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

[A case of subglottic cysts in monochorionic monoamniotic twins]

The first observation in the world literature of the development of subglottic cysts in the larynx in monochorionic monoamniotic twins is presented. The girls were born prematurely at 34 weeks of gestation, from the first day of life for 7 and 8 days, respectively, were transferred to mechanical ventilation. At the fourth month of life, symptoms of laryngeal stenosis appeared and began to gradually progress, conservative therapy had no effect. The diagnosis of subglottic cysts was established on the basis of fibrolaryngoscopy; after endolaryngeal surgery, breathing returned to normal. This case demonstrates the importance of timely endoscopic examination of the respiratory tract in children with stridor.

[Laryngeal cysts in children]

Laryngeal cysts in children are relatively rare, occupying the 4-5th place in the structure of congenital malformations. The paper presents the combined experience of two Russian pediatric otorhinolaryngological clinics traditionally involved in the rehabilitation of patients with congenital and acquired pathology of the larynx.

OBJECTIVE

To analyze the features of the clinic, diagnosis and treatment of laryngeal cysts in children.

MATERIAL AND METHODS

The study included 68 children with laryngeal cysts aged from 3 days to 16 years (on average 39.5±37.0 months, Me=15.5 months). The cyst was localized in the vestibular region of the larynx in 15 (22.1%) patients, in the vocal region - in 15 (22.1%) patients, and in the sub-vocal region - in 38 (55.9%) patients. Data on the presence of a history of tracheal intubation were available in 35 (89.7%) children, including 35 (92.1%) of 38 children with a subfold cyst. 11 patients were admitted with a previously applied tracheostomy.

RESULTS

The main reasons for going to the clinic were signs of laryngeal stenosis (stridor, signs of obstruction of the upper airways) in 60.3% of patients, dysphonia - in 33.8%, and in 5.9%, the detection of a cyst became an accidental finding. To eliminate the cyst, the method of laser marsupialization was used in 10 patients, coagulatory ablation - in 2 patients, in the remaining 56 patients, decortication was performed with microinstruments, followed by laser treatment of the cyst bed. In the follow-up, children were traced from 6 months to 7 years. We did not observe a recurrence of a cyst in any case.

CONCLUSION

Currently, the lining department is the "favorite" localization of the cyst in childhood. Subclavian cysts are more common in preterm infants who need tracheal intubation. A necessary condition for radical elimination is the resection of the cyst walls.

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.

Endoscopic orbital fat decompression for the management of proptosis in Grave's orbitopathy using a laryngeal skimmer blade

BACKGROUNDS/OBJECTIVES

Intraoperative handling and manipulation of orbital fat remains a challenge to orbital surgeons. We present a case series of endoscopic orbital fat decompression with medial orbital wall decompression for proptosis management in Grave's orbitopathy, describing a technique for fat excision using a laryngeal skimmer blade, reporting clinical and surgical outcomes, and complications.

SUBJECTS/METHODS

All patients who underwent endoscopic orbital fat decompression, with medial orbital wall decompression, for proptosis management in Grave's orbitopathy between 2011 and 2018, under the care of a single surgeon, were included in this retrospective interventional case series.

RESULTS

Nineteen patients were included in this study. Using a laryngeal skimmer blade, orbital fat was excised endoscopically at the time of medial orbital wall decompression. The mean volume of orbital fat excised was 1.45 ± 0.63 ml and the mean reduction in proptosis was 4.5 ± 1.02 mm. There were no intraoperative complications.

CONCLUSIONS

In this study, we describe our experience of using a laryngeal skimmer blade as a method of excising orbital fat for orbital decompression in patients with proptosis secondary to Grave's orbitopathy.

Subglottic Stenosis

Subglottic stenosis refers to narrowing of the airway diameter below the vocal folds and may be congenital or acquired. Typical signs and symptoms range from recurrent croup and exertional stridor to complete airflow obstruction requiring tracheotomy. Management of moderate and severe subglottic stenosis often requires intricate surgical techniques. To optimize the success of these surgeries, a thorough assessment of the child's airway, lungs, reflux, and swallow needs to be evaluated. In order to provide concerted and coordinated care between typically otolaryngology (ENT), pulmonary, gastroenterology (GI), speech, swallow and language pathologists (SLP), "aerodigestive" teams have been developed and increasing in prevalence at children's medical hospitals. This article sets out to provide a brief overview of an aerodigestive program and evaluation, review a few of the more common laryngotracheal conditions, and the surgical techniques involved to augment the airway.

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.