[Review of surgical treatment of suprastomal collapse in tracheostomised children]. / Übersichtsarbeit zur chirurgischen Behandlung des suprastomalen Kollapses bei tracheotomierten Kindern.

BACKGROUND: Suprastomal collapse (SSC) is considered a major late complication of paediatric tracheostomy and can be responsible for decannulation failure in up to 20% of tracheostomised children. Depending on the severity of SSC, surgery may be required. Various strategies and techniques are available, of which the treating with airway team should be aware. OBJECTIVE: This article intends to summarise the aetiology of SSC, its classification, clinical presentation, and the gold standard diagnostic and therapeutic algorithms according to the current literature. MATERIALS AND METHODS: A panel of experts reviewed the available literature on SSC. Published evidence on the different surgical techniques and their advantages and disadvantages was reviewed in detail, and a treatment algorithm created. RESULTS: The gold standard diagnostic procedure for SSC is flexible transnasal laryngotracheoscopy in spontaneous breathing followed by microlaryngoscopy (MLS) under general anaesthesia. Two main types of SSC can be differentiated, which differ in terms of surgical treatment. Purely anterior SSC is usually treated by tracheoplasty using an anterior costal cartilage graft (ACCG). Simple closure of the tracheostomy or excision of SSC with a potassium-titanyl-phosphate (KTP) laser are also described as less invasive approaches. For anterolateral SSC, segmental tracheal resection with end-to-end anastomosis or tracheoplasty with ACCG represent promising treatment options. Tracheal reinforcement with absorbable microplates is also discussed in the literature. With both types of SSC and depending on severity and the age of the child, a watch-and-wait strategy should always be considered. CONCLUSION: Dynamic airway endoscopy in spontaneous breathing followed by MLS in general anaesthesia should always be performed before decannulation. It is particularly important to visualise all segments of the airway during spontaneous breathing. The decision regarding the best surgical option for each child is based on the type and localisation of SSC, as well as on the patient's medical and surgical history and age.

Analysis of Complications in (Crico-) Tracheal Resection Anastomosis in Adults: A Multicenter Study.

OBJECTIVES: The gold standard treatments for advanced laryngotracheal stenosis (LTS) are represented by partial crico-tracheal (PCTRA) or tracheal resection and anastomosis (TRA). These procedures are potentially burdened by high postoperative complication rates. We investigated the impact of the most common stenosis and patient-related characteristics on the onset of complications in a multicentric cohort. METHODS: We retrospectively analyzed patients who underwent PCTRA or TRA for LTS of different etiologies in three referral centers. We tested the effectiveness of these procedures, the impact of complications on the outcomes, and identified factors causing postoperative complications. RESULTS: A total of 267 patients were included in the study (130 females; mean age, 51.46 ± 17.64 years). The overall decannulation rate was 96.4%. Altogether, 102 (38.2%) patients presented at least one complication, whereas 12 (4.5%) had two or more. The only independent predictor of post-surgical complications was the presence of systemic comorbidities (p = 0.043). Patients experiencing complications needed additional surgery more frequently (70.1% vs. 29.9%, p < 0.001), and had a longer duration of hospitalization (20 ± 10.9 vs. 11.3 ± 4.1 days, p < 0.001). Six of 102 (5.9%) patients with complications had restenosis, although this event did not occur among patients without complications. CONCLUSION: PCTRA and TRA have an excellent success rate even when performed for high-grade LTS. However, a significant percentage of patients may experience complications associated with a longer duration of hospitalization or the need for additional surgeries. The presence of medical comorbidities was independently related to an increased risk of complications. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2910-2919, 2023.

Hormone pathway comparison in non-idiopathic and idiopathic progressive subglottic stenosis.

PURPOSE: Our previous study on the idiopathic progressive subglottic stenosis (IPSS) highlighted a possible hormonal mechanism, with over-expression of estrogen receptors alpha (ER-α) and progesterone receptors (PR). We tested whether such over-expression take place in non-idiopathic subglottic stenosis (NISS) as well. METHODS: 37 specimens of iatrogenic NISS were analyzed (20 females; mean age, 59 ± 12 years; range 41-85). Immunoreactivity of ER-α and PR was calculated as the product of intensity (1 = weak, 2 = moderate, 3 = strong) and positive cells percentage (1 to 4, for < 10%, 10-50%, 50-80%, and > 80%). This score was calculated on the stenotic tissue (ST), and stenosis margins (SM). RESULTS: The expression of PR was significantly higher in ST of IPSS compared with female and male NISS patients (8.7 ± 3.1 vs. 4.9 ± 3.2, p < 0.001 for IPSS vs. female and 8.7 ± 3.1 vs. 2.1 ± 2.7, p < 0.01 for IPSS vs. male NISS patients). Contrarily, ER-α showed gender differences, as both IPSS and female NISS patients had similar, yet higher ER-α expression compared with male NISS patients (7.0 ± 4.2 vs. 6.5 ± 2.5, p = NS for IPSS vs. female and 7.0 ± 4.2 vs. 3.4 ± 2.0, p < 0.02 for IPSS vs. male NISS patients). There was no difference in fibroblast receptor expression between ST and SM. However, ER-α and PR expression was significantly lower in marginal mucous glands when compared with ST. CONCLUSIONS: The IPSS pathogenesis appears to be driven by hormonal mechanisms, in particular, by over-expression of PR. Marginal cells display a reduced hormone receptor density. This finding could be interpreted as a compensatory mechanism. These findings could open up for targeted IPSS treatment.

Organ Preservation Strategies in Laryngeal Chondrosarcoma.

OBJECTIVES/HYPOTHESIS: Laryngeal chondrosarcoma (LC) is a rare, slowly growing malignancy. The preferred treatment is laryngeal preservation surgery (LPS). Some patients may require multiple interventions or total laryngectomy (TL). We investigated risk factors for retreatment and TL, and assessed the impact of LPS on oncological and functional outcomes. STUDY DESIGN: Case series METHODS: We searched our institution database for LC. Tumor grading, localization, and margin status were tested as predictors of recurrence and organ preservation. RESULTS: We included 21 patients (seven females, mean age 58 ± 12 years). LPS was applied in 20 (95.2%) of them as a primary procedure. Six patients were treated by transoral approach and 14 received "open-neck" LPS. Fifteen (71.4%) were operated only once, while six patients underwent a total of 15 adjunctive procedures. Additional operations were always performed for recurrence of tumors localized within the cricoid plate. The histological grading was G1 in 81% and G2 in 19%. However, two patients with a primary G1 LC showed a G2 recurrence. Reoperations for recurrence were more frequent among patients with G2 in respect to G1 histology (83% vs. 7%, P < .001). Fifty percent of G2 LC and 8% of G1 underwent TL (P < .05). Margin status had no influence on recurrence rate. CONCLUSIONS: Patients with G2 LC have more recurrences requiring surgery and a higher incidence of TL. Cricoid plate localization is relevant for organ preservation. Margin status signals possible disease persistence, without influencing the need for future surgeries. Need for reoperation entails a risk of not being able to maintain organ functionality. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:838-843, 2022.

Working as a team in airway surgery: History, present and perspectives.

Teamwork is one of the most important trend in modern medicine. Airway team were created in many places to respond in a multidisciplinary and coordinated way to challenging clinical problems which were beyond the possibility of an individual management. In this chapter, we illustrate the historical steps leading to the development of an airway team in a pediatric referral hospital, describe the present teamwork activity defining the key points for the creation of a team and discussing different organization models; finally we delineate possible future directions for the airway teams in the globalized world.

Transoral management of adult benign laryngeal stenosis.

PURPOSE: Management of benign laryngeal stenosis (BLS) remains challenging even though transoral treatments in selected cases have shown satisfactory results, at least comparable to open-neck approaches, with reduced invasiveness. To date, no overall consensus has been reached on many issues. The aim of this study is to assess the effectiveness of a purely transoral treatment in a cohort of patients affected by BLS. METHODS: We evaluated 40 patients affected by BLS, treated by transoral surgery between 2013 and 2017. The European Laryngological Society classification for laryngotracheal stenosis was applied for the staging. Improvement in airway patency and quality of life was assessed by decannulation rate, Airway-Dyspnea-Voice-Swallowing (ADVS) score, Voice handicap index (VHI)-30, and Eating assessment tool (EAT)-10 questionnaires. RESULTS: Mean age was 61 years and M:F ratio was 1.4:1. Previous laryngeal surgery was the most common cause of stenosis (50%), followed by radiotherapy (20%), idiopathic etiology (12%), granulomatosis with polyangiitis (10%), and prolonged intubation (8%). Transoral treatment entailed an improvement in quality of life with a significant decrease in the VHI score (p < 0.0001) and improvement in Airway (p = 0.008), Dyspnea (p < 0.0001), and Voice (p < 0.0001) scores. No major perioperative complications were observed. The decannulation rate among patients with a tracheostomy in place (N = 16) was 63%. CONCLUSIONS: Transoral treatment of selected BLS managed by a team with high-level expertise in surgery and anesthesiology is associated with significant improvement of quality of life, especially with regard to voice and breathing functions.

[Impact of benign parotid gland tumors on whole salivary flow rate]. / Einfluss gutartiger Tumoren der Glandula parotis auf die Gesamtspeichelflussrate.

OBJECTIVE: The impact of benign tumors of the parotid gland on whole salivary flow or sialochemistry is unclear. MATERIAL AND METHODS: A total of 22 patients with benign parotid tumors and 18 healthy controls underwent measurements of unstimulated and stimulated whole saliva flow and sialochemistry (Na+, K+, Ca++, Amylase, and pH). Assessment of xerostomia was performed by means of a visual analogue scale (VAS) and a questionnaire (QoL). RESULTS: Stimulated whole salivary flow was significantly lower in patients with benign parotid tumors in comparison to the control group (2.76 ±â€Š0.96 ml/min vs. 3.85 ±â€Š0.72 ml/min; p = 0.009). However, assessment of unstimulated whole salivary flow, sialochemistry, and subjective parameters (VAS, QoL) showed no significant differences between the patient and control groups (0.73 ±â€Š0.41 ml/min vs. 0.68 ±â€Š0.39 ml/min; p = 1). CONCLUSIONS: Benign salivary gland tumors appear to reduce whole stimulated salivary flow and leave unstimulated whole salivary flow and sialochemistry unchanged. The patients' subjective feelings of dry mouth do not seem to be influenced by the reduction in salivary flow.

Multicentric study applying the european laryngological society classification of benign laryngotracheal stenosis in adults treated by tracheal or cricotracheal resection and anastomosis.

OBJECTIVES/HYPOTHESIS: Introduction and widespread use of cricotracheal resection and anastomosis (CTRA) as routine treatment for high-grade benign laryngotracheal stenosis (LTS) led to the need for a new classification system that could accurately predict surgical outcomes by integrating crucial stenosis and patient-related information. In 2015, the European Laryngological Society (ELS) proposed a new classification for benign LTS. We retrospectively tested it in adults treated at three referral centers to assess its reliability in predicting surgical outcomes. STUDY DESIGN: Retrospective cohort study. METHODS: We included 166 adults treated by open tracheal resection and anastomosis (TRA) and CTRA procedures, restaged according to the ELS classification evaluating grade of stenosis (I-IV, Myer-Cotton), number of subsites involved, and presence of systemic comorbidities. We correlated these parameters with decannulation, number of retreatments, and complications. RESULTS: Final decannulation was predicted by a proposed ELS score ≥ IIIb, history of previous treatment, and length of resection (P < .05). Decannulation was achieved in 99% of patients without and in 88% of patients with surgical complications (P < .01). The incidence of surgical complications was related to the proposed ELS score (P < .01); an ELS score < IIIb showed a lower complication rate compared to patients with a ≥ IIIb score (32.8% vs. 57.7%, P < .01). Additional treatment was required in 73 (44%) patients (mean = 2.7 ± 2.2, range = 1-11). ELS score ≥ IIIb, length of resection, and occurrence of surgical complications predicted the number of such treatments (P < .05, P < .05, and P < .001, respectively). CONCLUSIONS: ELS classification of benign LTS is able to accurately predict success in adult TRA/CTRA procedures and may be helpful in choice of therapy and patient counseling. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:1640-1645, 2020.

Implementation of the European Laryngological Society classification for pediatric benign laryngotracheal stenosis: a multicentric study.

PURPOSE: The European Laryngological Society (ELS) has published a revised classification for benign laryngotracheal stenosis (LTS), based on their degree, longitudinal extension, and associated comorbidities. We retrospectively applied this classification to pediatric patients treated in four referral centers to assess its reliability in predicting surgical outcomes. METHODS: We included 191 pediatric LTS patients treated by segmental resection, restaged according to the degree of stenosis (I-IV according to Myer-Cotton grading system), number of subsites involved ("a" to "d" for 1-4 subsites among supraglottis, glottis, subglottis and trachea), and presence of systemic comorbidity ("+" sign). We analyzed the ability of this scoring system in predicting the rates of decannulation and complications, as well as the number of re-treatments. RESULTS: The mean decannulation rate was 88%; a higher rate was observed in patients without comorbidities (95.7% vs. 78.1%, p < 0.001), with two or fewer vs. three or four subsites involved (89% vs. 72%, p < 0.01), and in those with an ELS score of IIIa+ or less vs. patients with IIIb or more (96% vs. 82%, p < 0.001). Surgical complications were not dependent on the degree of stenosis, but rather on the number of affected subsites (p < 0.05), as well as on the presence of associated comorbidities (RR 7.5, p < 0.01). The number of re-treatments was dependent on length of resection (p < 0.05), stage according to the revised ELS classification (p < 0.001), and presence of surgical complications (RR 17, p < 0.001). CONCLUSIONS: The revised ELS classification system is easy to apply in everyday practice and offers a sound contribution in the decision-making process.

Nature and role of surgical margins in transoral laser microsurgery for early and intermediate glottic cancer.

PURPOSE OF REVIEW: Summarize recent findings regarding the impact of margin status on oncologic outcomes and organ preservation, as well as evaluate possible management policies of close and positive margins after transoral laser microsurgery (TLM) for Tis-T2 glottic carcinomas. RECENT FINDINGS: Impact of margin status on survival rates remains controversial, whereas some authors found close and positive margins to be independent risk factors for recurrence and poorer survival rates, others did not find any significant variations compared with negative ones. A common trend can be observed in performing a watchful waiting policy or second look TLM in patients with close-superficial and positive single-superficial margins. Further treatment seems preferable in case of deep and positive multiple superficial margins. SUMMARY: Positive margins are present in up to 50% of patients treated by TLM, even though a high rate of false positivity, reaching 80%, has been described. Close and positive single superficial margins seem to be linked to higher recurrence rates compared with negative margins, even though watchful wait and see policy, especially when performed by adjunctive visual aids like Narrow Band Imaging, maintains good final oncological and organ preservation outcomes. Further treatments are required in case of deep margin positivity.

Correction to: Laser-assisted surgery of the upper aero-digestive tract: a clarification of nomenclature. A consensus statement of the European Laryngological Society.

The article 'Laser-assisted surgery of the upper aero-digestive tract: a clarification of nomenclature. A consensus statement of the European Laryngological Society,' written by Marc Remacle, Christoph Arens, Mostafa Badr Eldin, Guillermo Campos, Carlos Chiesa Estomba, Pavel Dulguerov, Ivana Fiz, Anastasios Hantzakos, Jerôme Keghian, Francesco Mora, Nayla Matar, Giorgio Peretti, Cesare Piazza, Gregory N. Postma, Vyas Prasad, Elisabeth Sjogren, Frederik G. Dikkers, was originally published Online First without open access. After publication in volume 274 issue 10, page 3723-3727 the authors decided to opt for Open Choice and to make the article an open access publication. Therefore, the copyright of the article has been changed to

Hormone receptors analysis in idiopathic progressive subglottic stenosis.

OBJECTIVE: Idiopathic subglottic stenosis predominantly affects fertile and perimenopausal women. Estrogens and/or progesterone have been proposed as mediators of its pathogenesis by stimulating collagen deposition within the upper airway. We evaluated the presence and expression of estrogen-alpha (ER-α), estrogen-beta (ER-ß), and progesterone receptors (PR) in idiopathic stenotic patients. STUDY DESIGN: A retrospective analysis on 42 surgical specimens from idiopathic stenosis female patients (mean age, 52.4; age range, 31-79) and 28 gender- and age-matched controls. METHODS: Immunoreactivity of ER-α, ER-ß, and PR was calculated as the product of intensity (1 = weak, 2 = moderate, 3 = strong) and positive cell percentage (1-4, for < 10/10-50/50-80/ > 80%). This score was calculated on the stenotic and peristenotic tissues. Influence of menopausal status on hormonal expression and stenotic grade was tested. RESULTS: Stenosis showed ER-α overexpression versus peristenotic tissue and controls (score 6.6 ± 4.4, 0.3 ± 0.5, and 2.2 ± 1.5, respectively; P < 0.001). Overexpression was even more marked for progesterone receptors (score 8.3 ± 3.6, 0.8 ± 0.6, and 1.0 ± 0.7, respectively; P < 0.001). There was no expression of ER-ß in stenosis (score 0), whereas it was normally expressed in peristenotic tissue and controls (score 0.7 ± 0.5 and 0.5 ± 0.5; P < 0.001 vs. stenosis). Expression of ER-α was higher in postmenopausal stenotic patients (P < 0.01). This subgroup included a higher proportion of Cotton-Myer grade III stenosis than in premenopausal subjects (P < 0.001). CONCLUSION: An imbalance between ER-α, ER-ß, and PR is present in idiopathic stenosis patients. The hormonal background may be involved in inappropriate inflammation and increased stenosis susceptibility. Menopausal changes seem to play a role in both stenosis grade and receptor patterns. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:E72-E77, 2018.

Impact of Close and Positive Margins in Transoral Laser Microsurgery for Tis-T2 Glottic Cancer.

INTRODUCTION: Transoral laser microsurgery (TLM) represents one of the most effective treatment strategies for Tis-T2 glottic squamous cell carcinomas (SCC). The prognostic influence of close/positive margins is still debated, and the role of narrow band imaging (NBI) in their intraoperative definition is still to be validated on large cohort of patients. This study analyzed the influence of margin status on recurrence-free survival (RFS) and disease-specific survival (DSS). METHODS: We retrospectively studied 507 cases of pTis-T1b (Group A) and 127 cases of pT2 (Group B) glottic SCC. We identified the following margin status: negative (n = 232), close superficial (n = 79), close deep (CD) (n = 35), positive single superficial (n = 146), positive multiple superficial (n = 94), and positive deep (n = 48) and analyzed their impact on RFS and DSS. Close margins were defined by tumor-margin distance <1 mm. Pre-TLM margins were defined by white light in 323 patients, whereas NBI was employed in 311 patients. RESULTS: In Group A, DSS and RFS were reduced in positive multiple superficial and positive deep margins (DSS = 96.1 and 97%, both p < 0.05; RFS = 72%, p < 0.001 and 75.8%, p < 0.01). In Group B, DSS was reduced in positive multiple superficial margins (82.4%, p < 0.05). RFS was reduced in positive single superficial, positive multiple superficial, and positive deep margins (62.5, 41.2, and 53.3%, p < 0.01). In the entire population, RFS was reduced in CD margins (77.1%, p < 0.05). Use of NBI led to improvement in RFS and DSS. CONCLUSION: The study indicates that close and positive single superficial margins do not affect DSS. By contrast, all types of margin positivity predict the occurrence of relapses, albeit with different likelihood, depending on stage/margin type. CD margins should be considered as a single risk factor. Use of NBI granted better intraoperative margins definition.

Laser-assisted surgery of the upper aero-digestive tract: a clarification of nomenclature. A consensus statement of the European Laryngological Society.

Acronyms and abbreviations are frequently used in otorhinolaryngology and other medical specialties. CO2 laser-assisted transoral surgery of the pharynx, the larynx and the upper airway is a family of commonly performed surgical procedures termed transoral laser microsurgery (TLM). The abbreviation TLM can be confusing because of alternative modes of delivery. Classification and definition of the different types of procedures, performed transorally or transnasally, are proposed by the Working Committee for Nomenclature of the European Laryngological Society, emphasizing the type of laser used and the way this laser is transmitted. What is usually called TLM, would more clearly be defined as CO2 laser transoral microsurgery or CO2 TOLMS or CO2 laser transoral surgery only (with a handpiece) would be defined as CO2 TOLS. KTP transnasal flexible laser surgery would be KTP TNFLS. Transoral use of the flexible CO2 wave-guide with a handpiece would be a CO2 TOFLS. One can argue that these clarifications are not necessary and that the abbreviation TLM for transoral laser microsurgery is more than sufficient. But this is not the case. Laser surgery, office-based laser surgery and microsurgery are frequently and erroneously interchanged for one another. These classifications allow for a clear understanding of what was performed and what the results meant.