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Dutta M, Jana D, Mukherjee D, Panja T, Shukla AK, Daga D, Yadav KK, Mondal S, Bandyopadhyay SN. Endoscopic Screening for Laryngotracheal Complications in Children Following Prolonged Mechanical Ventilation Maintained Through Endotracheal Intubation: A Cross-Sectional Pilot Project. Ann Otol Rhinol Laryngol 2025; 134:310-319. [PMID: 39720852 DOI: 10.1177/00034894241308411] [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: 12/26/2024]
Abstract
BACKGROUND An endoscopic screening program following successful weaning from prolonged mechanical ventilation maintained through endotracheal tube (ET; prolonged intubation) may be justified to assess the upper (laryngotracheal) airway in children who may not always be symptomatic for intubation-related complications. OBJECTIVES To evaluate effects of prolonged intubation in children through endoscopic screening of the laryngotracheal airway. METHODS In this cross-sectional pilot project, children (2 months-12 years) successfully extubated following prolonged intubation were selected, irrespective of having symptoms, for a 1-time flexible nasolaryngoscopy at third to sixth month post-extubation (follow-up window). Laryngotracheal airway changes, if present, were noted. RESULTS Out of 122 children, 42 developed symptoms of complications. Five of them attended within 3 months post-extubation, the rest were evaluated in the follow-up window. Eighty children aged ≤6 years and 4 children >6 years were intubated with uncuffed ET. Symptoms, when present, included respiratory distress (100%), noisy breathing (~36%), cough (~29%), and dysphagia (~12%). Screening revealed positive findings in 40 out of 42 symptomatic children, and in 8 out of 80 asymptomatic children (χ2 = 80.314; after Yate's correction; significant at P < .0001). The commonest lesion was subglottic stenosis (~54%) and intubation granuloma (~48%). Relationship between the nature of ET (cuffed/uncuffed) and complications of prolonged intubation was statistically significant (χ246.553; significant at P < .0001). CONCLUSION The present study proposes the potential utility of follow-up endoscopic screening of upper (laryngotracheal) airway in children successfully weaned from prolonged intubation. A statistically significant relationship existed between prolonged intubation and upper airway complications that were not always symptomatic.
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Affiliation(s)
- Mainak Dutta
- Department of Otorhinolaryngology & Head-Neck Surgery, All India Institute of Medical Sciences, Kalyani; Basantapur, Saguna, Nadia, West Bengal, India
| | - Debjit Jana
- Department of Otorhinolaryngology & Head-Neck Surgery, Medical College & Hospital, Kolkata; West Bengal, India
| | - Diptanshu Mukherjee
- Department of Otorhinolaryngology & Head-Neck Surgery, Medical College & Hospital, Kolkata; West Bengal, India
| | - Tanaya Panja
- Department of Otorhinolaryngology & Head-Neck Surgery, Medical College & Hospital, Kolkata; West Bengal, India
| | - Amit Kumar Shukla
- Department of Otorhinolaryngology & Head-Neck Surgery, Medical College & Hospital, Kolkata; West Bengal, India
| | - Divya Daga
- Department of Otorhinolaryngology & Head-Neck Surgery, Medical College & Hospital, Kolkata; West Bengal, India
| | - Krishna Kumar Yadav
- Department of Otorhinolaryngology & Head-Neck Surgery, Medical College & Hospital, Kolkata; West Bengal, India
| | - Swarnali Mondal
- Department of Otorhinolaryngology & Head-Neck Surgery, Medical College & Hospital, Kolkata; West Bengal, India
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Suresh R, Roohani C, Wang CS, Kou YF, Johnson RF, Chorney SR. Subglottic Stenosis After Pediatric Tracheostomy. Laryngoscope 2025; 135:402-408. [PMID: 39189344 DOI: 10.1002/lary.31736] [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: 06/04/2024] [Revised: 08/12/2024] [Accepted: 08/16/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVES To determine the incidence of subglottic stenosis (SGS) in children after tracheostomy and identify risk factors for development. STUDY DESIGN Retrospective cohort. METHODS All patients (<18 years) undergoing tracheostomy at a tertiary children's hospital between 2015 and 2020 were included. Patients with a direct laryngoscopy (DL) concurrent with tracheostomy and a subsequent DL were included. Medical records, including operative reports, were reviewed to identify subglottic stenosis and associated risk factors. RESULTS A total of 140 patients were included with mean age at tracheostomy of 2.4 years (standard deviation [SD]: 4.3) (median: 0.5 years, interquartile range [IQR]: 0.3-1.5 years) and gestational age of 33.8 weeks (SD: 5.9) (median: 36 weeks, IQR: 28-39 weeks). At initial DL, 24% (N = 34) had subglottic injury and 26% (N = 37) developed SGS. The incidence of SGS after tracheostomy was 11.5 cases per 100 patients per year. At tracheostomy, lower birth weight (1.8 vs. 2.3 kg, p = 0.005), shorter gestational age (31.8 vs. 34.6 weeks, p = 0.01), younger age (0.8 vs. 2.9 years, p = 0.01), lower weight (5.8 vs. 14.7 kg, p = 0.01), and subglottic injury (44% vs. 21%, p = 0.01) were associated with the development of SGS. Multivariable logistic regression analysis associated birth weight (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.31-0.75, p = 0.001) and early subglottic injury (OR: 3.22, 95% CI: 1.31-7.88, p = 0.01) with SGS development. CONCLUSIONS The incidence of SGS after pediatric tracheostomy is estimated at 11.5 cases per 100 patients per year. Low birth weight and subglottic injury at the time of tracheostomy were associated with SGS in this vulnerable population of children. LEVEL OF EVIDENCE 3 Laryngoscope, 135:402-408, 2025.
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Affiliation(s)
- Rishi Suresh
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
| | - Cheyenne Roohani
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
| | - Cynthia S Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
- Department of Pediatric Otolaryngology, Children's Health, Dallas, Texas, 75207, U.S.A
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
- Department of Pediatric Otolaryngology, Children's Health, Dallas, Texas, 75207, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
- Department of Pediatric Otolaryngology, Children's Health, Dallas, Texas, 75207, U.S.A
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
- Department of Pediatric Otolaryngology, Children's Health, Dallas, Texas, 75207, U.S.A
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Saldarriaga CA, Choi B. The Perils of Pregnancy: A Case Report of Subglottic Stenosis. Cureus 2024; 16:e76525. [PMID: 39872570 PMCID: PMC11771771 DOI: 10.7759/cureus.76525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2024] [Indexed: 01/30/2025] Open
Abstract
Subglottic stenosis (SGS) presents a rare, yet challenging condition characterized by airway obstruction below the glottis, with diverse etiologies ranging from congenital to acquired factors like intubation or autoimmune diseases. Diagnosis and management of SGS during pregnancy are particularly complex due to limited literature and diagnostic consensus. This article presents a case of a 26-year-old pregnant woman presenting with escalating dyspnea and stridor attributed to SGS, most likely secondary to idiopathic etiology. Initial assessments, including a CT scan and fiberoptic laryngoscopy, confirmed the diagnosis of SGS showing a narrow subglottic trachea. Given the complexity of the case, she was transferred to a tertiary care center where she underwent CO2 laser excision, balloon dilation, and submucosal Triamcinolone injection. Pre and postoperatively, the patient was managed with corticosteroids, antibiotics, and bronchodilators. Her condition improved significantly, as evidenced by a follow-up strobovideolaryngoscopy on day 15, which showed a symmetric vocal fold, adequate vibratory motion, and widely patent subglottic larynx. This report emphasizes the importance of tailored, multidisciplinary management of SGS during pregnancy, with endoscopic resection and adjuvant therapies proving to be effective interventions. Regular follow-up is crucial due to the potential for recurrence within three years post-treatment.
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Affiliation(s)
| | - Bryan Choi
- Emergency Department, Bayhealth Hospital, Dover, USA
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Sindi A, Alhedaithy A, Almutairi N, Alshareef W, Aljasser A, Alammar A. Unveiling Progress: A Systematic Review and Meta-Analysis of Endoscopic Posterior Cricoid Split With Posterior Cartilage Graft. Cureus 2024; 16:e73830. [PMID: 39691144 PMCID: PMC11651782 DOI: 10.7759/cureus.73830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2024] [Indexed: 12/19/2024] Open
Abstract
Subglottic and posterior glottic stenosis (PGS) narrows distinct areas of the larynx, while bilateral vocal fold immobility (BVFI) is characterized by static cords. Treatments include open surgeries and newer endoscopic methods, offering comparable safety, quicker recovery, and fewer complications. This study assesses the decannulation rate of endoscopic posterior cricoid split with posterior cartilage grafting (EPCCG) in pediatric patients with posterior glottic stenosis, subglottic stenosis (SGS), and BVFI. Other outcomes include complications, symptom relief, need for additional airway procedures, and hospital stay. We retrieved relevant records published between 2003 and 2024 from PubMed, Scopus, Web of Science, and Cochrane Library. Using OpenMeta v5.26.14 software, we pooled the decannulation rates from individual studies. Other outcomes reported in fewer studies than what justifies a meta-analysis were synthesized manually. The selection process yielded 15 articles, 11 of which were eligible for analysis. The decannulation rate had an estimated proportion of approximately 83.2% (95% CI: 74.0-92.4%). Complications were present in 6/70 patients, and no mortality was reported. Additional airway procedures were needed in 14/82 patients for whom the outcome was reported. Hospital stays averaged 6.1 days in four studies reporting the outcome. Symptomatic relief was achieved in most of the patients; however, some cases reported odynophagia and concerns about voicing. EPCCG shows promise in treating less severe cases of PGS, SGS, and BVFI, offering safety, short hospital stays, and symptomatic relief. However, its efficacy for advanced cases and comorbidities needs more research. The limitations, including multiple pathologies and comorbidities in patients, hinder broader applicability. More extensive studies with standardized protocols are required in order to overcome these limitations.
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Affiliation(s)
- Abdullah Sindi
- Otolaryngology - Head and Neck Surgery, King Saud University Medical City, Riyadh, SAU
- Otolaryngology - Head and Neck Surgery, King Abdullah Medical Complex, Jeddah, SAU
| | - Alhanouf Alhedaithy
- Otolaryngology - Head and Neck Surgery, King Fahad Medical Military Complex, Dhahran, SAU
| | - Nasser Almutairi
- Otolaryngology, Alfaisal University College of Medicine, Riyadh, SAU
- Otolaryngology - Head and Neck Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, SAU
| | - Waleed Alshareef
- Otolaryngology - Head and Neck Surgery, Maternity and Children's Hospital, Makkah, SAU
| | - Abdullah Aljasser
- Otolaryngology - Head and Neck Surgery, King Saud University Medical City, Riyadh, SAU
| | - Ahmad Alammar
- Otolaryngology - Head and Neck Surgery, King Saud University Medical City, Riyadh, SAU
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5
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Siddiqui KM, Baig UA, Yousuf MS. Single stage cricoid split laryngoplasty with costochondral rib grafting is a novel approach to treat subglottic stenosis in a paediatric patient: A case report. Int J Surg Case Rep 2024; 121:109952. [PMID: 38943940 PMCID: PMC11261409 DOI: 10.1016/j.ijscr.2024.109952] [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: 05/17/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/01/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Subglottic stenosis (SGS) appears to be a commonly encountered condition in the paediatric age group. Single stage cricoid split laryngoplasty with costochondral rib grafting in paediatric patients is a unique, innovative, and advanced operation in nature. Morbidity and mortality rates can be minimized with early diagnosis and prompt treatment. PRESENTATION OF CASE Presenting the case of a 13-month-old child diagnosed with Grade II SGS who was managed for cricoid split laryngoplasty with a costochondral rib graft. It was a unique strategy for providing infants and neonates with symptomatic SGS with a safe and efficient substitute for long-term tracheostomy. When healing was completed, the patient regained the function of their airway. The approach was successful, and preventable to long-term tracheostomy. DISCUSSION Performing this procedure early in children has shown higher rates of success and it is safe and effective. Further extensive research and studies need to be conducted in this domain, and every patient's status should be reviewed time and again to tend to their specific needs, and the choice of procedure should be made optimally based on clinical evaluations. CONCLUSION Successful management of a 13-month-old child with Grade II subglottic stenosis through cricoid split laryngoplasty with costochondral rib grafting is a challenging and novel approach to treating single-stage SGS.
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Affiliation(s)
| | - Umair Aftab Baig
- Department of Anaesthesiology, Aga Khan University, Karachi, Sindh, Pakistan
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Veder LL, Joosten KFM, Timmerman MK, Pullens B. Factors associated with laryngeal injury after intubation in children: a systematic review. Eur Arch Otorhinolaryngol 2024; 281:2833-2847. [PMID: 38329528 PMCID: PMC11065910 DOI: 10.1007/s00405-024-08458-7] [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: 10/16/2023] [Accepted: 01/04/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE The purpose of this study is to evaluate all potential factors associated with laryngeal injury after endotracheal intubation in the pediatric population. METHODS A systematic literature search was conducted in Medline, Embase, Cochrane, web of science and Google scholar up to 20th of March 2023. We included all unique articles focusing on factors possibly associated with intubation-injury in pediatric patients. Two independent reviewers determined which articles were relevant by coming to a consensus, quality of evidence was rated using GRADE criteria. All articles were critically appraised according to the PRISMA guidelines. The articles were categorized in four outcome measures: post-extubation stridor, post-extubation upper airway obstruction (UAO) necessitating treatment, laryngeal injury found at laryngoscopy and a diagnosed laryngotracheal stenosis (LTS). RESULTS A total of 24 articles with a total of 15.520 patients were included. The incidence of post-extubation stridor varied between 1.0 and 30.3%, of post-extubation UAO necessitating treatment between 1.2 and 39.6%, of laryngeal injury found at laryngoscopy between 34.9 to 97.0% and of a diagnosed LTS between 0 and 11.1%. Although the literature is limited and quality of evidence very low, the level of sedation and gastro-esophageal reflux are the only confirmed associated factors with post-extubation laryngeal injury. The relation with age, weight, gender, duration of intubation, multiple intubations, traumatic intubation, tube size, absence of air leak and infection remain unresolved. The remaining factors are not associated with intubation injury. CONCLUSION We clarify the role of the potential factors associated with laryngeal injury after endotracheal intubation in the pediatric population.
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Affiliation(s)
- L L Veder
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
| | - K F M Joosten
- Department of Pediatrics, Intensive Care Unit, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M K Timmerman
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - B Pullens
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
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7
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Sweidan AJ, Anaim HY, Patel NM, Longoria JA. Management and Discussion of COVID-19 Related Tracheal Stenosis: A Single Center Retrospective Review. Int Med Case Rep J 2024; 17:423-431. [PMID: 38737213 PMCID: PMC11088833 DOI: 10.2147/imcrj.s436903] [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] [Received: 08/24/2023] [Accepted: 04/19/2024] [Indexed: 05/14/2024] Open
Abstract
SARS-CoV-2 virus has led to an unprecedented amount of tracheal stenosis. Rigid bronchoscopy can serve as a curative measure or bridge therapy to tracheal resection. We also briefly discuss the pathophysiology of tracheal stenosis from prolonged intubation and SARS-CoV-2 virus. This should be differentiated from other forms of airway obstruction such as tracheobronchomalacia which would be considered a pseudo-tracheal stenotic disease. The aim of this study is to evaluate stenosis that is unable to be improved with positive airway pressure or "PAP" therapies and required stenting and/or subsequent tracheal resection. By performing Rigid Bronchoscopy and subsequent stenting of airways, we demonstrated outcomes for long term airway patency regarding patients who were intubated secondary to the SARS-CoV-2 virus. We demonstrate superb outcomes in a consecutive case series of 6 patients managed with rigid bronchoscopy, airway stent and tracheal resection. The patients were all managed from a pulmonary perspective by the physicians mentioned in this study.
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Affiliation(s)
- Alexander J Sweidan
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonary, University of California, Irvine, CA, USA
| | - Haron Y Anaim
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonary, University of California, Irvine, CA, USA
| | - Niral M Patel
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonary, University of California, Irvine, CA, USA
| | - Javier A Longoria
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonary, University of California, Irvine, CA, USA
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8
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Dabbous H, Chorney SR, Johnson RF, Kou YF. Surgical Outcomes by Early Airway Endoscopy Findings after Pediatric Staged Laryngotracheoplasty. Laryngoscope 2024; 134:963-967. [PMID: 37458330 DOI: 10.1002/lary.30875] [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: 04/27/2023] [Revised: 06/13/2023] [Accepted: 06/27/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVES To determine how initial postoperative airway endoscopy findings after stent removal predict successful decannulation in children undergoing double-staged laryngotracheoplasty (dsLTP). Secondary objectives assessed timing of decannulation and number of endoscopic interventions needed after dsLTP. METHODS A case series with chart review included children who underwent dsLTP at a tertiary children's hospital between 2008 and 2021. Rates of decannulation, time to decannulation, and number of interventions after dsLTP were recorded for children with high- or low-grade stenosis at the first bronchoscopy after stent removal. RESULTS Of the 65 children who were included, 88% had high-grade stenosis and 98% had a preoperative tracheostomy. Successful decannulation happened in 74% of the children, and 44% of the children were decannulated within 12 months of surgery. For children with low-grade stenosis at the first endoscopy after stent removal, 84% were successfully decannulated compared with 36% of the children with high-grade stenosis (p = 0.001). After dsLTP, children with high-grade stenosis required 7.5 interventions (SD: 3.3) compared with 4.0 interventions (SD: 3.0) for children with low-grade stenosis (p < 0.001). Decannulated children with high-grade stenosis necessitated more endoscopic procedures (7.0 vs. 3.7, p = 0.02). Time to decannulation was similar between children with high- and low-grade early postoperative stenosis (21.9 vs. 17.8 months, p = 0.63). CONCLUSIONS Higher grade stenosis identified on the first airway endoscopy after suprastomal stent removal is correlated with lower decannulation rates and more postoperative endoscopic interventions. Although time to decannulation was not impacted by early stenosis grade, surgeons might utilize these early airway findings to counsel families and prognosticate possible surgical success. LEVEL OF EVIDENCE 4 Laryngoscope, 134:963-967, 2024.
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Affiliation(s)
- Helene Dabbous
- Department of Otolaryngology-Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology-Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
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Doi Y, Ekuni S. Anesthetic management of inguinal hernia in an ex-premature infant with subglottic stenosis: a case report. JA Clin Rep 2023; 9:60. [PMID: 37700065 PMCID: PMC10497473 DOI: 10.1186/s40981-023-00652-6] [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: 07/20/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND We report the anesthetic management of inguinal hernia repair for an infant with subglottic stenosis. A previously scheduled operation had been cancelled due to unexpected airway trouble during the induction. CASE PRESENTATION A boy was born at 24 weeks of gestation and his trachea was intubated for 45 days. At 16 months old, surgery for inguinal hernia was planned, but cancelled due to unexpected narrow airway, and subglottic stenosis was first suspected. At 17 months old, he was transferred to us for inguinal hernia surgery. After careful discussion between the surgical team and the anesthesiologists, a strategy to manage this patient was developed. He underwent open hernia surgery under spinal anesthesia and diagnostic rigid bronchoscopy under tubeless general anesthesia separately, which revealed low-grade stenosis and some subglottic cysts. The postoperative course was uneventful. CONCLUSION Interdepartmental discussion weighing risks and benefits may deduce the safest and most appropriate anesthesia method.
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Affiliation(s)
- Yumi Doi
- Department of Anesthesia, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka, 5691192, Japan.
- Pediatric Perioperative Center, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka, 5691192, Japan.
| | - Satoshi Ekuni
- Department of Anesthesia, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka, 5691192, Japan
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Pinzas LA, Bedwell JR, Ongkasuwan J. Glottic and Subglottic Injury and Development of Pediatric Airway Stenosis. Otolaryngol Head Neck Surg 2023; 168:469-477. [PMID: 35608918 DOI: 10.1177/01945998221100829] [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: 11/24/2021] [Accepted: 04/28/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine how often children with airway injury at the time of tracheostomy develop airway stenosis. STUDY DESIGN A 7-year retrospective review of a prospectively maintained database of pediatric patients who underwent endotracheal intubation followed by tracheostomy with concurrent and follow-up direct laryngoscopy. SETTING Tertiary care hospital. METHODS Outcomes included glottic or subglottic injury and progression to stenosis. Univariate and multivariate analyses were performed via SPSS. RESULTS Of the 222 patients (median age at surgery, 0.6 years; 54% male) who met study criteria, 46% had airway injury at the time of tracheostomy. Patients with congenital cardiovascular disease had 2.33-times increased risk of developing airway injury (P = .01). Patients with airway injury on initial direct laryngoscopy developed stenosis significantly more frequently than those without injury (30% vs 12%, P < .01). Risks factors for developing stenosis in children with airway injury include prematurity (P = .02), younger age at time of surgery (P < .01), endotracheal tube size (P < .01), Down syndrome (P = .03), and neonatal (P = .02) and/or congenital cardiovascular (P < .01) diagnosis. However, none of these variables were significant on multivariate analysis. CONCLUSIONS Intubated patients with evidence of glottic or subglottic injury at the time of tracheotomy are more likely to develop airway stenosis than those without. Congenital heart disease was associated with twice the risk of developing airway injury, while progression to stenosis was associated with younger age, prematurity, and/or comorbid diagnoses.
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Affiliation(s)
| | - Joshua R Bedwell
- Department Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Julina Ongkasuwan
- Department Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
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Al-Khatib T, Kurdi A, Maqbul WA, Maqboul A, Alghamdi T. Treatment of Childhood High-Grade Subglottic Stenosis (SGS) Through Laryngotracheoplasty (LTP) in a Tertiary Pediatric Center from 2013 to 2020. Indian J Otolaryngol Head Neck Surg 2022; 74:363-368. [PMID: 36213461 PMCID: PMC9535041 DOI: 10.1007/s12070-021-02767-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022] Open
Abstract
Laryngotracheal reconstruction is the most common and effective treatment in childhood subglottic stenosis (SGS). Our aim is to review the success rate of laryngotracheoplasty (LTP) in pediatric high grade SGS cases in our tertiary center. The retrospective review was conducted on children with high grade subglottic stenosis who had undergone laryngotracheoplasty over a 7-year period (2013-2020) in tertiary pediatric care. A total of 20 patients who had history of high grade SGS during the stipulated period were included. All of them had undergone LTP. Decannulation was considered the primary outcome measure of success. Surveillance bronchoscopy was performed one year post airway reconstruction to detect residual stenosis. From January 2013 to December 2020, 20 patients aged between 1 and 16 years old underwent LTP. Among them, 10 patients (50%) had Grade III SGS while 5 had Grade III SGS with glottis stenosis (25%). The remaining 5 (25%) had severe Grade IV stenosis. Decannulation was achieved in 14 patients overall (70%) including 1 with revision. These 14 patients who achieved decannulation included 7 out of the 10 patients (70%) with Grade III, 2 out of the 5 (40%) patients with Grade III with glottic involvement, and 4 out of the 5 patients (80%) with Grade IV SGS. Fifteen (80%) patients had double stage LTP while 5 patients had single stage LTP. The study suggests that LTP is a promising approach in the treatment of Complex SGS. Furthermore, pediatric SGS, which is inherently complicated, can be treated with LTP effectively.
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Affiliation(s)
- Talal Al-Khatib
- Consultant Otolaryngology, Head and Neck Surgery Department, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Anas Kurdi
- Consultant Otolaryngology, Head and Neck Surgery Department, Almadinah Hospital, Almadinah, Saudi Arabia
| | - Wafa Abdullah Maqbul
- Associate consultant, Otolaryngology Head and Neck Surgery Department, King Abdullah Medical city, Makkah, Saudi Arabia
| | | | - Talal Alghamdi
- Medical Intern, King Abdulaziz University, Jeddah, Saudi Arabia
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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: 0.7] [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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Continuous epidural chloroprocaine after abdominal surgery is associated with lower postoperative opioid exposure in NICU infants. J Pediatr Surg 2022; 57:683-689. [PMID: 34154813 DOI: 10.1016/j.jpedsurg.2021.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/27/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Epidural anesthesia in infants undergoing open abdominal surgery has the potential to reduce opioid consumption, lower pain scores, and expedite tracheal extubation. We evaluated associations between use of continuous epidural chloroprocaine and improved intra- and post-operative outcomes. METHODS This matched retrospective cohort study first identified 24 patients who between April 2018 through December 2019 were treated with a caudal catheter and epidural chloroprocaine infusion for a laparotomy at postnatal age of 6 months or less. A matched comparator group of 24 patients was derived based on age and type of surgery. Exclusion criteria were the presence of a preoperative opioid infusion, comorbidities that would preclude appropriate pain assessment, or a recent surgical procedure. Primary outcomes included opioid consumption and pain scores; we secondarily analyzed intraoperative anesthetic requirements, other systemic analgesic use, vital signs, tracheal extubation time, and procedural times. RESULTS Treatment with epidural anesthesia was associated with lower 5-day total postoperative opioid consumption (3.2 mg/kg vs. 19.7 mg/kg in the respective epidural vs. systemic groups, p = 0.001) and time to tracheal extubation (1.3 days vs. 3.2 days, p = 0.005). Any statistically significant differences in pain scores were not clinically meaningful. There were no differences in mean arterial pressure or intraoperative inhaled anesthetic doses. CONCLUSION Continuous infusion of epidural chloroprocaine in infants following open abdominal surgery may limit exposure to systemic opioid medications while providing adequate postoperative analgesia and shortening time to tracheal extubation.
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Johnson RF, Bradshaw S, Jaffal H, Chorney SR. Estimations of Laryngotracheal Stenosis After Mechanical Ventilation: A Cross-Sectional Analysis. Laryngoscope 2021; 132:1723-1728. [PMID: 34542167 DOI: 10.1002/lary.29866] [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: 05/25/2021] [Revised: 07/29/2021] [Accepted: 09/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To estimate the incidence of laryngotracheal stenosis among adults after intubation. STUDY DESIGN Cross-sectional analysis. METHODS We used the Nationwide Readmission Database to examine adult patients readmitted within 45 days after admission for mechanical ventilation. Those with a diagnosis of laryngotracheal stenosis or tracheostomy dependence on their index admission were excluded. Patient demographics, associated comorbidities, and intubation lengths were compared among those with and without a diagnosis of airway stenosis at readmission. RESULTS An estimated 624,918 patients met inclusion with a mean age of 59 years (standard error = 0.2). There were 1,230 patients readmitted within 45 days and diagnosed with laryngeal (N = 362) or tracheal stenosis (N = 920) estimating an incidence of 1.98 per 1,000 discharges. Compared with those without a diagnosis of airway stenosis, those with stenosis were younger (57 vs. 59 years, P < .001), more often female (62% vs. 45%, P < .001) and frequently intubated for >96 hours (47% vs. 32%, P < .001). Additionally, a history of respiratory failure, pneumonia, obesity, gastroesophageal reflux disease, and chronic steroid use were also more common among patients with stenosis. Multiple logistic regression analysis identified a decreased risk of stenosis with advancing age while an increased risk was associated strongest for females (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.58-2.44, P < .001) and those with chronic steroid use (OR: 2.69, 95% CI: 1.80-4.02, P < .001). CONCLUSION The incidence of laryngotracheal stenosis after intubation in adults is rare but is associated with female gender and younger age. LEVEL OF EVIDENCE N/A Laryngoscope, 2021.
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Affiliation(s)
- Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Medical Center, Dallas, Texas, U.S.A
| | - Stanley Bradshaw
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Hussein Jaffal
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Medical Center, Dallas, Texas, U.S.A
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Dorris ER, Russell J, Murphy M. Post-intubation subglottic stenosis: aetiology at the cellular and molecular level. Eur Respir Rev 2021; 30:30/159/200218. [PMID: 33472959 PMCID: PMC9489001 DOI: 10.1183/16000617.0218-2020] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/20/2020] [Indexed: 02/07/2023] Open
Abstract
Subglottic stenosis (SGS) is a narrowing of the airway just below the vocal cords. This narrowing typically consists of fibrotic scar tissue, which may be due to a variety of diseases. This review focuses on post-intubation (PI) SGS. SGS can result in partial or complete narrowing of the airway. This narrowing is caused by fibrosis and can cause serious breathing difficulties. It can occur in both adults and children. The pathogenesis of post-intubation SGS is not well understood; however, it is considered to be the product of an abnormal healing process. This review discusses how intubation can change the local micro-environment, leading to dysregulated tissue repair. We discuss how mucosal inflammation, local hypoxia and biomechanical stress associated with intubation can promote excess tissue deposition that occurs during the pathological process of SGS. COVID-19 may cause an increased incidence of subglottic stenosis (SGS). In this review, the cellular and molecular aetiology of post-intubation SGS is outlined and we discuss how better knowledge of the underlying biology can inform SGS management.https://bit.ly/2RSliRK
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Affiliation(s)
- Emma R Dorris
- National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland .,School of Medicine, University College Dublin, Dublin, Ireland
| | - John Russell
- Children's Hospital Ireland Crumlin, Dublin, Ireland
| | - Madeline Murphy
- National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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