Microdebrider better than CO2 laser for removal of most pediatric airway lesions

Citing improved safety and effectiveness at lower cost, a major medical center has adopted the microdebrider to replace the CO2 laser for removal of most pediatric airway lesions, including stenoses, granulation tissue, and cysts.

The microdebrider, a powered rotary dissection device with suction assistance, is designed to remove hard and soft tissue as well as minimize trauma. For decades, this device was used in orthopedic and lower jaw surgery; about 15 years ago this device was incorporated into endoscopic sinus surgery.

Newer blades that are longer and have angulated tips have been more recently introduced for laryngeal and tracheal application. The effectiveness of the microdebrider in laryngeal papilloma surgery to remove benign tumors has been well-documented. Now, researchers have investigated a new application of this device – removal of pediatric airway lesions including stenoses, granulation tissue, and cysts.

They have reported their experience of using the microdebrider for endoscopic treatment of a variety of pediatric airway lesions in a study, “Expanding Applications for the Microdebrider in Pediatric Endoscopic Airway Surgery.” The authors are Catherine J. Rees MD, Trina I. Tridico MD, and Daniel J. Kirse MD, all at the Wake Forest University Baptist Medical Center, Winston-Salem, NC. Their findings are being presented at the American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting & OTO EXPO, being held September 19-22, 2004, at the Jacob K. Javits Convention Center, New York City, NY.

Methodology:

A surgical log containing video and photodocumentation was kept by the primary surgeon for all pediatric endoscopic airway procedures from June 2002 to August 2004. The log monitored all endoscopic airway cases in which the microdebrider was used. The subjects’ medical records were reviewed to obtain age, sex, date of surgery, indication for surgery, type of anesthesia, surgical time, postoperative course, and complications.

Although the location of the airway pathology determines surgical technique, the same basic approach can be applied in most cases. An epinephrine-soaked tuft of cotton is applied to the lesion both before and after debridement to control bleeding. Microdebridement may be performed with the binocular microscope, but the researchers found that simultaneous use of the telescope in one hand and the microdebrider in the other allows for the best visualization and maneuverability.

Results:

For more than a two year period, the microdebrider was used in 75 pediatric endoscopic airway procedures. Fifty-three cases of laryngeal papillomas were done, three involving debridement of tracheal papilloma in addition to laryngeal papilloma. The microdebrider was also employed for one case of glottic stenosis, four of subglottic stenosis, and four for tracheal stenosis. Suprastomal granulation tissue was removed with the microdebrider in six cases. Other cases involving granulation tissue include one each for posterior glottic, subglottic, and tracheal granulation. A true vocal cord cyst was removed with the microdebrider, as were three subglottic cysts.

Except in the presence of an existing tracheotomy or obstructing laryngeal papillomas, all cases were performed with the patient spontaneously ventilating. There were no surgical complications in this series, including bleeding problems.

Conclusions:

The operating microscope and the carbon dioxide laser have resulted in major advances in endoscopic treatment of pediatric airway lesions. However, the CO2 laser has inherent risks that have led many surgeons to look for alternative tools such as potential thermal injury to surrounding soft tissues and airway fire, a rare but devastating risk. In addition, operating room personnel must have special training to use the CO2 laser, and both the patient and staff must have eye protection. The microdebrider has no such risks.

The researchers suggest there are some disadvantages to use of the microdebrider. Unlike the CO2 laser, hemostasis is a concern with the cold technique. Other considerations include the need to rupture round cyst-like lesions with the laser or cold steel instruments before the microdebrider can be used at the free edge. While most tracheal lesions can be reached in children with the longer microdebrider blades, the microdebrider can not be used with a ventilating bronchoscope for tracheal lesions.

This is the first report to address microdebridement of pediatric airway lesions other than laryngeal papillomas. Although the technique may be initially awkward, the findings reveal that surgeons rapidly become quite adept at manipulating both the microdebrider and the telescope through the suspended laryngoscope. In cases, where the CO2 laser is too dangerous or impossible to use, the microdebrider has proven to be an indispensable tool for pediatric endoscopic airway procedures. Essentially, the microdebrider has made management of many airway lesions commonly encountered by pediatric otolaryngologists safer, more expedient, less expensive, and simpler than previously described methods.