© Borgis - New Medicine 2/2001, s. 23-25
Lidia Zawadzka-Głos, Mieczysław Chmielik, Anna Gabryszewska
The application of argon plasma coagulation in the treatment of laryngeal stenosis in children
Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw
Head of Department: Prof. Mieczysław Chmielik, MD.
Summary
The aurthors present their own method for the treatment of postintubation laryngeal stenosis with argon plasma coagulation (a.p.c.). The study is based on 7 children aged from 6 months to 9 years with from Ist to IVth degrees of postinubation laryngeal stenosis. We describe the method of treatment, postoperative care and the therapeutic effects of management. An improvement was achieved in all children treated with a.p.c. Side-effects and changes for the worst weren´t observed. Up to now the authors havent found information in the available literature about treatment of postinubation laryngeal stenosis using a.p.c. We assess a.p.c. as a safe and promising method.
The most common reason for tracheostomy in children is postinubation laryngeal stenosis. The treament of postinubation stenosis is multi – phase and long – lasting. Care of children with a tracheostomy must be stressed, particularly in infants and children up to 3 years old. There is a high risk of death, because of tracheostomy tube obstruction by secretions or involuntary removal of the tracheostomy tube. Typical surgical treatment of postintubation stenosis of the larynx consists of an incision of the laryngeal scars with classic instruments for microsurgery of the larynx, or using laser equipment. A separator is put in the incision site.
Since 1996 a.p.c. has been introduced as a new method in endoscopic surgery. The authors found, in the available literature, information about the application of a.p.c. in the reduction of hypertrophic nasal concha (1), in tonsillectomy (2), in treatment of skin lesions (3), T1 – stage tumours of the gastrointenstinum (4) and neoplastic tumours of the respiratory tract, in the removal of granulation tissue that had formed on an end – to – end anstomosis (6), in endoscopic treatment of haemorrhages in the gastrointenstinum (5), in epistaxis (Osler´s disease) (9, 10) and in the treatment of papillomatosis of the larynx and bronchus (11). Information about treatment of postintubation laryngeal stenosis was not found.
MATERIALS
The purpose of this study was to assess the effectiveness of the treatment of postintubation laryngeal stenosis with a.p.c. Seven children (3 boys and 4 girls) suffering from postintubation laryngeal stenosis, aged from 6 months to 9 years, were qualified for treatment with a.p.c. Four children were found to have the IVth degree of stenosis (no lumen of the larynx), 2 children were found to have the IInd degree of stenosis, and 1 child was found to have the Ist degree of stenosis. All children had prolonged intubation due to respiratory failure, because of inflammatory diseases of the lower respiratory tract (2), prematuriti (1), multi – organ trauma (2), an operation for congentital heart disease in children with Down´s Syndrome (1), or repeated intubation of a child with multi – congenital defects (1).
Children with the IVth degree of stenosis were previously most often treated using a separator many times without a successful improvement. The child with Down´s Syndrome with the IInd degree of stenosis had suffered 3 operations for dilation of laryngeal stenosis with tubes without using a separator. Two children have not so far been treated because of laryngeal stenosis. One of them has the IInd degree of stenosis, and the second the Ist degree of stenosis. All the children (6) with IInd and IVth degree of stenosis have had a tracheotomy. One boy with the Ist degree of stenosis breaths naturally, stridor and dyspnoea occuring only on exercise.
METHODS
A.p.c. was used for the treatment of laryngeal stenosis. Our a.p.c. equipment consist of an argon gas source and high – frequency surgical unit (APC 300 ERBOTOM ICC 350 – ERBE Electromedizine GmbH), and a rigid probe with ceramic nozzle at 0° or 90° relative to the axis of the probe. Different coagulation times were used, ranging from 1 to 3 seconds. The flow rate of the argon gas during coagulation was set at 1.0-1.2 l/min. All operations were performed under general anaesthesia. From the first day after the operation, we applied inhalation with a mucolytic drug, hydrocortisone, and breathing exercises with a closed tracheostomy tube were performed (the children breathing through the aperture of the tracheostomy tube situated at the lumen of the trachea).
RESULTS
The effects of the treatment were assessed on the following endoscopic measurements of the larynx. In the child (K.B.) with total atresia of the larynx 6 operations for dilation of the stenosis with a.p.c. were performed, and a 3.5 bronchoscope was passed through the stenosis after two operations. This effect was intermittent, the lumen of the larynx gradually constricting. We achieved constant dilation after fifth operation, with a bronchoscope diameter of 3.0 extended to admit an instrument of 3.5 diameter. The scar closing the lumen of the subglottic region was very thin. The operation was initially repeated at intervals of from 7 to 14 days. The last operation was performed after the passage of 6 weeks.
In the 9-year old girl (A.G.) with the IVth degree of stenosis due to 6 operations for dilation of the larynx with a.p.c., we opened feedom the lumen of the larynx to pass a 3.5 bronchoscope. The girl was found to have two concentric scars: the first (I) just below the glottis and the second (II) about 1 cm below the glottis. She only has the first stenosis (I) now, and it is definitely thinner than before the first coagulation. The operations were performed at intervals of 24 days, 35 days, 25 days, 90 days and 11 days.
The 11-months old boy (I.H.) with multiple congenital defects, after repeated inubations due to operations correcting congenital heart disease and cleft palate, has had 4 a.p. coagulations for stenosis of the larynx. We found total atresia before the first operation. The lumen of the larynx, before the 5th coagulation, is now slit – like and the scar is still thick. The lumen of the larynx will pass a 3.0 bronchoscope after the last operation. In this case we also suspect a congenital anomaly of the cricoid cartilage. The child is under diagnostic investigation.
A boy (Ł.K) 1-year and 1-month old, with the IVth degree of stenosis of the larynx, has had 3 operations with a.p.c. The lumen of the larynx is now sufficient to pass a 2.5 bronchoscope.
Two children with IInd degree of stenosis and one boy with Ist degree of stenosis have had 1 or 2 operations with a.p.c. It is too early to describe any significant effect of the treatment. These children are under care and further operations will be performed. We have achieved an improvement in each of these children so far.
DISCUSSION
Treatment with a.p.c. was included in the therapy of 7 children with different degrees (I-IV) of postintubation laryngeal stenosis. First, the method was included in the treatment of 4 children with the IVth degree of stenosis, in which up to that time other methods of treatment had not been successful. The good results of treatment encouraged us to treat 3 other children with a.p.c. We observed differentiated improvement in all children treated this way, including a constant lumen of the larynx in children with the IVth degree of stenosis and decreasing of scar thickness in others. The advantages of a.p.c. are: good control of intraoperative haemostasis and absence of bleeding, no granulation in the place of coagulation, short operation time, controllable doses of energy, shorter postoperative care period than after classic management with a laryngeal separator. Side-effects were not observed in any patient.
In the literature, a.p.c. and laser therapy were compared to each other (9). A.p.c. dosen´t require laser protection methods. The depth of penetration in tissue is more controllable and consequently there is a lower risk of perforation of the wall of the respiratory tract. Carbonization of tissue, produced by lasers, isn´t observed with a.p.c. Also the a.p.c. has advantages in the treatment of children with coagulation defects. Of course, it is not a perfect method. Argon, although it doesn´t react with other gases, can eliminate oxygen from the airways, so it is necessary to monitor oxygenation of the blood during the operation and also in the postoperative period.
CONCLUSION
Analysis of a.p.c. treatment of postintubation laryngeal stenosis shows that the method of treatment proposed by the authors is safe, and gives an improvement in condition. Up to now the authors haven´t found information about the use of a.p.c. in treatment of postintubation laryngeal stenosis. On analysis of information from other reaserchers, we can say that a.p.c. is a method with wide perspectives.
Twety – three operations with a.p.c. have been performed. None of the operated children showed worsening of their condition. Monitoring the saturation of blood during the operation and in the postoperative care period showed normal ranges. Side – effects or complications didn´t occur in any cases.
Piśmiennictwo
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