Totally obstructing tracheotomy-associated suprastomal granulation tissue

Although tracheotomy-associated suprastomal granulation tissue is quite common, suprastomal granulation tissue that totally obstructs the airway is relatively rare and can be associated with serious complications. In this report the complications and management of six cases of totally obstructing suprastomal granulation tissue (TOSGT) are presented. Complications associated with the presence or management of TOSGT included progression of subglottic stenosis, development of posterior laryngeal stenosis, development of supraglottic stenosis following CO(2) laser supraglottoplasty, and dislodgement of the TOSGT with distal tracheal obstruction resulting in anoxic brain injury. It is recommended that the tracheotomy tube remains in position at all times during attempted removal, and that if endoscopic removal is not possible, that open tracheoplasty is the safest method for removal. Measures that may decrease the chances of recurrence include diligent diagnosis and treatment of gastroesophageal reflux disease (GERD) and bacterial infection. TOSGT may be a marker for some patients with abnormal wound healing.     

KTP laser treatment of suprastomal obstruction prior to decannulation in paediatric tracheostomy

OBJECTIVE: Decannulation following tracheostomy in the paediatric patient is often complicated by the development of secondary suprastomal obstruction. We describe the technique of bronchoscopic KTP laser therapy in the management of such conditions, and have audited the results of this treatment with 12 children treated with this modality before attempted decannulation over the last 2 years at Great Ormond Street Hospital for Children (GOSH). METHOD: Via a retrospective record review. RESULTS: Eight (67%) were successfully decannulated, with four being unsuccessful. All children with less than 50% suprastomal obstruction were successfully decannulated following bronchoscopic KTP laser treatment. CONCLUSIONS: Bronchoscopic KTP laser therapy is a useful tool in the abolition of suprastomal obstruction prior to decannulation following paediatric tracheostomy. Children with greater than 50% obstruction are likely to require an open procedure.     

Surgical management of severe suprastomal cricotracheal collapse complicating pediatric tracheostomy

OBJECTIVE: Suprastomal tracheal collapse may interfere with decannulation in tracheostomized patients. The purposes of the study are to evaluate the role of tracheotomy technique in the ethiology of suprastomal cricotracheal collapse and to report our results in the treatment of this complication. METHODS: A retrospective review of children showing severe suprastomal collapse during the period 1990-2007, in a tertiary care children's hospital, was performed. Medical records were assessed for the following data: sex, age, original indication for tracheotomy, surgical technique, endoscopic findings, type of surgical correction, complications, result, and follow-up. RESULTS: Fourteen patients were included in the study, nine girls and five boys. Average age at tracheotomy was 17 months (range: 21 days-8 years), and prolonged ventilatory support was the most common indication (57%). Horizontal H-type tracheotomy was the most frequent technique in patients with suprastomal collapse (n=9), whereas only one patient with a vertical tracheotomy showed this complication (p<0.05). In every case bronchoscopy disclosed a suprastomal tracheal obstruction of at least 50% of the lumen. Mean age at surgical decannulation was 38 months (range: 12-147 months). Two surgical techniques have been used in the treatment of suprastomal collapse: anterior cricotracheal suspension (n=13) and reconstruction with autologous cartilage graft (n=1). All the patients were successfully decannulated although in one case two procedures were required. No recurrence has been observed during long-term follow-up (mean: 8.6 years). CONCLUSIONS: Endoscopical examination is essential for the diagnosis of suprastomal collapse and to rule out other causes of decannulation failure. In our experience, the tracheotomy technique seems to have an ethiologic role, and anterior cricotracheal suspension is a simple and effective procedure in the treatment of this tracheostomy related complication.     

KTP laser assisted excision of glomus tympanicum

A 39-year-old female with a two-year history of mild hearing loss and discomfort on air flight descent was found to have a pulsatile mass behind an intact tympanic membrane. A suspected diagnosis of glomus tympanicum was confirmed by computed tomography (CT) scan imaging. The lesion filled the mesotympanum and hypotympanum but the jugular bony plate was intact, confirming the tympanic site of the lesion. This very vascular tumour was exposed by a tympanomeatal flap and the KTP laser used to shrink and coagulate the tumour progressively with minimal haemorrhage and blood loss. Complete excision of the lesion was achieved without the need for bony removal, and with minimal blood loss. The use of the KTP laser to coagulate this vascular lesion allowed safe removal of the tumour and avoided the need for extended facial recess or hypotympanotomy surgery.     

KTP/532 laser excision of trichoepithelioma of the ear

A rare case of trichoepithelioma of the external ear is presented Conventional excision with cold instruments is likely to result in excessive bleeding increased post-operative morbidity and scar tissue. This case was treated with KTP/532 laser excision almost bloodlessly with practically no post-operative morbidity and unimimal scar tissue.     

Endoscopic laser excision in the management of laryngotracheal stenosis

Sixteen cases of Chronic laryngotracheal stensis were included in the study. They underwent endoscopic CO₂ laser excision of the stenotic segment. Three patients were decannulated. giving a success rate of 18.75%.     

Application of potassium-titanyl-phosphate (KTP) laser in the excision of pyriform fossa hemangioma

Pyriform fossa hemangioma, especially of the cavernous type, is a rare case and very few such lesions have been encountered in general otolaryngological practice. We report such a lesion in a 36-year-old, middle-aged woman presenting with complaint of foreign body sensation in the throat. Examination revealed a hemangioma in the right pyriform fossa that was successfully managed using KTP-532 laser and bipolar cautery.     

Endoscopic repair of unilateral choanal atresia with the KTP laser: a one stage procedure

This paper, describes the endoscopic repair of unilateral choanal atresia with the KTP laser, a one-stage procedure, with no requirement for stenting. Three patients are presented with unilateral choanal atresia, aged six, nine and 38-years-old. The procedure combines the excellent endoscopic visualization, with the good haemostatic and penetrating properties of the KTP laser. Follow up was between 12 months and four years with all choanae remaining patent, no dilatation was required. No surgical complications were noted.     

Endoscopic excision of Angiofibroma

We present a case of Juvenile Nasopharyngeal Angiofibroma (JNA) managed by endoscopic excision alone. The selection of the case, technical difficulties and the advantages offered by this technique are detailed.     

Endoscopic dacryocystorhinostomy vs KTP 532 laser-assisted endoscopic dacryocystorhinostomy

Objectives  Advances in endoscopy and lasers have improved surgical management of chronic nasolacrimal duct obstruction. This is a preliminary comparison between standard and laser assisted endoscopic dacryocystorhinostomy (DCR). Study Design  Combined retrospective and prospective study. Setting  Tertiary referral hospital. Patients and Methods  Thirty-eight cases of chronic nasolacrimal duct obstruction underwent endoscopic DCR (26 standard and 12, laser-assisted) and were assessed at 3 and at 6 months postoperatively by nasal endoscopy. Results  Three months postoperatively (n=38), total relief of epiphora among the nonlaser group was 80.76 vs 75% in the laser group (P=0.982). At 6 months (n=19), the laser group had recorded 100% symptomatic relief compared to 85.71% in the nonlaser group (P=0.964). The laser group suffered fewer complications (33.33 vs 46.15% for nonlaser group). Conclusion  Lasers show promise in long-term management of duct obstruction and are associated with fewer complications. A larger study is required before and generalization is made.     

Endoscopic and KTP laser-assisted surgery for juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibroma is a highly vascular tumor arising from the area around the sphenopalatine foramen. Various radical and extended radical surgeries have been advocated to surgically excise both extranasopharyngeal and nasopharyngeal juvenile angiofibromas. However angiofibromas involving the nasopharynx, nose, and sphenoid with minimal lateral extension via the sphenopalatine foramen can also be adequately managed endoscopically either alone or with 1 of the traditional approaches. Nine cases of juvenile nasopharyngeal angiofibroma were successfully managed between January, 1999, and March, 2001, by preoperative selective embolization of the internal maxillary artery with or without external carotid artery clamping, followed by endoscopic excision. Two of the 9 cases underwent KTP/532 laser-assisted endoscopic excision, whereas the transpalatal approach was used along with the endoscope in another 2 cases. The patients remained free of disease after a median follow-up period of 17 months. We report our preliminary experience in endoscopic and KTP laser-assisted excision of juvenile nasopharyngeal angiofibroma.     

Endoscopic microsurgical excision of internal laryngocele

Internal laryngoceles are relatively rare, and a variety of surgical treatments have been proposed. A case is presented which was treated by endoscopic microsurgical excision.     

Long-term results of KTP/532 laser uvulopalatopharyngoplasty

The symptom of snoring is no longer one of humorous content and with the ever increasing awareness of its detriments, it has become even more important to find a treatment that would be immensely beneficial to the patient. We would like to present our experiences with the use of the KTP/532 Laser in performing the UP3. This study is significant as it presents a long term four year follow up of cases based on the patients' assessments. The technique itself is tailor made to suit the individual patient, ensuring optimal results which revealed that most patients i.e.; 84% were extremely pleased with the operation. The series also showed minimal morbidity and no intra or post-operative complications which reiterates the need for meticulous, atraumatic technique and judicious, discriminate selection of patients.     

Endoscopic laser-assisted excision of juvenile nasopharyngeal angiofibromas

BACKGROUND: Juvenile nasopharyngeal angiofibromas (JNAs) are highly vascular tumors that originate in the nasopharynx of young males. The primary treatment is surgical excision. Traditional surgical approaches are associated with significant morbidity and facial deformity. We introduce and outline the clinical advantages of an endoscopic surgical approach to JNAs using the Nd:YAG laser with image-guided surgery. DESIGN: Case series. SETTING: Tertiary care medical center. PATIENTS AND METHODS: Our study included 5 male patients (age range, 8-21 years) with extensive JNAs. Their tumors were large and ranged from Fisch stage IIA to IIIA. Embolization of tumor-feeding vessels was performed before surgery. The tumors were photocoagulated via a transnasal endoscopic approach using a Nd:YAG laser. Devascularized, lased tumor was removed with a microdebrider. Image-guided navigation systems were used to assist skull base tumor removal, and sublabial and buccolabial incisions were used as needed to gain lateral endoscopic tumor access. Endoscopic tumor margins were obtained for frozen section. RESULTS: All patients achieved symptomatic remission, with no complications. No blood transfusions were necessary. The patients were ready for discharge 1 to 2 days after surgery. Postoperative and magnetic resonance imaging scans showed 2 skull base recurrences, which were removed endoscopically. Follow-up ranged between 2 and 3 years. CONCLUSIONS: Traditional external surgical approaches to large JNAs may result in significant morbidity. Laser-assisted image-guided endoscopic excision of JNAs is a safe and effective minimally invasive surgical treatment. Its distinct advantages include (1) diminished blood loss, (2) superior cosmesis without observed altered facial growth, (3) direct access of skull base with minimal morbidity, and (4) ease of endoscopic follow-up.