1
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Blumenthal D, Leonard JA, Behzadpour H, Zalzal G, Preciado D. Recalcitrant Stenosis Following Pediatric LTR: Contributing Factors and Clinical Impact. Otolaryngol Head Neck Surg 2024; 171:247-253. [PMID: 38482949 DOI: 10.1002/ohn.696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/09/2024] [Accepted: 02/05/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES Laryngotracheal reconstruction (LTR) has revolutionized the management of pediatric subglottic stenosis (SGS). However, postoperative stenosis remains a difficult hurdle to overcome. Our goal is to determine the clinical impact of recalcitrant stenosis after LTR and the factors contributing to postoperative stenosis. STUDY DESIGN Retrospective review of 181 open LTR patients between 2008 and 2021. SETTING Stand-alone tertiary children's hospital. METHODS Recalcitrant stenosis was defined as new or worsening stenosis despite open LTR. Fisher's exact and Mann-Whitney tests were used to detect differences in categorical and continuous clinical data between patients with and without treatment-resistant stenosis. Time-to-decannulation analysis of both groups was performed using Kaplan-Meier analysis and evaluated with log-rank and Cox proportional hazards regression. Multivariate logistical regression was used to assess the validity of associations found in univariate analysis. RESULTS As expected, the 27 patients with postoperative stenosis were less likely to be decannulated (P < .001, Fisher's Exact), more likely to require a postoperative tracheostomy (P < .001, Fisher's Exact) or revision LTR (P < .001, Fisher's Exact) and had prolonged time to decannulation (P < .001, Log-rank). Children with Grade IV SGS (P = .004, Fisher's Exact), and those with longer suprastomal stent duration (P = .03, Fisher's Exact) were more likely to suffer from recalcitrant stenosis. Stent duration longer than 4 weeks (P = .01) contributed to refractory stenosis when controlling for all aforementioned variables using multivariable logistic regression. Interposition grafts had a protective effect (P = .005). CONCLUSION Maintaining suprastomal stents over 4 weeks after LTR increases the risk for postoperative stenosis and its sequelae. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Daniel Blumenthal
- Department of Pediatric Otolaryngology, Children's National Hospital, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, Medstar Georgetown University Hospital, Washington, USA
| | - James A Leonard
- Department of Pediatric Otolaryngology, Children's National Hospital, Washington, USA
- Department of Otolaryngology-Head and Neck Surgery, Medstar Georgetown University Hospital, Washington, USA
| | - Hengameh Behzadpour
- Department of Pediatric Otolaryngology, Children's National Hospital, Washington, USA
| | - George Zalzal
- Department of Pediatric Otolaryngology, Children's National Hospital, Washington, USA
| | - Diego Preciado
- Department of Pediatric Otolaryngology, Children's National Hospital, Washington, USA
- George Washington University School of Medicine, Washington, USA
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2
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Leonard JA, Blumenthal DL, Behzadpour HK, Lawlor CM, Preciado D. Decannulation in Revision Pediatric Laryngotracheal Reconstruction. Laryngoscope 2024; 134:1926-1932. [PMID: 37658702 DOI: 10.1002/lary.30985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/20/2023] [Accepted: 08/07/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES To evaluate how patient characteristics and surgical techniques influence the rate of and time to decannulation after pediatric revision laryngotracheal reconstruction. METHODS The study was a retrospective cohort investigation of children with a history of laryngotracheal stenosis treated between 2008 and 2021 with revision open airway surgery. The primary outcome evaluated was decannulation. The secondary outcome analyzed was time to decannulation. RESULTS Thirty-nine children were included in the study with median age 49 months; 61.5% were male. Children undergoing single stage revision surgery were far more likely to be decannulated (OR 6.25, 95% CI 1.33-45.97, p = 0.0343). Rolling logistic regression of the probability of decannulation stratified by time between open surgeries demonstrated significantly decreased chance of decannulation with reoperation within 6 months. Children managed with anterior/posterior grafting compared with a single graft were observed to have an increased time to decannulation, (HR 0.365, 95% CI 0.148-0.899, p = 0.005, Log-Rank). CONCLUSION We observe that in the case of revision pediatric open airway surgery, chance of decannulation is improved when surgery is performed in a single stage as well as 6 months after the most recent procedure. Patients and families should be counseled that complex stenosis requiring double stage procedures or anterior/posterior grafting is associated with a decreased probability of decannulation and increased postoperative time with a tracheostomy, respectively. LEVEL OF EVIDENCE 4 Laryngoscope, 134:1926-1932, 2024.
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Affiliation(s)
- James A Leonard
- Department of Otolaryngology - Head & Neck Surgery, MedStar Georgetown University Hospital, Washington, DC, U.S.A
| | - Daniel L Blumenthal
- Department of Otolaryngology - Head & Neck Surgery, MedStar Georgetown University Hospital, Washington, DC, U.S.A
| | | | - Claire M Lawlor
- Department of Pediatric Otolaryngology, Children's National Medical Center, U.S.A
- Department of Pediatrics and Surgery, George Washington University School of Medicine, Washington, DC, U.S.A
| | - Diego Preciado
- Department of Pediatric Otolaryngology, Children's National Medical Center, U.S.A
- Department of Pediatrics and Surgery, George Washington University School of Medicine, Washington, DC, U.S.A
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3
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Drury E, Anderson B, Haupert M, Thottam PJ. Steroid-Eluting Implants: An Adjunctive Therapy After Double-Stage Laryngotracheal Reconstruction. Ann Otol Rhinol Laryngol 2024; 133:244-248. [PMID: 37776286 DOI: 10.1177/00034894231202067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
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.
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Affiliation(s)
- Emily Drury
- Department of Otolaryngology, Ascension Macomb-Oakland Hospital, Madison Heights, MI, USA
| | - Brian Anderson
- Department of Otolaryngology, Ascension Macomb-Oakland Hospital, Madison Heights, MI, USA
| | - Michael Haupert
- Department of Pediatric Otolaryngology, Beaumont Hospital-Royal Oak, Royal Oak, MI, USA
| | - Prasad John Thottam
- Department of Pediatric Otolaryngology, Beaumont Hospital-Royal Oak, Royal Oak, MI, USA
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Moran S, Anderson C, Sheni R, Azmy M, Li DT, Loizides AM, Yang CJ. Factors associated with eosinophilic esophagitis in an urban, tertiary care pediatric aerodigestive population undergoing triple endoscopy. Am J Otolaryngol 2024; 45:104096. [PMID: 37956499 PMCID: PMC10842024 DOI: 10.1016/j.amjoto.2023.104096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Children with aerodigestive dysfunction often undergo triple endoscopy (flexible bronchoscopy, rigid direct laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) for diagnostic evaluation as well as screening prior to airway reconstruction. Prevalence and risk factors for eosinophilic esophagitis (EoE) in this population are poorly understood. METHODS A retrospective chart review was performed for pediatric patients, aged 0-21 years, who received a triple endoscopy with biopsy from January 1, 2015, to December 31, 2019, at the Children's Hospital at Montefiore (CHAM). Bivariate and multivariable analyses were used to compare the baseline characteristics between patients with and without EoE to assess for potential predictors of EoE. RESULTS Of the 119 cases included in the analysis, 16.0 % (19) received a histopathologic diagnosis of EoE following triple endoscopy. Patients with EoE were more likely to have a family history of eczema (p = 0.02) and a dairy-free diet (p = 0.02). Age, sex, history of environmental allergies, and recency of initiating oral diet were not significantly associated with increased odds of an EoE diagnosis. CONCLUSIONS A family history of eczema and a diet lacking allergenic foods, such as milk, may be associated with an increased risk of a future diagnosis of EoE in patients with aerodigestive dysfunction. Larger, multi-institutional studies are needed to identify early predictors of EoE.
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Affiliation(s)
- Sheila Moran
- Albert Einstein College of Medicine, United States of America
| | | | - Risha Sheni
- Albert Einstein College of Medicine, United States of America
| | - Monica Azmy
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, NY, United States of America
| | - Daniel T Li
- Department of Otolaryngology, Yale School of Medicine, New Haven, CT, United States of America
| | - Anthony M Loizides
- Albert Einstein College of Medicine, United States of America; Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, United States of America
| | - Christina J Yang
- Albert Einstein College of Medicine, United States of America; Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, NY, United States of America; Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, United States of America.
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5
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Dahan Z, Pincivy A, Nhan C, Bergeron M. Characterizing Dysphonia After Pediatric Open Airway Reconstruction: Systematic Review and Meta-Analysis. J Otolaryngol Head Neck Surg 2024; 53:19160216241266570. [PMID: 39138869 PMCID: PMC11325326 DOI: 10.1177/19160216241266570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Pediatric laryngotracheal stenosis often requires open airway reconstruction. While these surgeries establish an airway for adequate ventilation, many patients develop subsequent dysphonia. Numerous studies have reported outcomes related to voice. OBJECTIVE This study aims to evaluate dysphonia in pediatric patients following open airway reconstruction, focusing on acoustic parameters, perceptual voice quality, and voice-related quality of life. METHODS A comprehensive search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines across 6 databases identified articles involving pediatric patients who underwent open airway reconstruction and reported postoperative vocal acoustic parameters, perceptual voice quality, voice-related quality of life, or vocal mechanics. Articles were assessed for bias risk, and common outcomes were synthesized qualitatively and quantitatively using meta-analyses. RESULTS Among 4089 articles, 21 were included, involving 497 pediatric patients. Laryngotracheoplasty was the most common procedure followed by cricotracheal resection. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scale was frequently used to assess voice quality, with a mean score of 55.6 [95% confidence intervals (CIs): 47.9-63.3]. Voice-related quality of life was measured using the pediatric Voice Handicap Index (pVHI) and Pediatric Voice-Related Quality of Life Survey, with mean scores of 35.6 (95% CI: 21.4-49.7) and 83.7 (95% CI: 74.1-93.2), respectively. The fundamental frequency was 210.5 (95% CI: 174.6-246.3). Other common findings included supraglottic phonation, anterior commissure blunting, posterior glottic diastasis, and abnormal vocal cord mobility. CONCLUSION Pediatric patients experiencing dysphonia after open airway reconstruction exhibited moderately decreased voice quality and reduced voice-related quality of life. However, there was inconsistency in study protocols and outcome measures used. Preserving voice quality during airway reconstruction is crucial to avoid negative impacts on quality of life.
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Affiliation(s)
- Zachary Dahan
- Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Alix Pincivy
- Medical library, CHU Sainte Justine, Montreal, QC, Canada
| | - Carol Nhan
- Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
- Department of Pediatric Otolaryngology-Head and Neck Surgery, CHU Ste-Justine, Montreal, QC, Canada
- CHU Sainte Justine Research Institute, CHU Sainte Justine, Montreal, QC, Canada
| | - Mathieu Bergeron
- Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
- Department of Pediatric Otolaryngology-Head and Neck Surgery, CHU Ste-Justine, Montreal, QC, Canada
- CHU Sainte Justine Research Institute, CHU Sainte Justine, Montreal, QC, Canada
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6
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Li C, Chun R, Modi VK. Practice patterns and complications of balloon dilation for pediatric airway stenosis: A survey of ASPO members. Int J Pediatr Otorhinolaryngol 2023; 174:111721. [PMID: 37734175 DOI: 10.1016/j.ijporl.2023.111721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/23/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Carol Li
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, USA; Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Robert Chun
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Vikash K Modi
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York, NY, USA
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7
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Gluvajić D, Bhate JJ, Sandu K. Revision surgery for laryngotracheal stenosis in children: A single center's 44 years experience. Laryngoscope 2023; 133:3200-3207. [PMID: 36856162 DOI: 10.1002/lary.30632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVES Outcome measures of revision open airway surgery in pediatric laryngotracheal stenosis (LTS) are reported. METHODS Data on 46 pediatric LTS patients undergoing revision open airway surgery were collected retrospectively. The measured outcomes were decannulation rate, time to decannulation, postoperative complications, additional surgery to achieve decannulation, and functional results. RESULTS The most common revision surgery was partial cricotracheal resection (PCTR) in 21/46, followed by extended PCTR (ePCTR) in 20/46, and laryngotracheal reconstruction (LTR) in 5/46 patients. A 90.7% overall decannulation rate (ODR) and a 74.4% operation-specific decannulation rate (OSDR) were achieved. Delayed decannulation was identified in children aged 5 years or less (p = 0.038) and in patients with previous primary open airway surgery (p = 0.039). Complications were observed in 52.2% of patients. To achieve optimal airway patency, additional open or endoscopic airway surgeries were necessary in 30.4% and 47.7% of patients, respectively. Age 5 years or less (p = 0.034), multiple comorbidities (p = 0.044), revision ePCTR (p = 0.023), and laryngeal stenting (p = 0.018) were risk factors requiring additional open surgery to achieve age-appropriate airway. Failed primary open airway surgery (p = 0.034) and comorbidities (p = 0.044) were risk factors for a higher rate of additional endoscopic surgeries. Postoperatively 63.0% of patients achieved normal breathing, 82.2% were dysphonic and 91.1% were orally fed. CONCLUSIONS In this report, the patient's age under 5 years, previous primary open airway surgery, medical comorbidities, and laryngeal stenting had a significant negative impact on revision open airway surgery outcomes. LEVEL OF EVIDENCE Level 4 Laryngoscope, 133:3200-3207, 2023.
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Affiliation(s)
- Daša Gluvajić
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janhvi Jayesh Bhate
- Department of Otorhinolaryngology, Amrita School of Medicine, Amrita Vishwa Vidyapeeth, Kochi, Kerala, India
| | - Kishore Sandu
- Department of Otorhinolaryngology, Head and Neck Surgery, Lausanne University Medical Center (CHUV), Lausanne, Switzerland
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Lee AJ, Prager JD, Mandler TN, Chatterjee D, Wine TM, Janosy NR. Anesthesia for laryngotracheal reconstruction in children: A narrative review. Paediatr Anaesth 2023; 33:883-893. [PMID: 37408495 DOI: 10.1111/pan.14716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023]
Abstract
Laryngotracheal stenosis, congenital or acquired, is a common cause of pediatric airway obstruction. Acquired subglottic stenosis frequently results from prolonged neonatal intubation. The clinical presentation of subglottic stenosis is variable, ranging from biphasic stridor and frequent upper respiratory infections to acute airway compromise. Optimal patient care requires clinical coordination within a multidisciplinary subspecialty team. Medical management includes optimizing respiratory status, gastroesophageal reflux, speech, feeding, nutrition therapies, and providing psychosocial support. If surgical intervention is required, the otolaryngologist, anesthesiologist, and perioperative team must collaborate closely to ensure successful operative outcomes. This narrative review of laryngotracheal stenosis will discuss the pathophysiology, clinical evaluation, medical management, and surgical interventions, and focus on the perioperative anesthetic considerations for children undergoing laryngotracheal reconstruction.
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Affiliation(s)
- Amy J Lee
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeremy D Prager
- Department of Otolaryngology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tessa N Mandler
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Debnath Chatterjee
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Todd M Wine
- Department of Otolaryngology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Norah R Janosy
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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9
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Gombert E, Gorostidi F, Sandu K. Congenital Malformations of the Cricoid Cartilage: Upper Airway Obstruction and Treatment Strategy. Laryngoscope 2023; 133:3185-3191. [PMID: 36856166 DOI: 10.1002/lary.30626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/18/2023] [Accepted: 02/04/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVES To review treatment and outcomes in patients with congenital cricoid cartilage malformation. METHODS Retrospective analysis of patients with diagnosis of congenital cricoid malformation (CCM) treated in a single tertiary pediatric referral center between 1985 and 2022. Patients were grouped according to the morphology of the cricoid cartilage that was diagnosed during endoscopy. We reviewed the treatment strategy(s), decannulation rate, complications, and functional outcomes. RESULTS Twenty-nine patients were grouped into four morphological subtypes of cricoid cartilage: 10 patients had a hypoplastic cricoid, eight had an elliptic shape, five had severe anterior thickening, and six an accentuated V-shape posterior cricoid plate. Twenty-four patients underwent surgery, and five were closely followed up without surgical treatment. Eight patients had a tracheostomy prior to surgery, and the majority had a hypoplastic cricoid. Most patients (20 out of 24) required additional procedures postoperatively to achieve an age-appropriate airway. Thirteen patients needed endoscopic dilatation(s) and granulation tissue removal; four needed more aggressive treatment, and three patients required revision open surgery. Decannulation was achieved after a median of 4.5 months in all previously tracheostomized patients. Endoscopy at the last follow-up showed an age-appropriate airway in 27 patients; 20 patients had normal oral feeding, and 11 patients had a normal voice. CONCLUSION Endoscopy is important to diagnose CCM and most of the time patients would need only watchful waiting. In this report, surgery was required for patients who continued to remain symptomatic and had a compromised airway. The type of surgery depends on the type of cricoid malformation and the grade of stenosis. LEVEL OF EVIDENCE 4 Laryngoscope, 133:3185-3191, 2023.
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Affiliation(s)
- Edwige Gombert
- Centre Hospitalier Universitaire Vaudois, ENT - Lausanne, Lausanne, Switzerland
| | - Francois Gorostidi
- Centre Hospitalier Universitaire Vaudois, ENT - Lausanne, Lausanne, Switzerland
| | - Kishore Sandu
- Centre Hospitalier Universitaire Vaudois, ENT - Lausanne, Lausanne, Switzerland
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10
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Redmann AJ, Moore C, Kou YF, Tabangin ME, Wilcox L, Smith MM, Hart CK, Rutter MJ, de Alarcon A. Revision Endoscopic Posterior Costal Cartilage Grafting: Is It Feasible? Otolaryngol Head Neck Surg 2023. [PMID: 36939543 DOI: 10.1002/ohn.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 02/10/2023]
Abstract
The objective of this work is to examine the feasibility of revision endoscopic posterior costal cartilage graft (EPCCG) placement for posterior glottic stenosis (PGS) and bilateral vocal fold immobility (BVFI). Revision and primary cases were compared with respect to decannulation rates, and it was hypothesized that there would be no difference in outcomes. Twenty-one patients met inclusion criteria (14 primary, 7 revision). Thirteen (62%) had a primary indication of PGS, and 8 (42%) were for BVFI. There were no differences between revision and primary groups with respect to age, gender, or comorbidities (p > .05). There was no difference between groups with respect to decannulation rate (85% primary vs 100% revision, p = .32). Thus, revision EPCCG appears to have comparable results to primary EPCCG with respect to decannulation rate and time to decannulation. EPCCG may be a feasible alternative to open airway reconstruction for PGS and BVFI in selected patients.
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Affiliation(s)
- Andrew J Redmann
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's Minnesota, Minneapolis, Minnesota, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Charles Moore
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas-Southwestern, Dallas, Texas, USA
| | - Meredith E Tabangin
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lyndy Wilcox
- Division of Pediatric Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew M Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Catherine K Hart
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael J Rutter
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alessandro de Alarcon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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11
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Open paediatric laryngotracheal reconstruction: a five-year experience at a tertiary referral centre. J Laryngol Otol 2023; 137:192-199. [PMID: 35057879 DOI: 10.1017/s0022215121004217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Laryngotracheal reconstruction with costal cartilage graft is a cornerstone procedure in treatment of multiple paediatric airway pathologies. The current study aimed to report on the experience of laryngotracheal reconstruction and document post-operative outcomes and complications. METHOD Records of laryngotracheal reconstruction procedures performed between 2016 and 2020 were retrospectively reviewed. Primary indication, clinical data, decannulation rate, voice assessment, need for revision surgery and possible complications were analysed. RESULTS A total of 41 patients were treated with laryngotracheal reconstruction. Subglottic stenosis formed the largest percentage of cases followed by congenital glottic web (20 and 14 patients, respectively). Three patients (7.3 per cent) underwent single stage surgery, and the remaining cases had a double stage procedure. Revision laryngotracheal reconstruction was needed in a single case, and 38 out of 39 tracheostomised patients were successfully decannulated. CONCLUSION Favourable outcomes were reported with costal cartilage laryngotracheal reconstruction as a definitive treatment for a large range of paediatric airway problems.
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12
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Management of paediatric laryngotracheal trauma. The Journal of Laryngology & Otology 2022; 136:1125-1129. [DOI: 10.1017/s0022215121003972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Objective
To summarise and describe the clinical presentations, diagnostic approaches and airway management techniques in children with laryngotracheal trauma.
Methods
The clinical data related to laryngotracheal trauma diagnosed and treated at the Beijing Children's Hospital, between January 2013 and July 2018, were retrospectively reviewed. Disease diagnosis, treatment, management and outcomes were analysed.
Results
A total of 13 cases were enrolled, including 7 cases of penetrating laryngotracheal trauma. The six cases of blunt laryngotracheal trauma were caused by collisions with hard objects. In all cases, voice, airway and swallowing outcomes were graded as ‘good’, except for one patient who had residual paralysis of the vocal folds.
Conclusion
Flexible fibre-optic laryngoscopy and computed tomography can play an important role in diagnosing laryngotracheal trauma. The airway should be secured and, if necessary, opened by tracheal intubation or tracheostomy.
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13
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Pediatric Open Airway Reconstruction. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-020-00317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Wineland AM. Surgical management of an infantile elliptical cricoid: Endoscopic posterior laryngotracheoplasty utilizing a resorbable plate. Int J Pediatr Otorhinolaryngol 2020; 138:110285. [PMID: 32795728 DOI: 10.1016/j.ijporl.2020.110285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/27/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
The cricoid is a circular "ring" of cartilage in the airway. When the lateral walls of the cricoid approximate, it takes the shape of an ellipse. In severe cases, this also reduces the glottic aperture and causes respiratory distress, stridor, and failure to thrive. The elliptical cricoid has limited surgical options outside of open laryngotracheal procedures and tracheostomy. Recently, alternatives to autologous grafts have been utilized in airway reconstruction to reduce harvest site morbidity and increase operating room efficiency. Herein a case is presented that demonstrates the successful use of a resorbable plate in augmenting the posterior larynx in an infant with a severely elliptical cricoid to avoid a tracheostomy.
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Affiliation(s)
- Andre' M Wineland
- University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 836, Little Rock, AR, 72202, USA.
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15
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Kennedy AA, de Alarcon A, Tabangin ME, Rutter MJ, Myer CM, Smith MM, Hart CK. Tracheal A-Frame Deformities Following Airway Reconstruction. Laryngoscope 2020; 131:E1363-E1368. [PMID: 32846022 DOI: 10.1002/lary.28996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/07/2020] [Accepted: 07/12/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Airway reconstruction for subglottic and tracheal stenosis is often successful in achieving tracheostomy decannulation and improving airway symptoms. However, one common reason for late failure is development of a tracheal A-frame deformity, which can necessitate additional surgery. Although knowledge of this deformity exists, the incidence and risk factors have not been reported. This study seeks to determine the incidence of A-frame following airway reconstruction and define factors that correlate with development of this deformity. STUDY DESIGN Retrospective case series. METHODS Patients under 21 years of age undergoing open airway reconstruction at our institution between January 2005-December 2006 were retrospectively reviewed. Demographic data, comorbidities, airway history/reconstruction type, and follow-up airway findings were examined using multivariable logistic regression. Kaplan-Meier curves were used to examine time to A-frame repair. RESULTS Two hundred patients underwent airway reconstruction and 69 (34.5%) developed an A-frame deformity. History of tracheostomy was the most significant contributor to A-frame development (P < .0001). Double- versus single-stage procedures were not associated with increased odds of A-frame development (P = .94), however, patients undergoing resection procedures as opposed to laryngotracheal reconstruction (LTR) with cartilage grafts had a significantly lower chance of developing this deformity (P = .004). Of the patients with an A-frame, 27 (39%) required further surgical intervention. CONCLUSION Approximately one-third of patients undergoing airway reconstruction developed a tracheal A-frame deformity, with a significantly higher rate among patients with a history of tracheostomy and those undergoing LTR. Patients should be followed long term to assess for the development of an A-frame. LEVEL OF EVIDENCE IV Laryngoscope, 131:E1363-E1368, 2021.
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Affiliation(s)
- Aimee A Kennedy
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Meredith E Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Michael J Rutter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Charles M Myer
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Matthew M Smith
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Catherine K Hart
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
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16
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GER characteristics after fundoplication in children with aerodigestive disorders. J Pediatr Surg 2020; 55:456-460. [PMID: 31767193 DOI: 10.1016/j.jpedsurg.2019.08.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 08/11/2019] [Accepted: 08/31/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to determine GER characteristics after Nissen fundoplication in children with aerodigestive disorders using pH-impedance technology. METHODS In this cross-sectional study, the institutional database of Cincinnati Children's Hospital Medical Center was reviewed to identify patients ages below 21 years who had a Nissen fundoplication and underwent esophageal pH-impedance (pH-MII) monitoring over a nine-year period. All reflux-related metrics were modeled as a Poisson random variable as a function of time since fundoplication. RESULTS A total of 242 patients were included in the study. The range for time since surgery was 1-192 months. Median total reflux events were 8.5 episodes per 24 h, median acidic reflux events were 0, and median proximal reflux event was 2. There was no significant trend towards increasing reflux episodes over time. CONCLUSIONS Children had a low number of reflux events after a fundoplication, as measured by pH-impedance, and there was no statistically significant increase observed in the number of reflux events over time. Despite most patients having a functional fundoplication with minimal reflux events throughout the entire age range, up to 58% of our cohort was still on a proton pump inhibitor.
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17
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Bergeron M, de Alarcon A, Hart CK, Rutter MJ. Outcomes of Prophylactic Epiglottic Petiole Suspension at the Time of Complete Laryngofissure. Otolaryngol Head Neck Surg 2019; 161:652-657. [DOI: 10.1177/0194599819852619] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
ObjectivesTo compare the clinical outcomes of patients with prophylactic petiole suspension (PPS) at the time of laryngofissure and patients without PPS.Study DesignRetrospective case series.SettingTertiary pediatric hospital from May 2003 to August 2017.Subjects and MethodsPatients included those undergoing airway reconstruction with complete laryngofissure. Patients in the study group had PPS at the time of laryngofissure, while control group patients did not.ResultsEighty-one patients underwent complete laryngofissure (22 study patients, 59 controls) at a median age of 4.8 years (interquartile range, 2.1-9.7). Patients in the control group were younger at the time of the surgery (3.7 vs 6.5 years, P = .04). Other demographic and clinical data, including subglottic stenosis (SGS) grades, were similar. For patients with SGS, 53.8% and 46.2% in the study group had a grade 1-2 and 3-4 SGS, respectively, as compared with 46.2% and 53.8% in the control group ( P = .65). Manifestations of petiole prolapse included failure of decannulation (8.6%), exercise intolerance (16.0%), and obstructive sleep apnea (11.1%). After 4 years of follow-up, 4.5% of the study group versus 27.1% of the control group had prolapse of the petiole ( P = .04). Petiole prolapsed affected >50% of patients with no PPS after 10 years of follow-up. Patients with petiole prolapse at the first surveillance microlaryngoscopy and bronchoscopy after stent removal had an odds ratio of 10.2 (95% CI, 1.1-94.8; P = .04) of becoming symptomatic.ConclusionPatients with PPS had significantly fewer symptoms after complete laryngofissure as compared with patients without PPS. PPS should be considered when a complete laryngofissure is being performed during airway reconstruction.
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Affiliation(s)
- Mathieu Bergeron
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatric Otolaryngology–Head and Neck Surgery, Sainte-Justine Hospital, Montreal, Quebec, Canada
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Aerodigestive and Esophageal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Catherine K. Hart
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Aerodigestive and Esophageal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael J. Rutter
- Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Aerodigestive and Esophageal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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18
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Li L, Black K, White M, Zalzal G, Preciado D. An evaluation of arytenoid prolapse following laryngotracheal reconstruction. Laryngoscope 2019; 130:247-251. [DOI: 10.1002/lary.27864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/13/2019] [Accepted: 01/22/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Lilun Li
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
| | - Kaelan Black
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
| | - Michelle White
- School of MedicineDrexel University College of Medicine Philadelphia Pennsylvania U.S.A
| | - George Zalzal
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
| | - Diego Preciado
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
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19
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Bergeron M, de Alarcon A, Hart CK, Rutter MJ. Factors associated with epiglottic petiole prolapse repositioning success. Laryngoscope 2018; 129:1984-1988. [DOI: 10.1002/lary.27705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Mathieu Bergeron
- Division of Pediatric Otolaryngology–Head and Neck Surgery Cincinnati OH U.S.A
- Department of Pediatric Otolaryngology–Head and Neck SurgerySainte‐Justine Hospital, University of Montreal Montreal, Quebec Canada
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology–Head and Neck Surgery Cincinnati OH U.S.A
- the Aerodigestive and Esophageal CenterCincinnati Children's Hospital Medical Center Cincinnati OH U.S.A
- Department of Otolaryngology–Head and Neck SurgeryUniversity Of Cincinnati College of Medicine Cincinnati OH U.S.A
| | - Catherine K Hart
- Division of Pediatric Otolaryngology–Head and Neck Surgery Cincinnati OH U.S.A
- the Aerodigestive and Esophageal CenterCincinnati Children's Hospital Medical Center Cincinnati OH U.S.A
- Department of Otolaryngology–Head and Neck SurgeryUniversity Of Cincinnati College of Medicine Cincinnati OH U.S.A
| | - Michael J. Rutter
- Division of Pediatric Otolaryngology–Head and Neck Surgery Cincinnati OH U.S.A
- the Aerodigestive and Esophageal CenterCincinnati Children's Hospital Medical Center Cincinnati OH U.S.A
- Department of Otolaryngology–Head and Neck SurgeryUniversity Of Cincinnati College of Medicine Cincinnati OH U.S.A
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20
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Balakrishnan K, Sidell DR, Bauman NM, Bellia-Munzon GF, Boesch RP, Bromwich M, Cofer SA, Daines C, de Alarcon A, Garabedian N, Hart CK, Ida JB, Leboulanger N, Manning PB, Mehta DK, Monnier P, Myer CM, Prager JD, Preciado D, Propst EJ, Rahbar R, Russell J, Rutter MJ, Thierry B, Thompson DM, Torre M, Varela P, Vijayasekaran S, White DR, Wineland AM, Wood RE, Wootten CT, Zur K, Cotton RT. Outcome measures for pediatric laryngotracheal reconstruction: International consensus statement. Laryngoscope 2018; 129:244-255. [DOI: 10.1002/lary.27445] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/29/2018] [Accepted: 06/21/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Karthik Balakrishnan
- Department of Otorhinolaryngology and Mayo Clinic Children's Center; Rochester Minnesota
| | - Douglas R. Sidell
- Department of Otolaryngology-Head and Neck Surgery; Stanford University; Palo Alto California
| | - Nancy M. Bauman
- Division of Otolaryngology, Children's National Health System; Washington DC
| | - Gaston F. Bellia-Munzon
- Department of Pediatric Surgery; General Hospital of Children Pedro de Elizalde; Buenos Aires Argentina
| | - R. Paul Boesch
- Department of Pediatric and Adolescent Medicine and Mayo Clinic Children's Center; Mayo Clinic; Rochester Minnesota
| | | | - Shelagh A. Cofer
- Department of Otorhinolaryngology and Mayo Clinic Children's Center; Rochester Minnesota
| | - Cori Daines
- Department of Pediatrics; University of Arizona Health Sciences; Tucson Arizona
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology and Aerodigestive and Esophageal Center; Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Nöel Garabedian
- Department of Otorhinolaryngology; Hôpital Universitaire Necker-Enfants Malades; Paris France
| | - Catherine K. Hart
- Division of Pediatric Otolaryngology and Aerodigestive and Esophageal Center; Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Jonathan B. Ida
- Department of Otolaryngology, Head and Neck Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Nicolas Leboulanger
- Department of Otorhinolaryngology; Hôpital Universitaire Necker-Enfants Malades; Paris France
| | - Peter B. Manning
- Section of Pediatric Cardiothoracic Surgery; St. Louis Children's Hospital and Washington University School of Medicine; St. Louis Missouri
| | - Deepak K. Mehta
- Department of Pediatric Otolaryngology; Texas Children's Hospital; Houston Texas
| | - Philippe Monnier
- Department of Otolaryngology, Head and Neck Surgery; University Hospital of Lausanne (CHUV); Lausanne Switzerland
| | - Charles M. Myer
- Division of Pediatric Otolaryngology and Aerodigestive and Esophageal Center; Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Jeremy D. Prager
- Department of Otolaryngology; University of Colorado; Aurora Colorado
| | - Diego Preciado
- Division of Otolaryngology, Children's National Health System; Washington DC
| | - Evan J. Propst
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Reza Rahbar
- Department of Otolaryngology; Boston Children's Hospital, Harvard Medical School; Boston Massachusetts
| | - John Russell
- Department of Paediatric Otolaryngology; Our Lady's Hospital for Sick Children; Dublin Ireland
| | - Michael J. Rutter
- Division of Pediatric Otolaryngology and Aerodigestive and Esophageal Center; Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Briac Thierry
- Department of Otorhinolaryngology; Hôpital Universitaire Necker-Enfants Malades; Paris France
| | - Dana M. Thompson
- Department of Otolaryngology, Head and Neck Surgery; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Michele Torre
- Airway Team and Surgical Department; Instituto Giannina Gaslini; Genoa Italy
| | - Patricio Varela
- Pediatric Surgery Department; University of Chile, Clinical Las Condes Medical Center; Santiago Chile
| | - Shyan Vijayasekaran
- Department of Otolaryngology, Head and Neck Surgery; Princess Margaret Hospital for Children; Perth Australia
| | - David R. White
- Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston South Carolina
| | - Andre M. Wineland
- University of Arkansas School for Medical Sciences; Department of Otolaryngology-Head & Neck Surgery, Arkansas Children's Hospital; Little Rock Arkansas
| | - Robert E. Wood
- Division of Pulmonary Medicine, Cincinnati Children's Hospital; Cincinnati Ohio
| | | | - Karen Zur
- Center for Pediatric Airway Disorders, Children's Hospital of Philadelphia, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania U.S.A
| | - Robin T. Cotton
- Division of Pediatric Otolaryngology and Aerodigestive and Esophageal Center; Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine; Cincinnati Ohio
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21
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Abstract
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.
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Affiliation(s)
- Katherine Hanlon
- The Center for Pediatric Airway Disorders, Division of Otolaryngology, The Children's Hospital of Philadelphia, Philadelphia, PA.
| | - R Paul Boesch
- Mayo Clinic, Children's Center, Pediatric and Adolescent Medicine, Rochester, MN
| | - Ian Jacobs
- The Center for Pediatric Airway Disorders, Division of Otolaryngology, The Children's Hospital of Philadelphia, Philadelphia, PA
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22
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Piccione J, Boesch RP. The Multidisciplinary Approach to Pediatric Aerodigestive Disorders. Curr Probl Pediatr Adolesc Health Care 2018; 48:66-70. [PMID: 29571542 DOI: 10.1016/j.cppeds.2018.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Multidisciplinary programs for the care of children with upper and lower respiratory and gastrointestinal tract disorders have emerged across the United States and become known as aerodigestive centers. This model is designed to improve clinical outcomes and healthcare value through a coordinated approach by a team that appreciates the inter-relatedness of these disorders. The primary elements include: (1) Interdisciplinary medical and surgical team, (2) Care coordination, (3) Team meeting, and (4) Combined endoscopic procedures. This article will describe the origin and current trends in the multidisciplinary approach to pediatric aerodigestive disorders.
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Affiliation(s)
- Joseph Piccione
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia & Center for Pediatric Airway Disorders, Philadelphia, PA.
| | - R Paul Boesch
- Division of Pediatric Pulmonology, Mayo Clinic Children's Center, Rochester, MN
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23
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Smith DF, de Alarcon A, Jefferson ND, Tabangin ME, Rutter MJ, Cotton RT, Hart CK. Short- versus Long-term Stenting in Children with Subglottic Stenosis Undergoing Laryngotracheal Reconstruction. Otolaryngol Head Neck Surg 2017; 158:375-380. [PMID: 29064319 DOI: 10.1177/0194599817737757] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Suprastomal stents are routinely used in laryngotracheal reconstruction (LTR) to stabilize grafts and provide framework to sites of repair. However, the duration of stenting varies according to patient history and physician preference. We examined outcomes of short- versus long-term stenting in children with subglottic stenosis (SGS) undergoing LTR. Study Design Case series with chart review. Setting Tertiary care pediatric hospital. Subjects and Methods Thirty-six children <18 years old who underwent double-stage LTR for SGS from January 2012 to January 2015 were included. Demographic data, stenosis grade, and decannulation rates were compared between children with short-term stenting (≤21 days; n = 14) and those with long-term stenting (>21 days; n = 22). Results No significant difference between groups was seen for sex, age, race, or previous repair. Children in the short-term group were stented for 10.9 ± 4.9 days, compared with 44.0 ± 10.6 for those long-term ( P < .0001). A similar number of children with short- versus long-term stents had grade 3/4 stenosis preoperatively (71.4% vs 77.2%). Although time to decannulation was not significantly different, 72.7% of children with long-term stents were decannulated, as opposed to 35.7% with short-term stents ( P = .03). After adjusting for grade at surgery and age, children with long-term stents had 4.3 greater odds (95% CI, 1.0-18.3) of decannulation than children with short-term stents. Conclusions Children with long-term stenting were more likely to be successfully decannulated. Although long-term stenting improved outcomes for children with SGS, additional research is needed to better define ideal candidates for short- versus long-term stenting.
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Affiliation(s)
- David F Smith
- 1 Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,2 Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alessandro de Alarcon
- 2 Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,3 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Niall D Jefferson
- 2 Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Meredith E Tabangin
- 4 Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael J Rutter
- 2 Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,3 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Robin T Cotton
- 2 Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,3 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Catherine K Hart
- 2 Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,3 Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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24
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Abstract
Subglottic stenosis (SGS) is a congenital or acquired condition characterized by a narrowing of the upper airway extending from just below the vocal folds to the lower border of the cricoid cartilage. With the introduction of prolonged intubation in neonates (mid 1960s), acquired SGS became the most frequent cause of laryngeal stenosis; unlike congenital SGS, it does not improve with time. Laryngeal reconstruction surgery evolved as a consequence of the need to manage these otherwise healthy but tracheotomized children. Ongoing innovations in neonatal care have gradually led to the salvage of premature and medically fragile infants in whom laryngeal pathology is often more severe, and in whom stenosis often involves not only the subglottis, but also the supraglottis or glottis-causing significant morbidity and mortality. The primary objective of intervention in these children is decannulation or preventing the need for tracheotomy. The aim of this article is to present a more detailed description of both congenital and acquired SGS, highlighting the essentials of diagnostic assessment and familiarizing the reader with contemporary management approaches.
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Affiliation(s)
- Niall D Jefferson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, Ohio 45229-30309
| | - Aliza P Cohen
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, Ohio 45229-30309
| | - Michael J Rutter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, Ohio 45229-30309; Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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25
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Ahmad FI, O'Dell K, Peck JJ, Wax MK, Milczuk HA. Pediatric airway reconstruction with a prefabricated auricular cartilage and radial forearm free flap. Laryngoscope 2015; 125:1979-82. [PMID: 25645935 DOI: 10.1002/lary.25128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 11/25/2014] [Accepted: 12/11/2014] [Indexed: 11/11/2022]
Abstract
Prefabricated composite free flaps for complex airway reconstruction have been described for an adult series at our institution. We extended this approach to a pediatric patient with lifelong subglottic stenosis who had failed previous open airway reconstructions. A staged procedure was utilized in which a composite graft was created using conchal cartilages and a radial forearm free flap. This reconstruction improved the patency of her airway and decreased her dependency on intermittent airway dilations. Airway reconstruction with prefabricated conchal cartilage composite free flaps may be used as a salvage procedure for complex pediatric airway reconstruction when other methods have failed.
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Affiliation(s)
- Faisal I Ahmad
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Karla O'Dell
- Department of Otolaryngology-Head & Neck Surgery, University of Southern California, Los Angeles, Los Angeles, California, U.S.A
| | - Jessica J Peck
- Department of Otolaryngology-Head & Neck Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, U.S.A
| | - Mark K Wax
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Henry A Milczuk
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
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26
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Bliss M, Houtz D, Smith ME. Cricoid reduction laryngoplasty for treatment of dysphonia after pediatric laryngotracheal reconstruction. Int J Pediatr Otorhinolaryngol 2015; 79:80-2. [PMID: 25465446 DOI: 10.1016/j.ijporl.2014.10.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/19/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
Abstract
Dysphonia is common after pediatric laryngotracheal reconstruction (LTR). Surgical techniques designed to rehabilitate the voice after LTR have not yet been proposed. Herein we describe a case of a patient with severe glottal insufficiency after LTR who was treated with a cricoid reduction laryngoplasty in order to surgically rehabilitate the voice. Removal of the posterior costal cartilage graft was effective at improving the quality of the voice and left the patient with an adequate airway even during moderate exercise.
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Affiliation(s)
- Morgan Bliss
- Division of Otolaryngology/Head and Neck Surgery, Primary Children's Hospital, The University of Utah School of Medicine, United States.
| | - Dan Houtz
- Voice Disorders Center, University Hospital, The University of Utah, Salt Lake City, UT, United States
| | - Marshall E Smith
- Division of Otolaryngology/Head and Neck Surgery, Primary Children's Hospital, The University of Utah School of Medicine, United States; Voice Disorders Center, University Hospital, The University of Utah, Salt Lake City, UT, United States
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Hart CK, de Alarcon A, Tabangin ME, Hamilton S, Rutter MJ, Pentiuk SP, Garza JM. Impedance Probe Testing Prior to Pediatric Airway Reconstruction. Ann Otol Rhinol Laryngol 2014; 123:641-6. [DOI: 10.1177/0003489414528867] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: This study aimed to determine if preoperative impedance testing changed management and if testing was associated with surgical outcome in patients undergoing airway reconstruction. Methods: Retrospective review of patients who had impedance testing prior to airway reconstruction at a tertiary pediatric hospital from January 2010 to September 2011. Charts were reviewed for demographics, medical/surgical history, impedance testing, and surgical outcomes. Results: Fifty-seven patients were included. Forty-seven (82%) were premature. Forty-seven (82%) had a primary diagnosis of subglottic stenosis. Twenty-six (45%) had prior airway surgery. Thirty-six (63%) had gastroesophageal reflux and 21 (36%) had undergone fundoplication. Patients without fundoplication had a median 46 total reflux, 7 proximal, and 14.5 acidic events compared to a median 5 total reflux, 0 proximal, and 0 acidic events in patients with fundoplication. Impedance testing changed management in 22% (8/36) of nonfundoplication patients and 9.5% (2/21) of fundoplication patients. In unadjusted analysis, fewer fundoplication patients had successful surgery compared to those without (33% vs 67%, P = .01). Prematurity, age at surgery, and previous airway surgery were also important predictors of surgical success. Conclusion: Fewer patients than anticipated had a change in management. Impedance testing was unlikely to change management in fundoplication patients. Patients with fundoplication were less likely to have a successful outcome, suggesting that factors other than reflux influence airway reconstruction outcomes.
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Affiliation(s)
- Catherine K. Hart
- Division of Pediatric Otolaryngology–Head & Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Aerodigestive and Esophageal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology–Head & Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Aerodigestive and Esophageal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Meredith E. Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Steven Hamilton
- Division of Pediatric Otolaryngology–Head & Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Michael J. Rutter
- Division of Pediatric Otolaryngology–Head & Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Aerodigestive and Esophageal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Otolaryngology–Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Scott P. Pentiuk
- Aerodigestive and Esophageal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jose M. Garza
- Aerodigestive and Esophageal Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Miller CK, Kelchner LN, de Alarcon A, Willging JP. Compensatory Laryngeal Function and Airway Protection in Children Following Airway Reconstruction. Ann Otol Rhinol Laryngol 2014; 123:305-13. [DOI: 10.1177/0003489414525920] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Laryngotracheal reconstruction (LTR) procedures for repair of complex congenital or acquired airway stenosis of the larynx and/or trachea in pediatric patients have advanced over recent decades. The aim of the present project was to investigate the relationships among diagnoses, type of surgical intervention, and laryngeal findings in a post-LTR patient cohort to identify factors associated with adequate airway protection and swallowing outcomes. Methods: A retrospective review of 30 airway patients undergoing simultaneous or close interval functional laryngeal and swallowing examinations was completed. Analyses of the data were performed to examine factors associated with postoperative airway protection and swallowing function. The patient cohort was separated into 2 groups according to the adequacy of their airway protection (aspiration and no aspiration) as judged by clinicians via instrumental examination. Results: Data analyses revealed statistically significant differences between the 2 groups for 3 key parameters: laryngeal closure, laryngeal closure timeliness (relative to bolus flow), and overall swallowing coordination. Conclusions: These findings contribute to the knowledge of laryngeal closure patterns present in patients undergoing airway reconstruction and the effect on the essential laryngeal function of airway protection during swallowing. Implications of the data for swallowing function in this population are discussed.
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Affiliation(s)
- Claire Kane Miller
- Cincinnati Children’s Hospital Medical Center, Division of Speech Pathology/Aerodigestive and Esophageal Center, Cincinnati, Ohio, USA
- University of Cincinnati, Division of Communication Sciences and Disorders, Cincinnati, Ohio, USA
| | - Lisa N. Kelchner
- University of Cincinnati, Division of Communication Sciences and Disorders, Cincinnati, Ohio, USA
- Cincinnati Children’s Hospital Medical Center, Division of Speech-Language Pathology, Cincinnati, Ohio, USA
| | - Alessandro de Alarcon
- Cincinnati Children’s Hospital Medical Center, Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - J. Paul Willging
- Cincinnati Children’s Hospital Medical Center, Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
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de Alarcón A. Voice outcomes after pediatric airway reconstruction. Laryngoscope 2013; 122 Suppl 4:S84-6. [PMID: 23254615 DOI: 10.1002/lary.23814] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2012] [Indexed: 11/10/2022]
Affiliation(s)
- Alessandro de Alarcón
- Center for Pediatric Voice Disorders, University of Cincinnati, Cincinnati, Ohio, USA.
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Varghese AM, Cheng AT. Epiglottic Repositioning Procedure for Supraglottic Stenosis/Collapse. Ann Otol Rhinol Laryngol 2011; 120:478-83. [DOI: 10.1177/000348941112000710] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Supraglottic stenosis/collapse is an uncommon condition. It can be difficult to detect and may be a cause of failed decannulation following tracheostomy. We present a novel technique to correct supraglottic stenosis/collapse. Methods: We performed a retrospective analysis of the records of patients in whom attempts at decannulation had failed at our center between 2003 and 2007. A subgroup with supraglottic stenosis/collapse with posterior displacement of the base of the epiglottis was identified. Our epiglottic repositioning procedure was performed in these patients. Through an external incision, the epiglottis was divided above the anterior commissure and attached to the superior border of the thyroid cartilage. Results: Eight decannulation failures out of 36 attempted decannulations were identified. Three of these 8 cases involved supraglottic stenosis/collapse due to posterior displacement of the base of the epiglottis. Correction of the supraglottic stenosis/collapse led to successful decannulation in all cases. Conclusions: Diagnosis-directed laryngoscopy is required to identify this condition. We describe precisely a technique of repositioning the epiglottis to correct supraglottic stenosis/collapse.
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Kurien G, Uwiera TC. Tracheal stenosis in hyper immunoglobulin E syndrome: a novel case report. Int J Pediatr Otorhinolaryngol 2011; 75:868-71. [PMID: 21459460 DOI: 10.1016/j.ijporl.2011.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 02/25/2011] [Accepted: 03/06/2011] [Indexed: 11/25/2022]
Abstract
Hyper Immunoglobulin E Syndrome, or Job's Syndrome, is a rare multisystem disorder that classically presents in early childhood with a triad of clinical manifestations that include severe eczematous dermatitis, recurrent infections (skin and lung), and elevated serum immunoglobulin E. Hyper Immunoglobulin E Syndrome is a relatively uncommon condition and as such requires careful consideration of a constellation of patient symptoms to correctly diagnose the underlying disease. In this report we present a unique case of a child with previously undiagnosed Hyper Immunoglobulin E Syndrome presenting with biphasic stridor associated with multiple areas of tracheal stenosis.
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Affiliation(s)
- G Kurien
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Partial Cricotracheal Resection in Children. Otolaryngol Head Neck Surg 2009; 141:225-31. [DOI: 10.1016/j.otohns.2009.04.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Revised: 03/17/2009] [Accepted: 04/21/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVES: To delineate the various factors contributing to failure or delay in decannulation after partial cricotracheal resection (PCTR) in children. STUDY DESIGN: Case series. SETTING: Academic tertiary medical center. SUBJECTS AND METHODS: A retrospective case review of 100 children who underwent PCTR between 1978 and 2008 for severe subglottic stenosis using an ongoing database. RESULTS: Ninety of 100 (90%) patients were decannulated. Six patients needed secondary tracheostomy. The results of the preoperative evaluation showed grade II stenosis in four patients, grade III in 64 patients, and grade IV in 32 patients. The overall decannulation rate was 100 percent in grade II, 95 percent in grade III, and 78 percent in grade IV stenosis. Fourteen (14%) patients required revision open surgery. The most common cause of revision surgery was posterior glottic stenosis. Partial anastomotic dehiscence was seen in four patients. Delayed decannulation (>1 year) occurred in nine patients. Overall mortality rate in the whole series was 6 percent. No deaths were directly related to the surgery. No iatrogenic recurrent laryngeal nerve injury was present in the entire series. CONCLUSION: Comorbidities and associated syndromes should be addressed before PCTR is planned to improve the final postoperative outcome in terms of decannulation. Perioperative morbidity due to anastomotic dehiscence, to a certain extent, can be avoided by intraoperative judgment in the selection of double-stage surgery when more than five tracheal rings need to be resected. Subglottic stenosis with glottic involvement continues to pose a difficult challenge to pediatric otolaryngologists, often necessitating revision procedures.
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Partial cricotracheal resection for congenital subglottic stenosis in children: the effect of concomitant anomalies. Int J Pediatr Otorhinolaryngol 2009; 73:981-5. [PMID: 19447507 DOI: 10.1016/j.ijporl.2009.03.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 02/04/2009] [Accepted: 03/21/2009] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To review the surgical outcomes of partial cricotracheal resection in children with severe congenital subglottic stenosis and define the effect of concomitant anomalies or syndromes affecting outcome. METHODS Forty-one children with subglottic stenosis of congenital and mixed (acquired on congenital) etiologies who underwent partial cricotracheal resection were identified from a prospectively collected database. Children with congenital subglottic stenosis and concomitant anomalies/syndromes were compared to children with congenital subglottic stenosis with no syndromes or concomitant anomalies. Operation-specific decannulation rates and complication rates were the primary outcome measures. We performed a two-sample test of proportion using the STATA-10 software for categorical variables to detect differences in proportions. Significance was set at p value<0.05. RESULTS Twenty-seven (66%) of 41 children had concomitant anomalies/syndromes and 14 (34%) had congenital subglottic stenosis without concomitant anomalies/syndromes. Four patients needed revision surgery in the concomitant anomaly group and two patients needed revision surgery in the non concomitant anomaly group before achieving decannulation. The operation-specific decannulation rate in the concomitant anomaly group was 85% and 86% in the non anomaly group. When compared to children without concomitant anomaly, children with concomitant anomalies were more likely to have delayed decannulation following partial cricotracheal resection. However, this difference was not found to be statistically significant. The complication and operation-specific decannulation rates after partial cricotracheal resection were comparable to children without concomitant anomalies. Mortality rate was 11% (three of 27 patients) in the group with associated congenital anomalies or syndromes. Two patients succumbed to the primary pathology and one patient died due to tracheostomy-tube obstruction. There was no post-operative death in the non anomaly group. CONCLUSION Partial cricotracheal resection can be done safely and effectively in children with concomitant anomalies/syndromes to achieve decannulation. The post-operative course may be prolonged but the decannulation and the complication rates are comparable to those children with congenital subglottic stenosis without concomitant anomalies.
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