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The Application of the Potassium-Titanyl-Phosphate (KTP) Laser in the Management of Subglottic Hemangioma
David Madgy, DO;
Syed F. Ahsan, MD;
Darren Kest, DO;
Ira Stein, MD
Arch Otolaryngol Head Neck Surg. 2001;127:47-50.
ABSTRACT
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Background Subglottic hemangioma is the most common neoplasm of the infant airway.
Most lesions involute spontaneously; however, some may grow to cause life-threatening
respiratory tract distress. The standards of treatment have been tracheotomy,
corticosteroids, and laser vaporization. However, use of the carbon dioxide
laser has been associated with increased risk of damage to adjacent mucosa
and an increased risk for the development of subglottic stenosis postoperatively.
Objective To review our experience with the use of the potassium-titanyl-phosphate
laser in the treatment of subglottic hemangioma.
Patients and Methods A retrospective review of 6 patients with subglottic hemangioma treated
with the potassium-titanyl-phosphate laser was carried out at a tertiary care
children's hospital. Patients' medical charts were evaluated for factors such
as age, sex, degree of airway obstruction, location of hemangioma, number
of laser procedures performed, and postoperative results, including short-
and long-term complications.
Results All 6 patients had significant relief of airway obstruction after use
of the potassium-titanyl-phosphate laser. Five of the patients had localized
disease, and one had circumferential subglottic involvement. The average number
of procedures was 1.7. There were no intraoperative complications. One patient
had prolonged intubation following surgery, and only one developed grade 1
subglottic stenosis requiring dilation. Long-term results have been promising
in that all patients are asymptomatic and follow-up laryngoscopy and bronchoscopy
have shown complete resolution of the hemangioma.
Conclusion The potassium-titanyl-phosphate laser can be used to provide significant
clinical relief of airway obstruction due to grade 1 and 2 subglottic hemangioma,
with minimal complications.
INTRODUCTION
SUBGLOTTIC hemangioma is considered one of the most common neoplasms
of the infant airway. As opposed to a vascular malformation, which is a collection
of abnormal vessels forming a lesion that is present at birth and grows with
the child, a hemangioma is a vascular tumor that enlarges by rapid proliferation
of epithelial cells and is usually not present at birth.1
These lesions can undergo cellular growth, vascularization, ulceration, hyperkeratosis,
and, rarely, malignant change.2
Infantile subglottic hemangioma usually presents with stridor during
the first 6 months of life and can cause life-threatening respiratory tract
distress. It has been estimated that approximately 1.5% of all congenital
laryngeal anomalies are hemangiomas. However, this may be an underestimation.
The mean age at diagnosis is between 3 and 4 months. Girls are affected twice
as often as boys. There is no hereditary predisposition, and the condition
is rare in the African American population.3
Brodsky et al4 observed that a cutaneous
hemangioma was present in 50% of patients with subglottic hemangioma. The
natural history of this disorder consists of a phase of rapid growth during
the first 8 months of life followed by a slow involutional phase that generally
begins by the age of 12 months. However, in 10% to 20% of children, the subglottic
hemangioma may seriously compromise the airway before involution has taken
place.5 Because of the potential for significant
airway obstruction, these histologically benign lesions require intervention.
Report6 of the first successful treatment
by New and Clark (1919) has prompted numerous others to advocate various different
treatment modalities, including tracheotomy, radiation therapy, cryotherapy,
electrocautery, interferon alfa-2a, sclerosing agents, corticosteroids, embolization,
open surgical excision, and laser ablation. The fact that so many treatments
are still used suggests that an ideal method of management has not been found.
Recent advances in technology have made lasers a common management option.
There are numerous reports describing the use of various types of lasers.
The carbon dioxide laser has been widely used. It is characterized by a wavelength
of 10 000 nm (invisible) and requires an aiming beam during operation.
This laser is absorbed by tissues with a high water content, has poor tissue
penetration, and is less effective for coagulation. Therefore, it is less
effective in the treatment of vascular lesions.6
Sie et al,7 in 1994, reported a 10-year experience
with use of the carbon dioxide laser for subglottic hemangioma and noted that
serial procedures were required and that approximately 20% of the patients
developed posttreatment subglottic stenosis.
The Nd:YAG laser is considered a "coagulating laser." It has a wavelength
of 1064 nm (invisible) and requires an aiming beam for use. It has a deep
coagulating effect. However, there is significant danger of transmural injury
and possibly increased risk of subglottic stenosis if used for subglottic
hemangiomas.8
The potassium-titanyl-phosphate (KTP) laser has a wavelength in the
visible light range (532 nm). It does not require an aiming beam and can be
delivered via fiberoptic fibers. It is also preferentially absorbed by hemoglobin
and, therefore, is effective in the treatment of vascular lesions such as
subglottic hemangiomas.6
Since 1990, we have treated subglottic hemangioma using endoscopic vaporization
of the lesion with the KTP laser. Because of the preferential absorption by
hemoglobin and the ability to direct the laser via fiberoptics, we believed
this would be more effective in vaporizing the hemangioma while being less
destructive to the surrounding tissue.
PATIENTS AND METHODS
This was a retrospective medical record review of children treated with
the KTP laser for symptomatic subglottic hemangioma. Between September 1990
and February 1998, 6 patients were diagnosed as having mild disease and were
treated for subglottic hemangioma using the KTP laser at the Children's Hospital
of Michigan, Detroit. This procedure was chosen because it was believed that
the mild form of the disease would be more amenable to the KTP laser.
Hospital, clinic, and surgical records were reviewed for age at onset
of symptoms, age at diagnosis, sex, site of lesion, site of associated lesions,
initial treatment modality, number of laser treatments, end point of treatment,
need for tracheotomy, postoperative complications, duration of intubation
after surgery, period of follow-up, long-term response to therapy, and complications,
if any.
The procedures were performed under the guidance of the senior surgeon
(D.M.). The technique involved the use of rigid bronchoscopy with the KTP
laser adaptation and application. General anesthesia was used with spontaneous
ventilation. The KTP laser flexible fiber is passed down the side channel
of the rigid ventilating bronchoscope, thus maintaining a closed anesthesia
technique. The laser was used with continuous vaporization at a setting of
5 W in a single or repeated pulse mode at 0.5 second. The hemangiomas were
partially or completely vaporized. The end point of each treatment was at
least 60% to 70% patency of the airway. Of the 6 patients, 5 were extubated
postoperatively. All patients received preoperative dexamethasone (Decadron),
0.5 mg/kg.
RESULTS
Table 1 summarizes the pretreatment
patient data. Of the 6 patients, 4 were girls. Age at onset of symptoms ranged
from 1 to 8 months. The age at diagnosis ranged from 1 to 10 months (mean,
4 months). There was a median duration of 5 weeks before diagnosis.
Symptoms consisted of biphasic stridor, hoarseness, and/or raspy cry. One
patient presented with poor feeding. Five patients also had associated respiratory
tract compromise. Fifty percent had associated cutaneous hemangiomas at the
time of diagnosis. These were noted only in female patients.
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Table 1. Pretreatment Patient Data*
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The lesion involved the left subglottis in 4 of the 6 patients. One
patient had circumferential subglottic hemangioma, and the other had posterior
subglottic involvement. The degree of stenosis ranged from 30% to 70%. In
one patient, there was no information available on the degree of stenosis.
Table 2 lists the number
of procedures performed and the results. Four patients required 2 laser procedures
for 90% to 95% removal of the hemangioma. Two patients required only one treatment.
The end point of each treatment was to gain at least 50% to 90% reduction
of the hemangioma so that the airway would have approximately 60% to 70% patency.
The patients who required 2 procedures (patients 1, 3, 5, and 6) had the second
procedure performed 1 month after the first to complete the excision of the
lesion. Patients 1, 5, and 6 had approximately 50% to 70% reduction of the
hemangioma on the first attempt, which gave a reasonably patent airway. Meanwhile,
patient 3 had 90% reduction on the first attempt. Patients 2 and 4 required
only one procedure, with 80% reduction in patient 2 and 100% removal in patient
4.
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Table 2. The Number of Treatments and Results of KTP Laser Excision
of Subglottic Hemangiomas*
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There were no intraoperative complications. However, one patient (patient
4) had prolonged intubation after the procedure. She was extubated on postoperative
day 9. The length of follow-up ranged from 1 to 9 years (average, 3.2 years).
The long-term results have been promising in that all patients are asymptomatic
and follow-up direct laryngoscopy and rigid bronchoscopy have shown complete
resolution of the hemangioma. Long-term complications include granuloma formation
in patient 2, requiring laser excision, and grade 1 subglottic stenosis in
patient 4, requiring tracheal dilation. In addition, patients 2, 3, and 5
had 10% to 15% subglottic stenosis secondary to scarring, which was asymptomatic
and did not require intervention. No patient required a tracheotomy.
COMMENT
Infantile subglottic hemangioma is the most common head and neck neoplasm
of infancy. It is a self-limiting but potentially fatal disease. The most
common presenting symptom is stridor, which is usually progressive, and most
cases present within the first 6 months of life. Some patients may present
with recurrent or persistent croup, cough, noisy breathing, cyanosis, failure
to thrive, hoarseness, dysphagia, progressive dyspnea, hemoptysis, vomiting,
or the presence of a cutaneous lesion. Symptoms are directly related to the
size and location of the lesion and to the age of the patient. The diagnosis
of infantile subglottic hemangioma is made by history and physical examination
results, along with a high index of suspicion.2, 3, 4, 5, 9
The use of fiberoptic laryngoscopy may provide some information about the
presence of a lesion but does not allow for a complete assessment of the entire
subglottic airway. Radiographic evaluation may demonstrate symmetric or asymmetric
subglottic narrowing.10 A definitive diagnosis
is made by direct laryngoscopy and bronchoscopy, and thorough airway evaluation
must be undertaken to rule out coexisting pathologic features. There are many
accepted treatment options in the literature. When selecting the appropriate
treatment, one must consider the size of the lesion, lesion thickness, patient
age, urgent nature of the patient's presenting condition, and available treatment
modalities within the surgeon's institution. In this review, the KTP laser
appears to be a useful mode of therapy in managing patients with subglottic
hemangiomas. All patients in our study avoided a tracheotomy tube. In addition,
all but one patient had limited one-sided involvement; this patient had a
circumferential lesion. None had previous surgical treatment before use of
the KTP laser.
Since the original description of laryngeal hemangiomas in 1864, many
methods of treatment have been recommended. Many of the lesions will spontaneously
involute, and their biological behavior has made observation a viable option
for some. However, with untreated lesions, the mortality may be as high as
50%.9 The unpredictable nature of this lesion
and its significant risk of airway obstruction generally lead to either medical
or surgical intervention.
There have been several forms of management suggested. These include
use of sclerosing agents; intralesional corticosteroids, with or without endotracheal
intubation; tracheotomy; interferon alfa-2a; cryosurgery; open surgical excision;
external beam irradiation or endoscopic placement of a radioactive gold grain;
and laser endoscopic surgery. All modalities have had some success, but generally
the accepted treatment has been the use of laser excision, expectant management
with use of corticosteroids, and open surgical excision.11, 12, 13, 14, 15
Radiation treatment has been used for many years. However, the theoretical
concerns of radiation therapy–induced malignant neoplasms have placed
this treatment out of favor.16 Interferon alfa-2a
is promising for the management of massive cervicofacial hemangiomas, but
its effects are delayed and therefore would not be appropriate for life-threatening
or symptomatic hemangiomas causing airway obstruction. Tracheotomy is associated
with significant morbidity and mortality, and solutions have been developed
to avoid tracheotomy in infants. One-stage open surgical procedures can relieve
the obstruction while avoiding a tracheotomy and complications of prolonged
tracheotomy (speech and language delay).17
Open surgical procedures are recommended for large hemangiomas at the
beginning of the rapid growth phase, for bilateral subglottic hemangiomas,
when there is extralaryngeal extension, and/or for airway obstruction of 50%
or more.17 The decision to use an open surgical
procedure is not an easy one, but it is a viable option when large lesions
have not responded to other modalities and in cases that would otherwise necessitate
tracheotomy.
The use of the carbon dioxide laser has been of therapeutic value. Some
suggest that it is useful in avoiding tracheotomy, but this conclusion is
confounded by the concomitant use of corticosteroids. There often is the need
for several treatments when there is more than 50% airway obstruction. There
also is risk of severe subglottic stenosis due to absorption of laser energy
by uninvolved mucosa.7, 17
The use of the KTP laser in our patient group has presented us with
a satisfactory management option in our experience, to date. All of our patients
were completely asymptomatic after treatment. On average, our patients required
1.7 procedures. There was only one significant long-term complication associated
with the KTP laser—patient 4 developed grade 1 subglottic stenosis requiring
dilation. No tracheotomy tube was necessary, and there were no intraoperative
complications. In our experience, the preferential absorption of the KTP laser
by the hemoglobin molecule and the ability to direct it by fiberoptics have
made it more effective and less destructive to the surrounding tissue, with
limited sequelae of subglottic scarring.
Our experience does not advocate against other forms of treatment "tailored"
to particular problems, ie, circumferential lesions or extensive lesions beyond
the airway or associated with other causes of airway obstruction. More extensive
lesions may require an open procedure.
The main concern of infantile subglottic hemangioma appears to be the
potential for airway obstruction during the proliferative phase. No specific
treatment is without the potential for morbidity, mortality, or both. In our
opinion, the least invasive treatment instituted to maintain the patient as
symptom free as possible, to keep the patient safe from potential airway obstruction
without introducing significant risk of treatment sequelae for this benign
lesion, and to deliver the patient to the threshold of lesion involution is
a reasonable goal.
In our experience, the results with the use of the KTP laser have been
encouraging in patients with mild cases of subglottic hemangioma (grade 1
and 2 stenosis). It can be favorably compared with other "standards" of treatment.
The facility with which the KTP laser can be serially used to provide significant
relief of airway obstruction, due to infantile subglottic hemangiomas, in
the absence of significant associated complications warrants continued investigation
with this modality. As no perfect treatment exists, our philosophy regarding
management is not rigid and we optimistically await advancement in the treatment
of this debilitating and potentially life-threatening congenital airway lesion.
AUTHOR INFORMATION
Accepted for publication July 13, 2000.
Presented at the American Society of Pediatric Otolaryngology Meeting,
Palm Beach, Fla, May 15, 1998.
From the Department of Pediatric Otolaryngology, Children's Hospital
of Michigan, Detroit (Drs Madgy, Kest, and Stein); and the Department of Otolaryngology–Head
and Neck Surgery, Wayne State University, Dearborn, Mich (Dr Ahsan).
Corresponding author: Syed F. Ahsan, MD, Department of Otolaryngology–Head
and Neck Surgery, Wayne State University, 4941 Heather Dr, Apartment 105,
Dearborn, MI 48126 (e-mail: Sydahsan{at}aol.com).
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