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Medical Laser Application 20 (2005) 297–302www.elsevier.de/mla

Endoscopic laser application in 56 children with hemangiomas of the

larynx and trachea

Jurgen Waldschmidt�, Henning Giest, Lutz Meyer

Department of Pediatric Surgery, St. Joseph Hospital Berlin-Tempelhof, Baumerplan 24, 12101 Berlin, Germany

Received 12 July 2005; accepted 18 August 2005

Abstract

Background: Hemangiomas of the larynx and trachea are life-threatening diseases in infants often requiring urgentsurgical intervention. The typical sign is a stridor during the first trimester of infancy.

Method: Retrospective analysis of all children with angiomas of the airways admitted to our department from 1983to 2003.

Localization: In 46 children the most involved segments were the larynx and the subglottic area. In six cases thethoracic trachea and in further four children the bronchi were involved. The extension of growth is similar to thecutaneous hemangiomas: limited to mucosa (27 cases), infiltrating the submucosa with tumorous endoluminal bulging(21 cases) and transmural spreading into the neighboring tissue (eight cases).

Technique and laserparameter: All patients were treated by Nd:YAG Laser Medilas fibertom 5100. For capillaryangiomas we preferred the non-contact technique, 15–20W, 0.1–0.2 s, interrupted. Submucous and intramural locatedcavernomas were treated by interstitial laser therapy (LITT), 2–3W, cw.

Results: Endoscopic endoluminal laser treatment has been used successfully in all children we have seen. All childrenare alive. One therapeutic session was sufficient in 50 children. In six children two to four sessions were necessary. In 16children temporary tracheostomy had to be performed, followed by decannulation within 2 weeks to 1 year.

Conclusion: With Nd:YAG Laser it is possible to reach all parts of the larynx, trachea and bronchi and tosuccessfully treat angiomas of the airways. Through this it was possible to avoid tracheostomy in 40 of our 56 children.r 2005 Elsevier GmbH. All rights reserved.

Keywords: Tracheal stenosis; Nd:YAG laser; Infancy

Introduction

In 1871 Mac Kenzie [8] was the first describingangioma in the larynx and in 1919 New Clark et al.[19] reported on the first successful treatment. This was

e front matter r 2005 Elsevier GmbH. All rights reserved.

la.2005.08.005

ing author. Tel.: +4930 7882 2728;

2 2605.

ess: dr.waldschmidt@web.de (J. Waldschmidt).

followed by numerous publications on infantile laryngealhemangiomas treated by various procedures [1,3,5,8,12,14–16,18,22–24]. Today, therapy is mostly performedendoscopically by endoluminal laser application. Thus, adistinction must be made between the different lasers andindividual techniques in order to evaluate the treatmentmethods [6,7,9,11–13,16,17,20,25,26]. This study de-scribes the endoscopic techniques using the Nd:YAGlaser 1064nm.

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Materials and methods

In our department of pediatric surgery we treated from1983–2003 56 children with hemangiomas of the respira-tory tract. All children presented within the first year oflife. The youngest child was 6 days old and the oldest 11months. The median age was 12 weeks. This is the typicalpredilection age. The percentage of premature infantswas 20%. Nine children had additional diseases: threewith a heart malformation, one with an aortic ringanomaly, one with facial paresis and one with hydro-cephalus (Fig. 1). Additional hemangiomas with differentlocalizations were found in 26 children (Table 1).

Procedure

Tracheobronchoscopy was performed in generalanesthesia and relaxation. We used a rigid bronchoscopewith Hopkins’ optic. Our findings were documented byvideo, print and photography. Laser treatment wasperformed in the same session. This was followed by3-day postoperative antibiotic prophylaxis.

Fig. 1. Localization of hemangiomas of the airways in 56

children.

Table 1. Hemangiomas of larynx and trachea in 56 children

Associated hemangioma

Localization n

Face 11

Parotis 4

Ear 2

Different loc. 9

Classification of the hemangioma of the airways

It is necessary to differentiate between the varioustypes of angiomas. We have to distinguish betweencapillary and cavernous hemangiomas. The capillaryhemangiomas grow in a mucous and plane, planotuber-ous and tuberonodal manner. The cavernous heman-giomas are located submucous or transmural and mayeven spread extramural into the adjoint tissue. Thegrade of stenosis was classified according to COTTON.Grade I corresponded to a 70% stenosis, grade IIbetween 70% and 90%, grade III over 90% and grade IVshows a complete occlusion [7] (Fig. 2).

Laser technique

In all cases we used the Nd:YAG laser 1064nm with a0.4mm bare fiber light conductor[6,25,26]. For plane orplanotuberous hemangiomas the non-contact (nc) trans-mucous technique was used (Fig. 3), with an expositiontime of 70–100ms and 15–20W. This technique benefitsfrom the high absorption in blood compared to themucous membrane and prevents damage to the adjacentstructures by the limited application time and heatconduction. Coagulation was achieved by the ‘‘polkadot’’ technique alike the technique in hemangiomas of theskin. The coagulation zone is limited to a depth of0.5–1mm; thus, cartilage damage is not to be feared. Intuberonodal hemangiomas, thrombosis of the surfacecomponents is first induced by nc mode and subsequentlythe resection is made in contact mode (Fig. 4). Insubmucous cavernous hemangiomas interstitial lasertherapy (LITT) is used with 2–3W power in cw mode(Fig. 5). The fiber placed in the tumor coagulates thetissue in a time-dependent and concentric manner. Themucosa remains intact. Due to the volume shift thecoagulation process is endoscopically registered as tumorshrinkage. Intra- and extramural hemangiomas can alsobe treated using LITT. In addition, the process can becontrolled endosonographically by placing an echo scantransducer in the esophagus (Table 2).

Fig. 2. Extension of hemangiomas of the airways in 56

children.

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Discussion

Hemangiomas of the larynx and trachea are the mostcommon congenital diseases causing an upper respira-tory obstruction in infants and young children [2,4].These infants are asymptomatic at birth but haveprogressive inspiratory or biphasic stridor with life-threatening acute respiratory distress at second or third

Fig. 3. Intramucous capillary hemangioma. a. nc transmucous

application, 15–20W, application time: 50–100ms. b. Contact

application with standard mode, application time: 70ms. c.

Before laser session. d. After one laser session.

Fig. 5. LITT. a. Endoscopic guided by Echo scan controlled LITT

Fig. 4. Subglottic hemangiomas. a. Before laser session. b.

Ablations mode contact 20W. c. After laser session.

month of life. Often emergency surgery is necessary [10].Nearly 50% of the children will have associatedcutaneous hemangiomas [8,13]. Spontaneous regressionis possible [14,16]. In acute situation high doses ofintravenous corticosteroids are helpful. Waiting for theireffect is to recommend [21].

Stridor was the most common indication for tracheo-scopy and was seen in all children with hemangiomas ofthe larynx or proximal trachea. Three children withhemangiomas of the distal trachea or bronchi sufferedfrom recurrent bronchopneumonia and atelectasis of thelung. The most common preliminary non-invasivetreatment was unsuccessful steroid therapy (12 patients).Previous unsuccessful treatment also included a tra-cheostoma in a 6-month-old boy and a selectiveangiographic embolization in an 11-month-old girl.More than 50% of the children had concomitantcutaneous hemangiomas, which were located on thehead, throat or neck (17 children). In the endoscopicexamination we found a total of nearly 100 hemangio-mas of the respiratory tract in these 56 children. Twentypatients had solitary involvement. Three children evenhad four localizations in the tracheobronchial system.The most frequently affected areas were the larynx andsubglottic trachea in 46 children of all the cases. In only10 infants the main findings were located in the tracheaor bronchi. In 39 children the localization was lateral. Inthe other seven children, semicircular spread was seenon the posterior wall. Half of the children had capillaryhemangiomas, in which the planotuberous type waspredominant in 13 infants. Submucous hemangiomaspresented mostly as common cavernous type. Nd:YAGlaser therapy was the first and only therapeutic choice in25 children. Four patients with capillary hemangiomashad a slight stenosis with less than 50% volumeconstriction, so that treatment was initially delayed.Control endoscopy in an 8-week-old girl revealedprogressive growth of a planotuberous subglottichemangioma. Laser treatment was only carried outduring the second tracheoscopy. Thus, a total of 53children were treated with Nd:YAG laser 1064 nm. Intwo cases, we inserted a protective tracheostomabecause of concomitant ulcerous laryngotracheitis.Ulceration of a subglottic hemangioma was observedin another patient. A 5-year-old boy additionally had

application. b,c. LITT technique before and during lasering.

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Table 2. Laser technique and parameter. Nd:YAG laser 1064 nm, Dornier Medilas 5100 0.4mm bare fiber

Angioma Procedure Mode Power (W)

Capillary plane and tuberous Direct coagulation non-contact Standard 70–100ms intermittent mode 15–20

Cavernous submucous Vaporisation contact Ablation single impulse 20

Mural, transmural Intralesional coagulation LITT 2–3

Table 3. Hemangiomas of larynx and trachea in 53 children

Number of laser application (n)

1 session 24

2 sessions 24

More than 2 sessions 5

Temporary tracheostoma 16Fig. 6. Polypous hemangioma of the left main bronchus.

a. X-ray before. b. the distended left lung. c. after laser

application.

Fig. 7. Percutaneous insertion of the laser fiber via puncture

needle into a transmural hemangioma.

J. Waldschmidt et al. / Medical Laser Application 20 (2005) 297–302300

hypoplastic cricoid cartilage. He required cricoid split-ting and temporary tracheal stent therapy. In a pretermchild who had required long-term respiration therapy,this was combined with marked larnygomalacia.Although good regression of the subglottic hemangiomawas achieved by a single transmucous laser application,the child could not be extubated due to persistentstridor. For this reason, a tracheostoma was created 10weeks later in another center. The larnygeal cartilagestabilized, and the stoma was closed 2 years later.

One therapeutic Nd:YAG laser session was sufficientin 24 children (Table 3). Two laser applications wererequired in further 24 children with tuberonodalcapillary hemangioma with grade III stenosis. Morethan two sessions were necessary in five patients with thecavernous form.

A high-grade stenosis was present in all childrenundergoing more than two sessions. Transmucous laserapplication in the nc mode was most frequently used. Itwas the only type of treatment we used in grade Istenosis. LITT was used in a total of six patients fiber. Inone case, the bare fiber was percutaneously insertedvia puncture needle into the transmural hemangioma(Figs. 6 and 7). A single interstitial laser coagulationstopped the growth in the affected trachea. The higherthe stenosis grade, the more frequent disobliteration byresection is necessary. One hemangioma with grade IIstenosis and three with grade III stenosis were resectedin the contact or ablations mode, respectively. Directpostoperative edematous swelling of the treated areamay occur in the first 3 days after laser coagulation. Theswelling regresses within the next 4–5 days. This is thedesired moment point for extubation. This was per-formed in 12 children. Five children with grade Istenosis were already extubated in the operating roomas well as six children with grade II stenosis. Five

children were intubated for more than 1 week because ofmore severe findings. In three of these five children,extubation could only be planned after the secondsession. Extubation after 5 days was unsuccessful in twoinfants and reintubation was required. In 17 casesangioma remnants were found after single Nd:YAGlaser application and in 10 cases after transmucoustherapy in which zones of intact epithelium wereintentionally left in place. In eight children, theremnants required intermission and were re-lasered. Inthe control tracheoscopy, granulomas were seen in atotal of 11 cases, only four of them needed treatment.Single endoscopic Nd:YAG laser removal was successfulin all four patients. There were no intraoperativecomplications. Smoke development was negligible. Weregistered no hemorrhage not even in the four cases, in

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Table 4. Results

Outcome n

Well, without stoma 40

Well, temporary tracheostoma 15

Died (3-month after laser disobliteration with

intracranial hemorrhage, Sturge–Weber-syndrome

1

J. Waldschmidt et al. / Medical Laser Application 20 (2005) 297–302 301

which a biopsy specimen was taken. There was only onepatient with postoperative complications due toNd:YAG laser therapy. One boy developed a subglotticcicatrical stenosis after resection in the contact mode.Disobliteration was achieved in 53 children by onlyendoscopic therapy with Nd:YAG laser. Another threechildren were successfully treated by a combination ofsurgery and laser application (Table 4).

Conclusion

With Nd:YAG laser it is possible to reach allsegments of intra- and extramural growing hemangio-mas of the airways in infancy. Therefore, it was possibleto avoid tracheostomy in 40 of our 56 children.

Zusammenfassung

Endoskopische Laseranwendung (Nd:YAG Laser

1064 nm) bei 56 Kindern mit Hamangiomen des Larynx

und der Trachea

Einfuhrung: Hamangiome des Larynx und der Tra-chea sind lebensgefahrliche Erkrankungen im fruhenSauglingsalter und erfordern oft einen kinderchirur-gischen Noteingriff.

Methode: Der Artikel gibt die Ergebnisse einer retro-spektiven Analyse aller unserer Kinder (n ¼ 56), die indem Zwanzigjahreszeitraum von 1983–2003 in unsererkinderchirurgischen Abteilung behandelt worden sind.

Lokalisation: Bei 46 Kindern waren Larynx undsubglottische Region betroffen, bei weiteren 6 Kinderndie thorakale Trachea und bei 4 Kindern das Bronchi-alsystem. Meist waren sie auf die Mukosa (n ¼ 27) unddie Submukosa (n ¼ 21) begrenzt und entwickelten sichintraluminal mit einem das Tracheallumen einengendenTumor (Grad III nach COTTON). 8x breitete sich dasHamangiom mural und transmural in die Nachbar-strukturen aus.

Technik und Laserparameter: Alle Kinder wurden mitdem Nd:YAG Laser 1064 nm Dornier Medilas 5060 und5100 behandelt. Fur kapilliare Hamangiome wurde dieKoagulation mit der non contact Technik (70–100ms,

getaktet), fur die tuberosen Hamangiome die Vaporisa-tion mit dem Ablationsmodus (20W, Einzelimpulse)angewendet. Die muralen und extramuralen Haman-giome wurden dagegen mit der LITT (2–3W, cw)behandelt.

Ergebnisse: Mit diesem Vorgehen konnten wir beiallen Kindern die komplette Regression erreichen. Meistreichte eine Sitzung aus, bei 6 Kindern waren 2–4Sitzungen notwendig. Nur bei Zusatzveranderungen(Larynxgranulome durch Tubusschaden, congenitaleKrikoidhypoplasie, doppelter Aortenbogen) waren Zu-satzeingriffe wie eine Spanplastik erforderlich.

Schlussfolgerung: Der Nd:YAG Laser 1064 nm bietetden Vorteil, dass mit der dunnen Barefiber alleAbschnitte der Atemwege erreicht werden konnen unddass auch die sich extramural ausbreitenden Haman-giome erreicht werden konnen. So konnte bei 40Kindern auf ein Tracheostoma verzichtet werden. Nurbei 16 Kindern war eine temporare Notfalltracheotomienotwendig.r 2005 Elsevier GmbH. All rights reserved.

Schlusselworter: Trachealstenosen; Nd:YAG Laser; Sauglinge

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