Surgical partial removal of papillomatosis for endotracheal intubation as an alternative to tracheostomy for an "almost completely" occluded airway.

To the Editor,

Recurrent papillomatosis due to human papilloma virus infection can occur in multiple organs and systems.[1] Juvenile recurrent laryngeal papillomatosis is one of the most life-threatening diseases due to it's potential for airway obstruction and ventilatory compromise. When these patients are scheduled for surgery, ventilation and intubation can pose serious challenges for anesthesiologists. We report an alternative rescue strategy to tracheostomy to deal with the papillomatosis-induced occluded airway by surgically removing partial papillomatosis tissue and creating an opening for endotracheal intubation.

A 10-month-old girl, with a history of laryngeal papillomatosis and previous surgical removal, was scheduled for surgical removal of papillomatosis due to recurrent tumor-induced increasing hoarseness and wheezing. Preoperative fiberoscopic inspection indicated possible complete glottic obstruction [Figure 1]. Possible intraoperative tracheostomy was preoperatively discussed with surgery team. Intraoperatively, general anesthesia was induced with 5% sevoflurane. The intubating anesthesiologist immediately realized the patient's glottis was completely filled with papillomatous masses and no glottic opening could be identified for endotracheal intubation. After two attempts, the anesthesiologists and surgeons decided to remove some papillomatous mass to create a small hole for intubation. At this time, the patient's spontaneous breath became increasingly more obstructive, pulse oximetry (SpO2) started declining under the positive pressure assisted ventilation. Surgeons immediately proceeded to direct laryngoscopy [Figure 2], and removed a portion of the massive papillomatosis tissue. A small hole was created and endotracheal intubation with #3 tube was accomplished [Figure 3]. The whole process lasted <2 min. Bleeding was minimal to affect the surgeon's visualization. The patient's heart rate did not decline even at the lowest SpO2 reading of 70%. After intubation, her SpO2 quickly returned to 100%. Complete removal of papillomatosis was achieved as scheduled. General anesthesia was maintained with 3% sevoflurane. Intravenous methylprednisolone 40 mg was given to alleviate potential airway edema. The patient was kept intubated and transferred to intensive care unit at the end of the procedure. Her trachea was extubated next morning without respiratory compromise. The patient fully recovered and discharged in good condition. Monthly follow-up for 6 months after discharge did not identify any complications from either surgery or anesthesia.

Figure 1

Preoperative fiberoscopic inspection

Figure 2

Image from direct laryngoscopy before intubation

Figure 3

Successful intubation after partial papillomatous tissue removal

Anesthesia for patients with massive laryngeal papillomatosis can be very challenging due to the possibility of developing complete airway obstruction during induction and intubation, especially in the pediatric population due to their smaller opening of glottis and trachea. Laryngeal papillomatosis which occurs at or before 2 years of age is associated with frequent and severe upper airway problems.[2] Some patients often require tracheostomy at some point during the treatment process. Sharing of the airway passage with surgical sites during surgical manipulation poses particular challenges, especially in children.[2] During the process of induction and intubation, patients with papillomatosis may evolve into “can’t intubate, can’t ventilate” situation very quickly.[3] Thorough review of patient's history and preoperative airway, assessment is critically important in providing safe anesthesia care. Our patient had a fibrotic laryngoscopy preoperatively [Figure 1], which showed the glottis was almost completely occluded, though the patient did not have significant dyspnea. Alternative airway strategies including surgical airway should be readily accessible when inducing general anesthesia. Inhalational induction of general anesthesia, especially with sevoflurane is preferred to intravenous induction.[4] Management of “can’t intubate, can’t ventilate” situation due to completely occluded glottis is usually tracheostomy or cricothyrotomy. Cricothyrotomy is commonly used to provide a rescue airway, the incision site is higher than that of tracheostomy, and it is not used as frequently as tracheostomy during the papillomatosis operation. Tracheostomy may potentially induce the development of tracheal papillomatosis. Orji et al. reported tracheobronchial spread of papillomatosis occurred in a patient with prolonged tracheostomy.[5] Thus, tracheostomy may not be ideal for the therapy and rehabilitation of recurrent papillomatosis.

Our approach was different. By removing partial papillomatous masses surgically we created a “hole” for endotracheal tube insertion. The papillomatous masses occluding glottis were visualized under laryngoscopy and easily removable. A legitimate argument would be that this approach might potentially lose the critical time for other life-saving maneuver(s). However, if part of the papillomatous mass can easily be removed by experienced surgeon(s), our approach does offer another option in the management of the airway for this kind of situation. It is significantly less-invasive to the laryngeal/tracheal anatomical structure, and mucous membrane maintains contact, minimizing the risk of laryngeal papillomatous spread and tumor implanting in/near this incision.