Coblation intracapsular tonsillectomy in a paediatric tertiary centre: Revision surgery rates over a nine-year period.

OBJECTIVES: Coblation intracapsular tonsillectomy (ICT) is increasingly being used in the paediatric population because of the rapid recovery and low rates of complications associated with it. There is, however, a risk of symptomatic regrowth with this technique. The objective of our study is to establish the rate of, and risks for, revision surgery over time in a major tertiary referral centre with a large cohort of paediatric Coblation ICT cases. METHODS: A retrospective review of all children (0-19 years) undergoing Coblation ICT from April 2013 to June 2022 was undertaken, using electronic databases and clinical records. Post-operative follow up was reviewed and revision cases were subsequently identified and examined. Statistical analysis was performed using a Chi-Squared test. RESULTS: 4111 patients underwent Coblation ICT during the studied period, with or without concomitant adenoidectomy. Of these, 135 (3.3 %) required revision tonsil surgery, primarily for recurrence of initial symptoms; two patients required two consecutive revision procedures (137 revision procedures in total). Eight-eight (n = 88) (64 %) of these were revised with a repeat Coblation ICT procedure and 49 (36 %) with bipolar diathermy extracapsular tonsillectomy (ECT) of remnant tonsil tissue. The revision rates after Coblation ICT declined steeply on a year-on-year basis since the commencement of this technique (from 10.6 % early on, to 0.3 % at the end of the study period P<0.001). A significantly higher revision rate was noted in children below the age of two at the time of primary surgery, compared to those older than two years of age (P<0.001). CONCLUSIONS: This study demonstrates real-world departmental revision rates over a nine-year period from the technique's commencement of use. With Coblation ICT, symptomatic re-growth occurs rarely, but may be clinically significant, with higher rates of recurrent symptoms seen in children under two years of age at the time of primary surgery. The revision rate apparently drops over time in parallel with overall experience of surgeons and formalised training.

Balloon dilatation for paediatric airway stenosis: Evidence from the UK Airway Intervention Registry.

OBJECTIVES: To assess the safety and efficacy in routine clinical practice of balloon dilatation procedures in the treatment of paediatric airway stenosis. DESIGN: Observational data collection in prospective online research database. SETTING: Acute NHS Trusts with ENT department undertaking complex paediatric airway work. PARTICIPANTS: Children (<18) undergoing balloon dilatation treatment for airway stenosis. MAIN OUTCOME MEASURES: Airway diameter, complications, hospital resource usage. RESULTS: Fifty-nine patients had 133 balloon procedures during 128 visits to 10 hospitals. Sixty-nine (52%) of balloon procedures were conducted with a tracheostomy. Intra-operative Cotton-Myer grade decreased in 43 (57%). The mean pre-balloon subglottic diameter was 4.2 [95% CI: 3.8 to 4.5] mm, and its rate of increase was 0.8 [0.5 to 1.2] mm per year modelled on 30 patients' long-term data. As the primary treatment of stenosis, the procedural success rate of balloon dilatation (n = 52) was 65% (22% with tracheostomy, 88% without tracheostomy), and 71% as an adjunct to open reconstructive surgery (n = 7). In the 64 hospital visits where a balloon procedure was conducted with a tracheostomy in place, only one in-hospital complication (lower respiratory tract infection) occurred. For those without a tracheostomy in place, in-hospital complications occurred in seven of 64 balloon hospital visits, all related to ongoing or worsening stenosis. Six out-of-hospital complications were deemed related to ongoing or worsening stenosis following the procedure, and two complications were a combination of lower respiratory infection and ongoing or worsening stenosis. CONCLUSIONS: Balloon dilation increases the size of the airway intraoperatively and is associated with long-term increase in airway diameter. Safety outcomes mostly relate to ongoing or worsening stenosis and are more common in patients without a tracheostomy.

Treatment of severe tracheobronchomalacia: Ten-year experience.

INTRODUCTION: Paediatric tracheobronchomalacia is a rare but potentially serious condition. Severe tracheobronchomalacia requires intervention or operation. This is an evaluation of a ten-year experience at an institution. METHODS: In this retrospective study all patients were included that required an intervention for severe tracheobronchomalacia from 2003 to 2012. Symptoms, aetiology, comorbidities, localisation of the malacia, age at diagnosis, therapeutic measures and associated complications were evaluated. RESULTS: Forty-four patients with severe tracheobronchomalacia underwent intervention/operation. The predominant aetiology was vascular compression in 48%. The majority of patients had complex comorbidities, most importantly cardiac pathology in 66%. The median age at diagnosis was 3 months. A total of 17 aortopexies, 21 tracheostomies and 25 stent placements were performed. The mean follow-up was 2.6 years. Severe complications occurred in 12 patients. The most common complications were stent obstruction/fracture and tracheostomy tube obstruction. CONCLUSION: The management of severe tracheobronchomalacia is complex and the population of patients is very heterogeneous. Therefore the treatment has to be adapted for each patient individually. The decision strategies are discussed in this article. The surgical techniques for placement and safe removal of expandable bare metallic stents employed in our institution are presented. A multidisciplinary team of ENT surgeons, Intensivists, Cardiologists and Cardiac surgeons is of great importance.

Buccal mucosa graft for laryngotracheal reconstruction in severe laryngeal stenosis.

OBJECTIVE: An operative technique is described as a salvage treatment for severe subglottic and supraglottic laryngeal stenosis. In addition to expansion of the laryngeal framework with an anterior cartilage graft, as used in a classical laryngotracheal reconstruction, the scar tissue obliterating the airway lumen is excised and a mucosal graft is placed to reconstruct the inner lining of the airway. The graft is harvested from buccal mucosa. METHODS: The operative technique is outlined. Three cases, 2 paediatric and one adult, with complete or near complete laryngeal stenosis are presented where this operative technique was employed. In all patients several surgeries had been performed previously which were unsuccessful. RESULTS: In all 3 patients a patent airway was achieved with decannulation of the tracheostomy in the 2 paediatric patients. CONCLUSIONS: In patients with severe subglottic or supraglottic airway stenosis where other surgeries have failed, excision of endoluminal scar tissue and placement of a buccal mucosal graft, in addition to conventional laryngotracheal reconstruction, is a promising technique. In revision cases of subglottic stenosis cricotracheal resection might not be an option because of scarring from previous surgeries. This operation is an alternative, which allows an increase in the airway lumen by excising the scar tissue then re-lining the exposed internal lumen. The buccal mucosa reduces granulation formation and re-stenosis.

Combined transoral and nasendoscopic resection of an eustachian tube hairy polyp causing neonatal respiratory distress.

Hairy polyps are rare congenital malformations that can arise in the nasopharynx. It is rarer for them to originate from the eustachian tube. They present with intermittent airway obstruction and respiratory distress. A thorough ear, nose, and throat examination can be required to identify these lesions. We present a case of eustachian tube hairy polyp causing neonatal respiratory distress in a 1-month baby successfully removed by a combined transoral and nasendoscopic resection.

Lung contusion in children--early computed tomography versus radiography.

OBJECTIVE: To investigate, in children, the correlation between the extent of lung contusion as detected on early radiologic examination (chest radiograph [CXR] and/or thoracic computed tomography [TCT]) and subsequent clinical outcome measures. DESIGN: Retrospective chart review study with blinded assessment of thoracic imaging. SETTING: A university-affiliated, level 1 designated pediatric trauma center. INTERVENTIONS: None. PATIENTS: Patients (1-18 yrs) who, between April 2000 and October 2005, were diagnosed with lung contusion were eligible for study entry. The medical records of those patients who underwent early (within the first 24 hrs of admission) thoracic imaging (CXR and/or TCT) were reviewed. A pulmonary contusion score (PCS) was assigned to each thoracic image according to the extent of contusion injury by two investigators blinded to each others score and the clinical details of the patient. RESULTS: Seventy-four patients were included in the study. Twenty patients had undergone CXR only, whereas 54 had undergone both CXR and TCT. The mean PCS on CXR was 3.9 +/- 3.6 compared with 6.5 +/- 3.49 on TCT (p < .001). In eight patients (15%) who underwent TCT and CXR, the CXR failed to demonstrate a lung contusion. The PCS derived from CXR examination correlated positively with lower Pao2/Fio2 (r = -.36, p = .019), higher ventilation index (r = .35, p = .014), and longer length of ventilation (r = .28, p = .019). No such correlation was seen with TCT-derived PCS. CONCLUSIONS: The severity of lung contusion determined by CXR, but not TCT, correlates with impairment of oxygenation, CO2 exchange, and duration of ventilatory support.

Ten-year review of laryngotracheal reconstruction for paediatric airway stenosis.

OBJECTIVES: To review the outcomes of paediatric patients with laryngotracheal stenosis treated at our institution by laryngotracheal reconstruction (LTR). METHODS: A single surgeon personal series retrospective review of case notes over a 10-year period from a single site tertiary referral paediatric otolaryngology department in patients with laryngotracheal stenosis treated with laryngotracheal reconstruction. Evaluation was based on the last laryngotracheal endoscopy, and a retrospective review of the patient's data. RESULTS: Seventy-three open laryngotracheal procedures were undertaken for paediatric laryngotracheal stenosis from the period 1995-2005. Fourteen were cricoid split operations and will be described elsewhere. The remaining 59 procedures were cartilage graft laryngtracheal reconstructions, performed on 53 patients (37 single stage and 16 staged) with 6 having required revisions. CONCLUSIONS: LTR provides good results for subglottic stenosis (SGS) as primary or salvage operations. The procedure has no deleterious effects on laryngeal growth. The causes of failed procedures are discussed.

Balloon dilatation following tracheal reconstruction for congenital microtrachea.

A male infant presented with failed extubation was diagnosed with congenital microtrachea. After primary combined surgery with excision of a left pulmonary artery sling and microtracheal resection with anastomosis incorporating the excised microtrachea as an autologous anterior tracheal graft he was treated with balloon dilatation of the re-stenosed segment on three occasions during the following year. During the 4 years follow-up, stridor has been minimal and intermittent. His feeding and growth have been normal. We have found balloon dilatation to be a useful adjunct to tracheal reconstructive surgery in this difficult condition.