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Sindi A, Alangari FS, Akkielah Y, Almutairi N, Aljasser A, Alammar A. Factors affecting graft healing in laryngotracheal reconstruction: a retrospective single-center experience. Eur Arch Otorhinolaryngol 2024; 281:3083-3093. [PMID: 38564008 DOI: 10.1007/s00405-024-08611-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE To examine the factors that affect graft healing after laryngotracheal reconstruction (LTR). METHODS We conducted a retrospective chart review at King Abdulaziz University Hospital, Riyadh, Saudi Arabia, between January-2008 and October-2023. We included all patients who underwent LTR and required anterior and/or posterior graft placement, while those who underwent procedures without graft placement and those with incomplete information were excluded. RESULTS Forty-nine patients were analyzed. Most patients were pediatric (65.3%), male (65.3%), had no coexisting comorbidities (55.1%), and harbored grade 3-4 stenosis (59.2%). Thirty patients (61.2%) underwent open surgery. Various graft complications occurred including infection (n = 1, 2%), dehiscence (n = 3, 6.1%), scar (n = 6, 12.2%), and granulation (n = 29, 59.2%). Only 15 patients (30.65%) achieved the composite status of "healthy" graft. Among 43 patients who had postoperative cultures, positive results for Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were observed in 10 and four patients, respectively. Open surgery and double-stage procedure were significantly associated with higher rates of granulation tissue formation. Pediatric-age group had significantly higher rate of complete epithelization compared to adult-age group. A significantly greater proportion of patients who had unhealthy grafts had open surgery. The rate of double-stage LTR was significantly higher in unhealthy grafts compared to healthy grafts. Prolonged stent duration was linked to various graft-related complications. Multivariate logistic regression analyses showed no statistically significant correlations between various factors and postoperative graft-related complications. CONCLUSION Open surgery, double-stage procedure, pediatric age group, and stent duration were not significant risk factors associated with postoperative graft-related complications during LTR in multivariate analysis.
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Affiliation(s)
- Abdullah Sindi
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia.
- Department of Otolaryngology, King Abdullah Medical Complex, Jeddah, Saudi Arabia.
| | - Fatima S Alangari
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Yara Akkielah
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Nasser Almutairi
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Otolaryngology-Head and Neck Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdulah Aljasser
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed Alammar
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
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El-Sobki A, Elkahwagi M, El-Deeb ME, Habaza FR, Salem MA, Hemdan A, El-Kholy NA, Alsobky MEI. A refashioned foley catheter: novel cost-effective available stent in pediatric laryngotracheal reconstruction. Eur Arch Otorhinolaryngol 2023; 280:1827-1833. [PMID: 36282424 PMCID: PMC9988795 DOI: 10.1007/s00405-022-07707-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/12/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Pediatric laryngotracheal reconstruction (LTR) for laryngotracheal stenosis (LTS) mandates stenting in certain situations. This study presents a novel commercially available and cost-effective stent, a refashioned foley catheter. METHODS This prospective clinical study was performed on pediatric cases with LTS up to 8 years. The study was performed in a tertiary referral center. The selection of the proper foley catheter size for age was explained. The atraumatic insertion maneuver of the stent was also shown in detail in different situations of LTS. The endoscopic removal of the stent was also described. The mean follow-up was 6.45 ± 1.3 months. RESULTS The study included 31 cases using the refashioned foley catheter stents. The study included 17 males and 14 females with a mean age of 3.45 ± 1.09. Subglottic stenosis was the most common cause of LTR in the study (74.2%) cases. The mean duration of stenting was 40.5 ± 3.7 days. Decannulation was achieved in 96.8% of cases. No stent complications were encountered like stent migration, excess granulation tissue, intractable aspiration, or pressure necrosis. CONCLUSION The refashioned foley catheter is a novel, available, and inexpensive stent that can be utilized for LTR cases for pediatric LTS. The newly described stent is soft, pliable with atraumatic insertion and easy endoscopic removal with minimal complications.
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Affiliation(s)
- Ahmed El-Sobki
- Otorhinolaryngology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Elkahwagi
- Otorhinolaryngology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed E El-Deeb
- Otorhinolaryngology Department, Faculty of Medicine, Kafrelsheikh University, El-Giesh Street, Kafrelsheikh, Egypt.
| | - Fedaey R Habaza
- Otorhinolaryngology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Ahmed Hemdan
- Otorhinolaryngology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Noha Ahmed El-Kholy
- Otorhinolaryngology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Gosman RE, Sicard RM, Cohen SM, Frank-Ito DO. A computational analysis on the impact of multilevel laryngotracheal stenosis on airflow and drug particle dynamics in the upper airway. EXPERIMENTAL AND COMPUTATIONAL MULTIPHASE FLOW 2023; 5:235-246. [PMID: 37305073 PMCID: PMC10024600 DOI: 10.1007/s42757-022-0151-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/31/2022] [Accepted: 11/24/2022] [Indexed: 06/13/2023]
Abstract
Laryngotracheal stenosis (LTS) is a type of airway narrowing that is frequently caused by intubation-related trauma. LTS can occur at one or multiple locations in the larynx and/or trachea. This study characterizes airflow dynamics and drug delivery in patients with multilevel stenosis. Two subjects with multilevel stenosis (S1 = glottis + trachea, S2 = glottis + subglottis) and one normal subject were retrospectively selected. Computed tomography scans were used to create subject-specific upper airway models. Computational fluid dynamics modeling was used to simulate airflow at inhalation pressures of 10, 25, and 40 Pa, and orally inhaled drug transport with particle velocities of 1, 5, and 10 m/s, and particle size range of 100 nm-40 µm. Subjects had increased airflow velocity and resistance at stenosis with decreased cross-sectional area (CSA): S1 had the smallest CSA at trachea (0.23 cm2) and resistance = 0.3 Pa·s/mL; S2 had the smallest CSA at glottis (0.44 cm2), and resistance = 0.16 Pa·s/mL. S1 maximal stenotic deposition was 4.15% at trachea; S2 maximal deposition was 2.28% at glottis. Particles of 11-20 µm had the greatest deposition, 13.25% (S1-trachea) and 7.81% (S2-subglottis). Results showed differences in airway resistance and drug delivery between subjects with LTS. Less than 4.2% of orally inhaled particles deposited at stenosis. Particle sizes with most stenotic deposition were 11-20 µm and may not represent typical particle sizes emitted by current-use inhalers.
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Affiliation(s)
- Raluca E. Gosman
- Duke University School of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27708 USA
- Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC 27708 USA
| | - Ryan M. Sicard
- Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC 27708 USA
| | - Seth M. Cohen
- Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC 27708 USA
| | - Dennis O. Frank-Ito
- Duke University School of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27708 USA
- Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC 27708 USA
- Computational Biology & Bioinformatics PhD Program, Duke University, Durham, NC 27708 USA
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC 27708 USA
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4
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Gosman RE, Sicard RM, Cohen SM, Frank-Ito DO. Comparison of Inhaled Drug Delivery in Patients With One- and Two-level Laryngotracheal Stenosis. Laryngoscope 2023; 133:366-374. [PMID: 35608335 PMCID: PMC10332660 DOI: 10.1002/lary.30212] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/08/2022] [Accepted: 05/03/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVES/HYPOTHESIS Laryngotracheal stenosis (LTS) is a functionally devastating condition with high respiratory morbidity and mortality. This preliminary study investigates airflow dynamics and stenotic drug delivery in patients with one- and two-level LTS. STUDY DESIGN A Computational Modeling Restropective Cohort Study. METHODS Computed tomography scans from seven LTS patients, five with one-level (three subglottic, two tracheal), and two with two-level (glottis + trachea, glottis + subglottis) were used to reconstruct patient-specific three-dimensional upper airway models. Airflow and orally inhaled drug particle transport were simulated using computational fluid dynamics modeling. Drug particle transport was simulated for 1-20 μm particles released into the mouth at velocities of 0 m/s, 1 m/s, 3 m/s, and 10 m/s for metered dose inhaler (MDI) and 0 m/s for dry powder inhaler (DPI) simulations. Airflow resistance and stenotic drug deposition in the patients' airway models were compared. RESULTS Overall, there was increased airflow resistance at stenotic sites in subjects with two-level versus one-level stenosis (0.136 Pa s/ml vs. 0.069 Pa s/ml averages). Subjects with two-level stenosis had greater particle deposition at sites of stenosis compared to subjects with one-level stenosis (average deposition 2.31% vs. 0.96%). One-level stenosis subjects, as well as one two-level stenosis subject, had the greatest deposition using MDI with a spacer (0 m/s): 2.59% and 4.34%, respectively. The second two-level stenosis subject had the greatest deposition using DPI (3.45%). Maximum deposition across all stenotic subtypes except one-level tracheal stenosis was achieved with particle sizes of 6-10 μm. CONCLUSIONS Our results suggest that patients with two-level LTS may experience a more constricted laryngotracheal airflow profile compared to patients with one-level LTS, which may enhance overall stenotic drug deposition. LEVEL OF EVIDENCE NA Laryngoscope, 133:366-374, 2023.
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Affiliation(s)
- Raluca E Gosman
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina, U.S.A
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Ryan M Sicard
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Seth M Cohen
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Dennis O Frank-Ito
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina, U.S.A
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, U.S.A
- Computational Biology and Bioinformatics PhD Program, Duke University, Durham, North Carolina, U.S.A
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, U.S.A
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Komina EI, Alkhasov AB, Rusetsky YY, Latysheva EN. [Surgical treatment of postintubation stenosis of the larynx in children]. Vestn Otorinolaringol 2023; 88:50-55. [PMID: 37450391 DOI: 10.17116/otorino20228803150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Post-intubation laryngeal stenosis is the most common cause of upper respiratory obstruction in children. According to published data, the incidence of post-intubation stenosis ranges from 0.1 to 20%. Treatment of children with chronic laryngeal stenosis is a special branch of respiratory surgery. It remains one of the most complex and urgent problems in pediatrics, pediatric otorhinolaryngology, and pediatric surgery. Although numerous studies have described various methods for treating stenosis of the infraglottic space, there is no standard management approach. Currently, there are two main treatment methods: endoscopic interventions and open reconstructive surgery. Each method has its benefits and drawbacks. Despite the use of various techniques, the effectiveness of cicatricial laryngeal stenosis repair and decannulation in children is 63-64%, according to published data. With combined lesions of infraglottic and vocal cord parts of the larynx, especially with their cicatricial obliteration, reconstructive surgery is successful only in 50% of cases. Thus, treating children with post-intubation respiratory stenosis remains a complex problem and is a relevant direction for further research.
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Affiliation(s)
- E I Komina
- National Medical Research Center for Children's Health, Moscow, Russia
| | - A B Alkhasov
- National Medical Research Center for Children's Health, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Yu Yu Rusetsky
- National Medical Research Center for Children's Health, Moscow, Russia
- Central State Medical Academy of the Department of Presidential Affairs of the Russian Federation, Moscow, Russia
| | - E N Latysheva
- National Medical Research Center for Children's Health, Moscow, Russia
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Carta F, Piras N, Mariani C, Marrosu V, Tatti M, Chuchueva N, Bekpanov A, Medeulova AR, Shetty SA, Puxeddu R. The surgical treatment of acquired subglottic stenosis in children with double-stage laryngotracheal reconstruction. Int J Pediatr Otorhinolaryngol 2022; 158:111164. [PMID: 35490607 DOI: 10.1016/j.ijporl.2022.111164] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/05/2021] [Accepted: 04/24/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study is to report our experience with double-stage laryngotracheal reconstruction with anterior or antero-posterior cartilage grafting in the management of acquired laryngotracheal stenosis in children. Patients were treated by the same surgeon at the UMC National Research Center for Maternal and Child Health of Astana (Kazakhstan), and Sfendiyarov Kazakh National Medical University, Almaty (Kazakhstan). METHODS From November 2011 to September 2019, 9 children underwent surgery for grade III and IV laryngotracheal stenosis according to the European Laryngological Society classification (mean age of 6 years, range of 2-12 years). RESULTS Six patients underwent double-stage laryngotracheal reconstruction with anterior and posterior cartilage graft, and 3 patients underwent double-stage laryngotracheal reconstruction with single anterior cartilage graft. In all patients, a T-tube was used to stabilize the airway (mean time of 5.8 months, range of 5-9 months). One patient required additional dilation with bougies to obtain a viable laryngotracheal diameter. No postoperative complications were observed. One patient experienced recurrence of the stenosis 5 months after double-stage laryngotracheal reconstruction with double anterior and posterior cartilage grafts and is waiting for revision surgery. After a mean follow-up of 14 months (range of 4-36 months), 8 patients are tracheostomy-free, and all patients are feeding tube-free. CONCLUSIONS Double-stage laryngotracheal reconstruction with a single or double cartilage grafting represents a safe and effective option in the management of complete or severe laryngotracheal stenosis.
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Affiliation(s)
- Filippo Carta
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy.
| | - Nicoletta Piras
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy
| | - Cinzia Mariani
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy
| | - Valeria Marrosu
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy
| | - Melania Tatti
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy
| | - Natalia Chuchueva
- I. M. Sechenov First Moscow State Medical University, Moscow, Russian Federation, Central State Medical Academy of Department for Presidential Affairs of the Russian Federation, Moscow, Russia.
| | - Almat Bekpanov
- UMC National Research Center for Mother and Child Health, Astana, Kazakhstan.
| | | | | | - Roberto Puxeddu
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Italy
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Frank-Ito DO, Cohen SM. Orally Inhaled Drug Particle Transport in Computerized Models of Laryngotracheal Stenosis. Otolaryngol Head Neck Surg 2021; 164:829-840. [PMID: 33045904 PMCID: PMC8294408 DOI: 10.1177/0194599820959674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Adjuvant management for laryngotracheal stenosis (LTS) may involve inhaled corticosteroids, but metered dose inhalers are designed for pulmonary drug delivery. Comprehensive analyses of drug particle deposition efficiency for orally inhaled corticosteroids in the stenosis of LTS subjects are lacking. STUDY DESIGN Descriptive research. SETTING Academic medical center. METHODS Anatomically realistic 3-dimensional reconstructions of the upper airway were created from computed tomography images of 4 LTS subjects-2 subglottic stenosis and 2 tracheal stenosis subjects. Computational fluid dynamics modeling was used to simulate airflow and drug particle transport in each airway. Three inhalation pressures were simulated, 10 Pa, 25 Pa, and 40 Pa. Drug particle transport was simulated for 100 to 950 nanoparticles and 1 to 50 micron-particles. Particles were released into the airway to mimic varying inhaler conditions with and without a spacer chamber. RESULTS Based on smallest to largest cross-sectional area ratio, the laryngotracheal stenotic segment shrunk by 57% and 47%, respectively, for subglottic stenosis models and by 53% for both tracheal stenosis models. Airflow resistance at the stenotic segment was lower in subglottic stenosis models than in tracheal stenosis models: 0.001 to 0.011 Pa.s/mL vs 0.024 to 0.082 Pa.s/mL. Drug depositions for micron-particles and nanoparticles at stenosis were 0.06% to 2.48% and 0.10% to 2.60% for subglottic stenosis and tracheal stenosis models, respectively. Particle sizes with highest stenotic deposition were 6 to 20 µm for subglottic stenosis models and 1 to 10 µm for tracheal stenosis models. CONCLUSION This study suggests that at most, 2.60% of inhaled drug particles deposit at the stenosis. Particle size ranges with highest stenotic deposition may not represent typical sizes emitted by inhalers.
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Affiliation(s)
- Dennis Onyeka Frank-Ito
- Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Computational Biology & Bioinformatics PhD Program, Duke University, Durham, North Carolina, USA
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| | - Seth Morris Cohen
- Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
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Chen Y, Liao H, Niu Y, Ni X, Wang J. Anesthetic consideration for airway management in patient undergoing tracheal resection and reconstruction for severe postintubation tracheal stenosis: a case report. Postgrad Med 2021; 133:544-547. [PMID: 33593198 DOI: 10.1080/00325481.2021.1889849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction Severe postintubation tracheal stenosis (PITS) is a rare iatrogenic complication after endotracheal intubation.Case presentation A case of PITS in a 51-year-old male undergoing partial pericardiectomy with a principal diagnosis of tuberculous constrictive pericarditis. Within 6 hours of extubation, a second emergency intubation lasting 120 hours was performed. The patient reported exertional dyspnea 30 days after discharge. High-resolution tracheobronchial tree computed tomography with three-dimensional reconstruction revealed constriction of the tracheal lumen of more than 80% at the thyroid planar upper third of the trachea. Flexible bronchoscopy revealed a tracheal stenosis located 3-4 cm from the glottis that could not be passed prior to general anesthesia. Mechanical ventilation with a ProSeal laryngeal mask airway (PLMA) and preparation for extracorporeal circulation as a final rescue option were performed to maximize patient safety. The patient underwent a tracheal resection and reconstruction without complications.Conclusion A supraglottic airway mode may be a practical and worthwhile alternative for patients with severe PITS.
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Affiliation(s)
- Yi Chen
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Hong Liao
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Yuanyuan Niu
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Xinli Ni
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Jianzhen Wang
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
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Liu Y, Wu W, Huang Q. Endoscopic management of pediatric extubation failure in the intensive care unit. Int J Pediatr Otorhinolaryngol 2020; 139:110465. [PMID: 33120102 DOI: 10.1016/j.ijporl.2020.110465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Yupeng Liu
- Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Ear Institute, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, 1665 Kongjiang Road, Shanghai, 200092, China.
| | - Wenjin Wu
- Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Ear Institute, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, 1665 Kongjiang Road, Shanghai, 200092, China.
| | - Qi Huang
- Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Ear Institute, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China; Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, 1665 Kongjiang Road, Shanghai, 200092, China.
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Xie DX, Rehman SC, Francis DO, Netterville JL, Garrett CG, Gelbard A, Lipscomb B, Wootten CT. Association Between Red Blood Cell Distribution Width and Outcomes of Open Airway Reconstruction Surgery in Adults. JAMA Otolaryngol Head Neck Surg 2020; 145:210-215. [PMID: 30629096 DOI: 10.1001/jamaoto.2018.3793] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Airway reconstruction for adults with laryngotracheal stenosis (LTS) is directed toward improving airway caliber to mitigate the patient's dyspnea and achieve prosthesis-free breathing (ie, without tracheostomy, intraluminal stent, or T-tube). Despite the importance of preoperative risk stratification to minimize postoperative complications, consensus on an objective predictive algorithm for open airway reconstruction is lacking. Objective To determine whether the ability to achieve a prosthesis-free airway in adults after open airway reconstruction is associated with red blood cell distribution width (RDW) at the time of surgery. Design, Setting, and Participants Case series study investigating 92 consecutive patients 18 years and older with laryngotracheal stenosis who underwent open airway reconstruction at a US tertiary care hospital from January 1, 2006, to January 1, 2017. Main Outcomes and Measures The main outcome was a prosthesis-free airway (absence of tracheostomy, intraluminal stent, or T-tubes) at last follow-up. Multivariate logistic regression modeling was used to identify independent factors associated with this outcome. Results Of the 92 patients who met inclusion criteria, the median (interquartile range) age was 44 (33.0-60.3) years; 50 (53%) were female, and 82 (89%) were white. In all, 74 patients (80%) were prosthesis free at the last follow-up (mean, 833 days; 95% CI, 10-4229 days). In multivariate analyses, airway decannulation was significantly correlated with reduced RDW (odds ratio [OR], 0.40; 95% CI, 0.19-0.84) and the absence of posterior glottic stenosis (OR, 0.12; 95% CI, 0.04-0.37). Conclusions and Relevance These data suggest that surgical success in open airway reconstruction is significantly associated with RDW and whether the patient had posterior glottic stenosis. The RDW is a routine laboratory parameter that may provide some insight to the preoperative probability of prosthesis removal, facilitate risk stratification, promote informed patient decision making, and optimize health care resource management.
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Affiliation(s)
- Deborah X Xie
- Vanderbilt University School of Medicine. Nashville, Tennessee.,Surgical Outcomes Center for Kids, Vanderbilt University Medical Center. Nashville, Tennessee
| | - Saad C Rehman
- Vanderbilt University School of Medicine. Nashville, Tennessee.,Surgical Outcomes Center for Kids, Vanderbilt University Medical Center. Nashville, Tennessee
| | - David O Francis
- Division of Otolaryngology, Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - James L Netterville
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C Gaelyn Garrett
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander Gelbard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brittany Lipscomb
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center. Nashville, Tennessee.,Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher T Wootten
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center. Nashville, Tennessee.,Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Virk RS, Bansal S, Nayak G, P L. Plasma Ablation–Assisted Endoscopic Management of Postintubation Laryngotracheal Stenosis: An Alternate Tool for Management. Otolaryngol Head Neck Surg 2019; 161:993-995. [DOI: 10.1177/0194599819881439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The current study was conducted to highlight the use of plasma ablation as a promising method in management of adult laryngotracheal stenosis. We present our institutional experience with a minimum follow-up of 6 months. Seventy adult patients with acquired postintubation laryngotracheal stenosis were included. Efficacy and clinical outcomes of plasma ablation in endoscopic management and eventual decannulation rate were studied. Number of patients with Myer-Cotton stenosis grades 1, 2, 3, and 4 were 20, 25, 18, and 7, respectively. The mean number of surgical interventions required in each grade of stenosis were 1, 2, 3.8, and 4, respectively. Overall, 47 patients (67%) were without tracheotomy by the end of 6 months. Plasma ablation is an effective treatment option for adult laryngotracheal stenosis, with a better success rate for lower-grade stenosis. It has lesser complications and requires fewer surgical interventions.
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Affiliation(s)
- Ramandeep Singh Virk
- Department of Otolaryngology–Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Bansal
- Department of Otolaryngology–Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gyanaranjan Nayak
- Department of Otolaryngology–Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Lokesh P
- Department of Otolaryngology–Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Redondo-Sedano J, Antón-Pacheco JL, Valverde RM, Díaz ML, Paredes CL, Guardia LM, Alelu RM, Huerta IJ, Gordo MIB, Fraile AG. Laryngeal stenosis in children: Types, grades and treatment strategies. J Pediatr Surg 2019; 54:1933-1937. [PMID: 30503025 DOI: 10.1016/j.jpedsurg.2018.09.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/15/2018] [Accepted: 09/17/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Laryngeal stenosis is infrequent in children and usually secondary to endotracheal intubation. The aims of this study were to review the outcomes of the distinct endoscopic and surgical procedures and to suggest a technical modification for one of them. METHODS Retrospective review of patients with the diagnosis of laryngeal stenosis treated in an academic tertiary care institution between 2000 and 2017. The following variables were analyzed: demographic data, endoscopic findings including anatomic type and severity of the lesion, associated anomalies, type of treatment, outcomes, and time of follow-up. RESULTS Seventy-eight children were included in the study (39 boys) with a median age at diagnosis of 9 months, and 33 (42.3%) showed an associated anomaly. Lesions were acquired in 84.6% of cases and the subglottic region was most frequently involved (77%). Thirty patients (38.4%) had a severe stenosis (Myer-Cotton grades III and IV) and a tracheotomy was performed as an initial treatment in 38 patients (48.7%). Overall, 91% of endoscopically or surgically treated patients showed a good outcome and the decannulation rate in the series was 79.4%. Fourteen patients were managed conservatively. Median follow-up was 29 months (I.R. 10-60 m.) CONCLUSIONS: Laryngeal stenosis in children is usually acquired and exhibit a wide range of anatomic presentations. Endoscopic therapeutic procedures may be useful in the management of low grade immature stenosis. Reconstructive surgical techniques may provide a high success rate with an appropriate selection of candidates.
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Affiliation(s)
- Jesús Redondo-Sedano
- Pediatric Surgery Division, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain
| | - Juan L Antón-Pacheco
- Pediatric Airway Unit and Pediatric Surgery Division, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain, Universidad Complutense de Madrid.
| | - Rocio Morante Valverde
- Pediatric Airway Unit and Pediatric Surgery Division, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain
| | - María López Díaz
- Pediatric Airway Unit and Pediatric Surgery Division, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain
| | - Carmen Luna Paredes
- Pediatric Airway Unit and Division of Pediatrics, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain
| | - Leonor Melero Guardia
- Pediatric Surgery Division, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain
| | - Rubén Martín Alelu
- Pediatric Surgery Division, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain
| | - Ignacio Jiménez Huerta
- Pediatric Airway Unit and ENT Division, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain
| | | | - Andrés Gómez Fraile
- Pediatric Surgery Division, Hospital Universitario 12 de Octubre, Avda. De Córdoba s/n, Madrid 28041, Spain
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Li L, Black K, White M, Zalzal G, Preciado D. An evaluation of arytenoid prolapse following laryngotracheal reconstruction. Laryngoscope 2019; 130:247-251. [DOI: 10.1002/lary.27864] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/13/2019] [Accepted: 01/22/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Lilun Li
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
| | - Kaelan Black
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
| | - Michelle White
- School of MedicineDrexel University College of Medicine Philadelphia Pennsylvania U.S.A
| | - George Zalzal
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
| | - Diego Preciado
- Department of OtolaryngologyChildren's National Health System Washington DC U.S.A
- Division of OtolaryngologyGeorge Washington University Washington DC U.S.A
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Cheng T, Carpenter D, Cohen S, Witsell D, Frank-Ito DO. Investigating the effects of laryngotracheal stenosis on upper airway aerodynamics. Laryngoscope 2018; 128:E141-E149. [PMID: 29044543 PMCID: PMC5867224 DOI: 10.1002/lary.26954] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/09/2017] [Accepted: 09/10/2017] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Tracy Cheng
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - David Carpenter
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - Seth Cohen
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - David Witsell
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - Dennis O. Frank-Ito
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
- Division of Head and Neck Surgery & Communication Sciences, Duke University MedicalCenter, Durham, NC, USA
- Computational Biology & Bioinformatics PhD Program, Duke University, Durham, NC, USA
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC
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Hohenforst-Schmidt W, Zarogoulidis P, Steinheimer M, Schneider T, Benhassen N, Rupprecht H, Freitag L. A retrograde y-stenting of the trachea for treatment of mediastinal fistula in an unusual situation. Ther Clin Risk Manag 2017; 13:655-661. [PMID: 28579789 PMCID: PMC5449159 DOI: 10.2147/tcrm.s129820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Stents have been used for quite some time for the treatment of benign and malignant airway stenosis. Silicon stents are preferred for benign situations, whereas metallic self-expanding stents are preferred for malignant comorbidities. PATIENT AND METHODS In general, stents can be placed in different approach directions, although in pulmonary medicine it is logical to apply only antegrade techniques - until now. A 63-year-old patient, 168 cm height and 53 kg weight on referral, suffered chronical diseases. The patient was diagnosed with a papillary thyroid carcinoma in 1989, which was treated by resection and radiotherapy. In the following years, she developed a stenosis of the esophagus. The decision to try endobronchial stenting was made upon the plan to close that fistula with a pedicled omentum majus replacement through the diaphragmal opening of the esophagus. This surgical plastic needed an abutment and a secured continuous airway replacement above the tracheostoma level. A Freitag stent (FS), 11 cm in length (110-25-40) and an inner diameter of 13 mm, was placed successfully retrograde into the trachea and completely bridged the big fistula. Unfortunately the patient passed away due to pulmonary infections after several weeks. DISCUSSION In this case report, a successful but unusual case of retrograde stent placement of a modified FS is presented.
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Affiliation(s)
| | - Paul Zarogoulidis
- Pulmonary Department-Oncology Unit, "G Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michael Steinheimer
- Medical Clinic I, "Fuerth" Hospital, University of Erlangen, Fuerth, Germany
| | - Thomas Schneider
- Medical Clinic I, "Fuerth" Hospital, University of Erlangen, Fuerth, Germany
| | - Naim Benhassen
- Medical Clinic I, "Fuerth" Hospital, University of Erlangen, Fuerth, Germany
| | - Holger Rupprecht
- Department of General, Vascular and Thoracical Surgery, "Fuerth" Hospital, University of Erlangen, Fuerth
| | - Lutz Freitag
- Department of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen, University of Essen-Duisburg, Essen, Germany
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Yang H, Chen Z, Zhou SH, Wang QY, Weng LX, Wang F, Wu TT, Zhou ML, Bao YY. Traumatic laryngotracheal stenosis treated by hyoid-sternohyoid osseomuscular flap combined with xenogenic acellular dermal matrix: A case report and literature review. J Int Med Res 2017; 45:1486-1494. [PMID: 28480810 PMCID: PMC5718716 DOI: 10.1177/0300060517705985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The treatment of laryngotracheal stenosis is a major therapeutic challenge. Various treatments include observation, medical management, and surgical management. The most effective surgical management is resection and reconstruction. To the authors’ knowledge, no reports have described the use of xenogenic acellular dermal matrix (ADM) for laryngotracheal stenosis. Methods A 27-year-old man presented with hemoptysis of the neck due to a traffic accident. Emergency orotracheal intubation was performed. Tracheostomy was then performed under local anesthesia. Computed tomography revealed fractures of the right thyroid cartilage and posterior arc of the cricoid cartilage and stenosis of the subglottis and first and second tracheal rings. We used a composite hyoid–sternohyoid osseomuscular flap with xenogenic ADM and a straight silicone tube as a lumen stent to reconstruct the laryngotracheal stenosis. Results Surgical recovery was uneventful. The tracheotomy opening was changed to a metal tube 5 days postoperatively. Four months postoperatively, the silicone tube was endoscopically removed under local anesthesia. The patient was decannulated 20 days later. The patient satisfied with his voice, respiration, and deglutition at the 16-month postoperative follow-up. Conclusion The use of ADM for laryngotracheal stenosis may reduce the growth of granulation tissues and promote the repair process.
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Affiliation(s)
- Hang Yang
- 1 Department of Otorhinolaryngology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,2 Department of Otorhinolaryngology, People's Hospital of Jiangshan City, Zhejiang Province, China
| | - Zhe Chen
- 1 Department of Otorhinolaryngology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shui-Hong Zhou
- 1 Department of Otorhinolaryngology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qin-Yin Wang
- 1 Department of Otorhinolaryngology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Li-Xia Weng
- 3 Department of Operation Room, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Fang Wang
- 3 Department of Operation Room, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ting-Ting Wu
- 1 Department of Otorhinolaryngology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Min-Li Zhou
- 1 Department of Otorhinolaryngology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yang-Yang Bao
- 1 Department of Otorhinolaryngology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Kaye R, Goldstein T, Zeltsman D, Grande DA, Smith LP. Three dimensional printing: A review on the utility within medicine and otolaryngology. Int J Pediatr Otorhinolaryngol 2016; 89:145-8. [PMID: 27619046 DOI: 10.1016/j.ijporl.2016.08.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 08/07/2016] [Accepted: 08/09/2016] [Indexed: 01/24/2023]
Abstract
Three dimensional (3D) printing is a novel technique that has evolved over the past 35 years and has the potential to revolutionize the field of medicine with its inherent advantages of customizability and the ability to create complex shapes with precision. It has been used extensively within the fields of orthopedics, dentistry, and craniofacial reconstruction with wide ranging utility including, medical modeling, surgical planning and the production of custom plates, screws and surgical guides. Furthermore, it has been used for similar means in the field of Otorhinolaryngology and also has potential to revolutionize the treatment of airway malacia. In fact, 3D printed external tracheal splints have already been studied in several pediatric patients with very promising results. The emerging field of 3D bioprinting, which integrates tissue engineering with 3D printing, may produce a paradigm shift with the potential introduction of customized functional biologic replacements.
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Affiliation(s)
- Rachel Kaye
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Todd Goldstein
- The Feinstein Institute for Medical Research, Manhasset, NY, USA; Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - David Zeltsman
- Division of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA; Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Daniel A Grande
- The Feinstein Institute for Medical Research, Manhasset, NY, USA; Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Lee P Smith
- Division of Pediatric Otolaryngology, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA; Hofstra Northwell School of Medicine, Hempstead, NY, USA.
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