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CANBONDIOXIDE LASER IN TREATMENT OF LARYNGO TRACHEAL STENOSIS D. M. Parikh • H. K. Parikh • R. R a o

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aryngo-tracheal stenosis is a partial or complete cicatricial narrowing of the endolarynx or trachea, which may be congenital or acquired, located at the glottis, above or below it and is characterized by a submucosal scar with an intact cartilaginous framework. Amongst the known etiological factors today, prolonged intubation for mechanical ventilation, accidental injuries and malignancy are common, besides congenital stenosis.

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Conventional surgical procedures involve knife excisions of webs, dilatation, intralesional and systemic steroids, stenting and finally major tracheal resections for difficult cases. The introduction of carbondioxide laser (CO2 laser) and microlaryngoscopy has opened a new era in the effective management of the problem. We present here, or experience of the use of CO2 laser in treatment of laryngo-tracheal stenosis.

I since October 1987. So farwe have treated 6 cases of laryngo-tracheal stenosis. We use the Sharplan CO2 LASER Generator coupled with a Zeiss OPMI 1 operating microscope. We describe briefly our cases : Case 1 : Baby H V R a 6 year old female child was seen with a swelling of the left neck, which was diagnosed as an embryonal rhabdomyosarcoma. She underwent an emergency tracheostomy for stridor, and then received 6 cycles of chemotherapy (Inj Vincristme and Inj Endoxan) over 12 months, with concommitant radiotherapy upto 5600 cGys. The patient was disease free at the end of 1 year of treatment. Attempts at weaning off the tracheostomy were unsuccessful. A microlaryngoscopy revealed a posterior web of the glottis. This was excised with the CO2 laser in 4 sittings in a staged manner. She was decannulated and has a normal airway and voice, 3 months after the last laser sitting.

Material a n d M e t h o d s

We have been using the CO2 laser for treatment of various pathologies %.

M. Parikh, H. IC Parikh, IL Rao.

Deparonent of Surgical Oncology, Tam Memorial Hospita~ Dr. E. Borges Marg Pare~ Bombay-400 012 Address for Reprints Dr. D. M. Parikh, Assistant Surgeon,

Tam Memorial Hospita~ (Tam Memorial Centre), Dr. Ernest Borges Mar~ Pareg ~.Bornbay - 400 022

Fig.1. Photograph showing anterior web due to caustic ingestion. (Case SI. No : 4)

Case 2 : N D male aged 58 years was

seen with a history of hoarseness of voice and a direct laryngoscopy revealed a growth of the anterior commisure and anterior 1/3rd of both vocal cords. A punch biopsy showed a squamous carcinoma, staged as T2, No. H e received 6250 cGys of radiotherapy and was controlled. H e came 30 months later with a recurrence of hoarseness and a direct laryngoscopy revealed an anterior laryngeal web, but no evidence of recurrence of disease. The web was excised at a single sitting with laser and he remains well on follow up, 12 months after laser treatment. Case 3 : JKP female aged 22 years was seen with a history of dyspnoea and stridor for which a tracheostomy was performed. The patient had undergone a tracheostomy during her first delivery, the cause for which could not be ascertained. Subsequently during her second pregnancy, she was again tracheostomized, when a shaggy growth was seen on the posterior tracheal wall, the biopsy of which was unequivocal. A microlaryngoscopy revealed a subglottic growth, the biopsy of which showed only inflammatory tissue. A subglottic stenosis was suspected due to repeated tracheostomies. She underwent graded excision of the stenosis with CO2 laser over 5 sittings, and she was subsequently decannulated and has a normal voice. A recent direct laryngoscopy and fibreoptic bronchoscopy reveal a

Indian Journal of Otolaryngology, Volume 43, No. 2, June 1991 _ 53

Carbondioxide Laver in Trealraent o f Laryngo- Tracheal Stenoais - - Parikh et al

normal trachea with no evidence of restenosis, 6 months after treatment. Case 4 : SVS a female aged 19 years was seen with a history of hoarseness of voice following accidental ingestion of an alkali. On microlaryngoscopy, a web was seen occupying and obliterating the anterior half of the aditus of the glottis. She underwent excision of the web over 3 sittings. At present time she remains completely asymptomatic with a normal voice, 6 months after treatment. Case 5 : K K rrmle aged 20 years was seen with a history of caustic ingestion 1½years ago, and dysphagia of recent origin. Laryngoscopy revealed a complete web in the supraglottic region with a small sinus leading to the airway. The web was excised with laser and he remains well and asymptomatic 6 months after treatment.

cases. In no case was dilatation, stenting, intralesional or systemic steroids used. Success was measured by our ability to decannulate a patient with a tracheostomy or avoid one. Supraglottic Stenosis : One case, which was effectively managed with excision and remains well 6 months after treatment. Glottic Stenosis : Of three cases, 2 were due to a malignant process and a result of their treatment ; one of caustic ingestion. All cases were effectively treated and one of them with a tracheostomy was decannulated with preservation of voice. Subglottic Stenosis : Of 2 cases, one

was possibly die to an iatrogenic cause and the other of probable infoctive pathology. Both patients had tracheostomies at presentation and were successfully decannulated after treatment.

Recurrent stenosis in 2 cases led them to undertake a staged excision of the lesion and interstitial steroid injection, with good results. Duncavage et at, (1985) treated 20 patients with good results in ten. Eight of these required no further supplemental treatment. Their conclusions were equivocal in regard to the effectiveness of CO2 laser in the treatment of laryngo-tracheal stenosis. But, they suggested that anterior webs did well and other lesiohs like posterior e omrnisure, subglottic, or combined lesions did poorly because of extensive vertical depth and the circumferential nature of these lesions, or fixed fibrotic arytenoids. Shygar et al, (1982) treated 16 cases of laryngo-tracheal stenosis and suggested that the treatment plan and

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TABLE 1

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Patient Characteristic Treated With Co2 Laser. SL.NO. 1. 2. 3. 4. 5. 6.

Age/sex 20 / M 6 / F.ch. 58 / M 19 / F 49 / F 22 / F

Etiology . Caustic Ingestion sts# Neck Ca. Vocal Cord

Lesion Sup.glot.* Glottic Glottic

Caustic Ingestion

Glottic

7 Infection ? Inflammation

Sub. Glot.@ Sub. Glot.

Tracheostomy nil yes nil nil yes yes

Adj. R~ nil nil nil all nil nll

Result Good (6 Months) Decannulated (3 Months) Good (12 Months) Good (6 Months) Decannulated (3 Montl~s) Decannulated (6 Montl~s)

* Supraglottic. # Soft Tissue Sarcoma @ Subglottic

Case 6 : IJ female aged 49 years was first seen with a history of brassy cough of 3 months duration. History was non-contributory to the possible cause, but an X-ray chest suggested a prdbable tubercular lesion of the lung. Biopsy of the lesion done previously at a tracheostomy was non-contributory, On microlaryngoscopy, a subglottic stenosis of the posterior wall of the trachea was seen, which was excised with laser in 3 sittings. She was decannulated and remains well 3 months after treatment.

Results

We have used the CO2 laser, as a single modality, for treatment of our

The table lists our cases and their treatment outcome. (Table I) Discussion

McGee et al, (1981) demonstrated the use of CO2 laser in the treatment of subglottic and upper tracheal stenosis in dogs. They, however, observed restenosis in 2 to 3 weeks and concluded that an adjunct like stents or coverage of the raw areas should be used alongwith laser fulguration. Healy, in 1982, further corroborated McGee's findings. Lyons et al, (1980) treated 6 patients of laryngeal stenosis of varying etiology and initially adopted laser excision coupled with dilatation.

54 -Indian Journal o f Otolar)rngology, Volume 43, No. 2, June 1991

outcome should be evaluated on the basis of the location of the stenosis, either supraglottic, glottic, subglotti c or tracheal. They achieved the best results in supraglottic lesions and attribute success to the accuracy and atraumatic property of lasers. However, in glottic, subglottic and tracheal stenosis they feel that the closeness of the raw surfaces disallows good healing and hence restt s in failures. In such situations, they suggest that adjuvant treatment in the form of keels, stents and steroid injections may be useful an d conclude that lasers have a limited use in treatment of laryngotracheal stenosis. Simpson et al, treated 60 patients of laryngo-tracheal stenosis with CO2

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Fig. 3. Complete healing with adequate aixway

Fig. 2. rmmediate poat laser photograph.

laser and had success in 41 cases (68.3%). They did not fred any difference in the success obtained in stenosis of different regions, except tracheal stenosis, where the results were poor,

believe that an ideal situation for assessment of CO2 laser as a single modality of treatment, exists in our series, since none of our patients received any adjuvant therapy and our results have been good.

The reviewed literature provides evidence that failures of treatment with CO2 laser were primarily due to re-stenosis, which can be attributed to scar formation. Stenosis, with strictures of more than I cm and circumferential in nature had poorer success rates than others. Success with surgery depends on the re-epithelialization before scar formation can occur. Hall (1971), Mihashi et al, (1976), and Madden et al, (1970) have shown that there is a delay in scar formation in wounds treated with laser. Dedo and Sooy, (1984) in a unique technique of forming a mucosal micro-trapdoor flap, treated 19 patients with a 90% success rate. They feel that this technique is specially important in subglottic and posterior glottic stenosis. We have had only a small experience in the treatment of laryngo-tracheal stenosis of varying etiology, but have had very satisfactory results. We

The conclusions that can be drawn are : (1) conventional modalities like dilatation has no place in the management" of laryngo-tracheal stenosis, (2) circumferential excisions should be avoided and be done in a staged manner, (3) posterior webs and interarytenoid lesions can be easily lyzed with laser, (4) lesions of more than I cm depth require staged and repeated treatments, (5) laser surgery is the procedure of choice in laryngo-traeheal stenosis. References 1.

Dedo HH and Sooy CD (1984) : Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or mierotrapdoor flap. Laryngoscope. 94 : 445-450. 2. Duncawage JA, O s ~ f f RH, Toohil RJ (1985) : Carbondioxide laser management of laryngeal stenosis.

Ann~ of ototo~,, Rhinoloo Laryngolo~,. 94 : 565-569. 3.

Hall RR (1971) : The he~.ling of tissues incised by ca.rbondioxide laser. Br/z/ah

4.

5.

Healy GB (1982) : Experimental model for the endoscopic correction of subglottie stenosis with clinical application. Laryngoscop~ 92 1103-1115. Lyons GD, Owens R, Lousteau R J, Trail M L (1980) : Carbondioxide laser treatment of laryngeal stenosis.

Archives of Otolaryngology. 106 : 255-256. 6. Madden JE, Edlich RF, Custer JR, et al (1970) : Studies in the management of the contaminated wound, IV. Resistance to infection of surgical wounds made by knife, electrocautery and laser. American Journal of Surgery. 119 : 222-224. 7. McGee KC, Nagle JW, Toohill ILl (1981) : CO2 laser repair of McGee KC, Nagle JW, Toohill ILl (1981) : C02 laser repair of subglottie and upper tracheal stenosis. OtolaryngologyHead and Neck Surgery 89 : 92-95. 8. Mihashi S, Jako G J, Incze J, et al (1976) : Laser surgery in otolaryngology : Interaction of CO2 laser and soft tissue. Annals of new YorkAcademy of Sciences. 208 : 263-294. 9. Shugar JMA, Som PM, Biller H F (1982) : A n evaluation "of the carbondioxide laser in the treatment of traumatic laryngeal stenosis. Laryngoscope. 92 : 23-26. 10. Simpson GT, Strong MS, Healy GB, Shapshay SM, Vaughan CW. Predictive factors o f success o r failure in t h e endoscopic management of laryngeal and tracheal stenosis.Anna/s of Otolo~y, Rhinolo~ and Laryngology. 9I : 384-388..

Journal of Surgery. 5g : 222-225.4

l~dLnn ?oun~ of Otolaryngology, Volume 43, No. 2, June 1991 - 55