What is dilation or dilation surgery?
Once you have been diagnosed with SGS your surgeon will most likely book you in for a dilation operation (a dilation and a dilatation refer to the same thing – an operation aimed at opening your narrowing). While this does sound quite daunting at first (after all it may be your first ever visit to the theatre without enjoying the show!), hopefully we can help quell the nerves.
I've heard about different types of dilation. What is the difference between these?
Technique
Pros
Cons
Laser dilation (or laser and balloon or laser and manual manipulation of scar)
A precise manner of dilation, particularly in experienced hands allowing the doctor to carefully open the scarring without damage to the rest of the airway
In less experienced hands there is some risk of the laser causing damage to healthy tissue therefore making the scar tissue spread.
Balloon dilation (sometimes with a small blade to do some cuts first)
Not likely to cause problems in other areas of the airway/cause the tissue to grow.
Slightly less precise, using the balloon to ‘tear’ open the scar tissue. If cuts are done first, then the balloon can open the scar tissue in a more regulated way.
Coblation dilation (Radiofrequency cold coblation) - uses controlled energy delivery to operate at the relatively low temperature of 60-65°C.
This aims to reduce surrounding tissue damage and postoperative pain and to avoid seeding of viral particles during the process.
Even in experienced hands it can be a challenge to control the exact area being treated. Anecdotal findings from doctors suggest there is a risk of this method causing the scar to travel up towards the vocal cords meaning it is not recommended.
Cryotherapy (could be cryotherapy with balloon). This uses a technique whereby the scar tissue is frozen and defrosted before being dilated.
There is limited research suggesting this can be successful among some patients
Not used in the major centres. Key concerns are the inability to direct the cryotherapy only to the scar tissue, opening the healthy airway tissue surrounding it to potentially becoming damaged and scarring. This is thought to cause the scar to travel up the airway closer to the vocal cords (thereby causing permanent loss of voice).
Rigid bronch (use of a set of steel pipes, small to larger, in succession, to stretch the trachea) without balloon.
Doctors with a lot of experience with this technique prefer it to laser or balloon and believe it delivers better results.
The surgical view is quite poor with this technique resulting in a less precise procedure. High risk of permanent damage to vocal cords and therefore voice.
CO2 laser wedge excision (sometimes referred to as wedge resection)
Using a laser, the doctor will cut wedges out of the scar tissue. The patient will take some medication postsurgery to maximise success rate.
This technique (and associated medication protocol) has high success rates in keeping the airway open while minimising risk to vocal cords.
Argon Plasma Coagulation (APC) - an electrosurgery using flexible endoscopy to treat trachea/bronchial stenosis. APC uses gas discharges to induce thermal therapy with small electrical bolts on soft tissue with no contact, meaning no cutting. This allows the surgeon to carefully destroy the scar tissue.
Minimum bleeding from stenosis removal. Less invasive option for treating stenosis. May be beneficial in removing more difficult scar tissue.
Some surgeons like to perform a series of this procedure (3-4 times every few weeks) to arrive at the best outcome. Whether this is more effective than a single procedure, is uncertain.
Use this information to ask questions before you have your surgery. Make sure you know what operation you are having in advance. If you have had one of the ‘higher risk’ dilations in the past, do not panic - it does not mean your scar tissue is going to travel up towards your vocal cords, but you may want to ensure you have a less risky surgery in the future.
How long does the dilation operation take?
It takes up to an hour in total. It may take longer if there are cuts made in the area with either a sickle knife or laser. Also, steroids or mitomycin C may be administered.
How will I breathe while I am being dilated?
‘Jet ventilation’ is the most used technique. This allows continuous oxygenation during the dilatation procedure without intubation.
What is mitomycin C?
Looking it up online can be quite daunting when you find it is a drug used in cancer treatment (chemo). It does not mean you have cancer or are having chemotherapy. It is sometimes applied to your scarring at the end of the dilation in the hope that it will stop the scar cells from growing back. There is little evidence that this works, but most patients do not experience any adverse side effects (you might be able to taste it as a bitter flavour when you cough once you wake up). Some patients experience a longer time between dilations when this is applied.
Use of mitomycin C seems to be declining with most experienced surgeons.
My Doctor mentioned steroid injections with my dilation – what does this mean?
It is becoming increasingly best-practice for steroids to be injected at the site of your scarring once the dilation has been completed. This will be in similar quantities to those injected in office (see section on in-office/awake steroid injections) but administered while you are under a general anaesthetic. It is possible you may experience minor side effects (such as flushing and/or insomnia) from these for the 24 hours following your surgery.
How long will I be in hospital?
Most people are only in hospital for the day with some staying overnight. The reason for the overnight stay is as a precaution for possible swelling in the airway - particularly for people who do not live near the hospital.
How will I feel afterwards?
You will have a sore throat and feel sleepy from the anaesthesia but generally should feel good - within two or three days you should feel the benefit breathing wise.
Some people may have a husky voice for a few days post operation but this will go as any bruising and inflammation subsides.
Your neck and back may feel stiff and sore from the positioning of you during surgery. The longer the surgery, the more prone you will be to be sore. You may also feel aching in your ribs from the air flow in your lungs. All this dies down within a couple of days.
There is a nerve in the airway which links directly to your ear. As this may be irritated during the surgery, there is a chance you will have pain in one or both ears for a short time (up to a week).
You may have a cough for a week or so in response to the healing. This is normal.
A saline nebuliser for 30 minutes a day for a few days post op can help soothe your airway and ease the coughing.
What medication am I likely to be on afterwards?
Some doctors prescribe Tylenol 2 with Codeine (USA) or Panadeine Forte (Paracetamol with Codeine – UK and Australia). This provides pain relief and suppresses any cough for the first few days. Some doctors prescribe a steroid inhaler to use for a month post op.
If you have the endoscopic laser wedge excision/resection you are likely to be asked to use inhaled corticosteroid and trimethoprim/sulfamethoxazole (an antibiotic such as Bactrim, Cotrim or Septra) post the procedure. Some patients are also prescribed antibiotics for 5 days post-surgery.
How long before I should go back to work?
Usually recommend about 3 days away from work to rest post operation, with at least 2 days resting the voice post op. Do not whisper as this strains the vocal cords.
How long until I can resume normal activity or exercise?
Most patients are not given any advice on this - basically do what feels best. The day after your surgery you should be able to manage a short walk, but your throat will be sore so would not advise running or anything too strenuous. Basically, go with gut feel. The anaesthetic will make you feel sluggish for a day or two, after that you should be able to go back. Best advice: listen to your body - if you do not feel like it, then don't do it! Do not over stress yourself and put back your recovery.
Will I only need one dilation?
Most patients will have a second dilation within two years, sometimes sooner.