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A novel approach to excision of distal tracheal granulation tissue in tracheostomy patients with difficult anatomy.

Abstract

Tracheostomy predisposes patients to various complications. The most common late complication is granuloma formation; others include tracheal stenosis, bleeding, infection, and fistula development. Small granulomas may not require treatment, but large ones necessitate removal to prevent bleeding, obstruction, respiratory distress and, in rare cases, death. Various treatment options have been described, but no single modality has proved to be superior. We describe a novel approach to treating substomal tracheal granulation by using trans-stomal Coblation for patients whose granulation is difficult to visualize. This procedure offers several advantages over other means, including better hemostasis, less risk of distal tissue loss, ease of use, and potentially less operative time.

Introduction

The most common indications for tracheostomy are the need for prolonged mechanical ventilation, airway protection, and secretion management. (1) The most common early complications of tracheostomy include infection, hemorrhage, and tube displacement. (2)

Late complications of tracheostomy have been reported in 10 to 80% of cases. (1) Common late complications include tracheal stenosis, bleeding, infection, and the development of a tracheoinnominate artery fistula. (1) However, the most common late complication remains the formation of granulation tissue, which has been reported in as many as 80% of cases; in fact, in children it is actually considered to be a routine finding. (3,5) Late complications can be directly related to the tracheostomy tube itself, to leaving the tube in place for a prolonged period of time, and to abnormal healing of the tracheal mucosa. (6)

The exact pathophysiology behind the formation of granulation tissue is unknown, but itmayrelate to trauma to the cartilage during the surgery, to chronic or recurrent infection, and/or to chronic pooling of secretions. The signs and symptoms of tracheal granulation tissue vary depending on the location involved; glottic, subglottic, stomal, and substomal granulation have been reported.

Small, nonobstructing granulomas typically do not warrant removal given their high rate of recurrence and their low degree of morbidity. (5) They often remain asymptomatic for a long time, as the tracheal lumen generally must be reduced by 50 to 75% before obstructive symptoms become apparent. (3) However, for large granulomas, early intervention is recommended because they can induce bleeding, affect voice production, predispose a patient to accidental decannulation, and/ or cause respiratory distress (and death in rare cases). (5)

The historical treatment approaches to post-tracheostomy granulation tissue include topical steroid creams, antibiotic preparations, silver nitrate, and/or inhaled beclomethasone. (4,5) Surgical interventions include open and closed excisions using a variety of instruments, including lasers, optical forceps, sphenoid punches, skin hooks for hook eversion, and stents (table). (4,5) The most severe potential complication of laser treatment is the risk of airway fire. Hook eversion and the use of optical forceps and sphenoid punches carry the risk of bleeding and possible loss of tissue into the distal airways. (5) In addition, visualization of the surgical field can be poor.

We describe Coblation as a novel approach to removing distal tracheal granulation tissue in a patient with a well-established tracheostomy and difficult-to-visualize anatomy. This procedure offers several advantages over other treatments, including (but not limited to) better hemostasis, less risk of tissue loss into the distal airway, ease of use, and potentially less operative time. (5)

Case report

A 24-year-old woman was transferred to our facility for the evaluation of tracheal granulation tissue. The patient had a history of cerebral palsy and recurrent respiratory infections, which had necessitated tracheostomy placement 10 years earlier. Subsequently, the patients family performed routine home tracheostomy care and suctioning. The patient did well with her tracheostomy until 3 months before presentation, when she was diagnosed at another facility with methicillin-resistant Staphylococcus aureus pneumonia. At that time, bronchoscopy detected a moderately sized tracheal granuloma that was causing a ball-valve obstruction of her tracheostomy tube.

Upon the patient's transfer to our facility, flexible laryngoscopy through the tracheostomy tube confirmed the presence of lateral tracheal wall granulation tissue that had obstructed approximately 50% of the tracheal lumen. The patient was taken to the operating room, but direct laryngoscopy was unsuccessful due to her severe scoliosis and neck contractures. The difficulty in evaluating her airway from above was overcome by removing her tracheostomy tube to allow us to approach the granulation tissue trans-stomally. This required an apneic technique and a 0[degrees] rigid Hopkins rod camera placed through the stoma to achieve good visualization of the area.

Endoscopic examination revealed that the granulation tissue had obstructed approximately 50 to 60% of the tracheal lumen. The proximal edge of the granulation tissue began approximately 2 cm inferior to the stoma, and it extended nearly to the mainstem bronchus, a distance of approximately 1.0 cm. Beyond it, the mainstem bronchus was found to be of normal caliber (figure, A).

Inserting both the 0[degrees] rigid telescope and the Coblator wand through the stoma, we were able to easily visualize and excise the left lateral wall granulation tissue with minimal bleeding and nearly complete removal of the obstructing tissue (figure, B). The wand was set on the standard setting of 6 for ablation and 3 for bipolar coagulation. This approach required three apneic periods for completion, with intermittent placement of a standard endotracheal tube through the stoma for ventilation. The entire removal portion of the procedure was completed in approximately 15 minutes. At the conclusion of the procedure, the distal airways were suctioned to remove some saline that had escaped from the Coblator.

A chest x-ray performed several days after surgery revealed no evidence of consolidation or pneumonia. The patient was placed on a steroid inhaler for 2 weeks after the procedure.

Discussion

The origin of granulation tissue is believed to be multifactorial. In tracheostomized patients, granulation can form anywhere along the tracheostomy tract, including the stoma, subglottis, and substomal tracheal wall. The most prominent contribution to development is believed to be the presence of the tracheostomy tube itself. As a foreign body, a tracheostomy tube stimulates mucus production and negatively impacts the mucociliary stream. (4) Mucosal metaplasia subsequently occurs, predisposing to the development of granulation tissue. Additional contributing factors include ischemic injury, localized trauma, and chronic bacterial infection. (3,4)

The granulation tissue in our patient was likely caused by repetitive mucosal irritation from regular deep suctioning and by the tracheostomy angulation as a result of her severe scoliosis.

Prevention of granulation tissue has largely focused on surgical technique, appropriately sized tubes, and meticulous tracheostomy site care. (3) Some studies have suggested that the number of patients who require surgical intervention for the management of granulation tissue is significantly reduced with regular tracheostomy tube changes. (4)

Morbidity associated with large granulomas ranges from bleeding and poor voice production to the potentially life-threatening complications of respiratory distress and accidental decannulation. (1,5) Indeed, granulation tissue obstruction has been reported as the cause of death in several patients. (4) Therefore, large granulomas often require prompt recognition and removal.

As mentioned, options for the treatment of granulation tissue range from topical application of medication to surgical intervention (table). Each option has inherent advantages and disadvantages. To date, no studies have assessed the efficacy of each treatment approach in specific patient populations, and no technique has otherwise been proven to be superior. (4)

Our case brings to the forefront a novel approach to treatment: the use of Coblation for the removal of substomal tracheal granuloma tissue. The literature contains only 1 published case report describing Coblation removal of granuloma tissue in the airway; in that case, it was used in a patient with suprastomal disease. (5) In our case, the use of the Coblator inserted trans-stomally allowed for successful reduction of distal disease in a patient with difficult anatomy.

Coblation is a non-heat-driven process that involves the use of bipolar radiofrequency energy to excite electrolytes in a saline solution. This creates a focused plasma field that dissociates organic molecular bonds within soft tissue at a lower temperature than what is used in standard cautery. (1,3) The lower temperature significantly reduces the risk of thermal injury to surrounding tissue. (2,7)

The Coblator wand is equipped with surface irrigation and suction to help prevent saline escape while simultaneously removing free tissue. The suction feature also helps avoid the risk of losing significant tissue into the lower airway. The use of a Coblator helps control superficial bleeding and provides a relatively precise dissection with good reduction of tissue bulk.

There are a few risks of using trans-stomal Coblation in the treatment of distal tracheal granulation tissue. Specifically, Coblation requires both a saline field and an apneic technique. Despite the suction feature, some saline may escape into the lower airways. Using deep suctioning intraoperatively helps to remove the saline and prevents any associated complications. However, not all patients are suitable candidates for an apneic approach, so the decision whether to use it must be made preoperatively with the consultation of an anesthesiologist.

As seen in our case, the use of Coblation can be an effective way to remove substomal tracheal granulation tissue in specific patient populations. This procedure offers several advantages over other methods, including improved hemostasis, a lower risk of distal tissue loss, ease of use, and potentially less operative time.

References

(1.) O'Connor HH, White AC. Tracheostomy decannulation. Respir Care 2010;55(8):1076-81.

(2.) Wilson YL, Merer DM, Moscatello AL. Comparison of three common tonsillectomy techniques: A prospective randomized, double-blinded clinical study. Laryngoscope 2009;119(l):162-70.

(3.) Bhatia G, Abraham V, Louis L. Tracheal granulation as a cause of unrecognized airway narrowing. J Anesthesiol Clin Pharmacol 2012;28(2):235-8.

(4.) Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue. Laryngoscope 2003;113(1):1-10.

(5.) Kitsko D, Chi DH. Coblation removal of large suprastomal tracheal granulomas. Laryngoscope 2009;119(2):387-9.

(6.) Epstein SK. Late complications of tracheostomy. Respir Care 2005;50(4):542-9.

(7.) Meslemani D, Benninger MS. Coblation removal of laryngeal Teflon granulomas. Laryngoscope 2010;120(10):2018-21.

Allison Rasband-Lindquist, MD; Keith Sale, MD

From the Department of Otolaryngology-Head and Neck Surgery, Northwestern Memorial Hospital, Chicago (Dr. Rasband-Lindquist); and the Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City (Dr. Sale). The case described in this article occurred at the University of Kansas Medical Center.

Corresponding author: Allison Rasband-Lindquist, MD, Department of Otolaryngology-Head and Neck Surgery, Northwestern Memorial Hospital, 675 N. St. Clair St., Suite 15-200; Chicago, IL 60611. Email: allisonrasband@gmail.com

Table. Options for removing granulation tissue

Topical approaches

Corticosteroid creams
Antibiotic preparations
Silver nitrate
Inhaled beclomethasone

Surgical approaches

Open excision
C02, YAG, KTP laser
Optical forceps
Sphenoid punch
Hook eversion
Stent placement
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Author:Rasband-Lindquist, Allison; Sale, Keith
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Oct 1, 2016
Words:1762
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