Health Care Costs and Cost-effectiveness in Laryngotracheal Stenosis

An Ovine Model Yields Histology and Gene Expression Changes Consistent with Laryngotracheal Stenosis

OBJECTIVES

Animal models for laryngotracheal stenosis (LTS) are critical to understand underlying mechanisms and study new therapies. Current animal models for LTS are limited by small airway sizes compared to human. The objective of this study was to develop and validate a novel, large animal ovine model for LTS.

METHODS

Sheep underwent either bleomycin-coated polypropylene brush injury to the subglottis (n = 6) or airway stent placement (n = 2) via suspension microlaryngoscopy. Laryngotracheal complexes were harvested 4 weeks following injury or stent placement. For the airway injury group, biopsies (n = 3 at each site) were collected of tracheal scar and distal normal regions, and analyzed for fibrotic gene expression. Lamina propria (LP) thickness was compared between injured and normal areas of trachea.

RESULTS

No mortality occurred in sheep undergoing airway injury or stent placement. There was no migration of tracheal stents. After protocol optimization, LP thickness was significantly increased in injured trachea (Sheep #3: 529.0 vs. 850.8 um; Sheep #4: 933.0 vs. 1693.2 um; Sheep #5: 743.7 vs. 1378.4 um; Sheep #6: 305.7 vs. 2257.6 um). A significant 62-fold, 20-fold, 16-fold, 16-fold, and 9-fold change of COL1, COL3, COL5, FN1, and TGFB1 was observed in injured scar specimen relative to unaffected airway, respectively.

CONCLUSION

An ovine LTS model produces histologic and transcriptional changes consistent with fibrosis seen in human LTS. Airway stent placement in this model is safe and feasible. This large airway model is a reliable and reproducible method to assess the efficacy of novel LTS therapies prior to clinical translation.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2024.

Mapping quality of life after balloon dilatation in subglottic stenosis using Dyspnea index and Short Form Health Survey-36

PURPOSE

An accurate diagnosis and proper treatment plan are required to restore an adequate patent airway in fibrotic subglottic stenosis (SGS). Currently, the definitive treatment entails single-stage balloon dilatation with steroid injections. The primary aim was to evaluate successful airway restoration and general quality of life in cases with SGS in northern Sweden using robust patient reported outcomes.

METHODS

All participants with need of surgical treatment due to SGS that had been referred to the department of otorhinolaryngology, University Hospital of Umeå from September 2020 to August 2023 was included. Exclusion criteria included malignant, extrathoracic or cartilaginous cause, age < 18 years, or incompetent to sign consent documents. We assessed the patient-reported outcome measures pre- as well as 3 months postoperatively.

RESULTS

Of the 40 cases fulfilling the eligibility criteria's, 33 cases completed the Dyspnea index (DI) and the short form health survey (SF-36) pre- as well as 3 months post-operatively. Receiver operating characteristics showed significant improvement in DI as well as in SF 36 scores post-operatively.

CONCLUSIONS

Evaluation of balloon dilatation in SGS in this cohort follow-up analysis shows clear improvement in patient quality of life using robust PROM 3 months postoperatively, ensuring the use of a safe and well-tolerated procedure.

Drug delivery systems for wound healing treatment of upper airway injury

INTRODUCTION

Endotracheal intubation is a common procedure to maintain an open airway with risks for traumatic injury. Pathological changes resulting from intubation can cause upper airway complications, including vocal fold scarring, laryngotracheal stenosis, and granulomas and present with symptoms such as dysphonia, dysphagia, and dyspnea. Current intubation-related laryngotracheal injury treatment approaches lack standardized guidelines, relying on individual clinician experience, and surgical and medical interventions have limitations and carry risks.

AREAS COVERED

The clinical and preclinical therapeutics for wound healing in the upper airway are described. This review discusses the current developments on local drug delivery systems in the upper airway utilizing particle-based delivery systems, including nanoparticles and microparticles, and bulk-based delivery systems, encompassing hydrogels and polymer-based approaches.

EXPERT OPINION

Complex laryngotracheal diseases pose challenges for effective treatment, struggling due to the intricate anatomy, limited access, and recurrence. Symptomatic management often requires invasive surgical procedures or medications that are unable to achieve lasting effects. Recent advances in nanotechnology and biocompatible materials provide potential solutions, enabling precise drug delivery, personalization, and extended treatment efficacy. Combining these technologies could lead to groundbreaking treatments for upper airways diseases, significantly improving patients' quality of life. Research and innovation in this field are crucial for further advancements.

Airway Sequelae After Mechanical Ventilation for COVID-19: Protocol for a Scoping Review

BACKGROUND

The epidemiology, morbidity, and burden of disease related to airway sequelae associated with invasive mechanical ventilation in the context of the COVID-19 pandemic remain unclear.

OBJECTIVE

This scoping review aims to summarize the current knowledge regarding airway sequelae after severe SARS-CoV-2 infection. This knowledge will help guide research endeavors and decision-making in clinical practice.

METHODS

This scoping review will include participants of all genders, and no particular age group who developed post-COVID-19 airway-related complication will be excluded. No exclusion criteria will be applied from country, language, or document type. The information source will include analytical observational studies. Unpublished data will not be completely covered as gray literature will be covered. A total of 2 independent reviewers will participate in the process of screening, selection, and data extraction, and the whole process will be performed blindly. Conflict between the reviewers will be solved through discussion and an additional reviewer. The results will be reported by using descriptive statistics, and information will be displayed on RedCap (Research Electronic Data Capture).

RESULTS

The literature search was conducted in May 2022 in the following databases: PubMed, Embase, SCOPUS, Cochrane Library, as well as LILACS and gray literature to identify observational studies; a total of 738 results were retrieved. The scoping review will be finished by March 2023.

CONCLUSIONS

This scoping review will describe current knowledge on the most frequently encountered laryngeal or tracheal sequelae in patients exposed to mechanical ventilation due to SARS-CoV-2 infection. This scoping review will find the incidence of airway sequelae post COVID-19 and the most common sequelae such as airway granuloma, vocal fold paralysis, and airway stenoses. Future studies should evaluate the incidence of these disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41811.

Serial In-Office Steroid Injections for Airway Stenosis: Long-Term Benefit and Cost Analysis

OBJECTIVES

To evaluate the long-term benefit of serial in-office steroid injections (SISI) in the treatment of subglottic and proximal tracheal stenosis (SG/PTS). Evaluate cost of SISI compared to endoscopic dilation (ED).

STUDY DESIGN

Retrospective study and cost analysis.

METHODS

All patients with SGS/PTS with at least two consecutive in-office steroid injections between 2013 and 2021 were evaluated. Patients with less than 2 years of follow-up data after the initial SISI series were excluded. Demographics, etiology of stenosis, total injections performed, time between steroid series, surgery-free interval (SFI) and adverse events were collected. For patients with known surgical history before SISI, pre-SISI SFI was compared. Institutional billing records and the national CMS average reimbursement were evaluated. Total charges for three treatment strategies (ED alone, ED with post-operative SISI and primary intervention with SISI) were also compared.

RESULTS

Forty-nine patients were included; 29 (59%) idiopathic, 11 (22%) traumatic and 9 (18%) rheumatologic. Mean (SD) follow-up time after the first SISI was 3.41 years (1.5), range (2.08-7.25 years). 79% (39/49) did not require additional surgery during the entire follow-up period. The SFI improved from a mean 13.5 months (SD 12.6; range 2-42 months) pre-SISI to a mean (SD) of 42 months (SD 20.2; range 10-87 months) (p < 0.0001) after SISI. Annual average charges for ED alone in our cohort was $15,383.28, compared to $7,070.04 for SISI.

CONCLUSIONS

SISI are an effective treatment for patients with SG/PTS. In-office steroid injections could offer cost savings for the patient.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2673-2679, 2023.

Developing a Tracheal Rendezvous Procedure for Complete High Subglottic Stenosis

Complete subglottic stenosis is often managed with surgical resection. However, involvement of the high subglottis can limit candidacy for open resection, and there are few treatment options for these patients. We refined an endoscopic approach that evolved into a tracheal rendezvous technique with T-tube placement as an alternative to open surgical resection. Here, we present our series, technique, and outcomes. A retrospective review was performed to identify patients who underwent endoscopic management of complete high subglottic stenosis at the University of California San Diego. The surgical technique was initially a two-step staged procedure and was subsequently revised to a single-stage procedure with stenosis ablation, dilation, and insertion of a T-tube, which was completed in one day. Patients were seen at regular follow-up intervals for reassessment. Five patients were identified with complete stenosis not amenable to surgical resection. The average age of the cohort was 44.8 years. The etiology of stenosis in all patients was related to prolonged intubation and tracheostomy, and the average length of stenosis was 19.6 mm. Stenosis resection was accomplished via laser ablation and balloon dilation, and the average T-tube length was 50.3 mm. All patients were discharged on postoperative day one. Two patients developed airway crusting within the T-tube and required emergency department visits. Decannulation was attempted in three patients, although failed in two. Tracheal rendezvous is a safe and effective procedure for patients with grade IV subglottic stenosis. This provides a feasible endoscopic alternative to patients who are not candidates for open surgical resection, ye are motivated to have phonatory capacity.

Can the Remote Use of a Peak Flow Meter Predict Severity of Subglottic Stenosis and Surgical Timing?

OBJECTIVE

We aimed to assess the relationship between patient-performed and patient-reported peak flow meter (PFM) measurements with pulmonary function testing (PFT) and Dyspnea Index (DI) scores as a tool for monitoring Subglottic stenosis (SGS) disease progression remotely.

METHODS

Thirty-five SGS patients were prospectively enrolled. Patients were given PFMs to report serial measurements from home. DI scores and PFT were recorded at serial clinic visits. Data were analyzed to determine the correlation between PFM measurements and PFT data. Pre-operative and post-operative PFM measurements, PFT, and DI scores were analyzed for patients who underwent operative intervention. Receiver operating characteristic (ROC) curves were created for PFM measurements, PFT data, and DI scores to predict the likelihood of surgery.

RESULTS

PFM measurements had a "strong" correlation with the peak expiratory flow rate (PEFR), r = 0.78. Means of PEFR, PIFR, EDI, PFM measurements, and DI scores all significantly improved after the operative intervention (p ≤ 0.05). The area under the curve for ROC curves for DI scores, PFM measurements, and EDI were highest in our cohort with values of 0.896, 0.823, and 0.806, respectively.

CONCLUSION

In our SGS cohort, PFM measurements correlate strongly with PEFR measurements. PFM measurements can adequately demonstrate disease progression and predict the need for surgery in this patient population. Together, DI scores and PFM measurements may be a useful tool to remotely follow patients with SGS and inform timing of in-person assessments.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:628-633, 2023.

Cost of pediatric laryngotracheal reconstruction: Differences between single-versus double-stage procedures

OBJECTIVE

Examine differences in cost between single stage (ss) versus double stage (ds) laryngotracheal reconstruction (LTR) for pediatric subglottic stenosis.

STUDY DESIGN

Retrospective chart review of children who underwent ssLTR or dsLTR from 2014 to 2018 at a single institution.

METHODS

Costs related to LTR and post-operative care up to one year after tracheostomy decannulation were extrapolated from charges billed to the patient. Charges were obtained from the hospital finance department and the local medical supplies company. Patient demographics including baseline severity of subglottic stenosis and co-morbidities were noted. Variables assessed include duration of hospital admission, number of ancillary procedures, duration of sedation wean, cost of tracheostomy maintenance, and time to tracheostomy decannulation.

RESULTS

Fifteen children underwent LTR for subglottic stenosis. D Ten patients underwent ssLTR, while five underwent dsLTR. Grade 3 subglottic stenosis was more prevalent in patients who underwent dsLTR (100%) than ssLTR (50%). The average per-patient hospital charges for ssLTR was $314,383 versus $183,638 for dsLTR. When estimated mean cost of tracheostomy supplies and nursing care until tracheostomy decannulation was included, the mean total charges associated with dsLTR patients was $269,456. Average hospital stay after initial surgery was 22 days for ssLTR versus 6 days for dsLTR. Average time to tracheostomy decannulation for dsLTR was 297 days. Average number of ancillary procedures needed was 3 versus 8 for ssLTR versus dsLTR.

CONCLUSION

For pediatric patients with subglottic stenosis, dsLTR may have a lower cost than ssLTR. Although ssLTR has the benefit of immediate decannulation, it is associated with higher patient charges, as well as longer initial hospitalization and sedation. For both patient groups, fees associated with nursing care comprised the majority of charges. Recognizing the factors that contribute to cost differences between ssLTR and dsLTR may be useful when performing cost-benefit analyses and assessing value in health care delivery.

Healthcare disparities for the development of airway stenosis from the medical intensive care unit

Objectives/hypothesis

Study design

Methods

Results

Conclusion

Level of evidence

A survey of patients with laryngotracheal stenosis on future clinical trial design

BACKGROUND/AIMS

Laryngotracheal stenosis is a rare but devastating proximal airway fibrosis that restricts a patient's ability to breathe. Treatment is primarily surgical and to date, there has never been a multi-institutional, randomized, prospective, and interventional clinical trial for a medical therapy to treat laryngotracheal stenosis. Therefore, we aimed to obtain patient feedback to guide successful trial design, recruitment, retention, and for identifying potential barriers to study participation.

METHODS

Over 1000 members of an international laryngotracheal stenosis online support community (the Living with Idiopathic Subglottic Stenosis Facebook group) were sent two questionnaires for a proposed interventional double-blinded, randomized, placebo-controlled clinical trial.

RESULTS

A total of 317 and 558 participants responded to the first and second surveys, respectively. The majority of participants (77%) were willing to consider enrollment, regardless of having a 50% chance of receiving placebo versus treatment (78%). The majority (84%) of participants were willing to travel 200 miles to participate for up to six in-person visits over 50 days. Specific side effects, including anemia/thrombocytopenia (72%) or risk of infection (69.3%) had the greatest impact on clinical trial participation with other side effects (peripheral edema (53%), oral ulcers (51%), and gastrointestinal side effects (41%)) having less impact.

CONCLUSION

Patients with laryngotracheal stenosis possess nuanced insight into their disease and treatment options. As a group, they are extremely motivated for better therapies. Future laryngotracheal stenosis clinical trials should focus on providing excellent side effect -related education and utilizing feedback from online advocacy groups to optimize recruitment and retention.

Serial Intralesional Steroid Injection for Subglottic Stenosis: Systemic Side Effects and Impact on Surgery-Free Interval

Objectives

In-office serial intralesional steroid injections (SILSIs) have become a commonly used treatment for subglottic stenosis. We characterized the impact of SILSIs on the time between operating room visits and incidence of glucocorticoid systemic side effects.

Study Design

Retrospective case series.

Setting

Academic tertiary care center.

Methods

All patients with subglottic stenosis receiving SILSIs at 1 institution from 2016 to 2020 were included. Surgery-free interval was compared using paired t tests. Side effect incidence was calculated with Kaplan-Meier methodology for visualization.

Results

Nineteen patients and 207 procedures were included. The majority of patients were White (95%) and female (95%) and had idiopathic subglottic stenosis (53%). Mean surgery-free interval for all patients was 8.7 months (95% CI, 5.6-11.8) before initiating SILSIs. Of 11 patients with calculable surgery-free interval, 10 experienced improvement, with a mean surgery-free interval increase of 4.6 months (95% CI, 2.4-6.7). Seven patients have not required surgery since initiation of SILSIs, with a mean follow-up time of 28 months (95% CI, 25-31). Noncutaneous systemic side effects occurred at a mean 3.2 months (95% CI, 2.4-4.0) from first injection and included Cushing’s syndrome, increased intraocular pressure, central serous chorioretinopathy, and new insulin requirement in the setting of diabetes.

Conclusions

Ninety-one percent of patients who initiated SILSIs and had a subsequent return to the operating room experienced a mean 4.6-month increase in surgery-free interval. Systemic side effects of glucocorticoids occurred in 32% of patients after initiating SILSIs. This should be considered in preprocedure counseling and side effect monitoring during treatment.

Quantitative Assessment of the Immune Microenvironment in Patients With Iatrogenic Laryngotracheal Stenosis

OBJECTIVE

Iatrogenic laryngotracheal stenosis (iLTS) is characterized by fibroinflammatory narrowing of the upper airway and is most commonly caused by intubation injury. Evidence suggests a key role for CD4 T cells in its pathogenesis. The objective of this study is to validate emerging multiplex immunofluorescence (mIF) technology for use in the larynx and trachea while quantitatively characterizing the immune cell infiltrate in iLTS. In addition to analyzing previously unstudied immune cell subsets, this study aims to validate previously observed elevations in the immune checkpoint PD-1 and its ligand PD-L1 while exploring their spatial and cellular distributions in the iLTS microenvironment.

STUDY DESIGN

Controlled ex vivo cohort study.

SETTING

Tertiary care center.

METHODS

mIF staining was performed with formalin-fixed, paraffin-embedded slides from 10 patients with iLTS who underwent cricotracheal resection and 10 control specimens derived from rapid autopsy for CD4, CD8, CD20, FoxP3, PD-1, PD-L1, and cytokeratin.

RESULTS

There was greater infiltration of CD4+ T cells, CD8+ T cells, CD20+ B cells, FoxP3+CD4+ Tregs, and FoxP3+CD8+ early effector T cells in the submucosa of iLTS specimens as compared with controls (P < .05 for all). PD-1 was primarily expressed on T cells and PD-L1 predominantly on CD4+ cells and "other" cells.

CONCLUSION

This study leverages the power of mIF to quantify the iLTS immune infiltrate in greater detail. It confirms the highly inflammatory nature of iLTS, with CD4+ cells dominating the immune cell infiltrate; it further characterizes the cellular and spatial distribution of PD-1 and PD-L1; and it identifies novel immunologic targets in iLTS.

Not Just Dyspnoea: Swallowing as a Concern for Adults with Laryngotracheal Stenosis Undergoing Airway Reconstruction

Acquired laryngotracheal stenosis (LTS) is a rare condition causing dyspnea and stridor. Patients often require multiple surgical procedures with no guarantee of a definitive outcome. Difficulty swallowing is a recognised problem associated with LTS and the reconstructive surgeries required to manage the condition. The breathlessness patient's experience impacts on swallowing, and the vulnerable structures of the larynx are implicated during complex surgeries. This leads to dysphagia post-surgery, with some patients experiencing more chronic symptoms depending on the biomechanical impact of the surgery, or a pre-existing dysphagia. Despite this there is limited observational research about the dysphagia associated with LTS, with no exploration of the patient experience. Our aim was to investigate patient experience of living with LTS focussing on dysphagia in order to guide clinical practice. A qualitative study was completed using focus groups and semi-structured interviews with 24 patients who have had reconstructive surgery for LTS. Thematic analysis was used to identify three over-arching themes: The Physical Journey, The Emotional Journey and The Medical Journey. Key sub-themes included the importance of self-management and control, presence of symptoms, benefits of therapy, living with a life-long condition, fear and anxiety, autonomy, medicalisation of normal processes and the dichotomy between staff expertise and complacency. Swallowing was connected to all themes. The results are reviewed with consideration of the wider literature of lived experience particularly in relation to other chronic conditions and those that carry a high symptom burden such as head and neck cancer. Future clinical and research recommendations have been made. Akin to other clinical groups, adults with LTS are keen that management of their swallowing is person-centred and holistic.

Voice-Related Quality of Life Is Associated with Postoperative Change in Subglottic Stenosis

OBJECTIVES

To characterize the impact of subglottic stenosis (SGS) on voice-related quality of life (V-RQOL) and quantify the effect of treatment on voice outcomes.

STUDY DESIGN

Case series.

METHODS

Retrospective review of SGS patients treated from 1996 to 2018 at a single institution to assess for 1) V-RQOL association with individual patient cumulative treatment number and 2) V-RQOL correlation with treatment type, time between treatments, and degree of stenosis. Analysis included both parametric and nonparametric statistical comparison across treatment types and multivariable and univariate linear regression.

RESULTS

Sixty-one patients, predominantly white (93%) and female (93%), were included. Etiology of SGS included idiopathic (61%), iatrogenic (16%), granulomatosis with polyangiitis (16%), and other (7%). The plurality of patients had four or more treatments (44%), with the remainder having one (28%), two (13%), or three treatments (15%). Analysis of change between pre- and postoperative V-RQOL scores was completed for 130 treatments. These included dilation with laser incision (52%), in-office injection (34%), dilation without division (8%), cricotracheal resection (1%), and all other treatment (8%). For every 10% improvement in airway caliber postoperatively, there was a 1.3-point improvement in calculated V-RQOL (r = 0.27, P = .02). After adjustment for treatment type, age, sex, and SGS etiology, this association held (beta = 1.5, P = .02). Change in V-RQOL was not associated with treatment type, treatment number, or time between treatments.

CONCLUSION

Patients with subglottic stenosis who have greater degree of change in airway caliber experience greater improvement in V-RQOL scores following treatment. V-RQOL scores are not associated with treatment type or time between individual treatments.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:360-365, 2021.

Best Practice Recommendations for Pediatric Otolaryngology during the COVID-19 Pandemic

Objective

To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic.

Data Sources

Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples.

Methods

Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence.

Conclusions

In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety.

Implications for Practice

The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.

The increasing cost of pediatric otolaryngology care

INTRODUCTION

Defining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery. The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses.

METHODS

A retrospective cohort study using the Kids' Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period.

RESULTS

Of the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%.

CONCLUSIONS

The public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.