Carbon dioxide laser debulking for obstructing endolaryngeal carcinoma: a 10-year experience

Strategies for CO2 Laser Use in Laryngeal Microsurgery: A Systematic Review

OBJECTIVE

We aim to systematically review the literature addressing perioperative practices for optimal use of the CO2 laser in laryngeal transoral laser microsurgery (TOLMS), with a focus on safety.

DATA SOURCES

A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials which evaluated perioperative strategies for the use of CO2 laser in laryngeal TOLMS was conducted.

REVIEW METHODS

Records obtained from the search strategy were assessed for eligibility in a 2-step process by 2 independent researchers using the Covidence software.

RESULTS

Among 2143 identified records, 103 were included in this study. The majority of studies (n = 25) focused on the use of the CO2 laser in oncologic resection, while 20 addressed the treatment of vocal cord paralysis, 16 discussed the treatment of pediatric or congenital pathologies, 11 detailed the management of benign lesions, and 31 studies tackled other surgical indications. Strategies for safe CO2 TOLMS were highly heterogeneous across studies and included preoperative measures (ie, related to the environment, staff preparation, patient protection, and ventilation), intraoperative precautions (ie, protection of nontarget structures, technical considerations, topical and systemic medications), and postoperative strategies (ie, related to airway protection, oral intake, vocal rest, hospitalization duration, drug regimen, and consultant follow-up).

CONCLUSION

The results provided in this study can be used as a framework to guide the creation of laser safety protocols across institutions, guide quality improvement initiatives, the development of simulation training activities, and as a tool to facilitate resident teaching and skill assessment.

Debulking obstructing laryngeal cancers to avoid tracheotomy

Introduction

Upper airway obstruction, secondary to neoplasms presenting with stridor, is traditionally treated by tracheostomy. However, this common procedure can potentially have an impact on the long-term outcome, with tumor implantation into the tracheostomized wound leading to peristomal recurrence after laryngectomy, with the risk of stomal recurrence.

Objective

To describe our clinical experience with tumor debulking as an alternative treatment choice of tracheotomy in patients with advanced larynx cancer at a tertiary referral center.

Methods

A retrospective chart review of 87 subjects who had advanced larynx cancer (T3/4) with airway obstruction from our institutional database was conducted. Medical records including demographics, daily notes during hospitalization, and operative notes were used for clinical data of patients. The strategy for maintaining the airway patency was tracheotomy (emergency or awake) and tumor debulking (laser or coblation). Endophytic and exophytic laryngeal tumors were also noted.

Results

In 41/87 (47.1%) patients, a tracheotomy was performed as an initial treatment (11 were emergency, 30 were planned) to maintain airway patency. Tumor debulking was performed in 28 exophytic and 18 endophytic lesions by laser or coblation (17 and 29 patients, respectively). Tracheotomy was performed in 5 patients (4 endophytic, 1 exophytic) who could not tolerate debulking surgery due to aspiration, edema and dyspnea. Three of the them who required subsequent tracheotomy was in the laser group and two in the coblation group. The success rate of laser debulking was 82.35% (14/17) and 93.1% (27/29) for coblation.

Conclusion

Tumor debulking is a safe and effective method to avoid awake tracheotomy in patients suffering from airway obstruction due to advanced larynx cancer.

Cervical emphysema: an unusual presentation of laryngeal cancer

BACKGROUND

Acute respiratory decompensation can occur on a background of slowly progressive airway compromise, for example in laryngeal squamous cell cancer. Surgeons in ENT, together with anaesthetists, are often asked to evaluate airway risk and as yet there is no widely adopted standardised approach.

CASE REPORT

This paper reports the case of an 82-year-old male, who presented with acute airway compromise due to both endolaryngeal obstruction from a squamous cell cancer and extralaryngeal compression from massive subcutaneous emphysema.

RESULTS

Primary total laryngectomy was performed, but the patient declined adjuvant radiotherapy. He died a year later from a heart attack without evidence of recurrence.

CONCLUSION

To the best of our knowledge, this is the first case report of acute airway compromise from extralaryngeal subcutaneous emphysema secondary to laryngeal cancer. Options for acute airway management are discussed.

Endoscopic airway management of acute upper airway obstruction

The conventional treatment for patients with acute upper airway obstruction is tracheostomy, which is a safe, definitive procedure in most hands. Alternatively, a debulking procedure can be considered but this requires both surgical and anaesthetic skill and expertise. However, where possible, it provides a good alternative with the advantages of removing the cause of obstruction and yielding tissue for histopathological analysis, and avoiding the need for a tracheostomy, with its associated morbidity. We evaluated all patients who presented with acute upper airway obstruction and underwent endoscopic laser debulking surgery performed by the senior author, over a three and a half year period. We recorded patient demographic data, their underlying pathologies, complication rates associated with laser debulking surgery and the conversion to tracheostomy. Thirty patients were identified, including 19 males and 11 females, with a mean age of 57.10 ± 17.20 years (19-93 years). All patients underwent debulking procedures with carbon dioxide laser under general anaesthetic. All patients had their underlying diagnosis confirmed from their debulking surgery. Twelve patients were found to have benign pathology and 18 had malignant airway obstruction. There were no laser-associated complications. One patient required conversion to emergency tracheostomy, during their debulking surgery. Endoscopic laser assisted debulking surgery has successfully been used to establish a safe airway. It allows obtaining tissue specimens, to confirm the underlying diagnosis, thus avoiding the need for further biopsies under anaesthetic. For all malignant cases, patients were subsequently able to proceed to definitive treatment. It has obviated the need for emergency tracheostomy in almost all of the cases in our patient cohort.

Living with head and neck cancer and coping with dying when treatments fail

Palliative care in patients who have head and neck cancer is a complex topic that requires a multifaceted approach. The head and neck surgeon has an important duty to fulfill in managing and following the wishes of the incurable cancer patient and is obligated to direct them to the appropriate services in this challenging time.

Laser debulking in malignant upper airway obstruction

BACKGROUND

The conventional treatment for patients with upper airway obstruction secondary to malignancy is a tracheostomy. Although this effectively resolves the problem, a tracheostomy can be associated with complications and is irreversible in most patients. An alternative is to debulk part of the tumor causing airway obstruction to maintain the airway until the definitive procedure.

METHODS

The clinical course of 43 patients who underwent laser debulking for airway obstruction caused by laryngeal or hypopharyngeal malignancies was retrospectively studied. We present our technique of laser debulking and the efficacy of the procedure in avoiding a tracheostomy.

RESULTS

Fourteen patients who underwent this procedure received palliative treatment only. The number of debulking procedures per patient ranged from one to six, with a mean of 1.9 episodes. Although these patients had a higher comorbid burden, none were thought unsuitable for the procedure. A tracheostomy was avoided in 91% of patients. No laser-related complications were encountered.

CONCLUSIONS

Laser debulking is a viable alternative to tracheostomy in patients with malignant upper airway obstruction.

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.