© Borgis - New Medicine 3/2005, s. 43-44
Lidia Zawadzka-Głos, Mieczysław Chmielik, Anna Kaczmarczyk
Use of argon plasma coagulation in the treatment of subglottic stenosis in children
Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik MD, PhD
Summary
Subglottic laryngeal stenosis develops in most cases as a result of prolonged intubation. The selection of the treatment method depends on the degree of stenosis. In the present paper, authors present their own method for the treatment of post-intubation laryngeal stenosis by argon plasma coagulation (APC).
Introduction
Subglottic laryngeal stenosis develops in most cases as a result of prolonged intubation. Other causes of stenosis include: trauma, thermal or chemical burns, congenital stenosis and tracheotomy made at too high a level in the trachea. Multiple methods for post-intubation stenosis treatment are known, both classic methods for reconstruction of the larynx by external approach, and endoscopic methods for dilation of the larynx (2). The selection of the treatment method depends on the degree of stenosis and the nature of interventions performed earlier. Dilation of the larynx is usually preceded by tracheotomy. The authors present their own method for the treatment of post-intubation laryngeal stenosis by argon plasma coagulation (APC). The purpose of this study was to assess the effectiveness of the treatment of post-intubation laryngeal stenosis with APC.
Material and method
Sixteen children (eight boys and eight girls) aged from 6 months to 10 years, with post-intubation laryngeal stenosis degree I through IV according to the Myer-Cotton grading system, were qualified for treatment of laryngeal stenosis with APC. Six children were found to have degree IV stenosis, five children were found to have degree III stenosis, four children with degree II stenosis, and one child had degree I stenosis. All children had had prolonged intubation for different reasons. The post-intubation stenoses were located in the subglottic region and only laryngeal soft tissue was involved in all children. The chondroskeleton of the larynx was intact.
APC was applied to treat laryngeal stenosis. Parents of the treated children were informed about applications of APC and had the possibility to ask questions. The informed consent form was dated and signed by parents and appended to medical file. Our equipment consisted of an argon gas source and high-frequency surgical unit (APC 300 ERBOTOM ICC 350-ERBE Electromedizine GmbH) and a rigid probe with ceramic nozzle fitted at 0o or 90o relative to the axis of the probe. Different coagulation times were used, ranging from 1 to 3 s repeated a few times. The flow rate of argon gas during coagulation was set at 1,0-1,2 l/min. All procedures were performed under general anaesthesia. The effects of treatment were assessed on subsequent endoscopic measurements of the larynx, which were performed at 6-8 weeks intervals.
Results
We observed different improvement rates in thirteen children and failure in three children. An improvement from degree IV to III stenosis was achieved in one child and an improvement from degree IV to II was achieved in four children. We observed an improvement from degree III to II in two children. A decrease in the thickness of scar tissue stenosing the subglottic region has been observed. Six children had been decannulated.
The advantages of APC are: minimal intra-operative haemorrhage, absence of granulation in the coagulation location, short procedure times, controllable energy dose, and shorter postoperative care period than after classic management with intra-laryngeal incisions and laryngeal separator (4, 5, 6). No side-effects were observed in any treated patients. No progression of scarring in the subglottic region was observed.
In cases with stenosis degree III or IV and deformity of the chondrosceleton of the larynx, the endoscopic dilation of the lumen of the larynx with APC can not be a substitute for surgical treatment through external approach. The described procedures for endoscopic dilation with APC have been performed during the last 5 years. Patients are under continued follow-up of laryngologists. An analysis of the effects of treatment of post-intubation laryngeal stenosis shows that treatment with APC seems to be safe and effective.
Fig. 1. Dislocation of the right arytenoid.
Fig. 2. Subglottic region after five APC procedures.
Fig. 3. Stenosis of subglottic region.
Results
Sixteen children were qualified for treatment of post-intubation laryngeal stenosis witch APC. We observed good treatment results in thirteen treated children. A permanent improvement of the lumen of the larynx has been achieved in all children with degree IV stenosis. A decrease in the thickness of scar tissue stenosing the subglottic region has been observed in other children. Six children were decannulated. No side-effects were seen in any treated patients.
In the literature, APC and laser therapy have been compared. The depth of tissue penetration is better controllable with APC. There is a lower risk of penetration into the wall of the respiratory tract and tissue carbonisation does not occur with APC (1, 3, 4). In comparison with the classic method of intra-laryngeal incision, endoscopic treatment with APC does not cause formation of granulation tissue in the dilated section.
The application of APC during endoscopic dilation of the larynx allowed the decannulation of six children. Fifty procedures with APC have been carried out. In all cases no complications were observed and no progression of subglottic region scarring was observed. In cases with degree III and IV stenosis and deformity of the chondroskeleton of the larynx, endoscopic dilation of the larynx lumen with APC can not be a substitute for surgical treatment through external approach.
Piśmiennictwo
1. Bergler W., Riedel F., Gotte K., Hormann K.: The treatment of juvenile laryngeal papillomatosis with argon plasma coagulation. Dtsch.Med.Wochenschr. 122 ; 34-35, 1997. 2.Cotton R.T., Myer C.M.: Practical Pediatric Otolaryngology" Lippincott-Raven, Philadelphia, 1999, pp. 515-545. 3.Gierek T., Paluch J.: Use of coagulation in laryngology- personal experience. Otolaryngologia Polska 54(5); 505-509,2000. 4.Keller C.A., Hinerman R., Singh A., Alvarez F.: The use of endoscopic argon plasma coagulation in airway complications after solid argon transplantation. Chest 119 (6); 1968-1975, 2001. 5.Morice R.C., Ece T., Ece F., Kens L.: Endobronchial argon plasma coagulation for treatment of haemoptysis and neoplastic airway obstruction. Chest 119 (3); 781-787, 2001. 6.Zawadzka-Głos L., Chmielik M., Gabryszewska A.: The application of argon plasma coagulation in the treatment of laryngeal stenosis in children. New Med.4; 23-24, 2001.
