Endoscopic treatment of paediatric subglottic stenosis and cyst (with video)

OBJECTIVE

The aim of this article is to describe step by step the endoscopic treatment of acquired subglottic stenosis (SGS) in an infant and to show the endoscopic results one month after surgery.

STUDY DESIGN

Case presentation with instructional video.

SETTING

University Hospital of Verona, Italy.

METHODS

We present the case of a 6-month-old ex-26-week preterm female infant who required prolonged intubation in the neonatal period. She referred to our hospital for persistent inspiratory and expiratory stridor, and laboured breathing. The endoscopic dynamic examination of upper airway revealed the presence of type 3 laryngomalacia and subglottic stenosis grade III according to Myers-Cotton classification. An endoscopic balloon laryngoplasty was planned. Two laryngeal dilatations were performed. The endoscopic exploration after the first dilatation showed the presence of a subglottic cyst on the anterior surface of the subglottis. The treatment of subglottic cyst consisted of marsupialization of the cyst with cold microinstruments, and subsequent suction of its content.

RESULTS

An endoscopic check-up was carried out one month after surgery. The examination of the upper airway under spontaneous respiration didn't show significant subglottic stenosis. A very small subglottic cyst under the anterior commissure was observed. However, no more balloon dilatations or marsupialization of the cyst were performed in order to avoid the formation of synechiae.

CONCLUSION

Treatment of SGS must be planned according to the extent of the stenosis and the history of the patient. Endoscopic procedures, such as balloon dilatation and cyst marsupialization, are best chosen for patients with isolated SGS without prior treatment failure.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Balloon Laryngoplasty in Pediatric Population with Subglottic Stenosis: 5 Years Experience in King Abdulaziz University Hospital a Tertiary Center

We reviewed our experience with balloon laryngoplasty (BLP) as a primary management of SGS in a tertiary care center in Saudi Arabia. In this review, a total of 147 patients who underwent Laryngobronchoscopy were reviewed. Only 10 pediatric patients diagnosed with SGS who underwent BLP as primary treatment in the period from January 2012 to December 2017 were included. After obtaining ethical approval, included patients' charts were reviewed. Adult patients and those with airway anomalies other than SGS were excluded. This study describes the outcome of 25 episodes of BLP for the selected participants. Sixty percent of the participants were males. Participants' age ranged from 1 to 14 years (mean 6.4 years). Four participants had comorbidities other than SGS. Most patients required more than one episode of BLP (average 3 episodes). Mean hospital stay was 11.7 days. There was no difference in recurrence of symptoms between using laser or knife in subglottic tissue release (p = 0.182). Although recurrence of symptoms was seen in 56% of the patients, almost all patients (100%) became free of symptoms eventually. Patients with co-morbid diseases were more likely to be transferred to PICU post-operatively (p = 0.003). In the treatment of acquired SGS, BLP is an effective and relatively safe alternative to open airway surgery.

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.

Impact of balloon laryngoplasty on management of acute subglottic stenosis

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current trends of balloon laryngoplasty in Thailand

OBJECTIVE

To describe the current trend in balloon laryngoplasty usage and experience by practicing otolaryngologists in Thailand.

STUDY DESIGN

Anonymous 11 question online and paper survey of otolaryngologists on their current balloon laryngoplasty practices.

SUBJECTS AND METHODS

Current practices and experience in balloon laryngoplasty were queried with multiple choice and open-ended questions.

RESULTS

Laser use is the most commonly utilized instrument to treat airway stenosis in Thailand. 86% of respondents do not have experience with balloon dilatation; yet, almost half (47.6%) report they perform a minimum of five airway surgeries per year. Most respondents had been in practice for less than 6 years (41%) and reported that they did not have exposure to balloon use during residency training. The largest barrier reported for the use of balloon instrumentation in the airway is inexperience (44.4%) followed by cost (38.3%), yet most feel that treatment in airway stenosis could benefit by usage of balloons (95.5%).

CONCLUSIONS

Most otolaryngologists in Thailand do not have experience with the use of balloon dilatation and lack of exposure remains the largest barrier to its use. Otolaryngologists in Thailand feel that increased usage of balloons in the airway could improve airway stenosis treatment in the country.