10.14639/0392-100X-N0822
Objective. Respiratory papillomatosis involving the trachea is a challenging problem. In this paper, we present our experience in the management of 13 cases of tracheal papillomatosis and the difficulties encountered in the procedure. The surgical technique and results are discussed. Methods. A modified transoral trans-stomal approach was employed for the removal of papillomas by using microdebrider. All patients were operated on under general anaesthesia with intermittent removal of intubation tube and apnoea. All patients required repeated surgeries. Tracheostomy removal was considered after adequate surgery and recurrence-free interval. The follow-up period was 12-24 months. Results. The total number of surgeries per patient ranged from 3-35 (mean 10). Decannulation could be successfully achieved in 9 patients. There were no procedure-related complications. Conclusions. Transoral trans-stomal microdebrider assisted excision of tracheal papilloma showed excellent results without procedure-related complications. It can be used as a routine procedure for tracheal papillomas. The prognosis of tracheal involvement is fair and most patients can be decannulated.
application/xml
1827-675X
822
en
Alok Thakar
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
hemostasis
Tracheo-bronchial recurrent respiratory papillomatosis: role of powered instruments in overcoming surgical challenges
Text.Serial.Journal
https://www.actaitalica.it/
41
Laryngology
2021-05-14
2020-05-01
2021-05-17
2021-05-17
146-150
1
Alok Thakar
2021/05/14
10.14639/0392-100X-N0822
146
Department of Otorhinolaryngology, AIIMS, New Delhi, India
1827-675X
hemostasis
150
Tracheo-bronchial recurrent respiratory papillomatosis: role of powered instruments in overcoming surgical challenges
https://www.actaitalica.it/article/download/822/577
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:146-150; doi: 10.14639/0392-100X-N0822




Laryngology


Tracheo-bronchial recurrent respiratory
papillomatosis: role of powered instruments
in overcoming surgical challenges
Papillomatosi tracheale e bronchiale ricorrente: il ruolo della strumentazione avanzata
nel superamento delle sfide del trattamento chirurgico
Kapil Sikka1, Madan Gupta2, Hitesh Verma1, Rajeev Kumar1, Alok Thakar1
1
    Department of Otorhinolaryngology, AIIMS, New Delhi, India; 2 Tata Memorial Hospital, Bombay, India


SUMMARY
Objective. Respiratory papillomatosis involving the trachea is a challenging problem. In
this paper, we present our experience in the management of 13 cases of tracheal papilloma-
tosis and the difficulties encountered in the procedure. The surgical technique and results
are discussed.
Methods. A modified transoral trans-stomal approach was employed for the removal of
papillomas by using microdebrider. All patients were operated on under general anaesthesia
with intermittent removal of intubation tube and apnoea. All patients required repeated sur-
geries. Tracheostomy removal was considered after adequate surgery and recurrence-free
interval. The follow-up period was 12-24 months.
Results. The total number of surgeries per patient ranged from 3-35 (mean 10). Decannula-
tion could be successfully achieved in 9 patients. There were no procedure-related compli-        Received: May 1, 2020
cations.                                                                                          Accepted: July 13, 2020
Conclusions. Transoral trans-stomal microdebrider assisted excision of tracheal papilloma
showed excellent results without procedure-related complications. It can be used as a rou-        Correspondence
tine procedure for tracheal papillomas. The prognosis of tracheal involvement is fair and         Hitesh Verma
most patients can be decannulated.                                                                Department of Otorhinolaryngology, AIIMS,
                                                                                                  New Delhi, India
KEY WORDS: trachea, microdebrider, CO2 laser, trachesotomy, hemostasis                            Tel. +91 01126594862. Fax +91 01126588663
                                                                                                  E-mail: drhitesh10@gmail.com
RIASSUNTO
                                                                                                  Funding
Obiettivi. La papillomatosi respiratoria tracheale è un problema clinico impegnativo. In
                                                                                                  None.
questo articolo, presentiamo la nostra esperienza nella gestione di 13 casi di papillomatosi
tracheale e le difficoltà incontrate nel loro trattamento chirurgico. Vengono discussi la tec-
                                                                                                  Conflict of interest
nica chirurgica ed i risultati.
                                                                                                  The Authors declare no conflict of interest.
Metodi. Un approccio transorale trans-stomale modificato con l’impiego di microdebrider.
Tutti i pazienti sono stati operati in anestesia generale con rimozione intermittente del
tubo di intubazione e transitorie brevi fasi di apnea respiratoria. Tutti i pazienti sono stati     How to cite this article: Sikka K, Gupta M, Ver-
operati più di una volta. La rimozione della tracheotomia è stata presa in considerazione           ma H, et al. Tracheo-bronchial recurrent respira-
dopo interventi adeguati ed un lungo intervallo libero da recidive. Il periodo di follow-up         tory papillomatosis: role of powered instruments
è stato di 12-24 mesi.                                                                              in overcoming surgical challenges. Acta Otorhi-
                                                                                                    nolaryngol Ital 2021;41:146-150. https://doi.
Risultati. Il numero totale di interventi chirurgici per paziente variava da 3-35 (media 10).
                                                                                                    org/10.14639/0392-100X-N0822
La rimozione della tracheotomia è stata ottenuta con successo in 9 pazienti. Non ci sono
state complicazioni chirurgiche.
                                                                                                  © Società Italiana di Otorinolaringoiatria
Conclusioni. L’escissione transorale trans-stomale assistita da microdebrider del papillo-        e Chirurgia Cervico-Facciale
ma tracheale ha mostrato risultati eccellenti senza complicazioni correlate alla procedura.
Può essere utilizzato come procedura di routine per i papillomi tracheali. La prognosi del                       OPEN ACCESS
coinvolgimento tracheale è buona e la maggior parte dei pazienti può essere sottoposto a
                                                                                                  This is an open access article distributed in accordance with
rimozione di cannula tracheale.
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
PAROLE CHIAVE: trachea, microdebrider, laser CO2, trachesotomia, emostasi                         Commercial-NoDerivatives 4.0 International) license. The
                                                                                                  article can be used by giving appropriate credit and mentio-
                                                                                                  ning the license, but only for non-commercial purposes and
                                                                                                  only in the original version. For further information: https://
                                                                                                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




146
                                                                  Tracheo-bronchial respiratory papillomatosis: management challenges and results




Introduction                                                          excision was performed after clinical diagnosis of RP and
                                                                      diagnosis was confirmed on histopathology. Six of the 13
The management of respiratory papillomatosis (RP) in-
                                                                      patients received HPV detection and typing using a linear
volving the trachea can be extremely difficult and challeng-
                                                                      array HPV genotyping kit. Five of these had HPV 11 and
ing. The incidence of tracheal involvement in recurrent res-
                                                                      one had HPV 6 infection. Adjuvant medical treatment was
piratory papillomatosis is estimated at around 5%, with 1%
                                                                      prescribed in two cases. Intralesional bevacizumab was ad-
of cases having pulmonary involvement 1. The challenges
                                                                      ministered on two occasions each in these 2 cases (Tab. I).
of endoscopic surgery of trachea are obvious, as the air-
                                                                      One of these patients also received HPV vaccine Gardasil
way is shared with the anaesthetist. There is a risk of distal
                                                                      at 0, 2 and 6 month intervals, and pegylated interferon for
seeding of disease and difficulties are supplemented with a
                                                                      4 weeks.
lack of standard instrumentation. In addition, patients with
these lesions require multiple surgeries during the course of
                                                                      Operative technique
their illness. The literature on surgery of such tracheal le-
                                                                      The modified transoral, trans-stomal technique for papil-
sions has been sparse and techniques are not standardised.
Recent studies have demonstrated a technical advantage                lomatosis removal was performed. The blades were dou-
of a microdebrider in papillomatosis removal over lasers              ble curved with a small cutting point for adequate mu-
and conventional cold instruments 2-7. In this paper, we pre-         cosal safety (Fig. 1). The patients were anaesthetised via
sent our experience on the use of a microdebrider in the              a flexo-metallic tracheal tube. The patients were draped in
management of tracheal papillomatosis and the difficulties            such a way that the control of the cuff was under the surgi-
encountered in the procedure. The surgical technique and              cal team. It allowed easy manipulation of the tube and cuff.
results are discussed.                                                Patients were placed in a microlaryngoscopy position and
                                                                      a laryngoscope was inserted and fixed with suspension.
                                                                      A rigid tracheoscope was introduced transorally, through
Methods                                                               the laryngoscope, for visualisation and suprastomal papil-
This retrospective study was performed in the Department              lomas were debrided. Since control of both tracheoscope
of Otorhinolaryngology, Head & Neck Surgery at All India              and debrider can be difficult for a single surgeon, an endo-
Institute of Medical Sciences, New Delhi. A total of 56 RP            scope may be held in place by the assistant (Fig. 2). The
patients were managed surgically during the study period              stomal port was employed for introduction of the micro-
(2013-2019). Thirteen cases with tracheal and pulmonary               debrider for distal disease since the introduction of both
involvement were included in the current study. Surgical              tools through the stomal port was difficult. After adequate


Table I. Case summary of patients.
 Age (at          Sex        Duration of    1st surgery   Number of    Decanulation          Final status              Adjuvant therapy
 presentation)            disease (years)                 surgeries
26                  M           10            2006           13             No                Malignant           Intralesional bevacizumab on
                                                                                           transformation                 two occasions
38                  M           34            1981           35             Yes              No disease                        None
39                  M            3            2012            4             Yes              No disease                        None
34                  F           10            2004            3             No                Malignant                        None
                                                                                           transformation
15                  M           12            2001           12             Yes              No disease                         None
4                   M            4            2009           14             No            Persistent disease        Intralesional bevacizumab,
                                                                                                                      gardasil and pegylated
                                                                                                                             interferon
9                   F            3            2010           4              Yes              No disease                         None
11                  M            6            2007           6              Yes              No disease                         None
6                   M            5            2009           5              Yes              No disease                         None
11                  M            4            2008           3              Yes              No disease                         None
11                  F            3            2010           4              Yes              No disease                         None
8                   F            4            2009           5              Yes              No disease                         None
8                   M            4            2011           20             No            Persistent disease                    None




                                                                                                                                            147
K. Sikka et al.




Figure 1. Microdebrider blades: Double curved shape and fine cutting edge
facilitates precise and atraumatic debridement.


removal of suprastomal papillomas, and ensuring haemo-
stasis, the tracheal flexo-metallic tube was removed and                    Figure 2. Demonstrating the trans-stomal port and surgical field (line dia-
the patient maintained in apnoea. The apnoea time was                       gram).
used for debridement of distal tracheal papillomas with
the microdebrider inserted through a stomal port (Fig. 2).
Stomal collapse can be encountered making tube re-inser-                    airways should be avoided. None of our patients had seri-
tion difficult, after the apnoea time is over. This challenge               ous pulmonary complications related to surgery, but this is a
is frequently observed in very young children and recent                    theoretical possibility. Second suction by assistant and care
stomas. In such a scenario, two sutures at the stomal edges                 of bleeding by the inflated cuff of flexible endotracheal tube
can be used to keep the stoma patent and as a traction tool                 took care of minor field bleeds. Coblation equipment should
for easy insertion of the tube. An assistant also holds ad-                 be kept handy in case of major bleeds. Poor surgical anatomy
ditional flexible suction through a stomal port for clearing                with high disease volume has higher chances of inadvertent
the airway of any blood and acts as an additional port of                   injury of the complete luminal wall. The application of mi-
tissue suctioning to prevent distal seeding. We have found                  crodebrider blade below the first bronchus was very tricky.
this important, as debrider suction can be insufficient for                 The surgery was staged to prevent undue complications. A
the bulk of tissue and blood. The debrider was thus con-                    final endoscopy check is paramount for adequate haemosta-
trolled with both hands to clear lower airway papillomas.                   sis and to prevent aspiration-related complications.
The rotating function of the laryngeal blade facilitated re-
moval of the papilloma from all walls of the airway. The                    Results
endotracheal flexometallic tube was reinserted after the
apnoea time was over and the surgeon was signalled by                       Out of 13 patients, 9 were paediatric and 4 were adults with
the anaesthetist. The surgeon’s control of the endotracheal                 the same ratio of males and females. All patients presented
cuff prevented undue handling of drapes. It also main-                      with tracheostomy in situ and none had tracheostomy per-
tained the sterile surgical field and allowed control of cuff               formed at the time of debridement. Tracheostomy removal
inflation site to achieve haemostasis, if carefully inflated                was considered after adequate recurrence free interval.
at the site of debridement. A coblator was kept ready to                    The follow-up period was 12-24 months. Relevant data are
coagulate any persistent bleeding, but it was not required                  summarised in Table I.
in any case. The cycle of ventilation-debridement was re-                   Duration of disease ranged from 9-32 years (average 17
peated, until adequate clearance is achieved.                               years) in adults and 2-12 years (average 7 years) in the pae-
                                                                            diatric group. The total number of surgeries ranged from
Complications and pitfalls                                                  3-35 (mean 10). The disease was limited to the upper 1/3
The tube insertion at end of apnoea time needs to be swift.                 of the trachea in 5 patients, upper 2/3 in 3 patients and the
An experienced and alert assistant can make it easier for                   entire trachea in 5 patients. Two patients had pulmonary
the surgeon to focus on the main surgery. As already men-                   involvement (Fig. 3).
tioned, the stomal sutures can be used as a traction device                 Decannulation could be successfully achieved in 9 pa-
and make tube reinsertion easier.                                           tients. Two patients had pulmonary involvement that was
Aspiration of blood, secretions and papillomas into the lower               identified by peripheral cavitary lesions on CT scan (Fig.



148
                                                                                 Tracheo-bronchial respiratory papillomatosis: management challenges and results




Figure 3. Emblazon trachea with subsite frequency showing upper one third            Figure 4. HRCT chest of a patient with pulmonary involvement showing mul-
in 5, lower two third in 3, whole trachea in 5 and pulmonary involvement in 2.       tiple air filled cavities with thick wall in bilateral lung field.


4). Neither of these patients with pulmonary involvement                              A                                        B
could be decannulated, with one developing malignant
transformation. In the long term, two adult patients de-
veloped malignant transformation which recurred despite
curative attempts with chemoradiotherapy and surgical sal-
vage in one patient. There was no procedure related com-
plication. The representative intraoperative and follow-up
picture of one of the cases is presented in Figures 5a and b.

Discussion                                                                           Figure 5. Intraoperative view of tracheal papillomas debrided with microde-
Surgical removal of tracheal papillomas is difficult and                             brider inserted through stomal port. An additional suction can be seen to facili-
                                                                                     tate clearance of secretions. Right side picture is showing infrastomal trachea
challenging. It requires an adequate simultaneous visuali-                           at 6 weeks follow-up of same patient.
sation, instrumentation and ventilation.
Rees et al. 3 described the use of the microdebrider for
removal of tracheal papillomas in conjunction with visu-                             in the younger age groups. Ventilation through a small
alisation by a rigid telescope. They noted that the small                            2.5 bronchoscope may be ineffective, especially in older
confines of the paediatric larynx do not allow simultane-                            children. Moreover, we experienced inadequate visuali-
ous use of a ventilating bronchoscope and microdebrid-                               sation by insertion of the microdebrider blades through
er in the trachea. Ulualp et al. 4 described a technique                             bronchoscope lumen. We prefer visualisation by a rigid
for trans-stomal management of tracheal papillomas,                                  telescope through an oral port, constantly maintained by
where the bronchoscope and microdebrider are both in-                                the laryngoscope in suspension and hence, the debrider
troduced through the patient’s stoma. However, the size                              may be inserted through a stoma.
of the ventilating bronchoscope is limited to 2.5 due                                CO2 laser has been widely studied as a modality for the
to the constraints of stoma size. We have experienced                                treatment of respiratory papillomatosis. Recent studies
similar constraints in inserting the tracheoscope and                                have reported that a microdebrider is a safe, effective, quick
debrider blades through same stomal port, especially                                 and cheaper option. In addition, the use of carbon dioxide



                                                                                                                                                                149
K. Sikka et al.




laser in tracheal lesions is difficult with currently available      complications. It can be used as a routine procedure for
technologies 7,8. The technique, safety and efficacy of its us-      tracheal papillomas. The prognosis of tracheal involvement
age in the lower airways have not been well documented. The          is fair and most patients can be decannulated.
majority of tracheal RP presented in the emergency depart-
ment with some respiratory compromise, and we have found             References
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