Balloon laryngoplasty for acquired subglottic stenosis in children: predictive factors for success

Endoscopic balloon dilatation for pediatric subglottic stenosis: a meta-analysis of successful outcomes

OBJECTIVES

The primary goal of this study was to systematically identify all relevant published articles on the use of primary endoscopic balloon dilation for the management of pediatric patients with subglottic stenosis, critically assess the technique's success, and determine which patients are the best candidates for the procedure.

METHODOLOGY

This was a systematic review and meta-analysis that aimed to investigate the use and success rate of EBD for treating pediatric SGS. An electronic systematic literature search of three major databases, PubMed, EBSCO, and Web of Science&MEDLINE through Clarivate, was conducted to include the eligible articles.

RESULTS

A total of 14 unique studies were included in the final analysis, with 473 cases of pediatric SGS. The pooled success rate of EBD in treatment of pediatric SGS was 76% (k = 14 studies, 95% confidence interval [CI] = 0.65-0.86, P < 0.001, Q test for heterogeneity = 0.03, P < .001, I2 = 91%).

CONCLUSIONS

We reported a high success rate of EBD in treating pediatric SGS. The reported complications were uncommon, although they can be serious and life threatening. The intensity of SGS may be related to the likelihood of therapy failure.

Endoscopic balloon dilatation in the management of paediatric-acquired subglottic stenosis in children

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.

[Balloon dilation as an alternative to tracheotomy for acquired subglottic stenosis in children of the first year of life]

OBJECTIVE

To study the efficacy and safety of balloon dilation as the first choice method in the treatment of children of the first year of life with acquired subglottic stenosis.

MATERIAL AND METHODS

A retrospective analysis of the treatment of 25 patients aged 27 days to 11 months of life (average age 5.3±3.76 months) with subglottic stenosis caused by prolonged intubation, in whom balloon dilation was the first method of treatment. Grade III Cotton-Myer stenosis was preoperatively detected in 22 children, the remaining 3 had grade II stenosis.

RESULTS

The success rate of balloon dilation was 100%; tracheotomy was not required in any case, the absence of stenosis during a follow-up examination in the catamnesis was recorded in 14 (56%) children, the remaining 11 (44%) had grade 0-I stenosis and did not cause respiratory disorders. In 1 child (1.5 years old), a subglottic cyst was removed after balloon dilation. One dilation was required in 18 (72%) children, two - in 5 (20%), three and four - respectively for 1 patient. If additional intervention was necessary, the operation was repeated 10 days - 3 months after the previous one. There were no postoperative complications.

CONCLUSION

Balloon dilation is a highly effective and safe alternative to traditional surgical interventions for acquired subglottic stenosis in children of the first year of life and can be recommended as a method of first choice.

[Surgical treatment of postintubation stenosis of the larynx in children]

Post-intubation laryngeal stenosis is the most common cause of upper respiratory obstruction in children. According to published data, the incidence of post-intubation stenosis ranges from 0.1 to 20%. Treatment of children with chronic laryngeal stenosis is a special branch of respiratory surgery. It remains one of the most complex and urgent problems in pediatrics, pediatric otorhinolaryngology, and pediatric surgery. Although numerous studies have described various methods for treating stenosis of the infraglottic space, there is no standard management approach. Currently, there are two main treatment methods: endoscopic interventions and open reconstructive surgery. Each method has its benefits and drawbacks. Despite the use of various techniques, the effectiveness of cicatricial laryngeal stenosis repair and decannulation in children is 63-64%, according to published data. With combined lesions of infraglottic and vocal cord parts of the larynx, especially with their cicatricial obliteration, reconstructive surgery is successful only in 50% of cases. Thus, treating children with post-intubation respiratory stenosis remains a complex problem and is a relevant direction for further research.

Respiratory problems and associated factors following endoscopic balloon dilatation procedure in children with acquired subglottic stenosıs

OBJECTIVES

Endoscopic balloon dilatation (EBD) offers a safe and non-invasive surgical option for the treatment of subglottic stenosis. Patient selection is important to achieve good results and to detect which patients are more prone to the development of complications. The aim of this study was to determine predictors of postoperative problems and early complications in primary EBD surgeries.

METHODS

A retrospective analysis was made of patients with acquired subglottic stenosis who were operated on with the EBD technique between January 2010 and December 2019 in the Otolaryngology-Head and Neck Surgery Department of Baskent University Hospital. Demographic data including the age and sex of the patients were collected together with etiology, presence of chromosomal or craniofacial anomaly (C/CA), duration of prolonged intubation (DPI), and extubation dilatation timeframe (EDT). Intra and postoperative follow-up data were recorded of the need for intubation or tracheotomy, development of desaturation, and grade and type of stenosis.

RESULTS

The male to female ratio was 2:1. The patients comprised 42 males and 22 females with a mean age of 296.52 ± 551.93 days. The cause of prolonged intubation was surgery for congenital heart disease in 50 (78.1%) patients and prematurity in 14 (21.9%). The type of lesion was acute granulation in 44 (72.1%) and chronic granulation in 17 (27.9%) patients. C/CA was determined in 13 patients, the mean grade of stenosis was 76.33 ± 15.21%, mean DPI was 25.25 ± 35.49 days, and mean EDT was calculated as 78.23 ± 373.82 days. Desaturation following endoscopic balloon dilatation developed in 26 (40.6%), orotracheal intubation was required in 10 (15.6%), tracheotomy in 10 (15.6%), and cardiopulmonary arrest occurred in 4 (6.25%). Prematurity, a longer duration of preoperative intubation, longer time from extubation to dilatation, older age, and higher grade of stenosis were determined as factors associated with postoperative early respiratory complications.

CONCLUSION

EBD indication should be carefully considered in children with acquired subglottic stenosis. To achieve better results and minimise complications, EBD should be performed without delay.

Endoscopic management of pediatric extubation failure in the intensive care unit

OBJECTIVES

This study investigated the endoscopic findings associated with pediatric extubation failure (EF) and evaluated the prognosis of endoscopic procedures.

METHODS

We retrospectively reviewed the data of children with EF in the intensive care unit from January 1, 2013 to December 31, 2019. Fifty-one children receiving endoscopic examination were enrolled in this study. EF was defined as the need for reintubation within 72 h of the first attempted extubation.

RESULTS

Thirty-three children (65%) were successfully extubated after endoscopic procedures, and 18 children (35%) failed in extubation. There was a higher percentage of children transferred from other hospitals with intubation in the failure group (56% vs 12%, p = 0.002). Subglottic stenosis (SGS) (35%) and laryngeal and tracheal granulation (33%) were two of the most common findings. Fourteen patients (82%) with granulation were successfully extubated. Two children in the failure group were diagnosed with mitochondrial myopathies (chrM:3243) and congenital myasthenic syndrome (CHAT). The success rate in cases of SGS reached 83% (15/18). Five patients diagnosed with laryngomalacia and another 3 patients with tracheomalacia failed extubation after supraglottoplasty and needed a temporary tracheostomy.

CONCLUSION

Granulation and subglottic stenosis were the leading causes of extubation failure. Patients transferred with intubation might have a poor prognosis after endoscopic procedures. Neuromuscular and metabolic disorders could be a hidden reason for extubation failure.

Randomized Controlled Trial of Balloon Dilation in Treatment of Subglottic Stenosis With a Rabbit Model

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.

Balloon Laryngoplasty in Pediatric Population with Subglottic Stenosis: 5 Years Experience in King Abdulaziz University Hospital a Tertiary Center

We reviewed our experience with balloon laryngoplasty (BLP) as a primary management of SGS in a tertiary care center in Saudi Arabia. In this review, a total of 147 patients who underwent Laryngobronchoscopy were reviewed. Only 10 pediatric patients diagnosed with SGS who underwent BLP as primary treatment in the period from January 2012 to December 2017 were included. After obtaining ethical approval, included patients' charts were reviewed. Adult patients and those with airway anomalies other than SGS were excluded. This study describes the outcome of 25 episodes of BLP for the selected participants. Sixty percent of the participants were males. Participants' age ranged from 1 to 14 years (mean 6.4 years). Four participants had comorbidities other than SGS. Most patients required more than one episode of BLP (average 3 episodes). Mean hospital stay was 11.7 days. There was no difference in recurrence of symptoms between using laser or knife in subglottic tissue release (p = 0.182). Although recurrence of symptoms was seen in 56% of the patients, almost all patients (100%) became free of symptoms eventually. Patients with co-morbid diseases were more likely to be transferred to PICU post-operatively (p = 0.003). In the treatment of acquired SGS, BLP is an effective and relatively safe alternative to open airway surgery.

Revealing the needs of children with tracheostomies

INTRODUCTION

Small children with tracheostomy are at potential risk and have very specific needs. International literature describes the need for tracheostomy in 0.5% to 2% of children following intubation. Reports of children submitted to tracheostomy, their characteristics and needs are limited in developing countries and therefore there is a lack of health programs and government investment directed to medical and non-medical care of these patients. The aim of this study was to describe the characteristics of these children and identify problems related to or caused by the tracheostomy.

METHODS

A retrospective cohort study was performed based on a common database applied in four high complexity healthcare facilities to children submitted to tracheostomy from January 2013 to December 2015. Data concerning children's demographics, indication for tracheostomy, early and late complications related to tracheostomy, airway diagnosis, comorbidities and decannulation rates are reported. Patients who did not present a complete database or had a follow-up of less than six months were excluded.

RESULTS

A total of 160 children submitted to tracheostomy during the three-year period met the criteria and were enrolled in this study. Median age at tracheostomy was 6.9 months (ranging from 1 month to 16 years, interquartile range of 26 months). Post-intubation laryngitis was the most frequent indication (48.8%). Comorbidities were frequent: neurologic disorders were reported in 40%, pulmonary pathologies in 26.9% and 20% were premature infants. Syndromic children were 23.1% and the most frequent was Down's syndrome. The most common early complication was infection that occurred in 8.1%. Stomal granulomas were the most frequent late complication and occurred in 16.9%. Airway anomalies were frequently diagnosed in follow-up endoscopic evaluations. Subglottic stenosis was the most frequent airway diagnosis and occurred in 29.4% of the cases followed by laryngomalacia, suprastomal collapse and vocal cord paralysis. Decannulation was achieved in 22.5% of the cases in the three-year period. The main cause for persistent tracheostomy was the need for further treatment of airway pathology. Mortality rate was 18.1% during this period but only 1.3% were directly related to the tracheostomy, the other deaths were a consequence of other comorbidities.

CONCLUSION

Tracheostomies were performed mostly in very small children and comorbidities were very common. Once a tracheostomy was performed in a child in most cases it was not removed before a year. The most common early complication was stoma infection followed by accidental decannulation. The most frequent late complication was granuloma and suprastomal collapse. Airway abnormalities were very frequent in this population and therefore need to be assessed before attempting decannulation.

Current trends of balloon laryngoplasty in Thailand

OBJECTIVE

To describe the current trend in balloon laryngoplasty usage and experience by practicing otolaryngologists in Thailand.

STUDY DESIGN

Anonymous 11 question online and paper survey of otolaryngologists on their current balloon laryngoplasty practices.

SUBJECTS AND METHODS

Current practices and experience in balloon laryngoplasty were queried with multiple choice and open-ended questions.

RESULTS

Laser use is the most commonly utilized instrument to treat airway stenosis in Thailand. 86% of respondents do not have experience with balloon dilatation; yet, almost half (47.6%) report they perform a minimum of five airway surgeries per year. Most respondents had been in practice for less than 6 years (41%) and reported that they did not have exposure to balloon use during residency training. The largest barrier reported for the use of balloon instrumentation in the airway is inexperience (44.4%) followed by cost (38.3%), yet most feel that treatment in airway stenosis could benefit by usage of balloons (95.5%).

CONCLUSIONS

Most otolaryngologists in Thailand do not have experience with the use of balloon dilatation and lack of exposure remains the largest barrier to its use. Otolaryngologists in Thailand feel that increased usage of balloons in the airway could improve airway stenosis treatment in the country.

Paediatric subglottic stenosis - Have things changed? Our experience from a developing tertiary referral centre

BACKGROUND

Paediatric airway disorders are common, particularly in the context of improved ventilation methods for neonates in intensive care units. Management is not standardised.

OBJECTIVES

To assess the number, severity, management and outcomes of all patients diagnosed with subglottic stenosis at a developing tertiary referral centre.

STUDY DESIGN

19 month prospective longitudinal study.

STUDY POPULATION

All patients who underwent microlaryngobronchoscopy (MLB) were included. Subglottic stenosis (SGS) was graded intraoperatively using the Myer-Cotton classification.

RESULTS

102 patients underwent MLB during this period. 33 of 102 patients (32.4%) were diagnosed with SGS+/-other co-pathologies. Mean and median age at diagnostic procedure were 24.7 months (SD 23.5) and 18 months, respectively. At their first MLB, 22 of 33 patients (66.7%) were found to have a Grade 1 SGS, 7 of 33 (21.2%) were Grade 2 and the remaining 4 of 33 (12.1%) were Grade 3. We had no patients with Grade 4 SGS. During this period, these patients with SGS underwent 73 MLBs+/-interventions (2.21 per patient) such as incision and balloon dilatation, tracheostomy (2 of 33) or ultimately, laryngotracheal reconstruction (LTR) (2 of 33). A further 3 patients have since undergone LTR. No significant unexpected events occurred.

CONCLUSIONS

These findings suggest that subglottic stenosis may be evolving in terms of its presentation and management. Management can more often be endoscopic and perhaps avoid tracheostomy or laryngotracheal reconstruction. Further long term prospective studies are required.

Predicting outcomes of balloon laryngoplasty in children with subglottic stenosis

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.