© 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.
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Piśmiennictwo
1.Bergler W., Riedel F., Gotte K., Hormann K.: Argon plasma coagulation for inferior turbinate reduction. Ann. Otol. Rhinol. Laryngol. 2000 Sep; 109(9): 839-43. 2.Bergler W., Huber K., Hammershmitt N. et al.: Tonsillectomy with the argon plasma coagulation raspatorium – a prospective randomized single – blind study. HNO 2000 Feb; 48(2):135-41. 3.Brand C.U., Blum A., Schlegel A. et al.: Application of argon plsama coagulation in skin surgery. Dermatology 1998,197(2):152-7. 4.Sessler M.J., Becker H.D., Flesch I., Grund K.E.: Therapeutic effect of argon plasma coagulation on small malignant gastrointenstinal tumours. J. Cancer. Res. Clin. Oncol. 1995;121(4): 235-8. 5.Hauge T., Moum B., Sandvei P. et al.: Argon plasma coagulation – a new method in therapeutic endoscopy. Tidsskr. Nor. Laegeforen. 2000 May 10; 120(12): 1413-5. 6.Sato M., TeradaY., NakagawaT. et al.: Successful use of argon plasma coagulation to treat granulation tissue obstructing the airway after tracheal anastomosis. Chest 2000 Dec.; 118(6): 1829-31. 7.Gierek T., Paluch J.: Use of coagulation in laryngology – personal experience. Otolaryngol. Pol. 2000, 54(5): 505-9. 8.Erbe Elektromedizin GmbH, Tuebingen. Technology of argon plasma coagulation with particular regard to endoscopic applications. Endosc. Surg. Allied. technol. 1994 Feb; 2(1): 71-7. 9.Bergler W., Farin G., Fischer K., Hormann K.: Argon plasma surgery (APC) in the upper aerodigestive tract. Initial results. HNO 1998 Jul; 46(7): 672-77. 10.Grund K.E., Zindel C., Farin G.: Argon plasma coagulation through a flexible endoscope. Evaluation of a new therapeutic method after 1606 uses. Dtsch Med. Wochenschr 1997 Apr 4; 122(14): 143-8.
