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Mills JF, Monaghan NP, Nguyen SA, Nguyen CL, Clemmens CS, Carroll WW, Pecha PP, White DR. Characteristics and outcomes of interventions for pediatric laryngomalacia: A systematic review with meta-analysis. Int J Pediatr Otorhinolaryngol 2024; 178:111896. [PMID: 38364547 DOI: 10.1016/j.ijporl.2024.111896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/07/2024] [Accepted: 02/11/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVES To analyze characteristics of children treated for laryngomalacia to determine predictive factors and provide an updated meta-analysis on outcomes. METHODS A systematic review was conducted according to PRISMA guidelines from inception to May 2, 2023, using CINAHL, PubMed, and Scopus databases. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers. Data were meta-analyzed using fixed-/random-effects model to derive continuous measures (mean), proportions (%), and mean difference (Δ) with 95% confidence interval (CI). RESULTS 100 articles were identified with information on outcomes of pediatric patients with laryngomalacia (N = 18,317). The mean age was 10.6 months (range: 0 to 252, 95%CI: 9.6 to 11.6, p = 0.00) with a 1.4:1 male to female ratio. Many patients presented with stridor (87.9%, 95% CI: 69.8 to 98.4), and the most common comorbidity at time of diagnosis was gastroesophageal reflux disease (48.8%, 95%CI: 40.9 to 56.8). Based on the patient population included in our analysis, 86.1% received supraglottoplasty (95% CI: 78.7 to 92.1). A total of 73.6% (95% CI: 65.5 to 81.0) had reported complete resolution of symptoms. For patients with a concurrent diagnosis of sleep disordered breathing receiving supraglottoplasty, the apnea-hypopnea index improved with a mean difference of -10.0 (95%CI: 15.6 to -4.5) events per hour post-treatment. CONCLUSIONS Laryngomalacia continues to be a common problem in the pediatric population. Supraglottoplasty remains an effective treatment option leading to symptomatic improvement in many cases. For those with concurrent sleep disordered breathing, supraglottoplasty lowers the apnea-hypopnea index.
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Affiliation(s)
- John F Mills
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC, 29425, USA; Albany Medical College, 47 New Scotland Avenue, Albany, NY, 12208, USA
| | - Neil P Monaghan
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC, 29425, USA
| | - Shaun A Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC, 29425, USA.
| | | | - Clarice S Clemmens
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC, 29425, USA
| | - William W Carroll
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC, 29425, USA
| | - Phayvanh P Pecha
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC, 29425, USA
| | - David R White
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC, 29425, USA
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Gagnon C, Bérubé S, Sauthier M, Rouillard-Bazinet N, Bergeron M. Evaluating the Need for Intensive Care Admission After Supraglottoplasty for Severe Laryngomalacia. Laryngoscope 2024; 134:466-470. [PMID: 37334868 DOI: 10.1002/lary.30813] [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: 01/17/2023] [Revised: 05/21/2023] [Accepted: 05/30/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Postoperative airway concerns persist despite a low rate of post-supraglottoplasty complications for children with laryngomalacia. The objective of this study is to determine the factors associated with the need for intensive care unit (ICU) admission following supraglottoplasty. METHODS A 7-year retrospective cohort analysis was conducted between 2014 and 2021. A patient requiring ICU level of care was defined as the use of respiratory support such as intubation, positive pressure ventilation, high-flow nasal cannula, or multiple doses of nebulized epinephrine. RESULTS About 134 medical charts were reviewed; 12 patients were excluded because of concurrent surgery. Age at the time of surgery was 2.8 (4.3) months (median [interquartile range]). About 33 (27.0%) ultimately required ICU-level care. Prematurity (odds ratio [OR] 13.8), neurological condition (OR ∞), American Society of Anesthesiology class 3-4 (OR 6.5), and younger age (OR 1.8) were more likely to require ICU admission. No patient above 10 months of age needed ICU monitoring. The use of respiratory support justifying ICU was known within the first 4 h after surgery for almost all (32/33, 97%) of these patients. 4/33 (12.1%) were kept intubated and the remaining needed non-invasive ventilation. Only one patient (1/122, 0.8%) was reintubated 12 h after surgery for progressive respiratory distress. CONCLUSION Approximately a quarter of patients required ICU-level care after supraglottoplasty. For nearly all patients without comorbidities requiring ICU, this can be safely predicted within the first 4 h after surgery. Our data suggest that selected patients undergoing supraglottoplasty may be safely monitored outside of an ICU setting after an observation period in the post-anesthesia care unit. LEVEL OF EVIDENCE 4 Laryngoscope, 134:466-470, 2024.
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Affiliation(s)
- Carolanne Gagnon
- Department of Pediatric Otolaryngology-Head and Neck Surgery, CHU Ste-Justine, Montreal, Quebec, Canada
| | - Simon Bérubé
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Michaël Sauthier
- Department of Pediatrics, Pediatric Intensive Care Unit, CHU Ste-Justine, Montreal, Quebec, Canada
- CHU Sainte Justine Research Institute, CHU Sainte Justine, Montreal, Quebec, Canada
| | - Noémie Rouillard-Bazinet
- Department of Pediatric Otolaryngology-Head and Neck Surgery, CHU Ste-Justine, Montreal, Quebec, Canada
- CHU Sainte Justine Research Institute, CHU Sainte Justine, Montreal, Quebec, Canada
| | - Mathieu Bergeron
- Department of Pediatric Otolaryngology-Head and Neck Surgery, CHU Ste-Justine, Montreal, Quebec, Canada
- CHU Sainte Justine Research Institute, CHU Sainte Justine, Montreal, Quebec, Canada
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汪 景, 徐 梦, 金 蕾, 顾 美, 李 晓. [The airway management and treatment of newborns with micrognathia and laryngomalacia]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2023; 37:622-625;631. [PMID: 37551568 PMCID: PMC10645534 DOI: 10.13201/j.issn.2096-7993.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Indexed: 08/09/2023]
Abstract
Objective:To explore the perioperative airway management and treatment of newborns with micrognathia and laryngomalacia. Methods:From January to December 2022, a total of 6 newborns with micrognathia and laryngomalacia were included. Preoperative laryngoscopy revealed concomitant laryngomalacia. These micrognathia were diagnosed as Pierre Robin sequences. All patients had grade Ⅱ or higher symptoms of laryngeal obstruction and required oxygen therapy or non-invasive ventilatory support. All patients underwent simultaneous laryngomalacia surgery and mandibular distraction osteogenesis. The shortened aryepiglottic folds were ablated using a low-temperature plasma radiofrequency during the operation. Tracheal intubation was maintained for 3-5 days postoperatively. Polysomnography(PSG) and airway CT examination were performed before and 3 months after the surgery. Results:Among the 6 patients, 4 required oxygen therapy preoperatively and 2 required non-invasiveventilatory support. The mean age of patients was 40 days at surgery. The inferior alveolar nerve bundle was not damaged during the operation, and there were no signs of mandibular branch injury such as facial asymmetry after the surgery. Laryngomalacia presented as mixed type: type Ⅱ+ type Ⅲ. The maximum mandibular distraction distance was 20 mm, the minimum was 12 mm, and the mean was 16 mm. The posterior airway space increased from a preoperative average of 3.5 mm to a postoperative average of 9.5 mm. The AHI decreased from a mean of 5.65 to 0.85, and the lowest oxygen saturation increased from a mean of 78% to 95%. All patients were successfully extubated after the surgery, and symptoms of laryngeal obstruction such as hypoxia and feeding difficulties disappeared. Conclusion:Newborns with micrognathia and laryngomalacia have multi-planar airway obstruction. Simultaneous laryngomalacia surgery and mandibular distraction osteogenesis are safe and feasible, and can effectively alleviate symptoms of laryngeal obstruction such as hypoxia and feeding difficulties, while significantly improving the appearance of micrognathia.
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Affiliation(s)
- 景 汪
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
| | - 梦柔 徐
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
| | - 蕾 金
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
| | - 美珍 顾
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
| | - 晓艳 李
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
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Kothari DS, Kanotra SP. Optimal laser usage improves surgical efficiency in pediatric supraglottoplasty. Int J Pediatr Otorhinolaryngol 2023; 164:111412. [PMID: 36543062 DOI: 10.1016/j.ijporl.2022.111412] [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: 08/12/2022] [Revised: 11/08/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To compare patient specific and surgical efficiency outcomes in children undergoing supraglottoplasty (SGP) with flexible fiber CO2 laser in Ultrapulse mode versus cold steel at a tertiary care center. METHODS A single surgeon retrospective cohort study of pediatric patients with laryngomalacia undergoing SGP without concomitant or prior airway surgery. We reviewed perioperative complications, total hospital stay including intensive care admission, symptom resolution and the need for revision surgery. Surgical efficiency was measured as the mean total operative time and laryngeal suspension time. RESULTS Among 63 patients, 32 cold steel SGPs were compared with 31 flexible fiber CO2 Ultrapulse laser SGPs. There was no statistical difference in the demographic profile. There was no statistical difference in need for intraoperative resuscitation (1 [3.0%] vs 0 [0%] cases) or perioperative intubation (4 [12.1%] vs 2 [6.3%] cases), mean total days in ICU (1.09 [0.51] vs 1.06 [0.44] [p = 0.38]) or days hospitalized (1.73 [1.67] vs 1.62 [2.27] [p = 0.42]), symptom resolution, need for revision surgery (2 [6.3%] vs 0 [0%] [p = 0.49] patients) or mean operative time (29.0 [14.19] vs. 32.2 [22.71] [p = 0.95] minutes). There was a statistically significant decreased time in laryngeal suspension in the laser group versus cold steel group (5.9 [1.80] vs 7.9 [2.19] [p = 0.006] minutes). CONCLUSION For pediatric SGPs, optimal flexible fiber CO2 laser usage can improve surgical efficiency in comparison to cold steel, with no differences in postoperative outcomes or complications. Both the flexible fiber CO2 laser and cold steel SGPs are safe and effective methods for treatment of laryngomalacia.
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Affiliation(s)
- Dhruv Shreedhar Kothari
- University of Iowa Hospitals and Clinics, Department of Otolaryngology - Head & Neck Surgery, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| | - Sohit Paul Kanotra
- University of Iowa Hospitals and Clinics, Department of Otolaryngology - Head & Neck Surgery, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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Alshareef WA, Aldriweesh BA, Almutairi NK, Alsini AY, Zakzouk AS, Aljasser AI, Alammar AY. Adverse Respiratory Events After Pediatric Endoscopic Airway Surgeries. EAR, NOSE & THROAT JOURNAL 2022:1455613221128111. [PMID: 36112766 DOI: 10.1177/01455613221128111] [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: 12/22/2023] Open
Abstract
OBJECTIVE Perioperative risk stratification of pediatric patients undergoing airway intervention remains crucial in identifying those at a higher risk of requiring postoperative intensive care unit (ICU) care. Here we determined the likelihood of and possible risk factors for developing perioperative adverse respiratory events (PAREs) requiring ICU care after various pediatric endoscopic airway surgeries (EASs). METHODS We conducted a retrospective chart review of pediatric patients who were aged <18 years and underwent EAS between 2015 and 2021. Early postoperative adverse events within 24 h of surgery were recorded and analyzed. RESULTS Overall, 99 patients who underwent EAS were included. The age at the time of the intervention ranged from 8 months to 18 years. Fifty-eight patients, median age was 4.83 years, underwent papilloma debulking with no high likelihood of PARE in this patient subgroup (OR = 0.48; 0.16-1.44). Twenty-five patients, median age was 9.72 years, underwent balloon dilation of laryngotracheal stenosis with no increase in the likelihood of PARE in this patient population (OR = 2.02; 0.65-6.28). Early postoperative respiratory events occurred in 16 patients (16.2%). Most of these events (75%) manifested within 4 h after surgery. In a univariate analysis, intervention at the level of the subglottis or 2 or more laryngeal subsites increased the risk of PARE (OR = 6.57; 1.11-12.52 and OR = 3.73; 1.93-22.34, respectively). In a multivariate analysis, only intervention in the subglottic area maintained its effect (OR = 6.84; 1.82-25.65). CONCLUSION Respiratory adverse events following pediatric EAS are not uncommon, and the majority are encountered shortly after surgery. Intervention in the subglottic area was an independent predictor of PARE.
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Affiliation(s)
- Waleed A Alshareef
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Bshair A Aldriweesh
- Department of Otolaryngology-Head and Neck Surgery, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Nasser K Almutairi
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
- Department of Otolaryngology-Head and Neck Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Albaraa Y Alsini
- Department of Otolaryngology, Head and Neck Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Abdulmajeed S Zakzouk
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdullah I Aljasser
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed Y Alammar
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
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Initiation of acid suppression therapy for laryngomalacia. Am J Otolaryngol 2022; 43:103434. [PMID: 35483169 DOI: 10.1016/j.amjoto.2022.103434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/02/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Evidence supporting the use of acid suppression therapy (AST) for laryngomalacia (LM) is limited. The objective of this study was to determine if outpatient-initiated AST for LM was associated with symptom improvement, weight gain, and/or avoidance of surgery. METHODS A retrospective cohort was reviewed at a tertiary-care children's hospital. Patients were included if they were diagnosed with LM at ≤6 months of age, seen in an outpatient otolaryngology clinic between 2012 and 2018, and started on AST. Primary outcomes were improvement of airway and dysphagia symptoms, weight gain, and need for surgery. Severity was assessed by symptom severity. RESULTS Of 2693 patients reviewed, 199 met inclusion criteria. Median age of diagnosis was 4 weeks (range: 0-29 weeks). LM was classified as mild/moderate (71.4%) and severe (28.6%) based on symptom severity. Severity on flexible fiberoptic laryngoscopy (FFL) was not associated with clinical severity. Weight percentile, airway symptoms, and dysphagia symptoms improved within the cohort. In total, 26.1% underwent supraglottoplasty (SGP). In multivariate analysis, only severe LM on FFL was predictive of SGP (OR: 7.28, 95%CI: 1.91-27.67, p = .004). CONCLUSION Clinical symptom severity did not predict response to AST raising the question of utility of AST in LM. Severity of LM based on FFL, not clinical severity, was associated with decision to pursue SGP. Prospective randomized trials are needed to better understand the role of AST in LM. LEVEL OF EVIDENCE Level 3.
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Abstract
Stridor is a high-pitched extrathoracic noise associated with turbulent airflow, commonly associated with respiratory distress in infants. Workup for stridor requires evaluation of the upper-respiratory airway, with severe distress requiring evaluation under anesthesia. The differential diagnosis of stridor depends on location of the obstruction, age of the patient, and acuity of the symptoms. The most common reason is laryngomalacia; most patients can be managed conservatively with resolution of symptoms by 2 years of age. In children who do not improve or have severe disease, supraglottoplasty is the treatment of choice, and the majority will have resolution of stridor postoperatively.
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Affiliation(s)
- Habib G Zalzal
- Division of Otolaryngology, Children's National Medical Center, 111 Michigan Avenue, Northwest, Washington, DC 20010, USA.
| | - George H Zalzal
- Division of Otolaryngology, Children's National Medical Center, 111 Michigan Avenue, Northwest, Washington, DC 20010, USA
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Duncan DR, Larson K, Davidson K, Williams N, Liu E, Watters K, Rahbar R, Rosen RL. Acid Suppression Does Not Improve Laryngomalacia Outcomes but Treatment for Oropharyngeal Dysphagia Might Be Protective. J Pediatr 2021; 238:42-49.e2. [PMID: 34186104 PMCID: PMC9756139 DOI: 10.1016/j.jpeds.2021.06.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/28/2021] [Accepted: 06/22/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine whether the use of acid suppression and thickened feeds impact laryngomalacia outcomes in infants, including supraglottoplasty risk, time to supraglottoplasty, and hospitalization risk. STUDY DESIGN We performed a retrospective cohort study to compare risk and time with supraglottoplasty and frequency and duration of hospitalizations for infants diagnosed with laryngomalacia at Boston Children's Hospital between January 1 and December 31, 2017. The primary outcomes were supraglottoplasty requirement, time to supraglottoplasty, and hospitalization risk. Multivariate analyses were performed to determine predictors of supraglottoplasty and hospitalization risk after adjusting for laryngomalacia severity and comorbidities in addition to propensity score adjustment. Kaplan-Meier curves were created to determine the impact of acid suppression use on time to supraglottoplasty. RESULTS In total, 236 subjects with mean age 62.6 ± 4 days were included in the analysis; 55% were treated with acid suppression. Subjects treated with acid suppression had a greater risk of supraglottoplasty (hazard ratio 3.36, 95% CI 1.36-8.29, P = .009), shorter time to supraglottoplasty (5.64 ± 0.92 vs 7.98 ± 1.92 months, P = .006), and increased respiratory hospitalization risk (relative risk 1.97, 95% CI 1.01-3.85, 0.047), even after adjustment for covariates. Subjects receiving thickening had fewer respiratory hospitalization nights and longer time to supraglottoplasty (9.3 ± 1.7 vs 4.56 ± 0.73 months, P = .004), even after adjustment. CONCLUSIONS Acid suppression use does not reduce the frequency of supraglottoplasty and related hospitalizations compared with untreated subjects. However, patients treated with thickening have decreased hospitalization and longer time to supraglottoplasty, suggesting that thickening of feeds may be a preferred intervention over acid suppression.
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Affiliation(s)
- Daniel R. Duncan
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Kara Larson
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Kathryn Davidson
- Center for Airway Disorders, Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA
| | - Nina Williams
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Karen Watters
- Center for Airway Disorders, Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA
| | - Reza Rahbar
- Center for Airway Disorders, Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, MA
| | - Rachel L. Rosen
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
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Risk factors for peri-operative respiratory adverse events after supraglottoplasty. Int J Pediatr Otorhinolaryngol 2021; 149:110853. [PMID: 34364176 DOI: 10.1016/j.ijporl.2021.110853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/21/2021] [Accepted: 07/22/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine demographic and peri-operative characteristics that predict peri-operative respiratory adverse events (PRAE) requiring intensive care unit (ICU) level intervention after supraglottoplasty. STUDY DESIGN Case series with chart review. SETTING Tertiary care children's hospital. METHODS Retrospective chart review was conducted of children with laryngomalacia who underwent supraglottoplasty between October 2014 and November 2019. PRAE were defined as any of the following events or requirements within 24 h of surgery: 1) failure to extubate, 2) reintubation, 3) positive pressure ventilation, 4) more than one dose of racemic epinephrine, or 5) greater than 4 L of oxygen via nasal cannula. RESULTS Fifty-one subjects were enrolled, with a median age of 4.8 months and majority (62 %) Hispanic. Twenty-one (41 %) subjects experienced PRAE. After adjusting for age and gender on multivariate analysis, children admitted preoperatively to the ICU were more likely to have PRAE than those not admitted or admitted to a floor unit (OR 40.1, 95%CI: 4.1-388.6, p = 0.001). Additionally, children with intraoperative oxygen desaturations below 90 % for greater than 1 min were more likely to have PRAE than those who did not (OR 21.3, 95%CI: 2.4-189.9, p = 0.006). Other factors significantly associated with PRAE on univariate analysis included chronic lung disease, congenital cardiac abnormality, history of intubation, supplemental oxygen requirement, gastrostomy tube dependence, intraoperative intubation and longer surgery length. CONCLUSION Preoperative ICU admission and intraoperative oxygen desaturations are independent risk factors for PRAE after supraglottoplasty. Results from this study can help inform decisions regarding the appropriate level of postoperative care required after supraglottoplasty. LEVEL OF EVIDENCE IV.
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Cha H, Lee DY, Kim EH, Lee JH, Jang YE, Kim HS, Kwon SK. Feasibility of Surgical Treatment for Laryngomalacia using Spontaneous Respiration Technique. Clin Exp Otorhinolaryngol 2021; 14:414-423. [PMID: 33541038 PMCID: PMC8606294 DOI: 10.21053/ceo.2020.02061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/08/2021] [Indexed: 12/29/2022] Open
Abstract
Objectives. In this study, we review our institutional experience with pediatric laryngomalacia (LM) and report our experiences of patients undergoing supraglottoplasty using the spontaneous respiration using intravenous anesthesia and high-flow nasal oxygen (STRIVE Hi) technique. Methods. The medical records of 29 children with LM who visited Seoul National University Hospital between January 2017 and March 2019 were retrospectively reviewed. Surgical management was performed using the STRIVE Hi technique. Intraoperative findings and postoperative surgical outcomes, including complications and changes in symptoms and weight, were analyzed. Results. Of the total study population of 29 subjects, 20 (68.9%) were female. The patients were divided according to the Onley classification as follows: type I (n=13, 44.8%), II (n=10, 34.5%), and III (n=6, 20.7%). Twenty-five patients (86.2%) had comorbidities. Seventeen patients (58.6%) underwent microlaryngobronchoscopy under STRIVE Hi anesthesia. Four patients with several desaturation events required rescue oxygenation by intermittent intubation and mask bagging during the STRIVE Hi technique. However, the procedure was completed in all patients without any severe adverse effects. Overall, 15 children (51.7%) underwent supraglottoplasty, of whom 14 (93.3%) showed symptom improvement, and their postoperative weight percentile significantly increased (P=0.026). One patient required tracheostomy immediately after supraglottoplasty due to associated neurological disease. Conclusion. The STRIVE Hi technique is feasible for supraglottoplasty in LM patients, while type III LM patients with micrognathia or glossoptosis may have a higher risk of requiring rescue oxygenation during the STRIVE Hi technique.
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Affiliation(s)
- Hyunkyung Cha
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University college of medicine, Seoul, Republic of Korea
| | - Doh Young Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Boramae Medical Center, Seoul National University college of medicine, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seong Keun Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University college of medicine, Seoul, Republic of Korea
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AbdelFattah ElSobki A, Hashish MI, El-Kholy NA. One and half coblation supraglottoplasty: A novel technique for management of type II laryngomalacia. Int J Pediatr Otorhinolaryngol 2020; 138:110330. [PMID: 32889439 DOI: 10.1016/j.ijporl.2020.110330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/22/2020] [Accepted: 08/22/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Endoscopic supraglottoplasty is the mainstay surgical procedure in treatment of laryngomalacia. Various instruments have been used with coblation recently gaining widespread attention. Regarding the technique used, cutting the aryepiglottic folds is associated with rapid improvement but carries risk of restenosis while outer scar contracture method has delayed but established result. Therefore, this study was conducted to introduce a modified coblation supraglottoplasty technique gathering both benefits and evaluate its results and effectiveness. METHODS Retrospective study included patients diagnosed with type II laryngomalacia was conducted. Supraglottoplasty was done by "one and half coblation supraglottoplasty" technique which involves cutting of one aryepiglottic fold while the other one is laterally coagulated. Patients' basic and clinical data were assessed. Outcome measures included assessment of inspiratory stridor, failure to thrive, choking, cyanosis, lowest oxygen saturation levels and weight gain. RESULTS Seventeen patients were included in this study with a mean age of 3.71 ± 1.1 months. Significant statistical improvement was reached regarding stridor, failure to thrive and cyanosis. Also, minimal oxygen saturation and weight gain were significantly improved. None of the cases needed tracheostomy and no major postoperative complications occurred. CONCLUSION We conclude that "one and half coblation supraglottoplasty" is an effective and safe treatment for type II laryngomalacia with satisfactory outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ahmed AbdelFattah ElSobki
- Department of Otorhinolaryngology-Head & Neck Surgery, Faculty of Medicine, Mansoura University, Egypt
| | | | - Noha Ahmed El-Kholy
- Department of Otorhinolaryngology-Head & Neck Surgery, Faculty of Medicine, Mansoura University, Egypt.
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Yeung JC, Ali SO, McKeon MG, Grenier S, Kawai K, Rahbar R, Watters KF. Carbon dioxide laser versus cold-steel supraglottoplasty: A comparison of post-operative outcomes. Int J Pediatr Otorhinolaryngol 2020; 130:109843. [PMID: 31884047 DOI: 10.1016/j.ijporl.2019.109843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Supraglottoplasty is the mainstay of surgical treatment for laryngomalacia, and is commonly performed via two methods: cold steel or carbon dioxide (CO2) laser. The degree of post-operative monitoring following supraglottoplasty varies, both within and between institutions. The aim of this study was to compare the post-operative monitoring and interventions required by patients undergoing cold-steel versus CO2 laser supraglottoplasty. DESIGN Retrospective cohort of pediatric patients (age < 18 years) undergoing supraglottoplasty at a tertiary care pediatric hospital. The primary exposure was the surgical instrument(s) used during supraglottoplasty. The primary outcome was prolonged intensive care unit (ICU)-stay (defined as >24 h). RESULTS 155 cases were eligible for inclusion. Fifty-eight (37.4%) patients had a comorbid condition. Common indications for surgery included feeding difficulty (56.1%), severe respiratory distress (33.5%), and obstructive sleep apnea (25.2%). CO2 laser was employed in 49 cases and cold-steel in 106 cases. Prolonged ICU-stay (>24 h) was observed in 14 CO2 laser cases (28.6%) and 11 cold-steel cases (10.4%) (adjusted OR 3.42; 95% CI 1.43, 8.33). CO2 laser cases were more likely to require post-operative intubation, non-invasive positive pressure ventilation, and nebulized racemic epinephrine. Concomitant neurological condition was associated with an increased risk of prolonged ICU-stay, while extent of surgery and age were not. CONCLUSIONS CO2 laser supraglottoplasty is associated with an increased risk of prolonged ICU-stay and need for ICU-level airway intervention, compared to the cold-steel technique. While this association should not be misconstrued as a causal relationship, the current study demonstrates that specific surgical factors may influence the patient monitoring requirements following supraglottoplasty, particularly the choice of instrument and the extent of surgery.
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Affiliation(s)
- Jeffrey C Yeung
- Department of Otolaryngology - Head & Neck Surgery, McGill University, Canada; Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, USA.
| | - Syed O Ali
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, USA
| | - Mallory G McKeon
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, USA
| | - Samantha Grenier
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, USA
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, USA
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, USA; Department of Otology and Laryngology, Harvard Medical School, USA
| | - Karen F Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, USA; Department of Otology and Laryngology, Harvard Medical School, USA
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Coagulation of the lateral surface of aryepiglottic folds as an alternative to aryepiglottic fold release in management of type 2 laryngomalacia. Auris Nasus Larynx 2019; 47:443-449. [PMID: 31677853 DOI: 10.1016/j.anl.2019.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/08/2019] [Accepted: 10/15/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Endoscopic supraglottoplasty is the procedure of choice in treatment of laryngomalacia with CO2 laser and cold steel being the most common instruments used with excellent results. However, bleeding, supraglottic stenosis and aspiration may occur leading to serious complications. Using coblation in management of laryngomalacia was found to be beneficial. Therefore, we conducted this study to evaluate the outcome of supraglottoplasty done by coagulation using coblation of the lateral surface of aryepiglottic folds as an alternative technique to aryepiglottic fold release in management of type 2 laryngomalacia. METHODS Retrospective study was conducted at Mansoura University Hospitals; Egypt from November 2017 to March 2018 included patients diagnosed with severe type 2 laryngomalacia. Supraglottoplasty was done by using coblator applied to the lateral surface of aryepiglottic folds allowing for lateral scarring thus widening the airway, preventing supraglottic collapse and avoiding re-stenosis. Outcome measures included assessment of presence or absence of the following symptoms preoperatively and postoperatively: inspiratory stridor, failure to thrive, choking and cyanosis. Preoperative and postoperative lowest oxygen saturation levels, weight-by-age percentile, and need for tracheostomy were assessed. RESULTS Nine patients were included in this study with a mean age of 3.78 ± 1.20 months (range 2-6 months). Overall success rate was 89%. The most significantly improved symptom was stridor (p-value 0.008). Significant improvement in lowest oxygen saturation levels (from 89.11 ± 3.06% pre-operatively to 96.44 ± 3.50% post-operatively) and weight gain (from 4288.9 ± 643.1 gm. preoperatively to 5505.55 ± 1017.4 gm. 1 month postoperatively) was achieved. No detected re-stenosis on follow up and none of our cases needed tracheostomy. CONCLUSION Supraglottoplasty by coagulation of the lateral surface of aryepiglottic folds using coblation is an effective and safe technique and can improve airway symptoms and weight gain in patients with type 2 laryngomalacia.
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Sapundzhiev NR, Nikiforova LT, Stoyanov GS, Valkadinov I, Genova P, Platikanov V. Harmonic Shears in the Surgical Treatment of Laryngomalacia. Cureus 2019; 11:e5880. [PMID: 31772850 PMCID: PMC6837271 DOI: 10.7759/cureus.5880] [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: 11/05/2022] Open
Abstract
Introduction Laryngomalacia (LM) is a condition that is clinically diagnosed in the pediatric period with inspiratory stridor and is caused by a congenital or acquired collapse of laryngeal suprastructures. Endoscopic supraglottoplasty is the modern gold standard surgical treatment for severe or complicated laryngomalacia. Various cold and powered surgical devices have been used to approach the aryepiglottic folds, and their advantages and drawbacks have been widely discussed. The applicability of Ultracision Harmonic shears (Ethicon Inc., NJ, US) for the sake of supraglottoplasty has not been previously advocated in the literature and is the subject of this study. Methods This was a review of the medical records of pediatric patients, with moderate to severe congenital laryngomalacia, who underwent supraglottoplasty with Harmonic at a single institution, from 2013 to 2019. Results A total of six patients underwent bilateral aryepiglottic fold division with the use of Ultracision in the study period (4 male, 2 female; mean age 7+/-9 months, age range 1m-24m). Postoperatively, all of the children were extubated and admitted to the pediatric intensive care unit (PICU) as a precaution measure. There were no early or late complications after the intervention. The postoperative endoscopic picture was evaluated in three patients (two of which for another reason). A stable laryngeal frame with no collapse or excessive scarring was observed. None of the patients required repeat surgery. Conclusion Based on the ease of surgical access, performance, surgical precision, and postoperative results, the use of Harmonic scissors appears to be a safe, practical, affordable, and easily applicable alternative for supraglottoplasty Type 2.
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Affiliation(s)
| | | | - George S Stoyanov
- General and Clinical Pathology, Forensic Medicine and Deontology, Medical University of Varna, Varna, BGR
| | | | - Petya Genova
- Otolaryngology, Medical University of Varna, Varna, BGR
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Chen DW, Carol Liu YC. Routine admission to step-down unit as an alternative to intensive care unit after pediatric supraglottoplasty. Int J Pediatr Otorhinolaryngol 2019; 116:181-185. [PMID: 30554695 DOI: 10.1016/j.ijporl.2018.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the feasibility and the outcomes for step-down (SD) unit admission as an alternative to intensive care unit (ICU) admission after supraglottoplasty in the pediatric patient. METHODS A review of 98 patients who underwent supraglottoplasty from 2012 to 2017 at a tertiary referral pediatric hospital was performed. An SD unit had 1-to-3 nurse-to-patient ratio with noninvasive positive pressure ventilation capability. Data variables included demographics, comorbidities, preoperative and postoperative respiratory requirements, and length of stay. RESULTS Routine admission to SD occurred for 85% patients while 15% patients were selectively admitted to ICU due to intubation requirement or perioperative respiratory distress. In SD, noninvasive respiratory support was required for 28 (34%) patients. Three (4%) required re-intubation and ICU transfer without delay in care. Patients at high risk for requiring respiratory support after surgery have a neurologic condition (OR 7.0, 95% 2.4-20.2, p < 0.01) or intrinsic pulmonary disease (OR 4.5, 95% CI 1.5-13.3, p < 0.01). Median length of stay was shorter for patients in step-down (1 day, IQR 1-2). CONCLUSION Patients can be managed safely in a SD unit after supraglottoplasty supporting de-escalation of care. Patients with neurologic and pulmonary comorbidities may have higher respiratory needs postoperatively. Prospective studies are warranted to further optimize resource allocation.
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Affiliation(s)
- Diane W Chen
- Dept. Otolaryngology - Head & Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Yi-Chun Carol Liu
- Dept. Otolaryngology - Head & Neck Surgery, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA.
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Abstract
Stridor, a common presenting sign of respiratory distress in a newborn, has many systemic causes. It may arise from the larynx or the tracheobronchial airway. This article presents the most common pathologic conditions in this anatomic region, with highlights on management.
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Affiliation(s)
- Jay Bhatt
- Department of Pediatric Otolaryngology, Children's Hospital Colorado, 13123 E 16th Avenue, B-455, Aurora, CO 80045, USA
| | - Jeremy D Prager
- Department of Otolaryngology, University of Colorado School of Medicine, 12631 E. 17th Avenue, B-205, Aurora, CO 80045, USA.
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Wu D, Wasserman J, Boruk M. Practice Patterns of Systemic Corticosteroid Use in Complicated Acute Rhinosinusitis Among Rhinologists and Pediatric Otolaryngologist. Am J Rhinol Allergy 2018; 32:485-490. [DOI: 10.1177/1945892418797056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The use of systemic corticosteroids remains controversial in the treatment of orbital complications of sinusitis. Objective To compare and contrast the current practice patterns of the use of systemic corticosteroid in the management of orbital complications of acute bacterial rhinosinusitis (ABRS) among fellowship-trained members of American Society of Pediatric Otolaryngology (ASPO) and American Rhinologic Society (ARS). Study Design Cross-sectional survey. Methods A web-based survey was electronically distributed to 497 members of ASPO and 845 members of ARS focusing on the practice habits and opinions regarding the use of systemic corticosteroids in the treatment of ABRS with orbital complications in children and adults. Results Survey completion rate was 19.1% among ASPO membership and 10.3% from ARS; 45% of respondents utilized steroids almost always or frequently in children and 36% of the time in adults. Most commonly reported indication for the use of steroid was vision change. Fellowship-trained pediatric otolaryngologists are 2.88 times more likely to prescribe corticosteroids for children than rhinologists ( P < .02). The perceived level of evidence in the literature was split between expert opinions and cohort studies. Conclusion In orbital complications of ABRS, practice patterns of the use of steroid differ significantly between fellowship-trained ASPO and ARS members with respect to its use in children. Overall, corticosteroids are administered with significant frequency, although there is little actual or perceived evidence to support their safety or efficacy. In alignment of practicing evidence-based medicine, further studies are needed to guide the use of steroids in complicated ABRS with respect to timing, dosing, route, duration, and indication.
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Affiliation(s)
- Derek Wu
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York
| | - Jason Wasserman
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York
| | - Marina Boruk
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York
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Ching HH, Spinner AG, Reeve NH, O-Lee TJ. A novel technique for unilateral supraglottoplasty. Int J Pediatr Otorhinolaryngol 2018; 104:150-154. [PMID: 29287857 DOI: 10.1016/j.ijporl.2017.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Traditional supraglottoplasty for pediatric laryngomalacia is most commonly conducted with either CO2 laser or cold steel instruments. While the procedure enjoys high success rates, serious complications such as excessive bleeding, supraglottic stenosis and aspiration can occur. Unilateral coblation supraglottoplasty may reduce this risk, but data on respiratory and swallowing outcomes are lacking. This study reports our experiences with unilateral coblation supraglottoplasty. METHODS Pediatric patients with severe congenital laryngomalacia who underwent unilateral supraglottoplasty at a single institution from 2013 to 2016 were retrospectively reviewed. Bipolar radiofrequency ablation (Coblation) was utilized with partial arytenoidectomy, aryepiglottoplasty, and advancement of mucosal flaps. Outcome measures included apnea-hypopnea index (AHI), weight-by-age percentile, and decannulation rate. RESULTS Twelve patients were included with an average age of 13.1 months (range 2-28 months). In patients without tracheostomy, 88% had complete resolution of respiratory symptoms, while the remainder had significant improvement. In patients without gastrostomy tubes, there was an average increase in weight-age percentile of 6.1, 7.8, and 15.3 points at 1, 3, and 6 months postoperatively, respectively. Three patients had complete polysomnography data with a mean preoperative AHI of 19.3 and postoperative AHI of 4.0. Three of four patients with tracheostomy have been decannulated at a mean follow-up of 1.5 years. There were no early or late postoperative complications and no revision supraglottoplasty. CONCLUSION Unilateral supraglottoplasty with bipolar radiofrequency ablation can improve respiratory symptoms and decrease OSA severity in severe congenital laryngomalacia. This technique is safe and can lead to substantial improvement in AHI in patients with OSA.
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Affiliation(s)
- Harry H Ching
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas School of Medicine, 1701 W. Charleston Blvd., Suite #490, Las Vegas, NV 89102, USA.
| | - Alycia G Spinner
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas School of Medicine, 1701 W. Charleston Blvd., Suite #490, Las Vegas, NV 89102, USA.
| | - Nathaniel H Reeve
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas School of Medicine, 1701 W. Charleston Blvd., Suite #490, Las Vegas, NV 89102, USA.
| | - T J O-Lee
- Department of Otolaryngology - Head and Neck Surgery, University of Nevada Las Vegas School of Medicine, 1701 W. Charleston Blvd., Suite #490, Las Vegas, NV 89102, USA.
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Abstract
AbstractBackground:The advent of supraglottoplasty clearly has transformed the surgical management of severe laryngomalacia. The condition, however, generally runs a milder course, with spontaneous resolution the norm.Objectives:To identify gaps in the knowledge and identify topics for future study.Method:Systematic review of the literature.Results:The literature suggests that there is a range of abnormalities leading to the typical collapsing upper airway, and that neurological disease, other airway abnormalities, syndromes and gastroesophageal reflux all contribute to disease severity and influence outcomes. The procedures involved in supraglottoplasty are rarely specified, the indications for surgery are vaguely defined and the role of medical therapy is unclear.Conclusion:Every review article or survey of opinion suggests that there is still a marked variation in individual practice and a lack of consensus.
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Balakrishnan M, Raghavan A, Suresh GK. Eliminating Undesirable Variation in Neonatal Practice: Balancing Standardization and Customization. Clin Perinatol 2017; 44:529-540. [PMID: 28802337 DOI: 10.1016/j.clp.2017.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Consistency of care and elimination of unnecessary and harmful variation are underemphasized aspects of health care quality. This article describes the prevalence and patterns of practice variation in health care and neonatology; discusses the potential role of standardization as a solution to eliminating wasteful and harmful practice variation, particularly when it is founded on principles of evidence-based medicine; and proposes ways to balance standardization and customization of practice to ultimately improve the quality of neonatal care.
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Affiliation(s)
- Maya Balakrishnan
- Division of Neonatology, Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Aarti Raghavan
- Division of Neonatology, Department of Pediatrics, UIC Hospital, University of Illinois College of Medicine at Chicago, 1740 West Taylor Street, Chicago, IL 60612, USA
| | - Gautham K Suresh
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, W6104, Houston, TX 77030, USA.
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Cooper T, Harris B, Mourad A, Garros D, El-Hakim H. Comparison between selective and routine intensive care unit admission post-supraglottoplasty. Int J Pediatr Otorhinolaryngol 2017; 99:90-94. [PMID: 28688573 DOI: 10.1016/j.ijporl.2017.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/01/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare major post-operative respiratory complications, post-operative disposition and duration of hospital admission before and after adopting a selective intensive care unit (ICU) admission care plan following supraglottoplasty (SGP). METHODS Retrospective case series set in a tertiary pediatric referral center. Eligible patients undergoing SGP between October 2003 and July 2015 were identified through a prospectively kept surgical database. Historical cohorts with routine admission to ICU and selective admission to ICU were identified based on a shift in surgeon practice. The cohorts were compared with respect to demographics, presenting features, endoscopic findings, baseline sleep and swallowing study results, major respiratory complications (including repeat or unplanned ICU admission or intubation) and length of post-operative hospital admission. RESULTS 141 eligible patients were identified with 35 children in the routine ICU admission cohort and 106 in the selective ICU admission cohort. There were no significant differences between cohorts regarding major respiratory complications with only one patient in the selective ICU admission cohort requiring an unplanned admission to ICU (P = 1.00, Fisher's exact test). This gives a number needed to harm of 78 step-down unit admissions for 1 unplanned ICU admission. The rate of ICU admission was reduced from 71% to 26% with adoption of a selective ICU admission care plan (p < 0.01, χ2). Mean duration of post-operative hospitalization was reduced from 5.1 ± 3.5 days to 1.9 ± 2.3 days (P < 0.01, Student's t-test). CONCLUSIONS Selective post-operative ICU admission following SGP significantly reduces ICU utilization and may reduce length of hospital stay without compromising safety and care. This has significant cost benefit implications.
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Affiliation(s)
- Timothy Cooper
- Division of Otolaryngology-Head and Neck Surgery, Canada
| | - Bree Harris
- Division of Otolaryngology-Head and Neck Surgery, Canada
| | | | - Daniel Garros
- Division of Pediatric Critical Care, Canada; Department of Pediatrics, Canada
| | - Hamdy El-Hakim
- Department of Pediatrics, Canada; Divisions of Otolaryngology-Head and Neck Surgery and Pediatric Surgery, Canada; Department of Surgery, The Stollery Children's Hospital, University of Alberta, Edmonton, Alberta T6G 2B7, Canada.
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