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Powered Instrumentation in the Treatment of Recurrent Respiratory Papillomatosis
An Alternative to the Carbon Dioxide Laser
Mohamed A. El-Bitar, MD;
George H. Zalzal, MD
Arch Otolaryngol Head Neck Surg. 2002;128:425-428.
ABSTRACT
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Objective To assess the advantages of powered instrumentation vs the carbon dioxide
laser in treating patients with juvenile-onset recurrent respiratory papillomatosis.
Design A retrospective study.
Setting Tertiary care children's hospital.
Patients Patients operated on for juvenile-onset recurrent respiratory papillomatosis
between January 1, 1999, and December 31, 2000. Papillomas were excised using
the microdebrider in one group and the carbon dioxide laser in the second
group.
Interventions Direct laryngoscopy and bronchoscopy, suspension microlaryngoscopy,
and excision of papillomas by the carbon dioxide laser or the microdebrider.
Main Outcome Measures Operative time and postoperative complications.
Results Seventy-three operations were performed (23 with the laser and 50 with
the microdebrider). Sixteen patients were included, 10 with active disease
and 5 with disease in remission; 1 was lost to follow-up. They had a mean
age of 3.75 years, and the male-female ratio was 7:9. The patients presented
mostly with hoarseness (13 [81%]). Four (25%) had soft tissue complications
with the laser. The microdebrider was less time-consuming than the laser,
although those treated with the microdebrider had more active disease. No
factor could be used to measure treatment outcome due to disease variability.
Those who were older, female, and African American tended to have less severe
manifestations of disease.
Conclusions The microdebrider proved to be less time-consuming than the carbon dioxide
laser when used in patients with juvenile-onset recurrent respiratory papillomatosis.
Soft tissue complications were nonexistent. In addition to safety, the microdebrider
is more appealing to the surgeon, anesthesiologist, and parents, especially
because these children often need subsequent surgical procedures.
INTRODUCTION
JUVENILE-ONSET recurrent respiratory papillomatosis (JORRP) is a challenging
disease of viral etiology that is still perplexing parents and otolaryngologists
by its unpredictable course. In contrast to the adult form, JORRP is more
aggressive, necessitating frequent interventions to ensure airway patency.
Although the disease goes into remission in some patients, in others it will
never do so; in some, it will even recur after years of remission.
Juvenile-onset RRP affects children who have a mean age of 3.76 years
and is considered the second most common cause of hoarseness in the pediatric
age group. A triad has been noticed in several of these children, consisting
of firstborn child, vaginal delivery, and a young mother. It is a relatively
rare condition estimated to occur in 4.3 of 100 000 children younger
than 14 years in the United States.1
To communicate better among otolaryngologists dealing with RRP, a staging
system has been agreed on, whereby the patient receives a clinical score depending
on the presenting symptoms and a site score relying on the intraoperative
findings.2 Papillomas can arise at different
sites inside the aerodigestive tract, with a predilection to areas where squamous
and respiratory epithelia meet. The most commonly involved area is the larynx.
A wide variety of treatment options have been suggested and studied
since JORRP has been recognized. However, most researchers agree that surgery
is the primary modality. Knowing that the normal-appearing tissue adjacent
to the papillomas may harbor the human papillomavirus, especially in the active
more aggressive form,3 eradication is not possible
and, therefore, treatment should be conservative. To excise these papillomas,
the carbon dioxide (CO2) laser has been found by many surgeons
to be the best tool, allowing precise and bloodless vaporization of the lesion.
Recently, powered instrumentation was introduced in laryngology after
it was tried successfully in orthopedics and rhinology. We started using angled-tip
3.5-mm laryngeal and subglottic blades (Skimmer; XOMED Surgical Products,
Jacksonville, Fla) (Figure 1) on
all patients with JORRP who were being treated at Children's National Medical
Center around the beginning of 2000. This retrospective study assesses the
advantages of using the powered instrumentation vs the CO2 laser.
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A, The tip of the microdebrider (Skimmer; XOMED Surgical Products,
Jacksonville, Fla). B, Laryngeal papillomas (found to arise from the left
true vocal cord, sparing the anterior commissure). C, Excising the papillomas
with the microdebrider. D, Immediate postoperative view.
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PATIENTS AND METHODS
All patients operated on for JORRP at Children's National Medical Center
using the microdebrider were included in this study. These patients were seen
between January 1, 2000, and December 31, 2000.
For comparison purposes, the patients operated on for JORRP using the
CO2 laser during the preceding year (January 1, 1999, to December
31, 1999) were also enrolled in our study.
Knowing that different patients have differences in the severity, extent,
and recurrence rate of the disease, we included the same patients in both
groups (where applicable) to control these variables.
The medical records of these patients were reviewed, including clinic
visits, operative reports, marked preprinted laryngeal sketches, anesthesia
notes (preoperative and postoperative), and the clinical and site scores.
The clinical score relied on the history given by the parents at surgery
regarding the quality of the patient's voice, the presence of stridor or respiratory
distress, and the urgency of the surgical intervention. The site score depended
on the number of sites involved and the bulkiness of the lesion at each site,
as determined intraoperatively by the surgeon.2
Demographic information, including date of birth, sex, and race, was
collected. The age at initial presentation and the presenting symptoms were
noted. Intervals between operative sessions and the operative time were calculated.
Any reported intraoperative and immediate or delayed postoperative complications
were reviewed.
Because the operative time documented in the medical records included
only the actual operative procedure, we asked the experienced operating room
staff to time the preparation for each of the 2 methods studied herein. This
additional factor (preparation time) was added to the surgical time to obtain
the total operative time of the procedure:
We studied the feasibility of using the number of operative sessions,
the interval between these sessions, the clinical score, and the site score
as a measurement of treatment outcome. The age at diagnosis, sex, race, and
presenting symptoms were evaluated as possible predictors of disease severity.
Parents were called and asked by the clinical coordinator at our department
about their impression concerning the immediate postoperative course following
the use of the microdebrider compared with what they used to notice with the
CO2 laser, and their opinion was noted.
RESULTS
Sixteen patients with JORRP were operated on between January 1, 1999,
and December 31, 2000. During the study, the disease in 5 patients (31%) entered
remission; 1 patient was lost to follow-up. The remaining 10 patients underwent
73 operative sessions, with a mean interval between surgical procedures of
10 weeks; the CO2 laser was used in 23 sessions, and the microdebrider
was used in 50 sessions (Table 1).
The mean age of the patients at first presentation was 3.75 years, with a
male-female ratio of 7:9. The most common presenting symptoms were hoarseness
(13 patients [81%]), respiratory distress (8 patients [50%]), and stridor
(2 patients [12%]).
No serious intraoperative complications were noted, except for severe
glottic edema noted in 1 patient after using the CO2 laser. All
the postoperative complications were delayed, including the anterior glottic
web (in 3 patients [19%]) and posterior glottic scarring (in 1 patient [6%]),
which occurred when the CO2 laser was the tool of choice. Tracheotomy
was needed in only 1 case before presentation and was performed in another
institution to secure the airways in a patient with extensive laryngotracheal
disease. The patient later underwent decannulation uneventfully when the disease
activity settled down.
The severity of the disease, as reflected by the site score, was the
same or greater in patients treated with the microdebrider than in those treated
with the laser, except in 1 patient. As expected, more operative sessions
were needed in those treated with the microdebrider. However, the operative
time (actual and total) was markedly shorter with the microdebrider (Table 1). The lowest preparation time was
estimated to be 15 minutes for the laser and 5 minutes for the microdebrider.
The interval between the operative sessions was set by the surgeon (G.H.Z.)
at the end of each operation. The chosen period depended on the severity of
the disease, as reflected by the patient's symptoms and the intraoperative
findings, and on the recent time intervals used for that particular patient.
This interval highly influenced the number of operative sessions needed for
each patient. The clinical score was often unreliable, depending on the accuracy
of parents' history. Therefore, all 3 of these factors could not be considered
as possible measurements of a treatment outcome.
The site score was useful in reflecting the severity of the disease,
especially when coupled with an intraoperative drawing. However, the variability
of the disease even in the same patient, regardless of the treatment used
or the surgical interval set, makes its use in measuring treatment outcome
unrealistic.
The age at onset of the disease was highly predictive of the disease
severity pattern: the younger the patient, the more severe the disease. The
disease seemed to have a higher chance of entering remission in African American
female patients, while the presenting symptoms had no predictive value.
The parents of 7 patients in whom the CO2 laser and the microdebrider
were used during the study period were asked to comment freely on any differences
they noted when the microdebrider was introduced in treating the papillomas.
Five agreed that the operative session was shorter, their child was more comfortable
postoperatively, and their child could phonate more clearly sooner. In general,
parents were more comfortable with the idea that their child was not exposed
to the potential risks of the laser, which they always think about during
each session.
COMMENT
The CO2 laser has long been used to excise papillomas, starting
in the early 1970s. It has been favored over conventional instruments because
of its hemostatic ability (while vaporizing papillomas) and its relative precision,
especially with the introduction of the micromanipulator. In a survey published
by Derkay1 in 1995, 92% of the respondents
used the CO2 laser as the method of choice in treating papillomas.
However, the CO2 laser is not without potential risks and
is grossly time-consuming. The complications related to the CO2
laser on the airways are well-known and include airway fire, airway perforation,
and injury to distal airways. All of these can predispose to airway stenosis
or distal spread of the disease.4 It is believed
that traumatized epithelium may heal by squamous metaplasia, forming an ideal
site for human papillomavirus infection, which may be subclinical first and
then manifest later as papillomas at a new site.5
The patient, the surgeon, and the operating room staff may inhale the
surgical plume, which may contain the human papillomavirus DNA, as demonstrated
by Kashima et al.6 This DNA may still be infectious,
especially if it lodges in an abraded mucosal surface.4
Moreover, the plume contains combustion products and dispersed particles that
can be harmful to the airways, as shown in an animal study performed by Freitag
et al,7 in which decreases in arterial PO2 and tracheal cilia motility were noted.
Postoperative healing has also been a problem with the CO2
laser. Durkin et al8 demonstrated in an experiment
on dogs a delay in vocal cord wound healing when the CO2 laser
was used vs the conventional microcup forceps. The effect of the laser was
not limited to the epithelial layer treated but got beyond it, despite precise
control of the used beam. In the submucosa, for example, a giant cell reaction
was noticed, probably due to a char effect. At the vocalis muscle level, edema,
and even destruction, was found, which led to fibrosis later.
These complications were actually encountered in patients with RRP treated
by the CO2 laser. Crockett et al9
reported a 36% incidence of soft tissue complications, including an anterior
glottic web and posterior glottic and interarytenoids scarring. Moreover,
a stroboscopic examination of patients whose disease was in remission revealed
abnormalities in vocal fold function. Benjamin and Parsons10
found a 20% rate of an anterior glottic web in their patients, while Ossoff
et al11 reported an incidence of 13.6% (true
vocal cord scarring and posterior glottic webs). The rate of complications
was related to the surgical technique used rather than to the number of surgical
sessions or the interval between the sessions. In our series, this rate reached
25%, including an anterior glottic web and posterior glottic scarring.
To avoid these potential hazards and complications, we elected to use
the microdebrider on all our patients with JORRP. Our rate of soft tissue
complications decreased to zero after we adopted this new instrument.
During the past decade, powered instrumentation gained widespread use
in the field of rhinology. This success encouraged the introduction of similar
tools to be used on the larynx. Rare reports appeared recently in the English-language
literature describing the use of the microdebrider in excising laryngeal papillomas.
Myer et al12 described the function of this
instrument, found it safe and efficient in removing laryngeal lesions, and
considered it a valuable adjunct in treating RRP, especially when the lesion
is bulky, avoiding the disadvantages of the CO2 laser in cost,
required personnel, thermal injury, and staff injury. We found similar advantages,
yet we used this instrument as an alternative to the laser on all our patients,
whether they had bulky lesions or not and whether the diagnosis was new or
they underwent multiple procedures.
In another report by Patel and Mackenzie,13
the microdebrider was used on 5 adult patients with RRP who were previously
treated with the CO2 laser. These researchers concluded that the
new technique is faster and safer and that the patients found the postoperative
recovery with this method the same or better than that with the CO2
laser. To assess the time efficiency of this new technique, we measured the
actual and the total operative time and compared both methods. We found that
the microdebrider was by far less time demanding (Table 1). To avoid the differences existing among patients in age,
sex, race, and severity of disease, each patient was considered her or his
own control. More severe manifestations of disease (ie, a higher site score)
usually means more papillomas to excise and, thus, a higher operative time,
yet this variable was controlled by the fact that most of the patients treated
with the microdebrider had an equal or a higher site score than those treated
with the laser but still required a shorter operative time. Concerning the
postoperative period, our findings were similar to those of Patel and Mackenzie,
except that our patients belonged to the pediatric age group and, therefore,
we relied on the parents' opinion.
Because we are adopting a new technique, we tried to assess the feasibility
of measuring the treatment outcome. However, no single factor could be used
for that purpose. The unpredicted variation in disease activity makes it hard
to measure the benefit of any mode of treatment. We tried to identify predictors
of disease severity. Younger patients had more active disease, and the disease
entered remission more often in African American female patients.
Therefore, powered instrumentation seems to be promising in the treatment
of RRP. It provides a safer, faster, and cheaper way to excise laryngeal papillomas
repeatedly. Until a cure is found for this disease, it may become the method
of choice to keep patent airways in these patients.
AUTHOR INFORMATION
Accepted for publication October 26, 2001.
Corresponding author: George H. Zalzal, MD, Children's National Medical
Center, 111 Michigan Ave NW, Washington, DC 20010.
From the Department of Pediatric Otolaryngology–Head and Neck
Surgery, Children's National Medical Center, George Washington University,
Washington, DC.
REFERENCES
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1. Derkay CS. Task force on recurrent respiratory papillomas: a preliminary report. Arch Otolaryngol Head Neck Surg. 1995;121:1386-1391.
ABSTRACT
2. Derkay CS, Malis DJ, Zalzal G, Wiatrak BJ, Kashima HK, Coltrera MD. A staging system for assessing severity of disease and response to
therapy in recurrent respiratory papillomatosis. Laryngoscope. 1998;108:935-937.
FULL TEXT
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ISI
| PUBMED
3. Pignatari S, Smith EM, Gray SD, Shive C, Turek LP. Detection of human papillomavirus infection in diseased and nondiseased
sites of the respiratory tract in recurrent respiratory papillomatosis patients
by DNA hybridization. Ann Otol Rhinol Laryngol. 1992;101:408-412.
PUBMED
4. Kashima H, Mounts P, Leventhal B, Hruban RH. Sites of predilection in recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol. 1993;102:580-583.
ISI
| PUBMED
5. Favre M, Ramoz N, Orth G. Human papilloma viruses: general features. Clin Dermatol. 1997;15:181-198.
FULL TEXT
|
ISI
| PUBMED
6. Kashima HK, Kessis T, Mounts P, Shah K. Polymerase chain reaction identification of human papillomavirus DNA
in CO2 laser plume from recurrent respiratory papilllomatosis. Otolaryngol Head Neck Surg. 1991;104:191-195.
ISI
| PUBMED
7. Freitag L, Chapman GA, Sielczak M, Ahmed A, Russin D. Laser smoke effect on the bronchial system. Lasers Surg Med. 1987;7:283-288.
ISI
| PUBMED
8. Durkin GE, Duncavage JA, Toohill RJ, Tieu TM, Caya JG. Wound healing of true vocal cord squamous epithelium after CO2 laser ablation and cup forceps stripping. Otolaryngol Head Neck Surg. 1986;95:273-277.
PUBMED
9. Crockett DM, McCabe BF, Shive CJ. Complications of laser surgery for recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol. 1987;96:639-644.
PUBMED
10. Benjamin B, Parsons DS. Recurrent respiratory papillomatosis: a ten-year study. J Laryngol Otol. 1988;102:1022-1028.
PUBMED
11. Ossoff RH, Werkhaven JA, Dere H. Soft-tissue complications of laser surgery for recurrent respiratory
papillomatosis. Laryngoscope. 1991;101:1162-1166.
PUBMED
12. Myer III CM, Willging JP, McMurray S, Cotton RT. Use of a laryngeal micro resector system. Laryngoscope. 1999;109(pt 1):1165-1166.
13. Patel RS, Mackenzie K. Powered laryngeal shavers and laryngeal papillomatosis: a preliminary
report. Clin Otolaryngol. 2000;25:358-360.
PUBMED
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