Voice-related quality of life: Relation to objective spirometry measures in subglottic stenosis

OBJECTIVES

The current study seeks to identify the correlation between in-office spirometry data and voice-related quality of life in patients with subglottic stenosis (SGS).

METHODS

Patients with SGS of any etiology were included when in-office spirometric data was available in addition to voice-related patient-reported outcomes (PROM) data in the form of the Voice Handicap Index-10 (VHI-10) and/or the Voice-Related Quality of Life (V-RQOL) survey. Overall survey scores and individual question responses were assessed for degree of correlation to spirometric data.

RESULTS

Twenty-nine patients were included in the final analysis. Overall mean total VHI-10 scores totaled 7.15 (SD 9.11), while mean overall V-RQOL scores totaled 78.41 (SD 16.45). Both PEF and PIF rates correlated to total scores on the VHI and V-RQOL surveys. This correlation was stronger with PIF than with PEF, and with the V-RQOL than with the VHI. Questions related to breathlessness most closely correlated with spirometric data.

CONCLUSION

Voice-related QOL is impacted in patients with SGS in a predictable way. Breathlessness while speaking may be more impactful than inability to produce speech in this population.

Investigating the effects of laryngotracheal stenosis on upper airway aerodynamics

OBJECTIVE

Very little is known about the impact of laryngotracheal stenosis (LTS) on inspiratory airflow and resistance, especially in air hunger states. This study investigates the effect of LTS on airway resistance and volumetric flow across three different inspiratory pressures.

METHODS

Head-and-neck computed tomography scans of 11 subjects from 2010 to 2016 were collected. Three-dimensional reconstructions of the upper airway from the nostrils to carina, including the oral cavity, were created for one subject with a normal airway and for 10 patients with LTS. Airflow simulations were conducted using computational fluid dynamics modeling at three different inspiratory pressures (10, 25, 40 pascals [Pa]) for all subjects under two scenarios: 1) inspiration through nostrils only (MC), and 2) through both nostrils and mouth (MO).

RESULTS

Volumetric flows in the normal subject at the three inspiratory pressures were considerably higher (MC: 11.8-26.1 L/min; MO: 17.2-36.9 L/min) compared to those in LTS (MC: 2.86-6.75 L/min; MO: 4.11-9.00 L/min). Airway resistances in the normal subject were 0.051 to 0.092 pascal seconds per milliliter (Pa.s)/mL (MC) and 0.035-0.065 Pa.s/mL (MO), which were approximately tenfold lower than those of subjects with LTS: 0.39 to 0.89 Pa.s/mL (MC) and 0.45 to 0.84 Pa.s/mL (MO). Furthermore, subjects with glottic stenosis had the greatest resistance, whereas subjects with subglottic stenosis had the greatest variability in resistance. Subjects with tracheal stenosis had the lowest resistance.

CONCLUSION

This pilot study demonstrates that LTS increases resistance and decreases airflow. Mouth breathing significantly improved airflow and resistance but cannot completely compensate for the effects of stenosis. Furthermore, location of stenosis appears to modulate the effect of the stenosis on resistance differentially.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:E141-E149, 2018.

The presence of staphylococcal superantigens in nasal swabs and correlation with activity of granulomatosis with polyangiitis in own material

OBJECTIVES

Nasal carriage of Staphylococcus aureus and its superantigens (SAg) seem to be a risk factor disease exacerbation in granulomatosis with polyangiitis (GPA). We investigated the association between the presence of SAg in nasal swabs and activity of disease in GPA patients also taking into account correlation with an antimicrobial treatment.

METHODS

In a prospective study of a total of 150 GPA patients hospitalised in the period 2009-2016, nasal swabs were examined for the presence of Staphylococcus aureus and SAg. Subsequently, the association with disease activity was assessed.

RESULTS

Of 362 Staphylococcus aureus-positive nasal swab cultures from 115 of the 150 patients, the presence of at least one SAg in 126 samples (34.8%) from 56 patients (48.7%) was found. Among the 17 patients with limited to subglottic stenosis (SGS) disease, SAg were detected in 6 cases (35.3%). We did not find a significant correlation between the presence of SAg and disease activity (p=0.986), although when individual SAg were analysed separatively, SED and TSST-1 were more frequently present in active disease. Additionally, the results of the analysis demonstrated a protective effect of trimethoprim/sulfamethoxazole (T/S) treatment (0R 0.52, p<0.0092) in GPA patients. Interestingly, GPA limited to SGS appeared as an unfavourable factor associated with disease activity (0R 1.84, p=0.05).

CONCLUSIONS

The association between staphylococcal SAg in nasal swabs and GPA activity is not evident. Multiple mechanisms that may lead to disease activation still need to be investigated.

[The modern approach to the treatment of subglottic laryngeal stenosis]

The objective of the present study was to optimize the treatment of patients with subglottic laryngeal stenosis.

MATERIAL AND METHODS

We have examined a total of 14 patients presenting with subglottic laryngeal stenosis. The etiological factors and underlying conditions of laryngeal stenosis were the prolonged intubation in 4 patients, Wegener granulomatosis in 6 patients, and idiopathic stenosis of the larynx in 4 patients. All the patients underwent balloon dilatation with the application of the video endoscopic technique.

RESULTS

The surgical treatment of all the patients made it possible to achieve the persistent expansion of the lumen of the subglottic part of the larynx, to shorten the periods of the in-patient treatment and rehabilitation of the patients. Restenosis of laryngeal lining stenting was observed in one patient presenting with Wegener's granulomatosis which was associated with the relapse of the underlying disease.

The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction

INTRODUCTION

Exercise-induced laryngeal obstruction (EILO), the condition previously known as paradoxical vocal fold motion and vocal cord dysfunction, is characterized by inappropriate glottic or supraglottic obstruction during high-intensity exercise, causing exertional dyspnea, frequently with stridor. EILO is definitively diagnosed through upper-airway visualization during a characteristic episode. Although respiratory retraining is a primary therapy for EILO, many patients report symptom persistence despite adequate performance of traditional techniques. This report describes three novel breathing techniques for EILO, the Olin EILOBI (EILO biphasic inspiratory) breathing techniques. We include a teaching process and case series with patient-reported assessments.

MATERIALS AND METHODS

Following descriptions of the techniques and teaching process, we present data from a questionnaire offered to all patients who learned at least one of the techniques between September 2015 and March 2017. Subjects evaluated (1) expectation setting, (2) teaching processes, (3) their ability to implement the techniques during high-intensity exercise, and (4) perceived clinical effectiveness.

RESULTS

Ninety-five percent of eligible patients participated, a primarily young, female, and Caucasian sample. Over 50% of subjects competed at the high school varsity level. Sixty-two percent of subjects perceived reasonable expectations, and 82% positively evaluated the teaching process. Seventy-nine percent were able to employ their technique in the high-intensity activity of choice, and 66% perceived clinical effectiveness with the techniques.

CONCLUSIONS

The Olin EILOBI breathing techniques are novel respiratory retraining techniques for use in high-intensity exercise. Case series subjects reported reasonable expectations, a helpful teaching process, the ability to use these techniques during high-intensity exercise, and perceived clinical effectiveness.

Validation of the Airway-Dyspnoea-Voice-Swallow (ADVS) scale and Patient-Reported Outcome Measure (PROM) as disease-specific instruments in paediatric laryngotracheal stenosis

OBJECTIVE

To validate the Airway-Dyspnoea-Voice-Swallow (ADVS) instrument as a disease-specific Patient-Reported Outcome Measure in paediatric laryngotracheal stenosis.

DESIGN

Prospective observational study.

SETTING

A quaternary referral centre for complex airway disease.

PARTICIPANTS

Forty-eight patients (30 males) with a mean age of 49 ± 49 months who underwent laryngotracheal surgery or microlaryngoscopy and bronchoscopy (MLB) following laryngotracheal surgery.

MAIN OUTCOME MEASURES

Airway-Dyspnoea-Voice-Swallow summary scale and Patient-Reported Outcome Measure (PROM), Paediatric Quality of Life (PedsQL) scale, Paediatric Voice Handicap Index (pVHI) and Lansky performance scale were administered to patients before and 6-8 weeks following airway examination/surgery.

RESULTS

Most patients (73%) had intubation-related subglottic stenosis, and 60% of patients had prior airway treatments. The majority of patients (77%) had more than one major chronic morbidity, and the commonest procedures were diagnostic MLB (49%), followed by airway dilation (29%). Cronbach-α value for the ADVS PROM was 0.71 overall and 0.85, 0.86 and 0.64 for the dyspnoea, voice and swallow domains, respectively. Rank correlations between Dyspnoea, Voice and Swallow summary scale and PROM scores were 0.83, 0.71 and 0.81, respectively (P < 0.0001). For those patients undergoing diagnostic MLB, pre- and post-examination scores were highly correlated (intraclass correlations >0.75). There was a significant rank correlation between ADVS PROM score and Lansky performance score (r = -0.68; P < 0.0001). There were significant correlations between PROM score and PedsQL (r = -0.57; P < 0.0001) and between voice domain of the PROM and pVHI (r = 0.78; P < 0.0001). There were strong correlations between Myer-Cotton stenosis severity and dyspnoea scale and PROM score (r = 0.68; P < 0.0001). There were significant differences in voice and swallow ADVS scales and PROM scores between patients with and without concomitant laryngeal/oesophageal pathology. Patient age and presence of high dyspnoea and swallowing PROM scores were independently associated with poorer quality of life and performance status.

CONCLUSIONS

These series of observations validate the ADVS instrument as a disease-specific outcome measure for paediatric laryngotracheal stenosis. Dyspnoea and swallowing dysfunction appear to have the greatest impact on quality of life. More widespread adoption of the ADVS instrument could help create a shared language for outcomes communication and benchmarking for children with this complex condition.

Successful Treatment of Idiopathic Laryngotracheal Stenosis by Resection and Primary Anastomosis

We studied the early and long-term response of idiopathic laryngotracheal stenosis (ILTS) to treatment by 1-stage laryngotracheal or tracheal resection and reconstruction in 73 patients. Nineteen of the 72 (26%) noted no difference in their voices or any difficulty in breathing after reconstruction. Forty-seven (64%) described loss of ability to project their voices as loudly as before or noted some difficulty in singing as well as they did before. Five (7%) had various degrees of dyspnea or stridor on effort. One needed continued dilation. The median follow-up was 8 years. Surgical treatment gave good or excellent results in 90% of these patients with ILTS. Recurrence or progression of stenosis was not evident.

[The low-invasive treatment of laryngotrachealstenoses]

The objective of the present study was to evaluate the effectiveness and safety of balloonlaryngotracheoplasty for the treatment of laryngeal and tracheal stenosis We undertook the analysis of the case histories of the patients presenting withlaryngotracheal stenosis who had undergone balloonlaryngotracheoplasty during the period from October 2013 till February 2016. A total of 21 histories of the patients (6 men and 15 women) were available for the investigation. Most laryngotrachealstenoses that occurred in 18 (85.7%) patients were of the idiopathic, post-tracheotomy, and post-intubation types. Their most typical localization was the subfold part of the larynx and/or the upper third of the trachea (76.2%). The length of the stenotic lesions varied from 5 to 20 mm (76.2%) and corresponded to grade III if estimated based on the Cotton-Myer classification (81%). The number of the balloonlaryngotracheoplastic procedures ranged from 1 to 4 (a total of 36 operations). The interval between the consecutive interventions varied from 1.5 to 104 (mean 20) weeks. In 16 of the 36 cases, dilatation of the narrowed portion was followed by the 4 minute application of mitomycin C at a concentration of 0.4 mg/kg. No complications were documented during the surgical interventions and in the postoperative periods. The treatment was associated with a significant enhancement of the maximum expiratory flow rate from 2±1.13 l/s to 4.23±1.9 l/s (p=0.000). The duration of the follow up period varied from 1 to 105 (mean 36.2) weeks. Mitomycin C exerted nosignificant influence on the increment of the maximum expiratory flow rate (p=0.174).

[Laryngeal and tracheal stenosis caused by Wegener's granulomatosis]

Wegener's granulomatosis (WG) is a multisystem disease characterized by necrotizing granulomatous inflammation and vasculitis. WG classically involves the upper airway, lung and kidneys. Otolaryngologic manifestations are often the presenting symptoms in WG, Subglottic stenosis is a less common, but a life-threatening manifestation of WG, This paper studies about the laryngeal and tracheal stenosis diagnosis and surgical treatment of Wegener's granulomatosis in the past 20 years.

Sedation-related outcomes in postoperative management of pediatric laryngotracheal reconstruction

OBJECTIVE

Examine outcomes of varied postoperative sedation management in pediatric patients recovering from single stage laryngotracheal reconstruction.

DESIGN

Retrospective review of 34 patients treated with single stage laryngotracheal reconstruction from 2001 through 2011.

SETTING

Tertiary children's hospital.

METHODS

Patients were divided into 2 groups: those managed postoperatively with sedation, with or without paralysis (group 1), and those managed awake with narcotic pain medication as needed for primary management (group 2). Outcomes were measured as a function of sedation management. Outcomes investigated focused on those related to the success of the airway reconstruction, and those related to sedation management.

RESULTS

Out of 68 cases of laryngotracheal reconstruction reviewed from 2001 to 2011, 34 were single stage reconstructions. Nineteen patients were sedated postoperatively (group 1) and fifteen patients were left awake (group 2). There were no significant differences between groups in airway-related outcomes, including risk of accidental decannulation, revision rates, and need for secondary airway procedures such as balloon dilation. Sedation-related outcomes, specifically focusing on differences in medical management, showed significant increases in rates of withdrawal (p<0.0001), nursing concerns of withdrawal (p<0.0001) and sedation level (p<0.0001), pulmonary complications (OR 7.7, p=0.008), and prolonged hospital stay due to withdrawal (p=0.0005) in patients managed with sedation with or without paralysis. Multivariable regression analysis revealed that duration of sedation was the primary risk factor for increased postoperative morbidity, while younger age, lower weight, and use of a posterior graft were also significant variables assessed.

CONCLUSION

Avoiding sedation as the standard for postoperative management of single stage laryngotracheal reconstruction airway patients leads to an overall decreased risk of morbidity without increasing risk of airway-specific morbidity. This is specifically as related to withdrawal, pulmonary complications, concerns about sedation level and prolonged hospital course, all of which increase significantly with increased level and duration of sedation.

A new rat model for investigation of subglottic stenosis

CONCLUSION

This study attempted to develop a new rat model of subglottic stenosis (SGS), resulting from subglottic mucosal injury administered by electrocauterization. Despite failure of the posterior SGS model, the anterior SGS model was considered feasible.

OBJECTIVE

To investigate the feasibility of using rats as an animal model for SGS.

METHODS

Thirty-seven female Sprague-Dawley rats were assigned to the control group or to the anterior or posterior subglottic injury group. Electrical cauterization was performed on the anterior or posterior 180° of the subglottic mucosa. Animals were euthanized at 4 weeks after injury. Histologic features of the subglottis were evaluated as regards changes in the subglottic lumen, lamina propria, cartilage, and epithelium after hematoxylin and eosin and Masson trichrome staining.

RESULTS

Survival in the anterior injury group was 80% (13/15) until 4 weeks, and results of histologic evaluation showed an increase in thickness of lamina propria with fibrosis and cartilage damage, resulting in luminal narrowing. A high rate of mortality was observed in the posterior injury group.

[The experience with the rehabilitation of the patients with paralytic laryngeal stenosis]

This paper is designed to familiarize otorhinilaryngologists with the practical methods applied in the surgical rehabilitation of the patients presenting with paralytic laryngeal stenosis. We report the results of the treatment of 13 patients with this pathology differing in age and duration of the disease following strumectomy. Paralytic laryngeal stenosis was eliminated in 11 of the 13 patients. The favourable prognosis was strongly dependent on the time interval between the development of laryngeal paralysis and the surgical intervention. The total duration of the treatment of different patients varied from 8.5 months to 1.5 years because some of them required corrective surgery.

[The causes of the development of cicatrical stenosis of the larynx and trachea in the patients presenting with Guillain-Barré syndrome]

The problem of rehabilitation of the patients presenting with post-intubation stenosis of the larynx and trachea remains unresolved despite the development of new methods for the diagnostics and treatment of this condition. One of the indications for long-term artificial lung ventilation is the severe form of Guillaine-Barret syndrome associated with paralysis of breathing muscles, development of bulbar symptoms, and disturbances of trophic process in the skin and mucous membranes. However, prolonged (mean 26 days) artificial lung ventilation may result in the formation of many-layer stenosis of the larynx and trachea whereas disturbed trophic processes in the skin and mucous membranes coupled to inadequate innervation complicate the postoperative conditions of the patients and promote restenosis of the tracheal lumen.

[Treatment of the extensive cicatricial stenoses of the upper third of trachea]

Treatment tactics in patients with the extensive cicatricial stenoses of the upper third of tracheа were thoroughly analyzed. Circular resections of trachea was performed in 51 cases, 18 of those were supplemented with the distal laryngeal resection. Combination of the endoscopic treatment (tracheal bouginage and laser stenosis dissection or tracheal recanalization) and circular resection of the trachea was performed in 23 patients. Endoscopic treatment modality proved to be the temporary measure by the extensive cicatricial stenoses or supratracheostomic obliteration of the trachea, which, nevertheless, permit and facilitates further radical circular tracheal resection.

Endoscopie posterior cricoid split and rib grafting in 10 children

OBJECTIVE

To report our experience with endoscopic posterior cricoid split and rib graft insertion (EPCS/RG) in children with posterior glottic (PGS) and subglottic stenosis (SGS).

DESIGN

Retrospective analysis of case series, with 1 to 2 year follow-up.

SETTING

Tertiary-care pediatric referral center.

PATIENTS

Ten consecutive patients undergoing EPCS/RG.

INTERVENTION

EPCS/RG is a new procedure that expands the posterior glottic opening by dividing the posterior cricoid lamina endoscopically with a laser and inserting a rib cartilage graft through the laryngoscope.

MAIN OUTCOME MEASURES

Laryngeal function and hospital stay.

RESULTS

Successful decannulation in two of two patients with PGS and one of five patients with PGS and SGS without further surgery. Of the four not initially decannulated, two were decannulated with adjunctive procedures, and the other two can now tolerate tracheostomy capping for extended periods of time. We achieved improvement in exercise tolerance in three nontracheotomy-dependent patients. For those with established tracheotomies, median hospital stay was 3 days and intensive care unit care was unnecessary. There were no major complications or deterioration of voice or feeding.

CONCLUSIONS

EPCS/RG appears to be safe and effective in the management of PGS in selected pediatric patients. This minimally invasive procedure has advantages over traditional open approaches and destructive endoscopic techniques (cordotomy and arytenoidectomy). The role of EPCS/RG alone in the face of severe grades of SGS appears to be limited.

The thyroid foramen: a case report and literature review of a largely unrecognized laryngeal anomaly

A thyroid foramen is a congenital linear opening located in the lamina of the posterosuperior portion of the thyroid cartilage. Although its overall incidence is reported to be as high as 39%, few practitioners are aware of its existence. We report the case of a 19-year-old man who was involved in a motor vehicle accident. He experienced transient left true vocal fold paresis and what were initially thought to be "bilateral thyroid cartilage fractures" based on computed tomography of the neck performed as part of his trauma evaluation. On further scrutiny, however, the "fractures" were determined to be bilateral thyroid foramina. The presence of the paresis in the setting of these thyroid foramina prompted us to review the literature to examine the significance of thyroid foramina and the vessels and nerves that course through them. The average diameter of a thyroid foramen is approximately 2.5 mm. These openings appear in an oblique orientation, and they occur both unilaterally and bilaterally. In 70% of cases, an anastomotic branch connects the external and internal branches of the superior laryngeal nerve. Embryologically, thyroid foramina are believed to arise from a combined branchial and neurovascular origin. A detailed understanding of laryngeal anatomy, including its variations and their physiologic implications, is important to head and neck surgeons.

Flow-volume loops: clinical correlation

Flow volume loops are an essential part of spirometry testing. Their appearance can give information that can be helpful in the differential diagnosis of a patient's clinical condition. We present two clinical scenarios in which careful evaluation of the flow-volume loop gives an insight into the cause of the disease process.

Laryngopharyngeal Abnormalities in Hospitalized Patients With Dysphagia

OBJECTIVES

To determine the prevalence of laryngopharyngeal (LP) abnormalities in hospitalized patients with dysphagia referred for flexible endoscopic evaluation of swallowing (FEES).

STUDY DESIGN

Retrospective, blinded review by two otolaryngologists of 100 consecutive FEES studies performed and video-recorded by a speech-language pathologist (SLP).

METHODS

Two otolaryngologists reviewed videos of 100 consecutive FEES studies on hospitalized patients with dysphagia for the presence of abnormal LP findings.

RESULTS

Sixty-one male and 38 female patients comprised the hospital dysphagia cohort. The mean age was 62. One subject could not be evaluated because of the severity of the retained secretions, leaving 99 subjects in the cohort. Seventy-six percent had been previously intubated, with a mean intubation duration of 13 days. The overall prevalence of abnormal LP findings was 79%. Forty-five percent of the patients presented with two or more findings, which included arytenoid edema (33%), granuloma (31%), vocal fold paresis (24%), mucosal lesions (17%), vocal fold bowing (14%), diffuse edema (11%), airway stenosis (3%), and ulcer (6%). There was a significant difference in LP findings between those individuals who had or had not been intubated.

CONCLUSIONS

Hospitalized patients with dysphagia are at high risk for LP abnormalities, particularly if they have been intubated, and may benefit from either 1) an initial joint examination by the SLP and otolaryngologist or 2) an otolaryngologist's review of the recorded examination conducted by the SLP. Such otolaryngology involvement could identify airway stenosis patients at an earlier stage, initiate granuloma treatment sooner, enable earlier biopsy of unexpected lesions, and allow follow-up of mucosal and neuromuscular findings that do not respond to medical management.

Examination of aerodynamic measures and strain by vibratory source

OBJECTIVES

Patients with laryngotracheal stenosis often require airway reconstruction. Following surgical intervention, voicing may be produced with either a glottic or supraglottic vibratory source. The objective of this study was to compare average airflow, estimated subglottal pressure, and expert perceptual rating of strain between children with glottic and supraglottic vibratory sources post-airway reconstruction.

STUDY DESIGN

This study was a non-randomized prospective study conducted at the Cincinnati Children's Hospital Medical Center (CCHMC), Center for Pediatric Voice Disorders, and included 12 participants with a diagnosis of subglottic stenosis, post-laryngotracheal reconstruction.

RESULTS

Expert perceptual ratings of strain were significantly higher for participants with supraglottic versus glottic voicing (P = 0.0001). Although the mean airflow measure was higher for participants with glottic phonation and mean pressure measure was higher for those with supraglottic voicing, these comparisons failed to reach significance.

CONCLUSIONS

Patients who exhibit supraglottic phonation patterns demonstrate greater strain during speech, as well as potential alterations to aerodynamic patterns.

SIGNIFICANCE

The significant differences in perceived strain by vibratory source are noteworthy, as perceptual quality is always a patient's motivation to seek treatment.

Surgical treatment of exercise-induced laryngeal dysfunction

A method for combined ergo-spirometry and continuous laryngeal inspection during exercise, entitled continuous laryngoscopy exercise test (CLE-test) has been developed in order to study airway obstruction at the laryngeal level during exercise. The aim of the study was to apply the CLE-test on patients experiencing respiratory distress during exercise in order to reveal the usefulness of the CLE-test both as a diagnostic tool in the selection of patients for surgery and in evaluation of treatment effects postoperatively. Until now, 81 patients with a history of exercise-induced stridor have undergone the CLE-test. Ten of these patients were selected for surgical treatment based on the severity of symptoms and their motivation for treatment. All ten patients underwent endoscopic supraglottoplasty (ES), with laser incision in both aryepiglottic folds anterior to the cuneiform cartilages and removal of the mucosa around the top of the tubercles. Each patient was examined by the CLE-test before and 3 months after surgery. Eight patients felt subjectively that their breathing capacity during exercise was improved. When pre- and postoperative ergo-spirometry evaluations were compared, increased peak oxygen consumption was observed in four out of ten patients and better maximal minute ventilation in seven out of ten. Postoperative evaluation of the laryngeal images showed less prominent aryepiglottic folds. The typical adduction of the supraglottic structures concomitant with inspiratory stridor found preoperatively was not present in any of the patients during exercise postoperatively. The ES procedure is an efficient surgical treatment for exercise-induced laryngeal supraglottic obstruction and the CLE-test eases the selection of patients for surgery and facilitates the evaluation of treatment effects.

[Some mechanisms of a recurrent course of stenosing laryngotracheitis in children]

Staged development of dysbiotic disturbance of the upper airways was revealed in children suffering from stenosing laryngotracheitis in the presence of viral infection. Chronic persistent virus-bacterial inflammation of respiratory tract mucosa and resultant hypersensitivity of the airways produce chronic defects in lung ventilation in patients with recurrent stenosing laryngotracheitis. High sensitivity of the airways to histamine is related to bioelectric activity of the brain characterized by dominant irritation of the mesencephalo-diencephalic structures. Typical features of the curve flow-volume and paradoxic result of the test with broncholytic drugs verified tracheobronchial dyskinesia in patients with stenosing laryngotracheitis. Such dyskinesia promoted the recurrent disease with transformation into bronchial asthma.

Perceptual voice analysis of patients with subglottic stenosis

OBJECTIVES

To characterize the perceptual assessment of vocal quality in subglottic stenosis (SGS) patients and to identify risk factors for dysphonia.

STUDY DESIGN AND SETTING

Retrospective review, academic center.

METHODS

Perceptual voice assessment using GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain); patient characteristics determined for 31 SGS cases.

RESULTS

The mean GRBAS (0 to 3 scale, 0 = normal quality) for SGS patients at their initial visit was G(1.4)R(1.2)B(0.5)A(0.5)S(1.1). For males vs females: G(2.1 vs 1.1)R(2.0 vs 0.8)B(1.0 vs 0.4)A(1.0 vs 0.3)S(1.7 vs 0.9). The Grade (P < 0.03), Breathiness (P < 0.04), and Asthenia (P < 0.02) assessments were significantly more dysphonic in patients with multilevel stenosis; vocal fold motion impairment (VFMI) also impacted overall Grade (P < 0.01). Overall Grade (P < 0.002), Roughness (P < 0.007), and Breathiness (P < 0.006) were significantly worse in patients with prior airway surgery.

CONCLUSION

SGS patients demonstrate a mild to moderate change in perceptual voice characteristics with males in this series being more affected than females. Negative risk factors include multiple stenoses, VFMI, and previous airway surgery.

SIGNIFICANCE

This is the first systematic report of perceptual voice assessment in subglottic stenosis. SGS patients have notable degrees of dysphonia with identifiable risk factors.

Changes in speech and language development of a young child after decannulation

This report reviews the speech and language development of a child who, as result of complete subglottic stenosis, was aphonic from birth until 2 years and 11 months of age at which time laryngotracheal reconstruction provided normal respiration. The boy had congenital subglottic stenosis requiring neonatal tracheostomy. The congenital subglottic stenosis progressed to complete subglottic stenosis during the neonatal period. The child's speech and language development was monitored for a 24-week period following airway reconstruction.

LEARNING OUTCOMES

The reader will learn about and be able to describe: (1) the speech and language development of a child who was aphonic from birth until 35 months of age, (2) the effects of surgical repair of a tracheotomy on the child's speech and language development, (3) the likely importance of babbling in speech and language development.

[External respiration functions in patients with laryngeal and tracheal stenoses]

External respiration function (ERF) was examined in 89 patients with stenoses of the larynx and/or trachea (50 males, 39 females, age 23-62 years). ERF was assessed by correlation between air flow and volume during forced expiration. ERF parameters before surgical treatment were not sufficiently informative as tracheostoma does not allow complete air impermeability in the system patient-apparatus-ventilation. Suturing of tracheal defect improves ERF noticeably and its results can be assessed objectively.

Laryngomalacia induced by exercise in a pediatric patient

Exercise-induced laryngomalacia (EIL) is characterized by inspiratory stridor that is brought on by exercise (i.e. competitive sports) and fails to respond to treatment with bronchodilators (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541). During exercise, (1) spirometric flow volume loops show evidence of variable extrathoracic obstruction, and (2) laryngoscopy shows inspiratory prolapse of supraglottic structures with partial glottic obstruction. Only five cases of probable EIL have been reported in the literature (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541; Lakin et al., Chest 1984;86:499-501; Bittleman et al., Chest 1994;106:615-616; Bent et al., Ann Otol Rhinol Laryngol 1996;105:169-175; Chemery et al., Rev Mal Respir 2002;19:641-643). Here, a case of laryngomalacia induced by exercise in a previously asymptomatic 10-year-old athlete with a remote history of laryngomalacia in infancy is presented, and a review of previously reported cases is provided.

Paediatric laryngotracheal stenosis: a consensus paper from three European centres

Surgical reconstruction of paediatric laryngotracheal stenosis (LTS) has only been developed over the last 30 years, but during that period great advances have been made, and the operation is now very much tailored to the needs of the individual patient. Closed (endoscopic) techniques have a very limited place in the correction of LTS. Of the open surgical techniques, laryngotracheal reconstruction (LTR) with cartilage grafting can precisely correct grade II and mild grade III stenosis with minimal morbidity and high decannulation rates. Partial cricotracheal resection (PCTR) can deliver high success rates for more severe stenoses, but it is a more complex procedure. Because LTR is more straightforward, it tends to be preferred for grade II and mild grade III stenosis. For a suitably experienced surgeon, PCTR is the preferred option for grade IV and severe grade III stenosis, especially where there is a clear margin between the stenosis and the vocal cords. The best chance for the patient lies in the first operation: this means that the surgeon managing the problem must be fully trained in paediatric airway endoscopy and laryngotracheal surgery, since inappropriate initial management of LTS may lead to permanent intractable sequelae.

Central airways stenosis in school-aged children: differential diagnosis from asthma

This study assessed the value of spirometry and chest X-rays in the diagnosis of airways stenosis in the tracheal or laryngeal regions at school age. A series of 14 patients was studied. Six of them had vascular ring anomalies, four subglottic stenosis, two aberrant innominate artery, one tracheal stenosis and one a laryngeal web. Four patients were suffering from chronic cough and ten from dyspnoea, noisy breathing and cough upon physical exercise. Two had had their symptoms since infancy and five since 3-6 y of age, whereas seven had had their first symptoms at school age. Nine patients had previously been suspected of having asthma, and five of them had been using inhaled corticosteroids, one inhaled sodium cromoglycate and one peroral terbutaline without any effect. The ratio of forced expiratory volume in 1 s (FEV1) to peak expiratory flow (PEF) was abnormally high in most of the patients. All six children with vascular ring anomalies also had an abnormal aortic configuration on a chest X-ray, and narrowing of the trachea was seen in two of the four with subglottic stenosis. Two children had both chest X-rays and spirometry values within the normal limits.

CONCLUSION

The results show that children with stenosis in the laryngeal or tracheal region may not have their first symptoms until school age. Many patients are falsely suspected of having asthma. Simple spirometry and chest X-rays will help the physician to make the correct diagnosis in these patients.

Bilateral vocal fold posterior glottic/subglottic stenotic web resected with contact tip Nd-YAG laser

The standard treatment for respiratory failure remains endotracheal intubation, with periods of 22 or more days being commonplace. Posterior glottic stenotic web formation, from scarring in the posterior interarytenoid area, may occur after endotracheal intubation, thermal, corrosive, or direct surgical injury. A commonly used classification system for posterior glottic stenosis divides the occurrence into four types. Type I involves an interarytenoid scar band between the vocal folds that is anterior and separate from the posterior interarytenoid mucosa. Type II stenosis involves scarring of the mucosa or musculature of the posterior interarytenoid area. Types III and IV involve unilateral and bilateral cricoarytenoid joint fixation, respectively. Strobovideolaryngoscopy (SVL), rigid and flexible fiberoptic bronchoscopy, electromyography (EMG), radiologic imaging of the neck, larynx, and trachea as well as pulmonary function tests, including flow volume loops, provide important objective measurements of upper airway obstruction. A representative case of a professional voice user who suffered a Type II posterior glottic stenosis is presented. The treatment utilized a specific contact-tip neodymium-yttrium aluminum garnet (Nd-YAG) laser delivery system to achieve precise cutting, vaporization, and coagulation simultaneously, returning tactile touch technique to the airway/voice surgeon. Completely successful restoration of voice and airway have been maintained for 2 1/2 years postoperatively.

Comparing methods of administering high-frequency jet ventilation in a model of laryngotracheal stenosis

We administered high-frequency jet ventilation (HFJV) to a tracheal-lung model with connectors of internal diameter 2.5-8.5 mm to simulate ventilation through varying degrees of laryngotracheal stenosis. With reductions in diameter, end-expiratory pressure (EEP) and peak inspiratory pressure (PIP) increased. During supraglottic, translaryngeal, and transtracheal HFJV, respectively, EEP was > or =10 mm Hg at diameters narrower than 5.5, 4.0, and 3.5 cm, and PIP was >20 mm Hg at diameters narrower than 5.5, 3.5, and 3.0 cm. EEP and PIP were greater during supraglottic HFJV than during translaryngeal and transtracheal HFJV (P < 0.01). At diameters of <3.5 and 4.0 cm, respectively, PIP and EEP increased and were significantly greater (P < 0.01) during translaryngeal HFJV than during transtracheal HFJV. In a second experiment, the degree of ventilation and air entrainment was assessed by administering nitrous oxide 4 L/min to the model. Nitrous oxide concentrations were significantly (P < 0.01) smaller and nitrogen concentrations were significantly (P < 0.01) larger during supraglottic HFJV than either translaryngeal or transtracheal HFJV. The larger EEP and PIP associated with supraglottic HFJV may be attributable to increased ventilation and air entrainment compared with translaryngeal and transtracheal HFJV.

IMPLICATIONS

Ventilatory driving pressure during supraglottic high-frequency jet ventilation may be reduced to minimize high airway pressures and hence the potential for pulmonary barotrauma in patients with laryngotracheal stenosis.

The use of the laryngeal mask airway in children with subglottic stenosis

Patients with tracheal stenosis have a high incidence of difficult or failed tracheal intubation. Airway management with the laryngeal mask airway during fibreoptic laryngoscopy was used in two children with acquired subglottic stenosis during spontaneous breathing. The laryngeal mask airway may be superior to tracheal intubation or use of a face mask during anaesthesia management in severe subglottic stenosis. Ventilation may be improved and the use of a laryngeal mask airway can reduce or eliminate some of the problems associated with the other methods of airway management, such as further damage to stenotic tissue and gastric distention.

[Z-shaped surgical flaps in the treatment of acquired glottic stenosis: case report]

The Authors report a case of laryngeal stenosis initially treated through cervicotomy with the application of an Eliachar prosthesis and finally resolved, after recurrence, with two Z-shaped mucosa flaps. The Authors feel that this method is worthy of note because: its is simple to perform; provides excellent flap vitality; makes a stent unnecessary; and, above all, provides positive results.

Posterior glottic stenosis and bilateral vocal fold immobility: diagnosis and treatment

Posterior glottic stenosis and bilateral vocal fold immobility cause obstruction of the airway at the glottis. Presentation of this problem may vary according to the cause. Full evaluation of the status of the larynx is crucial with regard to the mobility of the arytenoid cartilage and innervation of the laryngeal musculature. There are many techniques for surgically treating this condition, each with advantages and disadvantages. The surgeon should be familiar with a variety of these procedures and be able to adapt to each patient's situation.

Preliminary results of intraoperative mitomycin-C in the treatment and prevention of glottic and subglottic stenosis

Mitomycin-C is an antineoplastic antibiotic that acts as an alkylating agent by inhibiting DNA and protein synthesis. It can inhibit cell division, protein synthesis, and fibroblast proliferation. The purpose of this pilot study is to investigate intraoperative applications of topical mitomycin-C in treatment and prevention of glottic and subglottic stenosis. Eight patients with posterior glottic and/or subglottic stenosis were treated with endoscopic CO2 laser excision followed by topical application of 0.5 cc of 0.4 mg mitomycin-C per milliliter of saline for 4 minutes at the surgical site. After mean follow-up of 15 months (10-20) all patients had clinical improvement of their airway and resolution of their preoperative symptoms. No complications were noted in this study. Although a longer follow-up and further controlled studies are needed, the use of topical mitomycin-C may prove useful in the treatment and prevention of subsequent restenosis and scar formation in the larynx and trachea.

Measuring in situ central airway resistance in patients with laryngotracheal stenosis

OBJECTIVES

To evaluate a newly developed bronchoscopic technique for the assessment of intratracheal pressures.

STUDY DESIGN

In situ measurement of central airway resistance in 20 consecutive spontaneously breathing subjects. Thirteen patients had benign glottic or subglottic stenosis. Seven patients without central airway disease served as normal control subjects.

METHODS

A pressure catheter was introduced into the trachea via the working channel. The pressure swing was measured upstream and downstream of the stenosis. Central airflow was monitored simultaneously using a commercial pneumotachograph attached to a mouthpiece. Data acquisition frequency was 500 Hz. Prestenotic and poststenotic inspiratory and expiratory resistances could be calculated and displayed from the raw data off-line.

RESULTS

Inspiratory and expiratory resistances measured in mid-trachea or below the stenosis (subglottic) were 0.36 +/- 0.13 and 0.35 +/- 0.13 kPa.s/L for the control subjects (C), 1.11 +/- 0.47 and 0.65 +/- 0.26 kPa.s/L for patients who did not need to be operated on (NOOP), 7.11 +/- 7.19 and 3.35 +/- 2.25 kPa.s/L respectively for those who required surgical correction (OP). Supraglottic inspiratory and expiratory resistances for C were 0.22 +/- 0.09 and 0.25 +/- 0.06 kPa.s/L, for NOOP 0.15 +/- 0.10 and 0.14 +/- 0.11 kPa.s/L, and for OP 0.26 +/- 0.13 and 0.24 +/- 0.07 kPa.s/L respectively. The cut-off point for surgical correction was estimated to be > 2.5 kPa.s/L of inspiratory resistance. Concurrent expiratory values showed a considerable overlap between OP and NOOP. No correlation could be established between local resistance values and dyspnea score.

CONCLUSIONS

In situ subglottic flow-pressure tracing in spontaneously breathing patients who present with benign obstruction of the upper airways is well tolerated and may help to identify patients who need surgical correction.

Acquired subglottic stenosis--depth and not extent of the insult is key

In contrast to skin, mucosal wound healing has not been extensively studied. Subglottic stenosis (SGS) is an excellent model for such investigation. The main objective of this pilot study was to develop a chronic model of SGS in a small animal (i.e. rabbit). In so doing, a serendipitous observation was made that the development of SGS is directly related to depth of the injury and is independent of circumferential extent. Animals with deep injury (i.e. deep to the lamina propria, reaching the perichondrium), independent of age and circumferential extent, experienced respiratory obstruction resulting from edema and granulation tissue formation and died or had to be sacrificed in the acute period. This was in contrast to no risk of mortality in the more superficially injured group. Histology was used to characterize this model of SGS. In the mucosal epithelium, or mucosa, changes of inflammation, squamous metaplasia, basal cell hyperplasia, necrosis and ulceration were only seen acutely and total regeneration of the epithelium was achieved by the end of the study period. In contrast, changes within the lamina propria, including chronic inflammatory cellular infiltrates and fibroplasia, were lasting and resulted in fibrotic repair, not regeneration. These findings are quite similar to the healing events in skin and suggest that SGS is the mucosal equivalent of a 'keloid' or, perhaps more appropriately, a 'hypertrophic scar.' Likewise, cartilage degeneration and deformation were persistent markers of the chronic phase of healing. Like the lamina propria, the response to injury was reparative. Therefore, injury to the connective tissue is a critical component of development of SGS.

Posterior glottic stenosis: a canine model

Posterior glottic stenosis is a disabling disease in which the vocal folds are fixed near the midline. This allows adequate vocal fold adduction for voicing, but does not permit useful abduction for ventilation. The most common cause is prolonged endotracheal intubation for mechanical ventilation, and the incidence is estimated at 4% for intubations between 5 and 10 days. Currently, our understanding and treatment modalities are based on retrospective reviews of small, nonrandomized clinical experiences. The purpose of this project was to develop an animal model that would improve our understanding of histologic changes and allow future prospective randomized trials for therapeutic intervention. Twelve dogs, 15 to 25 kg, were randomly divided into three groups. Animals in group I had a superficial injury produced in the tissue over the right cricoarytenoid joint; animals in group 2 had a deep soft tissue injury produced; and animals in group 3 underwent joint opening. The animals were allowed to recover for 2 months. Morphometric analysis of the harvested larynges demonstrated clinically significant limitation in motion in the animals with deep soft tissue injury and in animals with joint disruption. Histologic analysis revealed various degrees of injury, from loss of subepithelial soft tissue to cartilaginous resorption and fusion of the arytenoid to the cricoid. These findings were directly related to the depth of the initial injury. It is possible to produce posterior glottic stenosis in the canine species. This will serve as a reliable animal model for future study.

Jet ventilation in upper airway obstruction: description and model lung testing of a new jetting device

Patients with critical upper airway stenosis require a tracheotomy for corrective surgery. We describe a new transtracheal device that permits safe ventilation of these patients without tracheotomy. It is based on a coaxial bicannular design that allows "push-pull" ventilation by jetting gas through the inner cannula and applying suction through the outer cannula. It further allows monitoring of airway pressure, tidal volume, and end-tidal CO2. The device was placed in the "trachea" of an artificial lung, and the preparation was made airtight by sealing the proximal end of the trachea. Tidal volumes and their associated pressures were measured simultaneously at different parts of the airway at several lung compliances and airway resistance settings while varying the jet and suction pressures. A large range of tidal volumes was achieved at safe airway pressures using clinically relevant airway resistance and lung compliance settings. Airway pressures measured through the device correlated well with pressures measured directly in the airways at the same time. Tidal volumes, measured through a Wright respirometer in the suction line, exceeded actual values at high suction settings and decreased below actual values at low suction settings. This new form of jet ventilation allowed efficient ventilation of the artificial lung with a totally occluded upper airway.

IMPLICATIONS

Tracheotomy is required for surgery to relieve stridor because gas forced into the trachea at high pressures through a percutaneously placed needle (jetting) cannot be exhaled quickly enough for respiration. We describe a device that allows jetting in the stridorous patient by actively assisting expiration, thereby eliminating the tracheotomy requirement.

Porcine model of airway mucosal injury

PURPOSE

The development of a reliable animal model of laryngeal or tracheal stenosis has been limited by lack of reproducibility, high morbidity and mortality, and cumbersome technique. The small size of previously proposed models has limited the development of innovative reconstructive techniques.

MATERIALS AND METHODS

Eleven of 15 post-weanling commercial piglets underwent injury by a sharpened metal rod to the anterior half of the subglottic region at repeated intervals under endoscopic guidance. Four of 15 animals did not undergo injury and served as control for normal subglottic growth over time. Each airway was sized by endotracheal tube (ETT) passage and endoscopic photography over time, and the degree of total stenosis was estimated in comparison to the control animals.

RESULTS

The first two animals underwent daily injury and expired from copious granulation tissue. Eight additional animals developed symptomatic subglottic stenosis manifested by audible stridor and intercostal retractions while undergoing injury every third day. Photographs documented the size of the stenosis to be greater than 50% (40% by ETT sizing) with a mean of three injuries in a mean time of 18 days.

CONCLUSION

The porcine model shows a high degree of tolerance with minimal morbidity and consistent reliable results in an animal model of airway stenosis that is suitable for further innovative studies.

Longitudinal survey of voice quality after pediatric laryngotracheoplasty

This study assesses the effect of pediatric laryngotracheoplasty on voice quality. A group of ten children who underwent laryngotracheoplasty with thyrotomy and anterior cartilage graft were examined two or more times after decannulation and their voices were compared to those of sex- and age-matched controls. Each examination included a laryngoscopy, evaluation by a speech/language pathologist and measurement of maximum phonation times and fundamental frequencies using the Signalyse program. The strength of the voices and the maximum phonation times gradually improved. The fundamental frequency became lower with age, as in the controls. The data suggest that laryngotracheoplasty does not hamper the development of voice with age in children and that the voice improves without any further surgery, although hoarseness remains.

[Benign laryngotracheal stenoses in pediatric age]

The diagnosis and treatment of infants and children with laryngo-tracheal pathology has changed substantially over the last 20 years. The change is the result of the continued evolution of diagnostic instruments, surgical techniques and new advancements in critical care medicine. Abnormalities in the development of the larynx may lead to congenital subglottic stenosis. A variety of pathogenic processes, either inflammatory or iatrogenic, also may damage the cricoid cartilage and lead to subglottic stenosis. The stenosis may involve alone or in combination the subglottis, glottis, upper cervical trachea. In this article the author reports a 12 years experience in 114 patients affected by benign laryngo-tracheal stenosis. These patients are classified in two groups: 1) 75 patients with congenital stenosis, 2) 39 patients with acquired stenosis. For the diagnose video-endoscopy has been used, and for the classification the Cotton's technique has been used. To get the best results in this pathology it is very important to have a multidisciplinary approach.