Reconstructive Surgery of the Laryngotracheal Junction

The laryngotracheal junction is an anatomical region with special pathophysiological features. This review presents clinical pictures and malformations that manifest pre-dilectively at this localisation in children and adolescents as well as in adults. The diagnostic procedure is discussed. The possibilities of surgical reconstruction are presented depending on the pathology and age of the patient.

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.

Pediatric Airway Balloon Dilation: Urge for Safety Redesign

Airway balloons are widely used by otolaryngologists to treat laryngotracheal stenosis. We review an adverse event and interventions that may prevent similar occurrences. There are no other reports of similar incidents in the Food and Drug Administration Manufacturer and User Facility Device Experience. We implore Acclarent to redesign their airway balloon device to prevent accidental airway irrigation.

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.

Utilizing a Functional Lumen Imaging Probe for Evaluation of the Pediatric Airway, A Pilot Study

OBJECTIVES

Accurate and reproducible measurements of the pediatric airway are critical for diagnostic evaluation and management of subglottic and tracheal stenosis. The endoluminal functional lumen imaging probe (EndoFLIP) is a catheter-based imaging probe which utilizes impedance planimetry to calculate luminal parameters, including cross-sectional area and compliance. Herein, we demonstrate the feasibility of this system for multidimensional evaluation of the pediatric airway.

METHODS

3D-printed pediatric laryngotracheal models were created based on computed tomography scans, then artificially deformed to simulate both circumferential and posterior subglottic stenosis. Two observers made six measurements of the minimum cross-sectional area (MCSA) and length of stenosis of each model with EndoFLIP. Agreement between observer measurements and model dimensions was evaluated using Lin's concordance correlation coefficient; inter-observer reliability was assessed using intraclass correlation.

RESULTS

Four models were created: two without pathology (MCSA: 132.4, 44.3 mm2 ) and two with subglottic stenosis (MCSA: 28.7, 59.7 mm2 , stenotic length 27.8, 24.4 mm). Observer measurements of MCSA and length of stenosis demonstrated high concordance with the models (r = 0.99, 0.95, p < 0.001) with a mean error of 4.5% and 18.2% respectively. There was a low coefficient of variation (0.6%-2.8%) for measurements, indicating high precision. Interrater reliability was high for both MCSA and stenotic length (ICC: 0.99, 0.98).

CONCLUSIONS

The EndoFLIP system allows for accurate and reproducible measurements of cross-sectional area and stenotic length in pediatric airway models. This method may provide further advantages in the evaluation of airway distensibility, as well as measurements of asymmetric airway pathology.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:108-112, 2024.

Tuberculous bronchial stenosis: Diagnosis and role of interventional bronchoscopy

The reported prevalence of tuberculous bronchial stenosis in children is unknown and rarely reported in English-speaking literature. In adult patients with pulmonary tuberculosis, it varies from 40% in an autopsied series in the preantibiotic era to 10% in patients who have undergone routine bronchofibroscopy in modern times. We describe our experience of four cases of confirmed bronchial stenosis due to MTB collected between January 2000 and June 2021 in this case series descriptive study. The diagnosis of bronchial stenosis due to TB was made on flexible bronchoscopy. A TB diagnosis was made if MTB was cultured from respiratory secretions, when Ziehl-Neelsen smear or GeneXpert MTB/RIF test was positive, or if a chest radiograph revealed radiographic features typical of MTB. Bronchial stenosis due to TB is rare even if airway compression is frequently seen. Although an early diagnosis of bronchial stenosis due to TB is difficult on chest X-rays, all children in this series demonstrated parenchymal changes distal to the stenosis ranging from hyperinflation and lobar collaps to bronchiectasis. If bronchial stenosis resulting from TB disease is diagnosed early, balloon dilatation as described in this report, may be an effective and safe intervention, preventing long-term complications such as irreversible lung destruction, that may require pneumonectomy.

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.

Prognostic factors in the management of pediatric subglottic stenosis

OBJECTIVE

We report outcomes of endoscopic interventions in the management of pediatric subglottic stenosis (SGS), and factors that lead to open airway reconstruction.

METHODS

A retrospective cohort review of all pediatric patients with SGS, treated by a single surgeon, at a tertiary academic medical center from 2012 to 2020 was conducted. Variables recorded included patient demographics, initial grade of stenosis, gestational age, length of intubation, comorbidities as well as total number of interventions.

RESULTS

A total of 47 patients were included in the study, of which 51% (n = 24) were female. Laryngotracheal reconstruction (LTR) was performed in 49% (n = 23) of patients. Decannulation was achieved in 25 of 32 tracheostomized patients. Fifteen patients did not have tracheostomy. There was a significant difference in gestational age (28.7 ± 5.36 vs 33.2 ± 6.13), initial grade of stenosis (2.3 ± 0.82 vs 1.6 ± 0.88), and total number of interventions (5.7 ± 2.8 vs 2.3 ± 1.5) when stratifying patients proceeding to LTR versus not (p < 0.05). There was no significant difference, however, in the length of intubation between the two groups. Of the comorbidities recorded, none were found to have a significant impact on the outcome.

CONCLUSION

Subglottic stenosis is a challenging condition to treat, often requiring multiple interventions including LTR. We propose a set of risk factors that may assist in the treatment of SGS patients with certain comorbidities to minimize interventions and maximize outcomes.

Balloon tracheoplasty for tracheal stenosis after prolonged intubation: a simple procedure, but is it effective?

Background

Tracheal stenosis following prolonged intubation is a relatively rare but serious problem. This condition is usually managed by surgical or endoscopic interventions. Bronchoscopic balloon dilatation for tracheal stenosis is considered a valuable tool used for the management of tracheal stenosis. In this article, we try to evaluate the role of balloon tracheoplasty in the management of tracheal stenosis and to assess the number of dilatation sessions usually needed as well as the short to midterm outcome.

Results

This study involved 40 patients with tracheal stenosis diagnosed by computed tomography (neck and chest) and bronchoscopy at the Security Force Hospital in Riyadh, KSA, between January 2013 and August 2018. Patients’ data were retrospectively reviewed and analyzed. Patients’ age ranged between 18 and 60 years. Thirty patients were males (75%); those patients underwent balloon tracheoplasty via dilatation of areas of narrowing using catheter balloon insufflation guided by fiber-optic bronchoscope. Ninety-five percent of the patients had initial success with acceptable dilatation of the stenotic area and improvement of the symptoms. There were no technical or major problems which resulted from the procedure, and no patient complained of severe pain or severe discomfort after the procedure. From the total of 81 BBD sessions, no in-hospital mortality is related to the procedure itself, and ICU stay ranged between 1 and 5 days post-procedure. Among those 40 patients, 16 patients (40%) needed one session, 10 patients (25%) needed two sessions, 8 patients (20%) needed three sessions, and 6 patients (15%) needed more than three sessions of balloon dilatation.

Conclusion

Balloon tracheoplasty is a simple, safe method and could be a promising and effective approach that offers immediate symptomatic relief for tracheal stenosis in cases with a history of prolonged intubation. It is worth mentioning that BBD is considered as a temporary measure, and most of the cases will need definitive or additional treatment either resection or stent placement.

Pediatric bronchoscopy: recent advances and clinical challenges

Introduction: During the last 40 years equipment has been improved with smaller instruments and sufficient size working channels. This has ensured that bronchoscopy offers therapeutic and interventional options.Areas covered: We provide a review of recent advances and clinical challenges in pediatric bronchoscopy. This includes single-use bronchoscopes, endobronchial ultrasound, and cryoprobe. Bronchoscopy in persistent preschool wheezing and asthma is included. The indications for interventional bronchoscopy have amplified and included balloon dilatation, endoscopic intubation, the use of airway stents, whole lung lavage, closing of fistulas and air leak, as well as an update on removal of foreign bodies. Others include the use of laser and microdebrider in airway surgery. Experience with bronchoscope during the COVID-19 pandemic has been included in this review. PubMed was searched for articles on pediatric bronchoscopy, including rigid bronchoscopy as well as interventional bronchoscopy with a focus on reviewing literature in the past 5 years.Expert opinion: As the proficiency of pediatric interventional pulmonologists continues to grow more interventions are being performed. There is a scarcity of published evidence in this field. Courses for pediatric interventional bronchoscopy need to be developed. The COVID-19 experience resulted in safer bronchoscopy practice for all involved.

Subglottic Stenosis in Children: Preliminary Experience from a Tertiary Care Hospital

INTRODUCTION

This retrospective study describes our experience in the evaluation and management of infants with subglottic stenosis.

MATERIALS AND METHODS

The study included 10 patients aged between 1 wk and 18 months with 6 cases having congenital subglottic stenosis and 4 cases having acquired subglottic stenosis.

RESULTS

6 patients had grade I, 3 patients had grade II, and 1 patient had grade III subglottic stenosis. Tracheostomy was required in 4 patients at the time of presentation. 7 patients were treated successfully with Bougie dilation followed by topical application of mitomycin, whereas 1 patient who failed to serial dilation needed open reconstructive procedure. Laser excision of the anterior subglottic web was performed in one patient. Another patient with underlying cerebral palsy could not be operated upon and was managed with tracheostomy.

CONCLUSION

Subglottic stenosis may be effectively man-aged with endoscopic surgical techniques, although the number of such sittings required varies with the type and severity of stenosis. Open surgical procedures need to be individualised as per the needs of the patient only after all the other endoscopic possibilities have been exhausted.

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.

Dilation with rigid dilators as primary treatment of subglottic stenosis in pediatrics

INTRODUCTION

Acquired subglottic stenosis (SGS) occurs in 1-2% of children with a history of intubation. An alternative treatment is endoscopic dilation with rigid dilators.

MATERIAL AND METHODS

Seventy-four patients with SGS grade I to III were treated between 2003 and 2017. Dilations were performed with Hegar-type rigid dilators every 2-3 weeks.

RESULTS

Eighty-two percentage of patients responded to the treatment. 10% presented SGS grade I, 35% grade II and 55% grade III. Previous intubation time in successful cases was 12.4 days and it was 32 days in those that failed (p=0.02). The average number of dilations was 3.23 in the group that responded and 2.98 for those that did not respond (p=0.51). The presence of tracheostomy reduced the effectiveness of the treatment (p=0.002). The average follow-up was 43.5 months.

CONCLUSION

The use of rigid dilators under endoscopic control is an effective minimally invasive method for treating patients with SGS grades I to III. Previous intubation time and the presence of tracheostomy were identified as poor prognostic factors.

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.

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.

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.

Effects of supramaximal balloon dilatation pressures on adult cricoid and tracheal cartilage: A cadaveric study

OBJECTIVES/HYPOTHESIS

Cricoid fracture is a serious concern for balloon dilatation in airway stenosis. Furthermore, there are no studies examining tracheal rupture in balloon dilatation of stenotic segments. The aim of this study was to evaluate the effect of supramaximal pressures of balloons on the cricoid and tracheal rings.

STUDY DESIGN

Prospective cadaveric study.

METHODS

Seven cadaveric laryngotracheal complexes of normal adults with intact cricothyroid membranes were acquired. Noncompliant vascular angioplasty balloons (BARD-VIDA) were used for dilatation. The subglottis and trachea were subjected to supramaximal dilatation pressures graduated to nominal burst pressure (NBP) and, if necessary, rated burst pressure (RBP). Larger-diameter balloons, starting from 18 mm size to 24 mm, were used. Dilatations were maintained for 3 minutes.

RESULTS

The cricoid ring was disrupted by larger-diameter balloons (22 mm and 24 mm) even at lower pressures (less than NBP) in six cases. Tracheal cartilages were very distensible, and external examination after supramaximal dilatation (24 mm close to RBP) revealed no obvious cartilage fractures or trachealis tears. Histopathological examination revealed sloughing of mucosa in the areas corresponding to balloon placement, but no microfractures or disruption of the perichondrium of tracheal ring cartilages.

CONCLUSIONS

These results indicate that the cricoid is vulnerable to injury from larger balloons even at lower dilatation pressures. The tracheal cartilages and the membranous wall of the trachea remained resilient to supramaximal dilatation and larger balloons.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:1304-1309, 2018.

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.

Endoscopic management of tissue-engineered tracheal graft stenosis in an ovine model

OBJECTIVE

To evaluate the safety and efficacy of bronchoscopic interventions in the management of tissue-engineered tracheal graft (TETG) stenosis.

STUDY DESIGN

Animal research study.

METHODS

TETGs were constructed with seeded autologous bone marrow-derived mononuclear cells on a bioartificial graft. Eight sheep underwent tracheal resection and orthotopic implantation of this construct. Animals were monitored by bronchoscopy and fluoroscopy at 3 weeks, 6 weeks, 3 months, and 4 months. Bronchoscopic interventions, including dilation and stenting, were performed to manage graft stenosis. Postdilation measurements were obtained endoscopically and fluoroscopically.

RESULTS

Seven dilations were performed in six animals. At the point of maximal stenosis, the lumen measured 44.6 ± 8.4 mm² predilation and 50.7 ± 14.1 postdilation by bronchoscopy (P = 0.3517). By fluoroscopic imaging, the airway was 55.9 ± 12.9 mm² predilation and 65.9 ± 22.4 mm² postdilation (P = 0.1303). Stents were placed 17 times in six animals. Pre- and poststenting lumen sizes were 62.8 ± 38.8 mm² and 80.1 ± 54.5 mm² by bronchoscopy (P = 0.6169) and 77.1 ± 38.9 mm² and 104 ± 60.7 mm² by fluoroscopy (P = 0.0825). Mortality after intervention was 67% with dilation and 0% with stenting (P = 0.0004). The average days between bronchoscopy were 8 ± 2 for the dilation group and 26 ± 17 in the stenting group (P = 0.05). One hundred percent of dilations and 29% of stent placements required urgent follow-up bronchoscopy (P = 0.05).

CONCLUSION

Dilation has limited efficacy for managing TETG stenosis, whereas stenting has a more lasting clinical effect.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:2219-2224, 2017.

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.

Endoscopic management of congenital anterior glottic stenosis

INTRODUCTION

Congenital anterior glottic stenosis (web) is a rare condition usually presenting with airway obstruction, stridor or dysphonia. Symptomatic infants may require tracheotomy to bridge the neonatal period. Early open surgical reconstruction may have significant risks and failure may still result in tracheotomy. We introduce an endoscopic surgical approach with balloon dilation for primary management of congenital anterior glottic stenosis.

METHODS

We present three cases of congenital anterior glottic stenosis in children 7, 14, and 90 days old presenting with stridor, dyspnea, and dysphonia. The larynx was exposed by suspension microlaryngoscopy. The glottic stenosis was incised from a posterior to anterior direction using a laryngeal sickle knife. Subsequently, an airway balloon was guided through the stenotic lumen. Once the balloon was inflated, the balloon pressure was maintained for 30s or until the patient's oxygen saturation dropped below 92%. The dilation was repeated two or three times. The patients were kept intubated with an uncuffed endotracheal tube and monitored in the pediatric intensive care unit following surgery.

RESULTS

All three patients were extubated within 72h without complications. One patient failed the first extubation attempt and was reintubated and successfully extubated 24h later. Patients were re-evaluated with direct microlaryngoscopy within two weeks. All patients had symptomatic relief and did not require further surgical intervention.

CONCLUSION

Endoscopic balloon dilation laryngoplasty may be a safe and effective primary procedure for pediatric patients with congenital anterior glottic stenosis. It is technically simple and obviates the potential morbidities associated with an open surgical procedure or tracheotomy.

Pediatric laryngotracheal reconstruction with tissue-engineered cartilage in a rabbit model

OBJECTIVES/HYPOTHESIS

To develop an effective rabbit model of in vitro- and in vivo-derived tissue-engineered cartilage for laryngotracheal reconstruction (LTR).

STUDY DESIGN

1) Determination of the optimal scaffold 1% hyaluronic acid (HA), 2% HA, and polyglycolic acid (PGA) and in vitro culture time course using a pilot study of 4 by 4-mm in vitro-derived constructs analyzed on a static culture versus zero-gravity bioreactor for 4, 8, and 12 weeks, with determination of compressive modulus and histology as outcome measures. 2) Three-stage survival rabbit experiment utilizing autologous auricular chondrocytes seeded in scaffolds, either 1% HA or PGA. The constructs were cultured for the determined in vitro time period and then cultured in vivo for 12 weeks. Fifteen LTRs were performed using HA cartilage constructs, and one was performed with a PGA construct. All remaining specimens and the final reconstructed larynx underwent mechanical testing, histology, and glycosaminoglycan (GAG) content determination, and then were compared to cricoid control specimens (n = 13) and control LTR using autologous thyroid cartilage (n = 18).

METHODS

1) One rabbit underwent an auricular punch biopsy, and its chondrocytes were isolated and expanded and then encapsulated in eight 4 by 4-mm discs of 1% HA, 2% HA, PGA either in rotary bioreactor or static culture for 4, 8, and 12 weeks, respectively, with determination of compressive modulus, GAG content, and histology. 2) Sixteen rabbits underwent ear punch biopsy; chondrocytes were isolated and expanded. The cells were seeded in 13 by 5 by 2.25-mm UV photopolymerized 1% HA (w/w) or calcium alginate encapsulated synthetic PGA (13 × 5 × 2 mm); the constructs were then incubated in vitro for 12 weeks (the optimal time period determined above in paragraph 1) on a shaker. One HA and one PGA construct from each animal was tested mechanically and histologically, and the remaining eight (4 HA and 4 PGA) were implanted in the neck. After 12 weeks in vivo, the most optimal-appearing HA construct was used as a graft for LTR in 15 rabbits and PGA in one rabbit. The seven remaining specimens underwent hematoxylin and eosin, Safranin O, GAG content determination, and flexural modulus testing. At 12 weeks postoperative, the animals were euthanized and underwent endoscopy. The larynges underwent mechanical and histological testing. All animals that died underwent postmortem examination, including gross and microhistological analysis of the reconstructed airway.

RESULTS

Thirteen of the 15 rabbits that underwent LTR with HA in vitro- and in vivo-derived tissue-engineered cartilage constructs survived. The 1% HA specimens had the highest modulus and GAG after 12 weeks in vitro. The HA constructs became well integrated in the airway, supported respiration for the 12 weeks, and were histologically and mechanically similar to autologous cartilage.

CONCLUSIONS

The engineering of in vitro- and in vivo-derived cartilage with HA is a novel approach for laryngotracheal reconstruction. The data suggests that the in vitro- and in vivo-derived tissue-engineered approaches may offer a promising alternative to current strategies used in pediatric airway reconstruction, as well as other head and neck applications.

LEVEL OF EVIDENCE

NA. Laryngoscope, 126:S5-S21, 2016.

Mechanical Modeling of the Human Cricoid Cartilage Using Computer-Aided Design: Applications in Airway Balloon Dilation Research

OBJECTIVES

Balloon dilation is generally considered first-line treatment for airway stenosis. Some dilation systems utilize a compliant balloon that can conform around rigid structures. Others use a noncompliant balloon that does not conform, allowing for dilation of more rigid stenoses. We hypothesized that subglottic dilation with a noncompliant balloon increases the likelihood of fracture of the cricoid when compared to a compliant balloon.

METHODS

Three fresh human cricoid cartilages were placed in a universal testing system to determine the expansile force necessary for cricoid fracture. Using these data, a 3D printer was used to construct a synthetic cricoid model possessing near identical physical characteristics to the human cricoid. Simulated dilation was then performed on the model using a compliant and a noncompliant balloon.

RESULTS

Human cricoid fracture occurred at 97.25 N (SD = 8.34), and the synthetic cricoid model fractured at 100.10 N (SD = 7.32). Both balloons fractured the model in every replicate experiment. Mean balloon internal pressure at fracture was 7.67 ATM (SD = 1.21) for the compliant balloon and 11.34 ATM (SD = 1.29) for the noncompliant balloon.

CONCLUSIONS

These data show that fracture of the cricoid is a valid concern in balloon dilation procedures where the balloon spans the subglottis. Furthermore, the hypothesis was rejected in that the compliant balloon system was at least as likely to fracture the cricoid model as the noncompliant.

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

OBJECTIVE/HYPOTHESIS

To examine the short- and long-term histopathologic changes that occur in the subglottis in response to airway balloon dilation (ABD) with different balloon diameters and inflation pressures.

STUDY DESIGN

Prospective animal study using forty-two 8-month old New Zealand white rabbits at an academic animal research facility.

METHODS

Thirty-nine live New Zealand rabbits underwent a single ABD with diameters ranging from 6.0 mm to 10.0 mm and with pressures between 5.0 atmospheres (atm) to 15.0 atm. Animals were euthanized on postoperative days (POD) 1, 7, and 30, and the histopathological changes of the subglottis were examined. Three rabbits served as controls and underwent no ABD.

RESULTS

The subglottic airway diameter of all specimens measured 5.4 mm. When examining the fracture rate by balloon diameter, we found the following: 0 of 6 (0%) at 6 mm, 0 of 9 (0%) at 7 mm, 6 of 9 (67%) at 8 mm, 8 of 9 (89%) at 9 mm, and 6 of 6 (100%) at 10 mm. There was a statistically significant relationship with the rate of cricoid fracture as balloon diameter increased (P < .0001). All fractures occurred at the anterior cricoid lamina. On POD 1, we found mild ulceration in 5 of 6 (83%) using a 6-mm or 7-mm balloon and in 0 of 6 (0%) using an 8-mm, 9-mm, or 10-mm balloon; and moderate/severe ulceration in 1 of 6 (16.67%) using a 6-mm or 7-mm balloon and in 11 of 11 (100%) using an 8-mm, 9-mm, or 10-mm balloon (P < .0001). Also on POD 1, we found mild edema in 6 of 6 (100%) using a 6-mm or 7-mm balloon and in 5 of 11 (45%) using an 8-mm, 9-mm, or 10-mm balloon; and moderate/severe edema in 0 of 6 (0%) using a 6-mm/7-mm balloon and in 6 of 11 (55%) using an 8-mm, 9-mm, or 10-mm balloon (P =.048). On POD 7, we found fibroplasia in 5 of 6 (83%) using a 6-mm or 7-mm balloon and in 1 of 7 (14%) using an 8-mm, 9-mm, or 10-mm balloon; and moderate/severe fibroplasia in 1 of 6 (17%) using a 6-mm or 7-mm balloon and in 6 of 7 (86%) using an 8-mm, 9-mm, or 10-mm balloon (P =.029). Also on POD7, we found granulation tissue in 0 of 6 (0%) using a 6-mm or 7-mm balloon and in 5 of 7 (71%) using an 8-mm, 9-mm, or 10-mm balloon (P = .021). On POD 30, we found no fibrosis in 0 of 3 (0%) using a 7-mm balloon, mild fibrosis in 1 of 6 (16.67%), and moderate/severe fibrosis in 5 of 6 (83%) using an 8-mm or 9-mm balloon (P = .048). Also on POD 30, we found the mean subglottic cross-sectional luminal area was 23.79 mm(2) with a 7-mm balloon and 29.28 mm(2) with an 8-mm or 9-mm balloon (P = .019). Inflation pressure alone had no correlation with mucosal injury or probability of cricoid fracture.

CONCLUSIONS

Airway balloon dilation with balloon diameters that exceeded the airway diameter by 2.6 mm was associated with cricoid fractures. All cricoid fractures localized to the anterior cricoid lamina. Balloon diameters larger than the airway diameter by 2.6 mm resulted in a larger subglottic cross-sectional luminal area on POD 30. Airway balloon dilation with balloon diameters that could generate a cricoid fracture created more mucosal injury on POD 0, 1, and 7 than smaller balloon diameters. The histopathological effects of airway balloon dilation observed on POD 0, 1, and 7 resolved by POD 30. When balloon diameter is kept constant, inflation pressure alone had no correlation with mucosal injury or probability of cricoid fracture.

LEVEL OF EVIDENCE

NA (animal study). Laryngoscope, 125:S1-S11, 2015.

Predicting outcomes of balloon laryngoplasty in children with subglottic stenosis

The treatment of subglottic stenosis in children remains a challenge for the otolaryngologist and may involve procedures such as endoscopy, open surgery, and often both. In the recent past, high-pressure balloons have been used in endoscopic treatment due to their relative facility and high success rates.

OBJECTIVE

To report success rates in the treatment of acquired subglottic stenosis with balloon laryngoplasty in children and identify predictive factors for the success of the technique and its complications.

METHODS

Descriptive, prospective study of children who were diagnosed with acquired subglottic stenosis and underwent balloon laryngoplasty as the primary treatment.

RESULTS

Balloon laryngoplasty was performed in 48 children with an average age of 20.7 months: 31 presented with chronic subglottic stenosis and 17 with acute stenosis. Success rate was 100% for acute and 39% for chronic subglottic stenosis. Success was significantly associated with several factors, including recently acquired stenosis, initial grade of stenosis, younger patient age, and the absence of tracheotomy. Complications were transitory dysphagia observed in three children and a submucosal cyst in one of the patients.

CONCLUSIONS

Balloon laryngoplasty may be considered as a first line of treatment for acquired subglottic stenosis. In acute cases, the success rate was 100%, and even though results are less promising in chronic cases, complications were not significant and the patients can undergo open surgery without contraindications. Predictive factors of success were acute stenosis, less severe grades of stenosis, younger patient age, and the absence of tracheotomy.

Laryngotracheal stenosis and airway surgery--an outcomes based approach

OBJECTIVES

To review the outcomes of endoscopic, open or a combination of both surgical modalities for laryngotracheal stenosis and establish which factors influence results.

METHODS

Records of all children undergoing laryngotracheal procedures (excluding laryngomalacia and aspirated foreign bodies) by the Department of Otolaryngology at The Children's Hospital at Westmead between January 2003 and November 2011 were reviewed. Specific data on population, intervention, covariates and outcomes were recorded and analysed.

RESULTS

A total of 104 patients undergoing 277 procedures were included. 211 (76%) of the procedures were endoscopic, remaining 66 (24%) open. Patients undergoing open surgery were more likely to have significant co-morbidity, prior intubation, require ICU admission or tracheostomy and have a longer hospital stay. 57 (54.8%) patients were successfully treated with a single procedure (48 endoscopic and 9 open). Of the endoscopic patients requiring further surgery, 16 were managed with multiple endoscopic procedures, whilst 12 underwent subsequent open procedures. Open surgery was performed on 66 patients, 63.6% (42/66) of all open procedures required further endoscopic intervention and 45.2% (19/42) of these avoided further open surgery.

CONCLUSIONS

Both open and endoscopic surgery have a role in laryngotracheal stenosis, and many patients benefit from a combination of both. Ultimately the decision depends on experience of the treating team, social considerations, and institutional capabilities. A multi-centre prospective data collection would be a useful tool to further investigate optimal management approach.

Balloon dilatation of pediatric subglottic laryngeal stenosis during the artificial apneic pause: experience in 5 children

INTRODUCTION

Balloon dilatation is a method of choice for treatment of laryngeal stenosis in children. The aim of procedure in apneic pause is to avoid new insertion of tracheostomy cannula.

PATIENTS AND METHODS

The authors performed balloon dilatation of subglottic laryngeal strictures (SGS) in 5 children (3 girls and 2 boys) without tracheotomy. Two of them with traumatic and inflammatory SGS had a tracheal cannula removed in the past. The other 3 children with postintubation SGS had never had a tracheostomy before. The need for tracheostomy due to worsening stridor was imminent for all of them.

RESULTS

The total of seven laryngeal dilatations by balloon esophagoplasty catheter in apneic pause was performed in the 5 children. The procedure averted the need for tracheostomy placement in 4 of them (80%). Failure of dilatation in girl with traumatic stenosis and concomitant severe obstructive lung disease led to repeated tracheostomy.

CONCLUSION

Balloon dilatation of laryngeal stricture could be done in the absence of tracheostomy in apneic pause. Dilatation averted threatening tracheostomy in all except one case. Early complication after the procedure seems to be a negative prognostic factor for the outcome of balloon dilatation.

Long-term outcomes of balloon dilation for acquired subglottic stenosis in children

Objectives. Balloon dilation laryngoplasty has been suggested as an alternative treatment to open surgical treatment of acquired subglottic stenosis in children. We describe long-term outcomes of balloon dilation for acquired subglottic stenosis in children. Methods. The medical charts of children who had balloon dilation for subglottic stenosis secondary to intubation were reviewed. Data included demographics, relevant history and physical examination, diagnostic workup, and management. Outcomes of balloon dilation were assessed based on improvement in preoperative symptoms, grading of stenosis, complications, and need for additional procedures. Results. Three children (2 male, 1 female, age range: 14 weeks-1 year) underwent balloon dilation for acquired subglottic stenosis. Patients presented with stridor and increased work of breathing. Duration of intubation ranged from 2 days to 3 weeks. Patients became symptomatic 5 days to 6 weeks after extubation. Grade of subglottic stenosis was II in 2 patients and III in one. Subglottic stenosis patients had 2-3 dilations within 2-10 weeks. All patients were asymptomatic during 14-21-month follow-up. Conclusions. Serial balloon dilation was safe and successful method to manage acquired subglottic stenosis in this group of children. No recurrence was noted in a follow-up more than a year after resolution of symptoms.

A Systematic Review and Meta-analysis of Endoscopic Balloon Dilation of Pediatric Subglottic Stenosis

Objective

Endoscopic balloon dilation (EBD) is an inviting, noninvasive option to manage pediatric subglottic stenosis that could preclude the need for tracheostomy and/or laryngeal-tracheal reconstruction (LTR). However, treatment outcomes and patient selection criteria are not well described.

Data Sources

MEDLINE, EMBASE, and the Cochrane databases were systematically searched using multiple search terms.

Review Methods

A systematic review of pediatric EBD was performed and then reported in compliance with PRISMA principles. Inclusion criteria consisted of a sample size of 5 or greater, pediatric patients, and primary EBD without adjuvant procedures. Meta-analysis was performed with random effects modeling and pooled data regression.

Results

After systematic database search and detailed review, 7 studies were included in the final data set with 150 total subjects. All studies were case series (level 4 evidence). The mean sample size was 20 subjects (range, 5-44), and the grand mean age was 2.2 years (range, 2.2-60 months). The random effects model estimate of the overall treatment success (avoidance of tracheostomy or LTR) was 65.3% (k = 6 studies, 95% confidence interval [CI] = 60.1%-70.6%, P < .001, Q test for heterogeneity = 3.98, P = .552, I2 = 0%). Follow-up was inconsistently reported but averaged 4.6 months (range, 0.25-12.5 months). Only 1 study reported significant complications (1 death, 2 tracheal lacerations). Pooled data multivariate regression indicated that increasing Cotton-Meyers grade was associated with decreased odds of success (odds ratio = 0.198, 95% CI = 0.0451-0.870, P = .032). Funnel plot analysis suggested the possibility of publication bias.

Conclusions

EBD is successful in most patients over short-term follow-up. The reported complication rates are low. Increasing severity of subglottic stenosis increases the odds of treatment failure.

Otolaryngologic Challenges in Cleft/Craniofacial Care

An otolaryngology evaluation is an important aspect of care for any patient with craniofacial conditions. Otolaryngologists are commonly involved in the care of these patients to treat chronic otitis media, which frequently requires placement of pressure equalization tubes; however, there are many other otorhinolaryngologic issues that are addressed. Patients with craniofacial conditions may struggle with nasal obstruction, airway compromise, obstructive sleep apnea, dysphonia, swallowing, chronic sinonasal disease, and otologic disease.

Dexmedetomidine as a Primary Sedative Agent after Single-Stage Airway Reconstruction

Objective

To examine the outcomes of children receiving dexmedetomidine after single-stage airway reconstruction.

Study Design

Historical cohort study.

Setting

Tertiary care children’s hospital.

Subjects and Methods

Of 61 eligible patients, 50 children undergoing single-stage airway reconstruction were included in the study. Thirty children received dexmedetomidine (Dex) as a primary sedative agent, and 20 received a more traditional sedation protocol (no Dex). Primary outcomes included complications, intubation lengths, and lengths of pediatric intensive care unit (PICU)/hospital admission. Secondary analysis incorporating polypharmacy and age was performed using multivariate linear regression models.

Results

Median age was 18.0 months. Age, sex, and weight were similar between the groups. Intubation length was equal in the 2 groups, and there were no statistical differences between lengths of PICU or hospital stay after extubation. Similarly, overall and individual complications were all similar, and there was no difference between the 2 groups in the amount of polypharmacy administered. On multivariate analysis, polypharmacy and younger age were independently correlated with an increase in overall complications, and polypharmacy alone was correlated with an increased length of stay after extubation.

Conclusion

The use of dexmedetomidine as a primary sedation agent after single-stage airway surgery does not appear to improve outcomes or decrease the need for additional pharmacologic agents. Polypharmacy was associated with an increase in overall complications and an increased length of stay after extubation. Although success can be expected in greater than 90% of these surgical patients, the optimal postoperative sedation management remains challenging.