DEPARTMENT OFDEPARTMENT OF

OTORHINOLARYNGOLOGY OTORHINOLARYNGOLOGY

HEAD & NECK SURGERYHEAD & NECK SURGERY

CMH RAWALPINDICMH RAWALPINDI

Excision of Recurrent Respiratory Excision of Recurrent Respiratory Papillomatosis by Combined Technique Papillomatosis by Combined Technique

using COusing CO2 2 Laser & MicrodebriderLaser & Microdebrider

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Recurrent Airway ObstructionRecurrent Airway Obstruction

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Patient’s profilePatient’s profile

• Name: A B C

• Age: 3 ½ years

• Sex: Female

• Residence: Hangu

(Khyber-

Pakhtunkha)

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PresentationPresentation

• Voice change

• Breathing difficulty

• Taking medications from various physicians for URTI and bronchial asthma.

one year

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• Referred from some ENT clinic at Peshawar to CMH Rawalpindi.

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PresentationPresentation

• Birth History:– Full term spontaneous vaginal delivery

• Feeding History:– Breast fed for 1 year & weaning started

at 5 months

• Vaccination History– Vaccinated as per EPI schedule

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PresentationPresentation

• Developmental History:– Developmental milestones as per age

• Past History:– No history of any surgical intervention

• Family History:– 4th eldest among 5 siblings

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General Physical ExaminationGeneral Physical Examination

• A female child active, playful and cooperative but slightly distressed.

• Weight: 20 kg (lying on 50th percentile)

• Height: 90 cm (lying on 50th percentile)

• Vital Signs:– Pulse: 84/min– Temp: 98.4o F– Resp Rate: 22/min

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General Physical ExaminationGeneral Physical Examination

• Signs:• Stridor +• Recessions ++• Nasal ala flaring +++

• Cyanosis• Pallor• Clubbing• Jaundice• Edema

Negative

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ENT ExaminationENT Examination

• Detailed ENT examination of– Oral Cavity– Oropharynx/Throat– Nose – Ear

• Patient was not cooperative for Indirect Laryngoscopy

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Fiberoptic LaryngoscopyFiberoptic Laryngoscopy

• Findings – Extensive laryngeal papillomas over

glottic and supraglotic regions.

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Systemic ExaminationSystemic Examination

• Gastrointestinal System• Respiratory System• Cardiovascular System• Central Nervous System

Unremarkable

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DiagnosisDiagnosis

• Juvenile Onset Respiratory Papillomatosis

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Counselling of ParentsCounselling of Parents

• Parents counseled in detail about its nature, treatment and prognosis.

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Treatment PlanTreatment Plan

• Direct Laryngoscopy &

• Combined Carbon-dioxide laser ablation and Microdebridement under GA (on 10th Dec 2010)

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ConsentConsent

• Informed written consent (from parents of child)

– Risks of surgery– Chances of recurrence &– Need for additional surgical procedures

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Pre-Op work upPre-Op work up

• Blood CP• Urine RE• Coagulation profile• X-ray Chest PA view

• Pre-anesethesia assesment in ASA-I

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O P

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General anesthesia induction

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O P

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•Smaller endotracheal tube of size 5.0•Aluminum foiling

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Thorough endoscopic examination

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Staging sites and extent of lesion

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Largest possible laryngoscope placed

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Specimen for biopsy taken

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Laser Safety Measures

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COCO22 Laser Excision Laser Excision

• CO2 laser used at – 10 watt power – with 0.1 sec pulses

&– small plot size

O P

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A T

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S T

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S

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O P

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CO2 Laser Micromanipulator

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Intraoperative photograph before RRP removal

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O P

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Extensive papillomas covering glottis

Aluminium foiled endotracheal tube

Bulky Glottic Lesion

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O P

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He-Ne aiming beam pointing the glottic area being ablated

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Laser ablation in process

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O P

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Glottic chink after CO2 Laser ablation

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Surgical Microdebrider Surgical Microdebrider O

P E

R A

T I V

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S T

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Long laryngeal blade

Oscillating head

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O P

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Surgical Microdebrider

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O P

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Microdebrider debulking of RRP

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O P

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Glottis after excision of lesion

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O P

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Before Surgery

After Surgery

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Post-Operative Care Post-Operative Care

• Steroids, analgesics & antibiotics

• Steam inhalation

• Sniffing exercises

• Voice rest

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Follow upFollow up

• Marked improvement in her voice and breathing post-operatively.

• Parents advised regular follow up.

DEPARTMENT OFOTORHINOLARYNGOLOGY HEAD & NECK SURGERY

CMH RAWALPINDI

HOSPITAL DATAHOSPITAL DATA

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Hospital DataHospital Data

• July 2009 – Dec 2010• Total no of patients: 21

Juvenile Onset RRP

Adult Onset RRP

CO2 Laser 11 3

Microdebrider 2 -

Combined technique

5 -

Total 18 3

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Frequency of RRP

18, 86%

3, 14%

Child onset RRP Adult onset RRP

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ConclusionConclusion

• Relatively rare – Negative impact on evaluation of treatment

modalities

• Multiple recurrences results in poor quality of life for patients.

• Advances in surgical techniques allow safe airway and acceptable voice.

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