Recurrent Respiratory Papillomatosis
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Excision of Recurrent Respiratory Papillomatosis by Combined Technique using CO2 Laser & Microdebrider, Case presentation in power point
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Recurrent Respiratory Papillomatosis
- 2. DEPARTMENT OFDEPARTMENT OF OTORHINOLARYNGOLOGYOTORHINOLARYNGOLOGY HEAD & NECK SURGERYHEAD & NECK SURGERY CMH RAWALPINDICMH RAWALPINDI Excision of Recurrent RespiratoryExcision of Recurrent Respiratory Papillomatosis by Combined TechniquePapillomatosis by Combined Technique using COusing CO22 Laser & MicrodebriderLaser & Microdebrider
- 3. 3 Recurrent Airway ObstructionRecurrent Airway Obstruction
- 4. 4 Patient’s profilePatient’s profile • Name: A B C • Age: 3 ½ years • Sex: Female • Residence: Hangu (Khyber-Pakhtunkha)
- 5. 5 PresentationPresentation • Voice change • Breathing difficulty • Taking medications from various physicians for URTI and bronchial asthma. one year
- 6. 6 • Referred from some ENT clinic at Peshawar to CMH Rawalpindi.
- 7. 7 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
- 8. 8 PresentationPresentation • Developmental History: – Developmental milestones as per age • Past History: – No history of any surgical intervention • Family History: – 4th eldest among 5 siblings
- 9. 9 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: 98.4 o F – Resp Rate: 22/min
- 10. 10 General Physical ExaminationGeneral Physical Examination • Signs: • Stridor + • Recessions ++ • Nasal ala flaring +++ • Cyanosis • Pallor • Clubbing • Jaundice • Edema Negative
- 11. 11 ENT ExaminationENT Examination • Detailed ENT examination of – Oral Cavity – Oropharynx/Throat – Nose – Ear • Patient was not cooperative for Indirect Laryngoscopy
- 12. 12 Fiberoptic LaryngoscopyFiberoptic Laryngoscopy • Findings – Extensive laryngeal papillomas over glottic and supraglotic regions.
- 13. 13 Systemic ExaminationSystemic Examination • Gastrointestinal System • Respiratory System • Cardiovascular System • Central Nervous System Unremarkable
- 14. 14 DiagnosisDiagnosis • Juvenile Onset Respiratory Papillomatosis
- 15. 15 Counselling of ParentsCounselling of Parents • Parents counseled in detail about its nature, treatment and prognosis.
- 16. 16 Treatment PlanTreatment Plan • Direct Laryngoscopy & • Combined Carbon-dioxide laser ablation and Microdebridement under GA (on 10th Dec 2010)
- 17. 17 ConsentConsent • Informed written consent (from parents of child) – Risks of surgery – Chances of recurrence & – Need for additional surgical procedures
- 18. 18 Pre-Op work upPre-Op work up • Blood CP • Urine RE • Coagulation profile • X-ray Chest PA view • Pre-anesethesia assesment in ASA-I
- 20. 20 OPERATI •Smaller endotracheal tube of size 5.0 •Aluminum foiling
- 21. 21 Thorough endoscopic examination OPERATI Staging sites and extent of lesion
- 22. 22 Largest possible laryngoscope placed OPERATI
- 23. 23 OPERATI Specimen for biopsy taken
- 25. 25 COCO22 Laser ExcisionLaser Excision • CO2 laser used at – 10 watt power – with 0.1 sec pulses & – small plot size OPERATI
- 27. 27 OPERATI Intraoperative photograph before RRP removal
- 28. 28 OPERATI Extensive papillomas covering glottis Aluminium foiled endotracheal tube Bulky Glottic Lesion
- 29. 29 OPERATI He-Ne aiming beam pointing the glottic area being ablated
- 30. 30 OPERATI Laser ablation in process
- 31. 31 OPERATI Glottic chink after CO2 Laser ablation
- 32. 32 Surgical MicrodebriderSurgical Microdebrider OPERATI Long laryngeal blade Oscillating head
- 35. 35 OPERATI Glottis after excision of lesion
- 37. 37 Post-Operative CarePost-Operative Care • Steroids, analgesics & antibiotics • Steam inhalation • Sniffing exercises • Voice rest
- 38. 38 Follow upFollow up • Marked improvement in her voice and breathing post-operatively. • Parents advised regular follow up.
- 39. DEPARTMENT OF OTORHINOLARYNGOLOGY HEAD & NECK SURGERY CMH RAWALPINDI HOSPITAL DATAHOSPITAL DATA
- 40. 40 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
- 41. 41 Frequency of RRP 18, 86% 3, 14% Child onset RRP Adult onset RRP
- 42. 42 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.
- 43. 43
Editor's Notes
- I’ll present a case of recurrent respiratory papillomatosis operated at CMH Rwp by combined technique using CO2 Laser & Microdebrider
- Recurrent respiratory papillomatosis is a virus induced benign neoplastic process of the upper aerodigestive tract. It occurs in a relatively small number of individuals but is a particularly vexing condition to treat due to its recurrent nature and the negative impact on voice, swallowing, and respiratory function.
- My patient 3 ½ years old girl resident of Hangu,
- Presented with complaints of voice change and breathing difficulty for last one year. Patient was asymptomatic one year back when she initially developed complains of voice change and later she also started having breathing difficulty. It was insidious in onset, not associated with fever or any other illness and gradually increased in severity.
- Her parents had been taking medications from various physicians for URTI and bronchial asthma.
- Birth history is full term spontaneous vaginal delivery. She was breast fed for one year and weaning started at five months. She was vaccinated as per EPI schedule.
- Developmental milestones were as per age. No history of any surgical intervention or illness. She is 4th eldest among 5 siblings
- On general physical examination, a female child active, playful and cooperative. Her height and weight both were lying on 50th percentile. Her vital signs were within normal limits.
- She had mild inspiratory stridor and intercostals recessions. While there was no pallor, cyanosis, clubbing, jaundice and oedema.
- ENT examination of oral cavity, oropharynx, throat, nose and ear was normal. Patient was not cooperative for indirect laryngoscopy.
- Pre-op work up was done & consent for endoscopy under general anesthesia was taken from parents. D/L revealed extensive laryngeal papillomas over glottic and supraglotic regions.
- Her systemic examination including respiratory, gastrointestinal, cardiovascular and central nervous systems was unremarkable.
- On the basis of history, physical examination and direct laryngoscopy findings, final diagnosis of Juvenile Onset Respiratory Papillomatosis was made.
- Parents counseled and were told in detail about the nature of disease, treatment options available with their merits and demerits, possible risks involved in surgery and prognosis of the disease
- Direct Laryngoscopy, debulking of laryngeal papillomas with combined technique using Carbon-dioxide laser ablation and surgical microdebrider under GA.
- Informed written consent was obtained from parents of the patient & explaining risks of surgery, which include: bleeding, infection, recurrence, chipped teeth, altered taste, numbness or weakness of the tongue, persistent or worsened dysphonia, and the likely need for additional surgical procedures.
- Pre-operative investigations done for pre-anesthesia assessment were within normal limits. Patient was placed in ASA-I category for surgery under general anesthesia.
- After general anesthesia induction, airway was secured by intubation with smaller endotracheal tube of size 5.0 to allow more working space for excision of the lesions.
- After general anesthesia has been induced, the airway secured by intubation with smaller endotracheal tube of size 5.0 F to allow more working space for excision of the lesions. Aluminum foiling of the tube done to prevent accidental damage resulting in release of inflammable anesthetic gases.
- After securing the airway, thorough endoscopic examination of the oral cavity, oropharynx, hypopharynx, endolarynx, subglottis, trachea, and esophagus to accurately stage the sites and extent of the RRP.
- Largest laryngoscope possible placed for optimal visualization and ease of excision of the lesion.
- Specimen was taken from the lesion for biopsy with “cold steel” surgical instruments.
- All the laser safety precautions were taken and ensured to prevent any accidental injury to patient and operation theatre staff.
- CO2 laser used at 10 watt power with 0.1 sec pulses & small plot size for the precise surgical excision of RRP lesion.
- Later on surgical microdebrider was used to precisely debride papillomas especially in the region of anterior commisure avoiding thermal injury in this area and smoothing the rough and jagged edges.
- Adequate opening of the glottic chink ensured.
- In the end, haemostasis ensured by applying diluted adrenaline small gauze pieces.