Development of a survival animal model for subglottic stenosis.

OBJECTIVE: To develop a reproducible survival animal model for subglottic stenosis. STUDY DESIGN: Prospective study. METHODS: We evaluated five methods of inducing airway injury in 30 New Zealand white rabbits to produce a subglottic stenosis model. Experimental groups comprised: group 1 (n = 5), which underwent 4-hour intubation; group 2 (n = 5), which underwent induced subglottic injury with a nylon brush; group 3 (n = 10), which underwent subglottic injury with a nylon brush, followed by 4-hour intubation; group 4 (n = 5), which underwent subglottic injury with Bugbee cautery in 50% of the subglottic circumference, followed by 4-hour intubation; and group 5 (n = 5), which underwent subglottic injury with Bugbee cautery in 75% of the subglottic circumference, followed by 4-hour intubation. Five animals were used as controls. Endoscopy of the airway and sacrifice of animals were planned at an interval of 14 days postinjury. Histologic measurements were analyzed. RESULTS: No animals in groups 1 or 2 developed stenosis. In group 3, 50% of animals developed symptomatic grade 3 subglottic and tracheal stenosis, necessitating early endoscopy and sacrifice in three animals. Four animals in group 4 developed grade 1 subglottic stenosis, and four in group 5 developed grade 2 subglottic stenosis. Histologic measurements of lumen areas within each of these two groups were similar; all animals survived the follow-up period. CONCLUSION: We successfully developed a reproducible survival model for induced subglottic stenosis using a combination of cautery-induced subglottic injury followed by 4-hour intubation. This model lays the foundation for future studies that evaluate endoscopic interventions for the management of subglottic stenosis. LEVEL OF EVIDENCE: NA Laryngoscope, 129:989-994, 2019.

Morbidity and mortality associated with subglottic laryngotracheal stenosis in granulomatosis with polyangiitis (Wegener's granulomatosis): a single-centre experience in the United Kingdom.

OBJECTIVES: We aimed to determine the prevalence of symptomatic subglottic laryngotracheal stenosis in patients with granulomatosis with polyangiitis (Wegener's granulomatosis); we also wanted to characterise the clinical outcomes and surgical interventions required, and the relapse rate in our cohort. METHODS: We undertook a retrospective clinical review of all granulomatosis with polyangiitis patients with symptomatic subglottic laryngotracheal stenosis attending St Thomas' Hospital, London, United Kingdom. RESULTS: Symptomatic subglottic laryngotracheal stenosis developed in 16 per cent of granulomatosis with polyangiitis patients attending our clinic. The median age of patients at diagnosis was 44 years (range: 34-81 years); 78 per cent of those presenting with subglottic laryngotracheal stenosis were women and 22 per cent were men. All patients were white; 67 per cent of patients were proteinase 3-antineutrophil cytoplasmic antibody-positive and 67 per cent developed relapsing disease requiring repeated surgical intervention. Subglottic laryngotracheal stenosis relapse was not associated with active systemic vasculitis elsewhere. CONCLUSION: Subglottic laryngotracheal stenosis is an uncommon but significant complication of granulomatosis with polyangiitis. Management of subglottic laryngotracheal stenosis requires a multi-disciplinary approach, with both rheumatological and otolaryngological expertise involved, given the relapsing nature of the disease.

Feasibility and mortality of airway balloon dilation in a live rabbit model.

IMPORTANCE: Endoscopic balloon dilation is commonly performed in children with airway stenosis, but guidelines are needed for selecting safe and effective balloon inflation parameters. OBJECTIVE: To determine the feasibility and safety of airway balloon dilation in live rabbits using a range of balloon diameters and pressures. DESIGN AND SETTING: Prospective animal study using 32 adult New Zealand white rabbits with 1-week follow-up performed at an academic animal research facility. INTERVENTIONS: Rabbits underwent endoscopic laryngeal balloon dilation with diameters ranging from 6 to 10 mm and pressures of 5 to 15 atm. MAIN OUTCOMES AND MEASURES: Rabbits were observed for intraoperative complications and postoperative morbidity. RESULTS: All rabbit airways were sized to a 4-0 endotracheal tube (5.4-mm outer diameter). Balloon dilation was performed safely with no intraoperative complications in 25 of 30 cases. One rabbit developed transient cyanosis during balloon inflation. Three rabbits died while undergoing dilation with 10-mm balloons, and another rabbit developed respiratory failure shortly after the procedure. All rabbits that died perioperatively lacked endoscopic evidence of airway obstruction or gross trauma. Four rabbits developed postoperative feeding difficulties that did not correlate with balloon diameter or inflation pressure. CONCLUSIONS AND RELEVANCE: Endoscopic balloon dilation is generally well tolerated in New Zealand white rabbits. Intraoperative mortality from cardiopulmonary arrest reaches 50% when the balloon diameter exceeds the airway diameter by 4.6 mm. Postoperative feeding difficulties may occur with any balloon diameter or inflation pressure. Additional animal studies are necessary to determine the short- and long-term histologic effects of balloon dilation on the airway.

Single-center experience of outcomes of tracheostomy in children with congenital heart disease.

OBJECTIVE: A subset of children with repaired congenital heart disease (CHD) may require tracheostomy for ongoing ventilatory support. Data on outcomes of children with CHD and tracheostomy are scarce. Our objectives were to describe indications for tracheostomy and outcomes, including readmission data in this population. METHODS: This is a retrospective chart review of children (<18 years old) with CHD who underwent tracheostomy at a single center over a 12-year period. Exclusion criteria were prematurity with isolated patent ductus arteriosus ligation. Outcomes until discharge and data on all readmissions after the initial discharge were reviewed. RESULTS: A total of 21 subjects with CHD underwent tracheostomy at a median (range) age of 4 (1-84) months and mean (standard deviation) weight of 7.2 (5.9) kg. The most common indication for tracheostomy was tracheomalacia with ventilator-dependent respiratory failure (14/21 subjects), followed by subglottic stenosis (5) and vocal cord palsy (2). Genetic syndromes were present in 13 (62%) subjects. The mean (standard deviation) post-tracheostomy length of stay was 55 (35) days. All subjects survived to discharge; 17 (81%) required home ventilation. A total of 11 (52%) subjects died during follow-up, all of whom were mechanically ventilated while three (14%) children underwent successful decannulation. The mean number of nonelective readmissions decreased from 2.4/patient-year in the first year to 1.4/patient-year in the second year, respectively. The commonest reasons for readmission were respiratory deterioration, infections, and mechanical tracheostomy-related problems. CONCLUSIONS: The majority of children with CHD who underwent tracheostomy did so for ventilator dependence and tracheomalacia and had coexisting genetic syndromes. About half the cohort died; among survivors, readmissions were common but decreased after the first year. These results underscore the ongoing mortality and morbidity risks faced by this vulnerable population.

Sheath-assisted tracheal intubation: a further treatment option for patients with acute dyspnea or asphyxia caused by severe stenosis of the larynx or trachea.

PURPOSE: This report details our preliminary results for sheath-assisted tracheal intubation (SATI) for patients with acute dyspnea caused by severe stenoses in the larynx or trachea. DESCRIPTION: Of 289 patients with acute dyspnea who required tracheal intubation in the emergency department of our hospital, 21 who experienced intubation difficulty or failure were entered into this study. Data on technical success, clinical outcome, and complications related to SATI were collected and analyzed retrospectively. EVALUATION: Sheath-assisted tracheal intubation was successful in all patients. Clinical success was observed in all patients 1 to 7 days after the procedure. Tracheal stents or incisions, or both, were performed 1 to 3 days after SATI for all patients, once their general physical condition had improved. During follow-up, acute dyspnea had resolved in all patients. At the time of this report, 18 patients were well, with no dyspnea, but 3 patients had died, 2 of lung cancer and 1 of carcinoma of the larynx. CONCLUSIONS: Shealth-assisted tracheal intubation is a safe and feasible procedure, and may serve as an additional treatment option for patients with acute dyspnea caused by severe stenoses of the larynx or trachea.

Resource utilization in the management of subglottic stenosis.

OBJECTIVE: The purpose of this study was to determine resource utilization in managing subglottic stenosis. STUDY DESIGN: The Kids' Inpatient Database (KID) 2003 was analyzed. SUBJECTS AND METHODS: International Classification of Diseases, Ninth Revision code 478.74 was the inclusion criteria. RESULTS: Two thousand forty-six admissions with subglottic stenosis were sampled; there were 10 deaths (0.49%). States with the most admissions were Ohio, California, and Illinois; these did not have the highest spending per admission. Two hundred eighteen (10.7%) underwent a laryngeal graft procedure; states with the most were Ohio (35.8%), Texas, California, and Florida. Indicators of increased resource utilization include length of stay, nonelective admission, race, primary payer, hospital location, and type. CONCLUSIONS: For subglottic stenosis, three states account for 37% of admissions, and four states account for 56% of laryngeal graft procedures in 2003. The mean total charges were $53,787; 90% of admissions had total charges less than $139,253. Patients who underwent surgical procedures had total charges of $76,409.

Pediatric laryngotracheal obstruction: current perspectives on stridor.

OBJECTIVES/HYPOTHESIS: To assess how medical advances have impacted the diagnosis, management, and outcomes of pediatric laryngotracheal obstruction, and to describe the advantages of audio-video documentation of stridorous children. STUDY DESIGN AND METHODS: Retrospective. METHODS AND MATERIALS: 268 patients were referred for suspected laryngotracheal obstruction during the 30 months between September 1, 1995 and March 1, 1998: 173 had 206 flexible fiberoptic laryngoscopies, and 160 had 273 direct laryngoscopies. One hundred and forty-one children were identified with laryngotracheal obstruction, yielding 40 different diagnoses that could be classified into 9 major categories. Thirty-six children (25.5%) had multiple sites of upper airway obstruction. RESULTS: 138 children had follow-up >1 month. Twelve children died (8.7%), leaving 126 survivors (mean follow-up=21.1 months). Outcomes were classified as resolved (44.2%), improved (37.0%), stable (9.4%), failed (0.7%), or death (8.7%). Better outcomes were seen in more readily treated diagnostic categories, such as tracheobronchial foreign body, chronic laryngitis, and suprastomal granulation tissue; laryngeal stenosis, tracheomalacia, and recurrent respiratory papillomatosis, had less favorable outcomes (P<.001). The former group also showed superior outcome compared to laryngomalacia (P<.001) and vocal cord mobility disorders (P=.004). Ninety-four patients (68.1%) had comorbidities complicating their management. Comorbid conditions were universal among deceased patients and least common in the resolved outcomes category (56.7%), supporting the premise that patients with poor outcomes are more likely to have comorbidities than patients with resolution of laryngotracheal symptoms (P=.034). CONCLUSIONS: Audio-video recording of pediatric laryngotracheal obstruction offers numerous advantages. Children classified into an array of diagnostic categories usually have favorable outcomes, but opportunities for continued advances exist, particularly regarding management of comorbidity and chronic obstruction.

Dilatation for assisted ventilation-induced laryngotracheal stenosis.

OBJECTIVE: To assess the long-term results of dilatation and our experience with dilatation for assisted ventilation-induced laryngotracheal stenosis. DESIGN: A retrospective study of 32 patients primarily treated with dilatation for assisted ventilation-induced laryngotracheal stenosis between 1977 and 2002. SETTING: A tertiary care center and university teaching hospital. PATIENTS: There were 19 men and 13 women aged 15 to 76 years. The stenosis was cicatricial with some inflammatory process in 27 patients and completely mature in 5 patients. The stenosis involved the cricoid and the trachea in four patients. In 28 patients, the stenosis involved only the trachea. METHODS: Dilatation was performed with serially sized rigid bronchoscopes. Endoscopic laser vaporization was never performed in this series. Six patients were treated with only one dilatation. The 26 remaining patients were treated with successively 2 to 10 dilatations (mean, 3.3 dilatations). The dilatation success rate was analyzed using the Kaplan-Meier method. RESULTS: Median duration of follow-up was 1.8 years. Mortality rate was 9.4%. The overall failure rate was 71.8%. Twenty patients presented with recurrent stenosis. The treatment of recurrent stenosis consisted of tracheal resection with end-to-end anastomosis (11 patients, 55%), cricotracheal anastomosis (5 patients, 25%), tracheal endoprosthesis (2 patients, 10%), and tracheotomy (1 patient, 5%). All patients who underwent tracheal or cricotracheal anastomosis were successfully treated. None of the variables under analysis (sex, age, medical history, cause for intubation, intubation type and duration, delay from initial injury, degree of stenosis, length of trachea involved, number of dilatations) were statistically related to the incidence of complications and the success rate of dilatations. CONCLUSIONS: We do not recommend dilatation technique as the sole treatment for assisted ventilation-induced laryngotracheal stenosis. This technique is helpful in case of emergency to restore an airway and useful for the assessment of stenosis.

Tracheostomy: acute and long-term mortality and morbidity in very low birth weight premature infants.

Thirty-six very low birth weight premature infants (VLBW-PT) born at 24 to 32 weeks gestation and with birth weights 635 to 1,360 g who had tracheostomies performed for acquired subglottic stenosis or for prolonged mechanical ventilation were followed in relation to acute and long-term mortality and morbidity. Mortality due to the tracheostomy occurred in 4 patients (11%); mortality from all other causes was 25%. Death after hospital discharge was associated with the nonuse of prescribed cardiorespiratory monitors. Complications < 1 week postsurgery occurred in 31% of infants and complications > or = 1 week postsurgery occurred in 64% of infants. Fifty percent of infants required tracheostomy for > 2 years and/or extensive reconstructive surgery of the airway. Parents should be counselled that VLBW-PT infants with a tracheostomy may require extended medical and home care. An effective home care program requires parental training in tracheostomy care, the use of ancillary equipment, and infant cardiopulmonary resuscitation.

Anterior cricoid split. Update 1991.

The management of neonatal subglottic stenosis by the anterior cricoid split procedure (ACS) has evolved rapidly since this operation was first described by Cotton and Seid in 1980. Recent reports have specified criteria for the evaluation of patients for ACS, and adherence to these guidelines has increased the extubation rate and decreased the mortality rate in these series. Ninety-one patients have undergone anterior cricoid split at Children's Hospital Medical Center (Cincinnati, OH) since 1977. These cases were reviewed, emphasizing the 24 infants treated since January 1, 1988, and not previously reported. In comparison to our most recent report of 70% extubation and 10.4% mortality, 67% of the latest group were extubated, while mortality was reduced to 4.1%. These results were achieved despite some relaxation of strict patient-selection guidelines when this was appropriate in individual patients, emphasizing the need for careful clinical evaluation and close consultation between otolaryngologist and pediatrician in the selection of patients for ACS.

Pediatric tracheostomies: changing trends.

We reviewed all tracheostomies performed at Sainte-Justine Hospital between 1970 and 1975, and between 1980 and 1985. The study indicates a significant decrease in the number of tracheostomies for the last period and an increase in the decannulation time from 28 to 91 days. Acute infection of the upper respiratory tracts was the major indication in the early 1970s whereas complications of prolonged intubation and congenital malformation predominated in the early '80s. Complications and mortality rate are also compared.

Surgical correction of laryngotracheal stenoses in children.

A modified surgical technique according to Rhéti is described: the cricoid and the uppermost tracheal rings are longitudinally dissected ventrally and dorsally. The enlargement of the lumen is stabilized by interposition of a notched piece of costal cartilage into the dissected posterior wall of the cricoid. A total of 63 children with laryngotracheal stenosis have been operated on by this method in Zurich since 1973 and in Munich since 1982. Laryngotracheal plasty is successful in over 80% of small children in whom the procedure is necessary. The voice becomes a little hoarse, but respiration is adequate, as demonstrated by our juvenile patients, some of whom have been decannulated for over 10 years. The earlier opinion that laryngoplasty performed in small children might impair laryngeal growth and result in severe stenoses has been disproved by the results presented. Our experience shows that prognosis is worse in children with tracheal stenosis and associated anomalies, such as paralysis of the vocal cord.