DEPARTMENT OFDEPARTMENT OF
OTORHINOLARYNGOLOGY OTORHINOLARYNGOLOGY
HEAD & NECK SURGERYHEAD & NECK SURGERY
CMH RAWALPINDICMH RAWALPINDI
Excision of Recurrent Respiratory Excision of Recurrent Respiratory Papillomatosis by Combined Technique Papillomatosis by Combined Technique
using COusing CO2 2 Laser & MicrodebriderLaser & Microdebrider
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Patient’s profilePatient’s profile
• Name: A B C
• Age: 3 ½ years
• Sex: Female
• Residence: Hangu
(Khyber-
Pakhtunkha)
5
PresentationPresentation
• Voice change
• Breathing difficulty
• Taking medications from various physicians for URTI and bronchial asthma.
one year
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PresentationPresentation
• Birth History:– Full term spontaneous vaginal delivery
• Feeding History:– Breast fed for 1 year & weaning started
at 5 months
• Vaccination History– Vaccinated as per EPI schedule
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PresentationPresentation
• Developmental History:– Developmental milestones as per age
• Past History:– No history of any surgical intervention
• Family History:– 4th eldest among 5 siblings
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General Physical ExaminationGeneral Physical Examination
• A female child active, playful and cooperative but slightly distressed.
• Weight: 20 kg (lying on 50th percentile)
• Height: 90 cm (lying on 50th percentile)
• Vital Signs:– Pulse: 84/min– Temp: 98.4o F– Resp Rate: 22/min
10
General Physical ExaminationGeneral Physical Examination
• Signs:• Stridor +• Recessions ++• Nasal ala flaring +++
• Cyanosis• Pallor• Clubbing• Jaundice• Edema
Negative
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ENT ExaminationENT Examination
• Detailed ENT examination of– Oral Cavity– Oropharynx/Throat– Nose – Ear
• Patient was not cooperative for Indirect Laryngoscopy
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Fiberoptic LaryngoscopyFiberoptic Laryngoscopy
• Findings – Extensive laryngeal papillomas over
glottic and supraglotic regions.
13
Systemic ExaminationSystemic Examination
• Gastrointestinal System• Respiratory System• Cardiovascular System• Central Nervous System
Unremarkable
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Counselling of ParentsCounselling of Parents
• Parents counseled in detail about its nature, treatment and prognosis.
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Treatment PlanTreatment Plan
• Direct Laryngoscopy &
• Combined Carbon-dioxide laser ablation and Microdebridement under GA (on 10th Dec 2010)
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ConsentConsent
• Informed written consent (from parents of child)
– Risks of surgery– Chances of recurrence &– Need for additional surgical procedures
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Pre-Op work upPre-Op work up
• Blood CP• Urine RE• Coagulation profile• X-ray Chest PA view
• Pre-anesethesia assesment in ASA-I
25
COCO22 Laser Excision Laser Excision
• CO2 laser used at – 10 watt power – with 0.1 sec pulses
&– small plot size
O P
E R
A T
I V
E
S T
E P
S
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O P
E R
A T
I V
E
S T
E P
S
Extensive papillomas covering glottis
Aluminium foiled endotracheal tube
Bulky Glottic Lesion
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Surgical Microdebrider Surgical Microdebrider O
P E
R A
T I V
E
S T
E P
S
Long laryngeal blade
Oscillating head
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Post-Operative Care Post-Operative Care
• Steroids, analgesics & antibiotics
• Steam inhalation
• Sniffing exercises
• Voice rest
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Follow upFollow up
• Marked improvement in her voice and breathing post-operatively.
• Parents advised regular follow up.
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Hospital DataHospital Data
• July 2009 – Dec 2010• Total no of patients: 21
Juvenile Onset RRP
Adult Onset RRP
CO2 Laser 11 3
Microdebrider 2 -
Combined technique
5 -
Total 18 3
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ConclusionConclusion
• Relatively rare – Negative impact on evaluation of treatment
modalities
• Multiple recurrences results in poor quality of life for patients.
• Advances in surgical techniques allow safe airway and acceptable voice.