Surgical therapy for recurrent respiratory papillomatosis.
Since the recognition of recurrent respiratory papillomatosis (RRP RRP n abbr (= recommended retail price) → PVP m ) as a clinical entity, its management has centered on maintaining a patent, asymptomatic airway for those individuals afflicted with the condition. Advances in our understanding of its etiology and the factors that permit it to flourish have resulted in new opportunities to approach this disorder from a molecular biology approach. However, as we have yet to effectively "cure" RRP, the surgical endoscopist remains central to the management of this entity. That is not to say that additional nonsurgical efforts, such as antiviral therapy, are any the less important. As yet, however, surgery remains the mainstay of treatment.
Surgical technique can be broadly categorized as using either cold instruments or lasers. In the realm of elective management, the pendulum of physician popular preference has drifted in each direction during the past 40 years.
From the time of the early indexed reports in the 1950s, we used the tools available to us: the microscope, laryngoscope, and steel instruments. After the topical application of a vasoconstricting agent, visible disease is excised with an eye toward minimizing complications, such as vocal fold scarring, glottic glot·tic
1. Of or relating to the tongue.
2. Of or relating to the glottis.
pertaining to (1) the glottis, or (2) the tongue. webs, and stenosis of the supra- or subglottic airway. The routine use of submucosal submucosal /sub·mu·co·sal/ (-mu-ko´sal)
1. pertaining to the submucosa.
2. beneath a mucous membrane. infusion can diminish the likelihood of these events. (1) By filling Reinke's space with fluid, one can decrease the risk of injury to the deep lamina propria and vocalis muscle. The addition of phonosurgical techniques has further evolved this approach. (2) While cold excision demands precision on the part of a well-trained operator, it remains a cost-effective, technology-independent, safe way of managing RRP and has been proposed as the preferred strategy for adults. (3) Yet another option exists in the context of microlaryngoscopy-cryotherapy. This involves the controlled application of liquid nitrogen in order to induce hypothermic damage to the 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. . The tissue may then be abraded and suctioned away. However, the depth of tissue damage is often inadequately assessed at the time of surgery, and there is the danger of inadvertent spills resulting in "cold burns."
The introduction of the carbon dioxide (C[O.sub.2]) laser for clinical use in the 1970s ushered in a new era. This laser's wavelength is optimally absorbed by water and, therefore, it results in direct vaporization vaporization, change of a liquid or solid substance to a gas or vapor. There is fundamentally no difference between the terms gas and vapor, but gas is used commonly to describe a substance that appears in the gaseous state under standard conditions of of tissue. (4) It was adopted with enthusiasm because it provided precise tissue destruction as well as hemostasis of capillaries and small vessels.
Large, published series on laser excision have demonstrated its effectiveness in controlling disease when applied with appropriate frequency. (5,6) This leap forward came with several costs, however. The risk of fire from an energy source in the potentially oxygen-rich environment of the laryngoscope and airway necessitated the development of equipment, (7) anesthetic techniques, (8) and protocols (9) to safeguard the patient. In addition, laser technology does not eliminate the challenges intrinsic to 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. excision outlined above. Furthermore, the clinical manifestations of complications may be insidious and cumulative, since most patients require multiple procedures. (10)
In addition to risks for the patient, there has remained the specter of aerosolized viral dissemination. However, although viral DNA DNA: see nucleic acid.
or deoxyribonucleic acid
One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. identical to that found in the source patient can be identified in the plume of smoke generated as the tissue is vaporized va·por·ize
tr. & intr.v. va·por·ized, va·por·iz·ing, va·por·iz·es
To convert or be converted into vapor.
va , (11) there have been no reports to date of physician or support staff contracting and activating aerodigestive papillomatosis after exposure to this technique. Nevertheless, this concern is addressed by the active suctioning of the smoke/plume from within the laryngoscope, thus preventing its escape into the ambient environment.
Technology continued to broaden, and the microdebrider, familiar from endoscopic sinus applications, was adapted for use in the airway. This returned cold excision, albeit a variant, to popularity as lasers fell out of favor with some practitioners. The operating telescope may be used in place of the microscope, as it provides appropriate magnification. The powered instrumentation employs a technique similar to that used in manual excision, as one applies a topical vasoconstrictive va·so·con·stric·tive
Causing constriction of the blood vessels. agent and takes care neither to enter the deep structure of the vocal fold nor to denude de·nude
To divest of a covering, as myelin. the anterior commissure. (12) Although this approach does not provide for hemostasis, it has several advantages over laser therapy: (1) the risk of combustion is absent, (2) no special certifications are required for its operation, and (3) as the suction is integrated into the instrument, the field remains clear of obstructions.
A small prospective, randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. , matched clinical trial comparing C[O.sub.2] laser ablation with microdebrider excision demonstrated reduced operative time and expense and greater improvement in voice quality, while postoperative pain was unchanged. (13)
As otolaryngologists, we now have several techniques at our disposal for the management of RRP. It remains the duty of the clinician to be familiar with these methods, as well as the growing number of nonsurgical treatment options, and to apply the right approach to the right patient at the right time.
(1.) Dean C, Sataloff RT, Hawkshaw Hawkshaw
implacable detective with photographic memory. [Br. Lit.: The Ticket-of-Leave Man, Barnhart, 546]
See : Sleuthing M. Recurrent vocal fold papilloma: Resection using cold instruments. Ear Nose Throat J 1998;77: 882-4.
(2.) Zeitels SM, Sataloff RT. Phonomicrosurgical resection of glottal glot·tal
Of or relating to the glottis.
glottal (glot´ papillomatosis. J Voice 1999; 13:123-7.
(3.) Zeitels SM, Casiano RR, Gardner GM, et al. Voice and Swallowing Committee, American Academy of Otolaryngology-Head and Neck Surgery. Management of common voice problems: Committee report. Otolaryngol Head Neck Surg 2002;126:333-48.
(4.) Mihashi S, Jako GJ, Incze J, et al. Laser surgery in otolaryngology: Interaction of CO2 laser and soft tissue. Ann N Y Acad Sci 1976;267:263-94.
(5.) Strong MS, Vaughan CW, Cooperband SR, et al. Recurrent respiratory papillomatosis: Management with the CO2 laser Ann Otol Rhinol Laryngol 1976;85:508-16.
(6.) Dedo HH, Yu KC. CO2 laser treatment in 244 patients with respiratory papillomas. Laryngoscope 2001;111:1639-44.
(7.) Shaker MH, Konchigeri HN, Andrews AH Jr., Holinger PH. Anesthetic management for 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. surgery of the larynx. Laryngoscope 1976;86:857-61.
(8.) Ruder CB, Rapheal NL, Abramson AL, Oliverio RM Jr. Anesthesia for carbon dioxide laser microsurgery microsurgery
Surgical technique for operating on minute structures, with specialized, tiny precision instruments under observation through a microscope, sometimes equipped with cameras to show the operation on a monitor. of the larynx. Otolaryngol Head Neck Surg 1981;89:732-7.
(9.) Mohr RM, McDonnell BC, Unger M, Mauer TP. Safety considerations and safety protocol for laser surgery. Surg Clin North Am 1984;64:851-9.
(10.) Crockett DM, McCabe BF, Shive n. 1. A slice; as, a shive of bread s>.
2. A thin piece or fragment; specifically, one of the scales or pieces of the woody part of flax removed by the operation of breaking.
3. CJ. Complications of laser surgery for recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol 1987;96:639-44.
(11.) Kashima HK, Kessis T, Mounts P, Shah K. Polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is identification of human papillomavirus DNA in CO2 laser plume from recurrent respiratory papillomatosis. Otolaryngol Head Neck Surg 1991;104:191-5.
(12.) Parsons DS, Bothwell MR. Powered instrument papilloma excision: An alternative to laser therapy for recurrent respiratory papilloma. Laryngoscope 2001;111:1494-6.
(13.) Pasquale K, Wiatrak B, Woolley A, Lewis L. Microdebrider versus CO2 laser removal of recurrent respiratory papillomas: A prospective analysis. Laryngoscope 2003;113:139-43.
RONDA E. ALEXANDER, MD Department of Otorhinolaryngology--Head & Neck Surgery Montefiore Medical Center/ Albert Einstein College of Medicine
The Albert Einstein College of Medicine (AECOM) is a graduate school of Yeshiva University. It is a private medical school located in the Jack and Pearl Resnick Campus of Yeshiva University in the Morris Park Bronx, N.Y.
MARVIN MARVIN - U Dortmund, 1984. Applicative language based on Modula-2, enhanced by signatures (grammars) terms (trees) and attribute couplings (functions on trees). Used for specification of language translators. P. FRIED, MD University Chairman and Professor Department of Otorhinolaryngology--Head & Neck Surgery Montefiore Medical Center/ Albert Einstein College of Medicine Bronx, N.Y.