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.

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.

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.

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.

Outcomes of balloon dilation for paediatric laryngeal stenosis.

OBJECTIVE: Balloon dilation (BD) is a minimally invasive endoscopic treatment for paediatric laryngeal stenosis (LS) with reduced morbidity compared to open surgery. We retrospectively describe our experience in a cohort of children with chronic LS. METHODS: Fourteen children (median age: 28.5; range: 2-81 months) with chronic LS (multilevel in 8) were treated with tubeless total intravenous anaesthesia under spontaneous ventilation. RESULTS: Grade III LS was preoperatively detected in 12 children; the remaining 2 had grade IV stenosis. Six had prior tracheotomy, and one received it during the first intervention. Dilation laryngoplasty was the primary treatment in 11 children and was used as an adjuvant treatment in 3 after open reconstructive surgery. The median number of dilations was 2 (range: 1-6). There were no postoperative complications. At the end of the follow-up (median: 20.5; range: 2-46 months), detectable laryngeal lumen widening and/or respiratory improvement occurred in 12 children. Two of 7 patients with tracheostomy were decannulated. CONCLUSIONS: Balloon laryngoplasty is a valuable therapeutic option to improve laryngeal patency in children with chronic multilevel LS, both as a primary and secondary adjuvant treatment after reconstructive surgery.

Slide laryngotracheoplasty for congenital subglottic stenosis in newborns and infants.

OBJECTIVES: Subglottic stenosis is the most common laryngeal anomaly necessitating tracheostomy in early childhood. Crico- and laryngotracheal resection and laryngotracheal reconstruction-usually with autologous cartilage graft implantation-are the most effective treatments. These surgical techniques are obviously challenging in neonatal age and infancy. However, a reconstructive surgery performed at early age may prevent the sequel of complications. METHODS: The authors present their novel surgical method for congenital subglottic stenosis. Seven infants had inspiratory stridor; two of them had to be intubated and one required tracheostomy. Laryngotracheoscopy, CT or MRI revealed subglottic stenosis: Cotton-Myer grade II in one, and grade III in six cases. Slide laryngotracheoplasty was performed before 5 months of age (10-130 days), with a follow-up period of average 36 months (4-80 months). Phoniatry and quality of life questionnaire were used for evaluation of postoperative results. RESULTS: Slide laryngotracheoplasty in the neonatal age made the temporary tracheostomy unnecessary. All babies remained intubated for 3 to 10 days with an uncuffed tracheal tube. After extubation, no dyspnea or swallowing disorder occurred. A subjective quality of life questionnaire, laryngotracheoscopy, clinical growth charts showed satisfactory functional results. CONCLUSIONS: Single-stage slide laryngotracheoplasty might be a favorable solution for subglottic stenosis, even in early childhood. In one step, the airway can be maintained without stenting and tracheostomy. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E199-E205, 2020.

[Congenital tracheal stenosis: from clinic to treatment.] / La sténose trachéale congénitale: de la clinique au traitement.

Congenital tracheal stenosis is a rare malformation of the fibrino-cartilaginous tracheal skeleton, frequently associated with cardiac malformations. The symptoms and the age of presentation varie according to the severity of the stenosis. There is a risk of airway obstruction. The diagnosis is based on endoscopy and surgery is usually required.

La sténose trachéale congénitale est une malformation rare du squelette fibro-cartilagineux de la trachée, fréquemment associée à des malformations cardiaques. Le tableau clinique et l'âge de présentation varient en fonction de la sévérité de la sténose. Il existe un risque d'obstruction des voies aériennes. Le diagnostic repose sur l'endoscopie et le traitement est chirurgical.

Combined use of Ventrain and S-Guide for Airway Management of Severe Subglottic Stenosis.

The airway management of a patient with severe tracheal stenosis depends on its severity, length, location, and type of surgery. Its management is complex and requires the collaboration of an experienced team of anaesthetist and ear, nose, and throat surgeon. We report an innovative combination of Ventrain™ and S-Guide™ for airway management of a planned endoscopic dilation of a severe subglottic stenosis in an adult patient. This new alternative may offer advantages over existing airway management techniques in similar cases.

Lamb larynx model for training in endoscopic and CO2 laser-assisted surgeries for benign laryngotracheal obstructions.

PURPOSE: With adequate indication and meticulous execution, endoscopic procedures can efficiently treat a subset of adult and pediatric benign laryngotracheal stenosis and obstructions, but these procedures are precise and very demanding. The difference between a successful and a failed surgery, with potentially debilitating side effects, resides in small details. The learning curve is long and very few centers worldwide have a sufficient case load making adequate training difficult. While indications and concepts of endoscopic procedures can be learned in books and by observing trained colleagues, the dexterity and the precise realization need to be practiced, ideally not initially on patients. METHODS: We describe here the lamb model system for the initial training in such procedures. We provide a step-by-step guide for endoscopic approaches intended to treat pathologies such as laryngomalacia, bilateral vocal fold paralysis, posterior glottic stenosis, and laryngotracheal clefts. CONCLUSIONS: The lamb model system does not pose ethical issues, and it is easy to obtain and to handle. It was used during an international training course for laryngotracheal stenosis by novice and advanced airway surgeons. It was unanimously judged as relevant and useful by the participants.

Transoral robotic-assisted supracricoid partial laryngectomy with cricohyoidoepiglottopexy: Procedure development and outcomes of initial cases.

BACKGROUND: We report on the feasibility and functional outcome of transoral robotic (TORS) supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP). METHODS: Cadaveric studies and functional outcome at 3 years using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-H&N35), the Functional Outcome Swallowing Scale (FOSS), the Performance Status Scale for Head and Neck Cancer (PSS-HN), computerized voice analysis, and videotape recordings. Data were compared with a historical cohort of open CHEPs/cricohyoidopexies (CHPs). RESULTS: The EORTC-QLQ-H&N35 scores, FOSS scores, and PSS-HN scores at 3 years of 2 operated patients were 46 and 43, 2 and 1, and 75 of 100 (eating in public) and 100 of 100 (normalcy of diet), respectively. The mean fundamental frequency, jitter, shimmer, noise-to-harmonic ratio (NHR), and maximum phonation time (MPT) were 85 HZ and 81 Hz, 8.52% and 6.39%, 28.2% and 13.5%, 0.61 and 0.71, 19 seconds and 15 seconds, respectively. CONCLUSION: Functional outcome data suggest that the procedure is feasible and safe.

Extraluminal biodegradable splint to treat upper airway anterior malacia: A preclinical proof of principle.

OBJECTIVE: Upper airway malacia highly complicates the treatment of benign laryngotracheal stenosis, and no ideal option is available to date. We here explore the use of extraluminal biodegradable splints in an animal model of long-segment anterior tracheomalacia (TM). We show the efficacy, as well as the tissue tolerance, of a custom-made biodegradable extraluminal device surgically inserted around the trachea. STUDY DESIGN: Preclinical animal study. METHODS: Anterior TM was induced in rabbits through an anterior neck approach by removing eight consecutive anterior tracheal rings without damaging the underlying mucosa. Malacia was corrected during the same surgery by pexy sutures, suspending the tracheal mucosa to an experimental biodegradable device. Symptoms, survival, and tissue reaction were compared to healthy and sham surgery controls. RESULTS: The model induced death by respiratory failure within minutes. Ten animals received the experimental treatment, and those who survived the perioperative period remained asymptomatic with a maximum follow-up of 221 days. Histological studies at programmed euthanasia showed complete degradation of the prosthesis, with significant remnant fibrosis around the trachea. However, the tracheal stiffness of test segments was comparatively less than that of control segments. CONCLUSION: Extraluminal biodegradable splints rescued animals with a condition otherwise incompatible with life. It was well tolerated, leaving peritracheal fibrosis that was not as stiff as normal trachea. The external tracheal stiffening was sufficient for the test animals to live through the phase of severe acute hypercollapsibility. This represents a valid option to help pediatric patients with laryngotracheal stenosis and associated cartilaginous airway malacia. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:E53-E58, 2018.