Abstract
OBJECTIVE To investigate the advantages of applying microdebrider removal of juvenile-onset recurrent respiratory papillary epithelioma (JO-RRP), using an endoscopy-assisted prop-up laryngoscope.
METHODS The degree of severity of the neoplasms was divided into 3 scores (i.e. 1 point for a slight degree, 2 points for a moderate and 3 points for a severe degree). The involvement of 22 respiratory and digestive sub-areas was evaluated and the total accumulative scoring and the scores for the lesions in the vocal area were calculated and sub-grouped. All the papillary epitheliomas were excised using a laryngeal microdebrider or the micro laryngeal forceps under endoscopy-assisted suspension laryngoscopy. The differences between applications of the two modes of treatment for the cases of the groups with same scoring were compared as follows: the operation time, interval of operation, recent vocal quality after operation, postoperative scarring and incision of the trachea, as well as the distribution of tumors in a re-operation.
RESULTS The 142 operative procedures were performed in 33 pediatric patients, with application of a laryngeal microdebrider in 14 cases and excision in 19. Compared to the excision group (EG), the laryngeal microdebrider group (MDG) displayed many superior features, such as a short operation time, long Interval between operations, obvious Improvement in vocal quality soon after operation, and a low frequency of subsequent tumors. There was a significant difference between these modes of the operation. A postoperative incision of the trachea was required in 2 cases of EG, whereas no post-operation was needed in the MDG.
CONCLUSION There are many advantages in using laryngeal microdebrider removal of JO-RRP. The procedure is simple and convenient, having a distinct operating field, precise incision, minor wounds, fewer complications and better vocal quality soon after operation, as well as quicker rehabilitation and longer intervals between operations, etc.
keywords
Juvenile-onset recurrent respiratory papillary epithelioma (JO-RRP) is a common benign tumor with an incidence relating to infection of type-6 and 11 human papillary epithelioma virus (HPV). A major characteristic of the disease is repeated recurrence. The neoplasm can be involved in many parts of the respiratory tract, but it has a definite self-limitation at the saipe time, resulting in one of the tough problems puzzling clinical treatment. At present the main therapy consists of removal of the tumors by various means, maintenance of smooth respiratory passage and extension of the period between recurrences, thus attempting complete healing. Since 2001, the method of microdebrider removal has been applied in our ENT department of to treat JO-RRP, with good results. The experience of our treatment is summarized as follows.
MATERIALS AND METHODS
General data
Thirty-three cases, with complete clinical data of JO-RRP patients receiving surgical treatment in our hospital during the period from May 1, 2001 to December 1, 2005, were chosen in the study. All the patients, comprising 20 males and 13 females, were pathologically confirmed with papillary epithelioma. Their ages ranged from 0.8 to 8 years, with an average of 3.8. Among the patients, 66 laryngeal microdebrider removals were performed in 14 cases and 76 single resections in 19 cases, totaling 142 operative-procedures. The number of times of treatment for each child was 2 to 12. Clinical healing was attained in 9 cases, with 4 in the MDG group and 5 in the EG
Methods of treatment
Equipment
Storz prop-up laryngoscope, 12° Storz ultrawide-field rigid endoscope (cystoscope), digital image system, Xomed power system, a 3.5 mm-diameter Xomed Skimmer Angle-Tip tool bit and laryngeal microinstrument.
Methods
The Storz prop-up laryngoscope was introduced by mouth, with compound anesthesia and high frequency ventilation-assisted respiration; the root of the tongue was teased to expose the epiglottis and vocal area and then the tongue fixed. The 12° Storz ultrawide field rigid endoscope (cystoscope) was introduced to observe the position of the tumor with a transparent digital image system. The severity of the tumors in each sub-area of the anatomy was determined and the scores calculated. Biopsies were taken for pathologic examination, and then the laryngeal microdebrider (a rate of 3000 rpm) or micro laryngeal forceps were used to excise all tumors. For the tumors with a large volume or a pedicle, serial debridement was conducted when removing the tumor with the microdebrider. With direct vision, the tumors were held by the cutting tip of the microdebrider and removed. For the tumors with a minor volume or near the basilar part of the mucosa, the cutting tip should be close enough to the tumor to suck it up, with application of intermittent debridement, The tissues being removed were observed with direct vision to avoid harming the vocal ligaments or normal mucous membranes (Fig. 1,2).
The endoscopic view of the larynx of a pediatric patient before operation for a JO-RRP
The laryngeal view of a pediatric patient with JO-RRP after removal of a laryngeal papillary epithelioma using a laryngeal microdebrider.
Assessment of the severity of the papillary epitheliomas
Using the scoring criteria of Pasquale etc.,[1] combined with the clinical experience of our department, the bronchia and trachea were divided into 22 anatomical sub-areas. Among them, 11 were in the laryngeal area, i.e. the laryngeal and lingual surface of the epiglottis, left and right aryepiglottic fold, left and right ventricular bands, left and right vocal cords, commissura-anterior and commissura posterior, left and right vocal area and the left and right hypolarynx. Four anatomical sub-areas were in the trachea and bronchia, i.e. the trachea, left and right bronchia and the stoma of the trachea, and 7 in other locations were as follows: nose, pharynx, hard palate, left and right lung, esophagus and other organs. The severity of the tumors in each sub-area was respectively graded into 3 degrees, i.e. a slight (1 point) degree of tumor indicated that the area of the basilar part was under 0.1 cm2, a moderate (2 points) degree was above 0.1 cm2 but under 0.5 cm2, and the severe degree (3 points) meant that the area of basilar part of the tumor was over 0.5 m2. The total scores were then calculated.
Evaluation of the curative effect
Evaluation of vocal quality
With reference to the evaluation criteria for psychological subjective auditory sense of the voice established by the Japanese Association of Voice and Logopedics,121 the criteria were divided into 5 types, i.e. general grade of clarity (grade, G), rough type (rough, R), respiration type (breathy, B), asthenia type (asthenic, A) and strain type (strained, S), among which 4 degrees were set for each type, i.e. 0 degree for the normal, 1 for slight, 2 for moderate and 3 for severe degree. The average was taken for the 5-type comprehensive evaluations: 0 was a normal voice, (5 points); when the average was above 0 and lower than or equivalent to 1, it indicated a slight roughness of voice (4 points); when the average was above 1 and lower than or equivalent to 2, it indicated moderate roughness of voice (3 points); when the average was above 2 and lower than or equivalent to 3, it indicated severe roughness of voice (2 points). In addition, one more group was added combined with clinical research, i.e. aphonia (1 point). The assessment of vocal quality for the pediatric patients was respectively performed on admission and 1 week after operation.
Operation time
It started from the use of the prop-up laryngoscope for exposure of laryngeal cavity until the complete excision of the papillary epitheliomas was completed. The interval between operations indicates the interval between two operations expressed in months.
Statistical analysis
The t test and chi square test were used to analyze the data.
RESULTS
During the 142 hospitalizations, dyspnea of various degrees occurred in the 33 cases with JO-RRP before operation. All the cases had complete remission, with smooth breath. Most patients had to receive a reoperation for impaired breathing 1 to 6 months after treatment.
Comparison between the average operation times
The preoperative total scoring for severity of the patients' foci was 3 to 20, with an average scoring of 10.54 points in the laryngeal MDG and 9.21 points in the EG, suggesting that the condition in the former group was worse than the latter, but there was no statistical significance between the two groups (t=1.68, P=0.10). Based on the total scoring, the cases were divided into 4 groups, i.e. group 1 (with 3 to 6 points), group 2 (7 to 10 points), group 3 (11 to 14 points) and group 4 (15 to 20 points). There was a significant difference between the operation times for the two modes of treatment when comparing the groups with the same scoring (P<0.05, Table 1). Treatment using the microdebrider required less time.
Comparison of the two modes of operation on JO-RRP between the groups with same scoring
Comparison of the intervals between operations
The intervals between operations for the two modes of operation significantly differed for the groups with the same scoring (P<0.05, Table 1).
Condition of postoperative scarring
No preoperative scarring was found in 5 cases of the EG but scarring or adhesion of vocal cords was found when the patients received a re-operation. There was an enlargement of the former scar in 2 cases of the group. No new scar was found in the MDG after the operation, there being a significant difference between the groups (χ2 =3.37, P=0.04).
The condition of tumors at re-operation
A greater number of tumors was found at re-operation in 20 cases receiving a single resection. A significant difference was found between the groups, with 1 case of intratracheal implantation in the EG. No enhanced number of tumors was found in the laryngeal microdebrider group (χ2=11.67, P=0.00). There were 15 cases with less tumors in the cases treated with the microdebrider while there were only 3 receiving a single resection (χ2=9.056, P=0.03). SO the difference between the groups was significant.
Postoperative incision of the trachea
In the EG, edema developed in the laryngeal mucosa and there was difficulty in removing the tube for anes-thesia in 2 cases, so an incision of trachea had to be performed. No problem of this kind occurred in the laryngeal MDG.
Comparison of the postoperative vocal qualities
The cases were divided into 3 groups based on the total scoring of the dual vocal cords, ventricular bands and the anterior and posterior commissura, i.e. group 1 (1 to 2 points), group 2 (3 to 4 points) and group 3 (above 5 points). There was a significant difference between the vocal quality of the two different treatment groups with same total scoring, with the MDG having better vocal quality (Table 2).
. Comparison of the recent vocal quality after operation on JO-RRP between the groups with the scoring of same vocal area
DISCUSSION
The clinical characteristics of JO-RRP
Recurrent respiratory papillomatosis (RRP) is a common disease. These benign tumors account for 70% of the benign tumors of the respiratory tract, and can be divided into two types, i.e. the adult (adult-onset, AO-RRP) and the juvenile type (juvenile-onset, JO-RRP). The presence of JO-RRP indicates that the age of onset was below 18. The incidence of JO-RRP is 3.96/ 100,000,[2] of which 80% occur before the age of 7 with a preponderance below 4 years of age. The disease presents with multiple symptoms, with a predilection site of the larynx, trachea, prominentia laryngeal and bronchia, etc. The disease often recurs, trending to cure naturally during adolescence. The cause of the disease is not completely clear. Most specialists suggested that JO-RRP is related to infection by HPV. Some scholars have successfully detected HPV in the tumors in JO-RRP patients and suggested that the HPV-6 and HPV-11 were the major etiological factor causing JO-RRP.[3] More than half of otolaryngologists have come across cases in which a JO-RRP patient died from ineffective amelioration of dyspnea caused by extensive invasion of the larynx, trachea and bronchia. Clinical treatment of JO-RRP remains to be a puzzling problem.
Assessment of current therapy for JO-RRP
Currently the complete cure of JO-RRP is still unavailable. The goals of treatment remain the preservation of normal structure and functions, concurrently with removal of the tumors and keeping the respiratory tract smooth. The surgery is still the major means of treatment. Most surgeons have used excision or C02 laser therapy to treat the disease. Surgical excision is convenient with low expense, but requires surgical expertise, with the operating field often filled with blood. Also it is not easy to remove the tumors completely. C02 laser treatment of JO-RRP has an advantage of having a distinct operating field, no blood loss and complete removal of the tumors, etc. thus becoming one of the main means for treatment of JO-RRP. However, the C02 laser surgical procedure is time consuming, with a high expense and potential risk, e.g. burning of the air passage, heat injury of the basal body and environment of the diseased area, as well as possible laser injury to the medical staff, etc. In addition, the C02laser treatment can only be used as a linear treatment and it is usually difficult to treat the tumors such as those in the hypolarynx, trachea and bronchia. In recent years, with the emergence of a new generation of instruments for otorhinolaryngology and their laryngeal cuttingblades, some clinicians have started to apply the laryn-geal microdebrider for treatment of JO-RRP. Owing to the use of the endoscopy assisted prop-up laryngoscope, the microdebrider can conveniently reach the sites such as the throat and trachea, etc. Besides, with the consecutive suction and cutting action, the microdebrider can easily free or attract the tumors from the basilar part and precisely cut away the neoplasm. Because of these functions it is highly praised by otorhinolaryngologists. In recent years the use of microdebrider has gradually become the treatment of choice for JO-RRP overseas.[4-8]
The merits of grouping the cases in Ihe study
Over the past 10 years, the means for treating JO-RRP have increased. However, there has been no unified standard for diagnosis of the patient’s condition and no description of the pre and post-operative morphologic condition of the tumors. The results from various reports lacked consistency, which influenced appropriate evaluation and popularization of the new therapies. In our study, the respiratory tract and part of the alimentary tract were divided into 22 anatomical sub-areas, with the calculation of the total accumulated scoring and the grouping based on the severity of the foci in each anatomical sub-area. Afterwards the results between the groups with the same scoring were compared to improve the comparability of the cases, thus making the results much more reliable and the analysis of the curative effect more objective.
The comparison of laryngeal microdebrider removal of JO-RRP with excision
In comparison of the curative effect of the two modes of operation between the groups with same scoring, the operation time in the laryngeal MDG was less, with a longer interval between operations and better postoperative vocal quality. The difference between the groups was significant. Moreover, no postoperative scarring or enhanced number of tumors at re-operation was found in the group treated with the microdebrider and none of the patients required a postoperative incision of the trachea. We do believe that owing to the simple technical operation of the laryngeal microdebrider removal by endoscopy-assisted prop-up laryngoscope, that all the surgeons who have had the experience of handling a nasal endoscope can master the instrument quickly. The consecutive suction and cutting action of the microdebrider can essentially keep the raw surface bloodless, with a high degree of excision accuracy and causes only minor wounds in a clear operating field. The device rarely injures normal tissue and seldom produces scaring, thus promoting the quality of the operative procedure. With this simple procedure, clean removal of the tumors and good consistency, the operation time can be shortened. Owing to less injury of the normal tissue and slight vocal edema, the postoperative vocal quality was good. The long interval between operations may relate to clean resection of the tumors. The enhanced number of tumorous foci after operation occurred in many cases using the excision procedure. This might be related to inadvertent injury to the normal tissue in the procedure using the laryngeal microscope causing further papillary epithelioma formation. In the MDG, the postoperative number of the foci remained unchanged or diminished, which may relate to the minor wounds produced. The foci of tumors are reduced due to the gradual growth and enhancement of the resistance in the pediatric patients. In this study, postoperative incision of the trachea was conducted in 2 cases, both of which belonged to the EG. This may relate to two aspects, i.e. one was that the condition was more extensive and the other was that the operation was conducted with a lack of surgical expertise, which injured the vocal cords and the ventricular bands, causing severe laryngeal edema and difficulty in removal of the cannula.
Considering the international literature and our research research, the results suggest that, although the technology of the microdebrider to remove JO-RRP can not prevent tumor recurrence, it does have definite advantages over traditional surgical procedures and results in minimal trauma. Because of the self-limitation of JO-RRP, this mode of treatment produces conditions for a reduction in the frequency of the surgical procedures and allows complete recovery. If combined with application of specific anti-virus medicines, such as cidofovir, etc.,[9-10] it may bring improvement of the therapeutic efficacy and even complete healing of JO-RRP.
- Received April 20, 2006.
- Accepted June 1, 2006.
- Copyright © 2006 by Tianjin Medical University Cancer Institute & Hospital and Springer
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