Development of Cushing Syndrome After Serial In-office Subglottic Steroid Injections.

In-office subglottic intralesional steroid injections (SILSI) have gained popularity as an adjunct to operating room dilation in the treatment of subglottic stenosis. They are generally thought to have a low risk profile for development of systemic side effects. Here, we present a case of a 55 year old woman who developed symptoms of Cushing syndrome after receiving SILSI, including weight gain, striae, dorsal hump and alopecia. This case illustrates that despite the localized nature of SILSI, there is still a risk of developing systemic effects as a result of the treatment. Laryngoscope, 132:942-943, 2022.

Glutamine Inhibition Reduces Iatrogenic Laryngotracheal Stenosis.

OBJECTIVE/HYPOTHESIS: Glutamine inhibition has been demonstrated an antifibrotic effect in iatrogenic laryngotracheal stenosis (iLTS) scar fibroblasts in vitro. We hypothesize that broadly active glutamine antagonist, DON will reduce collagen formation and fibrosis-associated gene expression in iLTS mice. STUDY DESIGN: Prospective controlled animal study. METHODS: iLTS in mice were induced by chemomechanical injury of the trachea using a bleomycin-coated wire brush. PBS or DON (1.3 mg/kg) were administered by intraperitoneal injection (i.p.) every other day. Laryngotracheal complexes were harvested at days 7 and 14 after the initiation of DON treatment for the measurement of lamina propria thickness, trichrome stain, immunofluorescence staining of collagen 1, and fibrosis-associated gene expression. RESULTS: The study demonstrated that DON treatment reduced lamina propria thickness (P = .025) and collagen formation in trichrome stain and immunofluorescence staining of collagen 1. In addition, DON decreased fibrosis-associated gene expression in iLTS mice. At day 7, DON inhibited Col1a1 (P < .0001), Col3a1 (P = .0046), Col5a1 (P < .0001), and Tgfß (P = .023) expression. At day 14, DON reduced Co1a1 (P = .0076) and Tgfß (P = .023) expression. CONCLUSIONS: Broadly active glutamine antagonist, DON, significantly reduces fibrosis in iLTS mice. These results suggest that the concept of glutamine inhibition may be a therapeutic option to reduce fibrosis in the laryngotracheal stenosis. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:E2125-E2130, 2021.

A murine model of subglottic granulation.

OBJECTIVE: This study aimed to develop a functional model of subglottic stenosis by inducing direct airway irritation in transplanted mouse laryngotracheal complexes. METHODS: Laryngotracheal complexes from C57BL/6 mice were harvested and divided into three groups: uninjured, mechanically injured and chemically injured. Donor laryngotracheal complexes from each group were placed in dorsal subcutaneous pockets of recipient mice. Each week, the transplanted laryngotracheal complexes were harvested, and tissues were fixed, sectioned, and stained with haematoxylin and eosin. Representative slides were reviewed by a blinded pathologist, to determine the formation of granulation tissue, and graded as to the degree of granulation formation. RESULTS: Direct airway irritation induced granulation tissue formation under the disrupted epithelium of airway mucosa; this was seen as early as two weeks after chemical injury. CONCLUSION: Results indicate that granulation tissue formation in a murine model may be an efficient tool for investigating the development and treatment of subglottic stenosis.

Dysregulated Macrophages Are Present in Bleomycin-Induced Murine Laryngotracheal Stenosis.

OBJECTIVE: To define the inflammatory cell infiltrate preceding fibrosis in a laryngotracheal stenosis (LTS) murine model. STUDY DESIGN: Prospective controlled murine study. SETTING: Laboratory. SUBJECTS AND METHODS: Chemomechanical injury mice (n = 44) sustained bleomycin-coated wire-brush injury to the laryngotracheal complex while mechanical injury controls (n = 42) underwent phosphate-buffered saline (PBS)-coated wire-brush injury. Mock surgery controls (n = 34) underwent anterior transcervical tracheal exposure only. Inflammatory and fibrosis protein and gene expression were assessed in each condition. Immunohistochemistry served as a secondary outcome. RESULTS: In chemomechanical injury mice, there was an upregulation of collagen I (P < .0001, P < .0001), Tgf-ß (P = .0023, P = .0008), and elastin (P < .0001, P < .0001) on day 7; acute inflammatory gene Il1ß (P = .0027, P = .0008) on day 1; and macrophage gene CD11b (P = .0026, P = .0033) on day 1 vs mechanical and mock controls, respectively. M1 marker inducible nitric oxide synthase (iNOS) expression decreased (P = .0014) while M2 marker Arg1 (P = .0002) increased on day 7 compared with mechanical controls. Flow cytometry demonstrated increased macrophages (P = .0058, day 4) and M1 macrophages (P = .0148, day 4; P = .0343, day 7; P = .0229, day 10) compared to mock controls. There were similarities between chemomechanical and mechanical injury mice with an increase in M2 macrophages at day 10 (P = .0196). CONCLUSIONS: The bleomycin-induced LTS mouse model demonstrated increased macrophages involved with the development of fibrosis. Macrophage immunophenotype suggested that dysregulated M2 macrophages have a role in abnormal laryngotracheal wound healing. These data delineate inflammatory cells and signaling pathways in LTS that may potentially be modulated to lessen fibroblast proliferation and collagen deposition.

[Case of upper airway stenosis after accidental ingestion of neutral detergent containing cationic surfactant (HDQ Neutral)].

We had a case of upper airway stenosis after accidental ingestion of neutral detergent containing cationic surfactant (HDQ Neutral). An 85-year-old man was transported to our hospital by ambulance after ingesting 50 mL of HDQ Neutral. On arrival, he had an edematous buccopharyngeal membrane with bleeding. Laryngeal edema was observed by laryngoscopy, and severe upper airway stenosis occurred. He also had hypoxemia and was therefore intubated and put on mechanical ventilation. After admission, his respiratory condition was stable. On day 3, upper airway edema had improved and extubation was performed. He was cured without other complications. Surfactants generally have low toxicity but can cause damage to the mucous membrane of the respiratory tract and gastrointestinal tract. Therefore, immediate evaluation and treatment are needed for intoxication with them. They can also cause harm to circulation dynamics or the central nerve system, and careful follow-up is therefore needed.

Perflubron residua: 12 years following therapy.

Partial liquid ventilation therapy utilizing perfluorocarbons has been used for patients with severe respiratory distress. Perfluorocarbons such as perflubron have been demonstrated to clear from the lungs shortly after therapy. We present a 13-year-old boy with residual perflubron in his lungs, 12 years following therapy with perflubron. The imaging features are important to recognize as these patients return for additional care and imaging.

[Laryngoplasty with cutaneous tube--methods of surgical treatment in caustic stenosis]. / Laringoplastia cu lambou cutanat, modalitate de tratament chirurgical in stenozele postcaustice.

The authors present a retrospective study on 84 cases with laryngo-pharyngo-esophageal stenosis treated in ENT Department of "Sf. Spiridon" Emergency Clinical Hospital from Iasi, over 25 years, between 1980-2005 which were solved by surgical treatment. In order to solve the different types of the superior laryngeal stenosis and the hypo-pharynx, there have been used deltoid-pectoralis cutaneous flaps. In all these cases, the anatomical integrity of the recurrent nerve and his branches was preserved in order to obtain a good respiratory function.

Pediatric dyspnea caused by supraglottic stenosis: a rare complication of alkali corrosive injury.

Acquired supraglottic stenosis is a rare, but potential late sequela of corrosive injury, usually occurring 1 to 2 months after the initial trauma. The presentation may be delayed in children and is potentially lethal. We describe two pediatric patients, aged 31 and 16 months, who developed progressive inspiratory stridor and hoarseness about 2 months after accidental alkali ingestion. Fiberoptic laryngoscopy showed supraglottic stenosis. Intubation was achieved with a very small endotracheal tube under fiberoptic laryngobronchoscopic guidance prior to general anesthesia. Both patients successfully underwent CO(2) laser treatment under direct laryngoscopic guidance. There has been no case of recurrence reported after 1 year of follow-up other than a thin membranous scar in one case at the 3rd month of follow-up, which was easily dealt with by bronchoscopy dilatation. For such patients, monthly laryngoscopic examinations are advisable after alkaline corrosive injury for a minimum of 6 months. Prompt diagnosis and early airway intervention can reduce the need for tracheostomy and decrease the mortality rate.

[Pharyngeal scars stenosis in children]. / Rybtsovye stenozy glotki u detei.

The treatment and follow-up data are available for 18 children (12 boys and 6 girls) with persistent scarry pharyngostenosis. The disease was first diagnosed at the age of 1 year 8 months to 12 years. Pharyngostenosis has resulted from burn induced by KMnO4 crystals. After treatment (laser destruction in 13 patients and bourginage in 4 patients) 15 patients resumed free breathing. 2 patients continue the treatment.

Upper airway compromise after inhalation injury. Complex strictures of the larynx and trachea and their management.

OBJECTIVE: Strictures of the upper airway caused by burns have features distinct from other benign stenoses. The authors reviewed their experience with burn-related stenoses to define the principles of treatment. SUMMARY BACKGROUND DATA: The combined effects of inhaled gases and heat in burn victims produce an intense, often transmural, inflammation of the airway, further complicated by intubation. The incidence of laryngotracheal strictures in survivors of inhalation injury is high, but the reported experience with their treatment is limited and often unduly separated into injuries of larynx and trachea. METHODS: Presentation, treatment, and long-term follow-up are reviewed in 9 women and 9 men age 9 to 63 years, who were evaluated over a 22 year period for chronic airway compromise after inhalation injury. There were 18 tracheal stenoses, 14 subglottic strictures, and 2 main bronchial stenoses. Laryngotracheal strictures stenosis. T-tubes were placed in 15 patients, in low subglottic or tracheal stenosis below the vocal cords, in high subglottic stenosis through the vocal cords, and as a stent after resection of subglottic stenosis. RESULTS: There were two deaths during follow-up, one from respiratory failure and one from an unrelated cause. Two patients underwent evaluation only. Early in this series, one tracheal and one laryngotracheal resection resulted in prompt restenosis. Of the remaining 14 patients, 9 are without airway support from 2 to 20 years later. Four have permanent tracheal tubes. One patient required tracheostomy 8 years after successful subglottic reconstruction. CONCLUSIONS: Strictures of the upper airway related to inhalation injury are associated with prolonged inflammation and involve larynx and trachea in a majority of patients. These complex injuries respond to prolonged tracheal stenting (mean, 28 months) and resection or stenting of subglottic stenoses with recovery of a functional airway and voice in most patients. Early tracheal resection should be avoided.

Caustic ingestion injuries of the upper aerodigestive tract.

Few reports have described in detail the injuries that occur to the oral cavity, pharynx, and larynx following caustic ingestion. The role of dynamic radiographic studies to delineate the extent of damage has been minimized. In-depth radiographic analysis of such cases has not, to our knowledge, been previously reported. In order to examine the injuries and functional abnormalities of these sites following caustic ingestion, the records of The Johns Hopkins Swallowing Center were reviewed. Five patients were identified as having significant upper aerodigestive tract caustic injuries. All patients had dysphagia, epiglottis injuries, and incomplete laryngeal protection with aspiration. Four of five had sustained some degree of esophageal stenosis. Also noted were pharyngeal muscle dysfunction, nasopharyngeal regurgitation, tongue fixation, and hypopharyngeal stenosis. Roentgenographic findings are described and illustrated. The multidisciplinary approach to the management and rehabilitation of these patients is discussed.

Pharyngoesophageal bypass using a free jejunal graft for corrosive stricture--a case report.

The management of corrosive strictures of the esophagus involving the pharynx and/or larynx continues to be a challenge to surgeons. This paper presents a case of a corrosive stricture extending from the hypopharynx to the cervical esophagus associated with complete obstruction of the larynx, which was successfully treated by pharyngoesophageal bypass using a free jejunal graft. Postoperative recovery was smooth without any complications, and swallowing was restored. Three months after the bypass operation, the patient underwent laryngoplasty. Although aspiration occurred immediately after the laryngoplasty, six months later she was again able to tolerate the oral intake of semisolid food without any need for supplementary nutritional support. Reconstruction of a short segment of the pharyngoesophageal stricture by a free jejunal graft restores almost normal swallowing provided that dilatation of the lower esophagus is achieved.

[Stenosing laryngotracheitis (pseudocroup) and sulfur dioxide content of the air. Results of an 18-year retrospective long-term study of possible spatial and temporal relations]. / Stenosierende Laryngotracheitis (Pseudokrupp) und Schwefeldioxidgehalt der Luft. Ergebnisse einer 18jährigen retrospektiven Langzeitstudie über mögliche räumliche und zeitliche Zusammenhänge.

Based on the immission levels measured in the city of Bochum (approx. 20,000 readings), 1200 hospitalized children with pseudocroup were examined for a possible relationship between croup incidence and sulphur dioxide levels. Evaluation according to geographic location showed no statistically significant correlation between croup incidence and SO2 levels over a test period of 13 years. Only for 3 of 13 years did Spearman's rank correlation coefficient show a weakly significant positive correlation (P less than 0.05). In one test year, however, there was a statistically significant negative correlation (P less than 0.025). Evaluation of the 16-year study in terms of time-dependent relationships yielded no significant deviation of pseudocroup incidence from the expected mean value for the individual SO2 concentration ranges. Over the period of this study, there was therefore no cause-effect relationship between sulphur dioxide levels and pseudocroup incidence.

[Total "pharyngoplastia vera" with the colon in caustic pharyngo-laryngeal stenoses]. / "Pharyngoplastia vera" totale avec côlon dans les sténoses pharyngo-laryngiennes caustiques.

An original procedure for pharyngeal reconstruction with colon in pharyngolaryngeal stenosis due to chemical burns has been named "pharyngoplasty vera" by the authors, since the 3 walls of the pharynx are reconstituted by lining it with visceral material. This is in contradiction with previously used techniques in which the graft caps the pharyngostomy produced by resection of scar tissue (pharyngovisceral anastomosis). The procedure generally respects the principles of conventional cutaneous pharyngoplasty--similar approach, extirpation of scar tissue, epiglotto plasty, conservation of constrictor muscles and above all, solid attachment of visceral material to the latter, and finally suture of the colon at the base of tongue and closure of pharynx. The method was used in a patient who regained deglutition rapidly, but the insufficient glottic space did not allow reopening of the canal.

The surgical treatment of combined corrosive pharyngeal and oesophageal stricture.

A personal experience of reconstruction in 6 patients with combined pharyngeal and oesophageal corrosive stricture is reported. Oesophagectomy was performed in all patients and reconstruction was with whole stomach in 5 patients. In the sixth patient the stomach was destroyed by corrosive and reconstruction was attempted by colon interposition but this proved unsuccessful. In the 5 patients with pharyngogastrostomy, postoperative recovery was smooth without any instance of anastomotic leakage and swallowing was restored. Recurrent dysphagia occurring in the first two patients was due to construction of too narrow an anastomosis. Recurrent dysphagia did not occur in the subsequent 3 patients in whom a large pharyngogastrostomy anastomosis was established to the posterior pharyngeal wall. Minor tracheal aspiration occurred but even in the 2 patients with associated laryngeal injury, the symptoms subsided once swallowing was restored. Regurgitation was a problem only in one patient who developed gastric stasis; however the symptoms subsided after pyloroplasty. Reconstruction of pharyngo-oesophageal stricture by pharyngogastrostomy restores almost normal swallowing provided that laryngeal function is adequate and a large pharyngogastrostomy is established.