الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Obstructive laryngeal lesions have posed special challenges to surgeons, anesthesiologists, and patients. Management options of obstructive laryngeal tumours have included emergency laryngectomy, urgent tracheotomy, and endoscopic debulking.
Emergency laryngectomy has the disadvantage of depriving patients of ample time to entertain different treatment options. The preoperative workup by surgeons and anesthesiologists is hurried, and there is little time for preoperative speech therapy or psychological preparation of the patients and family. Long-term survival rates, however, are comparable for patients undergoing emergency laryngectomy or elective laryngectomy.
Tracheotomy under local anesthesia remains the safest method of managing the upper airway compromised by obstructive laryngeal lesion. Many surgeons feel, however, that urgent tracheotomy for obstructive malignant laryngeal tumors increases the risk of stomal recurrence. The risk of stomal recurrence following preoperative tracheotomy has been cited to be from 8% to 41% Stomal recurrence is associated with an approximately 90% mortality rate, and over 80% of the patients die in the first 24 months. Preoperative tracheotomy also creates a septic or scarred field for future laryngectomy, and results in a much more technically challenging procedure.
Endoscopic debulking of malignant laryngeal tumors has been performed for palliation by using endoscopic cautery, cold blade, or laser for the past few years as an alternative to tracheotomy and emergency laryngectomy. Postoperative edema has limited the use of debulking of the laryngeal airway via electrocautery. The CO2 laser has been used with good success secondary to its precise local effect and minimal postoperative edema. However, CO2 laser debulking is often a slow and laborious procedure requiring proper equipment and trained operating room staff. The risk of airway fire is a constant concern.
The microdebrider was introduced into clinical medicine in 1987 and initially used for endoscopic lumbar discectomy. It also achieved excellent treatment outcomes in arthroscopic surgery. It is effective in removing obstructing lesions and relief of symptoms. This electrically powered instrument combines suction and irrigation functions with an oscillating blade and has initially been applied for endoscopic sinonasal surgery in otolaryngology. As a result of further technological developments, the angulation of the blade and the length of the microresector have been modified for laryngeal and tracheal surgery.
The powered endoscopic laryngeal microdebrider was first used for management of recurrent respiratory papillomatosis. In case of bilateral vocal fold paralysis, microdebrider assisted posterior cordotomy has been performed to balance between airway maintenance and vocal quality. Since then, it has been used with increasing frequency for management of other variable obstructive laryngeal lesions.
The aim of the study was to determine the efficacy of the powered endoscopic microdebrider as a tool in the management of obstructive laryngeal lesions. And to compare the histopathological diagnosis between a biopsy taken using the laryngeal forceps and the resected tissue from the microdebrider
The study was conducted on thirty five patients, presenting with stridor due to variable obstructive laryngeal lesions. The diagnosis of all patients was categorized into 4 main groups; obstructive laryngeal carcinomas were encountered in 13 patients, bilateral vocal cords paralysis in 5 patients, laryngeal papillomas in 4 patients and other obstructive laryngeal lesions in 13 patients.
Assessment of degree of stridor by inspection of the patient respiratory retractions; mild degree with Suprasternal, supraclavicular retractions found in 6 patients, moderate degree with Intercostals retractions found in 15 patients and severe degree with subcostal retractions & chest in drawing found in 14 patients.
In the present work, Intraoperative assessment of microdebrider included operative time, intraoperative bleeding and safety measures required. While postoperative assessment included degree of stridor to assess improvement, duration of improvement, postoperative pain. (Visual analogue scale VAS) and postoperative complications.
Postoperative pathological assessment of resected tissues included histopathological diagnosis and difference in histopathology between 2 biopsies.
In this study, we found the following results:
1- Operative time (measured between introduction and removal of DL) ranged from 17 minutes to 65 minutes with the mean operative time of 32.23 ± 11.45.
2- Intraoperative bleeding was less than 100 cc blood loss in 27 patients (77.1%), bleeding was 100 – 250 cc blood loss in 4 patients (11.4%) whereas bleeding was more than 250 cc blood loss and in another 4 patients (11.4%) that required electrocautery to stop it and that made the procedure much longer than others.
3- No safety measures were required in all 35 patients (100%); no risk of fire damage for both the surgeon and the patient as occur in laser microlaryngosurgery.
4- Postoperative assessment of upper airway showed subjective complete improvement of stridor in 26 cases (74.2%) while other 9 patients showed partial improvement of stridor (25.8%) that required postoperative medical treatment to achieve their complete improvement
5- Assessment of postoperative pain was done using visual analogue scale (VAS) that is subjective way to measure intensity of pain that the patient feels postoperatively. VAS of all patients ranged from 2 to 6 with the mean VAS was 2.89 ± 1.08. the range of VAS was almost similar in all cases regardless preoperative diagnosis.
6- Among 30 cases from whom we took biopsy, the histopathological diagnosis was the same in the two biopsies taken from 28 patients (93.3%) whereas the resected tissues collected by the microdebrider were damaged in only 2 patients (6.7%) and no specific diagnosis could be made in the second biopsy.