- Email: [email protected]
CO 2 laser repair of permanent tracheostomy stricture
laser repair of permanent tracheostomy stricture CO 2
TSILAHEFER,MD, and HENRYZVI JOACHIMS, MD, Haifa, Israel
We present our experience in treating postlaryngectomy patients with respiratory disturbance caused by stricture of the permanent stoma by CO 2 laser surgery. Laser surgery is a simple procedure that can be performed with the patient under local anesthesia without bleeding and with minimal damage to the adjacent strictures resulting in a minimal postoperative edema and contracture. In our opinion the CO 2 laser is a useful surgical tool for enlargement of the airway lumen and for improvement of respiratory disturbance in postlaryngectomy patients with stomal stricture, and this procedure should be considered for treatment of selected patients. (Otolaryngol Head Neck Surg 1997;I 17:276-9,)
C a r b o n dioxide laser therapy is now a well-established procedure and an accepted method of treatment in laryngeal and tracheal surgery. It can precisely vaporize lesions that cause airway obstruction or stenosis with minimal danger of bleeding. 1 We present our experience in treating postlaryngectomy patients with stricture of the tracheal stoma by CO 2 laser, a method of treatment that to our knowledge has not been reported before.
METHODS AND PATIENTS From 1990 to 1996 five patients with severe narrowing of the tracheal stoma were treated by CO 2 laser surgery to widen the airway lumen. They were all men, and ages ranged from 58 to 73 years. All of them had undergone total laryngectomy for carcinoma of the larynx. One patient had also undergone partial pharyngectomy. Neck dissection was performed in three patients. Additional preoperative or postoperative radiation to the neck was given to four patients. Two patients underwent surgery in Israel, and three patients underwent surgery in the former Soviet Union and immigrated to Israel within the last 3 years.
All of the patients had severe narrowing of the permanent tracheostomy by fibrotic scar tissue, which caused severe respiratory disturbance (Figs. 1A and 2A). Two patients also had arteriosclerosis (cardiovascular disease and left heart failure), and one patient had second primary carcinoma of the lung. These disorders made the respiratory ability of all three even worse. One patient underwent Z-plasty repair of the stoma 2 years previously, but the results were not satisfying. The preoperative stoma diameters of those patients ranged from 8 to 12 mm. We used a hand-held system (Sharplan 700. continuous beam, spot size 700~t, power density 15 W). The CO 2 laser surgeries were performed with patients under local anesthesia with lidocaine 2% and adrenaline 1:100.000. The lumen of the stoma was widened with CO 2 laser coherent light cutting the skin, the subcutaneous tissue, and the ring of the scar tissue, until the cartilage of the trachea was exposed. The scar was excised completely, and dilatation by the use of a metallic Storz laryngectomy cannula for 3 weeks was achieved. Antibiotic ointment was applied daily for 7 days to the excised area around the cannula. Figure 2B shows the stoma at the end of the procedure. The posttreatment follow-up ranged from 10 months to 6 years
RESULTS From the Department of Otorhinolaryngology, Rambam Medical Center and Technion Faculty of Medicine. Presented at the Second International Symposiumon Laryngeal and Tracheal Reconstruction. Monte Carlo, May 22-26. 1996. Reprintrequests:TsilaHefer.MD. Departmentof Otorhinolaryngology, Rambam Medical Center, EO. Box 3360. Haifa 31033. Israel. Copyright © 1997 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation. Inc. 0194-5998/97/$5.00 + 0 23/77/83627
276
No bleeding was encountered during the procedure. and no side effects were detected. None of the patients reported any significant inconvenience or pain during or after the operation. The lumen of the stoma was widened, and excellent symptomatic relief was obtained immediately in four patients after one laser treatment. In one patient (the
OtolaryngologyHead and Neck Surgery Volume 117 Number 3 Part I
HEFERand JOACHIMS 277
Fig. I. Neck and stoma before laser treatment (A) and 6 weeks after procedure (8).
first patient we operated on), mild respiratory disturbance required additional CO 2 laser treatment with a marked improvement afterwards. In a follow-up of 10 months to 6 years, no respiratory disturbance was detected in any of the patients. The stoma diameters were widened from 8 to 12 mm before surgery to final postoperative diameter of 14 to 20 ram. Figures 1A and 2A show the neck and the stoma before the laser treatment, and Figs. 1B and 2C show the neck after the treatment. The wound healed nicely. In one of the patients (Fig. 3), who suffered from diabetes and also had a severe skin reaction caused by radiation, the healing duration was a little longer, but at the end it too healed nicely, and epithelization was completed after 9 weeks.
DISCUSSION Stricture of the tracheal stoma is not very common in postlaryngectomy patients, although when it occurs, it may cause severe respiratory disturbance. Strictures in the permanent tracheostomy may be the result of the surgical technique, an infection in the operated field, postoperative or preoperative radiation to the neck, or a previous tracheotomy. We think that the cause may be multiple factors acting in synergy. Each of them may play a minor role in the pathophysiologic process; how-
ever, collectively they may initiate a totally different clinical picture. One of our patients with stricture in the permanent stoma (Fig. 3) has diabetes. He had a previous tracheotomy for severe obstructive sleep apnea syndrome 5 years before the Iaryngectomy and was treated after surgery with radiation to the neck, which caused a severe skin reaction. Another patient (Fig. 2) had radiation to the neck before the total laryngectomy and partial pharyngectomy. That patient also had infection in the operated field. Unfortunately, we do not have relevant information about the other patients who were operated on elsewhere. The common procedure for widening the lumen of a strictured tracheostomy in postlaryngectomy patients is the Z-plasty repair. This procedure is not always easy to perform in postlaryngectomy patients, and the results are not always satisfactory. Therefore a search for an alternative surgical technique for that condition was required. The essential physics of stimulated emissions, which produce coherent laser light, were developed by Einstein in 1917. Patel in 1965 produced the continuous-wave CO 2 laser, which has become the laser most commonly used in otolaryngology. The first clinical
OtolaryngologyHead and Neck Surgery September 1997
278 HEFERand JOACHIMS
c Fig.2. Neck and stoma before laser treatment (A), immediately after procedure (B), and 4 months afterprocedure (O).
C O 2 laser system was developed by the American Optical Corp. in 1969, 2 and since then, the CO 2 laser has rapidly become an important surgical tool in laryngology. CO 2 laser has already been used to remove vocal cord nodules, polyps, granulomas, polypoid hypertrophy, mad vocal cord webs3,4; to excise a laryngeal cyst3; and to perform endoscopic cordectomy and/or arytenoidectomy in order to widen the airway in cases of bilateral vocal cord paralysis. 4,5 It is widely used for ablation of intraluminal masses
in cases of laryngotracheal stenosis 3 and in cases of subglottic hemangioma. 3,6 CO 2 laser is undoubtedly the method of choice for surgical removal of papillomata of the larynx and trachea. 3,4 There are reports of using CO 2 laser surgery for treatment of T1 carcinoma of the larynx with good results 4,7 and for ablation of unresectable intraluminal malignant tumor as a palliative treatment. 8 We found no reports in the literature of CO 2 laser surgery for widening a strictured and narrowed stoma in postlaryngectomy patients.
OtolaryngologyHead and Neck Surgery Volume 117 Number 3 Part 1
HEFERand JOACHIMS 279
The procedure is rapid and easy to perform. It can be done as an office procedure, which saves the cost of an operating room, and therefore the initial cost of the procedure is low. This fact is important because of the costconscious environment in which colleagues around the world now find themselves working. In addition, the CO 2 laser wave can reach inaccessible sites. This procedure can be performed precisely, with the ability to vary the amount of energy delivered, low morbidity in the procedure, and minimal hospitalization period. 4,7 Because of all the advantages mentioned above, in our opinion CO 2 laser surgery is a useful choice of treatment for releasing stricture and for widening the lumen of the tracheal stoma in postlaryngectomy patients, and this procedure should be considered in those selected patients. However, we think that in the more unusual type of situation in which there is actually a loss of or collapse of the cartilaginous framework or a stricture below, this shelf-like narrowing would be unlikely to respond to laser treatment, and another surgical technique should be considered.
Fig, 3. Stoma after laser treatment.
CO 2 laser waves are absorbed by water. The intracellular water absorbing the energy is vaporized at a relatively low temperature. Therefore it can be used with minimal damage to the underlying and surrounding tissue, resulting in minimal postoperative edema. 1,9 In the healing of CO 2 laser wounds of the larynx reported by Tranter et al. (1985), l° little inflammatory response and a few myofibroblasts with little collagen formation in the wounds were found, which meant that minimal scarring or deformation of tissues would result. Although healing of the skin incision cut by CO 2 laser would appear to be slower than incision by scalpel, the final strength of the scar is the same. 11,12 There is an important advantage in performing CO 2 laser incision when operating on vascular tissue, particularly in patients with hemorrhagic tendency. The CO 2 laser can be used to coagulate blood and seal small vessels in the vascular tissue. 1,13 Therefore the operative field around the stoma remains dry, which is an important advantage in extubated patients, preventing the possible aspiration of blood.
REFERENCES 1. Mihashi S, Jako G, Incze J, Strong MS, Vanghan CW. Laser surgery in otolaryngology:interactionof CO2 laser and soft tissue. Ann NY Acad Sci 1976;267:263-94. 2. CarruthJAS. The principlesof laser surgery. In: KerrAG, editor. Scott-Brown's otolaryngology. 5th ed. Vol. 1. London: Butterworth; 1987. p. 513-4. 3. VaughanCW. Use of the carbon dioxide laser in the endoscopic management of organic laryngeal disease. Otolaryngol Clin North Am 1983;16:849-64. 4. Motta G, Villari G, Motta G Jr, Ripa G, Salerno G. The CO2 laser in the laryngealmicrosurgery.Acta Otolaryngol(Stockh) Suppl 1986;433:1-30. 5. Dennis DR KashimaH. Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol 1989;98:930-4. 6. RemacleM, Declaye X, MayneA. Subglottichaemangiomain the infant: contribution by CO2 laser. J Laryngol Otol 1989;103:930-4. 7. Ossoff RH, Matar SA. The advantages of laser treatment of tumors of the larynx.Oncology 1988;2:58-61. 8. OssoffRH. Bronchoscopiclaser surgery: which laser when and why? OtolaryngolHead and Neck Snrg 1986;94:378-81. 9. Fisher S, FrameJ, Browne R, TranterRMD. A comparativehistological study of wound healing followingCO2 laser and conventionalsurgicalexcisionof canine buccal mucosa.Arch Oral Biol 1983;28:287-91. 10. TranterR, FrameJ, BrowneR. The healingof CO2 laser wounds of the larynx. J LaryngolOtol 1985;99:895-9. 11. HallR. The healingof tissues incisedby a carbon-dioxidelaser. Br J Surg 1971;58:222-5. 12. BuellB, SchullerD. Comparisonof tensile strengthin CO2 laser scalpel skin incision.Arch Otolaryngol1983;109:465-7. 13. Hall R. Haemostaticincision of the liver: Carbon-dioxidelaser. Br J Surg 1971;58:538-40.
TSILAHEFER,MD, and HENRYZVI JOACHIMS, MD, Haifa, Israel
We present our experience in treating postlaryngectomy patients with respiratory disturbance caused by stricture of the permanent stoma by CO 2 laser surgery. Laser surgery is a simple procedure that can be performed with the patient under local anesthesia without bleeding and with minimal damage to the adjacent strictures resulting in a minimal postoperative edema and contracture. In our opinion the CO 2 laser is a useful surgical tool for enlargement of the airway lumen and for improvement of respiratory disturbance in postlaryngectomy patients with stomal stricture, and this procedure should be considered for treatment of selected patients. (Otolaryngol Head Neck Surg 1997;I 17:276-9,)
C a r b o n dioxide laser therapy is now a well-established procedure and an accepted method of treatment in laryngeal and tracheal surgery. It can precisely vaporize lesions that cause airway obstruction or stenosis with minimal danger of bleeding. 1 We present our experience in treating postlaryngectomy patients with stricture of the tracheal stoma by CO 2 laser, a method of treatment that to our knowledge has not been reported before.
METHODS AND PATIENTS From 1990 to 1996 five patients with severe narrowing of the tracheal stoma were treated by CO 2 laser surgery to widen the airway lumen. They were all men, and ages ranged from 58 to 73 years. All of them had undergone total laryngectomy for carcinoma of the larynx. One patient had also undergone partial pharyngectomy. Neck dissection was performed in three patients. Additional preoperative or postoperative radiation to the neck was given to four patients. Two patients underwent surgery in Israel, and three patients underwent surgery in the former Soviet Union and immigrated to Israel within the last 3 years.
All of the patients had severe narrowing of the permanent tracheostomy by fibrotic scar tissue, which caused severe respiratory disturbance (Figs. 1A and 2A). Two patients also had arteriosclerosis (cardiovascular disease and left heart failure), and one patient had second primary carcinoma of the lung. These disorders made the respiratory ability of all three even worse. One patient underwent Z-plasty repair of the stoma 2 years previously, but the results were not satisfying. The preoperative stoma diameters of those patients ranged from 8 to 12 mm. We used a hand-held system (Sharplan 700. continuous beam, spot size 700~t, power density 15 W). The CO 2 laser surgeries were performed with patients under local anesthesia with lidocaine 2% and adrenaline 1:100.000. The lumen of the stoma was widened with CO 2 laser coherent light cutting the skin, the subcutaneous tissue, and the ring of the scar tissue, until the cartilage of the trachea was exposed. The scar was excised completely, and dilatation by the use of a metallic Storz laryngectomy cannula for 3 weeks was achieved. Antibiotic ointment was applied daily for 7 days to the excised area around the cannula. Figure 2B shows the stoma at the end of the procedure. The posttreatment follow-up ranged from 10 months to 6 years
RESULTS From the Department of Otorhinolaryngology, Rambam Medical Center and Technion Faculty of Medicine. Presented at the Second International Symposiumon Laryngeal and Tracheal Reconstruction. Monte Carlo, May 22-26. 1996. Reprintrequests:TsilaHefer.MD. Departmentof Otorhinolaryngology, Rambam Medical Center, EO. Box 3360. Haifa 31033. Israel. Copyright © 1997 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation. Inc. 0194-5998/97/$5.00 + 0 23/77/83627
276
No bleeding was encountered during the procedure. and no side effects were detected. None of the patients reported any significant inconvenience or pain during or after the operation. The lumen of the stoma was widened, and excellent symptomatic relief was obtained immediately in four patients after one laser treatment. In one patient (the
OtolaryngologyHead and Neck Surgery Volume 117 Number 3 Part I
HEFERand JOACHIMS 277
Fig. I. Neck and stoma before laser treatment (A) and 6 weeks after procedure (8).
first patient we operated on), mild respiratory disturbance required additional CO 2 laser treatment with a marked improvement afterwards. In a follow-up of 10 months to 6 years, no respiratory disturbance was detected in any of the patients. The stoma diameters were widened from 8 to 12 mm before surgery to final postoperative diameter of 14 to 20 ram. Figures 1A and 2A show the neck and the stoma before the laser treatment, and Figs. 1B and 2C show the neck after the treatment. The wound healed nicely. In one of the patients (Fig. 3), who suffered from diabetes and also had a severe skin reaction caused by radiation, the healing duration was a little longer, but at the end it too healed nicely, and epithelization was completed after 9 weeks.
DISCUSSION Stricture of the tracheal stoma is not very common in postlaryngectomy patients, although when it occurs, it may cause severe respiratory disturbance. Strictures in the permanent tracheostomy may be the result of the surgical technique, an infection in the operated field, postoperative or preoperative radiation to the neck, or a previous tracheotomy. We think that the cause may be multiple factors acting in synergy. Each of them may play a minor role in the pathophysiologic process; how-
ever, collectively they may initiate a totally different clinical picture. One of our patients with stricture in the permanent stoma (Fig. 3) has diabetes. He had a previous tracheotomy for severe obstructive sleep apnea syndrome 5 years before the Iaryngectomy and was treated after surgery with radiation to the neck, which caused a severe skin reaction. Another patient (Fig. 2) had radiation to the neck before the total laryngectomy and partial pharyngectomy. That patient also had infection in the operated field. Unfortunately, we do not have relevant information about the other patients who were operated on elsewhere. The common procedure for widening the lumen of a strictured tracheostomy in postlaryngectomy patients is the Z-plasty repair. This procedure is not always easy to perform in postlaryngectomy patients, and the results are not always satisfactory. Therefore a search for an alternative surgical technique for that condition was required. The essential physics of stimulated emissions, which produce coherent laser light, were developed by Einstein in 1917. Patel in 1965 produced the continuous-wave CO 2 laser, which has become the laser most commonly used in otolaryngology. The first clinical
OtolaryngologyHead and Neck Surgery September 1997
278 HEFERand JOACHIMS
c Fig.2. Neck and stoma before laser treatment (A), immediately after procedure (B), and 4 months afterprocedure (O).
C O 2 laser system was developed by the American Optical Corp. in 1969, 2 and since then, the CO 2 laser has rapidly become an important surgical tool in laryngology. CO 2 laser has already been used to remove vocal cord nodules, polyps, granulomas, polypoid hypertrophy, mad vocal cord webs3,4; to excise a laryngeal cyst3; and to perform endoscopic cordectomy and/or arytenoidectomy in order to widen the airway in cases of bilateral vocal cord paralysis. 4,5 It is widely used for ablation of intraluminal masses
in cases of laryngotracheal stenosis 3 and in cases of subglottic hemangioma. 3,6 CO 2 laser is undoubtedly the method of choice for surgical removal of papillomata of the larynx and trachea. 3,4 There are reports of using CO 2 laser surgery for treatment of T1 carcinoma of the larynx with good results 4,7 and for ablation of unresectable intraluminal malignant tumor as a palliative treatment. 8 We found no reports in the literature of CO 2 laser surgery for widening a strictured and narrowed stoma in postlaryngectomy patients.
OtolaryngologyHead and Neck Surgery Volume 117 Number 3 Part 1
HEFERand JOACHIMS 279
The procedure is rapid and easy to perform. It can be done as an office procedure, which saves the cost of an operating room, and therefore the initial cost of the procedure is low. This fact is important because of the costconscious environment in which colleagues around the world now find themselves working. In addition, the CO 2 laser wave can reach inaccessible sites. This procedure can be performed precisely, with the ability to vary the amount of energy delivered, low morbidity in the procedure, and minimal hospitalization period. 4,7 Because of all the advantages mentioned above, in our opinion CO 2 laser surgery is a useful choice of treatment for releasing stricture and for widening the lumen of the tracheal stoma in postlaryngectomy patients, and this procedure should be considered in those selected patients. However, we think that in the more unusual type of situation in which there is actually a loss of or collapse of the cartilaginous framework or a stricture below, this shelf-like narrowing would be unlikely to respond to laser treatment, and another surgical technique should be considered.
Fig, 3. Stoma after laser treatment.
CO 2 laser waves are absorbed by water. The intracellular water absorbing the energy is vaporized at a relatively low temperature. Therefore it can be used with minimal damage to the underlying and surrounding tissue, resulting in minimal postoperative edema. 1,9 In the healing of CO 2 laser wounds of the larynx reported by Tranter et al. (1985), l° little inflammatory response and a few myofibroblasts with little collagen formation in the wounds were found, which meant that minimal scarring or deformation of tissues would result. Although healing of the skin incision cut by CO 2 laser would appear to be slower than incision by scalpel, the final strength of the scar is the same. 11,12 There is an important advantage in performing CO 2 laser incision when operating on vascular tissue, particularly in patients with hemorrhagic tendency. The CO 2 laser can be used to coagulate blood and seal small vessels in the vascular tissue. 1,13 Therefore the operative field around the stoma remains dry, which is an important advantage in extubated patients, preventing the possible aspiration of blood.
REFERENCES 1. Mihashi S, Jako G, Incze J, Strong MS, Vanghan CW. Laser surgery in otolaryngology:interactionof CO2 laser and soft tissue. Ann NY Acad Sci 1976;267:263-94. 2. CarruthJAS. The principlesof laser surgery. In: KerrAG, editor. Scott-Brown's otolaryngology. 5th ed. Vol. 1. London: Butterworth; 1987. p. 513-4. 3. VaughanCW. Use of the carbon dioxide laser in the endoscopic management of organic laryngeal disease. Otolaryngol Clin North Am 1983;16:849-64. 4. Motta G, Villari G, Motta G Jr, Ripa G, Salerno G. The CO2 laser in the laryngealmicrosurgery.Acta Otolaryngol(Stockh) Suppl 1986;433:1-30. 5. Dennis DR KashimaH. Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis. Ann Otol Rhinol Laryngol 1989;98:930-4. 6. RemacleM, Declaye X, MayneA. Subglottichaemangiomain the infant: contribution by CO2 laser. J Laryngol Otol 1989;103:930-4. 7. Ossoff RH, Matar SA. The advantages of laser treatment of tumors of the larynx.Oncology 1988;2:58-61. 8. OssoffRH. Bronchoscopiclaser surgery: which laser when and why? OtolaryngolHead and Neck Snrg 1986;94:378-81. 9. Fisher S, FrameJ, Browne R, TranterRMD. A comparativehistological study of wound healing followingCO2 laser and conventionalsurgicalexcisionof canine buccal mucosa.Arch Oral Biol 1983;28:287-91. 10. TranterR, FrameJ, BrowneR. The healingof CO2 laser wounds of the larynx. J LaryngolOtol 1985;99:895-9. 11. HallR. The healingof tissues incisedby a carbon-dioxidelaser. Br J Surg 1971;58:222-5. 12. BuellB, SchullerD. Comparisonof tensile strengthin CO2 laser scalpel skin incision.Arch Otolaryngol1983;109:465-7. 13. Hall R. Haemostaticincision of the liver: Carbon-dioxidelaser. Br J Surg 1971;58:538-40.