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Leonard JA, Blumenthal DL, Harley EH, Shah RK. Pediatric Airway Balloon Dilation: Urge for Safety Redesign. Otolaryngol Head Neck Surg 2024; 170:987-988. [PMID: 37890052 DOI: 10.1002/ohn.569] [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: 07/01/2023] [Revised: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 10/29/2023]
Abstract
Airway balloons are widely used by otolaryngologists to treat laryngotracheal stenosis. We review an adverse event and interventions that may prevent similar occurrences. There are no other reports of similar incidents in the Food and Drug Administration Manufacturer and User Facility Device Experience. We implore Acclarent to redesign their airway balloon device to prevent accidental airway irrigation.
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Affiliation(s)
- James A Leonard
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Daniel L Blumenthal
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Earl H Harley
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Rahul K Shah
- Department of Pediatric Otolaryngology, Children's National Medical Center, Washington, District of Columbia, USA
- Department of Surgery, Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
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Hu L, He N, He S, Jiao Y. Endoscopic balloon dilatation in the management of paediatric-acquired subglottic stenosis in children. Auris Nasus Larynx 2024; 51:161-166. [PMID: 37544811 DOI: 10.1016/j.anl.2023.07.004] [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: 02/22/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE To summarise our experience and the outcomes of endoscopic balloon dilatation (EBD) in the management of paediatric-acquired subglottic stenosis (SGS), and to further explore the influencing factors of successful EBD. METHOD A retrospective case series study was conducted involving 33 paediatric patients diagnosed with acquired SGS who underwent EBD as the primary treatment from January 2012 to December 2021. The collected information included patient demographics, aetiology, time from extubation to operation, initial grade of SGS, descriptions of stenosis tissues, presence of tracheotomy, number of dilatation procedures and co-morbidity. The follow-up results were collected and analysed. RESULT Thirty-three paediatric patients with an average age of 31.0 months who underwent EBD were included in the study. According to the Myers-Cotton classification, four (12.1%) patients had Grade I stenosis, nine (27.3%) had Grade II, 20 (60.6%) had Grade III and none had Grade IV. Of these, 15 (45.5%) exhibited acute lesions and 18 (54.5%) exhibited chronic lesions. The mean number of dilatation procedures per patient was 1.88 ± 1.05, and 19 (57.6%) patients received dilatations more than once. The overall success rate was 72.7%, with 100% for Grade I, 88.9% for Grade II and 60.0% for Grade III. There was a significant difference between the distribution of the stenosis grades in the successful and failed cases (p < 0.05). The mean number of dilatation procedures was 1.47 ± 0.64 and 2.22 ± 1.22 per patient in those with acute lesions and chronic lesions, respectively. The patients with chronic lesions had a significantly higher number of dilatations than those with acute lesions (p < 0.05). The success rate was 86.7% for acute lesions and 61.1% for chronic lesions. The correlation between the type of subglottic lesions and procedural success was not statistically significant (p > 0.05). CONCLUSION Acquired SGS in paediatric patients can be successfully managed using EBD. The dilatation procedures should be performed in a timely manner, early treatment could prevent the need for multiple procedures and smaller stenosis grades could improve the success rate of the surgery.
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Affiliation(s)
- Lanye Hu
- Department of Otolaryngology and Oral and Maxillofacial Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ning He
- Department of Otolaryngology Head and Neck Surgery, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Shan He
- Department of Otolaryngology and Oral and Maxillofacial Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yu Jiao
- Department of Otolaryngology and Oral and Maxillofacial Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Önder Şahin S, Şahin Yılmaz A, Gergin Ö, Yılmaz B. Balloon Laryngoplasty for Pediatric Subglottic Stenosis: A 5-year Experience. Turk Arch Otorhinolaryngol 2020; 58:208-213. [PMID: 33554194 DOI: 10.5152/tao.2020.5795] [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: 07/19/2020] [Accepted: 08/25/2020] [Indexed: 11/22/2022] Open
Abstract
Objective The objective of this study was to present our experience and evaluate our results of endoscopic balloon laryngoplasty (BL) in children with subglottic stenosis (SGS) at a pediatric tertiary center over a 5-year period. Methods This study reviewed 41 pediatric patients diagnosed with acquired SGS who had undergone BL as the primary course of treatment. Cases were analyzed for details including patient demographics, SGS grade and length, timing and the type of surgery, presence of tracheostomy, comorbidities, postoperative management, complications and outcomes of balloon dilatation. Results Forty-one children (22 girls and 19 boys) who had undergone BL at a mean age of 26 months (range, 1 month to 14 years) were included in the study. Nineteen (46.3%) were diagnosed with acute SGS (12 thin stenosis, 7 thick stenosis) and 22 (53.7%) with chronic SGS (9 thin stenosis, 13 thick stenosis). The success rate of BL was 100% in patients with acute and chronic thin membranous stenosis. The effectiveness of BL was significantly higher in patients with acute thick stenosis than in patients with chronic thick stenosis (p=0.016). Conclusion This study confirms that BL in patients presenting with acquired SGS with thin membranous stenosis, regardless of whether acute or chronic, can have a good prognosis. However, the results are less promising in cases of chronic thick stenosis.
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Affiliation(s)
- Serap Önder Şahin
- Department of Otolaryngology, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Aslı Şahin Yılmaz
- Department of Otolaryngology, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Özgül Gergin
- Department of Otolaryngology, Medipol University Hospital, İstanbul, Turkey
| | - Begüm Yılmaz
- Department of Otolaryngology, University of Health Sciences, Ümraniye Training and Research Hospital, İstanbul, Turkey
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Wistermayer P, McIlwain W, Escalante D, Rogers DJ. Randomized Controlled Trial of Balloon Dilation in Treatment of Subglottic Stenosis With a Rabbit Model. Otolaryngol Head Neck Surg 2020; 163:1003-1010. [PMID: 32571137 DOI: 10.1177/0194599820931486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Identify the effects of balloon dilation duration and topical ciprofloxacin-dexamethasone application in treatment of subglottic stenosis. STUDY DESIGN Randomized controlled trial. SETTING Animal research facility. SUBJECTS AND METHODS Forty-four rabbits underwent subglottic injury in an Institutional Animal Care and Use Committee-approved study. One week after injury, the subglottis of each rabbit was measured and treated with endoscopic balloon dilation for 2 rounds of short duration (SBD; 3 seconds), long duration (LBD; 30 seconds), or LBD with topical ciprofloxacin-dexamethasone application (LBD+C). The subglottis of each rabbit was remeasured at the study endpoint: 1 month postdilation or following development of life-threatening respiratory distress. RESULTS Of 44 rabbits, 35 (80%) survived to endoscopic balloon dilation, with 21 rabbits developing a grade III Cotton-Myer stenosis. Prior to dilation, there was no difference in stenosis rates among groups (all subjects, P = .99; grade III stenosis only, P = .52). Among grade III subjects, improvement in stenosis after dilation was -1% (SD, 21%) for SBD, 27% (SD, 38%) for LBD, and 58% (SD, 29%) for LBD+C (P = .01). Early euthanasia/death rates among grade III subjects were 85% for SBD, 63% for LBD, and 17% for LBD+C (P = .03). Time to early euthanasia/death was 5.0 days for the SBD group and 8.4 days for the LBD group (P = .04). CONCLUSION SBD was inferior to LBD or LBD+C in multiple metrics. LBD+C offered significant improvements in stenosis size and mortality over the SBD group and had the lowest rate of early mortality. Further research is needed to identify optimal balloon dilation treatment duration.
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Schweiger C, Manica D. Ongoing Laryngeal Stenosis: Conservative Management and Alternatives to Tracheostomy. Front Pediatr 2020; 8:161. [PMID: 32351919 PMCID: PMC7174582 DOI: 10.3389/fped.2020.00161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 03/20/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Following tracheal intubation, some children may develop stridor, which is an indication of an obstructive lesion in the airway, such as an ongoing laryngeal stenosis (LS). This review focuses on evaluation of stridor and possible endoscopic predictors of progression to LS and, once post-intubation acute lesions are established, therapeutic choices to manage this disorder in avoidance of tracheostomy. Tracheostomy, due to its inherent increased morbidity, mortality and influence on social stigma, should be viewed only as a last resort. In this article, available conservative and alternative therapies for ongoing LS are thoroughly reviewed. Methods: A systematic review concerning randomized clinical trials and prospective studies on treatment modalities for LS was performed. A search strategy was developed for MEDLINE comprising terms related to disease, intervention and population. Title and abstract from captured references were peer-reviewed for eligibility. Selected studies full-texts were peer-reviewed and the results were compiled in a structured and narrative review. Stridor evaluation and post-extubation acute lesion classification were studied. Treatments such as balloon dilation, rigid dilation, corticosteroid-coated small tube intubation, and corticosteroid nebulization were described and evidence supporting their usage was discussed.
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Affiliation(s)
- Cláudia Schweiger
- Otolaryngology Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Denise Manica
- Otolaryngology Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Lee JC, Kim MS, Kim DJ, Park DH, Lee IW, Roh HJ, Lee BJ, Kim YA, Ko S, Sung ES. Subglottic stenosis in children: Our experience at a pediatric tertiary center for 8 years in South Korea. Int J Pediatr Otorhinolaryngol 2019; 121:64-67. [PMID: 30875621 DOI: 10.1016/j.ijporl.2019.02.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The incidence of SGS has been reported to be less than 8% after endotracheal intubation. Therefore there is an increasing trend in the number of patients with acute acquired SGS due to mechanical ventilation in the intensive care unit. However, there have been no reports describing the treatment of SGS in children in South Korea. The objective of this study was to evaluate the management and outcomes of children with SGS at a pediatric tertiary center in South Korea over an 8-year period. METHODS All patients underwent microlaryngobronchoscopy (MLB) with bougination, incision using cold knife or laser and balloon dilatation. Data on age, sex, grade of SGS, number of management interventions, tracheostomy, comorbidities, mean follow-up period, complications, and outcome were reviewed from patient medical charts. RESULTS Twenty patients (13 [65%] males, 7 [35%] females; mean [±SD] age at the diagnostic procedure 15.26 ± 22.54 months) underwent MLB between March 2009 and December 2017. According to the Myer-Cotton scale, twelve of the 20 (60%) patients had grade III SGS, 7 (35%) had grade II and 1 (5%) had grade 1; there were no patients with grade IV SGS. Nine (45%) patients were diagnosed with acute SGS, and 11 (55%) with chronic SGS. Patients with SGS underwent MLB with interventions (mean 2.41 ± 2.23 per patient). Tracheostomy was performed in 13 of 20 (65%) patients, 2 of 9 (22.2%) with acute SGS, and 11 of 11 (100%) with chronic SGS. Two of 13 (15.3%) patients underwent successful decannulation. One of 2 (50%) patients with acute SGS underwent successful decannulation. Seven of 9 (77.7%) patients with acute SGS underwent MLB only without tracheostomy. CONCLUSIONS In patients with acute acquired SGS, the outcome was good due to the lower rate of tracheostomy and higher decannulation rate. Therefore, it is recommended that MLB with balloon laryngoplasty be performed at the earliest in patients with acute acquired SGS.
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Affiliation(s)
- Jin-Choon Lee
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Min-Sik Kim
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Dong-Jo Kim
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Da-Hee Park
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Il-Woo Lee
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Hwan-Jung Roh
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Byung-Joo Lee
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Medical Research Institute, Pusan National University Hospital, Pusan, South Korea
| | - Young-A Kim
- Department of Pediatrics, College of Medicine, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Sunghwa Ko
- Department of Rehabilitation, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Eui-Suk Sung
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea.
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Jiao A, Liu F, Lerner AD, Rao X, Guo Y, Meng C, Pan Y, Li G, Li Z, Wang F, Zhao J, Ma Y, Liu X, Ni X, Shen K. Effective treatment of post-intubation subglottic stenosis in children with holmium laser therapy and cryotherapy via flexible bronchoscopy. Pediatr Investig 2019; 3:9-16. [PMID: 32851282 PMCID: PMC7331425 DOI: 10.1002/ped4.12113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 10/08/2018] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Post-intubation subglottic stenosis (SGS) in children can be life threatening. Definitive treatment varies and lacks a universally accepted approach. OBJECTIVE We performed a prospective study to assess the safety and feasibility of holmium laser combined with cryotherapy delivered via flexible bronchoscopy for the treatment of post-intubation SGS in children. METHODS This study involved all patients with post-intubation SGS seen at the Interventional Pulmonology Department of Beijing Children's Hospital between July 2014 and December 2016. Holmium laser treatment and cryotherapy was then performed under flexible bronchoscopy, whose parents refused to accept the alternative standard treatment of tracheotomy and balloon dilation under direct laryngoscopy. RESULTS Sixteen patients with post-intubation SGS were included in this study. Ages ranged from 2 months to 12.25 years old. According to the Cotton-Myer grading system, three cases were Grade II, 12 cases were Grade III, and one case was Grade IV. According to the McCaffrey system, eight cases were Stage 1, two cases were Stage 2, and six cases were Stage 3. The average number of procedures was 4.88. Fifteen of the 16 patients achieved clinical cure. One patient achieved clinical improvement. The average treatment course duration was 55.31 days. No severe complications were seen. Post-treatment clinical symptoms, endoscopic findings and quality of life showed marked improvement. INTERPRETATION Our study supports the conclusion that holmium laser treatment combined with cryotherapy via flexible bronchoscopy appears to be a safe and feasible treatment for post-intubation SGS in children.
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Affiliation(s)
- Anxia Jiao
- Interventional Pulmonology DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
| | - Fang Liu
- Interventional Pulmonology DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
| | - Andrew D. Lerner
- Division of Pulmonary and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Xiaochun Rao
- Interventional Pulmonology DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
| | - Yan Guo
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
- Respiratory DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Chenfang Meng
- Interventional Pulmonology DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
| | - Yuena Pan
- Interventional Pulmonology DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
| | - Gan Li
- Interventional Pulmonology DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
| | - Zheng Li
- Pediatric Intensive Care UnitBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Fang Wang
- Department of AnesthesiologyBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Jing Zhao
- Department of Otolaryngology, Head and Neck SurgeryBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- Beijing Key Laboratory for Pediatric Diseases of OtolaryngologyHead and Neck SurgeryMOE Key Laboratory of Major Disease in ChildrenBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yuyan Ma
- Interventional Pulmonology DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
| | - Xicheng Liu
- Interventional Pulmonology DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
| | - Xin Ni
- Department of Otolaryngology, Head and Neck SurgeryBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
- Beijing Key Laboratory for Pediatric Diseases of OtolaryngologyHead and Neck SurgeryMOE Key Laboratory of Major Disease in ChildrenBeijing Pediatric Research InstituteBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Kunling Shen
- China National Clinical Research Center for Respiratory DiseasesBeijingChina
- Respiratory DepartmentBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
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Cheng J, Liu B, Farjat AE. Areas for Quality Improvement for Airway Dilation in Children: NSQIP-Pediatric 30-Day Outcomes. Otolaryngol Head Neck Surg 2018; 158:1119-1126. [PMID: 29405845 DOI: 10.1177/0194599818756590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To identify predictors of adverse events and highlight areas for quality improvement for children who underwent laryngeal or tracheal dilation, without prior tracheostomy placement. Study Design Cross-sectional analysis using a US national database. Setting American College of Surgeons (ACS) National Surgical Quality Improvement Program (ACS NSQIP-pediatric), years 2012 to 2015. Subjects and Methods Patients 18 years and younger were included. Patients without prior tracheostomy placement were identified using 2017 Current Procedural Terminology ( CPT) codes: 31528, 31529, and 31630. Results We identified a total of 160 children who met inclusion criteria. Forty-three (26.9%) patients experienced an adverse event. Mortality was observed postoperatively in 1 patient (0.6%) 1 day after the operation. Younger age, increased number of days from hospital admission to operation, and increased number of days from operation to discharge were noted to be associated with adverse events. Last, the risk of adverse events appears to be mitigated by concurrent other laryngeal procedures. Conclusions There is a high rate of adverse events reported with airway dilation in children. Unplanned reoperations and hospital readmissions are highlighted areas for quality improvement. Airway dilation in children appears to avoid tracheostomy and open laryngotracheoplasty in most cases for at least 30 days postoperatively. Further investigation may be helpful to understand if younger age and delayed operative intervention contribute to increased adverse events.
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Affiliation(s)
- Jeffrey Cheng
- 1 Pediatric Otolaryngology, Department of Surgery, Division of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Beiyu Liu
- 2 Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Alfredo E Farjat
- 2 Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
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Modi VK, Visaya JM, Ward RF. Histopathological effect of balloon dilation in a live rabbit: Implications for the pediatric airway. Laryngoscope 2015; 125 Suppl 6:S1-11. [PMID: 26153243 DOI: 10.1002/lary.25425] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE/HYPOTHESIS To examine the short- and long-term histopathologic changes that occur in the subglottis in response to airway balloon dilation (ABD) with different balloon diameters and inflation pressures. STUDY DESIGN Prospective animal study using forty-two 8-month old New Zealand white rabbits at an academic animal research facility. METHODS Thirty-nine live New Zealand rabbits underwent a single ABD with diameters ranging from 6.0 mm to 10.0 mm and with pressures between 5.0 atmospheres (atm) to 15.0 atm. Animals were euthanized on postoperative days (POD) 1, 7, and 30, and the histopathological changes of the subglottis were examined. Three rabbits served as controls and underwent no ABD. RESULTS The subglottic airway diameter of all specimens measured 5.4 mm. When examining the fracture rate by balloon diameter, we found the following: 0 of 6 (0%) at 6 mm, 0 of 9 (0%) at 7 mm, 6 of 9 (67%) at 8 mm, 8 of 9 (89%) at 9 mm, and 6 of 6 (100%) at 10 mm. There was a statistically significant relationship with the rate of cricoid fracture as balloon diameter increased (P < .0001). All fractures occurred at the anterior cricoid lamina. On POD 1, we found mild ulceration in 5 of 6 (83%) using a 6-mm or 7-mm balloon and in 0 of 6 (0%) using an 8-mm, 9-mm, or 10-mm balloon; and moderate/severe ulceration in 1 of 6 (16.67%) using a 6-mm or 7-mm balloon and in 11 of 11 (100%) using an 8-mm, 9-mm, or 10-mm balloon (P < .0001). Also on POD 1, we found mild edema in 6 of 6 (100%) using a 6-mm or 7-mm balloon and in 5 of 11 (45%) using an 8-mm, 9-mm, or 10-mm balloon; and moderate/severe edema in 0 of 6 (0%) using a 6-mm/7-mm balloon and in 6 of 11 (55%) using an 8-mm, 9-mm, or 10-mm balloon (P =.048). On POD 7, we found fibroplasia in 5 of 6 (83%) using a 6-mm or 7-mm balloon and in 1 of 7 (14%) using an 8-mm, 9-mm, or 10-mm balloon; and moderate/severe fibroplasia in 1 of 6 (17%) using a 6-mm or 7-mm balloon and in 6 of 7 (86%) using an 8-mm, 9-mm, or 10-mm balloon (P =.029). Also on POD7, we found granulation tissue in 0 of 6 (0%) using a 6-mm or 7-mm balloon and in 5 of 7 (71%) using an 8-mm, 9-mm, or 10-mm balloon (P = .021). On POD 30, we found no fibrosis in 0 of 3 (0%) using a 7-mm balloon, mild fibrosis in 1 of 6 (16.67%), and moderate/severe fibrosis in 5 of 6 (83%) using an 8-mm or 9-mm balloon (P = .048). Also on POD 30, we found the mean subglottic cross-sectional luminal area was 23.79 mm(2) with a 7-mm balloon and 29.28 mm(2) with an 8-mm or 9-mm balloon (P = .019). Inflation pressure alone had no correlation with mucosal injury or probability of cricoid fracture. CONCLUSIONS Airway balloon dilation with balloon diameters that exceeded the airway diameter by 2.6 mm was associated with cricoid fractures. All cricoid fractures localized to the anterior cricoid lamina. Balloon diameters larger than the airway diameter by 2.6 mm resulted in a larger subglottic cross-sectional luminal area on POD 30. Airway balloon dilation with balloon diameters that could generate a cricoid fracture created more mucosal injury on POD 0, 1, and 7 than smaller balloon diameters. The histopathological effects of airway balloon dilation observed on POD 0, 1, and 7 resolved by POD 30. When balloon diameter is kept constant, inflation pressure alone had no correlation with mucosal injury or probability of cricoid fracture. LEVEL OF EVIDENCE NA (animal study). Laryngoscope, 125:S1-S11, 2015.
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Affiliation(s)
- Vikash K Modi
- Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, Weill Cornell Medical College, New York, New York
| | - Jiovani M Visaya
- Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, John Hopkins Medical School, Baltimore, Maryland, U.S.A
| | - Robert F Ward
- Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, New York University Langone Medical Center, New York, New York
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10
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Avelino M, Maunsell R, Jubé Wastowski I. Predicting outcomes of balloon laryngoplasty in children with subglottic stenosis. Int J Pediatr Otorhinolaryngol 2015; 79:532-6. [PMID: 25677564 DOI: 10.1016/j.ijporl.2015.01.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 01/14/2015] [Accepted: 01/19/2015] [Indexed: 11/30/2022]
Abstract
UNLABELLED The treatment of subglottic stenosis in children remains a challenge for the otolaryngologist and may involve procedures such as endoscopy, open surgery, and often both. In the recent past, high-pressure balloons have been used in endoscopic treatment due to their relative facility and high success rates. OBJECTIVE To report success rates in the treatment of acquired subglottic stenosis with balloon laryngoplasty in children and identify predictive factors for the success of the technique and its complications. METHODS Descriptive, prospective study of children who were diagnosed with acquired subglottic stenosis and underwent balloon laryngoplasty as the primary treatment. RESULTS Balloon laryngoplasty was performed in 48 children with an average age of 20.7 months: 31 presented with chronic subglottic stenosis and 17 with acute stenosis. Success rate was 100% for acute and 39% for chronic subglottic stenosis. Success was significantly associated with several factors, including recently acquired stenosis, initial grade of stenosis, younger patient age, and the absence of tracheotomy. Complications were transitory dysphagia observed in three children and a submucosal cyst in one of the patients. CONCLUSIONS Balloon laryngoplasty may be considered as a first line of treatment for acquired subglottic stenosis. In acute cases, the success rate was 100%, and even though results are less promising in chronic cases, complications were not significant and the patients can undergo open surgery without contraindications. Predictive factors of success were acute stenosis, less severe grades of stenosis, younger patient age, and the absence of tracheotomy.
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Affiliation(s)
- Melissa Avelino
- Universidade Federal de Góias-UFG, Faculdade de Medicina, Rua 235 com a Primeira Radial s/n, Setor Universitário, CEP 74605-020 Goiânia, GO, Brazil.
| | - Rebecca Maunsell
- Hospital Estadual de Sumaré, Universidade Estadual de Campinas-UNICAMP, Av da Amizade, 2400, CEP 13175-490 Sumaré, SP, Brazil.
| | - Isabela Jubé Wastowski
- Universidade Estadual de Goiás - UEG, Rua 14, n. 625, CEP 75650000 - Morrinhos, GO, Brazil.
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Balloon Dilation of the Pediatric Airway: Clinical and Research Updates. CURRENT OTORHINOLARYNGOLOGY REPORTS 2015. [DOI: 10.1007/s40136-014-0069-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Maunsell R, Avelino MA. Balloon laryngoplasty for acquired subglottic stenosis in children: predictive factors for success. Braz J Otorhinolaryngol 2014; 80:409-15. [PMID: 25303816 PMCID: PMC9444630 DOI: 10.1016/j.bjorl.2014.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 05/24/2014] [Indexed: 10/28/2022] Open
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Chueng K, Chadha NK. Primary dilatation as a treatment for pediatric laryngotracheal stenosis: a systematic review. Int J Pediatr Otorhinolaryngol 2013; 77:623-8. [PMID: 23453794 DOI: 10.1016/j.ijporl.2013.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 01/27/2013] [Accepted: 02/01/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To identify and review original studies on balloon and rigid dilatation as primary therapy for laryngotracheal stenosis (LTS) in pediatric patients. DESIGN Systematic review. METHODS A comprehensive search strategy in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials was conducted and limited to human studies published in English after 1980. Two independent reviewers identified original studies on primary dilatation therapy for LTS in patients younger than 18 years. Studies on tracheobronchial stenosis or stents for tracheomalacia were excluded. 22 of 369 identified studies (6%) met the inclusion criteria. Two reviewers independently appraised the level of evidence of each study, using the Oxford clinical evidence-based medicine guidelines, and extracted raw data using a standardized form developed a priori. RESULTS The patient population consisted of grades I-III LTS. Most studies used adjuvant therapy including laser or topical agents. The primary outcome of success was achieving a functional airway without open laryngo-tracheal surgery or ongoing need for a tracheostomy. In studies using balloon dilatation alone (6 studies, n=10) or rigid dilatation alone (5 studies, n=68), success rates were 50% and 53%, respectively. Success rates ranged from 50% to 78% for balloon dilatation with adjuvant therapy (6 studies, n=24) and 53%-100% for rigid dilatation with adjuvant therapy (5 studies, n=61). CONCLUSIONS Dilatation was successful as primary therapy in the majority of low-grade pediatric LTS. Given the lack of comparative studies among other study limitations, it could not be determined whether one method of dilatation was superior to another.
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Affiliation(s)
- Kristelle Chueng
- Division of Otolaryngology, University of British Columbia, Vancouver, British Columbia, Canada
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