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Kanotra SP, Rand D, Mulanax C. Transcervical Epiglottopexy: A versatile technique for managing epiglottic prolapse. Otolaryngol Head Neck Surg 2024; 170:380-390. [PMID: 37622519 DOI: 10.1002/ohn.488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/23/2023] [Accepted: 07/29/2023] [Indexed: 08/26/2023]
Abstract
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.
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Affiliation(s)
- Sohit Paul Kanotra
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Dayton Rand
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Catalina Mulanax
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
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Young AE, Hinkes-Molinaro L, Ida J, Valika T, Ghadersohi S, Thompson DM, Hazkani I. Swallowing Function After Epiglottopexy in Children. Otolaryngol Head Neck Surg 2024; 170:560-567. [PMID: 37855629 DOI: 10.1002/ohn.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/15/2023] [Accepted: 09/24/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE Epiglottopexy has been an increasingly utilized intervention in children with epiglottic prolapse and airway obstruction. Given the role of the epiglottis in protecting the airway during swallowing and the potential effect of repositioning the epiglottis on the passage of the bolus, we aimed to compare swallowing outcomes before and after epiglottopexy in children. STUDY DESIGN A retrospective cohort study. SETTING Tertiary care children's hospital. METHODS Data were extracted from charts of children who underwent epiglottopexy and had a subsequent instrumental swallowing evaluation between January 2018 and September 2022. RESULTS A total of 93 patients underwent epiglottopexy. Of these, 38 patients met inclusion requirements. The mean age at surgery was 41 ± 47 months. Most patients (n = 37, 97.4%) had significant comorbidities such as secondary airway lesions (n = 33, 91.7%), a genetic or syndromic disorder (n = 25, 69.4%), and dysphagia (n = 29, 76.3%). All patients had a concurrent procedure at the time of epiglottopexy with supraglottoplasty (n = 24, 63.2%) and lingual tonsillectomy (n = 16, 42.1%) being the most common. No changes in initiation or patterns of swallowing were noted postoperatively. A total of 7 (18.4%) patients had worsening swallow function: 2 had new-onset dysphagia, and 5 had worsening pre-existing dysphagia. Liquid or food textures penetrated remained unchanged or improved in most cases. No risk factors for worsening dysphagia were identified in our cohort. CONCLUSION Children with medical comorbidities undergoing epiglottopexy with additional airway interventions may experience new or worsening dysphagia. However, the procedure is generally safe without notable patterned changes in the swallowing mechanism.
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Affiliation(s)
- Ashley E Young
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura Hinkes-Molinaro
- Department of Speech Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jonathan Ida
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Taher Valika
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Saied Ghadersohi
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dana M Thompson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Hazkani I, Stein E, Ghadersohi S, Ida J, Thompson DM, Valika T. Epiglottopexy in Infants Younger Than 6 Months Old: A Case Series. Ann Otol Rhinol Laryngol 2023; 132:1393-1399. [PMID: 36960699 DOI: 10.1177/00034894231160693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Severe laryngomalacia, characterized by apnea, hypoxia, and feeding difficulties, is an uncommon diagnosis that often requires surgical intervention with supraglottoplasty. Children who require surgery at a young age and those with additional comorbidities pose a special challenge and may require further surgical interventions. Posterior displacement of the epiglottis has been noted in some infants with congenital stridor and is commonly treated with epiglottopexy. The goal of our study is to review the outcomes of epiglottopexy combined with supraglottoplasty in our cohort of infants younger than 6 months old with severe laryngomalacia. METHODS A retrospective chart review of infants younger than 6 months old who underwent epiglottopexy combined with supraglottoplasty for severe laryngomalacia from January 2018 to July 2021 at a tertiary care children's hospital. RESULTS 13 patients (age 1.3 week-5.2 months) underwent supraglottoplasty and epiglottopexy for severe laryngomalacia and epiglottis retroflection. The patients were admitted to the intensive care unit and remained intubated for at least one night. All patients demonstrated subjective and objective improvement in upper airway respiratory signs and symptoms. Ten patients demonstrated aspiration immediately postoperatively, despite 4 of them having no concern for aspiration at preoperative evaluation. On follow-up, 1 patient required revision supraglottoplasty and epiglottopexy for persistent laryngomalacia, and 2 patients required tracheostomy tube placement due to cardiopulmonary comorbidities. CONCLUSION Infants younger than 6 months old with medical comorbidities undergoing epiglottopexy with supraglottoplasty may demonstrate significant improvement in respiratory symptoms. Worsening dysphagia may complicate the postoperative period, particularly among children with medical comorbidities.
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Affiliation(s)
- Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago Illinois, IL, USA
| | - Eli Stein
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago Illinois, IL, USA
| | - Saied Ghadersohi
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago Illinois, IL, USA
| | - Jonathan Ida
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago Illinois, IL, USA
| | - Dana M Thompson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago Illinois, IL, USA
| | - Taher Valika
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago Illinois, IL, USA
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Ishman SL, Maturo S, Schwartz S, McKenna M, Baldassari CM, Bergeron M, Chernobilsky B, Ehsan Z, Gagnon L, Liu YCC, Smith DF, Stanley J, Zalzal H, Dhepyasuwan N. Expert Consensus Statement: Management of Pediatric Persistent Obstructive Sleep Apnea After Adenotonsillectomy. Otolaryngol Head Neck Surg 2023; 168:115-130. [PMID: 36757810 PMCID: PMC10105630 DOI: 10.1002/ohn.159] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/03/2022] [Accepted: 08/13/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged. METHODS An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology-Head and Neck Surgery to develop statements for a target population of children aged 2-18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey. RESULTS After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug-induced sleep endoscopy, surgical management, and postoperative care. CONCLUSION The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research.
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Affiliation(s)
- Stacey L. Ishman
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen Maturo
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Seth Schwartz
- Virginia Mason Medical Center, Seattle, Washington, USA
| | - Margo McKenna
- University of Rochester Medical Center/Golisano Children’s Hospital, Rochester, New York, USA
| | - Cristina M. Baldassari
- Eastern Virginia Medical School/Children’s Hospital of the King’s Daughter, Norfolk, Virginia, USA
| | - Mathieu Bergeron
- Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | | | - Zarmina Ehsan
- University of Missouri—Kansas City, Kansas City, Missouri, USA
| | - Lisa Gagnon
- Yale University/Connecticut Pediatric Otolaryngology, New Haven, Connecticut, USA
| | - Yi-Chun Carol Liu
- Baylor College of Medicine/Texas Children’s Hospital, Houston, Texas, USA
| | - David F. Smith
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey Stanley
- University of Michigan Health/Michigan Medicine, Ann Arbor, Michigan, USA
| | - Habib Zalzal
- Children’s National Health System, Washington, District of Columbia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology—Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Masárová M, Formánek M, Jor O, Novák V, Vrtková A, Matoušek P, Komínek P, Zeleník K. Epiglottopexy Is a Treatment of Choice for Obstructive Sleep Apnea Caused by a Collapsing Epiglottis. Life (Basel) 2022; 12:life12091378. [PMID: 36143414 PMCID: PMC9502758 DOI: 10.3390/life12091378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Drug-induced sleep endoscopy (DISE) reveals epiglottic collapse to be a frequent cause of obstructive sleep apnea (OSA) and intolerance of positive airway pressure (PAP). These patients require different management. This prospective study aimed to compare transoral laser epiglottopexy outcomes in patients with OSA caused by epiglottic collapse with the patients’ previous PAP outcomes. Fifteen consecutive adult patients with OSA and epiglottic collapse during DISE were included; ten were analyzed. Before inclusion, PAP was indicated and ineffective in six patients, one of whom underwent unsuccessful uvulopalatopharyngoplasty. PAP was performed during DISE in all patients before epiglottopexy and was uniformly ineffective. ENT control was performed at 1 week and 1 month, and control limited polygraphy to 6 months after surgery. The apnea−hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) were significantly improved (p < 0.001 and p = 0.003, respectively) in all patients after epiglottopexy. Surgery was successful in 9/10 patients; the remaining patient had a significantly decreased AHI and could finally tolerate PAP. Transoral laser epiglottopexy is used to treat OSA in patients with epiglottic collapse. Unlike other methods, it significantly reduces both AHI and ESS and should be considered for these patients. An active search for OSA patients with epiglottic collapse is recommended to prevent treatment failure.
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Affiliation(s)
- Michaela Masárová
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Faculty of Medicine, University of Ostrava, 708 52 Ostrava, Czech Republic
| | - Martin Formánek
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Faculty of Medicine, University of Ostrava, 708 52 Ostrava, Czech Republic
- Correspondence: ; Tel.: +42-0597375812
| | - Ondřej Jor
- Department of Anesthesiology, Resuscitation and Intensive Medicine, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
| | - Vilém Novák
- Department of Pediatric Neurology, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
| | - Adéla Vrtková
- Department of Applied Mathematics, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 708 52 Ostrava, Czech Republic
| | - Petr Matoušek
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Faculty of Medicine, University of Ostrava, 708 52 Ostrava, Czech Republic
| | - Pavel Komínek
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Faculty of Medicine, University of Ostrava, 708 52 Ostrava, Czech Republic
| | - Karol Zeleník
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Faculty of Medicine, University of Ostrava, 708 52 Ostrava, Czech Republic
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Abstract
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.
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Affiliation(s)
- Sohit Paul Kanotra
- Department of Otolaryngology-Head and Neck Surgery, 21782University of Iowa, Iowa City, IA, USA.,21782University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
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