The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Microdebrider Complications in Laryngologic and Airway Surgery Rebecca J. Howell, MD; Nancy L. Solowski, MD; Peter C. Belafsky, MD; Mark C. Courey, MD; Albert L. Merati, MD; Clark A. Rosen, MD; Paul M. Weinberger, MD; Gregory N. Postma, MD Objectives/Hypothesis: There is a paucity of experience in the published literature documenting complications of powered surgical instruments in laryngologic surgery. Our objective was to ascertain the nature of these complications from expert opinion and review of the literature, and to recommend strategies to decrease major complications. Study Design: Review of the literature and an e-mail survey. Methods: A literature review of microdebrider complications in laryngologic surgery was conducted using PubMed and Ovid (1985 to 2013), along with an analysis of a confidential e-mail survey of various surgeons in selected high-volume laryngologic centers. Results: Powered instrumentation is frequently used in the operating room for larynx and airway surgery. The microdebrider can improve efficiency, lower costs, and shorten operative times. However, use of the microdebrider has the potential for serious complications in the larynx and airway. Great care must be taken when utilizing the microdebrider in laryngologic surgery. Significant complications including major vocal fold scar, airway compromise, severe hemorrhage, and unintentional tissue loss have occurred. Conclusions: The microdebrider is a popular and valuable tool for the otolaryngologist. A thorough knowledge of the instrument and its potential complications will improve surgical outcomes and may prevent complications. Awareness of the risks and surgeon experience with use of the microdebrider will allow the surgeon to successfully utilize this device in a safe and effective manner. Key Words: Microdebrider, laryngology, airway surgery, complications, powered instrumentation. Level of Evidence: 5 Laryngoscope, 124:2579–2582, 2014
INTRODUCTION The introduction of powered instrumentation for use in suction and cutting simultaneously in otolaryngology was first utilized in endoscopic sinus surgery.1,2 Use of the microdebrider in the larynx was first described in recurrent respiratory papillomatosis (RRP) in 1999.3 The utilization of powered instrumentation was further delineated in laryngologic surgery by Flint in 2000.4 Flint discussed using telescopic or microscopic guidance and powered instrumentation with suspension microlaryngoscopy, yielding superior visualization and thereby improving precision in removing obstructing lesions and controlled excision of vocal fold pathology.4 Since then From the Department of Otolaryngology (R.J.H., N.J.L., P.M.W., G.N.P.), Georgia Regents University, Augusta, Georgia; Department of Otolaryngology (P.C.B.), UC Davis Health System, Sacramento, California; Department of Otolaryngology (M.C.C.), UCSF Medical Center, San Francisco, California; Department of Otolaryngology–Head & Neck Surgery (A.L.M.), University of Washington Medical Center, Seattle, Washington; and the Department of Otolaryngology (C.A.R.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A. Editor’s Note: This Manuscript was accepted for publication June 23, 2014. Presented at Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Vancouver, British Columbia, Canada, September 29–October 2, 2013. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Gregory N. Postma, MD, Georgia Regents University, Department of Otolaryngology, 1120 15th St. BP-4109, Augusta, GA 30912. E-mail: [email protected] DOI: 10.1002/lary.24842
Laryngoscope 124: November 2014
its use has been expanded to include laryngotracheal tumors, Reinke’s edema, laryngeal stenosis, suprastomal granulation, and subepithelial excision of benign vocal fold lesions, although some of these are not generally accepted.4–7 With increasing use of microdebrider technology in laryngologic surgery has come an increasing versatility of instrumentation in the operating room. The standard laryngeal blade is 22.5 cm in length; however, 27.5-cm up to 45-cm blades are available for distal tracheal lesions4 (the latter blade referring to the Tricut AngleTip Bronchial Blade by XOMED-Medtronic, Jacksonville, FL). The handpiece has variable pivots, and the tip can be straight or angled at 15 .8 Furthermore, there are four available blades, with the most aggressive being the Tricut (XOMED-Medtronic) (Fig. 1), and next the serrated, straight, and the least aggressive is the Skimmer blade (XOMED-Medtronic) (Fig. 2). The blade size ranges from 2.9 to 4 mm in cutting diameter.8 The commercial descriptions for blade selection are: for excision of a large obstructing lesion the preferred blade is the Tricut set between 1,200 and 3,000 rpm in an oscillating mode. Alternatively, for more delicate vocal fold surgery the manufacturer guidelines recommend 60 to 500 rpm using the round Skimmer tip in an oscillating mode.4,8 There is a paucity of experience in the adult literature regarding complications while using the microdebrider in laryngologic surgery, and there is no evidence of microdebrider complications in the pediatric laryngologic literature. Therefore, we reviewed documented Howell et al.: Microdebrider Complications in Laryngology
2579
Fig. 1. Tricut blade by XOMED-Medtronic, Jacksonville, Florida. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Fig. 2. Skimmer blade by XOMED-Medtronic, Jacksonville, Florida. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.].
powered instrumentation complications in laryngologic surgery in the adult population alone, and we discuss anecdotal reports of unpublished major complications involving the microdebrider described at tertiary care laryngology centers around the country.
on excising abnormal tissue while preserving normal epithelium and lamina propria. Violation of these structures and entrance into the vocalis muscle can yield serious damage and subsequent scar formation. Mortensen and Woo suggested the potential for greater tissue trauma using powered instrumentation could occur more easily due to an absence of tactile feedback.9 Sims and Lertsburapa described a case of subcutaneous emphysema, right pneumothorax, and pneumomediastinum after jet ventilation and use of a microdebrider for excising tracheal papilloma. The patient awoke from anesthesia without shortness of breath or evidence of hypoxia. On routine chest x-ray, the right pneumothorax and pneumomediastinum were diagnosed. Conservative measures were taken and the radiologic findings resolved spontaneously and the patient was observed. Chest computed tomography did not reveal a tracheal defect; however, the authors agreed the pattern of airflow suggested a breech of the anterior tracheal wall. It was suggested that a small mucosal tear spontaneously resolved after jet ventilation ceased. The authors recommended consideration of routine chest x-ray when jet ventilation was used in conjunction with a microdebrider. Furthermore, the use of the Tricut blade should be cautioned in the airway.10 Simoni et al. reported a case series of 29 patients using endoscopic microdebridement for laryngotracheal carcinoma. There was a brief description of one intraoperative hemorrhage in a coagulopathic patient requiring emergent tracheotomy for intraoperative bleeding. It is unclear from the article if the microdebrider was the ultimate cause of bleeding, as this was not the focus of the article but merely mentioned as a complication of surgery.5 Regarding the survey data, four centers reported no major complications. Five centers reported complications categorized as severe vocal fold scar, airway compromise, hemorrhagic complication, and unintentional excision.
MATERIALS AND METHODS A literature search was performed using the key words microdebrider, complications, otolaryngology, errors, airway, perforation, hemorrhage, powered instrumentation, and laryngology on PubMed and Ovid from 1985 to the present. All article abstracts were reviewed for laryngologic complications involving adult surgery. Due to the paucity of articles (three) meeting these criteria, all were included and discussed below. The scarcity of data led to a review of the senior author’s complications and an email survey of eight other tertiary laryngology centers. A confidential survey was sent to eight laryngologic centers in the United States to specialists with more than 150 years of combined patient-care experience. The survey asked about major complications involving the microdebrider during surgery over the prior decade. It asked participants to exclude moderate hemorrhage, mild scarring of the lamina propria, and moderate webbing, thereby providing only major complications. This included the surgeons’ own practice and those referred from outside institutions with microdebriderrelated complications. This was not a validated survey instrument, but asked the senior authors about their experiences with serious complications as well as their own surgical and microdebrider blade preferences. This demonstrated several categories of complications not discussed in the literature that allowed us to categorize adverse events in an attempt to increase awareness within the laryngologic community. Survey data included no personal health information but was kept confidential in accordance with our institutions own laryngology retrospective review institutional review board (HAC 07–09079).
RESULTS There are only three reported complications in adult airway patients using powered instrumentation. Mortensen and Woo were the first to describe an anterior glottic web from a patient referred after a procedure using a microdebrider to remove a polyp extending from the right true vocal fold to the anterior commissure. The concept of microdebrider use in glottic pathology relies Laryngoscope 124: November 2014
2580
Unreported Vocal Fold Scar This complication was reported by several voice centers, although the exact incidence is unknown. Decreased mucosal wave propagation and/or an Howell et al.: Microdebrider Complications in Laryngology
adynamic segment are best recognized on laryngovideostroboscopy and have been found in several patients following the use of the microdebrider.
Unreported Airway Compromise One case involved use of the microdebrider for an obstructing squamous cell carcinoma resulting in an anterior subglottic tear causing the patient to undergo urgent tracheostomy. The patient was decannulated shortly thereafter and was able to resume planned treatment with chemoradiation without delay of therapy. Another case described the use of the microdebrider for laryngeal and tracheal papilloma. This patient suffered a tracheal tear requiring a thoracotomy and a local muscle flap to repair the trachea. A third procedure resulted in a tracheal violation during removal of distal tracheal papilloma. Consultation with cardiothoracic surgery was obtained, and the hole with exposed mediastinal fat healed quickly with conservative management, and no additional surgical procedure was required.
Unreported Hemorrhagic Complications One patient with extensive laryngeal papilloma developed a massive hemorrhage during use of the microdebrider requiring intraoperative laryngeal packing to stabilize the patient prior to angiography after endoscopic measures to control the bleeding were unsuccessful. The patient was intubated for 4 days before the packing was removed in the operating room. The patient did well without permanent sequelae. A similar case was described after biopsies were taken and microdebrider was used for laryngeal obstruction for what was found to be invasive fungal laryngitis with extensive neovascularization. The third individual had supraglottic RRP treated with severe hemorrhage that was unable to be stopped endoscopically. The patient required laryngopharyngeal packing and angiography to halt the bleeding. Unfortunately, this patient developed pneumonia and died shortly thereafter. A final and shocking case of a hemorrhagic complication using the microdebrider for subglottic stenosis and removal of granulation tissue with intraoperative damage to the innominate artery resulted in another surgical mortality.
Unreported Unintentional Excision Inadvertent tissue removal may happen almost instantaneously. One laryngologist reported an entire false vocal fold removed in moments. Another described large divots in the true vocal fold that occurred unintentionally.
ary scar formation.11 Although no studies in the adult literature have proven better outcomes with powered instrumentation compared to either cold steel or laser, many would agree that the use of powered instrumentation allows for rapid debulking with no associated fire risk.12,13 Obvious limitations of powered instrumentation in airway surgery include hemostasis and less fine control. In Flint’s 1-year series describing the use of microdebrider in 22 endoscopic laryngeal and airway procedures in 18 patients, he noted that microdebridement of subglottic granulation tissue was problematic due to bleeding despite the application of topical vasoconstriction. This is a vast understatement compared to the case series described above, but nonetheless is the only other documented warning of potential hemorrhagic complications in airway surgery using the microdebrider.3 Regarding the type of blade preferred, there was a dichotomy among the senior authors. Answers ranged from 100% use of the Tricut to 97% use of the Skimmer blade. It should be noted that every major complication in this report occurred while using a Tricut blade. It is suspected that using a less-aggressive blade, although increasing operative time, may reduce the risk of complications. Higher suction power may allow more tissue to become engaged with the cutting edge of the blade. Microdebrider suction power has been suggested as a possible factor linked to surgical complications. Microdebrider injury often results in shredded tissue and removal of large portions of normal tissue, which may make functional repair more difficult or even impossible. Walker et al. recently described a novel technique to modulate the suction of a microdebrider allowing potentially safer removal of abnormal tissue by manual control of the suction tubing by the operating surgeon.14 We recommend using the lowest level of suction necessary to perform safe surgery and adequate hemostasis to ensure optimal visualization. This report does not determine the incidence or frequency of injury, but the severity of the complications is such that we see this as important information. According to the current coding system, we cannot distinguish from laser, microdebrider, or coblator used during suspension microlaryngoscopy with excision cases (current procedural terminology code 31541). Furthermore, we cannot access the number of cases with microdebrider complications to include those referred from outside the academic centers surveyed. Due to the gravity of the events described and the paucity of literature, our suspicion is that this is underreported. Admittedly, due to the nature of the questions asked, there is an inherent bias in those selected for the confidential survey. This article thereby does not represent a true case series, but is instead expert opinion. Future research would include a prospectively designed study on the use of laryngologic microdebrider to assess for incidence data, which could add depth to the current literature.
CONCLUSION DISCUSSION The debate among proponents of cold surgical procedures over laser technology in laryngology would argue that there is minimal collateral tissue injury and secondLaryngoscope 124: November 2014
The microdebrider is a useful tool for laryngologic surgery. It enables the rapid eradication of disease while preserving normal anatomy and function. Avoidance of complications begins with picking the appropriate tool Howell et al.: Microdebrider Complications in Laryngology
2581
for the surgery and patient. Knowing the types of microdebriders available and making the correct instrument choice can reduce complications. Careful preparation and mindfulness during surgery will help reduce the incidence of major complications.
BIBLIOGRAPHY 1. V€ olklein C, Thumfart WF, Sprinzl GM, Pototschnig C, Gunkel A. Using a rotating suction debridement instrument with power generator in endonasal paranasal sinus surgery [in German]. HNO 1996;44:98–100. 2. Christmas DA Jr, Krouse JH. Powered instrumentation in functional endoscopic sinus surgery. I: Surgical technique. Ear Nose Throat J 1996;75: 33–36, 39–40. 3. Myer CM III, Willging JP, McMurray S, Cotton RT. Use of a laryngeal micro resector system. Laryngoscope 1999;109(7 pt 1):1165–1166. 4. Flint PW. Powered surgical instruments for laryngeal surgery. Otolaryngol Head Neck Surg 2000;122:263–266. 5. Simoni P, Peters GE, Magnuson JS, Carroll WR. Use of the endoscopic microdebrider in the management of airway obstruction from laryngotracheal carcinoma. Ann Otol Rhinol Laryngol 2003;112:11–13.
Laryngoscope 124: November 2014
2582
6. Sant’Anna GD, Mauri M. Use of the microdebrider for Reinke’s edema surgery. Laryngoscope 2000;110:2114–2116. 7. Cheng AY, Soliman AM. Use of a microdebrider for subepithelial excision of benign vocal fold lesions. Ann Otol Rhinol Laryngol 2010;119:782– 785. 8. ENT Product and Instrument Catalogue 2010–2011. Medtronic, Jacksonville, FL. 9. Mortensen M, Woo P. An underreported complication of laryngeal microdebrider: vocal fold web and granuloma: a case report. Laryngoscope 2009; 119:1848–1850. 10. Sims HS, Lertsburapa K. Pneumomediastinum and retroperitoneal air after removal of papillomas with the microdebrider and jet ventilation. J Natl Med Assoc 2007;99:1068–1070. 11. Durkin GE, Duncavage JA, Toohill RJ, Tieu TM, Caya JG. Wound healing of true vocal cord squamous epithelium after CO2 laser ablation and cup forceps stripping. Otolaryngol Head Neck Surg 1986;95(3 pt 1):273– 277. 12. Honda K, Haji T, Maruyama H. Functional results of Reinke’s edema surgery using a microdebrider. Ann Otol Rhinol Laryngol 2010;119:32–36. 13. Holler T, Allegro J, Chadha NK, et al. Voice outcomes following repeated surgical resection of laryngeal papillomata in children. Otolaryngol Head Neck Surg 2009;141:522–526. 14. Walker P, Diggelmann H, Ropp BY, et al. Suction modulation for the laryngeal microdebrider. Laryngoscope 2013;123:1496–1499.
Howell et al.: Microdebrider Complications in Laryngology
Rhinological and Otological Society, Inc.
Microdebrider Complications in Laryngologic and Airway Surgery Rebecca J. Howell, MD; Nancy L. Solowski, MD; Peter C. Belafsky, MD; Mark C. Courey, MD; Albert L. Merati, MD; Clark A. Rosen, MD; Paul M. Weinberger, MD; Gregory N. Postma, MD Objectives/Hypothesis: There is a paucity of experience in the published literature documenting complications of powered surgical instruments in laryngologic surgery. Our objective was to ascertain the nature of these complications from expert opinion and review of the literature, and to recommend strategies to decrease major complications. Study Design: Review of the literature and an e-mail survey. Methods: A literature review of microdebrider complications in laryngologic surgery was conducted using PubMed and Ovid (1985 to 2013), along with an analysis of a confidential e-mail survey of various surgeons in selected high-volume laryngologic centers. Results: Powered instrumentation is frequently used in the operating room for larynx and airway surgery. The microdebrider can improve efficiency, lower costs, and shorten operative times. However, use of the microdebrider has the potential for serious complications in the larynx and airway. Great care must be taken when utilizing the microdebrider in laryngologic surgery. Significant complications including major vocal fold scar, airway compromise, severe hemorrhage, and unintentional tissue loss have occurred. Conclusions: The microdebrider is a popular and valuable tool for the otolaryngologist. A thorough knowledge of the instrument and its potential complications will improve surgical outcomes and may prevent complications. Awareness of the risks and surgeon experience with use of the microdebrider will allow the surgeon to successfully utilize this device in a safe and effective manner. Key Words: Microdebrider, laryngology, airway surgery, complications, powered instrumentation. Level of Evidence: 5 Laryngoscope, 124:2579–2582, 2014
INTRODUCTION The introduction of powered instrumentation for use in suction and cutting simultaneously in otolaryngology was first utilized in endoscopic sinus surgery.1,2 Use of the microdebrider in the larynx was first described in recurrent respiratory papillomatosis (RRP) in 1999.3 The utilization of powered instrumentation was further delineated in laryngologic surgery by Flint in 2000.4 Flint discussed using telescopic or microscopic guidance and powered instrumentation with suspension microlaryngoscopy, yielding superior visualization and thereby improving precision in removing obstructing lesions and controlled excision of vocal fold pathology.4 Since then From the Department of Otolaryngology (R.J.H., N.J.L., P.M.W., G.N.P.), Georgia Regents University, Augusta, Georgia; Department of Otolaryngology (P.C.B.), UC Davis Health System, Sacramento, California; Department of Otolaryngology (M.C.C.), UCSF Medical Center, San Francisco, California; Department of Otolaryngology–Head & Neck Surgery (A.L.M.), University of Washington Medical Center, Seattle, Washington; and the Department of Otolaryngology (C.A.R.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A. Editor’s Note: This Manuscript was accepted for publication June 23, 2014. Presented at Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Vancouver, British Columbia, Canada, September 29–October 2, 2013. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Gregory N. Postma, MD, Georgia Regents University, Department of Otolaryngology, 1120 15th St. BP-4109, Augusta, GA 30912. E-mail: [email protected] DOI: 10.1002/lary.24842
Laryngoscope 124: November 2014
its use has been expanded to include laryngotracheal tumors, Reinke’s edema, laryngeal stenosis, suprastomal granulation, and subepithelial excision of benign vocal fold lesions, although some of these are not generally accepted.4–7 With increasing use of microdebrider technology in laryngologic surgery has come an increasing versatility of instrumentation in the operating room. The standard laryngeal blade is 22.5 cm in length; however, 27.5-cm up to 45-cm blades are available for distal tracheal lesions4 (the latter blade referring to the Tricut AngleTip Bronchial Blade by XOMED-Medtronic, Jacksonville, FL). The handpiece has variable pivots, and the tip can be straight or angled at 15 .8 Furthermore, there are four available blades, with the most aggressive being the Tricut (XOMED-Medtronic) (Fig. 1), and next the serrated, straight, and the least aggressive is the Skimmer blade (XOMED-Medtronic) (Fig. 2). The blade size ranges from 2.9 to 4 mm in cutting diameter.8 The commercial descriptions for blade selection are: for excision of a large obstructing lesion the preferred blade is the Tricut set between 1,200 and 3,000 rpm in an oscillating mode. Alternatively, for more delicate vocal fold surgery the manufacturer guidelines recommend 60 to 500 rpm using the round Skimmer tip in an oscillating mode.4,8 There is a paucity of experience in the adult literature regarding complications while using the microdebrider in laryngologic surgery, and there is no evidence of microdebrider complications in the pediatric laryngologic literature. Therefore, we reviewed documented Howell et al.: Microdebrider Complications in Laryngology
2579
Fig. 1. Tricut blade by XOMED-Medtronic, Jacksonville, Florida. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Fig. 2. Skimmer blade by XOMED-Medtronic, Jacksonville, Florida. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.].
powered instrumentation complications in laryngologic surgery in the adult population alone, and we discuss anecdotal reports of unpublished major complications involving the microdebrider described at tertiary care laryngology centers around the country.
on excising abnormal tissue while preserving normal epithelium and lamina propria. Violation of these structures and entrance into the vocalis muscle can yield serious damage and subsequent scar formation. Mortensen and Woo suggested the potential for greater tissue trauma using powered instrumentation could occur more easily due to an absence of tactile feedback.9 Sims and Lertsburapa described a case of subcutaneous emphysema, right pneumothorax, and pneumomediastinum after jet ventilation and use of a microdebrider for excising tracheal papilloma. The patient awoke from anesthesia without shortness of breath or evidence of hypoxia. On routine chest x-ray, the right pneumothorax and pneumomediastinum were diagnosed. Conservative measures were taken and the radiologic findings resolved spontaneously and the patient was observed. Chest computed tomography did not reveal a tracheal defect; however, the authors agreed the pattern of airflow suggested a breech of the anterior tracheal wall. It was suggested that a small mucosal tear spontaneously resolved after jet ventilation ceased. The authors recommended consideration of routine chest x-ray when jet ventilation was used in conjunction with a microdebrider. Furthermore, the use of the Tricut blade should be cautioned in the airway.10 Simoni et al. reported a case series of 29 patients using endoscopic microdebridement for laryngotracheal carcinoma. There was a brief description of one intraoperative hemorrhage in a coagulopathic patient requiring emergent tracheotomy for intraoperative bleeding. It is unclear from the article if the microdebrider was the ultimate cause of bleeding, as this was not the focus of the article but merely mentioned as a complication of surgery.5 Regarding the survey data, four centers reported no major complications. Five centers reported complications categorized as severe vocal fold scar, airway compromise, hemorrhagic complication, and unintentional excision.
MATERIALS AND METHODS A literature search was performed using the key words microdebrider, complications, otolaryngology, errors, airway, perforation, hemorrhage, powered instrumentation, and laryngology on PubMed and Ovid from 1985 to the present. All article abstracts were reviewed for laryngologic complications involving adult surgery. Due to the paucity of articles (three) meeting these criteria, all were included and discussed below. The scarcity of data led to a review of the senior author’s complications and an email survey of eight other tertiary laryngology centers. A confidential survey was sent to eight laryngologic centers in the United States to specialists with more than 150 years of combined patient-care experience. The survey asked about major complications involving the microdebrider during surgery over the prior decade. It asked participants to exclude moderate hemorrhage, mild scarring of the lamina propria, and moderate webbing, thereby providing only major complications. This included the surgeons’ own practice and those referred from outside institutions with microdebriderrelated complications. This was not a validated survey instrument, but asked the senior authors about their experiences with serious complications as well as their own surgical and microdebrider blade preferences. This demonstrated several categories of complications not discussed in the literature that allowed us to categorize adverse events in an attempt to increase awareness within the laryngologic community. Survey data included no personal health information but was kept confidential in accordance with our institutions own laryngology retrospective review institutional review board (HAC 07–09079).
RESULTS There are only three reported complications in adult airway patients using powered instrumentation. Mortensen and Woo were the first to describe an anterior glottic web from a patient referred after a procedure using a microdebrider to remove a polyp extending from the right true vocal fold to the anterior commissure. The concept of microdebrider use in glottic pathology relies Laryngoscope 124: November 2014
2580
Unreported Vocal Fold Scar This complication was reported by several voice centers, although the exact incidence is unknown. Decreased mucosal wave propagation and/or an Howell et al.: Microdebrider Complications in Laryngology
adynamic segment are best recognized on laryngovideostroboscopy and have been found in several patients following the use of the microdebrider.
Unreported Airway Compromise One case involved use of the microdebrider for an obstructing squamous cell carcinoma resulting in an anterior subglottic tear causing the patient to undergo urgent tracheostomy. The patient was decannulated shortly thereafter and was able to resume planned treatment with chemoradiation without delay of therapy. Another case described the use of the microdebrider for laryngeal and tracheal papilloma. This patient suffered a tracheal tear requiring a thoracotomy and a local muscle flap to repair the trachea. A third procedure resulted in a tracheal violation during removal of distal tracheal papilloma. Consultation with cardiothoracic surgery was obtained, and the hole with exposed mediastinal fat healed quickly with conservative management, and no additional surgical procedure was required.
Unreported Hemorrhagic Complications One patient with extensive laryngeal papilloma developed a massive hemorrhage during use of the microdebrider requiring intraoperative laryngeal packing to stabilize the patient prior to angiography after endoscopic measures to control the bleeding were unsuccessful. The patient was intubated for 4 days before the packing was removed in the operating room. The patient did well without permanent sequelae. A similar case was described after biopsies were taken and microdebrider was used for laryngeal obstruction for what was found to be invasive fungal laryngitis with extensive neovascularization. The third individual had supraglottic RRP treated with severe hemorrhage that was unable to be stopped endoscopically. The patient required laryngopharyngeal packing and angiography to halt the bleeding. Unfortunately, this patient developed pneumonia and died shortly thereafter. A final and shocking case of a hemorrhagic complication using the microdebrider for subglottic stenosis and removal of granulation tissue with intraoperative damage to the innominate artery resulted in another surgical mortality.
Unreported Unintentional Excision Inadvertent tissue removal may happen almost instantaneously. One laryngologist reported an entire false vocal fold removed in moments. Another described large divots in the true vocal fold that occurred unintentionally.
ary scar formation.11 Although no studies in the adult literature have proven better outcomes with powered instrumentation compared to either cold steel or laser, many would agree that the use of powered instrumentation allows for rapid debulking with no associated fire risk.12,13 Obvious limitations of powered instrumentation in airway surgery include hemostasis and less fine control. In Flint’s 1-year series describing the use of microdebrider in 22 endoscopic laryngeal and airway procedures in 18 patients, he noted that microdebridement of subglottic granulation tissue was problematic due to bleeding despite the application of topical vasoconstriction. This is a vast understatement compared to the case series described above, but nonetheless is the only other documented warning of potential hemorrhagic complications in airway surgery using the microdebrider.3 Regarding the type of blade preferred, there was a dichotomy among the senior authors. Answers ranged from 100% use of the Tricut to 97% use of the Skimmer blade. It should be noted that every major complication in this report occurred while using a Tricut blade. It is suspected that using a less-aggressive blade, although increasing operative time, may reduce the risk of complications. Higher suction power may allow more tissue to become engaged with the cutting edge of the blade. Microdebrider suction power has been suggested as a possible factor linked to surgical complications. Microdebrider injury often results in shredded tissue and removal of large portions of normal tissue, which may make functional repair more difficult or even impossible. Walker et al. recently described a novel technique to modulate the suction of a microdebrider allowing potentially safer removal of abnormal tissue by manual control of the suction tubing by the operating surgeon.14 We recommend using the lowest level of suction necessary to perform safe surgery and adequate hemostasis to ensure optimal visualization. This report does not determine the incidence or frequency of injury, but the severity of the complications is such that we see this as important information. According to the current coding system, we cannot distinguish from laser, microdebrider, or coblator used during suspension microlaryngoscopy with excision cases (current procedural terminology code 31541). Furthermore, we cannot access the number of cases with microdebrider complications to include those referred from outside the academic centers surveyed. Due to the gravity of the events described and the paucity of literature, our suspicion is that this is underreported. Admittedly, due to the nature of the questions asked, there is an inherent bias in those selected for the confidential survey. This article thereby does not represent a true case series, but is instead expert opinion. Future research would include a prospectively designed study on the use of laryngologic microdebrider to assess for incidence data, which could add depth to the current literature.
CONCLUSION DISCUSSION The debate among proponents of cold surgical procedures over laser technology in laryngology would argue that there is minimal collateral tissue injury and secondLaryngoscope 124: November 2014
The microdebrider is a useful tool for laryngologic surgery. It enables the rapid eradication of disease while preserving normal anatomy and function. Avoidance of complications begins with picking the appropriate tool Howell et al.: Microdebrider Complications in Laryngology
2581
for the surgery and patient. Knowing the types of microdebriders available and making the correct instrument choice can reduce complications. Careful preparation and mindfulness during surgery will help reduce the incidence of major complications.
BIBLIOGRAPHY 1. V€ olklein C, Thumfart WF, Sprinzl GM, Pototschnig C, Gunkel A. Using a rotating suction debridement instrument with power generator in endonasal paranasal sinus surgery [in German]. HNO 1996;44:98–100. 2. Christmas DA Jr, Krouse JH. Powered instrumentation in functional endoscopic sinus surgery. I: Surgical technique. Ear Nose Throat J 1996;75: 33–36, 39–40. 3. Myer CM III, Willging JP, McMurray S, Cotton RT. Use of a laryngeal micro resector system. Laryngoscope 1999;109(7 pt 1):1165–1166. 4. Flint PW. Powered surgical instruments for laryngeal surgery. Otolaryngol Head Neck Surg 2000;122:263–266. 5. Simoni P, Peters GE, Magnuson JS, Carroll WR. Use of the endoscopic microdebrider in the management of airway obstruction from laryngotracheal carcinoma. Ann Otol Rhinol Laryngol 2003;112:11–13.
Laryngoscope 124: November 2014
2582
6. Sant’Anna GD, Mauri M. Use of the microdebrider for Reinke’s edema surgery. Laryngoscope 2000;110:2114–2116. 7. Cheng AY, Soliman AM. Use of a microdebrider for subepithelial excision of benign vocal fold lesions. Ann Otol Rhinol Laryngol 2010;119:782– 785. 8. ENT Product and Instrument Catalogue 2010–2011. Medtronic, Jacksonville, FL. 9. Mortensen M, Woo P. An underreported complication of laryngeal microdebrider: vocal fold web and granuloma: a case report. Laryngoscope 2009; 119:1848–1850. 10. Sims HS, Lertsburapa K. Pneumomediastinum and retroperitoneal air after removal of papillomas with the microdebrider and jet ventilation. J Natl Med Assoc 2007;99:1068–1070. 11. Durkin GE, Duncavage JA, Toohill RJ, Tieu TM, Caya JG. Wound healing of true vocal cord squamous epithelium after CO2 laser ablation and cup forceps stripping. Otolaryngol Head Neck Surg 1986;95(3 pt 1):273– 277. 12. Honda K, Haji T, Maruyama H. Functional results of Reinke’s edema surgery using a microdebrider. Ann Otol Rhinol Laryngol 2010;119:32–36. 13. Holler T, Allegro J, Chadha NK, et al. Voice outcomes following repeated surgical resection of laryngeal papillomata in children. Otolaryngol Head Neck Surg 2009;141:522–526. 14. Walker P, Diggelmann H, Ropp BY, et al. Suction modulation for the laryngeal microdebrider. Laryngoscope 2013;123:1496–1499.
Howell et al.: Microdebrider Complications in Laryngology
