examination, airway endoscopy, and other considerations are highlighted. A detailed description of the surgical and anesthetic management of these challenging cases is presented. Adjuvant modalities of surgical and nonsurgical treatment and their indications are discussed. Ongoing research initiatives and the Practice Guidelines of the Recurrent Respiratory Papillomatosis Task Force are also included.

Powered laryngeal shavers and laryngeal papillomatosis: a preliminary report

Carbon dioxide (CO2) laser ablation is widely accepted as the most effective first line surgical treatment of recurrent laryngeal papilloma. However, vaporization of papilloma with the CO2 laser exposes the patient and staff to a potentially infective plume. Furthermore, unsuitable pathological tissue specimens and scarring of the surrounding laryngeal architecture are inevitable consequences of the thermal energy generated by this instrument. Following their innovative use in endonasal surgery, powered laryngeal microresecting instruments (Xomed Shavers) have been developed for laryngeal surgery. We assessed the value of these new instruments in five patients who had previously undergone laser ablation. All of the patients reported that their postoperative recovery was the 'same as' or 'better than' that following laser surgery. The surgeon reported that though there was more bleeding, shaver excision of papilloma provided good clearance of disease; easy collection of pathological samples; and a potentially safer and faster alternative to laser excision.

Medical and surgical treatment of pediatric dysphonia

The production of sound for communication is the last of the prime functions of the larynx, yet it is its most salient feature. Pediatric dysphonia may be caused by a variety of general causes. These causes may be classified as infectious, anatomic, congenital, inflammatory, neoplastic, neurologic, and iatrogenic. When a child presents with hoarseness, a complete assessment is necessary. Fine points during the history and physical may help distinguish between those pathologic conditions found in these general categories.