management of suprastomal and tracheal granulomas: an update
TRANSCRIPT
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Management of
suprastomal and
tracheal granulomas:
An Update
Shraddha Mukerji, MD
Didactic Day - November 22, 2010
The University of Texas Medical Branch
Department of Otolaryngology
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Overview
• Etiology
• Incidence
• Indications for treatment
• Techniques for treatment
• Algorithm
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Incidence
• Suprastomalgranulomas (SG):4%-80% after pediatric
tracheostomies
• Site: Anterior tracheal wall just above the level of the
stoma
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Incidence contd
• <3 months: soft and friable, >6 months firm and fibrous
• Increased incidence with use of endoscopy to evaluate the
trachea
• Incidence increased with use of modern circular curve
shaped tracheostomy tubes
• Increased incidence with inappropriate sized tubes, cuffed
tubes
Shires et al. Management of suprastomal tracheal fibroma: Introduction of a new
technique and comparison with other techniques. Int J PedOtorhinolary 2009.
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Etiology of SG
• Frictional trauma of the tube
• Exposure of the stoma to the environment
• Secondary infection
• Stasis of secretions at the entry site of the tracheotomy tube
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Etiology of tracheal granulomas
• Mucosal injury and necrosis from
suction tips
• Frictional trauma from the tip of the tube
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When to treat?
• Majority of SG are asymptomatic and do not require
treatment
• Treatment is indicated if SG and tracheal granulomas
are associated with
• Bleeding
• Airway Obstruction
• Dysphonia, Aphonia
• Prior to decannulation
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Techniques available
• Endoscopic
techniques
• Hook eversion
• Sphenoid punch
• Optical forceps
• Endoscopic laser
• Electrocautery
• Microdebrider
• Coblation
• Open techniques
• Tracheostomaplasty
• Laryngeotracheoplas
ty (LTP)
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Endoscopic techniques
• Laryngeal suspension
• Ventilating
bronchoscope or Rigid
0 degree Hopkins
telescope
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Hook-eversion technique
• First described by
Reilly and Myer
• Direct visualization
• The skin hook is
introduced through
the stoma to evert the
granuloma
• The granuloma is then
grasped by hemostat
and excised using
tenotomy scissors
Reilly et al. Excision of suprastomal granulation tissue, Laryngoscope, 1985
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Hook eversion technique
• Indicated for small,
pedunculated,
granulomas
• Disadavantages:
• Exposure limited for
large granulomas
• Additional trained
assistant is required
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Sphenoid punch technique
• First described by
Prescott
• Direct visualization of
granuloma
• Punch forceps
introduced through the
stoma to grasp and cut
the tissue
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Sphenoid punch
• Advantages: Curve allows easy introduction, easy
removal, minimal bleeding
• Used primarily for fibrous granulomas
• Disdadvantage: Cannot be used for large, obstructing
granulomas: difficult to bypass the mass
Prescott CAJ. Persistent complications of pediatric tracheotomy. Int
J PediatrOtorhinolaryngol, 1992
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Optical Forceps
• Cupped optical forceps
• Used with a rigid
Hopkins system
• Indicated for small
friable granulomas
• Can cause bleeding due
to piecemeal
granuloma removal
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Electrocautery
• It consists of a long skinny wire passed through the
endoscopic bronchoscope
• The tip of the wire cauterizes the tissue with minimal
bleeding
• Advantages: Direct delivery of energy, minimal
bleeding
• Disdavantages: Learning curve, scarring
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Granulomas amenable to cold techniques
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Endoscopic laser
• CO2 laser is considered to be the work horse of
pediatric airway surgery
• The pediatric airway is smaller and has less tissue as
compared to an adult larynx.
• This precludes widespread use of KTP laser as it has
deeper penetrating properties
• CO2 laser: Shallow depth of penetration and minimal
non-specific thermal affect
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CO2 laser fiber
• This device delivers CO2 laser energy to target tissue
through a hollow, flexible wire
• The flexible wire can be introduced through the
ventilating bronchoscope or through custom designed
hand pieces
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CO2 laser fiber
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CO2 laser Fiber
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CO2 laser Fiber
• Advantages:
• CO2 laser properties are maintained
• Ease of use
• Direct delivery of energy to difficult to reach anatomical
areas such as distal trachea
• The tip of the carrier can be used for dissection
• Cumbersome, articulated line of sight CO2 delivery
systems are avoided
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Tip of CO2 fiber
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Case
• 4 yo s/p tracheostomy for Arnold Chiari
Malformation, hemifacial hypertrophy, tongue
hypertrophy
• Lost to f/u for more than a year following Ike
• Presented with inability to tolerate Passy Muir Valve
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Large SG/Tracheal
Granuloma
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Tracheal Granuloma: CO2 laser fiber
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Microdebrider
• Can use a tricut or a
skimmer blade
• Usually indicated for small
fibrous tracheal granulomas
• Can be introduced through
the stoma to reach distal
granulomas
• Disadvantage: Bleeding
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Laryngeal coblation
• This consists of using a laryngeal coblation wand for
suprastomal and tracheal granuloma removal
• Only a few case reports have been published in the
literature showing good results
Kitsko et al. Coblation removal of large suprastomal tracheal granulomas
Laryngoscope 2009
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Advantages of laryngeal coblation
• Less bleeding as compared to hook-eversion and
optical forceps technique
• Has a suction port, so less chances of loss of
granuloma into the distal airway
• Direct visualization and ease of use
• Laser precautions are avoided, external scars for open
procedures are avoided
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Laryngeal coblation technique
• Suspension of the larynx
• Introduction of an appropriate sized bronchoscope
into the larynx just above the stoma
• The coblation wand is slightly bent and introduced
through the tracheostoma
• Coblation is carried out at a setting of 7
• The shape of the wand, electrodes and suction prevent
injury to posterior and lateral tracheal walls.
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Laryngeal coblation wand
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Coblation
PRE
POST
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Indications for Open Procedures
• Large, broad-based obstructing granulomas especially
if planning for decannulation
• Associated anterior tracheal wall collapse
• Failure of Endoscopic Management
Gupta et al. Pediatric suprastomal granulomas: Management and
Treatment. Otolaryngol Head and Neck Surg, 2004
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Open Procedure Technique
Stoma and fibrous tract
dissected into anterior
tracheal wall
Tract excised in
continuity with
intraluminal granuloma
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Open procedure technique
• If there is associated anterior tracheal wall collapse, the
trachea may be hitched forward and sutured to the
strap muscles on either side.
• Closure of the tracheal opening with PDS suture
• Post-operative ICU monitoring for 48 hours (patient
remains intubated
• Steroids and antibiotics
Al-Saati et al. Surgical decannulation of children with tracheostomy,
Journal of Laryngology and Otology, 1993
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Algorithm
Small, moderate asymptomatic SG
Conservative, f/u endoscopy
Trial of endoscopic techniques unless very large Open procedures
Symptomatic SG
Large, obstructing SG
Prior decannulation
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Summary
• Suprastomal granulomas occur very commonly after
pediatric tracheotomies
• Majority are asymptomatic and do not require
treatment
• Endoscopic excision should be tried first for small or
moderate sized granulomas
• Open procedures should be carried out as a last resort
for specific indications