Endotracheal tube obstruction: a rare complication in laser ablation of recurrent laryngeal papillomas. (Original Article).
During the past 25 years, use of the carbon dioxide carbon dioxide, chemical compound, CO2, a colorless, odorless, tasteless gas that is about one and one-half times as dense as air under ordinary conditions of temperature and pressure. (CC2) laser has been accepted as the most appropriate surgical method for the treatment of recurrent laryngeal papillomatosis laryngeal papillomatosis
A condition characterized by multiple squamous cell papillomas of the larynx, seen most commonly in young children, usually due to infection by the human papilloma virus transmitted at birth from the maternal genital warts. . Although [CO.sub.2] laser technology and surgical techniques continue to improve, laser-related complications still occur. We describe a case of a very rare complication--to our knowledge, only the second such case reported in the literature--in which an endotracheal tube was almost completely obstructed by a piece of papillomatous pap·il·lo·ma·tous
Relating to a papilloma. tissue during [CO.sub.2] laser microlaryngoscopy for the treatment of recurrent laryngeal papillomatosis.
Recurrent laryngeal papillomatosis is a disease of viral etiology that occurs in both juvenile- and adult-onset forms. Lindeberg et al classified this disease into four clinical categories: juvenile single, juvenile multiple, adult single, and adult multiple. (1)
Over the past 2 decades, a variety of treatments has been proposed for the management of recurrent laryngeal papillomatosis, including surgical excision, (2) cryosurgery cryosurgery (krī`ōsr'jərē), bloodless surgical technique using a supercooled probe to destroy diseased or superfluous tissue. , (3) steroids, (4) podophyllum, (5) interferon, (6) and laser surgery. (7) None of these modalities can totally eradicate the disease, but the carbon dioxide ([CO.sub.2]) laser appears to be the most accepted method of treatment because of its ability to vaporize va·por·ize
To convert or be converted into a vapor.
To dissolve solid material or convert it into smoke or gas. papillomas without causing bleeding or edema edema (ĭdē`mə), abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts. and for the precise way in which it removes lesions without causing injury to underlying laryngeal laryngeal /lar·yn·ge·al/ (lah-rin´je-al) pertaining to the larynx.
la·ryn·geal or la·ryn·gal
Of, relating to, affecting, or near the larynx. structures. Even so, complications still occur.
In this article, we describe what we believe is only the second reported case of endotracheal tube obstruction caused by an avulsed papilloma papilloma /pap·il·lo·ma/ (pap?il-o´mah) a benign tumor derived from epithelium.papillo´matous
fibroepithelial papilloma a type containing extensive fibrous tissue. during intubation intubation /in·tu·ba·tion/ (in?too-ba´shun) the insertion of a tube into a body canal or hollow organ, as into the trachea.
endotracheal intubation in [CO.sub.2] laser surgery for the management of recurrent laryngeal papillomatosis.
A 4-year-old white girl was admitted for removal of recurrent papillomas of the larynx. The patient had undergone three previous [CO.sub.2] laser excisions. Evaluation in the clinic the day before surgery revealed that the child had a 3-week history of increasing hoarseness and increasing stridor Stridor Definition
Stridor is a term used to describe noisy breathing in general, and to refer specifically to a high-pitched crowing sound associated with croup, respiratory infection, and airway obstruction. while sleeping at night. Flexible endoscopy endoscopy
Examination of the body's interior through an instrument inserted into a natural opening or an incision, usually as an outpatient procedure. Endoscopes include the upper gastrointestinal endoscope (for the esophagus, stomach, and duodenum), the colonoscope (for the in the office had detected a large papillomatous mass in the left larynx. Findings on the remainder of the physical examination were unremarkable.
The patient was brought to the operating room and given mask sedation. After an intravenous peripheral catheter was placed, the patient was intubated with a 3.0-mm internal-diameter (ID) flexible metal laser endotracheal tube. At this point, the anesthesia personnel reported some mild difficulty in ventilating ventilating
Natural or mechanically induced movement of fresh air into or through an enclosed space. The hazards of poor ventilation were not clearly understood until the early 20th century. Expired air may be laden with odors, heat, gases, or dust. the patient. The difficulty appeared to resolve with albuterol albuterol /al·bu·ter·ol/ (al-bu´ter-ol) a ß agonist used as the base or sulfate salt as a bronchodilator.
n. treatment, and the patient retained her oxygen saturation level in the range of 99 to 100%. We proceeded with the surgery, and the patient was allowed to breathe spontaneously during the procedure.
A Dedo anterior commissure laryngoscope was introduced into the patient's oral cavity and advanced into the larynx under direct visualization. A large laryngeal papilloma that had originated in the left false vocal fold was noted. The lesion appeared to extend into the ventricle ventricle /ven·tri·cle/ (ven´tri-k'l) a small cavity or chamber, as in the brain or heart.ventric´ular
ventricle of Arantius the rhomboid fossa, especially its lower end. .
The papilloma on the left false vocal fold was ablated with continuous [CO.sub.2] laser energy at 5W. On examination of the right side of the larynx, a small area of papilloma on the right true vocal fold was noted. At this point, a small amount of papillomatous tissue was observed in the distal opening of the endotracheal tube; it had been inserted at the beginning of the operation, possibly when the patient was intubated. The laryngoscope was removed, and preparation for anesthesia reversal was initiated. Upon removal of the endotracheal tube, the patient exhibited no respiratory problems. However, we noted that a plug of papillo matous tissue had almost completely occluded the distal tip of the endotracheal tube (figure). With the use of flexible bronchoscopy, we noted no distal dislodgment of tissue in the tracheobronchial tracheobronchial /tra·cheo·bron·chi·al/ (-brong´ke-al) pertaining to the trachea and bronchi.
Of or relating to the trachea and the bronchi. tree. Following the bronchoscopy Bronchoscopy Definition
Bronchoscopy is a procedure in which a cylindrical fiberoptic scope is inserted into the airways. This scope contains a viewing device that allows the visual examination of the lower airways. , the patient was awakened from the general anesthesia, and she recovered uneventfully. Apparently, because the endotracheal tube was small, the patient was able to ventilate ventilate,
v 1. to provide with fresh air.
v 2. to provide the lungs with air from the atmosphere.
v 3. to open, to free, as in to openly express one's feelings. around it because she was allowed to breathe spontaneously during surgery.
Extensive information regarding the use of the [CO.SUB.2] laser in recurrent laryngeal papillomatosis has been accumulated since it was first used in the 1970s. (7) This experience includes the reporting of various immediate and long-term complications.
Reported complication rates. In a study of all types of [CO.SUB.2] laser surgery in the upper aerodigestive tract, Healy et al reported a complication rate of 0.2% (nine complications in 4,416 procedures). (8) Six of these nine complications were life-threatening; five involved a fire in the endotracheal tube and one involved the ignition of a dry sponge that was placed over a tracheostomy in a pediatric patient during laser bronchoscopy for papillomatosis of the tracheobronchial tree. The other three complications were minor: two cases of hemorrhage and one case of skin burn.
Ossoff et al reported a complication rate of 5.9% (12 complications among 204 procedures); none was lifethreatening. (9) Theirreview demonstrated the relative safety of the CO laser when it is used judiciously, and they 2 recommended the Rusch red rubber endotracheal tube wrapped with reflective metallic tape as the safest of these instruments.
Wetmore et al reviewed 222 cases of [CO.sub.2] laser surgery for recurrent laryngeal papillomatosis and reported a laser-related complication rate of 0.5%. (10) In their study, no airway fire was reported, and the only life-threatening complication was a case of bilateral pneumothorax pneumothorax (nmōthôr`ăks), collapse of a lung with escape of air into the pleural cavity between the lung and the chest wall. The cause may be traumatic (e.g. .
Types of complications. The complications of [CO.SUB.2] laser microlaryngoscopy can be classified as direct, secondary, or delayed (table):
Direct complications. Direct laser complications are caused by direct contact of the laser beam with objects in the operative field. The extent of resultant tissue damage is related with the basic parameters of the [CO.SUB.2] laser, such as the duration of exposure and the power density absorbed by the tissue. Direct complications include the most serious [CO.SUB.2] laser complication: endotracheal tube ignition. (8, 11) Most cases of endotracheal tube fire occurred during the early years of [CO.SUB.2] laser microlaryngoscopy when a laser beam made contact with the external surface of an unprotected endotracheal tube or a tube that was poorly wrapped with aluminum tape. Another major direct complication is tracheal tracheal
pertaining to or emanating from trachea.
see transtracheal aspiration.
tracheal band sign
on contrast radiography of a dilated esophagus, the impression made ventrally by the trachea. perforation per·fo·ra·tion
1. The act of perforating or the state of being perforated.
2. An abnormal opening in a hollow organ or viscus, as one made by rupture or injury.
A hole. , which can lead to pneumothorax and subcutaneous emphysema. (10)
Secondary complications. Secondary laser complications are indirectly related to the laser beam's impact on tissue. Major secondary complications include endotracheal tube ignition by flaming ablated tissue and tube obstruction by ablated tissue. Other secondary complications include airway obstruction from displaced aluminum foil, (12) mucosal charring, hemorrhage, edema, and perichondritis.
Delayed complications. Delayed laser complications occur after the healing process has been completed. They include vocal fold webs, (10) laryngeal and tracheal cicatrix cicatrix /cic·a·trix/ (si-ka´triks) (sik´ah-triks) pl. cica´trices [L.] scar.
vicious cicatrix one causing deformity or impairing the function of a limb. , glottic incompetence as a result of excessive tissue removal, (13) laryngeal carbon granuloma granuloma /gran·u·lo·ma/ (gran?u-lo´mah) pl. granulomas, granulo´mata an imprecise term for (1) any small nodular delimited aggregation of mononuclear inflammatory cells, or (2) such a collection of modified macrophages , (13) and papilloma implantation elsewhere in the upper aerodigestive tract. (14) Ossoff et al postulated that most delayed complications are related to excessive ablation of tissue and the transmission of thermal energy into the underlying lamina propria. (9)
To our knowledge, the only other case of such an endotracheal tube obstruction by ablated tissue was reported in 1980 by Torres and Reynolds. (15) Their case involved a 4.0-mm ID tube. Our patient was able to ventilate around the small, cuffless 3.0-mm ID tube because she was allowed to breathe spontaneously during surgery. If tube obstruction by papillomatous tissue is suspected, the tube should be removed and intraoperative bronchoscopy should be performed.
We conclude by emphasizing the necessity of surgeons being completely familiar with their laser equipment and the importance of safety protocols.
able Three types of complications of [CO.sub.2] laser microlaryngoscopy for recurrent laryngeal papillomatosis Direct complications Endotracheal tube ignition Ignition of cottonoid Tracheal perforation Pneumothorax Subcutaneous emphysema Mucosal burn Corneal burn Cuff rupture Secondary complications Endotracheal tube ignition from insufflated lasered tissue Endotracheal tube obstruction by lasered tissue Airway obstruction from displaced aluminum foil Mucosal charring Hemorrhage Edema Perichondritis Delayed complications Acquired vocal fold webs Laryngeal or tracheal cicatrix Glottic incompetence caused by excessive tissue removal Laryngeal carbon granuloma Papilloma implantation elsewhere in the upper aerodigestive tract
(1.) Lindeberg H, Oster S, Oxlund I, Elbrond O. Laryngeal papillomas: Classification and course. Clin Otolaryngol 1986;11:423-9.
(2.) Holinger PH, Schild JA, Maurizi DG. Laryngeal papilloma: A review of etiology and therapy. Laryngoscope 1968;78:1462-74.
(3.) Singleton GT, Adkins WY. Cryosurgical treatment of juvenile laryngeal papillomatosis juvenile laryngeal papillomatosis A neoplasm in children caused by HPV types 6 and 11, which may also occur in adults in the upper respiratory tract–known as recurrent respiratory papillomatosis; JLP is analagous to condyloma acuminatum of the genital tract; . An eight year experience. Ann Otol Rhinol Laryngol 1972;81:784-90.
(4.) Szpunar J. Laryngeal papillomatosis. Acta Otolaryngol 1967;63:74-86.
(5.) Dedo HH, Jackler RK. Laryngeal papilloma: Results of treatment with the CO2 laser and podophyllum. Ann Otol Rhinol Laryngol 1982;91:425-30.
(6.) Haglund S, Lundquist PG, Cantell K, Strander H. Interferon therapy in juvenile laryngeal papillomatosis. Arch Otolaryngol 1981;107:327-32.
(7.) Strong MS, Vaughan CW, Cooperband SR, et al. Recurrent respiratory papillomatosis: Management with the CO2 laser. Ann Otol Rhinol Laryngol 1976;85(Pt l):508-16.
(8.) Healy GB, Strong MS, Shapshay S, et al. Complications of CO2 laser surgery of the aerodigestive tract: Experience of 4416 cases. Otolaryngol Head Neck Surg 1984;92:13-18.
(9.) Ossoff RH, Hotaling AJ, Karlan MS, Sisson GA. C02 laser in otolaryngology-head and neck surgery: A retrospective analysis of complications. Laryngoscope 1983;93:1287-9.
(10.) Wetmore SJ, Key JM, Suen JY. Complications of laser surgery for laryngeal papillomatosis. Laryngoscope 1985;95(Pt l):798-801.
(11.) Leibowitz HM, Peacock GR. Corneal corneal
pertaining to the cornea. See also keratitis, keratopathy.
includes microcornea, coloboma, megalocornea, dermoid, congenital opacity.
corneal black body
see corneal sequestrum (below). injury produced by carbon dioxide laser The carbon dioxide laser (CO2 laser) was one of the earliest gas lasers to be developed (invented by Kumar Patel of Bell Labs in 1964), and is still one of the most useful. radiation. Arch Ophthalmol 1969;81:713-21.
(12.) Cozine K, Stone JG, Shulman S, Flaster ER. Ventilatory complication of carbon dioxide laser laryngeal surgery. J Clin Anesth 1991;3:20-5.
(13.) Feder RJ. Laryngeal granuloma as a complication of the CO2 laser. Laryngoscope 1983;93:944-5.
(14.) Meyers A. Complications of CO2 laser surgery of the larynx. Ann Otol Rhinol Laryngol 1981;90(Pt 1):132-4.
(15.) Torres LE, Reynolds RC. A complication of use of a microlaryngeal surgery endotracheal tube [letter]. Anesthesiology 1980;53:355.
From the Department of Otolaryngology-Head and Neck Surgery, University of Virginia Medical School, Charlottesville.
Reprint requests: Stilianos E. Kountakis, MD, PhD, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia In 1828, it was chartered by the state of Georgia as the Medical Academy of Georgia, with plans to offer a single course of lectures leading to a bachelor's degree. It opened the following year on October 1st at the Augusta hospital. , 1120 Fifteenth St., Augusta, GA30912-4060. Phone: (706) 721-6100; fax: (706) 721-0112; email: skountakis @mcg.edu