Open airway surgery for post-COVID laryngotracheal stenosis.

INTRODUCTION: This study reports our experience with open reconstructive surgery in patients with laryngotracheal stenosis (LTS) following prolonged intubation and/or tracheostomy in the context of COVID-19. METHODS: All patients underwent a preoperative endoscopic airway assessment. Posterior glottic lesions were graded according to the Bogdasarian classification, subglottic-tracheal lesions according to the Cotton-Myers classification and postoperative complications reported by the Clavien-Dindo classification. We report postoperative outcomes and functional results in this patient subset. RESULTS: We include 14 patients diagnosed to have post COVID LTS, one female and 13 males. This group was compared with a control group, diagnosed with LTS following prolonged intubation. In the COVID group, mean age of patients at the time of the airway surgery was 52.1 ± 16.8 years (range: 13.7-76.3). More than half the patients were multi-morbid with hypertension and obesity being the most common conditions. Eleven patients had multi-site stenoses. Open surgical interventions performed were tracheal resection and anastomosis, laryngotracheal reconstruction and extended cricotracheal resection, and postoperative complications were seen in 12 (85.6%) patients. 70% patients with pre-existing tracheostomy were decannulated. Oral swallowing was not tolerated in one-fifth of the patients and a significant number of them have poor voice quality. CONCLUSION: Post-COVID pandemic, airway surgeons are seeing an increased number of patients with complex LTS, and we report significant postoperative complications in this patient subset. Decannulation rates, voice and swallowing results are poor in patients with glottic involvement as compared to isolated tracheal stenosis.

External laryngotracheal trauma: a case series and an algorithmic management strategy.

OBJECTIVES: External laryngotracheal trauma (ELT), blunt or penetrating, is a rare but potentially life-threatening injury. Immediate care in the emergency department can be challenging because it requires managing a potentially unstable airway and may have associated vascular injuries with massive bleeding. Here, we look at the details of injury, treatment measures, and outcomes in patients following ELT. METHODS: We retrospectively analyzed 22 patients treated at our center for ELT from January 2005 up to December 2021 with varying grades of injury. We looked at their status at presentation, management strategy and functional status. RESULTS: In our report, we include 18 men and 4 women having varying Schaefer injury grades. Eight patients had tracheostomy at presentation and eight had vocal fold immobility. Two patients were treated endoscopically, 12 had open surgery and 8 received no treatment. Of the patients undergoing open surgery, thyroid cartilage fracture was seen in 9 patients, thyroid plus cricoid fracture and cricotracheal separation were seen in 3 patients each. All patients were safely decannulated and spontaneous recovery of vocal cord palsy was seen in some patients. CONCLUSION: The success of managing ELT relies on fast decision-making, correct patient evaluation, securing the airway and maintaining the hemodynamic stability. Early surgical intervention must be aimed at optimally treating the larygotracheal injuries to prevent long-term disastrous consequences.

Congenital laryngo-tracheo-esophageal clefts: updates from a quaternary care pediatric airway unit.

PURPOSE: To review the operative techniques, outcomes, and complications following surgery in pediatric patients with laryngo-tracheo-esophageal clefts (LTEC). We describe a new combined approach to treat long LTECs. METHODS: Twenty-five patients underwent surgical repair for LTEC from March 2012 to July 2022 at our hospital. Every patient underwent a diagnostic endoscopy under general anesthesia and spontaneous ventilation to assess the LTEC and synchronous aero-digestive comorbidities/malformations. All patients underwent at least one surveillance endoscopy after the repair at our institution. RESULTS: The patients had multiple other malformations, specifically gastro-intestinal, synchronous airway, and cardiac. The cleft distribution according to the modified Benjamin and Inglis classification was type I (n = 5, 20%), type II (n = 6, 24%), type IIIa (n = 8, 32%), type IIIb (n = 4, 16%), and type IVa (n = 2, 8%). The median follow-up was 44.6 months. Five patients (20%) had undergone previous cleft corrective surgery(s). Seven patients (28%) had partial to complete breakdown of the repair, needing additional intervention(s), and two required a combined-open plus endoscopic repair. Preoperatively, most patients (n = 18, 72%) needed a feeding assistance. At latest follow-up, feeding assistance was weaned off in 13 out of 18 patients, which was a 72% improvement. Ten patients (40%) needed ventilation assistance before the surgery. Post-operatively, ventilatory assistance was weaned off in 6 patients, meaning a 60% improvement. CONCLUSION: LTEC are rare malformations, and their management needs precise diagnosis, appropriate surgical planning, and execution, and dedicated post-operative care. Primary and revision repair of long clefts with tracheal extension may require a combined approach.

Enhancing Robustness of Adhesive Hydrogels through PEG-NHS Incorporation.

Tissue wounds are a significant challenge for the healthcare system, affecting millions globally. Current methods like suturing and stapling have limitations as they inadequately cover the wound, fail to prevent fluid leakage, and increase the risk of infection. Effective solutions for diverse wound conditions are still lacking. Adhesive hydrogels, on the other hand, can be a potential alternative for wound care. They offer benefits such as firm sealing without leakage, easy and rapid application, and the provision of mechanical support and flexibility. However, the in vivo durability of hydrogels is often compromised by excessive swelling and unforeseen degradation, which limits their widespread use. In this study, we addressed the durability issues of the adhesive hydrogels by incorporating acrylamide polyethylene glycol N-hydroxysuccinimide (PEG-NHS) moieties (max. 2 wt %) into hydrogels based on hydroxy ethyl acrylamide (HEAam). The results showed that the addition of PEG-NHS significantly enhanced the adhesion performance, achieving up to 2-fold improvement on various soft tissues including skin, trachea, heart, lung, liver, and kidney. We further observed that the addition of PEG-NHS into the adhesive hydrogel network improved their intrinsic mechanical properties. The tensile modulus of these hydrogels increased up to 5-fold, while the swelling ratio decreased up to 2-fold in various media. These hydrogels also exhibited improved durability under the enzymatic and oxidative biodegradation induced conditions without causing any toxicity to the cells. To evaluate its potential for clinical applications, we used PEG-NHS based hydrogels to address tracheomalacia, a condition characterized by inadequate mechanical support of the airway due to weak/malacic cartilage rings. Ex vivo study confirmed that the addition of PEG-NHS to the hydrogel network prevented approximately 90% of airway collapse compared to the case without PEG-NHS. Overall, this study offers a promising approach to enhance the durability of adhesive hydrogels by the addition of PEG-NHS, thereby improving their overall performances for various biomedical applications.

Oropharyngolaryngeal manifestations in severe toxic epidermal necrolysis: a single-center's retrospective case series.

BACKGROUND: Toxic epidermal necrolysis is a rare and life-threatening mucocutaneous disease. Although mucosal ear, nose, and throat (ENT) involvement is common, little is known about the characteristics, treatment modalities, and outcomes of these lesions. The aim of this study was to evaluate ENT mucosal lesions in severe toxic epidermal necrolysis patients and analyze their characteristics, treatment modalities, and outcomes, as well as proposing a management algorithm to prevent long-term debilitating sequalae of these lesions. METHODS: This is a retrospective review of toxic epidermal necrolysis cases treated at the tertiary burns unit of the Lausanne University Hospital CHUV, Switzerland, between 2006 and 2019. RESULTS: Out of 19 patients with severe toxic epidermal necrolysis, 17 (89%) underwent a complete ENT examination at admission and 14 (82%) had ENT mucosal involvement. Five (26.3%) patients died during the stay in the intensive care unit. Of the 16 patients who received maximal care, 13 (81%) required orotracheal intubation for a median time of 16 (IQR: 14) days. Out of the 14 patients who survived, four (29%) had long-term ENT complications consisting of synechiaes necessitating subsequent endoscopic procedures. Those four patients all required mechanical ventilation with an orotracheal tube and suffered from hypopharyngeal synechiaes as well as oral and endonasal synechiaes in individual cases. CONCLUSION: This study suggests a high prevalence of ENT synechiaes in patients with severe toxic epidermal necrolysis and requiring orotracheal intubation. Periodic ENT examination could prevent mature synechiae formation in these patients. We propose an algorithm to prevent long-term sequalae in ENT mucosal involvement.

Wet adhesive hydrogels to correct malacic trachea (tracheomalacia) A proof of concept.

Tracheomalacia (TM) is a condition characterized by a weak tracheal cartilage and/or muscle, resulting in excessive collapse of the airway in the newborns. Current treatments including tracheal reconstruction, tracheoplasty, endo- and extra-luminal stents have limitations. To address these limitations, this work proposes a new strategy by wrapping an adhesive hydrogel patch around a malacic trachea. Through a numerical model, first it was demonstrated that a hydrogel patch with sufficient mechanical and adhesion strength can preserve the trachea's physiological shape. Accordingly, a new hydrogel providing robust adhesion on wet tracheal surfaces was synthesized employing the hydroxyethyl acrylamide (HEAam) and polyethylene glycol methacrylate (PEGDMA) as main polymer network and crosslinker, respectively. Ex vivo experiments revealed that the adhesive hydrogel patches can restrain the collapsing of malacic trachea under negative pressure. This study may open the possibility of using an adhesive hydrogel as a new approach in the difficult clinical situation of tracheomalacia.

Feasibility study of the Nox-T3 device to detect swallowing and respiration pattern in neurologically impaired patients in the acute phase.

Dysphagia is a frequent complication in neurologically impaired patients, which can lead to aspiration pneumonia and thus prolonged hospitalization or even death. It is essential therefore, to detect and assess dysphagia early for best patient care. Fiberoptic endoscopic and Videofluoroscopy evaluation of swallowing are the gold standard exams in swallowing studies but neither are perfectly suitable for patients with disorders of consciousness (DOC). In this study, we aimed to find the sensitivity and specificity of the Nox-T3 sleep monitor for detection of swallowing. A combination of submental and peri-laryngeal surface electromyography, nasal cannulas and respiratory inductance plethysmography belts connected to Nox-T 3 allows recording swallowing events and their coordination with breathing, providing time-coordinated patterns of muscular and respiratory activity. We compared Nox-T3 swallowing capture to manual swallowing detection on fourteen DOC patients. The Nox-T3 method identified swallow events with a sensitivity of 95% and a specificity of 99%. In addition, Nox-T3 has qualitative contributions, such as visualization of the swallowing apnea in the respiratory cycle which provide additional information on the swallowing act that is useful to clinicians in the management and rehabilitation of the patient. These results suggest that Nox-T3 could be used for swallowing detection in DOC patients and support its continued clinical use for swallowing disorder investigation.

Revision surgery for laryngotracheal stenosis in children: A single center's 44 years experience.

OBJECTIVES: Outcome measures of revision open airway surgery in pediatric laryngotracheal stenosis (LTS) are reported. METHODS: Data on 46 pediatric LTS patients undergoing revision open airway surgery were collected retrospectively. The measured outcomes were decannulation rate, time to decannulation, postoperative complications, additional surgery to achieve decannulation, and functional results. RESULTS: The most common revision surgery was partial cricotracheal resection (PCTR) in 21/46, followed by extended PCTR (ePCTR) in 20/46, and laryngotracheal reconstruction (LTR) in 5/46 patients. A 90.7% overall decannulation rate (ODR) and a 74.4% operation-specific decannulation rate (OSDR) were achieved. Delayed decannulation was identified in children aged 5 years or less (p = 0.038) and in patients with previous primary open airway surgery (p = 0.039). Complications were observed in 52.2% of patients. To achieve optimal airway patency, additional open or endoscopic airway surgeries were necessary in 30.4% and 47.7% of patients, respectively. Age 5 years or less (p = 0.034), multiple comorbidities (p = 0.044), revision ePCTR (p = 0.023), and laryngeal stenting (p = 0.018) were risk factors requiring additional open surgery to achieve age-appropriate airway. Failed primary open airway surgery (p = 0.034) and comorbidities (p = 0.044) were risk factors for a higher rate of additional endoscopic surgeries. Postoperatively 63.0% of patients achieved normal breathing, 82.2% were dysphonic and 91.1% were orally fed. CONCLUSIONS: In this report, the patient's age under 5 years, previous primary open airway surgery, medical comorbidities, and laryngeal stenting had a significant negative impact on revision open airway surgery outcomes. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 133:3200-3207, 2023.

Congenital Malformations of the Cricoid Cartilage: Upper Airway Obstruction and Treatment Strategy.

OBJECTIVES: To review treatment and outcomes in patients with congenital cricoid cartilage malformation. METHODS: Retrospective analysis of patients with diagnosis of congenital cricoid malformation (CCM) treated in a single tertiary pediatric referral center between 1985 and 2022. Patients were grouped according to the morphology of the cricoid cartilage that was diagnosed during endoscopy. We reviewed the treatment strategy(s), decannulation rate, complications, and functional outcomes. RESULTS: Twenty-nine patients were grouped into four morphological subtypes of cricoid cartilage: 10 patients had a hypoplastic cricoid, eight had an elliptic shape, five had severe anterior thickening, and six an accentuated V-shape posterior cricoid plate. Twenty-four patients underwent surgery, and five were closely followed up without surgical treatment. Eight patients had a tracheostomy prior to surgery, and the majority had a hypoplastic cricoid. Most patients (20 out of 24) required additional procedures postoperatively to achieve an age-appropriate airway. Thirteen patients needed endoscopic dilatation(s) and granulation tissue removal; four needed more aggressive treatment, and three patients required revision open surgery. Decannulation was achieved after a median of 4.5 months in all previously tracheostomized patients. Endoscopy at the last follow-up showed an age-appropriate airway in 27 patients; 20 patients had normal oral feeding, and 11 patients had a normal voice. CONCLUSION: Endoscopy is important to diagnose CCM and most of the time patients would need only watchful waiting. In this report, surgery was required for patients who continued to remain symptomatic and had a compromised airway. The type of surgery depends on the type of cricoid malformation and the grade of stenosis. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:3185-3191, 2023.

Moderate grade subglottic stenosis in children: Laryngotracheal reconstruction versus cricotracheal resection and anastomosis.

Objective: The surgical treatment of choice of pediatric moderate subglottic stenosis (major grade II and minor grade III SGS or 60-80% lumen obstruction) remains controversial. Laryngotracheal reconstruction (LTR) (with anterior ± posterior grafts for airway expansion) and partial crico-tracheal resection (PCTR) are the mainly described open surgical techniques. We reviewed our pediatric cases with moderate subglottic stenosis to determine the efficacy of LTR versus PCTR. Methods: A retrospective study of all children between 0 and 18 years that underwent open reconstructive airway surgery between 2012 and 2019. Children who had either acquired or congenital moderate subglottic stenosis (late grade II and early grade III: 60-80% lumen obstruction) were selected. Results: Twenty-six children with moderate-grade subglottic stenosis were included. Seventeen were treated with LTR and nine with PCTR. No significant differences were observed between LTR and PCTR-treated cases. Decannulation rates were similar, as well as the functional results. Conclusion: Both LTR and PCTR are valid treatment options for moderate subglottic stenosis. This study indicates to perform the surgery that is most suitable for the characteristics of the patients' stenosis, the surgeons' expertise and preference, and the working infrastructure.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Evaluation and management of congenital tracheal stenosis.

OBJECTIVES: To outline an expert-based consensus of recommendations for the diagnosis and management of pediatric patients with congenital tracheal stenosis. METHODS: Expert opinions were sought from members of the International Pediatric Otolaryngology Group (IPOG) via completion of an 18-item survey utilizing an iterative Delphi method and review of the literature. RESULTS: Forty-three members completed the survey providing recommendations regarding the initial history, clinical evaluation, diagnostic evaluation, temporizing measures, definitive repair, and post-repair care of children with congenital tracheal stenosis. CONCLUSION: These recommendations are intended to be used to support clinical decision-making regarding the evaluation and management of children with congenital tracheal stenosis. Responses highlight the diverse management strategies and the importance of a multidisciplinary approach to care of these patients.

Early prediction of hospital outcomes in patients tracheostomized for complex mechanical ventilation weaning.

BACKGROUND: Tracheostomy is often performed in the intensive care unit (ICU) when mechanical ventilation (MV) weaning is prolonged to facilitate daily care. Tracheostomized patients require important healthcare resources and have poor long-term prognosis after the ICU. However, data lacks regarding prediction of outcomes at hospital discharge. We looked for patients' characteristics, ventilation parameters, sedation and analgesia use (pre-tracheostomy) that are associated with favorable and poor outcomes (post-tracheostomy) using univariate and multivariate logistic regressions. RESULTS: Eighty tracheostomized patients were included (28.8% women, 60 [52-71] years). Twenty-three (28.8%) patients were intubated for neurological reasons. Time from intubation to tracheostomy was 14.7 [10-20] days. Thirty patients (37.5%) had poor outcome (19 patients deceased and 11 still tracheostomized at hospital discharge). All patients discharged with tracheostomy (n = 11) were initially intubated for a neurological reason. In univariate logistic regressions, older age and higher body-mass index (BMI) were associated with poor outcome (OR 1.18 [1.07-1.32] and 1.04 [1.01-1.08], p < 0.001 and p = 0.025). No MV parameters were associated with poor outcome. In the multiple logistic regression model higher BMI and older age were also associated with poor outcome (OR 1.21 [1.09-1.36] and 1.04 [1.00-1.09], p < 0.001 and p = 0.046). CONCLUSIONS: Hospital mortality of patients tracheostomized because of complex MV weaning was high. Patients intubated for neurological reasons were frequently discharged from the acute care hospital with tracheostomy in place. Both in univariate and multivariate logistic regressions, only BMI and older age were associated with poor outcome after tracheostomy for patients undergoing prolonged MV weaning.

Long-term results of slide laryngotracheoplasty for congenital subglottic stenosis in newborns and infants.

OBJECTIVES: Slide laryngotracheoplasty is an effective, single-step procedure without tracheostomy and stenting for treating high-grade congenital subglottic stenosis in neonates and infants. Long-term outcomes were evaluated to assess the reliability of the procedure performed in this age of rapid development of the laryngeal structures. METHODS: We report five children who underwent slide laryngotracheoplasty before the age of 4 months, each with >3 years follow-up. Increases of length and bodyweight were systematically assessed. Breathing, swallowing, voice, and overall satisfaction was assessed by a quality of life questionnaire. Voice quality was objectively evaluated by measuring shimmer, jitter, fundamental frequency, and the harmonics-to-noise ratio. RESULTS: All patients had a stable and adequate airway during follow-up without any additional open airway surgery. The patients' voices were physiological, and the intervention had no negative impact on speech development. Swallowing function was optimally retained, and the patients' bodyweight gain and length were satisfactory. During at least 3 years of observation, the anastomosis remained stable and grew dynamically with the patient. CONCLUSIONS: Slide laryngotracheoplasty (as a single-step procedure) provides an adequate airway without tracheostomy, grafting, or stenting with good long-term functional results in selected neonates and infants with congenital subglottic stenosis.

Pediatric vascular anomalies with airway compromise.

Vascular anomalies are rare lesions of diverse nature that may affect the head and neck region. Any mass in or around the upper airway has the potential to obstruct or compromise it. The absolute priority, before etiologic treatment, is the evaluation of the risk for the airway and its management. Prenatal diagnosis of an upper airway obstruction requires a planned delivery in a center having a specialized team experienced in managing a compromised feto-neonatal airway, and who could perform an ex-utero intrapartum treatment to secure the airway. Even after birth, the airway remains central in the patient's overall management. Signs and symptoms of airway compromise must be evaluated keeping in mind the specific requirements of infants and small children and being aware that rapid worsening may occur. The treatment is then tailored to the patient and his lesion with the goal of improving symptoms while avoiding treatment-related complications. Maintaining reasonable expectations by the patient and families are part of a successful management. Cure is achievable for small and localized lesions, but symptom relief and mitigation of functional, esthetic and psychological impairments is the goal for large and complex lesions. If a tracheotomy was required, decannulation is one of the primary management goals.

Novel Technique for Fixing Tracheal Stents.

Endoscopic management of benign or malignant airway obstructions sometimes requires stenting after dilatation or debulking of the tumor. Straight stents are highly prone to migration in the trachea and the main bronchus, with potential catastrophic consequences. Multiple fixation strategies have been described to secure subglottic stents, each having certain limitations. This report describes a novel, "inside-to-outside" stent fixation in the upper airway using the Lichtenberger needle carrier in 2 consecutive patients.

Laryngotracheal Complications in Intubated COVID-19 Patients.

During the current COVID-19 pandemic, several emerging cases of laryngotracheal stenosis following prolonged intubation and tracheostomy are being reported. The patients' pre-existing comorbidities, the disease itself and the pronation maneuvers increase the risk for endolaryngeal and tracheal damage. In this commentary, we report 4 such patients with acquired severe laryngotracheal stenosis. We describe their airway lesions, the surgical treatment they received, and the outcomes.

Intubation Related Laryngeal Injuries in Pediatric Population.

Introduction: Laryngeal intubation related lesions (LIRL) in pediatric patients cause extreme morbidity in both elective and emergency settings. It has a wide range of presentations from minor laryngeal edema to a life-threatening airway obstruction. We report here our units' experience with LIRL in neonates, infants, and small children. Material and Methods: This is a retrospective monocentric cohort study between January 2013 and April 2019. Results: Thirty-nine patients with intubation lesions were included in the study. We looked at the lesions type, characteristics, management, and outcome. Half the patients were premature and having comorbidities. Main LIRL were subglottic stenosis (31%), ulcers (26%), granulations (18%), retention cysts (18%), posterior glottic stenosis (13%), and vocal cords edema (5%). Unfavorable lesions causing airway stenosis were associated with an intubation duration of over 1 week and were an important factor in causing airway stenosis (p < 0.05). The endoscopic treatment performed for these lesions was lesion and anatomical site-specific. Tracheostomy was needed in five patients, and was avoided in another two. Seven patients (18%) received open surgery prior to their decannulation. Conclusions: LIRL management is challenging and stressful in the pediatric population and optimal treatment could avoid extreme morbidity in them. Intubation duration and associated comorbidities are important factors in deciding the severity of these lesions. Protocols to prevent the formation of these lesions are critical.

Long-term intubation and high rate of tracheostomy in COVID-19 patients might determine an unprecedented increase of airway stenoses: a call to action from the European Laryngological Society.

INTRODUCTION: The novel Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, may need intensive care unit (ICU) admission in up to 12% of all positive cases for massive interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common airway-related complications of such ICU maneuvers are laryngotracheal granulomas, webs, stenosis, malacia and, less commonly, tracheal necrosis with tracheo-esophageal or tracheo-arterial fistulae. MATERIALS AND METHODS: This paper gathers the opinions of experts of the Laryngotracheal Stenosis Committee of the European Laryngological Society, with the aim of alerting the medical community about the possible rise in number of COVID-19-related laryngotracheal stenosis (LTS), and the aspiration of paving the way to a more rationale concentration of these cases within referral specialist airway centers. RESULTS: A range of prevention strategies, diagnostic work-up, and therapeutic approaches are reported and framed within the COVID-19 pandemic context. CONCLUSIONS: One of the most important roles of otolaryngologists when encountering airway-related signs and symptoms in patients with previous ICU hospitalization for COVID-19 is to maintain a high level of suspicion for LTS development, and share it with colleagues and other health care professionals. Such a condition requires specific expertise and should be comprehensively managed in tertiary referral centers.

International Pediatric Otolaryngology Group (IPOG) management recommendations: Pediatric tracheostomy decannulation.

OBJECTIVES: To provide recommendations to otolaryngologists, pulmonologists, and allied clinicians for tracheostomy decannulation in pediatric patients. METHODS: An iterative questionnaire was used to establish expert recommendations by the members of the International Pediatric Otolaryngology Group. RESULTS: Twenty-six members completed the survey. Recommendations address patient criteria for decannulation readiness, airway evaluation prior to decannulation, decannulation protocol, and follow-up after both successful and failed decannulation. CONCLUSION: Tracheostomy decannulation recommendations are aimed at improving patient-centered care, quality and safety in children with tracheostomies.