Update of the Cincinnati experience in pediatric laryngotracheal reconstruction

Recalcitrant Stenosis Following Pediatric LTR: Contributing Factors and Clinical Impact

OBJECTIVES

Laryngotracheal reconstruction (LTR) has revolutionized the management of pediatric subglottic stenosis (SGS). However, postoperative stenosis remains a difficult hurdle to overcome. Our goal is to determine the clinical impact of recalcitrant stenosis after LTR and the factors contributing to postoperative stenosis.

STUDY DESIGN

Retrospective review of 181 open LTR patients between 2008 and 2021.

SETTING

Stand-alone tertiary children's hospital.

METHODS

Recalcitrant stenosis was defined as new or worsening stenosis despite open LTR. Fisher's exact and Mann-Whitney tests were used to detect differences in categorical and continuous clinical data between patients with and without treatment-resistant stenosis. Time-to-decannulation analysis of both groups was performed using Kaplan-Meier analysis and evaluated with log-rank and Cox proportional hazards regression. Multivariate logistical regression was used to assess the validity of associations found in univariate analysis.

RESULTS

As expected, the 27 patients with postoperative stenosis were less likely to be decannulated (P < .001, Fisher's Exact), more likely to require a postoperative tracheostomy (P < .001, Fisher's Exact) or revision LTR (P < .001, Fisher's Exact) and had prolonged time to decannulation (P < .001, Log-rank). Children with Grade IV SGS (P = .004, Fisher's Exact), and those with longer suprastomal stent duration (P = .03, Fisher's Exact) were more likely to suffer from recalcitrant stenosis. Stent duration longer than 4 weeks (P = .01) contributed to refractory stenosis when controlling for all aforementioned variables using multivariable logistic regression. Interposition grafts had a protective effect (P = .005).

CONCLUSION

Maintaining suprastomal stents over 4 weeks after LTR increases the risk for postoperative stenosis and its sequelae.

LEVEL OF EVIDENCE: 4

Myer-Cotton Grade of Subglottic Stenosis Depends on Style of Endotracheal Tube Used

OBJECTIVES

Determine percentage of subglottic stenosis using current endotracheal tube (ETT) cross-sectional areas as actual, compared with previously published ETT cross-sectional areas as expected, and determine if style of ETT could result in a change in percentage of stenosis or Myer-Cotton grade.

STUDY TYPE

Cross-sectional study.

DESIGN

Prospective analysis.

METHODS

Eight styles of uncuffed pediatric ETT from four manufacturers ranging from 2.0 to 6.0 inner diameter (ID) were evaluated. ID and outer diameter (OD) measurements were obtained from each company's specification sheets. Cross-sectional area was calculated for each ETT using the formula (Area = πr2 ). The cross-sectional areas of each current ETT (actual) were compared with those of previously published ETTs (expected) based on age, and the degree of stenosis was calculated using the formula [1- (Area actual /Area expected )] × 100%. Ranges of percentage for each style of ETT were calculated.

RESULTS

There was an increase in range of OD and area with increasing size of ETT ID, with the largest range in OD being 0.8 mm, and the largest range in area being 10.55 mm2 . The median interquartile range (IQR), range of percentage stenoses was 11 (5%), ranging from 0% to 21%. Seven of 28 (25%) ranges were found to span two Myer-Cotton grades.

CONCLUSIONS

The Myer-Cotton grade of subglottic stenosis depends on the style of ETT used. Using updated values from currently available ETTs aims to keep this grading system valid with respect to surgical approach and outcomes following surgery.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2808-2812, 2023.

Open paediatric laryngotracheal reconstruction: a five-year experience at a tertiary referral centre

OBJECTIVE

Laryngotracheal reconstruction with costal cartilage graft is a cornerstone procedure in treatment of multiple paediatric airway pathologies. The current study aimed to report on the experience of laryngotracheal reconstruction and document post-operative outcomes and complications.

METHOD

Records of laryngotracheal reconstruction procedures performed between 2016 and 2020 were retrospectively reviewed. Primary indication, clinical data, decannulation rate, voice assessment, need for revision surgery and possible complications were analysed.

RESULTS

A total of 41 patients were treated with laryngotracheal reconstruction. Subglottic stenosis formed the largest percentage of cases followed by congenital glottic web (20 and 14 patients, respectively). Three patients (7.3 per cent) underwent single stage surgery, and the remaining cases had a double stage procedure. Revision laryngotracheal reconstruction was needed in a single case, and 38 out of 39 tracheostomised patients were successfully decannulated.

CONCLUSION

Favourable outcomes were reported with costal cartilage laryngotracheal reconstruction as a definitive treatment for a large range of paediatric airway problems.

Clinical effectiveness of treating laryngotracheal stenosis with free hyoid bone reconstruction of the cricoid cartilage: A case series

We reported the free hyoid bone reconstruction of the cricoid cartilage to treat LTS in children. This retrospective case series study included LTS children who underwent hyoid bone separation and T tube implantation. Thirty-four children were included. Twenty-five children were with good outcomes after free hyoid bone reconstruction of the cricoid cartilage. Specifically, the cure rate was 92.8% for the children with mixed stenosis, followed by 63.6% in children with glottis stenosis and 55.6% in children with subglottic stenosis. Free hyoid bone reconstruction of the cricoid cartilage for the management of LTS is feasible, with good outcomes and few complications.

Hybrid laryngotracheal reconstruction vs single and double stage: Indications and outcomes

OBJECTIVES

To describe outcomes from laryngotracheal reconstruction and decannulation rates for patients undergoing single stage, double stage and hybrid staged procedures at a single tertiary care institution and evaluate if the 1.5LTR is a viable reconstructive option for patients with subglottic stenosis.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care otolaryngology specialty hospital and internationally.

SUBJECTS

All patients who underwent LTR by a single pediatric otolaryngology surgeon from 2008 to 2018.

METHODS

Charts were assessed for age, gender, etiology, type of reconstruction, comorbidities, length of stay, tracheostomy status and socioeconomic status. Analysis was performed using Microsoft Excel and multivariate logistic regression models.

RESULTS

96 patients underwent laryngotracheal reconstruction at MEEI. Internationally, 36 patients underwent laryngotracheal reconstruction with the primary surgeon. Overall decannulation rates for ssLTR, dsLTR, and 1.5LTR were 95.6%, 77.8%, and 91.2% respectively. Our Operation Specific Decannulation Rates (one open airway procedure only) for ssLTR, dsLTR, and 1.5LTR were 87.5%, 33%, and 88% respectively. Adjusted odds of decannulation were not significantly different between males and females, white and non-white patients, or socioeconomic status. Neurological comorbidity was statistically significant for a decreased rate of decannulation (p = 0.0216).

CONCLUSION

The 1.5LTR is a viable option for airway reconstruction with strengths derived from both the ssLTR and dsLTR. At our institution we have seen decannulation rates and operation specific decannulation rates with the 1.5LTR approaching our ssLTR. It has replaced the bulk of our dsLTRs, which we reserve for patients that have significant neurological deficits and cannot tolerate extended sedation.

LEVEL OF EVIDENCE

4.

Standardization of Microcomputed Tomography for Tracheal Tissue Engineering Analysis

Tracheal tissue engineering has become an active area of interest among clinical and scientific communities; however, methods to evaluate success of in vivo tissue-engineered solutions remain primarily qualitative. These evaluation methods have generally relied on the use of photographs to qualitatively demonstrate tracheal patency, endoscopy to image healing over time, and histology to determine the quality of the regenerated extracellular matrix. Although those generally qualitative methods are valuable, they alone may be insufficient. Therefore, to quantitatively assess tracheal regeneration, we recommend the inclusion of microcomputed tomography (μCT) to quantify tracheal patency as a standard outcome analysis. To establish a standard of practice for quantitative μCT assessment for tracheal tissue engineering, we recommend selecting a constant length to quantify airway volume. Dividing airway volumes by a constant length provides an average cross-sectional area for comparing groups. We caution against selecting a length that is unjustifiably large, which may result in artificially inflating the average cross-sectional area and thereby diminishing the ability to detect actual differences between a test group and a healthy control. Therefore, we recommend selecting a length for μCT assessment that corresponds to the length of the defect region. We further recommend quantifying the minimum cross-sectional area, which does not depend on the length, but has functional implications for breathing. We present empirical data to elucidate the rationale for these recommendations. These empirical data may at first glance appear as expected and unsurprising. However, these standard methods for performing μCT and presentation of results do not yet exist in the literature, and are necessary to improve reporting within the field. Quantitative analyses will better enable comparisons between future publications within the tracheal tissue engineering community and empower a more rigorous assessment of results. Impact statement The current study argues for the standardization of microcomputed tomography (μCT) as a quantitative method for evaluating tracheal tissue-engineered solutions in vivo or ex vivo. The field of tracheal tissue engineering has generally relied on the use of qualitative methods for determining tracheal patency. A standardized quantitative evaluation method currently does not exist. The standardization of μCT for evaluation of in vivo studies would enable a more robust characterization and allow comparisons between groups within the field. The impact of standardized methods within the tracheal tissue engineering field as presented in the current study would greatly improve the quality of published work.

Platelet-rich plasma for laryngotracheal reconstruction: an experimental study

OBJECTIVES/HYPOTHESIS

This study was designed to evaluate the graft healing effect of topical application of platelet-rich plasma (PRP) for laryngotracheal reconstruction (LTR) in a rabbit model.

STUDY DESIGN

It is a prospective randomized control animal study.

MATERIALS AND METHODS

Sixteen healthy New Zealand White rabbits were assigned to two groups of eight animals each. The control group underwent LTR with anterior auricular cartilage graft. The PRP group underwent the same surgical procedure plus PRP application over the anastomosis and surgical field. Two animals in the PRP group and two animals in control group died due to severe respiratory distress on postoperative days 10, 12, 15, and 18. Six rabbits (n = 3 for control group and n = 3 for PRP group) were sacrificed at 4 weeks, and six rabbits (n = 3 for control group and n = 3 for PRP group) were sacrificed at 8 weeks. Laryngotracheal regions were evaluated histopathologically.

RESULTS

Macroscopically, the average anteroposterior and lateral diameter of the reconstructed region and the degree of lumen patency on postoperative 4th week and 8th week were not statistically different among two groups. There was no significant difference between the groups in terms of any of the microscopic findings when the analysis was made separately. However, analysis of the total number of rabbits has shown that new cartilage formation and angiogenesis were more pronounced in PRP group than control group.

CONCLUSIONS

Application of PRP contributed to better healing in airway surgery by promoting a release of growth factors that stimulate new cartilage formation and angiogenesis.

The Incidence of Laryngotracheal Stenosis in Neonates With a History of Ventilator-Associated Pneumonia

OBJECTIVES/HYPOTHESIS

Neonatal patients requiring prolonged intubation are susceptible to both infection and laryngotracheal stenosis (LTS). This study investigated the effect of ventilator-associated pneumonia (VAP) on the development of LTS in neonates.

STUDY DESIGN

Retrospective case-control study.

METHODS

The incidence of LTS in neonates with VAP was compared with the incidence of LTS in matched intubated controls without VAP. Patients were treated at a tertiary-care medical center from 2004 to 2014. Eligible patient records were assessed for the development of LTS. Demographics, medical comorbidities, infection characteristics, and treatment variables were compared using unpaired t test or χ² test. Statistical significance was set a priori at P < .05.

RESULTS

When comparing the VAP patients with matched non-VAP controls, we found no significant differences in the incidence of LTS (VAP vs. non-VAP, 8.3% vs. 6.7%; P = .73). In subgroup analysis of the VAP cohort, LTS and non-LTS patients demonstrated similar VAP organisms on broncho-alveolar lavage (Klebsiella pneumoniae, Pseudomonas aeroginosa, Escherichia coli, methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae, and Enterobacter). Additionally, within the VAP cohort, LTS and non-LTS patients showed similar gestational age (LTS vs. non-LTS, 31.3 days vs. 28.1 days; P = .22), birth weight (LTS vs. non-LTS, 1.6 kg vs. 1.2 kg; P = .33), and similar intubation duration (LTS vs. non-LTS, 37.8 days vs. 27.5 days; P = .52).

CONCLUSIONS

In this neonatal cohort, VAP was not associated with an increased incidence of LTS. Given severity of the burden of LTS on the healthcare system, multi-institutional longitudinal investigation into contributing risk factors for neonatal LTS is warranted.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:2252-2255, 2020.

Reevaluating a Standardized Sedation Weaning Protocol for Pediatric Laryngotracheal Reconstruction for Continuous Quality Improvement

Importance

Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation.

Objective

Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR).

Design, Setting, and Participants

A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients.

Main Outcomes and Measures

The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission.

Results

The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS.

Conclusions and Relevance

Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.

Structured care to improve outcomes in primary single stage laryngotracheal reconstruction

PURPOSE

To examine single stage laryngotracheal reconstruction (SSLTR) care to reduce complication and failure rate.

METHODS

Forty-five patients that underwent primary SSLTR were examined retrospectively. All had pre-operative direct laryngoscopy and bronchoscopy, esophagoscopy with biopsy and MRSA screening. Pre-operative subglottic stenosis (SGS) grade and associated comorbidities were recorded. Intraoperative graft location and type was documented. Hospital course and results were evaluated and compared to cited literature.

RESULTS

The median age at reconstruction was 2 years (0-15 years). 42.2% were male. 66.7% had gastroesophageal disease and 24.4% a MRSA history. Grade 2 SGS was noted pre-operatively in 37.8% and grade 3 or 4 in 57.7% of patients. Post-surgical hospital course was examined. 77.8% of patients were extubated on planned date. 95.6% of patients had operation specific successful decannulation. Graft type and variations of graft placement as well as MRSA and GERD status didn't affect procedure success rate. Active GERD was related to failure of extubation on planned day (p = 0.02). An abnormal pre-operative swallowing examination was associated with higher complication rates (p = 0.03).

CONCLUSION

Utilizing a more structured approach to SSLTR work-up and addressing potential SSLTR pitfalls may result in higher operation specific decannulation rates. Pre-operative GERD and swallowing dysfunction were associated with higher rates of adverse events.

Reinforced Electrospun Polycaprolactone Nanofibers for Tracheal Repair in an In Vivo Ovine Model

Tracheal stenosis caused by congenital anomalies, tumors, trauma, or intubation-related damage can cause severe breathing issues, diminishing the quality of life, and potentially becoming fatal. Current treatment methods include laryngotracheal reconstruction or slide tracheoplasty. Laryngotracheal reconstruction utilizes rib cartilage harvested from the patient, requiring a second surgical site. Slide tracheoplasty involves a complex surgical procedure to splay open the trachea and reconnect both segments to widen the lumen. A clear need exists for new and innovative approaches that can be easily adopted by surgeons, and to avoid harvesting autologous tissue from the patient. This study evaluated the use of an electrospun patch, consisting of randomly layered polycaprolactone (PCL) nanofibers enveloping 3D-printed PCL rings, to create a mechanically robust, suturable, air-tight, and bioresorbable graft for the treatment of tracheal defects. The study design incorporated two distinct uses of PCL: electrospun fibers to promote tissue integration, while remaining air-tight when wet, and 3D-printed rings to hold the airway open and provide external support and protection during the healing process. Electrospun, reinforced tracheal patches were evaluated in an ovine model, in which all sheep survived for 10 weeks, although an overgrowth of fibrous tissue surrounding the patch was observed to significantly narrow the airway. Minimal tissue integration of the surrounding tissue and the electrospun fibers suggested the need for further improvement. Potential areas for further improvement include a faster degradation rate, agents to increase cellular adhesion, and/or an antibacterial coating to reduce the initial bacterial load.

Systematic review/meta-analysis comparing successful outcomes after single vs. double-stage laryngotracheal reconstruction

OBJECTIVE

To compare operation-specific decannulation rates between single-stage (SSLTR) and double-stage laryngotracheal reconstruction (DSLTR) when controlling for grade of airway stenosis.

METHODS

A systematic review and meta-analysis were performed using PubMed, EMBASE and Cochrane databases from 1970 to 2015 to examine primary SSLTR and DSLTR for subglottic stenosis in patients 18 years or younger. Primary outcome was decannulation or extubation after LTR. Failures included patients not decannulated or requiring additional open airway procedures prior to decannulation. Only studies providing outcomes delineated by airway stenosis grade were included. Non-English language studies and case reports were excluded.

RESULTS

There were 712 abstracts reviewed and 16 studies with 663 pooled patients included in the systematic review analysis. The metaanalysis included 5 studies. Overall, the operation-specific decannulation success was statistically significantly different between SSLTR [93.2% (N = 221)] and DSLTR [83.7% (N = 442)] (P<0.001). When controlling for stenosis severity, however, no difference was found in decannulation success between SS- or DSLTR except in the grade 3 group: Grade 1-100% (N = 6) vs. 100% (N = 6), (P = 1); Grade 2 - 84.9% (N = 106) vs. 83.3% (N = 138), (P = 0.72); Grade 3-80.2% (N = 101) vs. 69.7% (N = 238), (P = 0.03); Grade 4-33.3% (N = 6) vs. 50% (N = 58), (P = 0.67).

CONCLUSION

No difference in decannulation rates was seen between SSLTR and DSLTR when comparing similar grades of stenosis except in grade 3 stenosis. With worsening stenosis, the success rate declines with both methods. Prospective studies with standardized enrollment criteria and reported outcomes are needed to better understand the advantages and disadvantages of each approach.

Accuracy of Magnetic Resonance Imaging for Grading of Subglottic Stenosis in Patients With Granulomatosis With Polyangiitis: Correlation With Pulmonary Function Tests and Laryngoscopy

OBJECTIVE

To compare magnetic resonance imaging (MRI)-based and laryngoscopy-based subglottic stenosis (SGS) grading with pulmonary function testing (PFT) in patients with granulomatosis with polyangiitis (GPA).

METHODS

In this retrospective study, we included 118 examinations of 44 patients with GPA and suspected SGS. All patients underwent MRI, laryngoscopy, and PFT. Stenosis was graded on a 4-point scale by endoscopy and MRI using the Meyer-Cotton (MC) score (score 1: ≤50%, 2: 51-70%, 3: 71-99%, and 4: 100%) and as percentage by MRI. Results were compared with peak expiratory flow (PEF) and maximum inspiratory flow (MIF) from PFT, serving as objective functional reference.

RESULTS

In MRI, 112 of 118 examinations (95%) were rated positive for SGS (grade 1 [n = 82], grade 2 [n = 26], and grade 3 [n = 4]), whereas in laryngoscopy 105 of 118 examinations (89%) were rated positive for SGS (grade 1 [n = 73], grade 2 [n = 24], and grade 3 [n = 8]). MRI and laryngoscopy agreed in 75 of 118 examinations (64%). MRI determined higher scores in 20 examinations (17%) and lower scores in 23 examinations (19%) compared to laryngoscopy. MC scores as determined by both MRI and laryngoscopy showed comparable correlations with PEF (r = -0.363, P = 0.016, and r = -0.376, P = 0.012, respectively) and MIF (r = -0.340, P = 0.024, and r = -0.320, P = 0.034, respectively). The highest correlation was found between MRI-based stenosis grading in percentage with PEF (r = -0.441, P = 0.003) and MIF (r = -0.413, P = 0.005).

CONCLUSION

MRI and laryngoscopy provide comparable results for grading of SGS in GPA and correlate well with PFT. MRI is an attractive noninvasive and radiation-free alternative for monitoring the severity of SGS in patients with GPA.

Potential Role of Growth Factors and Extracellular Matrix in Wound Healing after Laryngotracheal Reconstruction

Laryngotracheal reconstruction (LTR) has been used for more than 20 years to treat infants and children with subglottic stenosis. Results after pediatric LTR have been satisfactory; however, approximately 10% of children have recurrent airway narrowing after LTR. The purpose of our study was to determine whether a correlation existed between specific growth factors and extracellular matrix in patients with adequate wound healing capability as compared with patients with poor wound healing capability. Histologic sections from 27 patients who underwent LTR were cut, and immunohistochemical staining was performed for transforming growth factor-β, platelet-derived growth factor, fibronectin, tenascin, transforming growth factor-α, and vascular endothelial growth factor. Results showed that patients with adequate wound healing capability had a positive correlation with vasculature fibronectin, vasculature tenascin, and stromal fibronectin. Patients with poor wound healing capability had a positive correlation with stromal vascular endothelial growth factor.

Duration of Stenting in Single-Stage Laryngotracheal Reconstruction with Anterior Costal Cartilage Grafts

In single-stage laryngotracheal reconstruction (ss-LTR), the endotracheal tube is used as a stent. The optimal duration of stenting is not known. The stenting period requires a stay in the intensive care unit, as the patient is intubated. Sedation and, rarely, paralysis may be required. An analysis from a prospectively collected database was performed to investigate the effect of length of stenting on the outcome of ss-LTR. The outcomes used were reintubation rate and postoperative tracheostomy rate. Patients with anterior costal graft ss-LTR were selected, as they had undergone similar procedures and have similar stenosis types and grades. In 101 patients, the duration of stenting ranged from 2 to 14 days (mean, 7 days; SD, 2.6 days). No significant correlation was found between the number of days stented and the reintubation rate or the postoperative tracheostomy rate. Patients stented for longer than 1 week were an average of 15 months younger than those stented for less than 1 week; however, the stenosis grades for the two populations were equivalent. The differences in rates of reintubation (p = .68) and postoperative tracheostomy (p = .52) in these 2 groups were not significant. For patients undergoing ss-LTR with anterior costal cartilage grafts, no correlation was found between the number of days stented (intubated) and the reintubation rate or the postoperative tracheostomy rate.

Primary Cricotracheal Resection with Thyrotracheal Anastomosis for the Treatment of Severe Subglottic Stenosis in Children and Adolescents

Severe subglottic stenosis in children is best managed by laryngotracheal reconstruction or cricotracheal resection (CTR). We describe clinical outcomes with CTR and end-to-end anastomosis in pediatric patients with severe subglottic stenosis in a tertiary-care pediatric teaching hospital in Mexico City. We prospectively followed up all consecutive patients younger than 18 years of age with a Myer-Cotton grade 3 or 4 subglottic stenosis who underwent CTR between May 1, 2000, and March 31, 2003. The frequency of each clinical outcome was calculated. Twenty-two patients (16 boys [72.7%] and 6 girls [27.3%]) were included. The mean age at operation was 4.6 years (range, 11 months to 16 years). Eighteen patients (81.8%) required primary CTR, and 4 (18.2%) required extended CTR. Seventeen (77.3%) had grade 3 stenosis, and 5 (22.7%) had grade 4 stenosis. Six (27.3%) had associated clinical conditions, and 3 (13.6%) had associated vocal cord mobility defects. All were tracheostomy-dependent at presentation, and none had undergone previous airway surgery. Ten (45.5%) underwent one-stage surgery, and 12 (54.5%) had a concomitant temporary tracheotomy. No intraoperative complications occurred. Seventeen patients (77.3%) developed postoperative granulation tissue requiring endoscopic resection. The mean follow-up was 1.2 years (range, 2 months to 2.8 years). No deaths occurred. Fifteen children (88.2%) with grade 3 stenosis and 5 (100%) with grade 4 stenosis were decannulated, for an overall decannulation rate of 90.9%. Partial cricoid resection with end-to-end anastomosis has been a feasible procedure with reproducible successful results among our patients. We conclude that CTR performed as a primary procedure is an effective treatment for the management of severe subglottic stenosis in children.

Pediatric Airway Reconstruction: Principles, Decision-Making, and Outcomes at the University of Iowa Hospitals and Clinics

Pediatric airway stenosis challenges the treating surgeon, from the initial evaluation and decision-making process to the final postoperative care and follow-up setting. As our approach to these cases evolves, we must critically evaluate our outcomes in reference to our stated goals. We describe our process in treating this population and critically examine our outcome data from 1990 to the present. Emphasis is placed on selection of procedure and postoperative management.

Laryngotracheal reconstruction in congenital laryngeal webs and atresias

OBJECTIVE: To review the role of open laryngotracheal reconstruction (LTR) in congenital laryngeal webs and atresias.

STUDY DESIGN AND SETTING: A retrospective chart review was undertaken in a specialist otorhinolaryngology unit in an academic tertiary referral paediatric hospital. Twenty-one patients with congenital laryngeal subglottic stenosis (SGS) underwent LTR between 1993 and 2003. Two groups were identified; one group had SGS alone (n = 6) and the other group had SGS associated with a laryngeal web (n = 15). Information recorded included presenting features, classification of lesion, surgery performed, and whether decannulation was achieved.

RESULTS: All grades of stenosis (Myer-Cotton classification) and webs of type 2, 3, and 4 (Cohen's classification) were recorded. Fifteen patients had a staged reconstruction and 6 patients had a single-stage LTR. Complications included 2 revision procedures, 3 tracheocutaneous fistulas, and 1 death (cause unrelated). All appropriate patients were successfully decannulated at between 3 and 18 months post-LTR (median, 5 months).

CONCLUSION: This series illustrates the effective role of open LTR in both congenital SGS alone and that in association with glottic webbing.

Laryngotracheal stenosis of autoimmune aetiology

Autoimmune origin ranks fifth in the etiologic classification of laryngotracheal stenosis. Wegener's disease is the autoimmune illness most associated with stenosis; however, there are other autoimmune diseases that may also be associated with it. A descriptive, retrospective study of 9 cases of laryngotracheal stenosis associated with autoimmune disease was carried out. There were 9 patients (8 females and 1 male) with an average age of 27.9 years. Four of the patients suffered from Wegener's disease, 1 from ulcerative colitis and 1 from purple vasculitis. The other 3 patients only had positive c-ANA. Endoscopic treatment was performed in 3 cases. The other 6 patients required open surgery. Respiratory results were acceptable. Based on our study, we feel that the immunological profiles should be studied in all patients with stenosis, given that not only Wegener's disease is linked to stenosis.

Airway Disease and Management in Bronchopulmonary Dysplasia

This article presents an overview of the diagnosis and management of airway problems encountered in infants with severe bronchopulmonary dysplasia (BPD). Respiratory failure in premature infants develops as a result of parenchymal and airway diseases. The survival of increasingly premature infants and the ventilatory support required by premature lungs may result in airway disease. The management of respiratory failure depends on whether it is primarily caused by parenchymal versus airway diseases. Continuous airway pressure early in the neonatal period has favorably changed the incidence of BPD. This article discusses the indications, timing, and guidelines for care of tracheotomy.

Systemwide change of sedation wean protocol following pediatric laryngotracheal reconstruction

IMPORTANCE

Pediatric laryngotracheal reconstruction (LTR) remains the standard surgical technique for expanding a stenotic airway and necessitates a multidisciplinary team. Sedation wean following LTR is a critical component of perioperative care. We identified variation and communications deficiencies with our sedation wean practice and describe our experience implementing a standardized sedation wean protocol.

OBJECTIVE

To standardize and decrease length of sedation wean in pediatric patients undergoing LTR.

DESIGN, SETTING, AND PARTICIPANTS

Using Institute for Healthcare Improvement (IHI) methodology, we implemented systemwide change at a tertiary care center with the goal of improving care based on best practice guidelines. We created a standardized electronic sedation wean communication document and retrospectively examined our experience in 29 consecutive patients who underwent LTR before (n = 16, prewean group) and after (n = 13, postwean group) wean document implementation.

INTERVENTIONS

Implementation of a standardized sedation protocol.

MAIN OUTCOMES AND MEASURES

Presence of sedation wean document in the electronic medical record, length of sedation wean, and need for continued wean after discharge.

RESULTS

The sedation wean document was used in 92.3% patients in the postwean group. With the new process, the mean (SD) length of sedation wean was reduced from 16.19 (11.56) days in the prewean group to 8.92 (3.37) days in the postwean group (P = .045). Fewer patients in the postwean group required continued wean after discharge (81.3% vs 33.3%; P = .02).

CONCLUSIONS AND RELEVANCE

We implemented a systemwide process change with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean following LTR. Our methodological approach may have implications for other heterogeneous patient populations requiring a sedation wean.

Congenital laryngeal anomalies

Introduction

It is essential for clinicians to understand issues relevant to the airway management of infants and to be cognizant of the fact that infants with congenital laryngeal anomalies are at particular risk for an unstable airway.

Objectives

To familiarize clinicians with issues relevant to the airway management of infants and to present a succinct description of the diagnosis and management of an array of congenital laryngeal anomalies.

Methods

Revision article, in which the main aspects concerning airway management of infants will be analyzed.

Conclusions

It is critical for clinicians to understand issues relevant to the airway management of infants.

Laryngotracheal reconstruction for pediatric glotto-subglottic stenosis

BACKGROUND

The management of pediatric laryngotracheal stenosis (LTS) can be challenging, and laryngotracheal reconstruction (LTR) with cartilage interposition grafting remains the mainstay of surgical treatment for pediatric LTS in most experienced centers. The purpose of this study was to report the results of this procedure in a center where primary cricotracheal resection is frequently performed.

METHODS

A retrospective chart review was performed on 45 patients who underwent LTR in our hospital between October 1997 and July 2012. Demographic characteristics and information on the preoperative status, stenosis, and operation were collected. Primary outcomes were measured as overall (ODR) and operation-specific (OSDR) decannulation rates and secondary outcomes as morbidity, mortality, and postoperative functional results.

RESULTS

ODR and OSDR were 86.7% (39/45) and 66.7% (30/45), respectively. Re-stenosis was observed in 11/45 (24%) patients, all of whom were endoscopically or surgically treated. Revision surgery was performed in 10 patients, 6 for re-stenosis and 2 for peristomial tracheomalacia. Two children died of mucous obstruction of tracheostomy tube at 3 and 6 months postoperatively (4.4%). Respiratory, voice, and swallowing functions were excellent or good in 86, 75, and 84% of patients, respectively.

CONCLUSIONS

LTR for pediatric LTS has high decannulation rates with acceptable morbidity and mortality in selected patients. Most LTR procedures were double-stage for lower grade subglottic stenoses associated with glottic involvement that required stenting. Careful preoperative evaluation and adequate surgical indications are extremely important to achieve high decannulation rates.

Airway stenting with the LT-Mold™ for severe glotto-subglottic stenosis or intractable aspiration: experience in 65 cases

The purpose of this study was to assess the safety and efficacy of stenting in upper airway reconstructions for benign laryngotracheal stenosis (LTS) with a newly designed prosthesis, the LT-Mold™. The LT-Mold and its proper use during open surgery and endoscopy are described, and the experience gathered from a prospectively collected database on 65 patients treated for complex LTS or severe aspiration is reported. This series is compared to the results of other stenting methods. All patients were available for evaluation. In all but one case, the prosthesis was removed at the end of the study. The new prosthesis did not induce any stent-related trauma to the supraglottis, glottis and subglottis. Before adding a distal round-shaped silicone cap to the LT-Mold, granulation tissue was usually seen at the stent-mucosal interface at the tracheostoma level. In 14 cases, there has been a spontaneous extrusion of the prosthesis through the mouth; this problem was solved by fixing the prosthesis through the reinforced portion of the prosthesis at the cap level and by adding one fixation stitch in the supraglottis. We have to document the loss of the silicone cap in three cases. This problem was resolved by designing a new prototype with an integrated cap, glued with a slow hardening silicone glue. Fifty-four (83 %) of 65 patients were decannulated after a mean duration of stenting of 3 months (range 1-12 months). The mean follow-up after decannulation was 23 months (range 1 month to 10 years). The experience gathered with the LT-Mold shows that long-term stenting for complex LTS is safely achieved when the prosthesis is used with its distal integrated silicone cap. The softness and smoothness of the prosthesis with a round-shaped configuration of both extremities help avoid ulceration and granulation tissue formation in the reconstructed airway. Adequate fixation is mandatory to avoid extrusion.

Late complications of nickel-titanium alloy stent in tracheal stenosis

OBJECTIVES/HYPOTHESIS

To investigate and treat the late complications of using nickel-titanium alloy stents in laryngotracheal, bronchial, and esophageal stenosis patients who developed severe laryngotracheal stenosis (SLS).

STUDY DESIGN

Retrospective clinical study.

METHODS

Thirteen patients with SLS or tracheoesophageal fistula secondary to insertion of a nickel-titanium alloy stent for treatment of laryngotracheal, bronchial, or esophageal stenosis treated between May 2004 and March 2010 were retrospectively analyzed. Of the 13 total patients, nine had one stent placed, and four had two stents placed. The late complications observed were glottic and/or subglottic extension of cervical tracheal stenosis (n = 6), new stricture of the thoracic trachea (n = 4), severe left bronchial stricture with massive left pulmonary collapse (n = 1), and cervical tracheoesophageal fistula (n = 2).

RESULTS

Six patients with glottic and/or subglottic to cervical tracheal stenosis underwent successful laryngotracheal reconstruction. Two patients with subglottic and upper thoracic tracheal stenosis were successfully treated by staged operation for the stenosis. Two patients with subglottic and distal thoracic tracheal stenosis are still undergoing treatment. One patient with severe left bronchial stricture and massive left pulmonary collapse has been treated but has not achieved full recovery. One patient with cervical tracheoesophageal fistula underwent successful repair but died later from metastatic disease. One patient with tracheoesophageal fistula died from massive hemorrhage and asphyxiation induced by the stent, which had not been removed.

CONCLUSIONS

The nickel-titanium alloy stents should be used with extreme caution in patients with laryngotracheal, bronchial, or esophageal stenosis treatment that can be corrected by surgical therapy.

Thyroid Alar Cartilage Graft Laryngotracheal Reconstruction in Adults

Objective. To assess the outcomes of laryngotracheal reconstruction using thyroid alar cartilage grafting in adult patients with laryngotracheal stenosis.

Study Design. Case series with chart review.

Setting. Tertiary university hospital.

Subjects and Methods. Twelve adults who underwent thyroid alar cartilage graft laryngotracheal reconstruction from April 1997 to April 2009 for laryngotracheal stenosis were analyzed. The mean age of the study population was 29 years. Using the Myer-Cotton grading system, 3 patients had grade II stenosis, 7 had grade III, and 2 had grade IV. Seven of the 12 patients had subglottic stenosis, 3 had tracheal stenosis, and 2 had subglottic and upper tracheal stenosis.

Results. Nine of 12 (75%) patients were decannulated. Of the patients in whom laryngotracheal reconstruction failed, 2 had grade IV stenosis and 1 had severe grade III stenosis with a long segment of stenotic tissue. The postoperative complications were hematoma of the left laryngeal ventricle at the donor site in 1 patient, granulation tissues in the supraglottic and suprastomal region and at the graft site in 4 patients, and neck wound infection in 1 patient. Ossification of the thyroid alar cartilage was observed in 2 patients. A T-tube remained in situ for 6 to 18 months.

Conclusion. Laryngotracheal reconstruction with thyroid alar cartilage graft could be a viable alternative for the treatment of laryngotracheal stenosis in adults. However, it should be used only in cases of limited and minor subglottic or tracheal stenosis.

Laryngotracheoplasty to avoid tracheostomy in neonatal and infant subglottic stenosis

OBJECTIVE

To outline the authors' experiences with performing laryngotracheoplasty as an alternative to tracheostomy in neonates and infants with symptomatic subglottic stenosis (SGS).

STUDY DESIGN

Case series with chart review.

SETTING

A tertiary referral pediatric hospital.

SUBJECTS AND METHODS

Patients younger than 12 months undergoing single-stage laryngotracheoplasty for SGS at the authors' institution over a 3-year period.

RESULTS

Ten patients (8 boys and 2 girls) underwent single-stage laryngotracheoplasty during the study period. There were 9 cases of acquired SGS and 1 case of congenital SGS. Eight patients had grade III SGS, and 2 patients had grade II SGS. In 9 of 10 patients, the procedure performed was an anterior cricoid split (ACS) and posterior cricoid split (PCS), with the placement of an anterior thyroid ala cartilage graft. One patient underwent ACS and PCS with the placement of a posterior rib cartilage graft, in combination with a right vocal cord lateralization. The mean period of intubation after surgery was 6.8 days (range, 5-9 days). Nine of 10 patients had a complete resolution of their airway symptoms following airway surgery, with a mean duration of follow-up of 305 days (range, 30-780 days). One patient required the placement of a tracheostomy tube 69 days postoperatively due to a failure to wean from ventilation in the setting of multiple comorbidities.

CONCLUSION

Laryngotracheoplasty is a safe and effective alternative to long-term tracheostomy in infants and neonates with symptomatic SGS.

[The risks of autogenous cartilage grafting in laryngotracheal reconstruction in adults]

BACKGROUND

Laryngotracheal reconstruction with autogenous rib cartilage graft has become a well established surgical method for the repair of subglottic and glottic laryngotracheal stenoses in infants and children. There are far fewer reports on the application of this method in adult patients. In particular, detailed observations of the healing behaviour of autogenous adult rib cartilage grafts are lacking.

MATERIAL AND METHOD

The course of disease in five adult female patients (age 25-47 years) who underwent one- or two-stage laryngotracheal reconstruction with rib cartilage grafts are reported.

RESULTS

Primary healing was observed in the youngest patient (25 years) only. In the other four patients the cartilage graft had to be partly removed 4-6 weeks postoperatively due to partial necrosis, followed by open wound treatment. As a result of these measures a sufficiently large laryngotracheal lumen could be achieved in all cases.

DISCUSSION

Partial ossification of the adult rib cartilage was considered the reason for the observed healing difficulties. Endoscopic follow-up showed that epithelialization of the free endolaryngeal surface of the cartilage graft, i.e. graft healing, takes at least 3 months. Therefore, close endoscopic follow-up during this period appears indispensable.

Scaffold-free tissue-engineered cartilage implants for laryngotracheal reconstruction

OBJECTIVES/HYPOTHESIS

Donor site morbidity, including pneumothorax, can be a considerable problem when harvesting cartilage grafts for laryngotracheal reconstruction (LTR). Tissue engineered cartilage may offer a solution to this problem. This study investigated the feasibility of using autologous chondrocytes to tissue-engineer scaffold-free cartilage grafts for LTR in rabbits to avoid degradation that often arises from an inflammatory reaction to scaffold carrier matrix.

STUDY DESIGN

Animal study.

METHODS

Auricular cartilage was harvested from seven New Zealand white rabbits, the chondrocytes expanded and loaded onto a custom-made bioreactor for 7 to 8 weeks to fabricate autologous scaffold-free cartilage sheets. The sheets were cut to size and used for LTR, and the rabbits were sacrificed 4, 8, and 12 weeks after the LTR and prepared for histology.

RESULTS

None of the seven rabbits showed signs of respiratory distress. A smooth, noninflammatory scar was visible intraluminally; the remainder of the tracheal lumen was unremarkable. Histologically, the grafts showed no signs of degradation or inflammatory reaction, were covered with mucosal epithelium, but did show signs of mechanical failure at the implantation site.

CONCLUSIONS

These results show that autologous chondrocytes can be used to fabricate an implantable sheet of cartilage that retains a cartilage phenotype, becomes integrated, and does not produce a significant inflammatory reaction. These findings suggest that with the design of stronger implants, these implants can be successfully used as a graft for LTR.

Laryngotracheal reconstruction with posterior costal cartilage grafts: Outcomes at a single institution

Objective: To describe our outcomes after laryngotracheal reconstruction that required posterior costal cartilage grafting focused on decannulation rates and complications.

Study Design: Case series with chart review.

Subjects and Methods: Charts were reviewed on 58 patients. Operation specific and overall decannulation rates were determined. Complications were reviewed and correlated with technique of graft placement. Available voice outcomes were reviewed.

Results: Forty-eight patients were included. There was no statistically significant correlation between degree of stenosis and rate of decannulation. The overall decannulation rate, regardless of number of surgeries performed, was 96 percent. The relative risk for complications was higher among children who had a sutured versus a sutureless flanged posterior graft (RR = 2.5, P < 0.01). The most common voice anomaly was supraglottic compression.

Conclusions: Operation-specific decannulation rates are not significantly different with increasing disease severity, although the power to detect small differences in this study is low. Sutureless graft placement is associated with a lower complication rate. Supraglottic compression is a common postoperative compensatory vocal behavior and may correlate with disease severity.

Cricotracheal resection

A surgeon facing the problem of a child with subglottic stenosis currently has a wide range of surgical options. Cricotracheal resection is the preferred option for grade IV and severe grade III stenoses that are clear of the vocal cords. Laryngotracheal reconstruction as a less extensive procedure is preferred for some grade II and less severe grade III stenoses. Stenosis close to the vocal cords remains a challenge and can be treated by extended partial cricotracheal resection. Pediatric surgeons and otolaryngologists should learn carefully the technique of partial cricotracheal resection for use in infants and children to achieve better results than with laryngotracheal reconstructions.

Role of spiral computed tomography with 3-dimensional reconstruction in cases with laryngeal stenosis--a radioclinical correlation

PURPOSE

To study the efficacy of spiral computed tomography with 3-dimensional reconstruction (SCT-3DI) and endoscopy in cases with laryngeal stenosis with regard to site, type, grade, and length of stenosis and to determine the correlation among the findings of SCT-3DI, endoscopy, and surgery.

MATERIAL AND METHODS

This prospective study on 30 cases of laryngotracheal stenosis (acquired = 28 cases, congenital = 2 cases) was conducted in the Department of Otorhinolaryngology and Head Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, from 2001 to 2003. All patients were evaluated by SCT-3DI and rigid endoscopy. Twenty-three patients underwent open surgical procedure, and 7 patients underwent endoscopic dilatation. Correlation was established among the findings of SCT-3DI, endoscopy, and surgery by Pearson correlation coefficient (r), paired t test, and chi(2) test.

RESULTS

Findings of SCT-3DI, endoscopy, and surgery were found to well correlate with each other. SCT-3DI was found to be less accurate in measuring the exact length of stenosis but could measure the length of stenosis in all cases, whereas by endoscopy, the measurements could be made accurately in 14 cases (46.6%). The endoscopy was more accurate in diagnosing the site and grade of stenosis (P < .01). SCT-3DI gave 18.6% false-positive result regarding involvement of glottis in stenosis. A significant difference was found between endoscopy and SCT-3DI for grade III and IV stenoses (P < .01), and SCT-3DI found to give false-positive result in 19.2% cases for grade IV stenosis. SCT-3DI was found to be a better diagnosing modality in differentiating the circumferential Gupta and Parida. SCT-3DI was found to give a false-positive result in 19.2% cases for grade IV stenosis. SCT-3DI was found to be better a diagnosing modality in differentiating the circumferential and eccentric stenosis (P < .01) and to detect the cricoid and thyroid cartilage fracture, double stenosis, and laryngocele. A false-positive rate of 33.3% was seen in diagnosing fracture of cricoid cartilage on radiology.

CONCLUSION

The findings of SCT-3DI, endoscopy, and surgery well correlated with each other. Findings of SCT-3DI and rigid endoscopy are complementary to each other for a better surgical planning and outcome.

Radiologic and histologic characterization of silk fibroin as scaffold coating for rabbit tracheal defect repair

OBJECTIVES: To explore the feasibility of silk fibroin as a biomaterial coating used in tracheal defect reconstruction.

METHODS: Silk fibroin was subcutaneously embedded in three rabbits and as an artificial implant material coating to reconstruct 12 rabbits' tracheal defects. The postoperative radiologic and histologic characterization was summarized.

RESULTS: The thickness of the fibroblasts layer covering the porus and nonporus silk fibroin film was 240.4 ± 9.9 and 302.3 ± 10.5 μm, respectively, and there was no statistical difference ( P < 0.05) within each group. There was no foreign-body granuloma or macrophagocyte infiltration around the silk film. The tracheal reconstruction study showed a normal mucous membrane with normal cilial growth on the artificial implant and no visible granulation tissue in the reconstructed tracheal cavity.

CONCLUSIONS: Silk fibroin is a potential new biomaterial coating for tracheal defect reconstruction. The mechanism of silk fibroin appears to promote tracheal mucous membrane, which may be related to its molecular structure and biology.

Upper airway dimensions in children using rigid video-bronchoscopy and a computer software: description of a measurement technique

BACKGROUND

Pediatric airway management decisions are based primarily on results derived from indirect measures of laryngeal and tracheal dimensions. More recent methods could provide more direct information about absolute and relative changes in airway dimensions associated with growth and development.

STUDY OBJECTIVES

The aims of this study were (i) to determine whether a 'video-bronchoscopic' measurement method could be used to reliably measure airway dimensions in children and (ii) to provide a preliminary assessment of dimensions of the glottis and cricoid in children of various ages.

METHODS

Following approval from the institutional review board, validation experiments were performed to determine whether measurements obtained from the video image from the bronchoscope provided accurate measurements of tubular objects of known dimensions. The reliability of the measurements was determined by using two independent trained observers to measure video-bronchoscopic images of the larynx at the level of the glottis and the cricoid in 11 children. The observers measured the video-bronchoscopic images and airway measurements were obtained in 16 additional children to determine the utility of the measurement method.

RESULTS

There was good agreement between the direct and video-bronchoscopic measurement techniques (Bland and Altman plot) for both the cross-sectional area (CSA) and the diameter of objects. The interobserver measures for cricoid and glottis were reproducible as indicated by the concordance correlation coefficient (CCC) for cricoid anteroposterior diameter (CCC = 0.98, r = 0.98, accuracy = 0.99) and transverse diameter (CCC = 0.93, r = 0.8, accuracy = 0.99) as well as for the glottic anteroposterior diameter (r = 0.8, accuracy = 0.8, CCC = 0.6) and the glottic transverse diameter(r = 0.8, accuracy = 0.74, CCC = 0.6). Overall, for the 27 children studied [mean age 73 months (+/-24.7, range 30-140], the mean value of the cricoid CSA [45.3 mm(2) (+/-13.9)] was found to be greater than the glottic CSA [16.2 mm(2) (+/-10.1)].

CONCLUSIONS

The video-bronchoscopic imaging method provided an accurate, reliable measure of pediatric airway dimensions. This technique could be applied to assess absolute and relative airway size associated with growth and development. The relationship between glottic and cricoid dimensions during growth and development in children needs further investigation across various age groups.

Electrocautery versus 23% NaOH infiltration to induce subglottic stenosis in a canine experimental model

Subglottic stenosis (SGS) is defined as the narrowing of the lower larynx. Difficulties in the management of subglottic stenosis, especially in the pediatric population, justify the development of experimental models. The objective of this study was to compare the two methods of experimental subglottic stenosis induction. Twenty-three dogs were randomly selected and assigned by lottery to either one of the two groups: Gp I (n = 10) of electrocoagulation; and Gp II (n = 13) of 23% NaOH injection. In Gp I, self-interruption electrocoagulation was applied to one point in each of the four quadrants of the cricoid cartilage. In Gp II, 0.2 ml of 23% NaOH was injected in the submucosal layer in the anterior and posterior portions of the cricoid cartilage. Once a week, endoscopy was performed and the caliber of the subglottic region was measured using endotracheal tubes, and the injection was repeated if there were no signs of subglottic stenosis. The animals were killed on day 21; animals that developed respiratory distress were killed before day 21. One animal in Gp I died on day 14 after the injection and during transportation; two animals in Gp II died, one on day 7 due to a tracheoesophageal fistula, and the other of unknown causes on day 5. Significant subglottic stenosis (over 51% obstruction) was found in 67% of the animals in Gp I and in 64% of those in Gp II (P = 0.99). Median time to development of significant stenosis was 21 days in both groups, and required either two or three injections. Mean time for the performance of the procedures was significantly shorter (P < 0.01) in Gp I (mean: 6.36 min) than in Gp II (mean: 14.88 min). Electrocoagulation and 23% NaOH injection in the subglottic region were effective in the development of significant subglottic stenosis in dogs, both methods leading to stenosis in the same period of time and after the same number of procedures. However, electrocoagulation was the fastest method.

Hyaluronan-based scaffolds to tissue-engineer cartilage implants for laryngotracheal reconstruction

OBJECTIVES

Donor site morbidity, including pneumothorax, can be a considerable problem when harvesting cartilage grafts for laryngotracheal reconstruction (LTR). Tissue-engineered cartilage may offer a solution to this problem. This study investigated the feasibility of using Hyalograft C combined with autologous chondrocytes to tissue engineer cartilage grafts for LTR in rabbits.

STUDY DESIGN

Animal study.

METHODS

Eighteen New Zealand white rabbits underwent LTR: 12 rabbits received autologous tissue-engineered cartilage grafts and 6 animals, serving as a positive control group, native auricular cartilage. To determine any differences in response to the site of implantation and any potential immune response to the scaffold, a second piece of engineered neocartilage and a non-cell-loaded scaffold were inserted paralaryngeally into a subset of the rabbits. The rabbits were sacrificed 3, 6, 8, 10, and 12 weeks after the LTR and their larynx examined.

RESULTS

None of the 18 rabbits showed signs of respiratory distress. A smooth, noninflammatory scar was visible intraluminally. Histologically, the native auricular cartilage implants showed excellent integration without any signs of inflammation or cartilage degradation. In contrast, all tissue-engineered grafts and empty scaffolds revealed marked signs of an unspecific foreign body reaction, leading to a complete degradation of the neocartilage, whether implanted para- or intralaryngeally.

CONCLUSION

In contrast to the success with which Hyalograft C has been applied in articular defect repair, our results indicate that, in rabbits, Hyalograft C initiates a foreign body reaction if implanted intra- or paralaryngeally, leading to cartilage degradation and possible graft failure. These findings suggest limitations on the environment in which Hyalograft C can be applied.

Airway stenting with the LT-Mold: experience in 30 pediatric cases

OBJECTIVES

The purpose of this study was to assess the safety and efficacy of stenting in upper airway reconstructions for benign laryngotracheal stenosis (LTS) with a newly designed prosthesis, the LT-Mold.

MATERIAL AND METHODS

The LT-Mold and its proper use during open surgery and endoscopy are described, and the experience gathered from a prospectively collected database on 30 pediatric patients treated for complex LTS or severe aspiration is reported. This series is compared to the results with other stenting methods.

RESULTS

From the 30 patients, 24 were available for evaluation. In six cases, the prosthesis was still in place. In no patient did the prosthesis induce any pressure necrosis or granulation tissue formation in the supraglottis and glottis. Before adding a distal round-shaped silicone cap to the LT-Mold, some granulation tissue was seen at the upper margin of the tracheostoma. One prosthesis extrusion and loss of the silicone cap in three cases have to be reported. Twenty-one of 24 patients were decannulated after a mean duration of stenting of 3 months (range 1-12 months). The mean follow-up after decannulation was 1.5 years.

CONCLUSION

The early experience with the LT-Mold shows that long-term stenting for complex LTS is safely achieved when the prosthesis is used with its distal cap. The softness and smoothness of the prosthesis with a round-shaped configuration of both of its extremities help avoid ulceration and granulation tissue formation in the reconstructed airway. Adequate fixation is mandatory to avoid extrusion.

The Feasibility of Ultrasound to Assess Subglottic Diameter

BACKGROUND

In healthy patients, the narrowest diameter of the subglottic upper airway is the width of the air-column at the level of the cricoid cartilage. This diameter governs the selection of the endotracheal tube size, as excessive tube diameter may damage the tracheal mucosa leading to postextubation stridor or subglottic stenosis. Unfortunately, selecting endotracheal tube size based on height, weight, or age does not reliably lead to the proper tube. The knowledge of airway diameter, especially using a bedside noninvasive tool, could therefore be helpful in anesthesia and intensive care.

METHODS

We studied 19 healthy volunteers (27 +/- 3 yr, nine females) to compare the transverse diameter of the cricoid lumen assessed by ultrasonography and magnetic resonance imaging.

RESULTS

We found a strong correlation between the two techniques (r = 0.99, P < 0.05) confirmed by Bland-Altman analysis with a bias of 0.14 mm, a precision of 0.33 mm, and limits of agreement of -0.68 mm/0.96 mm.

CONCLUSION

In young healthy adults, ultrasonography appeared to be a reliable tool to assess the diameter of the subglottic upper airway.

[Our results in surgical treatment of laryngotracheal stenosis--ten years experience]

INTRODUCTION

There are numerous techniques for the treatment of laryngotracheal stenosis. The aim of this paper was to present surgical techniques and results of treatment of laryngeal and laryngotracheal stenosis in a ten-year period by retrospective analysis.

MATERIAL AND METHODS

Medical records of 34 patients (17 male and 17 female) surgically treated for laryngeal or laryngotracheal stenosis between 1995 and 2004 were analyzed. 19 (55.9%) patients had previous surgical procedures, whereas fifteen patients (44.1%) were diagnosed and treated for the first time.

RESULTS

5 patients had a glottic-subglottic stenosis, 11 patients had a subglottic stenosis, 16 patients had subglottic-tracheal stenosis and 2 patients had a glottic-subglottic-tracheal stenosis. 21 patients had normal vocal cord motion, 8 patients showed unilateral vocal cord fixation, and 5 had bilateral vocal cord fixation. Laryngotracheoplasty with anterior-posterior costal cartilage graft was performed in 24 patients, while single stage segmental laryngotracheal resection of the stenotic part was performed in 8 patients. One patient was operated in direct laryngomicroscopy and one with dilatation of the stenotic segment with T tube insertion. The most common complication was the development of granulation due to use of the Montgomery T-tube which was removed in direct laryngomicroscopy. Except for one patient, 33 (97%) patients were decannulated. There was no perioperative mortality.

CONCLUSION

Although laryngotracheoplasty with anterior-posterior costal cartilage graft placement cannot be used in all cases of laryngotracheal stenosis, it was the method of choice in previously operated patients with segmental resection of the stenotic segment. This method requires use of Montgomery T-tube or anesthesiological tube, which is very hard to keep clean. Better recovery, short hospitalization and excellent results were obtained with the cricotracheal segmental resection.

Evaluation and management of upper airway disorders in children

Upper airway disorders in children may be divided into those that are congenital in origin and those that are acquired. The presentation and management of these disorders is significantly influenced both by the anatomic location of the pathology, which is usually obstructive in nature, and by the severity of the obstruction. This discussion provides an overview of the presentation, diagnosis, management, and potential complications of the most commonly seen upper airway disorders. These disorders are presented within an anatomic framework, progressing from proximal at the nares to distal at the carina.