surgical technique

Angle-Tip RAD Airway Blades from Xomed

Powered Laryngeal Surgery Using the Angle-Tip RAD Airway Blades

presented by Paul Flint, MD

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Powered Laryngeal Surgery

Philosophy
Surgical technique presented by Paul Flint, MD Treatment for the removal of laryngeal lesions has progressed from cold steel techniques to the use of the CO2 laser and KTP fiber directed laser. While the laser is the standard treatment, a new development, the powered laryngeal shaver, provides an alternative that is safer, more accurate, and faster than laser tissue vaporization. First, with the laryngeal shaver, concerns such as airway fire and laser plume are eliminated. Additionally, laser burn is eliminated and post procedure edema is minimized since tissue injury resulting from the shaver technique is confined to the superficial mucosa only. Our RRP patients historically treated with the laser have reported reduced post-op pain and quicker recovery of voice since we adopted the shaver technique. Using the shaver blade with the aid of a rigid telescope with video system and a Hollinger style laryngoscope, lesions can be easily removed in the subglottic region and trachea. For treatment of the difficult to manage airway, the shaver is invaluable as it may be used to quickly debulk tissue in proximity or direct contact with the endotracheal tube. Cutting tips have been designed for applications ranging from rapid debulking of large, firm lesions (TRICUT Blade) to delicate shaving of superfical lesions off the folds themselves (SKIMMER Blade). Two lengths are offered, allowing surgical access to the laryngeal, subglottic, and tracheal regions. To address the fixed operating radius of the laryngoscope, an angle was added to the distal tip of the blade and thus the radius of surgical access is increased. This angle allows the surgeon the best view of the working tip plus enhanced access to lateral structures, the anterior commissure or the undersurface of the vocal folds. Equipment costs, setup and surgical time for the shaver are dramatically reduced versus the laser. If the hospital already owns the Xomed XPS power

Nota Bene: The technique description herein and the use of instructions for the related procedures are made available by Xomed Surgical Products, Inc. to the health care professional to illustrate the authors suggested treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which, in the health care professionals judgment, addresses the needs of the individual patient. The clinician is strongly recommended to have a thorough understanding of and experience with powered microresector surgical equipment prior to use.

Powered Laryngeal Surgery

system, the only cost incurred is that of the disposable shaver blade itself.

Patient Preparation
General anesthesia is induced and the airway secured by endotracheal tube intubation or tracheotomy if indicated. Size of endotracheal tube will vary depending on airway conditions (presence of stenosis) and intubation technique. In adults a small cuffed 5.0mm or 5.5mm ETT is adequate for ventilation and allows access for surgical instrumentation. With stenotic lesions, smaller cuffless ETTs may be required. In this situation, the laryngoscope may accommodate powered instrumentation, rigid telescope, and the ETT, allowing for uninterrupted surgery. The laryngoscope is positioned to allow access to the anatomy to be excised with the powered shaver. Access to the anterior commissure and subglottic region may be accomplished using an anterior commissure laryngoscope. Visualization is enhanced using 0 or 30 rigid telescopes and digital video systems. Console settings should be Oscillate mode with a maximum speed set at 1,000 rpms for superficial lesions or those located near or on the vocal folds (SKIMMER Blade). Use of variable mode of footswitch operation is preferred as it allows for more controlled excision with slow, single revolutions when needed. When debulking large, exophytic or fibrous lesions, higher speeds up to 3,000 rpms are recommended (TRICUT Blade). The appropriate blade should be selected and securely attached to the powered handpiece. Irrigation (a 1000cc or 3000cc bag at 6 ft. elevation) must be used with the blade and allowed to flow continuously throughout the procedure to prevent clogging (use of the XPS Irrigator Pump #18-95500 is not advised, as it does not allow the continuous irrigation to clear tissue through the long blade). Wall suction levels may be adjusted to provide enough vacuum to allow the blade to remove tissue at an efficient rate (150mm - 180mm Hg). Use of an in-line tissue trap is necessary to capture specimens for pathology.

Applications For Use

Detailed on the following pages are procedures in which the Angle-Tip RAD Airway Blades from Xomed are utilized.

Powered Laryngeal Surgery

Vocal Fold Papilloma

The SKIMMER Laryngeal Blade is ideal for delicate removal of papilloma from the vocal fold. (Figures 1-2) Oscillation speeds of 60-1,000 rpms will offer the most precise result. Note: For the most precise excisions, tissue can be pulled into the opening and with light pressure on the variable footswitch amputated with single blade revolutions.
Recommended Blade: Speed: 18-83523 18-84023 SKIMMER Angle-Tip Laryngeal Blade, 3.5mm SKIMMER Angle-Tip Laryngeal Blade, 4.0mm

601,000 rpm

Figure 1
Authors Note: A 5 or 5.5mm standard cuffed endotracheal tube is recommended for these procedures. (not shown in illustrations.)

Figure 2

Note: With the SKIMMER tip, discreet lesions may be accurately removed with trauma limited to the superficial mucosa. (Figure 3) For greatest precision when removing papilloma from the anterior commissure, endoscopic visualization with a 30 endoscope is recommended. (Figure 4)

Figure 3
Authors Note Regarding Bleeding: Light bleeding typically accompanies shaver tissue removal. Bleeding generally subsides as the open aspiration tip of the blade is applied to the site. Undesired bleeding may be controlled with the application of a soaked cotton strip or pad with 4% cocaine post excision.

Figure 4

Powered Laryngeal Surgery

Lesion Removal from Undersurface of Vocal Fold

The angle-tip design of the SKIMMER blade allows excellent access for removal of lesions located on the undersurface of the vocal fold. (Figures 5-6) With an oblique endoscope or aid of suction to elevate the vocal fold, delicate excision of pathology may be achieved.
Recommended Blade: Speed: 18-83523 SKIMMER Angle-Tip Laryngeal Blade, 3.5mm 18-84023 SKIMMER Angle-Tip Laryngeal Blade, 4.0mm 601,000 rpm

Figure 5
Authors Note: Images in Figures 5 and 6 assume microscopic, not endoscopic visualization and technique.

Figure 6

Removal of Vocal Fold Polyp

Vocal fold polyps may be quickly and precisely removed without tearing or trauma to periperal tissues. (Figures 7-8)
Recommended Blade: Speed: 18-83523 SKIMMER Angle-Tip Laryngeal Blade, 3.5mm 601000 rpm

Figure 7

Figure 8

Powered Laryngeal Surgery

Excision of Airway Tumor

Debulking airway tumors can effectively be achieved by using an aggressive toothed blade. (Figures 9-10) Higher oscillation speeds of 2,500 to 3,000 may be needed to remove dense or fibrous tumor tissue and minimize clogging of the blade.
Recommended Blade: Speed: 18-84030 18-84031 TRICUT Angle-Tip Laryngeal Blade, 4.0mm TRICUT Angle-Tip Subglottic Blade, 4.0mm

2,5003,000 rpm

Figure 9

Figure 10

After removal of bulk mass, edges may be more delicately sculpted with a SKIMMER tip Laryngeal Blade. (Figure 11)
Recommended Blade: Speed: 18-84023 SKIMMER Angle-Tip Laryngeal Blade, 4.0mm 18-84024 SKIMMER Angle-Tip Subglottic Blade, 4.0mm Oscillate, 60-1,000 rpm

Figure 11

Powered Laryngeal Surgery

Subglottic Stenosis
Using endoscopic video control and an aggressive subglottic blade, granulation tissue may be removed to restore patency to the airway. (Figures 12-13)
Recommended Blade: Speed: 18-84031 TRICUT Angle-Tip Subglottic Blade, 4.0mm 18-84024 SKIMMER Angle-Tip Subglottic Blade, 4.0mm 2,5003,000 rpm

Figure 12
Authors Note: A small diameter cuffed or cuffless endotracheal tube (4mm-5mm) is recommended in these procedures. (not shown in illustration)

Figure 13

Tracheal Stenosis
A significant advantage of the laryngeal shaver can be experienced in removal of tissue from the trachea where laser access is limited and cold steel techniques are inadequate. This technique is applicable for tracheal stenosis, obstructing tracheal lesions, or metastatic tumors obstructing the airway. (Figures 14-17)
Recommended Blade: Speed: 18-84030 TRICUT Angle-Tip Subglottic Blade, 4.0mm 2,5003,000 rpm

Figure 14

Figure 15

Powered Laryngeal Surgery

Figure 16

Figure 17

Lumen size may be improved to allow placement of a customized tracheostomy tube, T-tube, or tracheal stent.

General Precautions For Powered Equipment: Blade and bur accessories are available for resection of soft tissue and bone for various surgical procedures. Proper selection is dependent on the intended application and patient needs. Sharp cutting powered accessories are capable of inducing bleeding and removal of significant tissue and bone. Use care in application of the moving cutting end to only appropriate anatomical structures and the intended surgical site. Adequate visualization is to be employed. Discontinue powered application in the event of lack of visualization of the surgical site.

Reference
This clinical article is provided for additional background material related to the Powered Laryngeal procedure herein. The health care professional should seek out and review all other clinical reference materials as dictated by an individual patients clinical condition.

1. PIPE: Powered Instrumentation Papilloma Excision; white paper study; David S. Parsons, MD, FACS, FAAP (Lit. No. 891159)

Powered Laryngeal Surgery

Ordering Information
18-83523 SKIMMER Angle-Tip Laryngeal Blade, 3.5mm 18-83524 SKIMMER Angle-Tip Subglottic Blade, 3.5mm
Single use, sterile packaged with irrigation tubing

Product
18-83523 18-83524

Speed
60-1,000RPM 60-1,000RPM

Qty
3/box 3/box

18-84023 SKIMMER Angle-Tip Laryngeal Blade, 4.0mm 18-84024 SKIMMER Angle-Tip Subglottic Blade, 4.0mm
Single use, sterile packaged with irrigation tubing

Product
18-84023 18-84024

Speed
60-1,000RPM 60-1,000RPM

Qty
3/box 3/box

18-84030 TRICUT Angle-Tip Laryngeal Blade, 4.0mm 18-84031 TRICUT Angle-Tip Subglottic Blade, 4.0mm
Single use, sterile packaged with irrigation tubing

Product
18-84030 18-84031

Speed
2,500-3,000RPM 2,500-3,000RPM

Qty
3/box 3/box

XPS Model 2000: System 1 & System 2

System 1 includes: Console, STRAIGHTSHOT MAGNUM Handpiece, Multi-Function Footswitch, & Irrigator Pump System 2 includes: Console, STRAIGHTSHOT MAGNUM Handpiece, & Single-Function Footswitch

Product

Qty

Product
18-96001X XPS Model 2000: System 2

Qty
1 ea

18-96000X XPS Model 2000: System 1 1 ea

Powered Instrument Papilloma Excision (PIPE) Surgical Technique Video

Product
18-84019 NTSC version (U.S.)

Qty
1 ea

Product
18-84019P PAL version (International)

Qty
1 ea

6743 Southpoint Drive North Jacksonville, FL USA 32216-0980 904/ 296-9600 800/ 874-5797 www.xomed.com

In Australia 800/ 062-289 In Canada 800/ 710-5201 In France 33/ 169-187400

In Germany 49/ 8105-37-550 In the U.K. 44/ 1454-619555

Trademarks of Xomed. Registered marks of Xomed. Patents Pending. 1998 Xomed Surgical Products, Inc. LIT 891172 08.98

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