Predicting outcomes of balloon laryngoplasty in children with subglottic stenosis

Position paper of diagnosis and treatment of post-extubation laryngitis in children: a multidisciplinary expert-based opinion

OBJECTIVES

To make recommendations on the diagnosis and treatment of post-extubation laryngitis (PEL) in children with or without other comorbidities.

METHODS

A three-iterative modified Delphi method was applied. Specialists were recruited representing pediatric otolaryngologists, pediatric and neonatal intensivists. Questions and statements approached topics encompassing definition, diagnosis, endoscopic airway evaluation, risk factors, comorbidities, management, and follow-up. A consensus was defined as a supermajority >70%.

RESULTS

Stridor was considered the most frequent symptom and airway endoscopy was recommended for definitive diagnosis. Gastroesophageal reflux and previous history of intubation were considered risk factors. Specific length of intubation did not achieve a consensus as a risk factor. Systemic corticosteroids should be part of the medical treatment and dexamethasone was the drug of choice. No consensus was achieved regarding dosage of corticosteroids, although endoscopic findings help defining dosage and length of treatment. Non-invasive ventilation, laryngeal rest, and use of comfort sedation scales were recommended. Indications for microlaryngoscopy and bronchoscopy under anesthesia were symptoms progression or failure to improve after the first 72-h of medical treatment post-extubation, after two failed extubations, and/or suspicion of severe lesions on flexible fiberoptic laryngoscopy.

CONCLUSIONS

Management of post-extubation laryngitis is challenging and can be facilitated by a multidisciplinary approach. Airway endoscopy is mandatory and impacts decision-making, although there is no consensus regarding dosage and length of treatment.

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.

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.

Establishing an Endoscopic Chronic Subglottic Stenosis Rabbit Model

OBJECTIVES/HYPOTHESIS

To develop a reproducible and consistent chronic subglottic stenosis (SGS) in an endoscopic animal model.

STUDY DESIGN

Prospective study.

METHODS

We conducted a prospective study using New Zealand white rabbits. Chronic SGS was induced endoscopically by Bugbee electrocautery to 50% to 75% of the subglottic area's circumference, followed by 4-hour endotracheal intubation. The rabbit airways were endoscopically assessed and sized with uncuffed endotracheal tubes (ETTs) before the injury, during follow-up, and at the endpoints. There were four endpoints: 2, 4, 6, and 8 weeks post SGS induction. Animals were humanely euthanized for histopathological examination of the subglottic injury site and microscopic measurement of the cricoid lumen.

RESULTS

Twenty-two rabbits reached the endpoints, and 18 rabbits developed chronic SGS. ETT size significantly decreased by 0.5 from preinjury to the endpoint in all groups, P < .001. Control median cricoid lumen measurements were 20.48 mm² , the median cricoid lumen measurement for the 2 weeks endpoint was 14.3 mm² , 4 weeks 11.69 mm² , 6 weeks 16.03 mm² , and 8 weeks endpoint median was 16.33 mm² . Histopathological examination showed chronic scar tissue and new cartilage formation at the cricoid level, mainly at the posterior subglottic injury site starting from 4 weeks postinjury. Collagen staining revealed substantial amounts of organized collagen and different collagen orientation starting 4 weeks postinjury lasting until 8 weeks postinjury.

CONCLUSION

We developed an animal model to study chronic SGS. This model will be utilized to compare different endoscopic treatment interventions in acute SGS versus chronic SGS and further define the molecular basis of SGS.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Readmission and reoperation after laryngeal dilation in children: NSQIP-P analysis

OBJECTIVE

To identify specific comorbidities and their relationship to complications in children who underwent laryngeal dilation, specifically comparing children with tracheostomy versus no tracheostomy as well as differences in outcomes between age groups.

METHODS

Retrospective study analyzing data collected in the American College of Surgeons National Surgical Improvement - Pediatric Database (2015-2018). Patients were selected using Current Procedural Terminology code 31528. Variables analyzed include demographics, comorbidities, readmission, reoperation, reintubation and total length of stay.

RESULTS

982 cases were identified. Comorbidities significantly higher (p < .001) in age group 1 (Age ≤ 1 year, N = 245) versus age groups 2 (Age >1 but ≤ 3 years, N = 151) and 3 (Age > 3 years, N = 270) include premature birth, ventilator dependent, oxygen support, cardiac risk factors, steroid use, nutritional support, and hematologic disorders. Comorbidities significantly higher (p < .001) in children without a tracheostomy include premature birth, history of asthma, bronchopulmonary dysplasia/chronic lung disease, oxygen support, structural pulmonary/airway abnormality, esophageal/gastric/intestinal disease, history of previous cardiac surgery, developmental delay/impaired cognitive status, cerebral palsy, neuromuscular disorder, steroid use, and nutritional support. Younger children were significantly more likely (p < .001) to require reintubation and remain in the hospital longer. Children without a tracheostomy were significantly more likely (p < .001) to return to the operating room and remain in the hospital longer.

CONCLUSION

Younger children and those without a tracheostomy are more likely to have adverse outcomes after laryngeal dilation. Awareness of these associations and outcomes is helpful in establishing benchmarks for outcomes in this group.

Outcomes of balloon dilation for paediatric laryngeal stenosis

Objective

Balloon dilation (BD) is a minimally invasive endoscopic treatment for paediatric laryngeal stenosis (LS) with reduced morbidity compared to open surgery. We retrospectively describe our experience in a cohort of children with chronic LS.

Methods

Fourteen children (median age: 28.5; range: 2-81 months) with chronic LS (multilevel in 8) were treated with tubeless total intravenous anaesthesia under spontaneous ventilation.

Results

Grade III LS was preoperatively detected in 12 children; the remaining 2 had grade IV stenosis. Six had prior tracheotomy, and one received it during the first intervention. Dilation laryngoplasty was the primary treatment in 11 children and was used as an adjuvant treatment in 3 after open reconstructive surgery. The median number of dilations was 2 (range: 1-6). There were no postoperative complications. At the end of the follow-up (median: 20.5; range: 2-46 months), detectable laryngeal lumen widening and/or respiratory improvement occurred in 12 children. Two of 7 patients with tracheostomy were decannulated.

Conclusions

Balloon laryngoplasty is a valuable therapeutic option to improve laryngeal patency in children with chronic multilevel LS, both as a primary and secondary adjuvant treatment after reconstructive surgery.

Acute laryngeal lesions following endotracheal intubation: Risk factors, classification and treatment

Laryngeal stenosis is certainly one of the most severe complications of airway intubation in children, eventually leading to tracheostomy and sometimes to additional surgical procedures. Primary prophylaxis through modification of its risk factors and secondary prophylaxis through the management of post-extubation laryngeal acute lesions seem to be key to avoidance of this fearful complication. The present article addresses known risk factors for the development of laryngeal acute lesions with emphasis on sedation level and intubation time. It also discusses available classification systems proposed in medical literature, especially the Classification of Acute Laryngeal Injuries (CALI) conceived by our research group, and its positive predictive value for the development of chronic lesions. Finally, debate focuses on treatment of each individual lesion. Despite excellent results observed with endoscopic methods for treating these lesions, there is still doubts pending over their management, and there is need for further studies to define adequate treatment for each patient and for each type of lesion.

Treatment of complex laryngotracheal stenosis in childhood–experience of a tertiary University Hospital from 2016 to 2019

Background

Laryngotracheal stenosis is a major cause of airway obstruction in pediatric age. The correction of such abnormality still remains a challenge, both because of anatomical issues in childhood and also due to the difficulty in having properly trained professionals and adequate hospital facilities. As treatment, many different surgical techniques are offered ranging from endoscopic and less invasive procedures to open surgeries, such as laryngotracheal reconstruction and cricotracheal resection. The treatment for complex laryngotracheal stenosis is considered successful when we have decannulation or resolution of respiratory failure with release from intensive care unit. Eighteen patients who were monitored at the pediatric otorhinolaryngology service between 2016 and 2019 were diagnosed with complex stenosis, with the collection of demographic data, comorbidities, degree of initial stenosis, post-treatment aspect, and whether or not decannulation occurred.

Results

Of the eighteen cases, three had congenital stenosis, fourteen had acquired stenosis, and one had mixed stenosis. Ages ranged from 4 months old to 15 years old. Six (33.3%) underwent endoscopic dilation procedures only, six (33.3%) underwent laryngotracheoplasty, and five (27.7%) cricotracheal resections. One patient underwent a slide tracheoplasty. Seven patients (38.8%) had to undergo more than one type of procedure to improve stenosis. Out of the eighteen patients, three of them were never tracheostomized. Of the remaining fifteen patients, fourteen (93.3%) were decannulated.

Conclusions

The success rate in decannulation or the resolution of respiratory failure with discharge from the ICU, after the procedures for correcting stenosis in childhood in our service, was 94.4%.

Balloon Laryngoplasty for Pediatric Subglottic Stenosis: A 5-year Experience

Objective

The objective of this study was to present our experience and evaluate our results of endoscopic balloon laryngoplasty (BL) in children with subglottic stenosis (SGS) at a pediatric tertiary center over a 5-year period.

Methods

This study reviewed 41 pediatric patients diagnosed with acquired SGS who had undergone BL as the primary course of treatment. Cases were analyzed for details including patient demographics, SGS grade and length, timing and the type of surgery, presence of tracheostomy, comorbidities, postoperative management, complications and outcomes of balloon dilatation.

Results

Forty-one children (22 girls and 19 boys) who had undergone BL at a mean age of 26 months (range, 1 month to 14 years) were included in the study. Nineteen (46.3%) were diagnosed with acute SGS (12 thin stenosis, 7 thick stenosis) and 22 (53.7%) with chronic SGS (9 thin stenosis, 13 thick stenosis). The success rate of BL was 100% in patients with acute and chronic thin membranous stenosis. The effectiveness of BL was significantly higher in patients with acute thick stenosis than in patients with chronic thick stenosis (p=0.016).

Conclusion

This study confirms that BL in patients presenting with acquired SGS with thin membranous stenosis, regardless of whether acute or chronic, can have a good prognosis. However, the results are less promising in cases of chronic thick stenosis.

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.

Ongoing Laryngeal Stenosis: Conservative Management and Alternatives to Tracheostomy

Background: Following tracheal intubation, some children may develop stridor, which is an indication of an obstructive lesion in the airway, such as an ongoing laryngeal stenosis (LS). This review focuses on evaluation of stridor and possible endoscopic predictors of progression to LS and, once post-intubation acute lesions are established, therapeutic choices to manage this disorder in avoidance of tracheostomy. Tracheostomy, due to its inherent increased morbidity, mortality and influence on social stigma, should be viewed only as a last resort. In this article, available conservative and alternative therapies for ongoing LS are thoroughly reviewed. Methods: A systematic review concerning randomized clinical trials and prospective studies on treatment modalities for LS was performed. A search strategy was developed for MEDLINE comprising terms related to disease, intervention and population. Title and abstract from captured references were peer-reviewed for eligibility. Selected studies full-texts were peer-reviewed and the results were compiled in a structured and narrative review. Stridor evaluation and post-extubation acute lesion classification were studied. Treatments such as balloon dilation, rigid dilation, corticosteroid-coated small tube intubation, and corticosteroid nebulization were described and evidence supporting their usage was discussed.

Subglottic stenosis in children: Our experience at a pediatric tertiary center for 8 years in South Korea

OBJECTIVE

The incidence of SGS has been reported to be less than 8% after endotracheal intubation. Therefore there is an increasing trend in the number of patients with acute acquired SGS due to mechanical ventilation in the intensive care unit. However, there have been no reports describing the treatment of SGS in children in South Korea. The objective of this study was to evaluate the management and outcomes of children with SGS at a pediatric tertiary center in South Korea over an 8-year period.

METHODS

All patients underwent microlaryngobronchoscopy (MLB) with bougination, incision using cold knife or laser and balloon dilatation. Data on age, sex, grade of SGS, number of management interventions, tracheostomy, comorbidities, mean follow-up period, complications, and outcome were reviewed from patient medical charts.

RESULTS

Twenty patients (13 [65%] males, 7 [35%] females; mean [±SD] age at the diagnostic procedure 15.26 ± 22.54 months) underwent MLB between March 2009 and December 2017. According to the Myer-Cotton scale, twelve of the 20 (60%) patients had grade III SGS, 7 (35%) had grade II and 1 (5%) had grade 1; there were no patients with grade IV SGS. Nine (45%) patients were diagnosed with acute SGS, and 11 (55%) with chronic SGS. Patients with SGS underwent MLB with interventions (mean 2.41 ± 2.23 per patient). Tracheostomy was performed in 13 of 20 (65%) patients, 2 of 9 (22.2%) with acute SGS, and 11 of 11 (100%) with chronic SGS. Two of 13 (15.3%) patients underwent successful decannulation. One of 2 (50%) patients with acute SGS underwent successful decannulation. Seven of 9 (77.7%) patients with acute SGS underwent MLB only without tracheostomy.

CONCLUSIONS

In patients with acute acquired SGS, the outcome was good due to the lower rate of tracheostomy and higher decannulation rate. Therefore, it is recommended that MLB with balloon laryngoplasty be performed at the earliest in patients with acute acquired SGS.

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.

Pediatric acquired subglottic stenosis: Associated costs and comorbidities of 7,981 hospitalizations

OBJECTIVES

Numerous risk factors have been characterized for acquired subglottic stenosis (ASGS) in the pediatric population. This analysis explores the comorbidities of hospitalized ASGS patients in the United States and associated costs and length of stay (LOS).

METHODS

A retrospective analysis of the Kids' Inpatient Database (KID) from 2009 to 2012 for inpatients ≤ 20 years of age who were diagnosed with ASGS. International Classification of Diseases, Clinical Modification, Version 9 diagnosis codes were used to extract diagnoses of interest from 14, 045, 425 weighted discharges across 4179 hospitals in the United States. An algorithm was created to identify the most common co-diagnoses and subsequently evaluated for total charges and LOS.

RESULTS

ASGS was found in 7981 (0.06%) of total discharges. The mean LOS in discharges with ASGS is 13.11 days while the mean total charge in discharges with ASGS is $114,625; these values are significantly greater in discharges with ASGS than discharges without ASGS. Patients with ASGS have greater odds of being co-diagnosed with gastroesophageal reflux, Trisomy 21, other upper airway anomalies and asthma, while they have lower odds of being diagnosed with prematurity and dehydration. Aside from Trisomy 21 and asthma, hospitalizations of ASGS patients with the aforementioned comorbidities incurred a greater LOS and mean total charge.

CONCLUSION

Our analysis identifies numerous comorbidities in children with ASGS that are associated with increased resource utilization amongst US hospitalizations. The practicing otolaryngologist should continue to advocate interdisciplinary care and be aware of the need for future controlled studies that investigate the management of such comorbidities.

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.

Rigid dilatation of pediatric laryngotracheal stenosis as an adequate alternative to balloon dilatation

INTRODUCTION

Endoscopic balloon dilation (EBD) is the mainstay of endoscopic therapy for laryngotracheal stenosis (LTS), although there is no evidence that it achieves better results than traditional rigid laryngeal dilators. Rigid bougie dilators are less expensive and easier to use, and confer the advantage of providing tactile information about the stenosis to the surgeon. We analyzed the outcome of endoscopic rigid bougie dilatation of LTS in a large series of children and compared it to the reported results of EBD in the same setting.

PATIENTS AND METHODS

All cases of pediatric LTS treated by endoscopic rigid dilatation in a tertiary referral center between 2006 and 2015 were retrospectively studied. They were divided into a primary dilatation group (PDG) and a post-reconstruction dilatation group (PRG). The PDG children had no history of reconstructive airway surgery, and dilatation was the major treatment approach. The PRG children underwent dilatations after airway reconstruction surgery as part of routine postoperative management. A successful primary outcome was defined as improvement of dyspnea and achievement of a functional airway without reconstructive laryngotracheal surgery or need for a tracheostomy at final follow-up.

RESULTS

Sixty-two children (68 cases, mean age 5.1 years, range 0.7-17.2) underwent 156 endoscopic rigid dilatations. Successful outcome was achieved in 48 cases (70.6%), 73.0% in the PDG and 67.7% in the PRG. There were no procedure-related adverse events.

CONCLUSIONS

Endoscopic rigid dilatation is a relatively inexpensive and efficacious tool in endoscopic management of pediatric LTS. Its success rates are in the same range as those of EBD.

Impact of balloon laryngoplasty on management of acute subglottic stenosis

PURPOSE

To assess the impact of balloon laryngoplasty on clinical and surgical outcomes in pediatric patients with acute subglottic stenosis.

METHODS

Two case series were included and compared. The first group included patients treated initially either with tracheostomy (if severe symptoms) or with close follow-up (if mild symptoms). Those children underwent re-evaluation and specific treatment of their stenosis with laser incisions or open surgeries some weeks later. The other group included children treated initially with balloon laryngoplasty, reflecting a shift in surgical practice after 2009. Data as success of the procedure, mean hospital stay, mean pediatric intensive care unit (PICU) stay, post-procedure fever, need of antibiotics, procedure-related complications, and deaths were assessed and compared between both cohorts.

RESULTS

The sample comprised 38 pediatric patients aged 0-5 years. Fifteen children were treated before 2009, of who 10 (66.7%) required tracheostomy soon after the diagnosis. Ultimately, 13 (86.6%) underwent laryngotracheal reconstruction. Twenty-three children were treated after 2009 and the success rate in these patients treated primarily with balloon laryngoplasty was 82.6%. Of these, only 3 (13%) required tracheostomy and 1 (4.3%) required further open laryngotracheal reconstruction. Patients treated by balloon laryngoplasty underwent fewer procedures under general anesthesia and had a lower burden of treatment-related morbidity, as denoted by shorter PICU stay, less antibiotic use, earlier postoperative resumption of oral feeding, and a lower incidence of postoperative complications and fever.

CONCLUSION

When used for management of acute laryngeal stenosis, balloon laryngoplasty is associated with a high success rate, presenting lower morbidity than open surgery.

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.

Beyond dilation: current concepts in endoscopic airway stenting and reconstruction

PURPOSE OF REVIEW

To discuss current modalities of endoscopic airway management beyond balloon dilation therapy.

RECENT FINDINGS

Advances continue to be made through technology and bioengineering with exciting potential in the pediatric airway. Smaller robots and instrumentation allow increased endoscopic surgical success. Biodegradable stents and bioengineered grafts are on the horizon for use in airway surgery. Dysphonia following airway reconstruction is of increasing recognition with new endoscopic treatments being performed. Supraglottoplasty is further recognized as a treatment for obstructive sleep apnea for laryngomalacia diagnosed on sleep endoscopy. Interarytenoid injection may be beneficial in the normal larynx for aspiration and dysphagia as well as diagnosing and treating type I laryngeal clefts.

SUMMARY

Endoscopic airway surgery continues to be a popular and effective method of treating the pediatric airway. Technological advances such as in robotics may have an increasing role in the future of endoscopic airway surgery in children. Bioengineered airway adjuncts including biodegradable airway stents look to be promising in the future treatment of airway stenosis.

Noninvasive Treatment of Acquired Subglottic Stenosis

A 23-day-old infant referred to the neonatal intensive care unit with difficulty breathing and inspiratory stridor increasing with exercise. Medical history included a cardiothoracic surgery for transposition of the great arteries, patent ductus arteriosus, atrial septal defect, and a history of intensive care unit from surgery. Flexible fiberoptic transnasal laryngoscopy revealed subglottic stenosis that was probably caused by prolonged intubation with a higher airway pressure. Computed tomographic scan of the neck showed a tiny stenosis without cartilage deformity and limited in subglottic region. Tracheotomy and external open surgery was found risky for sternal wound infection or mediastinitis as the neonate had newly thoracotomy. The patient had a balloon dilation under general anesthesia without intubation. Presenting symptoms of the neonate were fully improved with balloon dilation.

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.

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.