Accepted Manuscript

A Novel Use of Coblation in the Treatment of Subglottic Stenosis

Craig A. Bollig, Eliav Gov-Ari

PII: S0165-5876(18)30227-1
DOI: 10.1016/j.ijporl.2018.05.023
Reference: PEDOT 9011

To appear in: International Journal of Pediatric Otorhinolaryngology

Received Date: 13 April 2018

Revised Date: 17 May 2018
Accepted Date: 17 May 2018

Please cite this article as: C.A. Bollig, E. Gov-Ari, A Novel Use of Coblation in the Treatment of
Subglottic Stenosis, International Journal of Pediatric Otorhinolaryngology (2018), doi: 10.1016/
j.ijporl.2018.05.023.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

A Novel Use of Coblation in the Treatment of Subglottic Stenosis

Craig A. Bollig, M.D.

Dept. of Otolaryngology- Head and Neck Surgery
University of Missouri School of Medicine

PT
Columbia, Missouri, USA

*Eliav Gov-Ari, M.D.

Associate Professor, Dept. of Otolaryngology- Head and Neck Surgery

RI
University of Missouri School of Medicine
govarie@health.missouri.edu
One Hospital Dr MA314

SC
Columbia, MO 65212
Phone/Fax: (573) 882-8173/ (573) 884-4205
*Corresponding Author

U
AN
There are no conflicts of interest or financial disclosures.
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
1

Abstract:

Bipolar radiofrequency plasma ablation (Coblation) technology has recently been described in

the treatment of airway stenosis. In these small case series and case reports, the mucosal and

submucosal tissues have been removed. We describe a novel use of coblation technology, in

PT
which a coblation needle was used to submucosally ablate subglottic stenosis in a 9 month-old

RI
girl with grade II subglottic stenosis who had previously undergone multiple balloon dilations.

This technique spared the overlying mucosa, similar to that utilized in coblation turbinoplasty.

SC
She experienced objective clinical improvement after the intervention and has not required

additional airway interventions to date.

Keywords: Subglottic Stenosis, Coblation

U
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
2

Introduction:

The treatment of subglottic stenosis (SGS) in pediatric patients continues to evolve and remains a

challenge for otolaryngologists. Open surgical airway reconstruction has served as the gold

standard treatment, but is typically reserved for complex refractory cases and higher grade SGS.

PT
Endoscopic techniques offer less morbidity and are increasingly being utilized for low-grade

RI
stenosis and as well as an adjunct to open reconstruction.1-3 Bipolar radiofrequency plasma

ablation (Coblation) technology was first utilized in orthopedic procedures and is now commonly

SC
used in various procedures in otolaryngology including adenotonsillectomy and turbinate

reduction. Most recently, its use has been reported in the treatment of laryngotracheal pathology

U
including respiratory papillomatosis4, vallecular cysts5, suprastomal granulation tissue6, and
AN
laryngotracheal stenosis1,7,8. To date, the literature on coblation for airway stenosis is limited to

very small case series and case reports. In all of these cases, both the mucosa and submucosal
M

tissues have been ablated. We describe a novel use of coblation technology, in which a coblation
D

needle, Reflex Ultra 55 (Smith & Nephew, Andover, MA) was used to submucosally ablate
TE

subglottic stenosis in a 9 month-old girl with grade II SGS while sparing the overlying mucosa.

Case Report:
EP

A 9-month-old girl with previously diagnosed grade II SGS presented to clinic with

worsening stridor. Her past medical history was significant for a premature, twin birth at 29
C

weeks, 3 days, which required intubation and ventilation for 2 days for respiratory distress. After
AC

extubation, she was quickly weaned to room air, and she was discharged home from the neonatal

intensive care unit 46 days later. Her maternal history was notable for polysubstance abuse,

hepatitis C, and major depressive disorder. Following discharge, she seen in our clinic at 3

months of age, and was noted to have biphasic stridor with subcostal and intercostal retractions.
 ACCEPTED MANUSCRIPT
3

A flexible laryngoscopy showed copious secretions, but she appeared to have normal vocal cord

mobility, no mucosal lesions, and no evidence of supraglottic collapse. She was started on a

proton pump inhibitor and taken to the operating room for a direct laryngoscopy and

bronchoscopy. Her direct laryngoscopy showed grade II SGS with bilateral subglottic narrowing

PT
laterally and preservation of the anterior-posterior dimension. An endoscopic balloon dilation

RI
was performed as well as topical application of mitomycin C. Over the next 4 months, she

required monthly balloon dilations, which included an additional topical application of

SC
mitomycin C and 2 injections of triamcinolone. She responded well to the dilations with notable

symptomatic improvement to her breathing for about 3-4 weeks, before experiencing a return of

stridor.
U
AN
As a result of her precarious social situation, she presented to our clinic approximately 2

months following her last intervention with worsening breathing over the past month as well as
M

intermittent retractions. She was gaining weight appropriately and had a body mass index in the
D

82nd percentile. Her vital signs were within normal limits. She had an audible biphasic stridor
TE

but no chest retractions. The remainder of her head and neck exam was unremarkable. Given

her symptomatic improvement with previous balloon dilation, submucosal hypertrophy was
EP

suspected as the underlying cause of her symptoms as opposed to mature scar tissue.

Submucosal coblation was offered to the patient’s mother as a potentially longer lasting
C

intervention than balloon dilation, but less invasive than a tracheostomy or laryngotracheal
AC

reconstruction. After a thorough discussion of the risks, benefits, and alternatives, she elected to

proceed.

After consent was obtained, the patient was taken to the operating room. General anesthesia

was induced and the patient was kept spontaneously ventilating. She was given a dose of
 ACCEPTED MANUSCRIPT
4

dexamethasone (0.5mg/kg). The larynx was exposed with suspension laryngoscopy and was

topically anesthetized with a weight appropriate dose of 1% lidocaine. A zero degree Hopkins

rod telescope (Karl Storz, Tuttlingen) was inserted for visualization, which revealed grade 2

subglottic stenosis (figure 1). A coblation needle, Reflex Ultra 55 (Smith & Nephew, Andover,

PT
MA) was coated with saline nasal gel and inserted into the submucosa of the left SGS, which

RI
was ablated for 5 seconds using a setting of 5/2. A minimal amount of mucosal sloughing was

created during this process, but no bleeding occurred. Postoperatively, she was kept overnight in

SC
the pediatric intensive care unit for observation, and discharged the following day. On post-

operative day 2, she presented to an outside emergency room with mild respiratory distress. She

U
clinically improved with racemic epinephrine and intravenous dexamethasone and was
AN
transferred to our facility the following day. Dexamethasone (0.25mg/kg) every 8 hours was

continued overnight, and she was discharged home the following day. Since then, she has been
M

taken back for two diagnostic direct laryngoscopies, but has not required any further surgical
D

intervention. Figures 2 and 3 show the appearance at 3 weeks and 7 months post-coblation,
TE

respectively. As of last contact, 7 months post-coblation, she was seen once in the emergency

department for an upper respiratory tract infection and treated with racemic epinephrine and
EP

dexamethasone. Otherwise, she was doing well with no stridor or breathing issues and has been

growing and developing appropriately.

C

Discussion:
AC

Most cases of pediatric airway stenosis are acquired, usually following intubation injury,

although the minority of cases have a congenital etiology.3 The subglottis is the most commonly

affected subsite, but glottic and tracheal stenosis may occur as well.3 Endoscopic techniques

may be successful in the management of appropriately selected patients, either as the initial
 ACCEPTED MANUSCRIPT
5

treatment modality or as an adjunctive treatment in cases of re-stenosis following open airway

surgery.9 The safety and efficacy of endoscopic balloon dilation2,10 and carbon dioxide laser11

have been well documented in the treatment of SGS. However, the likelihood of success with

minimally invasive endoscopic techniques as the primary treatment decreases with worsening

PT
initial grade of SGS.9 Recently, coblation has been investigated in the treatment of airway

RI
stenosis, although this has been limited to small case series1,7 and case reports8. Fastenburg et al.

reported their experience using a coblation microlaryngeal wand (Coblator Procise MLW, Smith

SC
& Nephew, Andover, MA) in 6 pediatric patients with a variety of airway pathology including

glottic stenosis (2), bilateral vocal cord paralysis (2), tracheal granulation tissue (1), and a

U
tracheal fibroma (1).1 Similarly, Chan et al. described a series of 10 adult patients with tracheal
AN
and subglottic stenosis who underwent resection of their stenosis down to the level of the

cartilage with a coblation PROcise LW Plasma Wand (Arthrocare, Austin, Texas, USA).7
M

Coblation technology is widely used in various procedures in otolaryngology. Recent surveys of

D

members of the American Society of Pediatric Otolaryngologists have reported that coblation is
TE

the most common method of turbinate reduction12, and second most common method of

tonsillectomy13. Operating at temperatures between 40-70°C, this technique produces a localized,

EP

high-energy plasma field which ablates tissue and seals blood vessels simultaneously.1 This

likely reduces collateral tissue damage in comparison to monopolar cautery and CO2 laser which
C

operate at 400-600°C.1
AC

We describe a novel use of coblation technology, in which a coblation needle, Reflex Ultra

55 (Smith & Nephew, Andover, MA) was used to submucosally ablate subglottic stenosis in a 9

month-old girl with grade II SGS. As described in detail above, the patient had multiple prior

endoscopic balloon dilations with symptomatic improvement for about a month before
 ACCEPTED MANUSCRIPT
6

experiencing a return of stridor. Given her response to balloon dilations, submucosal

hypertrophy was suspected as the underlying cause of her SGS and we offered submucosal

coblation as a potentially longer lasting intervention than balloon dilation. The novel technique

described above differs from previous reports1,7,8 in that the overlying mucosa was left

PT
undisturbed and the submucosal tissue was targeted. This is similar to the technique utilized in

RI
radiofrequency ablation turbinoplasty, which is a well-established method of reducing

submucosal hypertrophy in the inferior turbinates to address nasal obstruction.15 The patient

SC
experienced objective clinical improvement after the intervention and she has not required any

additional airway interventions to date. However, surgeons should be cautioned of a potential

U
initial worsening of symptoms as occurred in our patient. Given her rapid improvement with
AN
dexamethasone and racemic epinephrine, postoperative edema was suspected as the etiology of

her symptoms. Dexamethasone was not continued postoperatively, which may have been able to
M

attenuate the swelling post-treatment avoid the readmission. Reports of larger studies and long-
D

term follow-up are needed to further evaluate the continued use of this technique as an
TE

alternative to other available options.

Conclusion:
EP

Submucosal coblation can be considered as an alternative treatment in patients with subglottic

stenosis due to suspected submucosal hypertrophy. Surgeons should be cautioned of a potential

C

initial worsening of symptoms. Reports of larger studies and long-term follow-up are needed to
AC

further evaluate the continued use of this technique as an alternative to other available options.
 ACCEPTED MANUSCRIPT
7

PT
References

RI
1. Fastenberg JH, Roy S, Smith LP. Coblation-assisted management of pediatric airway stenosis.

Int J Pediatr Otorhinolaryngol. 2016;87:213-8.

SC
2. Lang M, Brietzke SE. A systematic review and meta-analysis of endoscopic balloon dilation

of pediatric subglottic stenosis. Otolaryngol Head Neck Surg. 2014;150(2):174-9.

U
3. Maresh A, Preciado DA, O'connell AP, Zalzal GH. A comparative analysis of open surgery
AN
vs endoscopic balloon dilation for pediatric subglottic stenosis. JAMA Otolaryngol Head Neck

Surg. 2014;140(10):901-5.
M

4. Rachmanidou A, Modayil PC. Coblation resection of paediatric laryngeal papilloma. J

D

Laryngol Otol. 2011;125(8):873-6.

TE

5. Gonik N, Smith LP. Radiofrequency ablation of pediatric vallecular cysts. Int J Pediatr

Otorhinolaryngol. 2012;76(12):1819-22.
EP

6. Brown CS, Ryan MA, Ramprasad VH, Karas AF, Raynor EM. Coblation of suprastomal

granulomas in tracheostomy-dependent children. Int J Pediatr Otorhinolaryngol. 2017;96:55-58.

C

7. Chan CL, Frauenfelder CA, Foreman A, Athanasiadis T, Ooi E, Carney AS. Surgical
AC

management of airway stenosis by radiofrequency coblation. J Laryngol Otol. 2015;129 Suppl

1:S21-6

8. Sim G, Vijayasekaran S. Novel use of Coblation technology in an unusual congenital tracheal

stenosis. J Laryngol Otol. 2014;128 Suppl 1:S55-8.

 ACCEPTED MANUSCRIPT
8

9. Quesnel AM, Lee GS, Nuss RC, Volk MS, Jones DT, Rahbar R. Minimally invasive

endoscopic management of subglottic stenosis in children: success and failure. Int J Pediatr

Otorhinolaryngol. 2011;75(5):652-6.

10. Wentzel JL, Ahmad SM, Discolo CM, Gillespie MB, Dobbie AM, White DR. Balloon

PT
laryngoplasty for pediatric laryngeal stenosis: case series and systematic review. Laryngoscope.

RI
2014;124(7):1707-12.

11. Lee GS, Irace A, Rahbar R. The efficacy and safety of the flexible fiber CO2 laser delivery

SC
system in the endoscopic management of pediatric airway problems: Our long term experience.

Int J Pediatr Otorhinolaryngol. 2017;97:218-222.

U
12. Jiang ZY, Pereira KD, Friedman NR, Mitchell RB. Inferior turbinate surgery in children: a
AN
survey of practice patterns. Laryngoscope. 2012;122(7):1620-3.

13. Walner DL, Mularczyk C, Sweis A. Utilization and trends in surgical instrument use in
M

pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2017;100:8-13.

D

14. Matt BH, Cottee LA. Reducing risk of fire in the operating room using coblation technology.
TE

Otolaryngol Head Neck Surg. 2010;143(3):454-5.

15. Acevedo JL, Camacho M, Brietzke SE. Radiofrequency Ablation Turbinoplasty versus
EP

Microdebrider-Assisted Turbinoplasty: A Systematic Review and Meta-analysis. Otolaryngol

Head Neck Surg. 2015;153(6):951-6.

C
AC
 ACCEPTED MANUSCRIPT
9

Figure Legends:

PT
RI
Figure 1:

Endoscopic view prior to coblation demonstrating grade II subglottic stenosis.

SC
Figure 2:

Endoscopic view 3 weeks following coblation. The previously coblated area remained patent

U
with normal overlying mucosa and overall grade I stenosis.
AN
Figure 3:

Endoscopic view 7 months following coblation.

M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC