Congenital laryngeal anomalies

Recent updates in laryngeal hemangioma management: a scoping review

PURPOSE

To provide a comprehensive review of the current strategies in the management of laryngeal hemangiomas, with an aim to introduce a management algorithm that aligns with the variable clinical presentations and anatomical complexities of these lesions.

METHODS

We conducted an extensive literature search across major databases using specific and general terms, combined with Boolean operators, to ensure comprehensiveness. Articles from January 2004 to August 2023 were included, with findings categorized by management approach.

RESULTS

Laryngeal hemangiomas exhibit a spectrum of manifestations, ranging from asymptomatic lesions to those causing severe airway obstruction. Optimal management demands an individualized approach tailored to the patient's unique presentation and anatomical considerations. Diverse treatment modalities, each with distinct indications, advantages, and limitations, are explored. Notable highlights encompass the prominent role of Beta-blockers, notably Propranolol, in addressing problematic infantile hemangiomas, the nuanced efficacy of laser therapies contingent upon hemangioma type and depth, and the critical relevance of tracheotomy in emergencies. Novel approaches like transoral robotic surgery and transoral ultrasonic surgery, demonstrate promise in specific scenarios. We propose a management algorithm based on the complexity and presentation of laryngeal hemangiomas, emphasizing individualized treatment strategies, thereby addressing the unique challenges and nuances of each case.

CONCLUSION

Laryngeal hemangioma management requires personalized approaches informed by diverse therapies, clinical expertise, and collaboration. The review introduces an algorithm spanning observation to advanced interventions, adapting to each case's complexity. Ongoing research promises innovative treatments.

Congenital subglottic cyst: a rare cause for sudden airway compromise in a newborn

A full-term infant developed stridor, respiratory distress and hypercarbia shortly after birth requiring urgent airway intervention. The patient underwent urgent intubation via rigid bronchoscopy. The diagnosis of congenital subglottic cyst was made. The cyst was decompressed and the patient was extubated the following day. On repeat laryngoscopy 1 month later, there was no residual disease and the patient remained symptom free. Congenital subglottic cysts are extremely rare and the diagnosis can be either missed or misdiagnosed with more common causes of stridor, such as laryngomalacia. Subglottic cysts may cause total airway obstruction and even death if they are large enough and not treated immediately.

3D bioprinting in airway reconstructive surgery: A pilot study

OBJECTIVES

Open surgery is a reliable choice for congenital subglottic stenosis, that represents the third most common congenital anomaly of the larynx. One of the procedures performed is anterior laryngotracheal reconstruction (LTR) with anterior rib graft. The objective of this preliminary study was to evaluate the potential of 3D printing technology for the realization of laryngo-tracheal scaffold in Polycaprolactone (PCL) implanted in vivo in ovine animal model.

METHODS

A 3D computer model of a laryngeal graft and a tracheal graft was designed and printed with PCL through 3D additive manufacturing technology. The scaffolds were seeded with autologous mesenchymal stem cells and cultured in vitro for up to 14 days. Anterior graft LTR with 3D printed scaffolds was performed on 5 sheep. The animals underwent endoscopic examinations at the first, 3rd, 6th, and 12th weeks after surgery and before sacrifice. The integration of the material was evaluated by the pathologist.

RESULTS

Two animals showed a favourable postoperative course and were sacrificed at 6 months postoperatively. In these cases, we observed endoscopically a complete integration of the cellularized PCL scaffold into the peri-implant tissues, and the pathologist found the growth of respiratory epithelium on the scaffold's inner surface. Other two animals showed a difficult post-operative recovery characterized by respiratory distress resulting in early sacrifice on postoperative days 31 and 33. In these animals we found a poor integration of the grafts into the tracheal structure, and a better integration of the laryngeal scaffold. The last animal developed a wound abscess and was sacrificed 80 days after surgery. We observed, in this case, a poor scaffold integration and an acute inflammatory reaction.

CONCLUSIONS

From the preliminary data obtained we found that the excessive stiffness of the material, along with the anatomical features of the sheep, is a major limitation of this study. It will be necessary in the future to create a new biocompatible, more flexible and elastic graft, to achieve greater integration into surrounding tissues. Bioconstructed grafts could simplify surgery for the treatment of laryngo-tracheal stenosis, particularly in the treatment of long tracheal stenoses, which have, at the moment, very complex surgical options.

LEVEL OF EVIDENCE

NA.

Factors associated to functional recovery of left vocal fold motion impairment at two-years-old age in very preterm infants

OBJECTIVE

To describe a cohort of neonates with left vocal fold motion impairment (LVFMI) and the factors associated to it in the neonatal period; procedures required during LVFMI treatment; and clinical outcomes at the age of 2-years. An additional objective was to study those factors which are likely to be most associated to functional recovery of LVFMI at this age.

METHODS

A cohort of patients born in a tertiary care hospital with a diagnosis of left VFMI was included. Factors registered were: gender; clinical presentation at the time of examination; diagnosis of other laryngeal defects associated; data related to their neonatal period (gestational age, congenital heart defects corrective surgery required, neurologic disease, bronchopulmonary dysplasia, non-invasive ventilation required, invasive ventilation required, and tracheostomy required); treatment applied for LVFMI (tracheostomy and/or laryngeal surgery); need of language and hearing therapy; and outcomes considered by the pediatric otolaryngologist at the 2 years-old follow-up visit.

RESULTS

A total of 56 patients with LVFMI diagnosis were included. Only 10 patients (17.9%) showed functional recovery from LVFMI at the age of 2 years. We found significant negative association between this recovery and language and hearing therapy (p = 0.03), which was also associated to psychomotor retardation (p < 0.001). Multivariate analysis produced similar results, being language and hearing therapy the only significant factor associated to a worse outcome (OR = 4.77 [CI95% 1.14; 20.08] p = 0.03).

CONCLUSION

Psychomotor development retardation is negatively associated to functional recovery of full speech in a preterm infant's population with LVFMI diagnosis, regardless of other factors related to LVFMI etiology and severity.

Post-intubation subglottic stenosis in children: Analysis of clinical features and risk factors

BACKGROUND

Subglottic stenosis (SGS) is a complication that develops after intubation and is characterized by respiratory distress. The aim was to evaluate patients with post-intubation SGS and to discover the factors contributing to its development.

METHODS

A total of 112 patients who had a history of intubation were included. The case group consisted of 50 patients with post-extubation persistent respiratory symptoms for which flexible bronchoscopy (FOB) was conducted and showed SGS. The control group consisted of 62 patient with no post-extubation persistent respiratory symptoms, for whom FOB was not done (n = 54), and who had post-extubation persistent respiratory symptoms and underwent FOB, which did not show subglottic stenosis (n = 8).

RESULTS

No significant differences were detected related to age, gender, and gestational age. The median number of recurrent intubations was 2.5 and 3 in the case group and in control group, respectively (P = 0.14). The median duration of intubation was 20.5 days in the case group, and 6 days in the control group (P < 0.001). The Myer-Cotton classification indicated a degree of obstruction of grade 1 (mild) in 30% (n = 15), grade 2 in 16% (n = 8), grade 3 in 48% (n = 24), and grade 4 in 6% (n = 3) of the case group.

CONCLUSION

The duration of intubation was found to be a significant risk factor for SGS development. Age at intubation, gender, gestational age, indication of intubation, and the number of recurrent intubations were found to have no significant association. Patients with post-extubation persistent respiratory problems, especially those with prolonged intubations, should be evaluated for SGS.

Laryngeal stenosis in children: Types, grades and treatment strategies

INTRODUCTION

Laryngeal stenosis is infrequent in children and usually secondary to endotracheal intubation. The aims of this study were to review the outcomes of the distinct endoscopic and surgical procedures and to suggest a technical modification for one of them.

METHODS

Retrospective review of patients with the diagnosis of laryngeal stenosis treated in an academic tertiary care institution between 2000 and 2017. The following variables were analyzed: demographic data, endoscopic findings including anatomic type and severity of the lesion, associated anomalies, type of treatment, outcomes, and time of follow-up.

RESULTS

Seventy-eight children were included in the study (39 boys) with a median age at diagnosis of 9 months, and 33 (42.3%) showed an associated anomaly. Lesions were acquired in 84.6% of cases and the subglottic region was most frequently involved (77%). Thirty patients (38.4%) had a severe stenosis (Myer-Cotton grades III and IV) and a tracheotomy was performed as an initial treatment in 38 patients (48.7%). Overall, 91% of endoscopically or surgically treated patients showed a good outcome and the decannulation rate in the series was 79.4%. Fourteen patients were managed conservatively. Median follow-up was 29 months (I.R. 10-60 m.) CONCLUSIONS: Laryngeal stenosis in children is usually acquired and exhibit a wide range of anatomic presentations. Endoscopic therapeutic procedures may be useful in the management of low grade immature stenosis. Reconstructive surgical techniques may provide a high success rate with an appropriate selection of candidates.

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.

Subglottic Stenosis

The subglottis is a narrow region of the pediatric airway that is exquisitely susceptible to the development of airway stenosis. The incidence of acquired subglottic stenosis in the setting of prolonged intubation has significantly decreased because of improved endotracheal tube management protocols. Advances in otolaryngology interventions, such as balloon dilation and endoscopic cricoid split techniques, may allow the avoidance of tracheostomy in patients with mild to moderate subglottic stenosis. However, patients with severe subglottic stenosis are often tracheostomy dependent. Open surgical techniques to treat severe disease, such as laryngotracheal reconstruction and cricotracheal resection, offer high rates of tracheostomy decannulation.

Flexible Laryngoscopy in Management of Congenital Stridor

The incidence of congenital stridor is on rise due to improved neonate and infant survival rate. The gold standard investigation for evaluation of stridor is rigid laryngotracheobronchoscopy, but this is invasive and requires general anesthesia. Flexible fibreoptic laryngoscopy, a relatively simple and less invasive procedure can be done under topical anaesthesia for evaluation of stridor. In this study, we have presented our experience of flexible laryngoscopy in children with congenital stridor, their results and management. Laryngomalacia was the commonest cause of stridor accounting for 80% of cases. 15% (6) patients required tracheostomy for relieving airway obstruction and 22.5% (9) patients required a definitive surgical procedure for correcting the cause. Flexible laryngoscopy is safe and gives a comprehensive analysis of airway including its dynamic functions. We also recommend flexible laryngoscopy as a frontline investigation for evaluation of stridor.

The outcomes of endoscopic management in young children with subglottic stenosis

Subglottic stenosis (SGS) is a common cause of obstructed airway in children, and the treatment of pediatric SGS, especially congenital SGS, remains a challenge for the otolaryngologist.

OBJECTIVE

To analyze the outcomes of endoscopic management in young children with SGS.

METHODS

We performed a retrospective review of treatment with endoscopic balloon dilation (EBD) or EBD combined with endoscopic anterior cricoid split (EACS) for young SGS children, from December 2008 to December 2015. The ages of patients ranged from 2 days to 12 years, median age was 5 months. The grade of them ranged from II to IV.

RESULTS

For acute acquired SGS, 19 cases received EBD alone and the other 3 cases received EBD and EACS, the success rate was about 95.5%; For chronic acquired SGS, EBD and EACS was performed in 6 patients with a success rate of 66.7%; For congenital SGS, EBD and EACS was performed in 28 patients with a success rate of 85.7%. Overall, the success rate of endoscopic management in 56 young children was about 87.5%. Besides, No procedure-related complications were observed in any patients.

CONCLUSIONS

Endoscopic surgical technique offers a safe and effective approach for treatment of young children with SGS, especially in congenital SGS.

Undersedation is a risk factor for the development of subglottic stenosis in intubated children

OBJECTIVE

To analyze the level of sedation in intubated children as a risk factor for the development of subglottic stenosis.

METHODS

All patients between 30 days and 5 years of age who required endotracheal intubation in the pediatric intensive care unit between 2013 and 2014 were included in this prospective study. They were monitored daily and COMFORT-B scores were obtained. Flexible fiber-optic laryngoscopy was performed within eight hours of extubation, and repeated seven to ten days later if the first examination showed moderate to severe laryngeal injuries. If these lesions persisted and/or if the child developed symptoms in the follow-up period, microlaryngoscopy under general anesthesia was performed to evaluate for subglottic stenosis.

RESULTS

The study included 36 children. Incidence of subglottic stenosis was 11.1%. Children with subglottic stenosis had a higher percentage of COMFORT-B scores between 23 and 30 (undersedated) than those who did not develop subglottic stenosis (15.8% vs. 3.65%, p=0.004).

CONCLUSION

Children who developed subglottic stenosis were less sedated than children who did not develop subglottic stenosis.

Assessment and causes of stridor

Stridor is a variably pitched respiratory sound, caused by abnormal air passage during breathing and often is the most prominent sign of upper airway obstruction. It is usually heard on inspiration (typically resulting from supraglottic or glottic obstruction) but also can occur on expiration (originating from obstruction at or below glottic level and/or severe upper airway obstruction). Stridor due to congenital anomalies may exist from birth or may develop within days, weeks or months. Various congenital and acquired disorders prevail in neonates, infants, children, and adolescents, and have to be distinguished. History, age of the child and physical examination together often allow a presumptive diagnosis. Further investigations may be necessary to establish a definite diagnosis, and flexible airway endoscopy is the diagnostic procedure of choice in most circumstances ("stridor is visible").

The changing face of the paediatric microlaryngobronchoscopy (MLB): A two year prospective study

BACKGROUND

Changes in the management and survival of paediatric patients with airway complaints combined with improving survival rates of premature babies have resulted in a different patient population for the paediatric airway surgeon than that previously described in the literature.

OBJECTIVES

To examine the presentation, diagnosis, clinical course and outcomes for patients undergoing microlaryngobronchoscopy (MLB).

STUDY DESIGN

2 year prospective longitudinal study.

STUDY POPULATION

210 microlaryngobronchoscopy examinations were performed on a total of 102 patients. Mean age at initial examination was 29.4 months with a male preponderance (68%).

RESULTS

72 (71%) patients had other documented medical co-morbidities with 30 children having no previous medical history. Of the 102 patients the primary diagnoses were: Subglottic Stenosis (29.4%), Laryngomalacia (20.6%), Laryngeal Cleft (16.7%), Normal Anatomy (11.8%) and Vocal Cord pathology (5.9%). The average rate of diagnoses per patient for the whole cohort was 1.57. Of those patients with a diagnosis on examination, 40 had a solitary diagnosis whilst 50 patients (55.5%) were found to have multiple diagnoses, equating to 2.35 diagnoses per patient. Children with a history of prematurity accounted for 18.6% of our cohort with a 100% rate of laryngo-tracheal pathology on examination and an average number of diagnoses per child of 2.21.

CONCLUSION

Our cohort illustrates the varied population served by today's paediatric airway surgeon alongside common diagnoses and co-pathologies affecting our patients.