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Xie KZ, Bowen AJ, O'Byrne TJ, Wallerius KP, Awadallah AS, Aden AA, Bayan SL, Edell ES, Vassallo R, Kasperbauer JL, Ekbom DC. Symptom-Free Intervals Following Laser Wedge Excision for Recurrent Idiopathic Subglottic Stenosis. Otolaryngol Head Neck Surg 2024; 171:799-807. [PMID: 38822766 DOI: 10.1002/ohn.831] [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: 10/29/2023] [Revised: 04/08/2024] [Accepted: 04/27/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE Analyze the duration of symptom-free intervals following laser wedge excision (LWE) for recurrent idiopathic subglottic stenosis (iSGS). Secondary aim includes evaluating the influence of patient-related or disease factors. STUDY DESIGN Retrospective review. SETTING Tertiary center. METHODS Review of iSGS patients who underwent LWE between 2002 and 2021. LWE patients without prior airway surgery were labeled LWE primary (LWEP) and those with prior history of dilation were labeled LWE secondary (LWES). A conditional frailty repeated events model was used to analyze the median time to recurrence (MTR) for each nth recurrence. Secondary analysis included stratification by use of medical therapy and initial preoperative characteristics of scar (Myer-Cotton grade, distance between the glottis and superior-most aspect of scar, DGS; length of scar, DL). RESULTS Two hundred and ten iSGS patients underwent LWE (131 LWEP, 79 LWES). The proportion of patients experiencing at least 1, 3, 6, and 12 recurrences, respectively, was 68.0% (n = 143), 40.7% (n = 85), 20.0% (n = 42), and 5.2% (n = 11). There was exponential time-shortening from the 1st to 12th recurrence (P < .0001). While MTR was 4.1 years after the first LWE, this fell to 2.8, 1.7, 1.0, and 0.7 years for the 2nd, 3rd, 6th, and 12th recurrences. Furthermore, LWEP patients experienced longer MTR than LWES counterparts within the first 6 recurrences (P < .01). There was no significant relationship between intersurgical interval and medication adherence, DL, DGS, or grade for recurrences beyond the first (P = .207, P = .20, P = .43, P = .16). CONCLUSION Symptom-free intervals in iSGS shorten with each subsequent recurrence and LWE. The difference in MTR between LWEP and LWES groups was significant within the first 6 recurrences with LWEP having longer MTR. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Katherine Z Xie
- Department of Otolaryngology-Head & Neck Surgery, University of Minnesota-Twin Cities, Minneapolis, Minnesota, USA
| | - Andrew J Bowen
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA
| | - Thomas J O'Byrne
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine P Wallerius
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Aisha A Aden
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Semirra L Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan L Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Dale C Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Altun D, Canbaz M, Altun D, Sen C, Çamcı E. Airway management during unusual tracheal stenosis: A clinical feasibility trial. Laryngoscope Investig Otolaryngol 2023; 8:1169-1177. [PMID: 37899870 PMCID: PMC10601558 DOI: 10.1002/lio2.1151] [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: 06/05/2023] [Revised: 08/12/2023] [Accepted: 08/18/2023] [Indexed: 10/31/2023] Open
Abstract
Objectives Prolonged intubation is a known risk factor of LTS. LTS related to COVID-19 may result in a different phenotype: pronation affects the location of stenosis and COVID-19 pneumonia can decline lung mechanics. Therefore, airway management in these patients may carry unique challenges for both anesthesiologists and surgeons.This prospective observational feasibility trial aims to evaluate the use of a novel thin, cuffed, endotracheal tube (Tritube) in combination with flow-controlled ventilation (FCV) in the management of patients with COVID-19-related LTS undergoing laryngeal surgery. Methods 20 patients suffering from COVID-19-related LTS, as diagnosed by CT, requiring endolaryngeal surgery, with or without CO2 laser, were included. Ultrathin endotracheal tube Tritube, together with FCV was used for airway management and ventilation. Feasibility, ventilation efficiency, and surgical exposure were evaluated. Results Median duration of mechanical ventilation during their ICU stay was 17 days, (range, 7-27), and all patients had been pronated. In 18/20 patients, endoscopic diagnosis confirmed the initial CT diagnosis: posterior subglottic stenosis. Surgeons' satisfaction on the view was rated 9 out of 10 (range 7-10), where 0 was the worst view and 10 was the best view. Hemodynamic and respiratory variables were within the normal clinical range during the surgical procedure. One patient that had a SpO2 of 90% before induction of anesthesia, a temporal drop to 89%, caused meeting the predefined requirement of "respiratory complication." Conclusion This study demonstrates the feasibility of using Tritube with FCV in patients with relatively unusual subglottic posterior location tracheal stenosis, undergoing laryngotracheal surgery. Tritube provides a good surgical field and FCV provides highly adequate ventilation especially in patients with compromised lung mechanics. Level of Evidence IV, non-comparitive prospective clinical trial with 20 patients.
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Affiliation(s)
- Demet Altun
- Istanbul Faculty of Medicine, Department of AnesthesiologyIstanbul UniversityIstanbulTurkey
| | - Mert Canbaz
- Istanbul Faculty of Medicine, Department of AnesthesiologyIstanbul UniversityIstanbulTurkey
| | - Dilek Altun
- Department of Anesthesiology and ReanimationBakırköy Acıbadem HospitalIstanbulTurkey
| | - Cömert Sen
- Istanbul Faculty of Medicine, Department of Otolaryngology&Head and Neck SurgeryIstanbul UniversityIstanbulTurkey
| | - Emre Çamcı
- Istanbul Faculty of Medicine, Department of AnesthesiologyIstanbul UniversityIstanbulTurkey
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3
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Parpucu UM, Aydemir S. Our Clinical Experience With Patients Requiring Intensive Care for Tracheal Stenosis: A Retrospective Case-Control Study. Cureus 2023; 15:e45978. [PMID: 37779683 PMCID: PMC10540508 DOI: 10.7759/cureus.45978] [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] [Accepted: 09/26/2023] [Indexed: 10/03/2023] Open
Abstract
Background and objective The clinical course in patients with tracheal stenosis (TS) ranges from being asymptomatic to respiratory failure requiring follow-up in the ICU. In this study, we aimed to assess the clinical characteristics, management, and outcome of TS patients who were admitted to the ICU. Materials and methods The data of patients hospitalized in the ICU due to TS between January 01, 2015, and January 01, 2016, were analyzed. The patients were classified into two groups: the post-intubation tracheal stenosis (PITS) group and the post-tracheostomy tracheal stenosis (PTTS) group. Demographic characteristics, body mass index (BMI), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment (SOFA) score of patients, factors that caused TS, management of TS, and ICU data of patients were compared. The outcome measures of our study were the ICU management of patients diagnosed with PITS or PTTS, their clinical characteristics, and differences in the treatment between patients diagnosed with PITS and those with PTTS in the ICU. Results Fifteen (75%) patients had PITS and five (25%) had PTTS. While BMI was significantly lower in patients in the PTTS group, the APACHE II and SOFA scores were significantly higher in PTTS patients (p<0.05). In most of the patients in the PITS group, the location of the stenosis was subglottic and at the 1/3 upper part of the trachea, while in the PTTS group, it was located only at the upper 1/3 of the trachea (p>0.05). Mechanical dilatation was performed in all patients in both groups. Mechanical dilatation and cryotherapy were performed in 10 (66.7%) patients in the PITS group (p>0.05), and a stent was applied in addition to this treatment in three (20%) patients in the PITS group and four (80%) patients in the PTTS group (p<0.05). Mechanical ventilation was not needed in 10 (66.7%) PITS patients and three (60.0%) PTTS patients after the interventional procedure. All patients were eventually discharged from the ICU after treatment. Conclusion While higher BMI was common in PITS patients, the PTTS patients were generally in worse condition. In this patient group, interventional pulmonology procedures in the ICU can be life-saving.
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Affiliation(s)
- Umit Murat Parpucu
- Anesthesiology and Reanimation, Gulhane Faculty of Medicine - University of Health Sciences, Ankara, TUR
| | - Semih Aydemir
- Anesthesiology and Reanimation, Ankara Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, University of Health Sciences, Ankara, TUR
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Ferney A, Ferney T, Giraud L, Briault A, Aboussouan MP, Castellanos PF, Atallah I. Endoscopic management of adult subglottic stenosis: an alternative to open surgery. Eur Arch Otorhinolaryngol 2023; 280:1865-1873. [PMID: 36401098 DOI: 10.1007/s00405-022-07733-9] [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: 09/29/2022] [Accepted: 10/26/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE Various surgical techniques could be used to treat subglottic stenosis (SGS). The aim of this study is to present our experience in endoscopic management of SGS and show the impact of symptoms' evaluation, clinical examination and spirometry in the therapeutic decision. METHODS Endoscopic treatment was performed in patients referred for SGS and consisted of CO2 scar lysis associated with balloon dilation and concomitant steroids' injection for patients with grade II or higher on the mMRC (modified Medical Research Council) dyspnea scale associated with a DI (Dyspnea Index) score higher than 10/40 and objective stenosis equal or higher than grade II. The preoperative DI score, EDI (expiratory disproportion index) and voice parameters were compared to postoperative results. The mean interval between endoscopic procedures (IEP) was calculated and we looked for the evolution of the IEP during repeated procedures. RESULTS Nineteen patients were included. 35 dilations were performed. The mean IEP was 86 weeks. There was a significant decrease of the postoperative DI scores by 18.6 points ± 11 (SD). An important difference of 20.1 ± 13.5 (SD) was identified between the pre and postoperative EDI. Minimal changes occured in voice parameters. CONCLUSIONS Endoscopic treatment with CO2 scar lysis associated with balloon dilation and concomitant steroids' injection is a safe, reliable and minimally invasive endoscopic procedure to treat SGS. Decision to treat has to be on an individual basis taking into account subjective symptoms including Dyspnea Index score and objective laryngoscopic findings and spirometry.
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Affiliation(s)
- Adrien Ferney
- Otolaryngology-Head and Neck Surgery Department, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France
- School of Medicine, Grenoble Alpes University, Domaine de la Merci, BP 170 La Tronche, 38042, Grenoble Cedex 9, France
| | - Thibault Ferney
- Food Science and Engineering, Nantes-Atlantic National College of Veterinary Medicine, Oniris, BP 40706, 44307, Nantes Cedex 03, France
| | - Ludovic Giraud
- Otolaryngology-Head and Neck Surgery Department, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France
- School of Medicine, Grenoble Alpes University, Domaine de la Merci, BP 170 La Tronche, 38042, Grenoble Cedex 9, France
| | - Amandine Briault
- School of Medicine, Grenoble Alpes University, Domaine de la Merci, BP 170 La Tronche, 38042, Grenoble Cedex 9, France
- Food Science and Engineering, Nantes-Atlantic National College of Veterinary Medicine, Oniris, BP 40706, 44307, Nantes Cedex 03, France
- Pulmonology Department, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France
| | - Marie-Pierre Aboussouan
- Department of Anesthesiology and Intensive Care Medicine, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France
| | - Paul F Castellanos
- Mercy Health, St. Rita's Ear, Nose and Throat, 770 West High Street, Suite 460, Lima, OH, 4580, USA
| | - Ihab Atallah
- Otolaryngology-Head and Neck Surgery Department, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France.
- School of Medicine, Grenoble Alpes University, Domaine de la Merci, BP 170 La Tronche, 38042, Grenoble Cedex 9, France.
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5
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Conforti S, Licchetta G, Reda M, Astaneh A, Pogliani L, Fieschi S, Rinaldo A, Torre M. Management of COVID-19-related post-intubation tracheal stenosis. Front Surg 2023; 10:1129803. [PMID: 36969759 PMCID: PMC10034358 DOI: 10.3389/fsurg.2023.1129803] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/01/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionThe Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has affected Italy since the beginning of 2020. Endotracheal intubation, prolonged mechanical ventilation, and tracheostomy are frequently required in patients with severe COVID-19. Tracheal stenosis is a potentially severe condition that can occur as a complication after intubation. The aim of this study was to evaluate the utility and safety of endoscopic and surgical techniques in the treatment of tracheal stenosis related to COVID-19.Materials and MethodsBetween June 2020 and May 2022, consecutive patients with tracheal stenosis who were admitted to our surgical department were considered eligible for participation in the study.ResultsA total of 13 patients were included in the study. They consisted of nine women (69%) and four men (31%) with a median age of 57.2 years. We included seven patients with post-tracheostomy tracheal stenosis. Bronchoscopy was performed to identify the type, location, and severity of the stenosis. All patients underwent bronchoscopic dilation and surveillance bronchoscopy at 7 and 30 days after the procedure. We repeated endoscopic treatment in eight patients. Three patients underwent tracheal resection anastomosis. Final follow-up bronchoscopy demonstrated no residual stenosis.ConclusionsThe incidence of and risk factors associated with tracheal stenosis in critically ill patients with COVID-19 are currently unknown. Our experience confirms the efficacy and safety of endoscopic management followed by surgical procedures in cases of relapsed tracheal stenosis.
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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: 3] [Impact Index Per Article: 1.0] [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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7
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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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8
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Long-term intubation and high rate of tracheostomy in COVID-19 patients might determine an unprecedented increase of airway stenoses: a call to action from the European Laryngological Society. Eur Arch Otorhinolaryngol 2020; 278:1-7. [PMID: 32506145 PMCID: PMC7275663 DOI: 10.1007/s00405-020-06112-6] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/03/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The novel Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, may need intensive care unit (ICU) admission in up to 12% of all positive cases for massive interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common airway-related complications of such ICU maneuvers are laryngotracheal granulomas, webs, stenosis, malacia and, less commonly, tracheal necrosis with tracheo-esophageal or tracheo-arterial fistulae. MATERIALS AND METHODS This paper gathers the opinions of experts of the Laryngotracheal Stenosis Committee of the European Laryngological Society, with the aim of alerting the medical community about the possible rise in number of COVID-19-related laryngotracheal stenosis (LTS), and the aspiration of paving the way to a more rationale concentration of these cases within referral specialist airway centers. RESULTS A range of prevention strategies, diagnostic work-up, and therapeutic approaches are reported and framed within the COVID-19 pandemic context. CONCLUSIONS One of the most important roles of otolaryngologists when encountering airway-related signs and symptoms in patients with previous ICU hospitalization for COVID-19 is to maintain a high level of suspicion for LTS development, and share it with colleagues and other health care professionals. Such a condition requires specific expertise and should be comprehensively managed in tertiary referral centers.
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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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10
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Fiz I, Koelmel JC, Piazza C, Fiz F, Di Dio D, Bittar Z, Peretti G, Sittel C. Predictors of recurrence after surgical treatment of idiopathic progressive subglottic stenosis. ACTA ACUST UNITED AC 2019; 38:417-423. [PMID: 30498269 PMCID: PMC6265673 DOI: 10.14639/0392-100x-1872] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/16/2017] [Indexed: 12/27/2022]
Abstract
Idiopathic progressive subglottic stenosis is a rare cause of tracheal narrowing. Partial cricotracheal resection and anastomosis can cure idiopathic stenosis, even if some patients may require multiple interventions and experience voice and swallowing deterioration. We investigated risk factors for retreatment and assessed the impact of crico-tracheal resection on functional parameters. We conducted a retrospective multicentric study on 44 female patients (mean age 52.6 ± 13.1 years) affected by idiopathic stenosis and treated by crico-tracheal resection between 2002 and 2016. Functional outcomes after crico-tracheal resection were assessed by the airway-dyspnoea-voice-swallowing score (range 1-5, with “1” expressing normal and “5” completely altered function). Previous treatments, grade of stenosis, site, airway comorbidities, age and resection length were tested as predictors of postoperative complications and number of additional treatments, using bivariate and multivariate analysis. The overall decannulation rate was 97.3%. The dyspnoea score improved (mean variation 1.4 ± 1.0; p < 0.001), while voice and swallowing were negatively affected (mean variation 1.6 ± 0.9 and 0.5 ± 0.7, respectively; p < 0.001). Airway comorbidities were associated with a higher rate of complications (p < 0.05). Retreatments were more frequent in patients with postoperative complications (p < 0.05). The length of resection correlated with the number of subsequent treatments (R = 0.52; p < 0.01). At multivariate analysis, post-operative complications were predicted by comorbidities and disease stage (p < 0.05); number of retreatments was linked to the length of resection (p < 0.05) as well as with the application of mitomycin C (p < 0.001). Crico-tracheal resection for idiopathic progressive subglottic stenosis offers good functional results in terms of airway patency. These data suggest that a higher complication rate can be expected in patients affected by comorbidities. Moreover, more extensive surgical resection seems to be associated with the occurrence and number of subsequent retreatments. On the contrary, the local application of an anti-proliferative drug does not seem to be of use in preventing recurrences.
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Affiliation(s)
- I Fiz
- Department of Otorhinolaryngology Head and Neck Surgery, Klinikum Stuttgart, Germany
| | - J C Koelmel
- Department of Otorhinolaryngology Head and Neck Surgery, Klinikum Stuttgart, Germany
| | - C Piazza
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Italy
| | - F Fiz
- Nuclear Medicine Unit, Department of Radiology, Uni-Klinikum Tuebingen, Germany.,Department of Internal Medicine, University of Genoa, Italy
| | - D Di Dio
- Department of Otorhinolaryngology Head and Neck Surgery, Klinikum Stuttgart, Germany
| | - Z Bittar
- Institute for Pathology, Klinikum Stuttgart, Germany
| | - G Peretti
- Department of Otorhinolaryngology Head and Neck Surgery, University of Genoa, Italy
| | - C Sittel
- Department of Otorhinolaryngology Head and Neck Surgery, Klinikum Stuttgart, Germany
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Yin LX, Padula WV, Gadkaree S, Motz K, Rahman S, Predmore Z, Gelbard A, Hillel AT. Health Care Costs and Cost-effectiveness in Laryngotracheal Stenosis. Otolaryngol Head Neck Surg 2018; 160:679-686. [PMID: 30481123 DOI: 10.1177/0194599818815068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Laryngotracheal stenosis (LTS) is resource-intensive disease. The cost-effectiveness of LTS treatments has not been adequately explored. We aimed to conduct a cost-effectiveness analysis comparing open reconstruction (cricotracheal/tracheal resection [CTR/TR]) with endoscopic dilation in the treatment of LTS. STUDY DESIGN Retrospective cohort. SETTING Tertiary referral center (2013-2017). SUBJECTS AND METHODS Thirty-four LTS patients were recruited. Annual costs were derived from the Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University. Cost-effectiveness analysis compared CTR/TR versus endoscopic dilation at a willingness-to-pay threshold of $50,000 per quality-adjusted life year (QALY) over 5- and 10-year time horizons. The incremental cost-effectiveness ratio (ICER) was calculated with deterministic analysis and tested for sensitivity with univariate and probabilistic sensitivity analysis. RESULTS Mean LTS costs were $4080.09 (SE, $569.29) annually for related health care visits. The major risk factor for increased cost was etiology of stenosis. As compared with idiopathic patients, patients with intubation-related stenosis had significantly higher annual costs ($5286.56 vs $2873.62, P = .03). The cost of CTR/TR was $8583.91 (SE, $2263.22). Over a 5-year time horizon, CTR/TR gained $896 per QALY over serial dilations and was cost-effective. Over a 10-year time horizon, CTR/TR dominated dilations with a lower cost and higher QALY. CONCLUSION The cost of treatment for LTS is significant. Patients with intubation-related stenosis have significantly higher annual costs than do idiopathic patients. CTR/TR contributes significantly to cost in LTS but is cost-effective versus endoscopic dilations for appropriately selected patients over a 5- and 10-year horizon.
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Affiliation(s)
- Linda X Yin
- 1 Department of Otorhinolaryngology, School of Graduate Medical Education, Mayo Clinic, Rochester, Minnesota, USA
| | - William V Padula
- 2 Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shekhar Gadkaree
- 3 Massachusetts Eye and Ear Infirmary, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Kevin Motz
- 4 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sabrina Rahman
- 2 Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Zachary Predmore
- 2 Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander Gelbard
- 5 Department of Otolaryngology, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA.,6 North American Airway Collaborative, Nashville, Tennessee, USA
| | - Alexander T Hillel
- 4 Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,6 North American Airway Collaborative, Nashville, Tennessee, USA
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Collins AM, Chorath K, Simpson CB. Subglottic stenosis: An evaluation of an elderly treatment‐seeking population. Laryngoscope 2018; 129:1155-1158. [DOI: 10.1002/lary.27495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/16/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Alissa M. Collins
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Health Science Center at San Antonio San Antonio Texas U.S.A
| | - Kevin Chorath
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Health Science Center at San Antonio San Antonio Texas U.S.A
| | - C. Blake Simpson
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Health Science Center at San Antonio San Antonio Texas U.S.A
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Asik MB, Birkent H. Analysis of Age-Related Differences of Risk Factors and Comorbidities in Laryngotracheal Stenosis Patients. Indian J Otolaryngol Head Neck Surg 2018; 71:510-514. [PMID: 31742012 DOI: 10.1007/s12070-018-1375-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022] Open
Abstract
Laryngotracheal stenosis (LTS) is a life threatening airway problem that is mainly caused by prolonged intubation. The authors intend to assess whether there was variability in the risk factors depending on age, and to determine which risk factors and comorbidities were more important in the development of LTS at older or younger ages. Fifty-two LTS patients were evaluated for comorbidities and risk factors retrospectively. The LTS etiologies, demographics, and medical and surgical histories of the patients were determined by the medical records. The patients under 40 years old were defined as group 1, and the patients 40 years of age or older were defined as group 2. Our study revealed that with regard to GERD, hypertension, DM2, and pulmonary infection, there was a statistically significant difference between group 1 and group 2 (p = 0.025, p = 0.0005, p = 0.002, and p = 0.000, respectively). Those patients ≥ 40 years old exhibited higher rates of GERD, hypertension, DM2, and pulmonary infection. However, there were no statistically significant differences between the groups with regard to smoking, alcohol consumption, COPD/asthma, immunological disease, and obesity (BMI > 30). There was a statistically significant difference between the groups for all the risk factors except a previous tracheotomy (p = 0.115). The risk factors and comorbidities thought to be involved in the development of LTS could show age-related variability. Therefore, in patients over 40 years of age with comorbidities (GERD, hypertension, DM2, and pulmonary infection), it is necessary to take precautions before the development of LTS. Prolonged intubation and tracheotomy history are the main risk factors for all patients, regardless of age.
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Affiliation(s)
- Mehmet Burak Asik
- Department of Otolaryngology, Head and Neck Surgery, Gulhane Research and Training Hospital, Ankara, Turkey
| | - Hakan Birkent
- Department of Otolaryngology, Head and Neck Surgery, Centrium Hospital, Istanbul, Turkey
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Donahoe L, Keshavjee S. Contemporary Management of Idiopathic Laryngotracheal Stenosis. Thorac Surg Clin 2018; 28:167-175. [DOI: 10.1016/j.thorsurg.2018.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shabani S, Hoffman MR, Brand WT, Dailey SH. Endoscopic Management of Idiopathic Subglottic Stenosis. Ann Otol Rhinol Laryngol 2016; 126:96-102. [PMID: 27864505 DOI: 10.1177/0003489416675357] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe a homogeneous idiopathic subglottic stenosis (ISS) population undergoing endoscopic balloon dilation and evaluate factors affecting inter-dilation interval (IDI). METHODS Retrospective review of 37 patients. Co-morbidity prevalence versus normal population was evaluated using chi-square tests. Correlations were evaluated using Pearson product moment tests. Independent samples t tests/rank sum tests assessed differences between groups of interest. RESULTS All patients were female aged 45.9 ± 15.4 years at diagnosis. Four required a tracheotomy during management. Most prevalent co-morbidity was gastroesophageal reflux disease (GERD) (64.9%; P = .036). Body mass indices (BMI) at first and most recent dilation were 29.8 and 30.8 ( P = .564). Degree of stenosis before first dilation was 53 ± 14%. Patients underwent 3.8 ± 1.8 dilations (range, 1-11). Average IDI was 635 ± 615 days (range, 49-3130 days), including 556 ± 397 days for patients receiving concomitant steroid injection and 283 ± 36 for those who did not ( P = .079). Inter-dilation interval was not correlated with BMI ( r = 0.0486; P = .802) or number of co-morbidities ( r = -0.225, P = .223). CONCLUSIONS Most patients with ISS can be managed endoscopically, and IDI may be increased with steroid injection. Gastroesophageal reflux disease is a common co-morbidity. Body mass index did not change over time despite potential effects on exercise tolerance; BMI did not affect IDI. Methods to determine optimal timing for next intervention are warranted.
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Affiliation(s)
- Sepehr Shabani
- 1 Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Matthew R Hoffman
- 1 Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - William T Brand
- 1 Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Seth H Dailey
- 1 Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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