Transcervical Epiglottopexy: A versatile technique for managing epiglottic prolapse

OBJECTIVE

Epiglottic prolapse (EP) presents a unique management challenge. The objective of the present case series is to present clinical outcomes using a novel technique of transcervical epiglottopexy (TCE) in etiologically diverse cases of EP and to discuss the evolution of the surgical technique with technical modifications to optimize the surgical procedure.

STUDY DESIGN

A retrospective case series review.

SETTING

Tertiary care academic setting.

METHODS

Pediatric cases with EP over a 3-year period. Demographic data including age, sex, presenting symptoms, operative details, and polysomnographic indices were collected.

RESULTS

A total of 18 patients with a mean age of 48.88 ± 37.3 months underwent TCE. Sixty-seven percent of patients had high-grade EP (grades 3 and 4). A previous endolaryngeal epiglottopexy had been performed in 5 (28%) patients. Fourteen (78%) patients had a concurrent airway procedure performed including 4 undergoing single-stage laryngotracheal reconstruction. The mean suspension time only for the TCE part ranged from 8 to 17 minutes with a mean of 11.23 ± 3.4 minutes. A stable EP defined as a healed glossoepiglottic adhesion was achieved in all but 1 case with an overall success rate of 95%. All cases with previous failed endoscopic epiglottopexy had a stable epiglottopexy. No immediate complications were noticed. Among the late complications, the most common was the formation of granulation tissue at the site of silastic disc placement which was seen in 3 patients.

CONCLUSION

TCE using an exo-endolaryngeal technique can achieve stable epiglottopexy in children with EP and can be adapted for any kind of EP.

Single stage pediatric airway reconstruction in solid organ transplant recipients

OBJECTIVES

To describe results of single stage laryngotracheal reconstruction (ssLTR) in patients with solid organ transplants and to discuss modifications which need to be considered in this subset of patients pre-operatively, intra-operatively and post-operatively.

STUDY DESIGN

We performed a retrospective case series review of children undergoing single stage laryngotracheal reconstruction in the context of prior solid organ transplant.

SETTING

A tertiary care academic setting.

METHODS

Pediatric cases undergoing Laryngotracheal reconstruction over a 3-year period. Demographic data including age, sex, presenting symptoms, operative details.

RESULTS

Two cases of ssLTR in solid organ transplant patients were found, one each with renal and cardiac transplants respectively. Both patients successfully underwent ssLTR for Grade 2 subglottic stenosis. The care of these patients was multidisciplinary and required alterations in their preoperative prophylactic antibiotics. While they did not require changes to the LTR post-operative sedation protocol, their immunosuppressant doses and target ranges were lowered. Special care was taken to avoid nephrotoxic and cardiotoxic medications throughout their hospital stay.

CONCLUSIONS

Although traditionally considered for double stage laryngotracheal reconstruction, single stage laryngotracheal reconstruction is a viable option in patients with solid organ transplant. These patients require a multidisciplinary approach and pharmacological protocol alterations pre-, intra-, and post-operatively.

Extended External Rhinoplasty Approach For Nasal Dermoids With Intracranial Extension

We present an extended external rhinoplasty approach with bilateral marginal and alar base incisions for removal of a nasal dermoid cyst with intracranial extension in a 3-year-old patient. This approach provides adequate exposure, enables nasal bone osteotomies, and allows access to the skull base while achieving a cosmetically acceptable scar. Laryngoscope, 133:2798-2802, 2023.

Preoperative Transfusion in Sickle Cell Disease Children Undergoing Adenotonsillectomy

Objective

To perform a systematic review and meta-analysis comparing two pre-operative transfusion regimens (conservative versus aggressive) in children with sickle cell disease(SCD) undergoing adenotonsillectomy in terms of post-operative complications, complications related to SCD and transfusion related complications.

Data Sources and Review Methods

A literature review was performed through PubMed, EMBASE, Cochrane, and Ovid databases using the following phrases: (Adenotonsillectomy OR Tonsillectomy) AND (Sickle Cell Disease OR Sickle Cell Trait). Using predetermined inclusion and exclusion criteria, seven articles were selected for systemic review and two control trials were included in meta-analysis.

Results

Out of a total of 3,146 results, seven articles were selected for review and two controlled trials were included in the meta-analysis. There was no statistically significant difference in the rate of primary and secondary hemorrhage between the aggressive and conservative transfusion regimens (RR = 3.1, CI = 0.84-11.4, p-value = 0.089). The rate of sickle cell disease related complications including vaso-occlusive crisis and acute chest syndrome was also not statistically significant between the two transfusion groups (RR = 1.4, CI = 0.7-2.8, p-value = 0.339). Even though, the transfusion related complications did not reach statistical significance, there was a higher complication rate in the group receiving aggressive blood transfusion.

Conclusion

In SCD children undergoing adenotonsillectomy, an aggressive transfusion regimen that focuses on reducing the Hemoglobin S ratio to below 30% has not been shown to be more effective in reducing post-operative complications when compared to a conservative transfusion regimen. Therefore, it is reasonable to utilize a conservative transfusion regimen, thereby reducing the transfusion-associated risks.

Endoscopic Versus Open Surgical Intervention for Congenital Laryngeal Webs: A Systematic Review and Meta-Analysis

OBJECTIVES

To examine and compare the outcomes of various surgical interventions for congenital laryngeal webs in terms of avoidance of tracheostomy, rate of decannulation, web recurrence, revision surgery, and mortality in children.

DATA SOURCES

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was conducted on December 10, 2021, using a comprehensive search in PubMed, Web of Science, Cochrane library, and Embase with no date restriction.

REVIEW METHODS

Articles on surgical intervention for congenital laryngeal webs in pediatric (<18 years) patients were included in the analysis. Articles including acquired laryngeal webs, no surgical intervention, or exclusively adult population were excluded.

RESULTS

9027 articles were reviewed, 24 articles met the inclusion criteria and 126 patients were included. In patients with Grades I and II webs, there was no significant difference in rates of tracheostomy or decannulation, between endoscopic (100%) versus open approach (100%). For Grades III and IV webs, 96% of patients who received open surgery were decannulated or avoided tracheostomy compared to 84% of those managed endoscopically (p = 0.081). There were significantly lower rates of revision surgery in the open group compared to the endoscopic group (77.8% vs 30.9%, p = 0.008).

CONCLUSION

This study showed no difference in rates of tracheostomy, decannulation, web recurrence, revision, or mortality between endoscopic and open approaches for the treatment of Grades I and II webs. For Grades III and IV, open surgical techniques achieved a lower revision rate. Results should be interpreted in light of associated increased morbidity with open procedures.

Optimal laser usage improves surgical efficiency in pediatric supraglottoplasty

OBJECTIVES

To compare patient specific and surgical efficiency outcomes in children undergoing supraglottoplasty (SGP) with flexible fiber CO2 laser in Ultrapulse mode versus cold steel at a tertiary care center.

METHODS

A single surgeon retrospective cohort study of pediatric patients with laryngomalacia undergoing SGP without concomitant or prior airway surgery. We reviewed perioperative complications, total hospital stay including intensive care admission, symptom resolution and the need for revision surgery. Surgical efficiency was measured as the mean total operative time and laryngeal suspension time.

RESULTS

Among 63 patients, 32 cold steel SGPs were compared with 31 flexible fiber CO2 Ultrapulse laser SGPs. There was no statistical difference in the demographic profile. There was no statistical difference in need for intraoperative resuscitation (1 [3.0%] vs 0 [0%] cases) or perioperative intubation (4 [12.1%] vs 2 [6.3%] cases), mean total days in ICU (1.09 [0.51] vs 1.06 [0.44] [p = 0.38]) or days hospitalized (1.73 [1.67] vs 1.62 [2.27] [p = 0.42]), symptom resolution, need for revision surgery (2 [6.3%] vs 0 [0%] [p = 0.49] patients) or mean operative time (29.0 [14.19] vs. 32.2 [22.71] [p = 0.95] minutes). There was a statistically significant decreased time in laryngeal suspension in the laser group versus cold steel group (5.9 [1.80] vs 7.9 [2.19] [p = 0.006] minutes).

CONCLUSION

For pediatric SGPs, optimal flexible fiber CO2 laser usage can improve surgical efficiency in comparison to cold steel, with no differences in postoperative outcomes or complications. Both the flexible fiber CO2 laser and cold steel SGPs are safe and effective methods for treatment of laryngomalacia.

Case Report: Ultrasound Guided Mucosal Fold Lateralization for Laryngeal Webs

The surgical management of Laryngeal webs is challenging and is associated with a high recurrence rate due the presence of opposing raw mucosal surfaces of the vocal cords, especially near the anterior commissure which causes re-scarring. We describe an endoscopic technique of mucosal flap lateralization (MFL) with ultrasound guidance, which prevents the apposition of the anterior raw surfaces of the vocal cords after web incision, thus avoiding recurrence.

Transcervical Epiglottopexy for the Management of Type 3 Laryngomalacia

Type 3 laryngomalacia (LM) is characterized by prolapse of the epiglottis into the airway. Endolaryngeal suturing is technically challenging considering the limited exposure. In the present article, we describe a simple technique of transcervical epiglottopexy (TE) via an exo-endolaryngeal technique using an 18-G needle prethreaded with a 2-0 Prolene suture in a looped fashion inserted through the inferior epiglottis. Another 20-G needle with a 2-0 Prolene suture with one free end is inserted above the previous stitch through the superior epiglottis. The single stitch is passed through the looped stitch, which is then pulled through the neck, leaving a single stitch precisely placed through the epiglottis. We have used this technique safely while achieving epiglottopexy in 3 cases of epiglottic prolapse. We describe a method of TE using easily available instruments. This method we believe can easily be adapted for any kind of epiglottic prolapse.

Surgical Management of Bilateral Vocal Fold Paralysis in Children: A Systematic Review and Meta-analysis

OBJECTIVES

To examine and compare the outcomes of various types of glottic widening surgery (GWS) for initial management of bilateral vocal fold paralysis (BVFP) in children, the outcomes of different GWS procedures in children who underwent initial tracheostomy, and the rate of decannulation in children who underwent tracheostomy alone versus tracheostomy followed by GWS.

DATA SOURCES

PubMed, Web of Science, Cochrane Library, and Embase were searched following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) on September 9, 2019, with no date restriction.

REVIEW METHODS

Articles focusing on GWS or tracheostomy for initial management of BVFP were included. Articles describing patients who received no surgical intervention for BVFP were excluded.

RESULTS

A total of 5989 articles were reviewed: 67 articles met inclusion criteria, and 240 patients were incorporated into the analysis. Patients who underwent primary GWS had an eventual tracheostomy rate of 6.0% (5/83). There were no statistically significant differences in the rate of tracheostomy, reoperation, or mortality among cricoid split, suture lateralization, and cordectomy/cordotomy. Patients who underwent primary tracheostomy failed to achieve decannulation in 36.9% (58/157) of cases. Decannulation was more likely in tracheostomized children who received GWS than those who did not (odds ratio, 6.336; P < .0001).

CONCLUSIONS

Most children who undergo primary GWS for BVFP avoid tracheostomy or reoperation. These data demonstrated no differences in surgical outcomes among the most common types of GWS for BVFP. For children who receive a tracheostomy as their first intervention for BVFP, GWS is associated with a significantly improved rate of decannulation.

Swallowing outcomes after pediatric epiglottopexy

INTRODUCTION

Persistent sleep apnea following tonsillectomy and adenoidectomy in children requires additional evaluation. One of the common areas of persistent upper airway obstruction in these children is the base of the tongue and lingual tonsils as well as epiglottic prolapse. Depending on the site of obstruction on sleep endoscopy or a cine MRI, surgical procedures include base of tongue reduction and lingual tonsillectomy with or without epiglottopexy.

OBJECTIVE

To assess the swallowing outcomes in children undergoing epiglottopexy with lingual tonsillectomy.

METHODS

A retrospective case series review of children undergoing epiglottopexy with or without lingual tonsillectomy. All patients underwent an epiglottopexy with lingual tonsillectomy using coblation. A detailed evaluation including a sleep study, sleep endoscopy, and thorough swallowing assessment preoperatively as well as postoperatively was performed.

RESULTS

Five children underwent epiglottopexy with lingual tonsillectomy for obstructive sleep apnea. Epiglottopexy improved sleep apnea with Apnea Hypopnea Index (AHI) falling significantly from 4.6 to 0.5 (p < 0.05). All patients had a normal swallowing assessment postoperatively with functional endoscopic evaluation of swallowing (FEES) revealing no evidence of aspiration and penetration.

CONCLUSION

In our case series epiglottopexy with lingual tonsillectomy is a safe and effective technique, which improves sleep apnea in pediatric patients. It does not affect the swallowing mechanism, and the epiglottis still retains the laryngeal protective role.

Endoscopic management of a prolapsed posterior costal cartilage graft in laryngotracheal reconstruction

Laryngotracheal reconstruction is the standard of care for management of high grade pediatric laryngotracheal stenosis. One of the complications of a reconstruction with a posterior costal cartilage graft is graft prolapse. Typically, a revision laryngotracheal reconstruction will be needed to correct this complication. We describe a case in which a non-invasive endoscopic approach using laser was undertaken for a prolapsed posterior costal cartilage graft in a child who had undergone an anterior-posterior costal cartilage laryngotracheal reconstruction for Grade 3 stenosis. This, according to our knowledge, has not been previously described and provides an alternative to revision surgery.

Pediatric Tracheal Rhabdomyosarcoma Masquerading as a Granuloma

We describe a posterior wall intratracheal embryonal rhabdomyosarcoma (RMS) arising in a 6-year-old tracheostomized child masquerading as reactive granulation tissue and review all reported cases of pediatric intratracheal RMS. The child underwent laser debulking of the tumor and postoperative radiation and chemotherapy with no evidence of recurrence at 2-year follow-up. A literature review revealed four previous cases of pediatric primary tracheal or intratracheal RMS, and remission was achieved in all but one case with surgery, chemotherapy, and radiation. Pathologic evaluation of tracheal mucosal granulation tissue may merit consideration, particularly in patients with increased risk factors.

Impact of supraglottoplasty on parental preception of swallowing using a 10 question swallowing index

INTRODUCTION

Laryngomalacia can have a significant impact on swallowing function. Most of the studies in literature have focused on evaluating swallowing dysfunction in children with Laryngomalacia using clinical assessment and swallowing studies i.e. functional endoscopic evaluation of swallowing or videofluroscopic evaluation of swallowing.

OBJECTIVE

The objective of the current study was to evaluate the parental perception of swallowing using a newly devised 10-point swallowing index before and after supraglottoplasty.

MATERIAL AND METHODS

This was a prospective study performed at a tertiary care Aerodigestive center over a period of 18 months. A total of 51 supraglottoplasties were performed by a single surgeon over an 18-month period. Parents were asked to fill a non validated 10-point questionnaire before and after supraglottoplasty. Of the 51 surgeries, 34 surveys were completed, and 28 surveys were included in the study. All the patients were classified in to mild, moderate and severe laryngomalacia based on the established criterion. Each point in the index was graded on the Likert scale.

RESULTS

A total of 28 patients who underwent supraglottoplasty were included in the study. There was a significant improvement in the overall parental perception in the swallowing of children with laryngomalacia following supraglottoplasty. There was statistically significant improvement in 9 out of 10 indices on the questionnaire.

CONCLUSION

Supraglottoplasty has an overall positive impact on parental perception of swallowing in children with Laryngomalacia. Caregivers had fewer concerns postoperatively, with fewer choking spells and breathing issues during feeds, and a greater satisfaction with the amount consumed at each feed. This Index adds a valuable subjective component to pediatric swallowing assessments pre and post supraglottoplasty. This tool could be used in conjunction with MBSS and FEES measures to provide a more comprehensive assessment.

Open resection and laryngotracheal reconstruction in a case of subglottic hemangioma in PHACE syndrome

We describe a 1 month old infant with PHACE syndrome who underwent successful management of subglottic hemangioma by open resection and laryngotracheal reconstruction using a thyroid ala graft. Propranolol is typically the treatment of choice for subglottic hemangiomas however, recent reports have suggested adverse complications with the use of propranolol in children with PHACE syndrome. The child had cerebral and cervical vascular anomalies associated with her PHACE syndrome making her at an increased risk of stroke with the use of propranolol.

Cleft palate secondary to an ingested foreign body: a learning experience

BACKGROUND

Cleft palate has usually been described as a congenital anomaly. Acquired clefting of the palate is rare and is usually due to penetrating trauma.

OBJECTIVE

To report a case of cleft palate developing after ingestion of a coin due to prolonged impaction in the nasopharynx.

CASE REPORT

A 4 1/2-year-old child presented with nasal regurgitation and nasal twang of voice. The parents reported a history of ingestion of a coin 2 years prior, which was undetectable on neck and chest X-ray study done at that time. Examination revealed a triangular cleft of soft palate. A diagnosis was made of an acquired cleft palate secondary to prolonged impaction of the coin in the nasopharynx. Under general anesthesia, the palatal defect was repaired in three layers.

CONCLUSION

The case highlights the fact that ingested foreign bodies can get lodged in the nasopharynx and that nasopharynx X-ray study should always be done in cases of a disappearing foreign body in the aerodigestive tract.

Chemoradiation in Advanced Head and Neck Cancers: A Comparison of two Radiosensitizers, Paclitaxel and Cisplatin

To compare the locoregional control rates, survival outcome and toxicity profiles between two groups of patients of squamous cell carcinoma (SCC) of Head and Neck (Stage III & IV) receiving concomitant chemo-radiotherapy with Paclitaxel and Cisplatin. A prospective study was done on 94 previously untreated patients of histopathologically proved squamous cell carcinoma of head and neck region-AJCC stage III & IV (T3 & T4 with N0 -N3, M0) treated with concomitant chemoradiation. The patients were divided into two groups. Group A (44 patients) received concomitant chemotherapy (C.T.) with Paclitaxel 40 mgm/m2 while Group B (50 patients) received concomitant chemotherapy with Cisplatin 40 mgm/m2. All the patients in both the groups responded. In Group A (Paclitaxel + R.T.), complete response was seen in 72.7% and partial response in 27.3%. In Group B (Cisplatin +R.T.) complete response was seen in 52% and partial in 48%. At one year follow up, the locoregional control rate (LRC) in Group A was significantly higher as compared to that in Group B (65.9 vs. 46%, P<0.05) while there was no difference in the disease free survival (DFS) and the overall survival (OS). A 3 year estimate of the LRC, DFS and OS using Kaplan Meier Estimator revealed no difference in the LRC, DFS and OS between the 2 groups. There was a higher incidence of skin and mucosal toxicity with Paclitaxel while the gastro-intestinal and hematological toxicity was more with Cisplatin. No significant chronic toxicity except xerostomia was observed in either group. Paclitaxel has better complete response and locoregional control rates at 1 year as compared to cisplatin. However, there is no difference in the estimated 3 year rates of locoregional control, disease free survival and overall survival between the 2 groups.

Pseudocyst of pinna: a recurrence-free approach

OBJECTIVE

The aims of the article were to study the epidemiological profile of pseudocyst of pinna in non-Chinese population, to propose a hormonal basis of pseudocyst formation, and to compare 2 commonly used treatment modalities of incision drainage with compression and deroofing with compression, so as to ascertain the definitive treatment of this frequently recurring condition.

MATERIAL AND METHODS

Twenty-nine patients were diagnosed with pseudocyst of the auricle between June 2005 and December 2006 in a medical college hospital. All the patients were initially subjected to aspiration with contour dressing. Of the 29 patients, 28 showed recurrence with in 1 week. These 28 patients were divided into 2 groups--13 patients underwent incision and drainage with curettage followed by buttoning, whereas 15 underwent surgical deroofing of the cyst along with buttoning.

RESULTS

All the 29 patients were males with a mean age of 32.6 +/- 4.3 years. Sixteen (55.17%) patients had a right-sided lesion, whereas 13 (44.82%) patients had a left-sided lesion. No case of bilateral pseudocyst was seen. The pseudocyst was most commonly located in the concha. After aspiration with contour dressing, 28 (96.55%) patients showed recurrence within 1 week. Of the 13 patients who underwent incision drainage with buttoning, 5 (38.46%) showed recurrence. Of the 13 patients who underwent incision drainage, 3 (23.07%) showed permanent thickening of the auricular cartilage. The 5 cases that recurred then underwent deroofing with buttoning along with 15 patients. Thus, a total of 20 patients underwent surgical deroofing. No recurrence was seen with this technique. The patients were followed up for 1 month. No complication was noted, and the results were cosmetically acceptable.

CONCLUSION

Pseudocyst of the pinna is an uncommon condition of the auricle presenting as a painless swelling in young adult males. The epidemiological profile of this condition is similar in Chinese and non-Chinese (Indian) population. A hormonal influence modulating the inflammatory process explains the marked male predominance of this condition. Surgical deroofing followed by buttoning is the definitive treatment of this entity as it is associated with no recurrence and gives a cosmetically acceptable result.

Congenital epulis

Congenital epulis or gingival granular cell tumour is a rare lesion occurring in the newborn, affecting females eight times more than males and arising more commonly from the maxillary than the mandibular alveolar ridge. We report the case of a five-day-old girl who presented to us with a large mass arising from the gingival mucosa of the mandible, causing feeding difficulty. Immediate surgical excision was followed by an uneventful recovery. The case is reported to make clinicians aware of this uncommon but easily treatable condition.