Laser in the management of stenosing oropharyngeal scleroma.
K Albuquerque, R Kannan, SA Pradhan
Dept of Surgery, Tata Memorial Hospital, Parel, Bombay, Maharashtra.,
Dept of Surgery, Tata Memorial Hospital, Parel, Bombay, Maharashtra.
We present here our experience of laser for the management of stenosed oropharyngeal scleroma. The diagnosis of scleroma was made 14 years ago and the patient underwent repeated procedures like dilatation, diathermy excision of adhesions and cryosurgery during this period. He attended our out-patient department with complaints of dysphagia and difficulty in breathing, progressing to stridor. On examination, severe oropharyngeal stenosis due to cicatrization extending between the base of the tongue and the post-pharyngeal wall was seen. Using CO2 laser, cicatrix was released by making radial cuts and the oropharyngeal opening was widened. No tracheostomy was needed; no blood loss occurred and the patient was discharged on the next day.
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Albuquerque K, Kannan R, Pradhan S A. Laser in the management of stenosing oropharyngeal scleroma. J Postgrad Med 1992;38:138-41
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Albuquerque K, Kannan R, Pradhan S A. Laser in the management of stenosing oropharyngeal scleroma. J Postgrad Med [serial online] 1992 [cited 2013 May 23 ];38:138-41
Available from: http://www.jpgmonline.com/text.asp?1992/38/3/138/691
Scleroma was described for the first time by von Hebra in 1870 as a disease confined to the nose, hence the name "rhinoscieroma". Later, it was realised that it involves adjacent sites of the upper aero-digestive tract with significant frequency, and sometimes with fatal sequelae the larynx, trachea and bronchi. It is basically a chronic granulomatous inflammation caused by a Gram-negative diplobacillus, Klebsiella rhinoscleromatis. Clinically, the disease passes through three stages: a catarrhal stage, a granulomatous stage and finally a cicatricial or sclerotic stage when because of obstruction to the air passages by dense fibrosis, life threatening complications can occur. We present a report of a patient with obstruction of the orophangeal airway due to cicatricial rhinoscleroma and its management by the CO2 Laser.
A 46-year-old male attended the outpatient department with a complaint of dysphagia to solid food and difficulty in breathing, progressing to stridor on moderate exertion. He was a known case of rhinoscleroma diagnosed 14 yrs back in this hospital. At that time, he presented with nasal blockage and a sore throat. A proliferative granulomatous lesion was observed involving the soft palate and destroying the uvula, which when biopsied, established a diagnosis of scleroma. After a pre-operative tracheostomy, the granulomatous mass, which was found to be arising from the posterior nasal cavity, was excised and the nasal passages were dilated. The patient was advised a complete course of streptomycin injections post-operatively. Subsequently, till date, the patient underwent multiple procedures, which included nasopharyngeal dilatations, diathermy excision of palatopharyngeal adhesions and cryosurgery sittings. The last procedure was performed in March 1989 when the patient presented with an oropharyngeal narrowing due to fibrotic adhesions between the posterior pharyngeal wall and base of the tongue. A tracheostomy followed by an excision of the adhesions with cautery was carried out. When seen by us two years later, he had severe oropharyngeal stenosis caused by dense cicatrix extending between the base of the tongue and the posterior pharyngeal wall. There was a tiny 0.5 cm aperture in the centre of this scar tissue through which the patient was both eating and breathing (See [Figure:1]). This was responsible for the dysphagia and the occasional stridor. The larger opening seen in the [Figure:1] leads to the nasopharynx. A lateral neck x-ray showed a normal air laryngogram indicating that the air passage below the stenosis was normal. After a difficult bronchoscopic intubation through the stenosed airway using a 4mm endotracheal tube to achieve general anaesthesia, the cicatrix was released making radial cuts with the CO2 laser using 7.5 watts continuous super pulse beam. Three such radial incisions were made at the 3, 9 and 12 O'clock positions. At the end of the procedure, the oropharyngeal opening became wide enough to permit intubation with a regular 9.5mm size endotracheal tube. Blood loss was nil. A tracheostomy was avoided and the patient was sent home the next day. He could eat and breathe well with the widely opened oropharyngeal passage (post- laser dilatation. See [Figure:2]). When seen four months later at the last follow-up, he was asymptomatic and the oro-pharyngeal aperture was adequate.
Scieroma of the nasal cavity (rhinoscleroma) is not an uncommonly diagnosed condition in any busy otorhinolaryngology outpatient department of a general hospital in India. This is generally in the catarrhal or granulomatous stage of the disease when the organisms can be easily cultured from secretions or granulation tissue. At this stage, the disease is most amenable to antibiotics (streptomycin with tetracycline) given over 4 - 6 weeks or till two consecutive cultures taken at weekly intervals are negative.
However, scleroma more frequently found at other sites, if left undiagnosed or untreated, progresses to the cicatricial stage leading to debilitating and sometimes life-threatening symptoms. In a study of 80 cases of rhinoscleroma by Gamea using endoscopic techniques, disease was found in as high as 20-30% of the cases at sites like the maxillary antrum, larynx, eustachian tube and tracheobronchial tree.
In our patient, there was a severe occlusion of the oropharyngeal airway by advanced cicatricial scleroma, which was compromising his life. Traditionally treatment for this problem is dilatation (as was tried initially in this patient), cautery excision and cryosurgery. All these treatment modalities however, induce trauma, which incites more fibrosis and leads to recurrence of the primary problem with a vengeance. With the advent of laser, an effective weapon is now available for this endstage of scleroma. The fibrotic process may recur and the dilatation may have to be repeated. The great advantage, however, is the ease with which it can be accomplished with the laser, almost as an outpatient procedure, with no blood loss or tracheostomy.
Maher et al have listed advantages of laser therapy in the management of rhinoscleroma as follows:
1. Time saving - one sitting often enough; 2. marked haemostasis; 3. minimal edema surrounding tissues; 4. minimal post-operative discomfort; 5. technical simplicity; 6. applicable to all ages; 7. minimal hospitalisation and 8. can be repeated as frequently as necessary.
These sum up the reasons why laser is the preferred modality in the terminal stages of this disease.
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