Postlaryngectomy supraglottic stenosis revealed by three-dimensional computed tomography reconstruction: A case report.

RATIONALE: Supraglottic stenosis is a rare cause of airway obstruction. It can be induced by radiation, trauma, autoimmune diseases, or caustic exposure, and is often misdiagnosed as asthma. Detailed airway information is necessary to re-establish the normal functioning of the airway. PATIENT CONCERNS: A 78-year-old woman with severe dyspnea and hypercarbia was scheduled for surgery to resolve airway obstruction, previously known as supraglottic stenosis. DIAGNOSES: To determine the exact internal shape of the stenotic lesion, we reconstructed three dimensional computed tomography (CT) images depicted a tubular supraglottic stenosis. INTERVENTIONS: The patient underwent tracheotomy under monitored anesthesia care and local anesthesia, followed by general anesthesia. For long-term management of the patient, the otorhinolaryngologist excised the supraglottic stricture via micro-laryngeal surgery using a CO2 laser and applied mitomycin to prevent further obstruction. OUTCOMES: The patient recovered uneventfully after anesthesia, and symptom due to supraglottic stenosis was improved. LESSONS: During airway management of patients with postlaryngectomy supraglottic stenosis, three-dimensional reconstructed computed tomography images facilitate airway configuration in addition to endoscopy and other radiological findings.

Correlation of airway ultrasonography and laryngoscopy findings in adults with subglottic stenosis: a pilot study.

PURPOSE: Ultrasonography of the airway has potential as an alternative, non-invasive, method to monitor patients with subglottic stenosis in an outpatient setting. This prospective, interventional, double-blinded study aimed to correlate ultrasound-based and laryngoscopy-based subglottic stenosis assessment in adults. METHODS: The study was conducted between July 2020 and March 2021 at a tertiary referral center. Consecutive adult patients with subglottic stenosis were evaluated using airway ultrasonography 1 day prior to scheduled laryngoscopy. The radiologist was blinded to the preoperative endoscopic findings, and the primary surgeon was blinded to the ultrasonographic measurements. The intraoperative subglottic diameter was defined as the outer diameter of an endotracheal tube passing through the subglottis without producing an air leak. RESULTS: Sixteen patients (11 females; age range, 17-66 years; mean = 44.06, SD = 12.79) were included. The ultrasonographic subglottic diameter ranged from 5.20 mm to 8.00 mm (mean = 6.24 mm, SD = 0.90). In 15 of 16 patients, the diameter difference between the ultrasonographic and intraoperative measurements ranged from -0.80 mm to 0.30 mm (mean = -0.20 mm, SD = 0.35). However, patient 6 had a difference of - 2.10 mm between the two measurements, which was attributed to thick laryngotracheal secretions interfering with the ultrasonographic air shadow. Data analysis of all 16 patients showed a statistically significant correlation between the readings obtained by the two techniques (r = 0.84, P = 0.000051). CONCLUSION: This study found a significant correlation between ultrasonography-based and laryngoscopy-based subglottic stenosis assessment in adult patients. It provides a basis for an alternative and potentially reliable method to monitor patients with subglottic stenosis.

Vía aérea difícil: ¿qué hacer cuando los algoritmos no funcionan? / Difficult airway If algorithm doesn't work?

Subglottic stenosis is a congenital and/or acquired pathology, which can be secondary to prolonged endotracheal intubation and tracheotomy. It is associated with hypoperfusion of the epithelium related to the cuff pressure of the endotracheal tube and/ or the tracheostomy cannula. Grade III-IV stenosis represents urgent and/or emergent airways, which must be managed by expert anesthesiologists who are extensively trained in techniques and algorithms. We report a case of a woman with multiple pre- dictors of difficult airway, obesity and mechanical ventilation due to tracheotomy; with subsequent grade III subglottic stenosis managed with tracheal dilation; who presented a new symptomatic episode, a non-dilatable stenosis of 2 mm and an indication for emergency tracheal reconstruction.

Las estenosis subglótica es una patología congénita y/o adquirida, que puede ser secundaria a intubación endotraqueal prolongada y necesidad de traqueostomía. Está asociada a una hipoperfusión del epitelio relacionado con la presión de cuff del tubo endotraqueal y/o de la cánula de traqueostomía. Las estenosis grado III-IV, representan vías aéreas urgentes y/o emergentes, que deben manejarse por anestesiólogos expertos y ampliamente entrenados en las técnicas y los algoritmos. Reportamos el caso de una mujer con múltiples predictores de vía aérea difícil, antecedente obesidad y de ventilación mecánica por traqueotomía; con posterior estenosis subglótica grado III manejada con dilatación traqueal; que presenta nuevo episodio sintomático, una estenosis no dilatable de 2 mm e indicación de reconstrucción traqueal de emergencia.

Three dimensional printed models of the airway for preoperative planning of open Laryngotracheal surgery in children: Surgeon's perception of utility.

BACKGROUND: Preoperative planning of open laryngotracheal surgery is important for achieving good results. This study examines the surgeon's perception of the importance of using life size 3D printed models of the pediatric airway on surgical decision making. METHODS: Life-size three-dimensional models of the upper airway were created based on CT images of children scheduled for laryngotracheal-reconstruction and cricotracheal resection with anastomosis. Five pediatric airway surgeons evaluated the three-dimensional models for determining the surgical approach, incision location and length, graft length, and need for single or double-stage surgery of seven children (median age 4.4 years, M:F ratio 4:3). They rated the importance of the three-dimensional model findings compared to the direct laryngoscopy videos and CT findings for each domain on a validated Likert scale of 1-5. RESULTS: The mean rating for all domains was 3.6 ± 0.63 ("moderately important" to "very important"), and the median rating was 4 ("very important"). There was full agreement between raters for length of incision and length of graft. The between-rater agreement was 0.608 ("good") for surgical approach, 0.585 ("moderate") for incision location, and 0.429 ("moderate") for need for single- or two-stage surgery. CONCLUSION: Patient-specific three-dimensional printed models of children's upper airways were scored by pediatric airway surgeons as being moderately to very important for preoperative planning of open laryngotracheal surgery. Large-scale, objective outcome studies are warranted to establish the reliability and efficiency of these models.

Surgery for laryngotracheal stenosis: Improved results.

OBJECTIVE: Laryngotracheal resection is still considered a challenging operation and few high-volume institutions have reported large series of patients in this setting. During the 5 years, novel surgical techniques as well as new trends in the intra- and postoperative management have been proposed. We present results of our increased experience with laryngotracheal resection for benign stenosis. METHODS: Between 1991 and May 2019, 228 consecutive patients underwent laryngotracheal resection for subglottic stenosis. One hundred eighty-three (80.3%) were postintubation, and 45 (19.7%) were idiopathic. Most of them (58.7%) underwent surgery during the past 5 years. At the time of surgery, 139 patients (61%) had received tracheostomy, laser, or laser plus stenting. The upper limit of the stenosis ranged between actual involvement of the vocal cords to 1.5 cm from the glottis. RESULTS: There was no perioperative mortality. Two hundred twenty-two patients underwent resection and anastomosis according to the Pearson technique; 6 patients with involvement of thyroid cartilage underwent resection and reconstruction with the laryngofissure technique. Airway resection length ranged between 1.5 and 8 cm (mean, 3.8 ± 0.8 cm) and it was >4.5 cm in 19 patients. Airway complication rate was 7.8%. Overall success of airway complication treatment was 83.3%. Definitive success was achieved in 98.7% of patients. Patients presenting with idiopathic stenosis or postcoma patients showed no increased failure rate. CONCLUSIONS: Laryngotracheal resection for benign subglottic stenosis is safe and effective, and provides a very high rate of success. Careful intra- and postoperative management is crucial for a successful outcome.

Quantitative Evaluation of Subglottic Stenosis Using Ultrashort Echo Time MRI in a Rabbit Model.

OBJECTIVE/HYPOTHESIS: To assess the ability of ultra-short echo time (UTE)-MRI to detect subglottic stenosis (SGS) and evaluate response to balloon dilation. To correlate measurements from UTE-MRI with endotracheal-tube (ETT)-sizing and to investigate whether SGS causes change in airway dynamics. STUDY DESIGN: Animal research study. METHODS: Eight adult New-Zealand white rabbits were used as they approximate neonatal airway-size. The airways were measured using ETT-sizing and 3D UTE-MRI at baseline, 2 weeks post-cauterization induced SGS injury, and post-balloon dilation treatment. UTE-MR images were acquired to determine airway anatomy and motion. Airways were segmented from MR images. Cross-sectional area (CSA), major and minor diameters (Dmajor and Dminor ), and eccentricity were measured. RESULTS: Post-injury CSA at SGS was significantly reduced (mean 38%) compared to baseline (P = .003) using UTE-MRI. ETT-sizing correlated significantly with MRI-measured CSA at the SGS location (r = 0.6; P < .01), particularly at the post-injury timepoint (r = 0.93; P < .01). Outer diameter from ETT-sizing (OD) correlated significantly with Dmajor (r = 0.63; P < .01) from UTE-MRI at the SGS location, especially for the post-injury timepoint (r = 0.91; P < .01). Mean CSA of upper trachea did not change significantly between end-expiration and end-inspiration at any timepoint (all P > .05). Eccentricity of the upper trachea increased significantly post-balloon dilation (P < .05). CONCLUSIONS: UTE-MRI successfully detected SGS and treatment response in the rabbit model, with good correlation to ETT-sizing. Balloon dilation increased CSA at SGS, but not to baseline values. SGS did not alter dynamic motion for the trachea in this rabbit model; however, tracheas were significantly eccentric post-balloon dilation. UTE-MRI can detect SGS without sedation or ionizing radiation and may be a non-invasive alternative to ETT-sizing. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E1971-E1979, 2021.

Superior Strategy in Benign Tracheal Stenosis Treatment: Surgery or Endoscopy?

INTRODUCTION: Due to the variations in (laryngeal) tracheal stenosis (TS) patient groups, there is still no consensus on which patient should be treated with endoscopy or surgery. The aim of the present study was to generate an algorithm in the light of the related literature and the data obtained from a clinic where both endoscopic and surgical treatments are conducted. METHOD: A retrospective analysis was performed on the data of a total of 56 patients during 2013 to 2019. A total of 38 patients were subject to surgery with 31 as a first treatment option and 7 due to the unsatisfactory results of endoscopic treatments. Endoscopic approaches were tried on a total of 29 patients with 25 as initial treatment and 4 due to postsurgical recurrence. RESULTS: Symptomatic full control ratio was determined as 69% with endoscopic treatments, 89.5% in subglottic stenosis (SGS) surgery (n = 19), and 89.5% in trachea surgery (n = 19). However, success rates with no recurrence were determined, respectively, as 40.0, 36.4, and 36.4% for patients subject to dilatation, stent, or T tube treatment. Dilatation was observed to be successful in patients with stenotic segment lengths of less than 1.5 cm (p = 0.02). Failure rates increased in SGS (p = 0.03) and TS (p = 0.12) in the surgical group with increasing stenotic segment length. The presence of comorbidities was not effective on treatment success. CONCLUSION: Endoscopic methods are preferred in cases of web-like stenosis. Surgical methods should first be considered for other patients and endoscopic methods should be used on patients who are not suited for surgery or in cases of postsurgical recurrence.

The direct laryngoscopy and rigid bronchoscopy findings and the subsequent management of infants with failed extubations.

INTRODUCTION: There is limited data regarding the role of direct laryngoscopy and rigid bronchoscopy (DLRB) in infants with failed extubations. Pediatric otolaryngologists are frequently consulted to perform DLRB in infants with failed extubations. OBJECTIVE: To determine the DLRB findings in infants with failed extubations and the interventions performed based on these findings. METHODS: A retrospective chart review was performed on infants less than 12 months old undergoing DLRB for failed extubations from January 2013-June 2017 at a tertiary care children's hospital. Data was collected on age, birth weight, perinatal complications, comorbid conditions, number of failed extubations, length of most recent intubation, operative findings, and subsequent interventions, including tracheostomy. Descriptive and comparative analyses were performed. RESULTS: Of the 62 subjects who met study criteria, median age at DLRB was 3.0 months, corrected age was 1.0 months, gestational age was 27.1 weeks, birth weight was 0.97 kg, and number of failed extubations was 2.0. About 80% had respiratory distress at birth requiring intubation, and 76% carried a diagnosis of bronchopulmonary dysplasia (BPD). The median number of days intubated prior to DLRB was 27. Twenty-seven percent of subjects had no significant abnormal findings on DLRB, and 26% had subglottic stenosis. The majority (74%) underwent tracheostomy. Eighteen percent of subjects had an initial intervention for abnormal DLRB finding(s) other than tracheostomy and were able to avoid tracheostomy as a future intervention. Tracheostomy placement was associated with a diagnosis of BPD (RR 1.78, 95% CI 1.02, 3.10), having a birth weight less than 0.71 kg (RR 1.45, CI 1.01, 2.10), and being intubated for 48 or more days prior to DLRB (RR 1.57, 95% CI 1.05, 2.36); it was not associated with the number of failed extubations prior to DLRB. CONCLUSIONS: Infants with failed extubations commonly had abnormal findings on airway evaluation by DLRB. Most children in this population still required tracheostomy placement, but about 20% were able to have an alternate intervention and avoid tracheostomy.

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.

Feasibility and potential of three-dimensional printing in laryngotracheal stenosis.

BACKGROUND: The use of three-dimensional printing has been rapidly expanding over the last several decades. Virtual surgical three-dimensional simulation and planning has been shown to increase efficiency and accuracy in various clinical scenarios. OBJECTIVES: To report the feasibility of three-dimensional printing in paediatric laryngotracheal stenosis and discuss potential applications of three-dimensional printed models in airway surgery. METHOD: Retrospective case series in a tertiary care aerodigestive centre. RESULTS: Three-dimensional printing was undertaken in two cases of paediatric laryngotracheal stenosis. One patient with grade 4 subglottic stenosis with posterior glottic involvement underwent an extended partial cricotracheal reconstruction. Another patient with grade 4 tracheal stenosis underwent tracheal resection and end-to-end anastomosis. Models of both tracheas were printed using PolyJet technology from a Stratasys Connex2 printer. CONCLUSION: It is feasible to demonstrate stenosis in three-dimensional printed models, allowing for patient-specific pre-operative surgical simulation. The models serve as an educational tool for patients' understanding of the surgery, and for teaching residents and fellows.

Subglottic stenosis and endobronchial disease in granulomatosis with polyangiitis.

OBJECTIVES: To describe tracheobronchial disease in patients with granulomatosis with polyangiitis (GPA) and evaluate the utility of dynamic expiratory CT to detect large-airway disease. METHODS: Demographic and clinical features associated with the presence of subglottic stenosis (SGS) or endobronchial involvement were assessed in a multicentre, observational cohort of patients with GPA. A subset of patients with GPA from a single-centre cohort underwent dynamic chest CT to evaluate the airways. RESULTS: Among 962 patients with GPA, SGS and endobronchial disease were identified in 95 (10%) and 59 (6%) patients, respectively. Patients with SGS were more likely to be female (72% vs 53%, P < 0.01), younger at time of diagnosis (36 vs 49 years, P < 0.01), and have saddle-nose deformities (28% vs 10%, P < 0.01), but were less likely to have renal involvement (39% vs 62%, P < 0.01). Patients with endobronchial disease were more likely to be PR3-ANCA positive (85% vs 66%, P < 0.01), with more ENT involvement (97% vs 77%, P < 0.01) and less renal involvement (42% vs 62%, P < 0.01). Disease activity in patients with large-airway disease was commonly isolated to the subglottis/upper airway (57%) or bronchi (32%). Seven of 23 patients screened by dynamic chest CT had large-airway pathology, including four patients with chronic, unexplained cough, discovered to have tracheobronchomalacia. CONCLUSION: SGS and endobronchial disease occur in 10% and 6% of patients with GPA, respectively, and may occur without disease activity in other organs. Dynamic expiratory chest CT is a potential non-invasive screening test for large-airway involvement in GPA.

3D Models in the Diagnosis of Subglottic Airway Stenosis.

PURPOSE: Preoperative assessment of benign subglottic stenosis is usually performed by endoscopy and a computed tomography scan. Both diagnostic modalities have relevant limitations and sometimes an accurate assessment of the extent of disease is challenging. DESCRIPTION: Based on computed tomography scans of benign glotto-subglottic stenosis and a control airway, color-coded three-dimensional (3D) models were produced using a commercially available 3D printer. The diagnostic relevance of 3D models was tested by means of a quiz. EVALUATION: 52 thoracic surgeons from 4 North American and 1 European institution with different levels of experience in airway surgery were invited to test the diagnostic accuracy of 3D models against endoscopy films and computed tomography scans. 3D models were found to be superior to the other two diagnostic tools in terms of grading the extent of the stenosis and selecting the correct surgical strategy. The group of residents benefited the most from the 3D models. CONCLUSIONS: 3D models of complex glotto-subglottic airway stenosis are a useful supplement of the preoperative assessment. In addition, they can serve as a teaching tool for residents and fellows.

Temporary Treatment of Complex Subglottic Stenosis by an On-Site Customized Stent.

Subglottic stenosis may be complex in shape, making challenging its treatment with standard commercially available stents. Personalized stents can lead to successful treatment; however they are not readily available due to the customization waiting time. We report the use of on-site customized temporary silicone stents for difficult benign subglottic stenosis in five patients unfit for surgery.

Cricoarytenoid Joint Ankylosis: Classification and Transoral Laser Microsurgical Treatment.

OBJECTIVE: This study aimed to describe a graduated approach for effective transoral mobilization of cricoarytenoid joint ankylosis (CJA) in the context of the Bogdasarian system of classifying posterior glottic web-based stenosis (PGWS). STUDY DESIGN: This is a retrospective cohort study through data from medical records and operative notes. A consecutive series of 23 patients who underwent reconstructive transoral laser microsurgery for PGWS with a significant degree of CJA (Bogdasarian grade III-IV) was included in the study. METHODS: Techniques necessary to remobilize their cricoarytenoid joints were reviewed in the context of the extent of scar tissue found. RESULTS: Arytenoids with CJA were successfully mobilized by resection of the fused portion of the cricoid and arytenoid cartilages achieving respiratory improvements as well as decannulation of tracheostomy-dependent patients. The majority (83%) of patient's voices improved. All patients tolerated a full diet after the procedures. Cases with Bogdasarian grade III PGWS with minor unilateral fixation should be classified as IIIa. If the fixation is severe, the case should be classified as a grade IIIb. Grade IVa would indicate that both sides were mildly to moderately ankylosed, and grade IVb involves ankylosis of both joints with subtotal or complete fusion of at least one; it presents the greatest surgical challenge. CONCLUSION: We provided effective transoral techniques for the re-mobilization of cricoarytenoid joint, along with a classification of CJA that aims to standardize the severity of disease in the context of the existing and widely accepted Bogdasarian scale.

Three-dimensional (3D) Printed Model to Plan the Endoscopic Treatment of Upper Airway Stenosis.

BACKGROUND: Endoscopic management of tracheal stenosis may be challenging, especially in the case of complex stenosis placed near the vocal folds, and needing stent placement. Herein, we evaluated the utility of the three-dimensional (3D) airway model for procedural planning in a consecutive series of patients with complex airway stenosis and scheduled for endoscopic treatment. METHODS: This strategy was applied to 7 consecutive patients with tracheal stenosis unfit for surgery. The model was printed in a rubber-like material, and almost 7 hours were needed to create it. All patients presented respiratory failure with a mean value of 3.4±0.4 Medical Research Council (MRC) dyspnea scale, 47±3.9 forced expiratory volume in 1 second (FEV1%), and an impairment in the 6-minute walking test (6MWT) (mean value, 175±53 m). The mean length of the stenosis was 19±3.4 mm; 3 of the 7 (43%) patients presented a subglottic stenosis. In 4/7 (57%) patients the stenosis was >5 mm, but its treatment required the placement of a stent because of the presence of tracheal cartilage injury. RESULTS: The mean operation time was 22.7±6.6 minutes. No complications were observed during and after the procedure. A significant increase of MRC (3.4±0.4 vs. 1.6±0.5; P=0.003), of FEV1% (47±3.9 vs. 77±9.7; P=0.001), and of 6MWT (175±53 vs. 423±101; P=0.0002) was observed after the procedure (mean follow-up, 11.1±8.8 mo). CONCLUSION: Our 3D airway model in the management of airway stenosis is useful for procedural planning, rehearsal, and education. The fidelity level of the 3D model remains the main concern for its wider use in patient care. Thus, our impressions should be confirmed by future prospective studies.

Anterior-posterior cricoid split combined with silastic T-tube stenting for subglottic stenosis in children: a single surgeon's experience.

PURPOSE: Treatment strategies and clinical outcomes of subglottic stenosis (SGS) in children are varied due to the degree and range of stenotic lesions. The optimal surgical procedure for SGS in children is still under debate. The aim of this study was to evaluate the clinical outcomes of our anterior-posterior cricoid (APC) split technique combined with long-term T-tube stenting for grade II or III SGS in children. METHODS: A retrospective chart review of children with SGS between January 2011 and December 2016 was conducted. APC split was performed via open procedure under rigid bronchoscopy. After splitting, a silastic T-tube was inserted as a stent and removed 6 months postoperatively. RESULTS: Seven children underwent APC split during the period. All children had undergone previous tracheostomy, and APC split was performed when the children were 3-9 years old without any intraoperative complications. Median duration of T-tube stenting was 11 months, and all children were decannulated successfully. There were T-tube-related complications, including two tube-tip granulation that required intervention and one accidental T-tube removal. CONCLUSION: APC split is a technically simple and reproducible procedure, and it could be employed as an optimal procedure for SGS in children.