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A 7-year-old female patient presents with hoarseness and stridor. The patient has a history of laryngeal papilloma.
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PREOPERATIVE CONSIDERATIONS
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Laryngeal papillomas are benign epithelial tumors that are caused by infection with the human papillomavirus (HPV). Papillomas can occur at any age; they occur frequently in children under 10 years of age, but in many cases they disappear after the patient has reached adolescence. They most commonly affect the larynx and upper respiratory tract of children, resulting in hoarseness, stridor, obstruction of the airway, and asphyxiation if left untreated. The leading cause of HPV infection in children is infection from the birth canal or the blood of the infected mother.
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Papillomas often recur and can spread to the hypolaryngeal vestibules, the epiglottis, and occasionally the trachea and lungs; this may also lead to head and neck cancers. Because of the growth of the papillomas in the narrow pediatric airway, severe laryngeal obstruction may occur. Many children are treated as outpatients and require numerous procedures throughout their childhood to remove the tumors once or twice a month as they reappear. Some children with severe airway obstruction may even need a tracheotomy.
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ANESTHETIC MANAGEMENT
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Maintain a patent airway during surgery to ensure adequate ventilation and surgical exposure.
Use mask or IV induction with propofol with spontaneous ventilation.
Spray the larynx with 1-2% lidocaine prior to suspension.
Maintain anesthesia with total intravenous anesthesia with propofol and remifentanil infusion.
If intubation is needed, a small-size tube is generally used.
If jet ventilation is needed, then subglottic jet ventilation is used at 20-25 breaths per minute at a pressure starting at 5-10 psi and titrated up while observing chest excursion and oxygen saturation.
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POSTOPERATIVE CONSIDERATIONS
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Bleeding and edema are typically minimal after surgery, and obstructive symptoms often show immediate improvement. Patients may require humidified oxygen in the postanesthesia care unit. Nebulized racemic epinephrine (2.25%) (0.05 mL/kg, max 0.5 mL) may be administered if patients have stridor. Patients are generally discharged home the day after surgery.
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DOs and DON’Ts
⊗ Do not premedicate if the patient has stridor or hoarseness with airway obstruction.
✓ Do maintain spontaneous ventilation.
✓ Do have instruments for emergency cricothyrotomy or tracheotomy available if complete airway obstruction occurs after induction.
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Surgical excision of tumors at frequent intervals to relieve the symptoms of airway obstruction is the mainstay of therapy in these patients. Carbon dioxide laser has been used for the excision of laryngeal papillomas. More recently, a laryngeal microdebrider has become the preferred method for excision of the papillomas in many centers.
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Human papillomavirus subtypes 6, 11, 16, and 18 have been identified. Although with the availability of human papillomavirus vaccinations, intralesional cidofovir ...