stlaryngeal

8/2/2019 STLaryngeal

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surgical technique

Powered Laryngeal Surgery Using

the Angle-Tip RAD Airway

Bladespresented by Paul Flint, MD

Angle-Tip RAD Airway Bladesfrom Xomed

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Surgical technique presented by

Paul Flint, MD

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Nota Bene: The technique description herein and the use of instructions for the related procedures are made

available by Xomed Surgical Products, Inc. to the health care professional to illustrate the authors suggested

treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which, in the

health care professionals judgment, addresses the needs of the individual patient. The clinician is strongly

recommended to have a thorough understanding of and experience with powered microresector surgical

equipment prior to use.

Powered Laryngeal Surgery

PhilosophyTreatment for the removal of laryngeal lesions has progressed from cold steel

techniques to the use of the CO2laser and KTP fiber directed laser.

While the laser is the standard treatment, a new development, the powered

laryngeal shaver, provides an alternative that is safer, more accurate, and faster

than laser tissue vaporization.

First, with the laryngeal shaver, concerns such as airway fire and laser

plume are eliminated. Additionally, laser burn is eliminated and post procedure

edema is minimized since tissue injury resulting from the shaver technique is

confined to the superficial mucosa only. Our RRP patients historically treated

with the laser have reported reduced post-op pain and quicker recovery of voice

since we adopted the shaver technique.

Using the shaver blade with the aid of a rigid telescope with video system and

a Hollinger style laryngoscope, lesions can be easily removed in the subglottic

region and trachea. For treatment of the difficult to manage airway, the shaver is

invaluable as it may be used to quickly debulk tissue in proximity or direct

contact with the endotracheal tube.

Cutting tips have been designed for applications ranging from rapid

debulking of large, firm lesions (TRICUT Blade) to delicate shaving of superfical

lesions off the folds themselves (SKIMMER Blade). Two lengths are offered,

allowing surgical access to the laryngeal, subglottic, and tracheal regions. To

address the fixed operating radius of the laryngoscope, an angle was added to the

distal tip of the blade and thus the radius of surgical access is increased. This

angle allows the surgeon the best view of the working tip plus enhanced access to

lateral structures, the anterior commissure or the undersurface of the vocal

folds.

Equipment costs, setup and surgical time for the shaver are dramatically

reduced versus the laser. If the hospital already owns the Xomed XPS power


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system, the only cost incurred is that of the disposable shaver blade itself.

Patient Preparation

General anesthesia is induced and the airway secured by endotracheal tube

intubation or tracheotomy if indicated. Size of endotracheal tube will vary

depending on airway conditions (presence of stenosis) and intubation technique.

In adults a small cuffed 5.0mm or 5.5mm ETT is adequate for ventilation and

allows access for surgical instrumentation. With stenotic lesions, smaller cuffless

ETTs may be required. In this situation, the laryngoscope may accommodate

powered instrumentation, rigid telescope, and the ETT, allowing for uninter-

rupted surgery.

The laryngoscope is positioned to allow access to the anatomy to be excised

with the powered shaver. Access to the anterior commissure and subglottic

region may be accomplished using an anterior commissure laryngoscope.

Visualization is enhanced using 0 or 30 rigid telescopes and digital video

systems.

Console settings should be Oscillate mode with a maximum speed set at

1,000 rpms for superficial lesions or those located near or on the vocal folds

(SKIMMER Blade). Use of variable mode of footswitch operation is preferred as

it allows for more controlled excision with slow, single revolutions when needed.When debulking large, exophytic or fibrous lesions, higher speeds up to 3,000

rpms are recommended (TRICUT Blade). The appropriate blade should be

selected and securely attached to the powered handpiece. Irrigation (a 1000cc or

3000cc bag at 6 ft. elevation) must be used with the blade and allowed to flow

continuously throughout the procedure to prevent clogging (use of the XPS

Irrigator Pump #18-95500 is not advised, as it does not allow the continuous

irrigation to clear tissue through the long blade). Wall suction levels may be

adjusted to provide enough vacuum to allow the blade to remove tissue at an

efficient rate (150mm - 180mm Hg). Use of an in-line tissue trap is necessary to

capture specimens for pathology.

Applications For Use

Detailed on the following pages are procedures in which the Angle-Tip RAD

Airway Blades from Xomed are utilized.


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Figure 3 Figure 4

Vocal Fold PapillomaThe SKIMMER Laryngeal Blade is ideal for delicate removal of papilloma from the

vocal fold. (Figures 1-2) Oscillation speeds of 60-1,000 rpms will offer the most

precise result. Note: For the most precise excisions, tissue can be pulled into the

opening and with light pressure on the variable footswitch amputated with single

blade revolutions.

Recommended Blade: 18-83523 SKIMMER Angle-Tip Laryngeal Blade, 3.5mm

18-84023 SKIMMER Angle-Tip Laryngeal Blade, 4.0mm

Speed: 601,000 rpm

Figure 1 Figure 2

Note: With the SKIMMER tip, discreet lesions may be accurately removed with

trauma limited to the superficial mucosa. (Figure 3) For greatest precision

when removing papilloma from the anterior commissure, endoscopic visual-

ization with a 30 endoscope is recommended. (Figure 4)

Authors Note: A 5 or 5.5mm

standard cuffed endotracheal tube is

recommended for these proce-

dures. (not shown in illustrations.)

Authors Note Regarding Bleeding:

Light bleeding typically accompanies

shaver tissue removal. Bleeding

generally subsides as the open aspir-

ation tip of the blade is applied to

the site. Undesired bleeding may be

controlled with the application of a

soaked cotton strip or pad with 4%

cocaine post excision.


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Lesion Removal from Undersurface of Vocal FoldThe angle-tip design of the SKIMMER blade allows excellent access for removal

of lesions located on the undersurface of the vocal fold. (Figures 5-6) With an

oblique endoscope or aid of suction to elevate the vocal fold, delicate excision of

pathology may be achieved.



Speed: 601,000 rpm

Figure 5 Figure 6

Authors Note: Images in Figures

5 and 6 assume microscopic, not

endoscopic visualization and

technique.

Removal of Vocal Fold Polyp

Vocal fold polyps may be quickly and precisely removed without tearing or

trauma to periperal tissues. (Figures 7-8)


Speed: 601000 rpm

Figure 7 Figure 8


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After removal of bulk mass, edges may be more delicately sculpted with a

SKIMMER tip Laryngeal Blade. (Figure 11)


18-84024 SKIMMER Angle-Tip Subglottic Blade, 4.0mm

Speed: Oscillate, 60-1,000 rpm

Figure 11

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Excision of Airway TumorDebulking airway tumors can effectively be achieved by using an aggressive

toothed blade. (Figures 9-10) Higher oscillation speeds of 2,500 to 3,000 may

be needed to remove dense or fibrous tumor tissue and minimize clogging of the

blade.

Recommended Blade: 18-84030 TRICUT Angle-Tip Laryngeal Blade, 4.0mm

18-84031 TRICUT Angle-Tip Subglottic Blade, 4.0mm

Speed: 2,5003,000 rpm

Figure 9 Figure 10


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Subglottic StenosisUsing endoscopic video control and an aggressive subglottic blade, granulation

tissue may be removed to restore patency to the airway. (Figures 12-13)

Recommended Blade: 18-84031 TRICUT Angle-Tip Subglottic Blade, 4.0mm


Speed: 2,5003,000 rpm

Figure 12 Figure 13

Authors Note: A small diameter

cuffed or cuffless endotracheal tube

(4mm-5mm) is recommended in these

procedures. (not shown in illustration)

Tracheal Stenosis

A significant advantage of the laryngeal shaver can be experienced in removalof tissue from the trachea where laser access is limited and cold steel techniques

are inadequate. This technique is applicable for tracheal stenosis, obstructing

tracheal lesions, or metastatic tumors obstructing the airway. (Figures 14-17)

Recommended Blade: 18-84030 TRICUT Angle-Tip Subglottic Blade, 4.0mm

Speed: 2,5003,000 rpm

Figure 14 Figure 15


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Figure 16 Figure 17

Lumen size may be improved to allow placement of a customized tracheo-

stomy tube, T-tube, or tracheal stent.

Reference

This clinical article is provided for additional background material related to the Powered Laryngeal procedure

herein. The health care professional should seek out and review all other clinical reference materials as dictated

by an individual patients clinical condition.

1. PIPE: Powered Instrumentation Papilloma Excision; white paper study; David

S. Parsons, MD, FACS, FAAP (Lit. No. 891159)

General Precautions For Powered Equipment: Blade and bur accessories are available for resection of soft tissue

and bone for various surgical procedures. Proper selection is dependent on the intended application and patient

needs. Sharp cutting powered accessories are capable of inducing bleeding and removal of significant tissue and

bone.

Use care in application of the moving cutting end to only appropriate anatomical structures and the intended

surgical site. Adequate visualization is to be employed. Discontinue powered application in the event of lack of

visualization of the surgical site.


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Ordering Information

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Single use, sterile packaged with irrigation tubing

Product Speed Qty

18-83523 60-1,000RPM 3/box

18-83524 60-1,000RPM 3/box

XPS Model 2000: System 1 & System 2

System 1 includes: Console, STRAIGHTSHOT MAGNUM Handpiece, Multi-Function Footswitch, & Irrigator Pump

System 2 includes: Console, STRAIGHTSHOT MAGNUM Handpiece, & Single-Function Footswitch

Product Qty Product Qty

18-96000X XPS Model 2000: System 1 1 ea 18-96001X XPS Model 2000: System 2 1 ea




Product Speed Qty

18-84023 60-1,000RPM 3/box

18-84024 60-1,000RPM 3/box

18-84030 TRICUT Angle-Tip Laryngeal Blade, 4.0mm

18-84031 TRICUT Angle-Tip Subglottic Blade, 4.0mm


Product Speed Qty

18-84030 2,500-3,000RPM 3/box

18-84031 2,500-3,000RPM 3/box

Powered Instrument Papilloma Excision (PIPE) Surgical Technique Video

Product Qty Product Qty

18-84019 NTSC version (U.S.) 1 ea 18-84019P PAL version (International) 1 ea


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Trademarks of Xomed. Registered marks of Xomed.

Patents Pending. 1998 Xomed Surgical Products, Inc. LIT 891172 08.98

6743 Southpoint Drive North In Australia 800/ 062-289 In Germany 49/ 8105-37-550

Jacksonville, FL USA 32216-0980 In Canada 800/ 710-5201 In the U.K. 44/ 1454-619555

904/ 296-9600 800/ 874-5797 www.xomed.com In France 33/ 169-187400

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