Serial intralesional steroid injection combined with balloon dilation as an alternative to open repair of subglottic stenosis

Steroid-Eluting Implants: An Adjunctive Therapy After Double-Stage Laryngotracheal Reconstruction

OBJECTIVES

The primary objective is to describe a case in which a steroid-eluting implant was utilized to help prevent postoperative granulation and restenosis in a patient who underwent double-stage laryngotracheal reconstruction (dsLTR) for subglottic stenosis.

METHODS

This case presents a 3-year-old female who underwent dsLTR with anterior cartilage graft placement and posterior sagittal split for subglottic stenosis. A silicone stent was placed at the time of the dsLTR. After stent removal, direct laryngoscopy and bronchoscopy (DLB) was performed at 4 to 5 week intervals. These visits revealed a significant amount of supraglottic and glottic edema, and granulation tissue at the proximal aspect of the graft contributing to airway obstruction and restenosis. This was treated twice with CO2 laser excision, balloon dilation, and triamcinolone injection. On the third treatment with these modalities, a mometasone furoate implant was inserted as an adjunctive therapy. The implant was inserted to lateralize the vocal folds, prevent webbing, and to extend to the narrowed area within the subglottis to prevent granulation and restenosis. These same treatments were repeated at the fourth visit with another mometasone furoate implant of a smaller size placed in the same location.

RESULTS

Findings on DLB since treatment with the steroid-eluting implants have shown persistent granulation tissue limited to the tracheostomy stoma site. Treatments with CO2 laser, balloon dilation, and triamcinolone injection have continued, with occasional use of silver nitrate cautery at the external stoma site. There has not been any significant evidence of edema, granulation, or stenosis in the glottis or subglottis to require another steroid-eluting implant.

CONCLUSIONS

Steroid-eluting implants appear to be a safe and effective adjunctive therapy in the routine surveillance of pediatric patients with a tracheostomy who have undergone dsLTR. They may help combat granulation formation and restenosis seen in some dsLTR patients.

Outcomes of Holmium Laser, Cryoablation, and Budesonide Inhalation for Treating Severe Central Airway Stenosis in Infants

BACKGROUND

Central airway stenosis (CAS) in infants is characterized by dysphonia, dyspnea, cyanosis, repeated apnea, and infection. This case series study aimed to evaluate the safety and efficacy of holmium laser, cryoablation and budesonide inhalation in treating infants with severe CAS.

METHODS

This retrospective study reviewed medical records data of 28 infants with severe CAS who underwent holmium laser treatment with cryoablation and/or balloon dilatation and budesonide inhalation therapy at Shanghai Children's Medical Center between June 2014 and May 2020. Outcomes were defined as treatment success when the stenotic area was <25% for the normal age group with stable reopening diameter at one-year follow-up.

RESULTS

Patients' mean age was 12.8 ± 8.8 months and 17 (60%) were male. Sixteen cases had web-like stenosis and 12 had scar contracture stenosis. Among 16 patients with web-like stenosis, 8 (50%) underwent balloon dilation with cryotherapy and 8 (50%) underwent balloon dilation only; treatment success was achieved in 10 (62.5%) cases and after revised treatments in 5 (31.25%) cases. Among 12 patients with scar contracture stenosis, 6 (50%) underwent balloon dilation with cryotherapy, 4 (33.3%) underwent cryotherapy and 2 (16.7%) underwent balloon dilation only; treatment success was achieved in 3 (23.1%) cases and after 1-4 revised treatments in 8 (61.5%) cases. Symptoms of the 2 unsuccessful (7.1%) cases were relieved after tracheal stent insertion. Neither severe adverse events nor complications were observed during follow-up.

CONCLUSION

Holmium laser with cryoablation followed by budesonide inhalation therapy safely and effectively cleans stenotic tissues and maintains airway reopening. Balloon dilation after holmium laser is recommended for treating web-like stenosis.

Dilation, Steroid Injection, and Cough Exercise for Correction of Posterior Glottic Stenosis

OBJECTIVE

To describe the DISCO protocol (Dilation, Steroid injection, and post-operative Cough Exercise); a novel treatment for posterior glottic stenosis (PGS). Restoring glottic mobility in PGS is a major challenge. In orthopedic and plastic surgery, post-operative physical therapy is associated with improved motion range and flexibility; yet, this principle was never applied to laryngeal surgery.

METHODS

A retrospective cohort of PGS adult patients, treated by the DISCO protocol during 2018-2020. DISCO involves the following: scar release, glottic dilation, and steroid injection, followed by post-operative cough as glottic physical therapy. Maximal glottic opening angle (MGOA), relative glottic opening area (RGOA), and relative glottic insufficiency area (RGIA) were calculated before and post-operatively.

RESULTS

Seventeen patients were included; PGS etiology was post-intubation (n = 10), post-irradiation (n = 3), both (n = 1) and joint sclerosis (n = 3). Six patients also had additional airway disorders. Sixteen patients were tracheostomy-dependent. 2 (12%), 8 (47%) and 7 (41%) patients had type II, III and IV stenosis, respectively. Surgery included scar release, dilation and steroid injection alone in 7 patients; and additional unilateral sub-mucosal arytenoidectomy in 10. The mean follow-up was 17.5 months. There were no major complications. Successful outcomes (e.g., decannulation or permanent capping) were achieved in 14 (82%) patients with some restoration of joint movement. None had a persistent voice or swallowing complaints. Both MGOA and RGOA increased in all patients (p < 0.001). RGIA remained unchanged (p = 0.878).

CONCLUSIONS

The DISCO protocol is a novel, effective and safe approach for PGS correction that can be easily applied. It can restore vocal fold mobility and may expand the glottic airway without causing glottic insufficiency.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:883-889, 2023.

Management of balloon dilatation in cases of subglottic stenosis in children: success and failure

PURPOSE

To assess efficacy and prognostic factors of endoscopic balloon dilatation for the treatment of subglottic stenosis in children.

METHODS

A retrospective review was performed on 49 pediatric patients with subglottic stenosis treated at the Shanghai Children's Hospital between December 2017 and December 2021. Specific demographic data, type and severity of the stenosis, number of balloon dilatations and outcomes were recorded and analyzed.

RESULTS

Forty-nine children (30 male, 19 female) were included in the study with a median age at diagnosis of 24 (13-36.5) months, of which 7 (14.3%) had received open laryngotracheal reconstruction previously. The degree of subglottic stenosis was grade I in six patients, grade II in 16 patients, grade III in 20 patients and grade IV in seven patients. After various numbers of balloon dilatations (1-7 times), 29 patients showed a good outcome (decannulation or prevention of tracheostomy) and the success rate in that series was 59.2%. Overall, prognosis of balloon dilatation was not dependent on pathogeny (congenital or acquired) or open surgical history(P > 0.05), but rather on the severity grade of stenosis and the number of dilatations (P < 0.05).

CONCLUSIONS

Endoscopic balloon dilatation can be safe and effective in the treatment of subglottic stenosis in children, except for more serious cases (grade IV). Open surgery should be considered if no significant improvement is observed after dilatation, especially after three or more dilatations.

The Safety of Intralesional Steroid Injections in Young Children and Their Effectiveness in Anastomotic Esophageal Strictures-A Meta-Analysis and Systematic Review

OBJECTIVE

Intralesional steroid injections (ISI) are a widely used technique for various pediatric indications and represent a possible adjuvant treatment for anastomotic esophageal strictures. Yet, no consensus has been reached neither on their safety in the pediatric population or their effectiveness in esophageal atresia patients. This systematic review aimed to assess the safety of ISI in young children through a meta-analysis and to summarize the current knowledge on the effectiveness of ISI in anastomotic esophageal strictures.

METHODS

A systematic literature search was performed in Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar up to August 16 2021. Studies focusing on ISI and involving children up to 2 years were included in the meta-analysis for the safety assessment. All studies evaluating the use of ISI as adjuvant treatment in anastomotic esophageal strictures in children were included in the systematic review to assess the effectiveness of the intervention.

RESULTS

The literature search yielded 8,253 articles. A total of 57 studies were included, of which 55 for the safety and five for the effectiveness assessment. The overall complication rate was 7%, with a greater incidence of local complications compared to systemic complications. Six studies (with a total of 367 patients) evaluated adrenocorticotropic hormone and cortisol levels, of which four reported hypothalamic-pituitary axis suppression. Two children (0.6%) received replacement therapy and all patients recovered uneventfully. A mean number of 1.67 ISI were performed per esophageal atresia (EA) patient. A reduction of needed dilatations was seen after ISI, compared to the number of dilatations performed before the intervention (5.2 vs. 1.3).

CONCLUSION

The insufficient data emphasized the need for further prospective and comparative studies. Results from this meta-analysis and systematic review address ISI as a safe and effective technique. Close clinical follow-up and growth curve evaluation are advisable in patients receiving ISI.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier: CRD42021281584.

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.

Effective treatment of post-intubation subglottic stenosis in children with holmium laser therapy and cryotherapy via flexible bronchoscopy

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.

Serial intralesional triamcinolone acetonide injections for acquired subglottic stenosis in premature infants

PURPOSE

Long-term intubation of premature infants sometimes induces acquired subglottic stenosis (SGS), causing glottic or supraglottic problems. These kinds of SGS often require tracheostomy and subsequently make decannulation difficult. The aim of our study was to clarify the efficacy of repeated intralesional steroid injections to the stenosis.

METHODS

Six children with acquired SGS, who were treated with triamcinolone acetonide injections to the subglottic space just below the vocal folds between September 2015 and December 2017 were retrospectively reviewed.

RESULTS

The patients' mean age was 4.3 (range 1.3-4.4) years, the mean gestational age at birth was 25 (23-28) weeks, and the mean birth weight was 591 (456-734) g. The degree of SGS was grade II in one patient and III in five patients, with both tracheostoma and glottic or supraglottic abnormalities. They generally underwent ten procedures, every 3-4 weeks. In most cases, the patency of the injected space improved by 25-220%, and the symptoms were relieved. One patient achieved decannulation, and another one underwent laryngotracheal reconstruction and decannulation. Two patients started using a speech cannula. There were no severe complications.

CONCLUSION

Serial intralesional steroid injections are likely to be effective in improving the patency of acquired SGS.

Profilactic role of simvastatin and mitomycin C in tracheal stenosis after tracheal damage: Study in rats

OBJECTIVES

We aimed to investigate the prophylactic effect simvastatin of and mitomycin C (MMC) on laryngeal and tracheal stenosis in tracheotomised rats by histopathological evaluation of laryngotracheal segment. Randomized prospective single-blind.

MATERIAL AND METHOD

Standard vertical tracheotomy was performed on 24 rats. Then the animals were randomly divided into three groups as A, B and C. In group A 0.4 mg/day once daily mitomycin C was injected to the paratracheal region for 14 days. In group B daily 30 mg/kg/day simvastatin was given via gavage to rats for 14 days. In group C 2 cc/day intraperitoneal saline given to rats and the created control group by 14 days follow up. After 10 days, tracheal cannulas were removed. Three weeks later, all animals were euthanized and trachea specimens were harvested. The present study investigates the effects of MMC and Simvastatin on fibrosis, inflammation, stenosis index and tracheal wall thickness in a tracheal injury model.

RESULTS

The difference between the groups in terms of degree of inflammation scores was statistically insignificant (P = 0,187). Differences between the groups were found to be insignificant in terms of the preventionof fibrosis (P = 0,993). There was no significant difference between groups in terms of stenosis index (P = 0.645). In terms of wall thickness, control, simvastatin and mitomycin C groups were statistically different (p = 0.038). The difference between post-hoc test results was between Mitomycin C and control groups (p = 0.036). Maximum wall thickness in the MMC group (0,299 mm) was significantly lower compared to the control group (0,382 mm)(P < 0,0001). Maximum wall thickness was statistically lower in the simvastatin (0.324 mm) group compared with the control group (0.382 mm) (P < 0.0001). There was no statistically significant difference between the simvastatin group (0,198 mm) and control group (0,200 mm) with respect to minimum wall thickness (P = 0.982). Minimum wall thickness was significantly lower in the mitomycin-C group (0,160 mm) comparison to the control group (0,200 mm) (P < 0.0001).

CONCLUSION

It was detected that the simvastatin and MMC is not effective in preventing the tracheal stenosis, inflammation and fibrosis formation.

The Efficacy of Intralesional Steroid Injection in the Treatment of Corrosive Esophageal Strictures in Children

PURPOSE OF THE STUDY

Esophageal dilatation can be insufficient in the treatment of severe corrosive esophageal strictures. In this study, we aimed to present the efficacy of intralesional steroid injection as an adjunct to dilatation therapy.

MATERIALS AND METHODS

Retrospective analysis of children who underwent intralesional steroid injection between 2004 and 2014 was performed. Patients' age, type of corrosive substance, length of stricture, number of injection and dilatation sessions and complications were reviewed. The success was evaluated by the comparison of number, frequency, and requirement of dilatation therapy before and after injection.

RESULTS

Intralesional steroid injection was performed to 32 children with a mean age of 3.6±2.5 years. The types of corrosive agents were alkali (24) or acid (8). Mean number of injection sessions was 2.5±1.1(1 to 6). Mean number of dilatation sessions was decreased from 10±8.8 to 5.4±4.6 after injection (P=0.003). Mean frequency of dilatations was extended from 3.6±0.9 weeks to 8.7±3.9 weeks (P=0.000). Dilatation treatment was successfully terminated in 25 of 27 children with short-segment strictures after injection (92%). Whereas all of the children with long-segment strictures could not resolved and finally required esophageal replacement (5 patients). One patient had transient cushingoid phenotype as a complication. There was not seen any major complication-like perforation. The mean follow-up period was 6±3 years.

CONCLUSIONS

Intralesional steroid injection is an effective adjunct to dilatation in most of the children with short-segment strictures. It should be performed as a safe and efficient treatment option in patients with short-segment corrosive esophageal strictures resistant to dilatation therapy.

Tertiary center experience with primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and literature review

Background and objectives

To share our experience with primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and critically review the previously published studies.

Setting

Tertiary Referral Centers, King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Patients and methods

A retrospective case series study was conducted, where the case notes of all pediatric patients who underwent endoscopic management as a primary surgical intervention for acquired subglottic stenosis (SGS) from 2004 to 2014 were reviewed. All patients who underwent surgical correction with primary open laryngoplasty for congenital subglottic stenosis had been excluded.

Results

A total of 60 patients with a workable diagnosis of subglottic stenosis were reviewed. Forty-five patients were included in the study and 15 patients were excluded because they underwent open laryngoplasty as a primary treatment modality for congenital subglottic stenosis. The majority of the patients were males 29 (64%), with 16 (36%) females. The main presentation was stridor and intercostal recession. Thirty-nine (86%) patients had subglottic stenosis due to prolonged intubation; 5 (11%) patients were idiopathic and one patient (3%) had inflammatory reasons. The site of stenosis was isolated SGS in 41 while 4 patients had glottic-subglottic stenosis (GSGS). In terms of the grade of stenosis: 13 patients had grade I; 23 had grade II and 9 had grade III. The character of stenosis was soft except in 5 patients with hard (mature) scar. The number of dilatation procedures ranged from 1 to 6 with a mean of 2. The endoscopic management was considered to be successful when the patient is completely asymptomatic after the follow up period of one year. No major complications were recorded among the patients. Thirty-seven (82.3%) patients had a benign course post endoscopic intervention without complications and 8 (17.7%) underwent a secondary open surgical management due to re-stenosis (P value < 0.01).

Conclusion

Our study showed that primary endoscopic management was successful in 82.3% of cases of acquired subglottic stenosis including those with high grade stenosis and long segment of more than 12 mm in terms of the craniocaudal length. CO₂ laser was an important tool to convert mature hard stenotic segment into a soft one. The latter yielded to the lateral pressure created by balloon dilatation better.

Safe balloon sizing for endoscopic dilatation of subglottic stenosis in children

Objectives:

To describe our experience and provide guidelines for maximum safe balloon sizes according to age in children undergoing balloon dilatation.

Method:

A retrospective review was conducted of children undergoing balloon dilatation for subglottic stenosis in a paediatric tertiary unit between May 2006 and February 2016.

Results:

A total of 166 patients underwent balloon dilatation. Mean ( ± standard deviation) patient age was 4.5 ± 3.99 years. The median balloon size was 8 mm, the median balloon inflation pressure was 10 atm, and the mean balloon inflation time was 65.1 ± 18.6 seconds. No significant unexpected events occurred. The Pearson correlation co-efficient for the relationship between patient age and balloon size was 0.85 (p = 0.001), suggesting a strongly positive correlation.

Conclusion:

This study demonstrated that balloon dilatation is a safe procedure for airway stenosis. The results suggest using a balloon diameter that is equal to the outer diameter of the age-appropriate endotracheal tube +1 mm for the larynx and subglottis and +2 mm for the trachea.

Laryngeal Trauma Following an Inhalation Injury: A Review and Case Report

The primary concern when managing a patient with inhalation injury is security of the airway. Airflow may be impeded by both edema of the upper airway and reduction of oxygen delivery to the lower respiratory tract. Although there has been much discussion regarding management of the latter, the focus of this article is the management of the former. This review aimed to determine the optimum management in burn victims with upper airway inhalation injury as an attempt to prevent laryngeal trauma leading to long-term voice disorders and upper airway dyspnea. We describe the case of a 57-year-old woman with significant inhalation injury and discuss the natural progression of her injuries and the laryngeal controversies surrounding her care. We conclude with advice on the optimal management of this condition based on our experience, combined with current best evidence.

Histopathological effect of balloon dilation in a live rabbit: Implications for the pediatric airway

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.

Balloon dilation in the management of severe airway stenosis in children and adolescents

BACKGROUND/PURPOSE

Children and adolescents with airway stenosis pose a clinical challenge. Recently, balloon dilation has been described, primarily for the treatment of early, immature, less severe airway stenosis. We describe our experience with 8 children and adolescents managed with balloon dilation, including severe, mature subglottic and tracheal stenosis.

METHODS

This is a case series of 8 children and adolescents with acquired subglottic and tracheal stenosis treated by the primary author with balloon dilation between August 2006 and April 2010 at an academic tertiary care center. In the four patients who were tracheotomy-dependent at the time of presentation, suprastomal stents or Montgomery T-tubes were used. In 1 patient with 99% subglottic stenosis (SGS), balloon dilation and stenting were used to create a lumen prior to laryngotracheal reconstruction (LTR).

RESULTS

All 4 patients with tracheotomy were decannulated. The remaining 4 patients were successfully managed without tracheotomy.

CONCLUSIONS

Mature, severe laryngeal and tracheal stenosis in pediatric patients can be successfully managed with balloon dilation. In the most severe cases with prior tracheotomy, stenting is necessary. Balloon dilation with stenting can also facilitate LTR. In patients without prior tracheotomy, tracheotomy and stenting can often be safely avoided with appropriate postoperative management.

Adjunctive procedures after pediatric single-stage laryngotracheoplasty

OBJECTIVES

We report the frequency and success rates of adjunctive airway procedures after pediatric single-stage laryngotracheoplasty (LTP) and review different adjunctive techniques in a prospectively enrolled and retrospectively reviewed case series.

METHODS

Of 31 LTP procedures performed from 2008 to 2011 at an academic tertiary care children's hospital, 10 were single-stage LTP procedures. These 10 cases were analyzed to determine the number and type, if any, of adjunctive procedures required after LTP, as well as the subglottic response and decannulation rates.

RESULTS

Of the 10 patients with single-stage LTP procedures, 6 patients required a total of 16 postoperative adjunctive airway procedures. The adjunctive procedures included granulation tissue removal with forceps or a carbon dioxide laser, stent placement, mitomycin C application, and triamcinolone acetonide injection. One patient also required tracheotomy placement and, eventually, cricotracheal resection. All 6 patients had significant improvement of subglottic and/ or tracheal stenosis on their most recent endoscopic examination. With a minimum follow-up of 12 months, all 6 patients were decannulated.

CONCLUSIONS

In this series, more than half of our pediatric patients who underwent single-stage LTP required 1 or more postoperative adjunctive procedures, and all had successful outcomes.

Primary dilatation as a treatment for pediatric laryngotracheal stenosis: a systematic review

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.

Cricoid split for acute subglottic injury in the older child

OBJECTIVES

To describe our experience of cricoid split in the older child for acquired subglottic stenosis secondary to chemical or thermal burns.

METHODS

A retrospective case series.

RESULTS

We describe two patients, both two years old, who benefitted from the procedure and had a return to a normal-sized airway. Neither child required a tracheostomy or further airway intervention after the cricoid split.

CONCLUSIONS

Laryngotracheal reconstruction (LTR) is the standard treatment for subglottic injuries with associated subglottic stenosis in children, infants and (where possible) neonates. We have found the cricoid split a useful technique in carefully selected older children with acute subglottic injury and associated early subglottic stenosis, where LTR or ballooning is not feasible, where there is limited experience of ballooning, and/or ballooning has failed in the early stages of treatment. Cricoid split is a technique that is part of the airway surgeon's open operative repertoire and therefore should be remembered as a management option.

Outcomes of Balloon Dilation in Pediatric Subglottic Stenosis

Objectives:

We report outcomes of balloon dilation in the endoscopic management of pediatric subglottic stenosis (SGS) and discuss the role of balloon dilation in both primary and adjuvant therapy.

Methods:

We performed a retrospective review of treatment with noncompliant, high-pressure balloons for SGS in the past 2 years at a tertiary pediatric hospital. Fifty-one dilations were performed in 28 children with SGS. The children's mean age was 42 months. The mean SGS grade was 2.46.

Results:

Fifteen children had primary balloon dilation, and 13 had adjuvant balloon dilation. Overall, 16 children (57.1%) had successful balloon dilation. Of those who underwent primary dilation, 9 (60.0%) were able to avoid open reconstruction or tracheotomy and 6 had their symptoms temporarily improved (average, 36 days) until definitive open reconstruction. Of the patients who underwent adjuvant dilation, 7 (53.8%) were successfully decannulated. Nine of the 12 failed balloon dilations were in children who had concomitant airway disorders; in contrast, only 6 of 16 children in whom treatment was successful had concomitant airway disorders (p = 0.048). There was no statistical association between successful versus failed treatment and age (51.6 versus 27.9 months; p = 0.23), degree of stenosis (grade 2.3 versus grade 2.6; p = 0.41), presence of lung disease (33.3% versus 70%; p = 0.07), or soft versus firm stenosis (60.0% versus 53.1%; p = 0.71).

Conclusions:

Balloon dilation plays an important role in the primary and adjuvant management of pediatric SGS. The presence of concomitant airway lesions is significantly associated with failure of balloon dilation treatment. Meticulous surveillance of the dilated airway is necessary, given this failure rate.

Endoscopic anterior cricoid split with balloon dilation in infants with failed extubation

Subglottic injury (SGI) is a known complication of prolonged intubation in neonates and infants and can lead to failed extubation. SGI is a spectrum that includes mucosal edema, ulceration, granulation perichondritis, and mature scar formation. Although medical management aimed at treating mucosal edema and extraesophageal reflux is successful in treating a majority of patients, some require surgical intervention to successfully achieve extubation. The surgical options for these patients include tracheostomy, open anterior cricoid split (ACS), and laryngotracheal reconstruction with cartilage grafting. Open ACS is performed through an external incision requiring placement of a drain for a few days. Extubation success rates in the 70% to 80% range have been widely reported. In this article we describe an endoscopic technique for ACS, in which after an endoscopic airway assessment confirms isolated SGI, the cricoid cartilage is divided transluminally with cold steel. Balloon dilation (BD) is then performed with an appropriately sized angiography balloon. We describe preliminary results in which two of three patients were successfully extubated after endoscopic ACS with BD. We believe that this novel technique is a promising alternative to open ACS with similar indications. In addition to the avoidance of a skin incision, endoscopic ACS with BD may enable extubation with comparably shorter lengths of postprocedure intubation than open ACS. Larger series will be required to further establish outcomes of this procedure, including success and complication rates.

The electrosurgical knife in an optimized intermittent cutting mode for the endoscopic treatment of benign web-like tracheobronchial stenosis

The established endoscopic treatment of web-like tracheobronchial stenosis is laser vaporization, but the appearance on the market of a new cutting mode with a lower coagulation effect has been proposed as an alternative to laser due to less injury to the tissue.

OBJECTIVES

To study the clinical and functional consequences, as well as the side effects of this technique. Afterwards, we investigated whether the use of an electrosurgical knife with this technique is as effective and convenient as an ND-YAG-laser.

PATIENTS AND METHODS

Between March 2005 and July 2007, included for study were 22 patients who had undergone 34 interventional bronchoscopy procedures with the VIO-300-D radiofrequency system, using a mode of the Endo-cut I program in conjunction with the reusable knife electrode.

RESULTS

All of the patients treated (100%) presented improvements in their symptoms, in the tracheobronchial lumen diameter and in lung function, which were statistically significant. Symptom-free time was 157 ± 93 days. There was an overall decrease observed in mean obstruction (P<.001). Improvements in FVC (P=.01), Raw (P=.0016) and RV/TLC (P=.01) were significantly significant. Less than 50% of the patients needed a second intervention. These patients were compared retrospectively with a similar group of 22 patients treated with Nd-YAG laser. The follow-up analysis showed that only 18% (4/22) of the patients treated with this new technique presented fibrin, compared with 41% (9/22) of those treated with laser therapy (P<.001).

CONCLUSION

The use of this technique is effective for the treatment of benign web-like tracheobronchial stenosis as all the patients showed clinical and functional improvement, and less than 50% required a second intervention. In comparison with laser therapy, an advantage of this technique is that less fibrin is produced, probably due to the reduced anti-coagulation effect.