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Endoscopic Removal of Suprastomal Granuloma Using a Flexible KTP laser

Surgical removal of suprastomal granuloma is a procedure performed prior to the probable decannulation of a tracheostomy. There are several ways of achieving this objective, but in certain cases, a KTP laser on a flexible delivery system offers a precise and controlled method to successful debulking of the granuloma with minimal risks of haemorrhage into the airway.

DOI: http://dx.doi.org/10.17797/pqzu0ns9y9

Editor Recruited By: Sanjay Parikh, MD, FACS

Diagnostic microlaryngoscopy and bronchoscopy (MLB) is performed regularly in patients who have had a tracheostomy placed. At the time of decannulation, a MLB would be taken prior to decannulation, and if it was found that there was a significant suprastomal granuloma at the site of the tracheotomy, this requires surgical removal before decannulation can be safely considered. The laryngoscope is placed into the vallecula, and a zero degree telescope is used to examine the laryngeal, tracheal and bronchial airway. If we have to remove the suprastomal granuloma, it can be performed in several ways. Our initial preference is to deliver the granuloma through the tracheostomy stoma, and divide it with a Bovie diathermy at the skin. If this is not possible, we have facilities to do it endoscopically with a KTP (potassium titanyl phosphate) laser. The KTP laser has a wavelength of 532 nm, emitting bright green visible laser light. In general, laser wavelengths from 532 to 595 nm have predominantly been used to treat vascular disorders of the skin or mucosa. The KTP laser beam is well absorbed by hemoglobin, and thus allows photocoagulation of microvascular lesions with minimal damage to the epithelium when used at a low power. All laser precautions are undertaken preoperatively, with proper eye protection, and instructions to the theatre staff about the use of the laser. Precautions are also undertaken in the event of an airway fire. The tissue to be treated is soaked in topical anaesthesia usually 1-2% lidocaine, with 1:10,000 epinephrine soaked in cotton pledgelets applied to the tissue, and removed completely before the use of the Laser. This is reapplied throughout the case. The laser beam was delivered through a flexible optical fiber attached to a curved hand piece with a suction channel for evacuating smoke. The laser was used at a low power of 3.0 W with a defocused beam in the continuous mode. The laser beam was delivered from just above the surface of the lesion allowing coagulation of the lesion. Once the lesion was appropriately coagulated at the base, the lesion was excised using microlaryngeal forceps and fine scissors. Any extra remnants was treated with the KTP laser.
Suprastomal granulation causing significant airway compromise and not allow successful tracheotomy decannulation; Provision of a temporary airway through the larynx should the tracheotomy be displaced for a prolonged period of time
Bleeding disorder may need to be optimised before surgery A neighbouring blood vessel may be exposed should the granuloma be excised, hence the requirement for imaging prior to surgery Poor visible access to the trachea or larynx from oral cavity
Microlaryngoscopy setup with chest support; KTP laser with delivery device and 200-300 nm fibre; Zero degree or 30 degree rod lens telescope ¢ 18-30 cm length to permit visualisation of the suprastomal area; Water to use in case of an airway fire; Protection for staff and patient whilst using the KTP laser;
Preoperative Imaging to exclude the presence of a vascular structure at site of surgery
Suprastomal granuloma is usually on the anterior wall of the trachea, just above the tracheostomy tube placement. It is usually based on the anterior wall of the trachea, a few centimeters below vocal cords.
Advantages: Precise visualisation of the granuloma; KTP laser fibre placed at 1-5mm from the granuloma allows precise ablation of the granuloma from an endoscopic view point; KTP laser has a predilection towards the blood vessels, allowing coagulation and ablation of the tissue which is usually very vascularised and fibrotic. Disadvantages: Laser setup with laser precautions required ¢ use of a laser safe tube; Costs of setup with instrumentation; Requires laser accredited staff
Risk of excessive bleeding into the airway; Risk of airway fire; Recurrence of granuloma if the tracheotomy is left in position for a prolonged period
Risk of excessive bleeding into the airway Risk of airway fire Recurrence of granuloma if the tracheotomy is left in position for a prolonged period
Nil
Ang AH et al (2005) Pediatric tracheostomies in an Asian Population: the Singapore experience. Otolaryngol Head Neck Surg 133:246-250 Benjamin B, Curley J. (1990) Infant tracheotomy - endoscopy and decannulation. IJPO 20 (1990) 113-121 Carter P, Benjamin B (1983) Ten year review of pediatric tracheotomy. Ann Otol Rhinol Laryngol 92:398-400 Gray RF et al (1998) tracheostomy decannulation in children: approaches and techniques. Laryngoscope 108:8-12 Kubba et al (2004) Can we develop a protocol for the safe decannulation of tracheostomies in children less than 18 months old? Int J Pediatr Otorhinolaryngol 68: 935-93 Waddell A et al (1997) The Great Ormond Street protocol for ward decannulation of children with tracheostomy: increasing safety and decreasing cost. int J Pediatr Otorhinolaryngol 39:111-118

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