The digital AcuBlade laser system to remove huge vocal fold granulations following subglottic airway stent

Interactive CardioVascular and Thoracic Surgery, Sep 2013

We report a case of granulations that complicated subglottic stent placement and completely destroyed vocal folds with luminal stent obstruction. A microbial aetiology significantly contributed to the occurrence of granulations associated with mechanical irritation. The granulations were successfully resected using a digital AcuBlade laser system, a new generation of CO2 laser used in otorhinolaryngology, particularly in vocal cord disease. It permitted a precise control of the scan line between vocal fold and granulation for several reasons. The scan line was completely electronic and integrated in the scanner. The sweep in speed was constant and the energy distribution was uniform along the entire length of the time. The interpulse pause was of ∼1 ms, allowing the tissue cooling with reduction of thermal spread and quicker healing support. The result was the radical excision of granulations without injuring vocal folds. The respiratory function was restored and no other treatments such as arytenoidectomy or cordectomy associated with the alteration of phonatry function were required. No intraoperative or/and postoperative complications were registered and the patient was discharged 7 days after the procedure.

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The digital AcuBlade laser system to remove huge vocal fold granulations following subglottic airway stent

Alfonso Fiorelli 1 Salvatore Mazzone 0 Adriano Mazzone 0 Mario Santini 1 0 Othorinolaryngoiatry Unit, Second University of Naples , Naples, Italy 1 Thoracic Surgery Unit, Second University of Naples , Naples, Italy We report a case of granulations that complicated subglottic stent placement and completely destroyed vocal folds with luminal stent obstruction. A microbial aetiology significantly contributed to the occurrence of granulations associated with mechanical irritation. The granulations were successfully resected using a digital AcuBlade laser system, a new generation of CO2 laser used in otorhinolaryngology, particularly in vocal cord disease. It permitted a precise control of the scan line between vocal fold and granulation for several reasons. The scan line was completely electronic and integrated in the scanner. The sweep in speed was constant and the energy distribution was uniform along the entire length of the time. The interpulse pause was of 1 ms, allowing the tissue cooling with reduction of thermal spread and quicker healing support. The result was the radical excision of granulations without injuring vocal folds. The respiratory function was restored and no other treatments such as arytenoidectomy or cordectomy associated with the alteration of phonatry function were required. No intraoperative or/and postoperative complications were registered and the patient was discharged 7 days after the procedure. - Despite several techniques are reported, the endoscopic treatment of granulation after stent placement just below the vocal cords is challenging. Herein, we report the use of digital AcuBlade robotic microsurgery system (Lumenis, Rome, Italy), a new generation of CO2, laser to remove huge vocal folds granulations after subglottic stent placement. A 47-year old man with post-intubation subglottic stenosis was dilated without success in another hospital; tracheostomy was then performed for respiratory failure and referred to our attention. Because the patient was unfit for surgery, the stenosis was dilated using rigid bronchoscopy and a Montgomery T-tube was placed. Unfortunately, the patient re-developed stenosis following the removal of the T tube after 9 months. A rigid bronchoscopy was performed under general anaesthesia. A subglottic stenosis located 1.5 cm from the vocal folds was found. The stenosis was redilated and a silicone Dumon stent (length: 60 mm, width: 17 mm) inserted in a standard manner at 1 cm from the vocal folds. After 2 weeks, the stent migrated under the stenosis. It was re-placed just below the vocal folds to avoid further migration and to preserve phonation. The patient was discharged 3 days later. In the first 5 months after the procedure, he underwent large-drop aerosol treatment and repeated bronchoscopy aspiration. The aspiration was stopped at the time of the summer holidays for 2 months. In this period, the patient complained of progressive symptoms: bad breath, difficult phonation and airway obstruction. He was re-admitted on the assumption that the stent had migrated further. Endoscopy showed the stent in situ but the vocal folds completely covered by huge granulations (Fig. 1A) obstructing the stent (Fig. 1B). Probably, mucus accumulation in the stent due to the lack of aspiration supported bacterial colonization. Then, the stent infection and the mechanical irritation promoted granulation growth. The patient was intubated with a small laser-safe endo-tracheal tube which passed through the stent. The granulations were ablated using the AcuBlade system through the suspended laryngoscope and with an operative microscope. To preserve the stent from laser thermal injury, a gauze was placed under the granulation (Fig. 1C). After the procedure, the vocal folds seemed to be normal and the luminal stent free (Fig. 2A). The patient was extubated the day after; bronchoscopy showed normal function of the vocal folds. The stent was in situ with normal patency; bacterial culture resulted negative for stent colonization. The patient was afebrile, having normal phonation and breathing. He was discharged 7 days after the procedure. Three months later, bronchoscopy showed normal vocal folds with stent patency (Fig. 2B). The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Figure 2: The granulations were completely resected, and after the procedure the vocal folds seemed to be normal and the luminal stent free (A). Endoscopic view showed patent glottic lumen at 3-month follow-up (B). AcuBlade connected with an operative microscope is reported in (C). The scanner is a device connected between the laser arm and the micromanipulator. By a computer-guided system of rotating mirrors, the scanner allows the beam to sweep a given surface with extreme rapidity. Scan patterns enable incision (linear or arc-incision) and ablation (circle) using parameters proposed by laser-controlling so (...truncated)


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Alfonso Fiorelli, Salvatore Mazzone, Adriano Mazzone, Mario Santini. The digital AcuBlade laser system to remove huge vocal fold granulations following subglottic airway stent, Interactive CardioVascular and Thoracic Surgery, 2013, pp. 591-593, 17/3, DOI: 10.1093/icvts/ivt226