[Paediatric Airway Surgery - Indications and Techniques]. / Pädiatrische Atemwegschirurgie: Indikationen und Techniken.

Even in specialised centres, surgical procedures on the airway are only rarely performed in paediatric patients. Moreover, knowledge of various specific anatomical characteristics, diseases and surgical techniques is a prerequisite to treat these patients. Most commonly, sequelae of long-term intubation or tracheostomy in multimorbid patients necessitate surgical repair. Moreover, congenital malformations of the airways might require surgical interventions. However, these are commonly associated with other organ malformations, which adds further complexity to the treatment concept. Thus, cooperation within an interdisciplinary team is absolutely necessary to treat these patients. However, good postoperative outcomes after paediatric airway surgery can be achieved in experienced centres with an appropriate infrastructure. Specifically, this means long-term tracheostomy-free survival with preserved laryngeal functions in most of the patients. This review provides a summary of common indications and surgical techniques in paediatric airway surgery.

Pädiatrische Atemwegschirurgie: Indikationen und Techniken.

Even in specialised centres, surgical procedures on the airway are only rarely performed in paediatric patients. Moreover, knowledge of various specific anatomical characteristics, diseases and surgical techniques is a prerequisite to treat these patients. Most commonly, sequelae of long-term intubation or tracheostomy in multimorbid patients necessitate surgical repair. Moreover, congenital malformations of the airways might require surgical interventions. However, these are commonly associated with other organ malformations, which adds further complexity to the treatment concept. Thus, cooperation within an interdisciplinary team is absolutely necessary to treat these patients. However, good postoperative outcomes after paediatric airway surgery can be achieved in experienced centres with an appropriate infrastructure. Specifically, this means long-term tracheostomy-free survival with preserved laryngeal functions in most of the patients. This review provides a summary of common indications and surgical techniques in paediatric airway surgery.

Use of the myocutaneous serratus anterior free flap for reconstruction after salvage glossectomy.

PURPOSE: To describe the use of a myocutaneous serratus anterior free flap (SAFF) for tongue reconstruction after salvage subtotal (STG) and total glossectomy (TG). METHODS: In this prospective case series, seven patients underwent salvage STG or TG and reconstruction with a myocutaneous SAFF between 10/2015 and 02/2017. Functional and oncologic outcomes were prospectively evaluated. Donor side morbidity was determined using the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: SAFF with mean skin paddles of 6.7 cm × 8.7 cm was used in five STG and two TG patients, respectively. There was a 100% flap survival and a mean DASH score of 10.8 reflected normal arm and shoulder function after surgery. One year after salvage surgery, 1 (14.3%) and 4 (57.1%) patients were tracheostomy and gastrostomy tube dependent. Gastrostomy tube dependence was significantly worse in patients with tumors of the base of tongue compared to other tumor sites (p = 0.030) and in patients who underwent transcervical compared to transoral tumor resection (p = 0.008). Local recurrence rate was 57.1% with a disease-free survival of 17.6 months. CONCLUSION: The myocutaneous SAFF represents a safe and reliable flap for tongue reconstruction after salvage glossectomy with satisfying functional outcomes and low donor side morbidity.

Assessment of nasalance and nasality in patients with a repaired cleft palate.

In patients with a repaired cleft palate, nasality is typically diagnosed by speech language pathologists. In addition, there are various instruments to objectively diagnose nasalance. To explore the potential of nasalance measurements after cleft palate repair by NasalView®, we correlated perceptual nasality and instrumentally measured nasalance of eight speech items and determined the relationship between sensitivity and specificity of the nasalance measures by receiver-operating characteristics (ROC) analyses and AUC (area under the curve) computation for each single test item and specific item groups. We recruited patients with a primarily repaired cleft palate receiving speech therapy during follow-up. During a single day visit, perceptive and instrumental assessments were obtained in 36 patients and analyzed. The individual perceptual nasality was assigned to one of four categories; the corresponding instrumental nasalance measures for the eight specific speech items were expressed on a metric scale (1-100). With reference to the perceptual diagnoses, we observed 3 nasal and one oral test item with high sensitivity. However, the specificity of the nasality indicating measures was rather low. The four best speech items with the highest sensitivity provided scores ranging from 96.43 to 100%, while the averaged sensitivity of all eight items was below 90%. We conclude that perceptive evaluation of nasality remains state of the art. For clinical follow-up, instrumental nasalance assessment can objectively document subtle changes by analysis of four speech items only. Further studies are warranted to determine the applicability of instrumental nasalance measures in the clinical routine, using discriminative items only.

Diplophonia Disturbs Jitter and Shimmer Measurement.

OBJECTIVES: The aims of this study are to investigate the effects of diplophonia on jitter and shimmer and to identify measurement limitations with regard to material selection and clinical interpretation. MATERIALS AND METHODS: Four hundred and ninety-eight audio samples of sustained phonations were analyzed. The audio samples were assessed for the grade of hoarseness and the presence of diplophonia. Jitter and shimmer were reported with regard to perceptual ratings. We investigated cycle marker positions exemplarily and qualitatively to understand their implications for perturbation measurements. RESULTS: Medians of jitter and shimmer were higher for diplophonic voices than for nondiplophonic voices with equal grades of hoarseness. The variance of jitter for moderately dysphonic voices was larger than the variance observed in a corpus from which diplophonic samples had been discarded. The positions of cycle markers in diplophonic voices did not match the positions of the pulses, indicating that the validity of jitter and shimmer values for these voices were questionable. CONCLUSION: Diplophonia biases the reporting of dysphonia severity via perturbation measures, and their validity is questionable for these voices. In addition, diplophonia is an influential source of variance in jitter measurements. Thus, diplophonic fragments of voice samples should be excluded prior to perturbation analysis.

The impact of previous endoscopic treatments on functional outcome after cricotracheal resection.

OBJECTIVES: Treatment options for benign subglottic stenosis include endoscopic techniques or open surgery. Although endoscopic treatment is less invasive, a considerable proportion of patients develop recurrent stenosis. Endoscopic pretreatments do not exclude patients from a later surgical repair; however, the impact of previous endoscopic treatment attempts on functional outcome after open surgery is unknown. METHODS: All patients, who received a cricotracheal resection (CTR) between January 2017 and June 2023 at the Department of Thoracic Surgery, Medical University of Vienna, were included in this retrospective study. Patient characteristics, surgical variables and postoperative outcome including a detailed functional assessment were analysed. RESULTS: A total of 65 patients received a CTR during the study period, of which 40 were treatment naïve and 25 had a median of 2 (range 1-9) endoscopic pretreatments. Less-invasive voice-sparing CTR or standard CTR were more often possible in treatment-naïve patients. In contrary, pretreated patients regularly required extended procedures (P = 0.049). Three or more endoscopic treatments resulted in a significantly lower mean fundamental frequency (F0) after open repair (P = 0.048). In addition, a trend towards smaller mean sound pressure levels, a higher voice handicap index, higher impairments in RBH scores (roughness, breathing and hoarseness) and a higher dysphagia severity index was found in pretreated patients. The respiratory outcome after surgery was comparable between both groups. CONCLUSIONS: Multiple endoscopic pretreatments lead to worse voice quality after CTR. The impact of prior endoscopic treatment before surgical repair should be considered when discussing treatment options with patients suffering from subglottic stenosis.

In-depth analysis of pre- and postoperative functional outcome parameters in patients receiving laryngotracheal surgery.

OBJECTIVES: Surgical treatment for airway stenosis necessitates personalized techniques based on the stenosis location and length, leading to favourable surgical outcomes. However, there is limited literature on functional outcomes following laryngotracheal surgery with an adequate number of patients. METHODS: We conducted a retrospective analysis of patients who underwent laryngotracheal surgery at the Department of Thoracic Surgery, Medical University of Vienna, from January 2017 to June 2021. The study included standardized functional assessments before and after surgery, encompassing spirometry, voice measurements, swallowing evaluation and subjective patient perception. RESULTS: The study comprised 45 patients with an average age of 51.9 ± 15.9 years, of whom 89% were female, with idiopathic being the most common aetiology (67%). Procedures included standard cricotracheal resection in 11%, cricotracheal resection with dorsal mucosal flap in 49%, cricotracheal resection with dorsal mucosal flap and lateral cricoplasty in 24% and single-stage laryngotracheal reconstruction in 16%. There were no in-hospital mortalities or restenosis cases during the mean follow-up period of 20.8 ± 13.2 months. Swallowing function remained intact in all patients. Voice evaluations showed a decrease in fundamental vocal pitch [203 (81-290) Hz vs 150 (73-364) Hz, P < 0.001] and dynamic voice range (23.5 ± 5.8 semitones vs 17.8 ± 6.7 semitones, P < 0.001). However, no differences in voice volume were observed (60.0 ± 4.1 dB vs 60.2 ± 4.8 dB, P = 0.788). The overall predicted voice profile changed from R0B0H0 to R1B0H1. CONCLUSIONS: Laryngotracheal surgery proves effective in fully restoring breathing capacity while preserving vocal function. Even in cases of high-grade and complex airway stenosis necessitating laryngotracheal reconstruction, favourable functional outcomes can be achieved.

A novel technique of voice-sparing cricotracheal resection.

Background: Cricotracheal resection (CTR) is considered the standard of care for patients suffering from idiopathic subglottic stenosis (iSGS). Although CTR results in permanent restoration of airway patency, it has a mild to moderate impact on voice quality. Here we propose modifications of the standard CTR technique to make it a voice-preserving procedure. Methods: Five women with iSGS underwent voice-sparing CTR between January 2022 and January 2023. In this procedure, through several technical adaptations, the function of the cricothyroid joint was preserved. Outcomes of these voice-sparing CTRs were compared to outcomes in patients who underwent standard CTR in our institution. All patients underwent full functional preoperative and postoperative workups, including spirometry, voice measurements, patient self-assessment, and fiberoptic endoscopic evaluation of swallowing. Results: All 5 patients in the study group suffered from iSGS with high-grade Myer-Cotton III° stenosis (100%); 1 patient had previously undergone endoscopic laser resection. Voice evaluation demonstrated a nearly unchanged fundamental pitch (mean preoperative, 191 ± 73.1 Hz; postoperative, 182 ± 64.2 Hz) and dynamic voice range (preoperative, 24.4 semitones; postoperative, 20.4 semitones). This was in contrast to the control group, in which significantly reduced voice quality was observed. Conclusions: In selected patients suffering from iSGS, excellent functional results can be obtained with voice-sparing CTR.

Oral microbial colonization in laryngectomized patients as a possible cofactor of biofilm formation on their voice prostheses.

AIM: Biofilm formation on voice prostheses, which are used for voice rehabilitation in laryngectomized patients, is a main cause of device failure. The aim of this study was to assess whether the presence of periodontal pathogens in the biofilm on voice prostheses is related to that in the oral cavity and associated with the periodontal status of the patients. METHODS: Thirty-one laryngectomized patients were invited to participate, 13 of whom met exclusion criteria. The remaining 18 were classified according to the community periodontal index of treatment needs (community periodontal index of treatment needs (CPITN), grades 0-4). Biofilm samples from the oral cavity and voice prostheses were analysed by PCR-based hybridization for 11 pathogens. RESULTS: All dentate patients required periodontal treatment (CPITN-3: n = 4, CPITN-4: n = 8); the remaining six were edentulous. The diversity (i.e. number of bacterial species detected) of pathogens detected on the voice prostheses correlated significantly positively with the diversity of pathogens in the oral cavity and with clinical parameters. Furthermore, the diversity of pathogens differed significantly between dentate and edentulous patients. CONCLUSIONS: Results emphasize the oral cavity as an important source of bacteria for biofilm formation on voice prostheses. Whether these pathogens reduce the lifetime of the device by increased biofilm formation and/or increase the risk of silicone deterioration requires further study.

Incidence of Post-extubation Stridor in Infants With Cuffed vs. Uncuffed Endotracheal Tube: A Retrospective Cohort Analysis.

Background: Endotracheal intubation is a common procedure in Neonatal Intensive Care. While cuffed endotracheal tubes (ETT) are the standard of care in adults and children, their use in infants is controversial. The aim of this study was to compare the incidence of post-extubation stridor between uncuffed and cuffed ETTs in infants. We further evaluated the safety of cuffed ETTs in infants with a bodyweight between 2 and 3 kg and performed baseline analysis on development of subglottic stenosis. Methods: In this retrospective study, we screened all infants admitted to two NICUs of the Medical University of Vienna between 2012 and 2019.The study cohort was screened twice: In the first screening we selected all infants who underwent the first intubation when attaining a bodyweight >2 kg (but <6 kg) to analyze the incidence of post-extubation stridor and only considered the first intubation of each included infant. Post-extubation stridor was defined as the administration of either epinephrine aerosol or any corticosteroid within 6 h post-extubation. In the second screening we searched for all infants diagnosed with acquired severe subglottic stenosis during the study period regardless their bodyweight and numbers of intubations. Results: A total of 389 infants received at least one intubation during the study period. After excluding infants who underwent the first intubation below a bodyweight of 2 kg, 271 infants remained for final analysis with an average gestational age of 38.7 weeks at the time of intubation. Among those, 92 (33.9%) were intubated with a cuffed and 179 (66.1%) with an uncuffed ETT. Seven infants (2.6%) developed a clinically significant stridor: five of those were intubated with a cuffed and two with an uncuffed ETT (71.4 vs. 28.6%, p = 0.053). All of them had a bodyweight >3 kg at the time of intubation. Infants who developed subglottic stenosis were more often intubated with an uncuffed ETT. Conclusion: In this study, no difference in the incidence of post-extubation stridor between cuffed and uncuffed ETTs in infants with a bodyweight from 2 to 6 kg could be found. The use of uncuffed ETTs does not exhibit higher risk for the acquired subglottic stenosis in this cohort.

Cervical Repair of Iatrogenic Tracheobronchial Injury by Tracheal T-Incision.

BACKGROUND: Tracheobronchial injury is a rare but potentially life-threatening condition. Various surgical treatment options have been described for symptomatic patients with full-thickness injury. However, studies comprising a meaningful number of patients are sparse. METHODS: We retrospectively analyzed all patients who received surgical repair of tracheobronchial injury between January 1999 and May 2021 at the Department of Thoracic Surgery, Medical University of Vienna. Patient characteristics, surgical variables, postoperative morbidity, and mortality were retrieved and analyzed. RESULTS: Fifty patients with a median age of 68 years (range, 17-88) were included in the analysis. The etiologies of the iatrogenic tracheobronchial injuries were emergency intubation (48%), elective percutaneous dilatation tracheostomy (38%), or elective intubation (14%). The most common location of tracheobronchial injuries was distal third (28%) with a median length of 50 mm (range, 20-100 mm). The surgical approach was cervicotomy in 52%, thoracotomy in 38%, sternotomy in 2%, and combined approaches in 8% of cases. Moreover, intraoperative venovenous (n = 4) or venoarterial (n = 2) extracorporeal membrane oxygenation support was required in 12% of cases. Procedure-related mortality was 0%. However, as patients with tracheobronchial injury usually have severe comorbidities, the rate of patients discharged alive from the intensive care unit was only 66%. The median follow-up period of discharged patients was 5.5 months (range, 0.7-209). Airway stenosis or dehiscence was not observed in any patient. CONCLUSIONS: Surgical repair of tracheobronchial injuries can be performed safely with a low procedure-related morbidity. If possible, the less-invasive cervical access should be preferred for patients with tracheobronchial injury, even for injuries extending to the main bronchi.

Functional outcome after single-stage laryngotracheal reconstruction with rib cartilage grafting.

OBJECTIVE: Single-stage laryngotracheal reconstruction (SSLTR) provides a definite surgical treatment for patients with complex glotto-subglottic stenosis. To date, the influence of SSLTR on the functional outcome after surgery has not been analyzed. METHODS: A retrospective analysis of all patients receiving a SSLTR between November 2012 and October 2019 was performed. Preoperatively and 3 months postoperatively, patients received a full functional evaluation, including spirometry; voice measurements (eg, fundamental frequency; dynamic range, singing voice range, and perceptual voice evaluation using the Roughness-Breathiness-Hoarseness [RBH] score, and fiberoptic endoscopic evaluation of swallowing [FEES]). RESULTS: A total of 15 patients with a mean age of 45 ± 17 years underwent SSTLR. Two (13%) patients were men and 13 (87%) were women. The majority of patients (67%) had undergone previous surgical or endoscopic treatment attempts that had failed. At the 3-month follow-up visit, none of the patients had signs of penetration or aspiration in their swallowing examination. Voice measurements revealed a significantly lower fundamental voice frequency (201.0 Hz vs 155.5 Hz; P = .006), whereas voice range (19.1 semitones vs 14.9 semitones; P = .200) and dynamic range (52.5 dB vs 53.0 dB; P = .777) was hardly affected. The median RBH score changed from R1 B0 H1 to R2 B1 H2. In spirometry, breathing capacity increased significantly (peak expiratory flow, 44% vs 87% [P < .001] and mean expiratory flow at 75% of vital capacity, 48% vs 90% [P < .001]). During a median follow-up of 32.5 months (range, 7-88 months), none of the patients developed re-stenosis. CONCLUSIONS: For complex glotto-subglottic stenoses, durable long-term airway patency together with reasonable voice quality and normal deglutition can be achieved by SSLTR.

Laryngotracheal resection can be performed safely without a guardian Chin stitch-a single-centre experience including 165 consecutive patients.

OBJECTIVES: A tension-free anastomosis is crucial to minimize the risk of airway complications after laryngotracheal surgery. The 'guardian' chin stitch is placed to prevent hyperextension of the neck in the early postoperative period. This manoeuvre was introduced early in tracheal surgery and is now routinely performed by many airway surgeons. However, the evidence for or against is sparse. METHODS: We performed a retrospective analysis of all adult patients receiving a (laryngo-)tracheal resection at our department from October 2011 to December 2019. According to our institutional standard, none of the patients received a chin stitch. Instead, a head cradle was used to obtain anteflexion of the neck during the first 3 days and patients were instructed to avoid hyperextension of the neck during the hospital stay. The postoperative outcome and the rate of anastomotic complications were analysed. RESULTS: A total of 165 consecutive patients were included in this study. Median age at surgery was 53 years (18-80). Seventy-four patients received a tracheal resection, 24 a cricotracheal resection, 52 an extended cricotracheal resection including dorsal mucosectomy and 15 a single-stage laryngotracheal reconstruction. The median resection length was 25 mm (range 10-55 mm). One hundred and sixty-two out of 165 (98.2%) patients had an unremarkable postoperative course. One patient (0.6%) had partial anastomotic rupture after a traumatic reintubation, which required revision surgery and re-anastomosis. Two patients (1.2%) after previous radiation therapy (>60 Gy) developed a partial necrosis of the anastomosis, resulting in prolonged airleak and fistulation. At follow-up, bronchoscopy 3 months after surgery, 92.7% (127/137) of the patients had a proper anastomosis, 6.6% (9/137) had minor granuloma formations at the site of the anastomosis, which were all treated successfully by endoscopic removal. One patient received dilatation for restenosis (0.7%). CONCLUSIONS: After sufficient mobilization of the central airways, postoperative anteflexion of the neck supported by a head cradle is sufficient to prevent excessive anastomotic tension and dehiscence. Considering the risk for severe neurological complications associated with the chin stitch, the routine use of this manoeuvre in laryngotracheal surgery should not be recommended.

Established and innovative surgical techniques for the treatment of benign subglottic stenosis.

Surgical treatment of benign subglottic stenoses can be challenging. It requires the close cooperation of an experienced team that includes various specialist disciplines. The treatment success will be evaluated with an extensive documentation of voice quality, lung function and swallowing function. The stenosis has to be analyzed in terms of its etiology, severity and pretreatment. Endoscopic removal of the stenotic tissue often leads to good short-term results. However, the proportion of re-stenoses is very high, which are often even more severe. Long-term treatment success can often only be achieved by surgical resection. The surgical technique used must be strictly adapted to the individual stenosis. In principle, a distinction can be made between classic cricotracheal resections and those that receive an expanded operative component. Particularly in the case of high-grade side-to-side stenoses, complex reconstruction with cartilage graft may be necessary. It is important not just to restore the airway flow. Maintaining the vocal function is an equally important treatment goal. Experienced centers can achieve very satisfactory long-term results with regard to functional outcome and voice quality.

Functional evaluation before and after laryngo-tracheal resection.

Laryngotracheal resections have become a clinical routine in experienced airway centers and even extended glotto-subglottic resections and reconstructions can be performed with low complication rates and excellent long-term airway patency. However, reports on the functional outcome after laryngotracheal resections are sparse and there is no general agreement among airway surgeons, which functional evaluations should be performed before and after surgery. The following review provides an overview on basic assessment tools, which can be used to objectively report functional outcome after laryngotracheal surgery.

Laryngeal Mask as the Primary Airway Device During Laryngotracheal Surgery: Data From 108 Patients.

BACKGROUND: Airway management during repair of laryngotracheal stenosis is demanding, and there is currently no accepted standard of care. Recently an increasing number of airway centers have started to use a laryngeal mask until the airway is surgically exposed and cross-table ventilation can be initiated. However detailed data on this approach are missing in the literature. METHODS: Patients receiving laryngotracheal surgery from November 2011 until October 2018 were retrospectively included in this single-center study, except for patients who presented with a preexisting tracheostomy at time of surgery. Airway management uniformly consisted of laryngeal mask ventilation until cross-table ventilation was established. Clinical variables, perioperative complications, and airway complications were analyzed. RESULTS: One hundred eight patients (65 women, 43 men) receiving tracheal resection (n = 50), cricotracheal resection (n = 49), or single-stage laryngotracheal reconstruction (n = 9) were included in the analysis. Of the included patients 23 (21.3%) had malignant disease and 85 (78.7%) a benign pathology. In the subgroup of patients with subglottic disease 85.1% had high-grade stenosis (Myer-Cotton III°). Airway management with a laryngeal mask was successful in all except 1 patient (99.1%). Mean pulse oximetry and mean end-tidal CO2 during laryngeal mask ventilation was 98.7% ± 2.4% and 34.8 ± 7.6 mm Hg, respectively. At the end of surgery 95 patients (88%) were successfully weaned from the respirator using the laryngeal mask. CONCLUSIONS: The laryngeal mask as the primary airway device is feasible and safe in patients undergoing laryngotracheal surgery even in cases with high-grade stenosis.

Pre-emptive glottic enlargement before laryngotracheal surgery in patients at high risk for postoperative bilateral vocal fold paralysis.

OBJECTIVES: Bilateral vocal fold paralysis (VFP) is a severe complication after laryngotracheal (LT) surgery. The reduced glottic opening leads to significant respiratory distress immediately after the operation and requires the placement of a tracheostomy in most cases. Patients with a pre-existing unilateral VFP or expected recurrent nerve resection are at the highest risk for glottic failure. These patients might benefit from a pre-emptive glottic enlargement before LT surgery. METHODS: We performed a retrospective review of patients who received a pre-emptive glottis enlargement before LT surgery at the Medical University of Vienna from October 2011 to December 2016. Peri- and postoperative outcomes of this strategy were analysed. RESULTS: Six patients underwent preparatory glottic enlargement prior to LT resection. Four patients had recurrent thyroid cancer, and 1 patient had thymic cancer invading the cervical airway. The remaining patient had a complex benign glotto/subglottic stricture complicated by a pre-existing bilateral VFP. All patients received oblique cricotracheal resections extending into the larynx [resection length 39 ± 7 mm (mean ± SD)]. Extubation within 24 h after surgery was achieved in 5 of 6 cases, although all patients had postoperative unilateral (n = 5) or bilateral (n = 1) VFP as anticipated. In 5 of the 6 patients, oral intake could be started immediately after the operation. The remaining patient regained full swallowing function after intensive swallowing rehabilitation. Postoperative voice quality was subjectively perceived as satisfactory by all patients. CONCLUSIONS: Pre-emptive glottic enlargement is a valuable treatment strategy in patients at highest risk for postoperative bilateral VFP. It facilitates immediate postoperative extubation, despite at least unilateral VFP and extensive LT surgical procedures.

Towards Objective Voice Assessment: The Diplophonia Diagram.

OBJECTIVES: Diplophonia is an often misinterpreted symptom of disordered voice, and needs objectification. An audio signal processing algorithm for the detection of diplophonia is proposed. Diplophonia is produced by two distinct oscillators, which yield a profound physiological interpretation. The algorithm's performance is compared with the clinical standard parameter degree of subharmonics (DSH). STUDY DESIGN: This is a prospective study. METHODS: A total of 50 dysphonic subjects with (28 with diplophonia and 22 without diplophonia) and 30 subjects with euphonia were included in the study. From each subject, up to five sustained phonations were recorded during rigid telescopic high-speed video laryngoscopy. A total of 185 phonations were split up into 285 analysis segments of homogeneous voice qualities. In accordance to the clinical group allocation, the considered segmental voice qualities were (1) diplophonic, (2) dysphonic without diplophonia, and (3) euphonic. The Diplophonia Diagram is a scatter plot that relates the one-oscillator synthesis quality (SQ1) to the two-oscillator synthesis quality (SQ2). Multinomial logistic regression is used to distinguish between diplophonic and nondiplophonic segments. RESULTS: Diplophonic segments can be well distinguished from nondiplophonic segments in the Diplophonia Diagram because two-oscillator synthesis is more appropriate for imitating diplophonic signals than one-oscillator synthesis. The detection of diplophonia using the Diplophonia Diagram clearly outperforms the DSH by means of positive likelihood ratios (56.8 versus 3.6). CONCLUSIONS: The diagnostic accuracy of the newly proposed method for detecting diplophonia is superior to the DSH approach, which should be taken into account for future clinical and scientific work.

Summarized institutional experience of paediatric airway surgery†.

OBJECTIVES: The management of paediatric airway stenosis is complex, and requires a dedicated team, consisting of thoracic surgeons, phoniatricians, logopaedics, paediatricians and anaesthetists. The majority of paediatric laryngotracheal stenosis is a sequela of prematurity and prolonged post-partal intubation/tracheostomy. Surgical correction is often difficult due to a frequent combination of glottic and subglottic defects. METHODS: In 2012, the Laryngotracheal Program Vienna was launched. Since then, 18 paediatric patients were surgically treated for (laryngo-)tracheal problems. RESULTS: The median age of our patients was 26 months (range 2-180 months). Laryngotracheal stenosis extending up to the level of the vocal cords was evident in 9 patients. Three children were diagnosed with an isolated subglottic, and four with a short-segment tracheal stenosis or malacia. Two patients had a long-segment congenital malformation together with vascular ring anomalies. Five children were pretreated by rigid endoscopy before surgical correction, 12 of our 18 patients had a tracheostomy, 3 children were intubated at the time of operation. Different techniques of corrections were applied: laryngotracheal reconstruction (n = 4), extended partial cricotracheal resection (n = 4), cricotracheal resection with or without anterior split or dorsal mucosal flap (n = 4), slide tracheoplasty (n = 2), tracheal resection (n = 4). In 8 patients, a rib cartilage interposition was necessary in order to obtain a sufficient lumen enlargement and in 7 of these patients, an LT-Mold was placed to stabilize the reconstruction. We lost 2 patients, who were referred to our institution after failure of multiple preceding interventions, 2 and 3 months after the operation. Twelve patients are currently in an excellent condition, one is in an acceptable condition without a need for an intervention. Two patients required an endoscopic reintervention 18 and 33 months after the operation, 1 child is currently still cannulated. CONCLUSIONS: Paediatric airway surgery is complex, and requires a dedicated interdisciplinary team. An armamentarium of different resection and reconstruction techniques is necessary in order to achieve good long-term results.

A modified technique of laryngotracheal reconstruction without the need for prolonged postoperative stenting.

OBJECTIVES: Repair of laryngotracheal stenosis with pronounced side-to-side narrowing and involvement of the glottis is challenging and usually requires laryngotracheal reconstruction with rib cartilage interpositions. This technique, as first described by Couraud, needs prolonged postoperative stabilization with Montgomery T-tubes, imposing significant morbidity and discomfort on patients. We describe our initial experience with a modified laryngotracheal reconstruction technique that avoids the need for prolonged postoperative stenting. METHODS: From November 2012 through May 2015, a series of 5 adult patients with glottosubglottic stenosis were operated in our institution. All patients had pronounced scar formation in combination with advanced side-to-side narrowing extending up to the level of the vocal folds. Operative technique consisted of a complete anterior and posterior laryngeal split followed by rib cartilage interposition in the cricoid plate posteriorly to enlarge the glottosubglottic diameter. The lateral edges of the rib graft were trimmed in such a way that lateral flanges were created, which allowed stable positioning of the graft. The distal trachea was then slid into the larynx, and the posterior defect was completely covered with a liberal membranous flap. The anterior part of the larynx was enlarged with a V-shaped segment of the anterior tracheal wall. RESULTS: This technique provided immediate stability without the need for temporary endoluminal stenting. The perioperative course was uneventful in all patients, and functional outcome was excellent. CONCLUSIONS: We conclude that this modified technique of laryngotracheal reconstruction represents a valid treatment option for patients with complex glottosubglottic stenosis, avoiding the need for prolonged postoperative stenting.