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Recurrent Respiratory Papillomatosis

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Excision of Recurrent Respiratory Papillomatosis by Combined Technique using CO2 Laser & Microdebrider,
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Recurrent Respiratory Papillomatosis

  1. 1. DEPARTMENT OFDEPARTMENT OF OTORHINOLARYNGOLOGYOTORHINOLARYNGOLOGY HEAD & NECK SURGERYHEAD & NECK SURGERY CMH RAWALPINDICMH RAWALPINDI Excision of Recurrent RespiratoryExcision of Recurrent Respiratory Papillomatosis by Combined TechniquePapillomatosis by Combined Technique using COusing CO22 Laser & MicrodebriderLaser & Microdebrider
  2. 2. 3 Recurrent Airway ObstructionRecurrent Airway Obstruction
  3. 3. 4 Patient’s profilePatient’s profile • Name: A B C • Age: 3 ½ years • Sex: Female • Residence: Hangu (Khyber-Pakhtunkha)
  4. 4. 5 PresentationPresentation • Voice change • Breathing difficulty • Taking medications from various physicians for URTI and bronchial asthma. one year
  5. 5. 6 • Referred from some ENT clinic at Peshawar to CMH Rawalpindi.
  6. 6. 7 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
  7. 7. 8 PresentationPresentation • Developmental History: – Developmental milestones as per age • Past History: – No history of any surgical intervention • Family History: – 4th eldest among 5 siblings
  8. 8. 9 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: 98.4 o F – Resp Rate: 22/min
  9. 9. 10 General Physical ExaminationGeneral Physical Examination • Signs: • Stridor + • Recessions ++ • Nasal ala flaring +++ • Cyanosis • Pallor • Clubbing • Jaundice • Edema Negative
  10. 10. 11 ENT ExaminationENT Examination • Detailed ENT examination of – Oral Cavity – Oropharynx/Throat – Nose – Ear • Patient was not cooperative for Indirect Laryngoscopy
  11. 11. 12 Fiberoptic LaryngoscopyFiberoptic Laryngoscopy • Findings – Extensive laryngeal papillomas over glottic and supraglotic regions.
  12. 12. 13 Systemic ExaminationSystemic Examination • Gastrointestinal System • Respiratory System • Cardiovascular System • Central Nervous System Unremarkable
  13. 13. 14 DiagnosisDiagnosis • Juvenile Onset Respiratory Papillomatosis
  14. 14. 15 Counselling of ParentsCounselling of Parents • Parents counseled in detail about its nature, treatment and prognosis.
  15. 15. 16 Treatment PlanTreatment Plan • Direct Laryngoscopy & • Combined Carbon-dioxide laser ablation and Microdebridement under GA (on 10th Dec 2010)
  16. 16. 17 ConsentConsent • Informed written consent (from parents of child) – Risks of surgery – Chances of recurrence & – Need for additional surgical procedures
  17. 17. 18 Pre-Op work upPre-Op work up • Blood CP • Urine RE • Coagulation profile • X-ray Chest PA view • Pre-anesethesia assesment in ASA-I
  18. 18. 19 OPERATI General anesthesia induction
  19. 19. 20 OPERATI •Smaller endotracheal tube of size 5.0 •Aluminum foiling
  20. 20. 21 Thorough endoscopic examination OPERATI Staging sites and extent of lesion
  21. 21. 22 Largest possible laryngoscope placed OPERATI
  22. 22. 23 OPERATI Specimen for biopsy taken
  23. 23. 24 OPERATI Laser Safety Measures
  24. 24. 25 COCO22 Laser ExcisionLaser Excision • CO2 laser used at – 10 watt power – with 0.1 sec pulses & – small plot size OPERATI
  25. 25. 26 OPERATI CO2 Laser Micromanipulator
  26. 26. 27 OPERATI Intraoperative photograph before RRP removal
  27. 27. 28 OPERATI Extensive papillomas covering glottis Aluminium foiled endotracheal tube Bulky Glottic Lesion
  28. 28. 29 OPERATI He-Ne aiming beam pointing the glottic area being ablated
  29. 29. 30 OPERATI Laser ablation in process
  30. 30. 31 OPERATI Glottic chink after CO2 Laser ablation
  31. 31. 32 Surgical MicrodebriderSurgical Microdebrider OPERATI Long laryngeal blade Oscillating head
  32. 32. 33 OPERATI Surgical Microdebrider
  33. 33. 34 OPERATI Microdebrider debulking of RRP
  34. 34. 35 OPERATI Glottis after excision of lesion
  35. 35. 36 OPERATI Before Surgery After Surgery
  36. 36. 37 Post-Operative CarePost-Operative Care • Steroids, analgesics & antibiotics • Steam inhalation • Sniffing exercises • Voice rest
  37. 37. 38 Follow upFollow up • Marked improvement in her voice and breathing post-operatively. • Parents advised regular follow up.
  38. 38. DEPARTMENT OF OTORHINOLARYNGOLOGY HEAD & NECK SURGERY CMH RAWALPINDI HOSPITAL DATAHOSPITAL DATA
  39. 39. 40 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
  40. 40. 41 Frequency of RRP 18, 86% 3, 14% Child onset RRP Adult onset RRP
  41. 41. 42 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.
  42. 42. 43

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