Acquired paediatric subglottic cysts: a series from Manchester

Subglottic cysts in preterm infants: superficially located cysts versus deeply buried cysts in the mucosa

PURPOSE

To analyze the reason for the diversity of the clinical course of subglottic cysts and discuss their pre- and coexistence with subglottic stenosis.

METHODS

The medical records of patients who were treated for subglottic cysts between 2003 and 2020 were retrospectively reviewed and direct laryngoscopy videos were analyzed to assess the healing patterns of their disease.

RESULTS

Of the 15 patients, 10 had a history of intubation in the neonatal period. In 11 patients, the cysts were transparent and well defined, and no recurrence of subglottic cysts occurred after the initial surgery. In four patients, the cysts were located deep in the mucosa and did not have the typical appearance of a cyst, but rather of a stenotic segment; all of them had a history of intubation and three of them required laryngotracheal reconstruction.

CONCLUSION

Transparent, thin-walled superficial subglottic cysts with healthy surrounding mucosa can easily be treated with endoscopic marsupialization; however, the treatment of deep subglottic cysts can be challenging. The coexistence of subglottic cysts and subglottic stenosis is not rare. We point out the need for considering the possibility of a missed deep submucosal cyst in a seemingly refractory case of pediatric subglottic stenosis with atypical endoscopic findings and with a background history of prior intubation.

Acquired subglottic cysts in children: A rare and challenging clinical entity. A systematic review

INTRODUCTION

Subglottic cysts (SGCs) are a rare cause of laryngeal stenosis that mainly seem to affect preterm infants with an intubation history.

PURPOSE

To review the related literature and compare different management protocols for patients presenting SGCs, as well as briefly report our clinical case treated at Verona University Hospital by Pediatric Airways Team.

METHODS

The articles resulting from a PubMed and MEDLINE search were analysed and selected using previously established criteria. A systematic review of the selected papers was conducted following PRISMA guidelines.

RESULTS

The search yielded 571 related articles; cross-checking of articles led to the identification and exclusion of 239 duplicates. The remaining 332 papers were screened according to previously established eligibility criteria. The final number of selected articles was 13.

CONCLUSIONS

Well-planned teamwork, with active collaboration between the ENT specialists, pediatricians and anesthesiologists, is the key to achieve multidisciplinary management of patients diagnosed with SGCs. Long-term follow-up is crucial considering the high recurrence rate of this disease.

Subglottic cysts: The Great Ormond Street experience in 105 patients

PURPOSE

The aim of the study was to assess the contemporary presentation and management of subglottic cysts and make recommendations on the treatment of these patients.

METHODS

Retrospective case series of 105 patients between October 1999 and November 2017 from a paediatric teaching hospital.

RESULTS

Ninety-one percentage (n = 96) had a history of prematurity, with a mean gestation of 27.2 weeks (SD ± 4.1). A history of intubation was found in 99% (n = 104) of cases [median 18 days (range = 1-176)]. Presenting symptoms were: Stridor 57.1%, (n = 60), difficult intubation 14% (n = 15), recurrent croup 11.4% (n = 12), failed extubation 7.6%, (n = 8), hoarseness/weak cry 10.5% (n = 10). Ninety percentage (n = 94) underwent intervention for management of SGCs with 86% (n = 81) treated with cold steel marsupialisation and 14% (n = 13) with CO ₂ laser. Recurrent cysts occurred in 56% (n = 53) of cases. Treatment modality did not affect recurrence (p = 0.594 ^Δ). Sixty-six percentage (n = 69/105) of patients had one or more concurrent airway pathology at MLB. Most frequent was subglottic stenosis 47% (n = 49), with 16% (n = 8) subsequently requiring open reconstructive airway surgery. Mean duration of follow-up was 47.6 months (SD ± 38.3).

CONCLUSION

SGC are an uncommon, reversible cause of upper airway obstruction and should be considered in the list of differential diagnoses in patients with a history of prematurity and perinatal intubation, presenting with stridor. While concurrent SGS is common, adequate symptom improvement in such cases may be achieved with SGC removal alone. Management is by surgical marsupialisation. Recurrence and additional airway pathologies are common and may necessitate longer-term treatment in centres with paediatric airway expertise.

Anesthesia for shared airway surgery in children

Shared airway surgery in children is a complex, high-risk undertaking that requires continuous communication and cooperation between the anesthetic and surgical teams. Airway abnormalities commonly seen in children, the surgical options, and the anesthetic techniques that can be used to care for this vulnerable population are discussed. Many of these procedures were traditionally carried out using jet ventilation, or intermittent tracheal intubation, but increasingly spontaneously breathing "tubeless" techniques are being used. This review has been written from both the surgical and anesthetic perspective, highlighting the concerns that both specialties have in relation to the maintenance of surgical access and operating conditions, and the need for the provision of anesthesia, oxygenation, and ventilation where the airway is the primary site of operation.

[Surgical treatment of laryngeal cysts in children with argonplasma coagulation]

Laryngeal diseases in young children are much less common than diseases of other ENT organs, which allows them to be attributed to the poorly studied section of pediatric otorhinolaryngology. This article presents the results of the examination and treatment of 37 children from different regions of the Russian Federation (aged 11 months to 3 years) with laryngeal cysts. The purpose of the study was to improve the results of surgical treatment for young children with laryngeal cysts.

Stridor Secondary to Acquired Subglottic Cyst: Rarity Makes it Missed

Subglottic cysts (SGCs) are a rare cause of airway obstruction in children. Medical advances, higher survival rates for preterm infants, and improved diagnostic equipment have increased the number of reported cases of SGCs over the last three decades, the majority occurring in infants who had been extremely premature neonates and had suffered from respiratory distress, therefore having been intubated and managed in neonatal ICUs. Symptoms of laryngeal cysts depend on the size and the location of the cyst and include a change in the tone of voice, dysphonia, hoarseness, dysphagia, stridor, and dyspnea. This condition is often misdiagnosed as laryngomalacia, asthma, croup, or other diseases, due to the fact that it manifests as recurring respiratory infections, stridor, and wheezing. Death can occur in severe cases that are not treated. When present, it may account for severe inspiratory stridor that compromise the airway. The accepted gold standard treatment is direct laryngoscopy with marsupialization of the cyst to prevent recurrence. Two cases of subglottic cyst in our centre are described here. Although all cases presented differently, but in both of our cases, which have previous history of intubation with prematurity were initially diagnosed as laryngomalacia and croup.

Anesthesia for patients with subglottic cysts

Acquired subglottic cysts can cause rapid development of respiratory distress. Subglottic cysts are a disease of premature infants and other pathologies of prematurity should be anticipated. Perioperative success is dependent on communication between surgeon and anesthesiologist. Contingency plans for an emergency surgical airway should be in place in the event of total airway obstruction.

Endoscopic airway findings in children with or without prior endotracheal intubation

BACKGROUND

Airway alterations found after endotracheal intubation are usually associated with mechanical trauma from the tube. However, no studies are available concerning alterations in airways that have never been intubated before. It was the aim of the study to compare endoscopic findings in the larynx and trachea of children who had undergone prior endotracheal intubation with findings in children who had not been intubated before.

METHODS

In 1021 children aged from 0 to 6 years, rigid endoscopies were performed before planned elective endotracheal intubation. The anonymized endoscopy videos were reviewed and graded by five international airway experts. Data was compared between the two groups using the chi-square test (P ≤ 0.05).

RESULTS

Endoscopic records of 971 children (473 with prior intubation; 498 without prior airway intubation) were included in the final calculations. Most patients (93.7%) with prior intubation had been intubated with a cuffed tube. The number of intubations ranged from 1 to 27. The median interval between intubation and endoscopy was 0.53 years (0.003-5.57 years). Abnormal findings were observed in 31.7% and 26.8% of patients with and without prior intubation, respectively (P = 0.063). Glottic granulomas were significantly more common after intubation (3.6% vs 1.4%; P = 0.028). The incidence of other abnormal findings was similar in both groups.

CONCLUSION

Endoscopic airway alterations can be observed in about one-quarter of children presenting for routine surgery without prior intubation. Except for glottic granulomas, the abnormalities are found with similar frequency in patients with and without prior intubation. No relevant airway damage from short-term endotracheal intubation was found.

Acquired subglottic cysts: management and long term outcome

OBJECTIVES

To assess the diagnostic strategy, treatment and outcome of acquired subglottic cysts.

MATERIALS AND METHODS

Retrospective, monocentric, tertiary referential center study of 172 preterm neonates assessed by endoscopic examination over a 10 years period. Identification of patients presenting with subglottic cysts.

RESULTS

17 children were diagnosed with subglottic cysts. Among them, 98% were prematurates (28 ± 4 weeks of gestation), and 76% had a history of hyaline membrane disease or a bronchopulmonary dysplasia. All patients were intubated during the neonatal period, for a mean duration of 14 days. Mean age at diagnosis was 8 months. An associated laryngotracheal anomaly was diagnosed in 30% of cases. Six procedures, including flexible controls, were needed to achieve full recovery. We used cold steel microinstruments, CO(2) or Thulium LASER. Mean follow up was 3 years.

CONCLUSIONS

Acquired subglottic cysts concern early preterm infants. Children treated for subglottic cysts should undergo a long term follow up, as there is a trend for cysts to recur, as well as a risk of secondary subglottic stenosis.

Subglottic cyst: the role of narrow-band imaging

A subglottic cyst is a rare cause of neonatal upper airway obstruction, which may be misinterpreted as a subglottic hemangioma. With the advent of narrow-band imaging, the application of its unique features in analyzing the mucosa surface's vascular structures in pediatric subglottic lesions remains to be investigated. Here, we report the case of a preterm baby who developed two subglottic cysts when he was 3-months old. Both traditional endoscopic examination and narrow-band imaging were performed pre-operatively. Both the potential impact of this new technique and the diagnosis and management of this disease are discussed.

Evaluation of pediatric subglottic cysts

INTRODUCTION

Subglottic cysts (SGCs) are increasingly recognized as a cause of upper airway obstruction in previously intubated infants. Endoscopic marsupialization with cold steel instruments or CO(2) laser has been reported to be the standardised treatment method for SGCs. SGC case series of 9 patients who were treated with endoscopic marsupialization with cold steel instruments or CO(2) laser and mechanical decompression with balloon dilatation are presented.

PATIENTS AND METHODS

Retrospective study of 9 cases of subglottic cysts treated between 2003 and 2010 was done. Diagnoses were made by performing flexible nasopharyngolaryngoscopy and surgical treatment was done through endoscopic marsupialization with cold steel instruments or CO(2) laser.

RESULTS

The age range of SGC patients were between 3 months and 36 months (average 12, 11 months). Two of the patients were female (2/9), 7 of them were male (7/9). SGC diagnoses were made by flexible nasopharyngolaryngoscopy. History of intubation was noted in 3 of the patients (3/9). Duration of intubation was 28 days, 6 days, and 8 days respectively. Cysts were multiple in all cases, and located posteriorly and laterally at the subglottic area and upper trachea. The patients presented with were stridor, fail to thrive, and recurrent croup attacks. Treatment methods preferred for these patients were endoscopic marsupialization with cold steel instruments or CO(2) laser and mechanical decompression with balloon dilatation. The follow-up period after treatment ranged between 8 months and 3 years. Recurrence of the SGCs did not happen and re-evaluation under general anesthesia was reserved for the symptomatic patients.

CONCLUSION

Diagnostic laryngoscopy and bronchoscopy are important in diagnosing SGC. History of premature birth and intubation are not 'sine qua non' of SGC as SGC may be congenital as well. Symptoms of SGCs may mimic the characteristic features of chronic obstructive lung disease, so evaluation of the airway should be considered in such infants if they have stridor or hoarseness not responding to routine treatment. Laryngoscopy and bronchoscopy are routinely indicated for airway evaluation in at-risk infants.

Management of subglottic cysts with Mitomycin-C-A case series and literature review

OBJECTIVES

To describe the management and outcomes of seven infants with subglottic cysts. To assess the role of Mitomycin-C in the management of subglottic cysts. To discuss the relationship of subglottic cysts with gastro-esophageal reflux. To extensively review the literature on subglottic cysts.

DESIGN

Retrospective case series and literature review.

METHODS

Case series of seven children with subglottic cysts at a tertiary care hospital. Charts were reviewed to determine birth history, gender, intubation history, comorbidities, age at presentation, presenting symptoms, interventions and follow-up.

RESULTS

Between 2001 and 2009, seven patients aged 4-13 months were diagnosed with and treated for subglottic cysts. All children had a history of intubation and had evidence of gastro-esophageal reflux. All children were treated with endoscopic marsupialization (CO(2)-laser, cupped forceps) or bronchoscopic rupture; with or without concomitant topical Mitomycin-C therapy. Infants were followed clinically and with interval endoscopy with a minimum follow-up of 6 weeks. No patients receiving topical post-marsupialization Mitomycin-C (0/4) had cyst recurrence. Those patients who did not receive Mitomycin-C therapy recurred more frequently (66% - 2/3). Cysts ruptured with the bronchoscope tip recurred (66% - 2/3) more often than cysts undergoing endoscopic marsupialization (0/6). The one bronchoscopic rupture case that did not recur was the one in which Mitomycin-C was used concomitantly. Patient follow-up was at 2, 4 and 6 weeks post-procedure.

CONCLUSION

Endoscopic marsupialization is the treatment of choice for subglottic cysts. Gastro-esophageal reflux has a strong association with subglottic cysts. The post-marsupialization application of Mitomycin-C may have a role in reducing the recurrence rate and scarring after surgical treatment of subglottic cysts.

Trends in paediatric airway surgery: a move towards endoscopic techniques

The endoscope has long been an invaluable tool in assessment of the paediatric airway. Recently, its applications for definitive surgery of the airway have greatly increased, due to innovative surgical techniques, development of new instruments, improvements in anaesthesia and availability of new medications for endoscopic use. This review discusses the move towards endoscopic techniques in the management of paediatric airway disorders.

Microdebrider resection of acquired subglottic cysts: case series and review of the literature

OBJECTIVE

Pediatric subglottic cysts (SGC) are a rare but curable cause of respiratory distress. Previous studies have described microsurgical marsupialization and carbon dioxide laser ablation to treat SGC. In this report we describe our experience performing endoscopic resection of SGC with a laryngeal microdebrider.

METHODS

A retrospective review of all patients who underwent endoscopic resection of SGC with a laryngeal microdebrider between January 2004 and October 2008 at a tertiary care children's hospital was performed.

RESULTS

Eight patients with one or more SGC were treated with microdebrider resection. All patients presented with stridor or respiratory distress, were born prematurely (mean gestational age 27 weeks), and had been intubated for between 1 and 91 days (mean 33 days). In all cases, suspension laryngoscopy was performed under general anesthesia. The SGC was visualized using a 4.0-mm Hopkins rod telescope and excised using a 2.9-mm diameter laryngeal microdebrider (skimmer blade). No patient experienced significant bleeding following excision. Mean surgical time was 36 min (range 26-59 min). Seven of eight patients (87.5%) were extubated by post-operative day 1. All patients had a follow-up bronchoscopy within 10 weeks. Six of eight patients (75%) had a single treatment, while two patients (25%) required a second resection. One patient had a symptomatic recurrence (12.5%). All eight patients are now free of disease with a mean follow-up of 21 months. No patient developed clinically significant scarring or subglottic stenosis.

CONCLUSIONS

The laryngeal microdebrider offers a safe and effective way to remove SGC with a low recurrence rate.

Microdebrider resection of bilateral subglottic cysts in a pre-term infant: a novel approach

Acquired subglottic cysts are a rare cause of stridor in infants. The two major risk factors for development of these cysts are prematurity and history of intubation. Microlaryngeal decompression and carbon dioxide laser resection of these cysts have been the most common treatment methods with recurrence rates as high as 43% [J. Lim, W. Hellier, J. Harcourt, S. Leighton, D. Albert, Subglottic cysts: the Great Ormond Street experience, Int. J. Pediatr. Otorhinolaryngol. 67 (2003) 461-465]. Carbon dioxide laser therapy also carries the risk of airway fire, injury to adjacent structures, and possible delayed scarring. We present a case of bilateral subglottic cysts in a premature infant with progressive stridor, treated using a microdebrider, and review the literature regarding the treatment of these lesions.