Impact of Pre-operative Multidisciplinary Evaluation on Laryngotracheal Reconstruction Outcomes

Pediatric Laryngopharyngeal Reflux: Epidemiology, Clinical Presentation, Diagnosis, and Therapeutic Outcomes

Gastroesophageal reflux (GER) involves retrograde transit of gastric contents into the esophagus, a physiologic, transient, and typically benign process in infants. By contrast, GER disease arises when reflux causes troublesome symptoms or complications. Laryngopharyngeal reflux (LPR)-a subset of extraesophageal reflux-occurs when gastric contents flow proximally to affect the larynx and pharynx. LPR in the pediatric population presents unique challenges due to incomplete understanding of its pathophysiology and overlapping signs and symptoms with other conditions. Multidisciplinary evaluation is crucial for accurate diagnosis and optimal treatment.

Comparative success of different graft types in pediatric laryngotracheal reconstruction: a systematic review and meta-analysis

BACKGROUND

Laryngotracheal stenosis (LTS) results from abnormal airway narrowing, primarily caused by iatrogenic injuries like prolonged intubation. It leads to respiratory distress and vocal complications, requiring interventions ranging from endoscopic procedures to open surgeries like laryngotracheal reconstruction (LTR) with autologous grafts. Pediatric patients pose unique challenges due to smaller airways but may have better healing outcomes. This review aims to synthesize evidence on the success and operative parameters of different grafts in pediatric LTR to guide clinical decision-making and improve patient outcomes.

METHODS

We retrieved relevant articles from PubMed, Scopus, Web of Science, and the Cochrane Library up to August 2024. Two independent authors extracted data from eligible studies, including baseline information, success rate, need for extra procedures, time to stent removal, and time to decannulation. All analyses were undertaken using RevMan v5.4.

RESULTS

We collected 1,201 records from four databases after excluding 788 duplicates. After screening titles and abstracts, 108 records were assessed for eligibility, resulting in 86 included articles. Of these, 64 had enough data for analysis. The overall success rate for LTR was 89% for costal grafts, 86% for thyroid grafts, and 85% for auricular grafts, with no significant differences between graft types. A third of cases required additional procedures. Time to stent removal averaged 7.85 days for single-stage LTR and 62.86 days for double-stage LTR. Decannulation took 198.29 days. Complications included respiratory issues like atelectasis and pneumonia, graft-related problems, infections, and wound complications. Donor site complications and deaths were rare but occurred due to respiratory arrest, pneumothorax, and tracheotomy tube obstruction.

CONCLUSION

Costal, thyroid, and auricular grafts are comparable and show similar success rates in pediatric LTR. Optimizing perioperative management is crucial for reducing complications. Future research should standardize postoperative care and address patient pathology heterogeneity to improve outcomes.

"Active Larynx": Preliminary Evaluation of the Reliability of Visual Assessments of Laryngeal Inflammation

OBJECTIVE

The term "active larynx" is a nonspecific and subjective term used by otolaryngologists to describe laryngeal inflammation that can influence the timing of airway reconstruction. We sought to measure the reliability of visual assessments of laryngeal inflammation for later scale development.

STUDY DESIGN

A cross-sectional study.

SETTING

Pediatric tertiary care center.

METHODS

We created an image library from a direct laryngoscopy and bronchoscopy database. Blinded judges were asked to rate the characteristics of laryngeal inflammation (edema, erythema, cobblestoned appearance, and ventricular eversion; 5-point Likert scale), the overall "activeness" of the larynx (10-point scale), and whether laryngeal inflammation would influence a delay in reconstructive surgery (yes/no). A tentative scale was also constructed. Intraclass correlations with 2-way random effects, and Fleiss's κ were used to evaluate interrater reliability. The convergent and discriminant validity of the tentative scale were measured.

RESULTS

Three pediatric otolaryngologists reviewed 15 larynges for a total of 45 image ratings. Intraclass coefficients indicated substantial agreement for edema (0.76) and erythema (0.83) and moderate agreement for ventricular eversion (0.58). Cobblestoning had low agreement (intraclass correlation coefficient [ICC] < 0.20). The agreement was substantial for overall "activeness" (ICC 0.76) and moderate for whether inflammation would delay surgery (ICC 0.47). By Fleiss's κ, edema and erythema had moderate agreement (0.50 and 0.61, respectively), whereas all others had poor agreement. The convergent and discriminant validity of the tentative scale were reassuring.

CONCLUSION

While the reliability of laryngeal inflammation by visual assessment is variable, the creation of an active larynx scale appears feasible.

Third Proceedings of The North American Airway Collaborative (NoAAC): Consensus Statement on Trial Design for Airway Stenosis

Importance

Airway stenosis is a rare but debilitating disorder that significantly degrades the quality of life in affected patients. Treatments are primarily surgical, and disease management lacks established medical therapies. The North American Airway Collaborative held its third symposium at The Johns Hopkins Hospital in Baltimore, Maryland, on April 15, 2024, focused on strategies to advance the care of these patients. The proceedings summarize the discussion of trial design in airway stenosis and the resulting North American Airway Collaborative consensus regarding clinical end points for rigorous study of novel therapies.

Observations

The lectures and panels centered on the translation of a growing body of preclinical data into therapeutic targets. Additionally, detailed discussion explored design of clinical trials to evaluate safety and efficacy of novel therapeutics. The need for a consensus regarding clinically meaningful end points in airway stenosis was identified to facilitate the comparison of outcomes across institutions and future multi-institutional trials.

Conclusions and Relevance

The group achieved consensus regarding change in peak expiratory flow as the primary clinical end point in airway stenosis. Additional clinical measures, such as disease recurrence (identified as time to recurrent intervention), anatomical characterization of subglottic scar via axial computed tomography imaging, and patient-reported outcome measures (Clinical COPD Questionnaire [CCQ], Voice Handicap Index-10 [VHI-10], Eating Assessment Tool-10 [EAT-10], and 12-Item Short-Form Health Survey, version 2 [SF-12]) were identified as essential secondary outcomes.

Azithromycin Prevents Subglottic Stenosis in Mice

OBJECTIVE

Pediatric subglottic stenosis (SGS) is characterized by subglottic narrowing which occurs when pathological fibroblasts deposit extracellular matrix that reduces airway patency. Recent clinical observations have suggested that azithromycin may have favorable impacts on SGS reduction while treating airway infections; furthermore, our recent work in mice demonstrated that the airway microbiome influences SGS. In this work, we characterize the protective effect of azithromycin as an immunomodulatory and antibacterial therapeutic against subglottic stenosis.

METHODS

Immunomodulatory and antifibrotic effects of azithromycin were assessed on TGF-β1-stimulated airway fibroblasts at 10 μg/mL for 5 days. Changes in gene expression were quantified by RT-qPCR and myofibroblast differentiation by α-SMA immunostaining. Murine airways were pretreated (2-weeks) with intranasal azithromycin before SGS injury by a twisted wire brush. Disease severity and immune response were characterized by histology and immunostaining for immune cells.

RESULTS

In vitro, azithromycin treatment of TGF-β1-stimulated fibroblasts exhibited strong reductions in extracellular matrix (COL1A1, LOX) and myofibroblast-related gene expression (ACTA2). Notably, there was a significant reduction in pro-fibrotic expression, which was observed with 10 μg/mL azithromycin. Immunostaining of fibroblasts for α-SMA revealed strong reductions in the number of positive-staining cells and the intensity of each positive cell. In vivo, azithromycin exhibited a significant decrease in lamina propria thickness indicative of reduced stenosis with associated changes in T-cell infiltration.

CONCLUSIONS

Overall, we show azithromycin prevents pro-fibrotic gene expression and myofibroblast differentiation and can help protect mice from developing SGS. This introduces azithromycin as a potential treatment for SGS.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:409-415, 2025.

Surgical Outcomes by Early Airway Endoscopy Findings after Pediatric Staged Laryngotracheoplasty

OBJECTIVES

To determine how initial postoperative airway endoscopy findings after stent removal predict successful decannulation in children undergoing double-staged laryngotracheoplasty (dsLTP). Secondary objectives assessed timing of decannulation and number of endoscopic interventions needed after dsLTP.

METHODS

A case series with chart review included children who underwent dsLTP at a tertiary children's hospital between 2008 and 2021. Rates of decannulation, time to decannulation, and number of interventions after dsLTP were recorded for children with high- or low-grade stenosis at the first bronchoscopy after stent removal.

RESULTS

Of the 65 children who were included, 88% had high-grade stenosis and 98% had a preoperative tracheostomy. Successful decannulation happened in 74% of the children, and 44% of the children were decannulated within 12 months of surgery. For children with low-grade stenosis at the first endoscopy after stent removal, 84% were successfully decannulated compared with 36% of the children with high-grade stenosis (p = 0.001). After dsLTP, children with high-grade stenosis required 7.5 interventions (SD: 3.3) compared with 4.0 interventions (SD: 3.0) for children with low-grade stenosis (p < 0.001). Decannulated children with high-grade stenosis necessitated more endoscopic procedures (7.0 vs. 3.7, p = 0.02). Time to decannulation was similar between children with high- and low-grade early postoperative stenosis (21.9 vs. 17.8 months, p = 0.63).

CONCLUSIONS

Higher grade stenosis identified on the first airway endoscopy after suprastomal stent removal is correlated with lower decannulation rates and more postoperative endoscopic interventions. Although time to decannulation was not impacted by early stenosis grade, surgeons might utilize these early airway findings to counsel families and prognosticate possible surgical success.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:963-967, 2024.

A Pilot Study of Decellularized Cartilage for Laryngotracheal Reconstruction in a Neonatal Pig Model

OBJECTIVE

Severe subglottic stenosis develops as a response to intubation in 1% of the >200,000 neonatal intensive care unit infants per year and may require laryngotracheal reconstruction (LTR) with autologous hyaline cartilage. Although effective, LTR is limited by comorbidities, severity of stenosis, and graft integration. In children, there is a significant incidence of restenosis requiring revision surgery. Tissue engineering has been proposed to develop alterative grafting options to improve outcomes and eliminate donor-site morbidity. Our objective is to engineer a decellularized, channel-laden xenogeneic cartilage graft, that we deployed in a proof-of-concept, neonatal porcine LTR model.

METHODS

Meniscal porcine cartilage was freeze-thawed and washed with pepsin/elastase to decellularize and create microchannels. A 6 × 10-mm decellularized cartilage graft was then implanted in 4 infant pigs in an anterior cricoid split. Airway patency and host response were monitored endoscopically until sacrifice at 12 weeks, when the construct phenotype, cricoid expansion, mechanics, and histomorphometry were evaluated.

RESULTS

The selective digestion of meniscal components yielded decellularized cartilage with cell-size channels. After LTR with decellularized meniscus, neonatal pigs were monitored via periodic endoscopy observing re-epithelization, integration, and neocartilage formation. At 12 weeks, the graft appeared integrated and exhibited airway expansion of 4 mm in micro-CT and endoscopy. Micro-CT revealed a larger lumen compared with age-matched controls. Finally, histology showed significant neocartilage formation.

CONCLUSION

Our neonatal porcine LTR model with a decellularized cartilage graft is a novel approach to tissue engineered pediatric LTR. This pilot study sets the stage for "off-the-shelf" graft procurement and future optimization of MEND for LTR.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:807-814, 2024.

Factors associated with eosinophilic esophagitis in an urban, tertiary care pediatric aerodigestive population undergoing triple endoscopy

BACKGROUND

Children with aerodigestive dysfunction often undergo triple endoscopy (flexible bronchoscopy, rigid direct laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) for diagnostic evaluation as well as screening prior to airway reconstruction. Prevalence and risk factors for eosinophilic esophagitis (EoE) in this population are poorly understood.

METHODS

A retrospective chart review was performed for pediatric patients, aged 0-21 years, who received a triple endoscopy with biopsy from January 1, 2015, to December 31, 2019, at the Children's Hospital at Montefiore (CHAM). Bivariate and multivariable analyses were used to compare the baseline characteristics between patients with and without EoE to assess for potential predictors of EoE.

RESULTS

Of the 119 cases included in the analysis, 16.0 % (19) received a histopathologic diagnosis of EoE following triple endoscopy. Patients with EoE were more likely to have a family history of eczema (p = 0.02) and a dairy-free diet (p = 0.02). Age, sex, history of environmental allergies, and recency of initiating oral diet were not significantly associated with increased odds of an EoE diagnosis.

CONCLUSIONS

A family history of eczema and a diet lacking allergenic foods, such as milk, may be associated with an increased risk of a future diagnosis of EoE in patients with aerodigestive dysfunction. Larger, multi-institutional studies are needed to identify early predictors of EoE.

Anesthesia for laryngotracheal reconstruction in children: A narrative review

Laryngotracheal stenosis, congenital or acquired, is a common cause of pediatric airway obstruction. Acquired subglottic stenosis frequently results from prolonged neonatal intubation. The clinical presentation of subglottic stenosis is variable, ranging from biphasic stridor and frequent upper respiratory infections to acute airway compromise. Optimal patient care requires clinical coordination within a multidisciplinary subspecialty team. Medical management includes optimizing respiratory status, gastroesophageal reflux, speech, feeding, nutrition therapies, and providing psychosocial support. If surgical intervention is required, the otolaryngologist, anesthesiologist, and perioperative team must collaborate closely to ensure successful operative outcomes. This narrative review of laryngotracheal stenosis will discuss the pathophysiology, clinical evaluation, medical management, and surgical interventions, and focus on the perioperative anesthetic considerations for children undergoing laryngotracheal reconstruction.

A multicenter study analyzing the impact of pre-existing comorbidities on laryngotracheal reconstruction (LTR) outcomes

INTRODUCTION

Comorbidities such as chronic lung disease and gastroesophageal reflux (GERD), prematurity, and numerous other conditions may impact the success of LTR. Single-center studies are limited in terms of patient numbers and may be underpowered.

OBJECTIVES

To analyze the impact of specific comorbidities on the operation-specific and overall surgical success of LTR in a large multicenter cohort and validate a predictive model for surgical success.

METHODS

A large retrospective multicenter 10-year review was undertaken to validate the data of a previous single-center study (Wertz et al. Laryngoscope 2020) which identified specific predictive comorbidities which impacted LTR outcomes. A Monte Carlo simulation based on the previous data set suggested that 300-400 cases would be needed to optimize the statistical power of a Bayesian model developed from the single-center data to predict surgical success. An IRB-approved data-sharing agreement was executed for 4 large U.S.

CENTERS

A virtual REDCap® data entry form inquired about patient characteristics that best predicted surgical success in the single-center model. These included demographics, surgical approaches, cardiac, airway, genetic, endocrine, musculoskeletal, gastrointestinal, and pulmonary comorbidities; details of the surgical procedures, and results of esophagogastroduodenoscopy (EGD), esophageal pH/impedance and flexible bronchoscopy with bronchioalveolar lavage (BAL) were included. Surgical success defined as successful decannulation or resolution of airway symptoms was recorded as single surgery success and overall success following open surgical revision surgery. Multivariate Bayesian analysis, logistical regression, and Kaplan-Meier analysis were performed.

RESULTS

542 patients were identified, including 165 from the single-center study and an additional 377 patients from the multicenter group. The median age was 36 months at the time of the most recent surgery. 70.9% of the LTRs were double-staged procedures. The overall success rate was 86.4% and operation-specific success rate was 69.2%. The specific comorbidities and aerodigestive test results that impacted success based on univariate analysis included staging, bronchiectasis, pulmonary hypertension, GERD, ASD, PDA, grade of stenosis, advanced levels of stenosis, Trisomy 21, MRSA, prior open surgery at another hospital, and gross appearance on EGD. Bayesian model averaging with backward selection was used to validate and refine a predictive model for surgical success with favorable receiver operating curve characteristics - AUC values of 0.827 for single surgery success and 0.797 for overall success.

DISCUSSION

With over 500 patients reviewed, this was the largest multicenter study of LTR to date, which elucidated the impact of comorbidities on success with LTR and was able to improve upon the predictive modeling based on single-center data. Patient factors are most critical in the outcome of LTR. Stage and levels of stenosis, as well as pulmonary and GI conditions most strongly impact the likelihood of success. Future prospective case-control studies will be performed to further optimize the current model for outcome prediction and patient management.

Amelioration of Subglottic Stenosis by Antimicrobial Peptide Eluting Endotracheal Tubes

Introduction

Pediatric subglottic stenosis (SGS) results from prolonged intubation where scar tissue leads to airway narrowing that requires invasive surgery. We have recently discovered that modulating the laryngotracheal microbiome can prevent SGS. Herein, we show how our patent-pending antimicrobial peptide-eluting endotracheal tube (AMP-ET) effectively modulates the local airway microbiota resulting in reduced inflammation and stenosis resolution.

Materials and Methods

We fabricated mouse-sized ETs coated with a polymeric AMP-eluting layer, quantified AMP release over 10 days, and validated bactericidal activity for both planktonic and biofilm-resident bacteria against Staphylococcus aureus and Pseudomonas aeruginosa. Ex vivo testing: we inserted AMP-ETs and ET controls into excised laryngotracheal complexes (LTCs) of C57BL/6 mice and assessed biofilm formation after 24 h. In vivo testing: AMP-ETs and ET controls were inserted in sham or SGS-induced LTCs, which were then implanted subcutaneously in receptor mice, and assessed for immune response and SGS severity after 7 days.

Results

We achieved reproducible, linear AMP release at 1.16 µg/day resulting in strong bacterial inhibition in vitro and ex vivo. In vivo, SGS-induced LTCs exhibited a thickened scar tissue typical of stenosis, while the use of AMP-ETs abrogated stenosis. Notably, SGS airways exhibited high infiltration of T cells and macrophages, which was reversed with AMP-ET treatment. This suggests that by modulating the microbiome, AMP-ETs reduce macrophage activation and antigen specific T cell responses resolving stenosis progression.

Conclusion

We developed an AMP-ET platform that reduces T cell and macrophage responses and reduces SGS in vivo via airway microbiome modulation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12195-023-00769-9.

Pathogenic bacteria in bronchoalveolar lavage cultures and pediatric laryngotracheal reconstruction outcomes

OBJECTIVE

The primary objective was to determine if treating pathogenic bacteria in bronchoalveolar lavage (BAL) cultures improves outcomes after pediatric double stage laryngotracheal reconstruction (dsLTR).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary children's hospital.

METHODS

All children (<18 years) obtaining flexible bronchoscopy with BAL cultures before dsLTR between 2016 and 2022 were included. Cultures identified abnormal bacterial growth or normal respiratory flora. Thirty-day postoperative surgical site or lung infections were captured and tracheostomy decannulation rates were obtained for children with at least 12 months of follow-up.

RESULTS

Twenty-seven children obtained presurgical BAL cultures before dsLTR. Median age at reconstruction was 2.9 years (interquartile range: 2.3-3.5) and 89% (24/27) had high grade subglottic stenosis. Positive cultures were obtained in 56% of children (N = 15) with Pseudomonas aeruginosa (40%, 6/15) and methicillin-resistant Staphylococcus aureus (33%, 5/15) the most frequent organisms. All children with positive cultures were treated based on culture and sensitivity data. Postoperative infections developed in 22% (6/27) of children with equal distribution of surgical site and respiratory infections among children with pathogenic bacteria and normal respiratory flora. At 12 months after surgery, the decannulation rate was no different between those treated and not treated for a presurgical positive BAL culture (47% vs. 58%, p = 0.70).

CONCLUSION

Pathogenic bacteria are common in BAL cultures from tracheostomy-dependent children before dsLTR. Treatment keeps respiratory infections and decannulation rates similar to children with negative cultures, suggesting continued benefit of flexible bronchoscopy and BAL in preparation for these surgeries.

The Role of Pediatric Gastroenterologists in the Evaluation of Complex Aerodigestive Disorders

PURPOSE OF REVIEW

Children with aerodigestive disorders frequently have concerns regarding difficulty breathing, swallowing, and growing. In this review, we explored the role of pediatric gastroenterologists in the evaluation of complex aerodigestive disorders and the overall approach to these often-challenging patients.

RECENT FINDINGS

Pediatric gastroenterologists evaluate children with aerodigestive concerns ranging from dysphagia and gastroesophageal reflux to complex congenital abnormalities such as esophageal atresia. Diagnostic tools, such as multichannel intraluminal impedance-pH monitoring, are used for diagnosing gastroesophageal reflux and assessing the correlation with symptoms. Endoscopic evaluation, and in some complex cases, with therapeutic dilations may also be performed. Gastrointestinal dysmotility evaluation with manometry studies are also being increasingly utilized. Multidisciplinary aerodigestive programs can provide a coordinated approach to children with complex airway, pulmonary and gastrointestinal tract disorders. A pediatric gastroenterologist's expertise and specialized skills not only offer many diagnostic tools for these complicated medical cases but are also important in long term medical management.

The follow up of complex infants in an aerodigestive clinic

The current available literature evaluating pediatric multidisciplinary aerodigestive programs for the management of aerodigestive disorders in infants was reviewed. Multidisciplinary aerodigestive programs have emerged to provide coordinated and comprehensive care for the growing population of children with aerodigestive conditions, including complex airway, pulmonary, gastrointestinal, and feeding disorders, which are prevalent among infants discharged from the neonatal intensive care unit (NICU). The team approach central to aerodigestive clinics offers a comprehensive diagnostic workup and unified management plan through consolidated interdisciplinary clinics, combined endoscopic procedures, and regular team discussions, leading to improved resource utilization and health care outcomes. We review common conditions presenting in the NICU that benefit from the aerodigestive model of care, including esophageal atresia, prematurity, bronchopulmonary dysplasia with or without tracheostomy or ventilator dependence, and dysphagia.

Three dimensional printed models of the airway for preoperative planning of open Laryngotracheal surgery in children: Surgeon's perception of utility

BACKGROUND

Preoperative planning of open laryngotracheal surgery is important for achieving good results. This study examines the surgeon's perception of the importance of using life size 3D printed models of the pediatric airway on surgical decision making.

METHODS

Life-size three-dimensional models of the upper airway were created based on CT images of children scheduled for laryngotracheal-reconstruction and cricotracheal resection with anastomosis. Five pediatric airway surgeons evaluated the three-dimensional models for determining the surgical approach, incision location and length, graft length, and need for single or double-stage surgery of seven children (median age 4.4 years, M:F ratio 4:3). They rated the importance of the three-dimensional model findings compared to the direct laryngoscopy videos and CT findings for each domain on a validated Likert scale of 1-5.

RESULTS

The mean rating for all domains was 3.6 ± 0.63 ("moderately important" to "very important"), and the median rating was 4 ("very important"). There was full agreement between raters for length of incision and length of graft. The between-rater agreement was 0.608 ("good") for surgical approach, 0.585 ("moderate") for incision location, and 0.429 ("moderate") for need for single- or two-stage surgery.

CONCLUSION

Patient-specific three-dimensional printed models of children's upper airways were scored by pediatric airway surgeons as being moderately to very important for preoperative planning of open laryngotracheal surgery. Large-scale, objective outcome studies are warranted to establish the reliability and efficiency of these models.