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.
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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)