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Sittel C, Koitschev A, Schön C, Reiter K. Reconstructive Surgery of the Laryngotracheal Junction. Laryngorhinootologie 2024; 103:S148-S166. [PMID: 38697146 DOI: 10.1055/a-2181-9576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
The laryngotracheal junction is an anatomical region with special pathophysiological features. This review presents clinical pictures and malformations that manifest pre-dilectively at this localisation in children and adolescents as well as in adults. The diagnostic procedure is discussed. The possibilities of surgical reconstruction are presented depending on the pathology and age of the patient.
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Affiliation(s)
- Christian Sittel
- Klinikum der Landeshauptstadt Stuttgart gKAöR, Klinik für Hals-, Nasen-, Ohrenkrankheiten, Plastische Operationen, Standort Katharinenhospital, Haus D, Allgemeine HNO-Heilkunde, Standort Olgahospital: Pädiatrische HNO-Heilkunde, Otologie
| | - Assen Koitschev
- Klinikum der Landeshauptstadt Stuttgart gKAöR, Klinik für Hals-, Nasen-, Ohrenkrankheiten, Plastische Operationen, Standort Katharinenhospital, Haus D, Allgemeine HNO-Heilkunde, Standort Olgahospital: Pädiatrische HNO-Heilkunde, Otologie
| | - Carola Schön
- Kinderklinik der Universität München am Dr. Haunerschen Kinderspital, Klinikum der Universität München, Campus Innenstadt
| | - Karl Reiter
- Kinderklinik der Universität München am Dr. Haunerschen Kinderspital, Klinikum der Universität München, Campus Innenstadt
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Evermann M, Roesner I, Kranebitter V, Denk-Linnert DM, Bauer J, Schweiger T, Hoetzenecker K. A novel technique of voice-sparing cricotracheal resection. JTCVS Tech 2024; 23:161-169. [PMID: 38352015 PMCID: PMC10859644 DOI: 10.1016/j.xjtc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 02/16/2024] Open
Abstract
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.
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Affiliation(s)
- Matthias Evermann
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Imme Roesner
- Division of Phoniatrics and Logopedics, Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
| | - Veronika Kranebitter
- Division of Phoniatrics and Logopedics, Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
| | - Doris-Maria Denk-Linnert
- Division of Phoniatrics and Logopedics, Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
| | - Johanna Bauer
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schweiger
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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Lorenz RR. The Evolution and Outcomes of the "Maddern Procedure" for the Treatment of Subglottic Stenosis. Laryngoscope 2023; 133:3100-3108. [PMID: 37194674 DOI: 10.1002/lary.30752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 04/19/2023] [Accepted: 04/29/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION A novel technique to treat subglottic stenosis, the "Maddern Procedure", has been gaining acceptance in academic centers. This study describes the technique in detail, as well as its evolution over the first 28 patients performed at an academic center. METHODS A prospective case-series, with descriptive technique modifications cataloged throughout the 6 years needed to accumulate the patient cohort with a minimum of 2 years of follow-up (11/2015-11/2021). Main outcomes examined included changes to surgical indications, complications, and post-operative outcomes as measured by validated measures of voice and breathing. RESULTS Complete resection of subglottic scaring was performed, at first transcervically (2 pts), then transorally (26 pts). Successful performance of the procedure occurred in all patients without complications, with either successful decannulation of previously existing tracheotomies, or removal of perioperative tracheotomies. Buccal grafts (8/26) replaced skin graft as the graft of choice. Although high subglottic disease was first thought to be a contraindication, superior results became evident in cases of high stenosis rather than disease that included the upper trachea, with 4/26 patients requiring subsequent tracheal resection or tracheal dilation. Of the 22 remaining patients, 19/22 had successful arresting of restenosis, with 2/22 undergoing subsequent cricotracheal resection, and 1/22 pts requiring subglottic dilation. Overall, 19/26 Maddern pts (73%) had objectively favorable outcomes, with 24/26 (92%) reporting that they would have undergone the procedure again. CONCLUSION Full-thickness mucosal resection and relining of the subglottis is a developing technique that is a safe, yet technically challenging procedure which addresses the recurrent nature of the disease. LEVEL OF EVIDENCE Level 4 (Case-series) Laryngoscope, 133:3100-3108, 2023.
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Affiliation(s)
- Robert R Lorenz
- Cleveland Clinic, Head and Neck Institute, Cleveland, Ohio, USA
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Schoeff S, Hoffman MR, Zhang Y, Yang Q, Dailey SH. Long-Term Follow-up of 64 Patients With Idiopathic Subglottic Stenosis: Treatment Pathways, Outcomes, and Impact of Serial Intralesional Steroid Injections. Ann Otol Rhinol Laryngol 2023; 132:1341-1348. [PMID: 36840325 DOI: 10.1177/00034894231156122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
OBJECTIVE To describe treatment pathways and long-term outcomes in 64 patients with idiopathic subglottic stenosis (iSGS), including the impact of serial intralesional steroid injection (SILSI) on degree of stenosis, need for subsequent operation, and patient-reported outcome measures. METHODS Retrospective review of 64 female patients with iSGS undergoing varied management approaches, 57 of whom underwent SILSI as at least part of their care. Treatment pathways included SILSI only, endoscopic intervention followed by SILSI only, endoscopic interventions only, endoscopic intervention followed by SILSI followed by need for repeat endoscopic intervention, open surgery, and tracheotomy. Outcomes assessed included subjectively estimated percent airway stenosis, dyspnea index (DI), modified medical research council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), number of operative and office-based procedures performed, need for subsequent operative intervention, and inter-operative interval. RESULTS Treatment pathways included SILSI alone (n = 6), endoscopic intervention(s) followed by SILSI only (n = 31), SILSI followed by additional endoscopic or office-based procedures (n = 16), open surgery (n = 3), and tracheostomy (n = 4). 57 of 64 patients underwent SILSI as at least part of their treatment. Inter-operative interval was increased after starting SILSI. Of patients undergoing SILSI, those with more procedures or shorter inter-operative interval prior to SILSI were more likely to return to the operating room. Estimated stenosis, DI, MMRC, and VHI-10 decreased with SILSI. Stenosis was not correlated with DI, MMRC, or VHI-10, though DI was correlated with both MMRC and VHI-10 score. CONCLUSION Of 57 patients undergoing SILSI, 37 did not require further operative intervention. Improvements in inter-operative interval, dyspnea, and voice were observed across patients. Randomized trials to identify which patients may benefit most from SILSI are warranted.
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Affiliation(s)
- Stephen Schoeff
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Matthew R Hoffman
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, IA, USA
| | - Yanchen Zhang
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Qiuyu Yang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Seth H Dailey
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Ntouniadakis E, Sundh J, Magnuson A, von Beckerath M. Balloon dilatation is superior to CO 2 laser excision in the treatment of subglottic stenosis. Eur Arch Otorhinolaryngol 2023; 280:3303-3311. [PMID: 36964409 PMCID: PMC10038384 DOI: 10.1007/s00405-023-07926-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/13/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION Endoscopic treatment of subglottic stenosis (SGS) is regarded as a safe procedure with rare complications and less morbidity than open surgery yet related with a high risk of recurrence. The abundance of techniques and adjuvant therapies complicates a comparison of the different surgical approaches. The primary aim of this study was to investigate disease recurrence after CO2 laser excisions and balloon dilatation in patients with SGS and to identify potential confounding factors. MATERIALS AND METHODS In a tertiary referral center, two cohorts of previously undiagnosed patients treated for SGS were retrospectively reviewed and followed for 3 years. The CO2 laser cohort (CLC) was recruited between 2006 and 2011, and the balloon dilatation cohort (BDC) between 2014 and 2019. Kaplan‒Meier and multivariable Cox regression analyzed time to repeated surgery and estimated hazard ratios (HRs) for different variables. RESULTS Nineteen patients were included in the CLC, and 31 in the BDC. The 1-year cumulative recurrence risk was 63.2% for the CLC compared with 12.9% for the BDC (HR 33.0, 95% CI 6.57-166, p < 0.001), and the 3-year recurrence risk was 73.7% for the CLC compared with 51.6% for the BDC (HR 8.02, 95% CI 2.39-26.9, p < 0.001). Recurrence was independently associated with overweight (HR 3.45, 95% CI 1.16-10.19, p = 0.025), obesity (HR 7.11, 95% CI 2.19-23.04, p = 0.001), and younger age at diagnosis (HR 8.18, 95% CI 1.43-46.82, p = 0.018). CONCLUSION CO2 laser treatment is associated with an elevated risk for recurrence of SGS compared with balloon dilatation. Other risk factors include overweight, obesity, and a younger age at diagnosis.
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Affiliation(s)
- Eleftherios Ntouniadakis
- Department of Ear Nose and Throat, Faculty of Medicine and Health, Örebro University, 70182, Örebro, Sweden.
- Ear Nose and Throat Department, Örebro University Hospital, Södra Grev Rosengatan, 701 85, Örebro, Sweden.
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, 70182, Örebro, Sweden
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 70182, Örebro, Sweden
| | - Mathias von Beckerath
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Gerstein N, Venkataramani R, Lewis A, Perez-Munoz I. Management of refractory hypoxemia during elective extracorporeal support for complex tracheal resection. Saudi J Anaesth 2022; 16:120-123. [PMID: 35261602 PMCID: PMC8846250 DOI: 10.4103/sja.sja_265_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/25/2021] [Accepted: 08/11/2021] [Indexed: 11/29/2022] Open
Abstract
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is increasingly used in managing challenging airway and thoracic cases with complex airway manipulations. We present a case of a complex tracheal resection needing prolonged apnea times for which VV-ECMO was electively planned. Intraoperatively, the team was faced with continued oxygen desaturations during periods of apnea. With an algorithmic approach to troubleshooting hypoxemia, several factors were taken into consideration. Apneic oxygenation was applied to the open tracheal segment. Despite an open airway, the applied apneic oxygenation facilitated oxygenation to the portion of the cardiac output that was being shunted through the lungs as opposed to the VV-ECMO circuit, enabling uninterrupted completion of the surgical resection and reanastomosis.
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Chan RK, Ahrens B, MacEachern P, Bosch JD, Randall DR. Prevalence and incidence of idiopathic subglottic stenosis in southern and central Alberta: a retrospective cohort study. J Otolaryngol Head Neck Surg 2021; 50:64. [PMID: 34772459 PMCID: PMC8588657 DOI: 10.1186/s40463-021-00544-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/10/2021] [Indexed: 11/26/2022] Open
Abstract
Background Subglottic stenosis (SGS) is a reportedly rare disease that causes recurrent severe airway obstruction. Etiologies reported for SGS include idiopathic, iatrogenic, autoimmune, congenital, and traumatic, with variable ratios among different centres. From empiric observation, southern and central Alberta was hypothesized to have a disproportionate distribution of SGS driven by increased idiopathic SGS (iSGS) compared to previous literature. Identification of causative agents of iSGS will help understand and guide future management options, so this study aimed to characterize the demographics of SGS subtypes, define prevalence and incidence rates of iSGS in southern Alberta, and geographically analyze for clustering of iSGS prevalence. Methods SGS patients from Alberta census divisions No. 1–9 and 15 were retrospectively reviewed. Patients were subtyped according to etiology of SGS and characterized. Idiopathic SGS prevalence and incidence was assessed; prevalence was further geographically segregated by census division and forward sortation area (FSA). Significant clustering patterns were assessed for using a Global Moran’s I analysis. Results From 2010 to 2019 we identified 250 SGS patients, who were substantially overrepresented by idiopathic patients (80.4%) compared to autoimmune (10.0%), iatrogenic (7.6%), congenital (1.2%), and traumatic (0.8%). The total iSGS prevalence was 9.28/100,000 with a mean annual incidence rate of 0.71/100,000 per year. Significant clustering was observed (Moran’s index 0.125; z-score 2.832; p = 0.0046) and the highest rates of prevalence were observed in southern Alberta and in rural communities heterogeneously dispersed around Calgary FSAs. Conclusion In southern and central Alberta, iSGS patients were disproportionately over-represented in contrast to other subtypes with the highest prevalence in southern Alberta. There was a three-fold higher annual incidence compared to previous literature demonstrating the highest rates of disease reported worldwide. Future research aims to expand the geographical scope and to assess for demographic or environmental differences within significant clusters that may contribute to disease pathophysiology. Level of evidence III. Graphical Abstract ![]()
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Affiliation(s)
- Ryan K Chan
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Beau Ahrens
- Interdisciplinary PhD Program, Dalhousie University, Halifax, NS, Canada
| | - Paul MacEachern
- Interventional Pulmonary Medicine, Division of Respirology - Thoracic Surgery and Medical Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - J Douglas Bosch
- Section of Otolaryngology - Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Calgary Voice Clinic, Richmond Road Diagnostic and Treatment Centre, Calgary, AB, Canada
| | - Derrick R Randall
- Section of Otolaryngology - Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Calgary Voice Clinic, Richmond Road Diagnostic and Treatment Centre, Calgary, AB, Canada.
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Eggerstedt M, Kim YJ, Ritz EM, Patel TR, Theis SM, Husain IA. Voice-related quality of life: Relation to objective spirometry measures in subglottic stenosis. Am J Otolaryngol 2021; 42:103013. [PMID: 33838356 DOI: 10.1016/j.amjoto.2021.103013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/08/2021] [Accepted: 03/23/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The current study seeks to identify the correlation between in-office spirometry data and voice-related quality of life in patients with subglottic stenosis (SGS). METHODS Patients with SGS of any etiology were included when in-office spirometric data was available in addition to voice-related patient-reported outcomes (PROM) data in the form of the Voice Handicap Index-10 (VHI-10) and/or the Voice-Related Quality of Life (V-RQOL) survey. Overall survey scores and individual question responses were assessed for degree of correlation to spirometric data. RESULTS Twenty-nine patients were included in the final analysis. Overall mean total VHI-10 scores totaled 7.15 (SD 9.11), while mean overall V-RQOL scores totaled 78.41 (SD 16.45). Both PEF and PIF rates correlated to total scores on the VHI and V-RQOL surveys. This correlation was stronger with PIF than with PEF, and with the V-RQOL than with the VHI. Questions related to breathlessness most closely correlated with spirometric data. CONCLUSION Voice-related QOL is impacted in patients with SGS in a predictable way. Breathlessness while speaking may be more impactful than inability to produce speech in this population.
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Affiliation(s)
- Michael Eggerstedt
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, United States of America
| | - Young Jae Kim
- Rush Medical College, Rush University Medical Center, United States of America
| | - Ethan M Ritz
- Bioinformatics and Biostatistics Core, Rush University, United States of America
| | - Tirth R Patel
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, United States of America
| | - Shannon M Theis
- Department of Communication Disorders and Sciences, United States of America
| | - Inna A Husain
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, United States of America.
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Compton EC, Beveridge S, Andreassen M, Gelfand G, McFadden S, Bosch D, Randall DR. Long-Term Voice Outcomes Following Cricotracheal Resection for Subglottic Stenosis: A Retrospective Analysis. Laryngoscope 2021; 132:1054-1060. [PMID: 34427329 DOI: 10.1002/lary.29827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/13/2021] [Accepted: 08/06/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Cricotracheal resection (CTR) is an effective treatment for refractory idiopathic subglottic stenosis (iSGS) but is associated with persistent dysphonia. Outcomes were measured longitudinally to characterize how patients' voices and self-perceived voice handicaps changed after CTR. STUDY DESIGN Retrospective case-series. METHODS We conducted a retrospective cohort study of patients with refractory iSGS treated by CTR from 2006 to 2017. Voice Handicap Index (VHI), Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), and acoustic analysis were prospectively collected preoperatively and postoperatively at 1, 3, 6, 12, and 24-month intervals. A linear mixed model was used to evaluate temporal change. RESULTS Thirty-three patients (97% female) were included. VHI scores increased significantly from baseline preoperative score (27.2 ± 22.7) to a mean value of 44.3 ± 25.6 (P < .001) 1-month postoperatively but decreased below preoperative scores after 2 years (18.8 ± 11.9, P = .795). Mean fundamental frequency (F0) values in speech decreased significantly from 192.0 ± 24.9 Hz preoperatively to 167.1 ± 19.8 Hz at a 2-year follow-up (P = .002), with a nadir value at 1-month postoperatively (148.4 ± 20.5, P < .001). CAPE-V scores increased significantly from preoperative to 1-month postoperative (3.0 ± 2.3 vs. 21.9 ± 17.3, P < .001) but returned toward baseline values at 24 months after CTR (6.9 ± 4.8, P = .027). CAPE-V measurements postoperatively were correlated with VHI and F0 (Pearson coefficient = 0.54 (VHI), -0.46 (F0), P < .001). CONCLUSIONS Following CTR, mean F0 values were significantly and consistently lower but did increase over time, correlating with patients' improving VHI and CAPE-V scores. VHI values indicate that patient's perception of their voice is not significantly impacted in long term. These results provide a framework to counsel patients about long term voice expectations. LEVEL OF EVIDENCE Level 4 Laryngoscope, 2021.
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Affiliation(s)
- Evan C Compton
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shari Beveridge
- Calgary Voice Program, Alberta Health Services, Calgary, Alberta, Canada
| | - Meri Andreassen
- Calgary Voice Program, Alberta Health Services, Calgary, Alberta, Canada
| | - Gary Gelfand
- Section of Thoracic Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean McFadden
- Section of Thoracic Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doug Bosch
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Derrick R Randall
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Davis RJ, Lina I, Motz K, Gelbard A, Lorenz RR, Sandhu GS, Hillel AT. Endoscopic Resection and Mucosal Reconstitution With Epidermal Grafting: A Pilot Study in Idiopathic Subglottic Stenosis. Otolaryngol Head Neck Surg 2021; 166:917-926. [PMID: 34253069 PMCID: PMC8755844 DOI: 10.1177/01945998211028163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe technical aspects and surgical outcomes of endoscopic resection and mucosal reconstitution with epidermal grafting (ie, the Maddern procedure) in the treatment of idiopathic subglottic stenosis. STUDY DESIGN Medical record abstraction. SETTING Johns Hopkins Hospital. METHODS Retrospective series of 9 adults with idiopathic subglottic stenosis who underwent the Maddern procedure by a single surgeon over a 5-year period. Prespecified outcomes included (1) perioperative outcomes (Clavien-Dindo grade 4/5 complications, need for staged tracheostomy, hospital length of stay), (2) postoperative outcomes (peak expiratory flow rate [PEFR], need for subsequent airway surgery, tracheostomy at follow-up), and (3) patient-reported quality-of-life outcomes (Clinical COPD Questionnaire, Voice Handicap Index-10, Eating Assessment Tool-10, and 12-Item Short Form Version 2). Wilcoxon matched-pairs signed rank test and Kaplan-Meier analysis were performed. RESULTS There were no Clavien-Dindo grade 4/5 complications; 2 patients required unplanned staged tracheostomy; and the median length of stay was 3 days. Following endoscopic resection and stent removal, a median of 2 laser resurfacing procedures were required. Two patients developed recurrent stenosis requiring cricotracheal resection (CTR). There were significant improvements in PEFR, Clinical COPD Questionnaire, and Voice Handicap Index-10, without significant difference in Eating Assessment Tool-10. The 12-Item Short Form Version 2 approximated the population norm. Kaplan-Meier analysis demonstrated significant improvement in time to surgery after the final laser resurfacing. CONCLUSION The Maddern procedure has a low complication rate and offers durable physiologic improvement in PEFR, limiting need for additional procedures. Risks included need for CTR salvage, temporary tracheostomy, phlegm accumulation, and laryngospasm. It is a surgical option for patients with short dilation intervals who prefer to avoid the risks of CTR.
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Affiliation(s)
- Ruth J Davis
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ioan Lina
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kevin Motz
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander Gelbard
- Department of Otolaryngology, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Robert R Lorenz
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Guri S Sandhu
- National Center for Airway Reconstruction, Department of Otolaryngology, Charing Cross Hospital, London, UK
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Slama A, Zaatar M, Demir M, Okumus O, Mattheis S, Kampe S, Darwiche K, Lang S, Aigner C. Tracheal Resection after Previous Treatment Provides Comparable Outcome to Primary Surgery. Thorac Cardiovasc Surg 2021; 70:505-512. [PMID: 34062598 DOI: 10.1055/s-0041-1728772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Tracheal and laryngotracheal surgery provides both excellent functional results and long-term outcomes in the treatment of tracheal stenosis. Consequently, challenging re-resections are rarely necessary. The purpose of this study was to compare the outcome of (laryngo-)tracheal re-resection and surgery after bronchoscopic interventions with that of primary surgery. METHODS Patients undergoing resection for benign tracheal stenosis at our center between 1/2016 and 4/2020 were included. Perioperative characteristics and functional outcomes of patients were used for statistical analysis. RESULTS Sixty-six patients who underwent (laryngo-)tracheal resection were included (previous resection [A = 6], previous stent [B = 6], previous bronchoscopic intervention w/o stenting [C = 19], untreated [D = 35]). Baseline parameters were largely comparable between groups with exception from group B that had significantly worse lung function. Group A necessitated more complex reconstructions (end-to-end: n = 1: 17%| cricotracheal n = 2: 33%| cricotracheal with mucosectomy n = 2: 33%| laryngoplasty: n = 1: 17%) than patients in group D (end-to-end n = 21: 60%| cricotracheal n = 14: 40%). Postoperative outcomes were comparable throughout groups (intensive care unit: 1[1-18] days; hospital stay: 8[5-71] days). Anastomotic complications were higher after previous stenting (A: 0%; B: 33.3%; C: 10.5%; D: 2.9%; B/D p = 0.008| surgical revisions: A: 16.7%; B: 33.3%; C: 0%; D: 5.7%; B/D, p = 0.035). Overall, postoperative lung function was significantly better (forced expiratory volume in 1 second: 63% ± 24 vs. 75% ± 20; p = 0.001 | PeakEF 3.3 ± 1.9 vs. 5.0 ± 2.2L; p = 0.001). No 90-day mortality was observed in any group. Median follow-up was 12(1-47) months. CONCLUSION In carefully selected patients treated in a specialized center, tracheal or laryngotracheal resection after previous tracheal interventions provides comparable outcome to primary surgery.
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Affiliation(s)
- Alexis Slama
- Department of Thoracic Surgery, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Mohamed Zaatar
- Department of Thoracic Surgery, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Muhittin Demir
- Department of Otorhinolaryngology, University Medicine Essen, Essen, Germany
| | - Oezlem Okumus
- Department of Thoracic Surgery, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Stefan Mattheis
- Department of Otorhinolaryngology, University Medicine Essen, Essen, Germany
| | - Sandra Kampe
- Department of Anesthesiology, Ruhrlandklinik, University Medicine Essen, Essen, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Kaid Darwiche
- Division of Interventional Pneumology, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Stephan Lang
- Department of Otorhinolaryngology, University Medicine Essen, Essen, Germany
| | - Clemens Aigner
- Department of Thoracic Surgery, Ruhrlandklinik, University Medicine Essen, Essen, Germany
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Gelbard A, Anderson C, Berry LD, Amin MR, Benninger MS, Blumin JH, Bock JM, Bryson PC, Castellanos PF, Chen SC, Clary MS, Cohen SM, Crawley BK, Dailey SH, Daniero JJ, de Alarcon A, Donovan DT, Edell ES, Ekbom DC, Fernandes-Taylor S, Fink DS, Franco RA, Garrett CG, Guardiani EA, Hillel AT, Hoffman HT, Hogikyan ND, Howell RJ, Huang LC, Hussain LK, Johns MM, Kasperbauer JL, Khosla SM, Kinnard C, Kupfer RA, Langerman AJ, Lentz RJ, Lorenz RR, Lott DG, Lowery AS, Makani SS, Maldonado F, Mannion K, Matrka L, McWhorter AJ, Merati AL, Mori MC, Netterville JL, O'Dell K, Ongkasuwan J, Postma GN, Reder LS, Rohde SL, Richardson BE, Rickman OB, Rosen CA, Rutter MJ, Sandhu GS, Schindler JS, Schneider GT, Shah RN, Sikora AG, Sinard RJ, Smith ME, Smith LJ, Soliman AMS, Sveinsdóttir S, Van Daele DJ, Veivers D, Verma SP, Weinberger PM, Weissbrod PA, Wootten CT, Shyr Y, Francis DO. Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis. JAMA Otolaryngol Head Neck Surg 2021; 146:20-29. [PMID: 31670805 PMCID: PMC6824232 DOI: 10.1001/jamaoto.2019.3022] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Question What are the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS)? Findings In this cohort study of 810 patients with iSGS who underwent 1 of the 3 most common surgical treatments, 23% of patients underwent a recurrent surgical procedure during the 3-year study period, but recurrence differed by modality (cricotracheal resection, 1%; endoscopic resection with adjuvant medical therapy, 12%; and endoscopic dilation, 28%). Among successfully treated patients, those who underwent cricotracheal resection reported the highest quality of life but the greatest perioperative risk and worst long-term voice outcomes. Meaning These results show the feasibility of integrating an engaged rare disease community with a network of surgeons to facilitate rapid and nuanced treatment comparisons; findings may help inform treatment decision-making in iSGS. Importance Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score–matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.
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Affiliation(s)
- Alexander Gelbard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Catherine Anderson
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynne D Berry
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Milan R Amin
- New York University Voice Center, Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York
| | - Michael S Benninger
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joel H Blumin
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - Jonathan M Bock
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - Paul C Bryson
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul F Castellanos
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Sheau-Chiann Chen
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Matthew S Clary
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Denver
| | - Seth M Cohen
- Duke Voice Care Center, Division of Otolaryngology-Head and Neck Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brianna K Crawley
- Department of Otolaryngology-Head & Neck Surgery, Loma Linda University Health, Loma Linda, California
| | - Seth H Dailey
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison
| | - James J Daniero
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
| | - Alessandro de Alarcon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Donald T Donovan
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dale C Ekbom
- Department of Otolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | | | - Daniel S Fink
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Denver
| | - Ramon A Franco
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston
| | - C Gaelyn Garrett
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth A Guardiani
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institution, Baltimore, Maryland
| | - Henry T Hoffman
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - Norman D Hogikyan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor
| | - Rebecca J Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Li-Ching Huang
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Lena K Hussain
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Michael M Johns
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles
| | - Jan L Kasperbauer
- Department of Otolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Sid M Khosla
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Cheryl Kinnard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robbi A Kupfer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor
| | - Alexander J Langerman
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert J Lentz
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert R Lorenz
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee
| | - David G Lott
- Department of Otorhinolaryngology, Mayo Clinic Scottsdale, Scottsdale, Arizona
| | - Anne S Lowery
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samir S Makani
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Laura Matrka
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Medical Center, Columbus
| | - Andrew J McWhorter
- Department of Otolaryngology, Louisiana State University Health Sciences Center-New Orleans, New Orleans
| | - Albert L Merati
- Department of Otolaryngology-Head & Neck Surgery, University of Washington Medical Center, Seattle
| | - Matthew C Mori
- Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York
| | - James L Netterville
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karla O'Dell
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles
| | - Julina Ongkasuwan
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Gregory N Postma
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta
| | - Lindsay S Reder
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Otis B Rickman
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco
| | - Michael J Rutter
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Guri S Sandhu
- National Centre for Airway Reconstruction, Charing Cross Hospital, Imperial College Healthcare National Health System Trust, London, United Kingdom
| | - Joshua S Schindler
- Department of Otolaryngology-Head & Neck Surgery, Northwest Clinic for Voice and Swallowing, Oregon Health and Science University, Portland
| | - G Todd Schneider
- Department of Otolaryngology, University of Rochester, Rochester, New York
| | - Rupali N Shah
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Andrew G Sikora
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Robert J Sinard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marshall E Smith
- Division of Otolaryngology-Head & Neck Surgery, The University of Utah, Salt Lake City
| | - Libby J Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ahmed M S Soliman
- Department of Otolaryngology-Head and Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | | | - Douglas J Van Daele
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - David Veivers
- Department of Otolaryngology-Head and Neck Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Sunil P Verma
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine
| | - Paul M Weinberger
- Departments of Otolaryngology, Molecular and Cellular Physiology, Feist-Weiller Cancer Center, Louisiana State University, Shreveport
| | - Philip A Weissbrod
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California, San Diego, San Diego
| | - Christopher T Wootten
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yu Shyr
- Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - David O Francis
- Department of Otolaryngology-Head and Neck Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
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Dwyer CD, Qiabi M, Fortin D, Inculet RI, Nichols AC, MacNeil SD, Malthaner R, Yoo J, Fung K. Idiopathic Subglottic Stenosis: An Institutional Review of Outcomes With a Multimodality Surgical Approach. Otolaryngol Head Neck Surg 2020; 164:1068-1076. [PMID: 33048608 DOI: 10.1177/0194599820966978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This article reports on a unique cohort of patients with idiopathic subglottic stenosis spilt fairly equally between endoscopic and open surgical approaches. Patients' sequence of operations and reinterventions over time are outlined, offering insight to improve surgical counseling and allow for informative, autonomous patient decision making. STUDY DESIGN Retrospective cohort study. SETTING Tertiary care academic center. METHODS Cases of consecutive adults with idiopathic subglottic stenosis managed surgically over a 12-year period (January 2006-December 2017) were retrospectively reviewed. Surgical workflow, complications, and outcomes, including reinterventions and tracheotomy dependence, are reported. RESULTS Seventy-two patients (71 women; mean age, 50.4 years) with idiopathic subglottic stenosis requiring surgical airway intervention were identified. Six patients underwent tracheotomy prior to attempt at airway stenosis surgery. Initial surgical approach thereafter included endoscopic (73.5%, n = 53) and open (26.4%, n = 19) procedures. Thirty-one patients underwent cricotracheal resection; the reintervention rate was 22.5%. Sixty patients underwent 147 endoscopic procedures; the reintervention rate was 75.5%, and the mean time between dilations was 83 weeks (range, 5-402). Two (2.8%) patients remain tracheotomy dependent. Adverse events were significantly higher in the cricotracheal group, especially with respect to dysphonia and temporary gastrostomy tube placement (P < .01). CONCLUSIONS Endoscopic and open surgical airway intervention can be employed successfully to avoid tracheotomy dependence and maintain airway patency; however, multiple procedures are usually required, regardless of surgical approach. Cricotracheal reintervention rates are lower than endoscopic dilation but with increased morbidity. Quality-of-life outcomes should be clearly discussed with patients before deciding on a surgical management strategy.
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Affiliation(s)
- Christopher D Dwyer
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Mehdi Qiabi
- Division of Thoracic Surgery, Western University, London, Canada
| | - Dalilah Fortin
- Division of Thoracic Surgery, Western University, London, Canada
| | | | - Anthony C Nichols
- Department of Otolaryngology-Head and Neck Surgery, Western Univer-sity, London, Canada
| | - S Danielle MacNeil
- Department of Otolaryngology-Head and Neck Surgery, Western Univer-sity, London, Canada
| | | | - John Yoo
- Department of Otolaryngology-Head and Neck Surgery, Western Univer-sity, London, Canada
| | - Kevin Fung
- Department of Otolaryngology-Head and Neck Surgery, Western Univer-sity, London, Canada
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Schuman AD, Neevel A, Morrison RJ, Hogikyan ND, Kupfer RA. Voice-Related Quality of Life Is Associated with Postoperative Change in Subglottic Stenosis. Laryngoscope 2020; 131:360-365. [PMID: 33026661 DOI: 10.1002/lary.29156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/11/2020] [Accepted: 09/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To characterize the impact of subglottic stenosis (SGS) on voice-related quality of life (V-RQOL) and quantify the effect of treatment on voice outcomes. STUDY DESIGN Case series. METHODS Retrospective review of SGS patients treated from 1996 to 2018 at a single institution to assess for 1) V-RQOL association with individual patient cumulative treatment number and 2) V-RQOL correlation with treatment type, time between treatments, and degree of stenosis. Analysis included both parametric and nonparametric statistical comparison across treatment types and multivariable and univariate linear regression. RESULTS Sixty-one patients, predominantly white (93%) and female (93%), were included. Etiology of SGS included idiopathic (61%), iatrogenic (16%), granulomatosis with polyangiitis (16%), and other (7%). The plurality of patients had four or more treatments (44%), with the remainder having one (28%), two (13%), or three treatments (15%). Analysis of change between pre- and postoperative V-RQOL scores was completed for 130 treatments. These included dilation with laser incision (52%), in-office injection (34%), dilation without division (8%), cricotracheal resection (1%), and all other treatment (8%). For every 10% improvement in airway caliber postoperatively, there was a 1.3-point improvement in calculated V-RQOL (r = 0.27, P = .02). After adjustment for treatment type, age, sex, and SGS etiology, this association held (beta = 1.5, P = .02). Change in V-RQOL was not associated with treatment type, treatment number, or time between treatments. CONCLUSION Patients with subglottic stenosis who have greater degree of change in airway caliber experience greater improvement in V-RQOL scores following treatment. V-RQOL scores are not associated with treatment type or time between individual treatments. LEVEL OF EVIDENCE 4 Laryngoscope, 131:360-365, 2021.
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Affiliation(s)
- Ari D Schuman
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A.,University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Andrew Neevel
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Robert J Morrison
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Norman D Hogikyan
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Robbi A Kupfer
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
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15
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Assessment of side effects after serial intralesional steroid injections for idiopathic subglottic stenosis. Eur Arch Otorhinolaryngol 2020; 278:445-450. [DOI: 10.1007/s00405-020-06371-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/10/2020] [Indexed: 12/22/2022]
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16
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Motz KM, Gelbard A. The role of inflammatory cytokines in the development of idiopathic subglottic stenosis. Transl Cancer Res 2020; 9:2102-2107. [PMID: 35117565 PMCID: PMC8797976 DOI: 10.21037/tcr.2019.12.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022]
Abstract
Idiopathic subglottic stenosis (iSGS) is a debilitating extrathoracic obstruction involving the lower laryngeal and upper tracheal airway. It arises without a known antecedent injury or associated disease process. iSGS is a fibrotic disease marked histologically by excessive accumulation of fibrous connective tissue components of the extracellular matrix (ECM, i.e., collagen and fibronectin) in inflamed tissue, which leads to airway obstruction and clinical dyspnea. Diverse diseases in divergent organ systems are associated with fibrosis, suggesting common pathogenic pathways. One of the most common is sustained host inflammation. Recent investigations focusing on the inflammatory response associated with iSGS have sought to characterize the immunophenotype and cytokine profile of the airway scar in iSGS. While the role of the immune response as inciting event in iSGS remains unresolved, the centrality of an active immune response to the observed subglottic tissue remodeling is becoming more defined.
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Affiliation(s)
- Kevin M Motz
- Department of Otolaryngology & Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alexander Gelbard
- Department of Otolaryngology & Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Fiz I, Monnier P, Koelmel JC, Di Dio D, Fiz F, Missale F, Piazza C, Peretti G, Sittel C. Multicentric study applying the european laryngological society classification of benign laryngotracheal stenosis in adults treated by tracheal or cricotracheal resection and anastomosis. Laryngoscope 2019; 130:1640-1645. [PMID: 31508817 DOI: 10.1002/lary.28274] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/06/2019] [Accepted: 08/16/2019] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Ivana Fiz
- Department of Otorhinolaryngology-Head and Neck Surgery, Stuttgart Hospital, Stuttgart, Germany
| | - Philippe Monnier
- Department of Otolaryngology-Head and Neck Surgery, University Hospital, Vaud University Hospital Center, Lausanne, Switzerland
| | - Jan C Koelmel
- Department of Otorhinolaryngology-Head and Neck Surgery, Stuttgart Hospital, Stuttgart, Germany
| | - Diana Di Dio
- Department of Otorhinolaryngology-Head and Neck Surgery, Stuttgart Hospital, Stuttgart, Germany
| | - Francesco Fiz
- Nuclear Medicine Unit, Department of Radiology, University of Tuebingen, Tuebingen, Germany
| | - Francesco Missale
- Departement of Internal Medicine, University of Genoa, Genoa, Italy.,Department of Otorhinolaryngology-Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Cesare Piazza
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, Scientific Institute for Research and Healthcare Foundation, National Cancer Institute of Milan, University of Milan, Milan, Italy
| | - Giorgio Peretti
- Departement of Internal Medicine, University of Genoa, Genoa, Italy.,Department of Otorhinolaryngology-Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Christian Sittel
- Department of Otorhinolaryngology-Head and Neck Surgery, Stuttgart Hospital, Stuttgart, Germany
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18
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Vocal fold fixation due to proximal stenosis progression complicating idiopathic subglottic stenosis. Eur Arch Otorhinolaryngol 2019; 276:2293-2300. [PMID: 31187240 PMCID: PMC6616212 DOI: 10.1007/s00405-019-05494-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/09/2019] [Indexed: 11/03/2022]
Abstract
Purpose This study examined the incidence and risk factors for vocal fold fixation due to proximal progression of idiopathic subglottic stenosis (ISS) over the course of serial treatments. Methods Records of 22 consecutive patients with ISS treated between 2004 and 2016 were retrospectively reviewed. Patient, stenosis, and treatment details were recorded. Cox regression was used to identify independent predictors of vocal fold fixation. Results All patients were female and mean age at diagnosis was 46 ± 7 years. In five patients, the stenosis was within 15 mm of the glottis at first treatment. Vocal fold fixation due to proximal stenosis progression occurred in seven (32%) patients. It led to permanent hoarseness due to unilateral vocal fold fixation in two patients and caused airway compromise due to bilateral vocal fixation in two other patients. No airway-related deaths occurred and no patient required a tracheostomy. Stenosis incision using coblation or potassium titanyl phosphate laser, and an initial glottis-to-stenosis (GtS) distance < 15 mm significantly increased the risk of proximal stenosis progression on univariable analysis. Conclusion Vocal fold fixation due to proximal stenosis progression is a significant complication of idiopathic subglottic stenosis and causes permanent voice and/or airway sequelae. It should be actively looked for and documented every time a patient is assessed. If a reduction in the GtS distance is observed, definitive surgery should be promptly considered before proximal stenosis progression compromises the efficacy and safety of definitive treatment or, worse, causes vocal fold fixation.
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