Laryngeal papillomatosis removal

Laryngeal papillomatosis removal

Anesthesia type	General (Topical/Local in select patients)
Airway	Shared airway ETT (microcuff) or jet ventilation or intermittent apnea
Lines and access	PIV
Monitors	Standard ASA
Primary anesthetic considerations
Preoperative	-Severity of airway obstruction (stridor, retractions) -Voice changes or feeding difficulties -Location and bulk of papillomas -Recent URI -Prior airway history
Intraoperative	-Shared airway with surgeon -Airway bleeding/edema -Airway fire prevention (laser precautions) -Smoke protection (N95, smoke evacuator)
Postoperative	-Laryngospasm risk -Airway edema
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Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

Overview

Indications

• Airway obstruction (symptomatic)
• Voice dysfunction (interfering with communication or quality)
• Recurrent disease debulking
• Distal airway spread into subglottic or lower

Urgency ranges from elective to emergent depending on obstruction severity

Surgery is palliative, not curative, and does not remove HPV from the tissue

Surgical procedure

Principles:

• Preserve healthy mucosa to minimize scarring and voice disruption
• Avoid overly aggressive resection to reduce webbing and dysphonia

Suspension microlaryngoscopy (SML) - surgeon visualizes the larynx with laryngoscope and removes papillomas using:

• Microdebrider
  • Rotating blade with suction to remove papillomas with minimal manipulation of surrounding tissue
  • Rapidly debulk lesions with shorter operative time and less injury to surrounding tissue than lasers
• Cold instruments
  • Traditional excision via forceps or scissors
  • Useful for small or focal lesions and biopsy
• Laser resection
  • CO2 historically used with precision and hemostasis
  • Photoangiolytic lasers (KTP, pulsed dye) more favored with potentially lower scar formation
  • Requires airway fire precautions

Office-based flexible endoscopic laser under topical sedation is possible in cooperative adults with limited disease

Tracheotomy possible in severe, airway-compromising disease unresponsive to repeated microlaryngoscopy, but carries risk of distal viral spread along tracheobronchial tree

Preoperative management

Patient evaluation

System	Considerations
Airway	-Stridor at rest (inspiratory vs biphasic) -Retractions, work of breathing -Voice quality (hoarseness suggests glottic involvement) -Prior tracheostomy -Prior anesthesia records
Neurologic	-N/a
Cardiovascular	-Tachycardia from distress -Exercise intolerance
Pulmonary	-Baseline oxygenation -Reactive airway disease history -Lower airway involvement
Gastrointestinal	-NPO guidelines -Feeding difficulties
Hematologic	-Low bleeding risk
Renal	-N/a
Endocrine	-N/a
Other	-OR precautions to possible viral aerosolization and laser plum (N95, smoke evacuator) -No isolation precautions outside OR

Labs and studies

Usually none. Consider imaging if distal airway involvement suspected

Operating room setup

Airway equipment

• Multiple small ETTs available (consider microcuff for pediatric patients)
• LMA as rescue
• Suction immediately available
• Laser-safe ETT if laser planned
• Backup rigid bronchoscope
• Jet ventilation equipment if used
• Difficult airway cart immediately available
• Tracheostomy equipment if used

Laser precautions (airway fire precautions)

• N95 mask with laser safe eyewear
• Smoke evacuator with ULPA filter
• Laser-safe ETT
• ETT cuff inflated with saline +/- methylene blue
• Saline available on field
• FiO2 < 30%, avoid nitrous

Patient preparation and premedication

• Standard premedication acceptable if minimal obstruction
• Avoid heavy sedation if airway obstruction presents
• Glycopyrrolate may improve visualization
• Dexamethasone to reduce airway edema

Regional and neuraxial techniques

Not routinely used

• Superior laryngeal nerve block or transtracheal block may be used in rare awake adults cases
• Office-based laser procedures in adults may use topical anesthesia with minimal sedation

Intraoperative management

Monitoring and access

Standard ASA monitors with 1 PIV often sufficient

Induction and airway management

Mild to moderate obstruction

• Standard IV induction with short acting paralytic (if paralysis for ETT is needed)
• Adults with partial obstruction typically tolerate paralysis and positive pressure ventilation
• Shared decision-making regarding airway plan (possibly mask ventilation until ENT intubates with SML)

Severe airway obstruction

1. Inhalational induction (sevoflurane)
   • Maintain spontaneous respirations
   • Avoid sudden loss of upper airway tone
   • More challenging in adults
2. TIVA with spontaneous ventilation
   • Propofol + low dose remifentanil, consider ketamine
   • Avoid neuromuscular blockade until secured
3. Awake vocal cord intubation (adults)
   • Topical anesthesia
   • Minimal sedation

Airway techniques

1. Endotracheal tube
   • Most common method with continuous ventilation
   • Appropriately downsized ETT (microcuff in pediatric)
2. Intermittent apnea
   • Advance surgical instruments between ventilation (either mask or withdrawn ETT)
   • Reintubate/ventilate between passes
3. Jet ventilation
   • Subglottic obtains best uninterrupted surgical view
   • Monitor pressure and other risks

Positioning

HOB likely away from anesthesia machine and towards surgeons

Maintenance and surgical considerations

• TIVA with propofol +/- remifentanil commonly used
• Balanced volatile more challenging due to shared airway
• Avoid nitrous oxide (increased combustion risk of airway fire)
• Ensure adequate anesthetic depth to prevent coughing or reflex movement during airway manipulation as SML can be very stimulating

Laser precautions

• Fire triad: oxidizer (O2 or N2O), ignition source (laser), fuel (ETT cuff/tube)
• Use laser-resistant ETT
• Maintain FiO2 < 30% (lowest safe possible)
• Inflate cuff with saline +/- methylene blue
• Smoke evacuator with ULPA filter
• Saline immediately available on field

Airway fire emergency protocol

• Stop oxygen and laser
• Remove ETT
• Flood airway with saline
• Ventilate with room air
• Reassess tube and airway injury (e.g. bronchoscopy)

Emergence

Goal

• Smooth
• Avoid coughing and bucking
• Prevent laryngospasm (especially in pediatric)

Strategies

• Deep extubation
• IV or topical lidocaine to blunt cough reflex
• Dexamethasone to reduce edema
• Racemic epinephrine and reintubation equipment readily available

Postoperative management

Disposition

PACU for mild disease

Observation or admission if

• Significant edema
• Severe preoperative obstruction
• Long case

Pain management

Typically mild

• Acetaminophen
• NSAIDs
• Opioids rarely required

Potential complications

Immediate

• Laryngospasm
• Airway edema
• Stridor
• Bleeding
• Airway fire

Delayed

• Recurrence (common)
• Subglottic stenosis (from repeated procedures)
• Distal airway spread

Procedure variants

	Microdebrider	Cold instruments	Laser excision	Office-based laser
Unique considerations	Less fire risk Tolerate higher FiO2	Spontaneous ventilation or intermittent apnea preferred	Laser precautions	Often local/topical anesthesia Minimal sedation
Advantages	Shorter operating time	No thermal injury	Precision Hemostasis	Avoids GA
Potential complications	Bleeding Mucosal trauma	Bleeding Airway edema	Airway fire Thermal injury	Laryngospasm