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At least 91 records · Page 5Linked to original sources
PubMed1998

Iatrogenic airway stenosis with recurrent respiratory papillomatosis.

OBJECTIVE: To describe the presentation of, factors contributing to, and treatment of iatrogenic airway stenosis (IAS) associated with recurrent respiratory papillomatosis (RRP). DESIGN: Retrospective case series. SETTING: Pediatric tertiary care center. PATIENTS: The charts of patients treated for RRP in our institution from 1980 to 1995 (N=50) were reviewed. Seven patients were identified as having IAS based on endoscopic findings. MAIN OUTCOME MEASURES: Prevalence and types of IAS within our RRP patient population, methods used to treat IAS, and successful treatment of IAS. RESULTS: Of the 7 patients identified, 3 had isolated posterior glottic stenosis (PGS) and 1 had isolated subglottic stenosis. The other 3 had multiple areas of IAS as follows: PGS with bronchial stenosis, supraglottic stenosis with PGS, and tracheomalacia with tracheal stenosis from a suprastomal granuloma. The factors associated with IAS were extensive papilloma growth in the posterior glottis, prolonged periods of frequent laryngoscopies, and the use of nonstandard therapies, which in our series included topical podophyllum resin or photodynamic therapy. Six patients, all of whom had tracheal RRP at some point in their disease process, required tracheotomy. Five patients required laryngotracheal reconstruction. Laryngotracheal reconstruction permitted decannulation in all cases. Tracheal papillomas became sessile and nonobstructive after decannulation. Laryngotracheal reconstruction with rib grafting was most frequently performed. Of our 50 patients, none who did not have IAS required a tracheotomy. Of the 44 patients who did not require a tracheotomy, only 1 had tracheal papillomas. CONCLUSIONS: Occasionally, therapy for RRP is complicated by IAS. In our series, PGS was most common. Tracheotomy was associated with the presence of both IAS and distal RRP. In selected cases, laryngotracheal reconstruction can be successfully accomplished when RRP is present, and subsequent regression of tracheal RRP is likely.

Airway Obstruction↗
PubMed1998

Gastroesophageal reflux in patients with subglottic stenosis.

OBJECTIVES: To determine the incidence of gastroesophageal reflux in patients with subglottic stenosis (SGS) and to determine if upper esophageal reflux occurs in addition to lower esophageal reflux in these patients. DESIGN: Esophageal pH probe studies were reviewed in patients diagnosed as having SGS. SETTING: A tertiary care pediatric medical center. PATIENTS: All patients diagnosed as having SGS between January 1990 and July 1996 who had undergone monitoring with an overnight esophageal pH probe. Seventy-four patients qualified for the study. All 74 patients underwent lower probe testing, and 55 of the 74 underwent dual (upper and lower) probe testing. MAIN OUTCOME MEASURES: The percent of time a pH measurement of less than 4.0 was recorded in the upper and lower esophagus. A lower probe pH measurement of less than 4.0 more than 10% of the study time was considered high risk for developing reflux-associated pathologic symptoms. A lower probe pH measurement of less than 4.0 for 5% to 10% of the study time was considered a marginal risk for developing reflux-associated pathologic symptoms. Upper probe criteria for reflux-associated symptoms have not been established. Therefore, patients were grouped as having a pH of less than 4.0 in the upper esophagus for 0%, 0.1% to 0.9%, 1.0% to 1.9%, 2.0% to 3.0%, or more than 3% of the study time. RESULTS: Thirty-seven of the 74 patients who underwent lower probe testing had a pH of less than 4.0 more than 5% of the study time, and 24 had a pH of less than 4.0 more than 10% of the study time. Twelve of the 55 patients who underwent upper probe testing had no measurable reflux; 27 of the 55 had a pH of less than 4.0 more than 1% of the study time; 14 had a pH of less than 4.0 more than 2% of the study time, and 11 had a pH of less than 4.0 more than 3% of the study time. CONCLUSIONS: Gastroesophageal reflux is frequently present in patients with SGS. Gastric contents frequently reach the upper and lower esophagus in these patients. In addition, the high incidence of gastroesophageal reflux in these patients suggests that it may play a role in the development of SGS. The possible effect of gastroesophageal reflux on the surgical repair of SGS requires further study.

Adolescent↗
PubMed1998

Posterior cricoidotomy lumen augmentation for treatment of subglottic stenosis in children.

OBJECTIVES: To determine the results of posterior cricoidotomy lumen augmentation in the treatment of moderate and severe subglottic stenosis in children, and to assess the effect of this surgery on the growth of the larynx in young children. DESIGN: A 17-year retrospective study. PATIENTS AND METHODS: Thirteen children with moderate and severe subglottic stenosis who underwent posterior cricoidotomy lumen augmentation from 1980 to 1996. Eight children (62%) were male and 5 (38%) were female. The average age was 4.7 years (age range, 8 months to 15 years). Six (46%) of the 13 children were younger than 3 years. Nine children (69%) had acquired subglottic stenosis, 3 of whom had a combined subglottic-posterior glottic stenosis, and 4 (31%) had congenital subglottic stenosis. All the children already had a tracheotomy tube placed and had undergone treatment at our clinic or at other institutions. The surgical procedure we used included a cricoid lamina split with grafting (2 children with costal cartilage graft and 11 with buccal mucosal graft) and stenting. RESULTS: Twelve (92%) of the 13 children underwent decannulation, and 1 (8%) is still undergoing treatment: decannulation is expected to be carried out in the near future. Of the 12 children who underwent decannulation, 9 demonstrated good postoperative voice quality and 3, who had combined subglottic-posterior glottic stenosis, developed impaired voice function. Following stent removal, all children experienced some degree of difficulty in swallowing saliva and liquids, which was soon overcome. No evidence of surgery-induced laryngeal growth impairment in younger children was observed. CONCLUSIONS: The posterior cricoidotomy lumen augmentation is a safe and effective technique for the treatment of moderate and severe subglottic stenosis in children of any age. This study lends further support to the assertion that external surgery does not affect the growth of the larynx in younger children.

Adolescent↗
PubMed1999

Single-stage laryngotracheal reconstruction: the Great Ormond Street experience and guidelines for patient selection.

OBJECTIVES: To review all patients undergoing single-stage laryngotracheal reconstruction and to determine guidelines to predict successful outcomes and prevent the necessity of tracheotomy following laryngotracheal reconstruction. DESIGN: Chart review. SETTING: Tertiary care children's hospital. PATIENTS: A retrospective chart review was performed at our institution involving all patients who underwent single-stage laryngotracheal reconstruction from 1993 through 1996. A total of 28 patients were reviewed. RESULTS: Based on this chart review, a statistically higher incidence of extubation complications (P = .045), ie, bleeding, reintubation, or subcutaneous emphysema, occurred in children who weighed less than 4 kg. Although not statistically significant (P>.99), the relative risks of failure, defined as tracheotomy dependent or significant airway compromise following single-stage laryngotracheal reconstruction, were 3.43 if the child's weight was less than 4 kg at the time of surgery and 2.31 if the gestational age was less than 30 weeks at the time of surgery. Length of time for intubation did not appear to have any effect on outcome. CONCLUSIONS: Patients' gestational age and weight at the time of surgery appear to have the most impact on successful outcome. Children weighing more than 4 kg and those with gestational age of greater than 30 weeks appear to have a greater chance at successful extubation and eventual patent airway. Duration of intubation following single-stage laryngotracheal reconstruction does not appear to affect outcome.

Body Weight↗
PubMed1999

Pitfalls in laryngotracheal reconstruction.

OBJECTIVE: To determine the causes of laryngotracheal reconstruction (LTR) failures. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: Seventeen pediatric patients who underwent revision LTR from October 1, 1986, to December 31, 1998. INTERVENTION: Laryngotracheal reconstruction. MAIN OUTCOME MEASURE: Decannulation. RESULTS: Seventeen patients required a total of 42 LTRs for decannulation. There were 17 primary LTRs and 25 revision LTRs. The primary LTRs were done either at our or other institutions. Two patients died after initial LTR failed, one because of tracheotomy tube plugging and the other because of a severe respiratory syncytial virus pneumonia. All 15 remaining patients have been decannulated. There were 27 failed LTRs with 17 being primary and 10 revision LTR failures. In 3 of the 27 failed procedures, no obvious causes for failure could be found. In the remaining 24 procedures, 1 or more factors that contributed to LTR failure could be found. Poor preoperative evaluation with subsequent failure to address the airway lesion was seen in 6 procedures. Intraoperative reasons for LTR failure included inappropriate choice of graft in 2 procedures; inappropriate stent in 7; inappropriate stent length in 1; and inappropriate duration of stent in 8. In 6 procedures, the airway abnormalities identified at endoscopy were not adequately addressed at LTR. Postoperative factors for failure were poor follow-up in 2, anterior suprastomal collapse in 2, and slipped or broken stent in 2. Other factors that contributed to LTR failures included intractable gastroesophageal reflux disease in 1 procedure and keloid formation in 5. CONCLUSIONS: Although some LTRs may fail secondary to factors that are not under the surgeon's control, many LTR failures can be avoided by accurate preoperative and intraoperative assessment of the stenosis, correct choice of surgical procedure, and close postoperative monitoring.

Adolescent↗
PubMed2001

Topical mitomycin application after laryngotracheal reconstruction: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To explore the effect of mitomycin treatment on the pediatric airway following laryngotracheal reconstruction. DESIGN: Randomized, double-blind, placebo-controlled trial. PATIENTS: Children aged 2 to 17 years with subglottic or upper tracheal stenosis undergoing laryngotracheal reconstruction at a single, tertiary care, children's hospital. INTERVENTION: At the time of extubation or stent removal, the children underwent bronchoscopy and 0.4 mg/mL (2 mL of a 0.2-mg/mL solution of either mitomycin or an equal volume of isotonic sodium chloride was directly applied to the subglottic region for a single application of 2 minutes. These children then underwent interval endoscopy at 2 weeks, 6 weeks, and 3 months postoperatively for assessment of their airways. RESULTS: Granulation tissue was graded on a scale of 0 (none) to 4 (near-total or total occlusion). Videotapes of endoscopies were independently observed and graded by 3 pediatric otolaryngology fellows with a subsequent interobserver agreement of 91.6%. The results were then dichotomized to represent a single cohort in which further surgical intervention would be required and another separate cohort in which further surgery would not be required. At the 1-year mark, interim analysis was performed by a Data Safety and Monitoring Committee. At this time, 13 children had been randomized to the mitomycin-treated arm of the study and 11 children to the placebo-treated arm. A 2-tailed Fisher exact test revealed a value of 1.00. The Data Monitoring and Safety Committee advised that the trial should be stopped because the distributions between the 2 populations were almost identical. CONCLUSION: We cannot reject the null hypothesis that a single topical dose of mitomycin exerts an equal benefit as does isotonic sodium chloride when applied to the pediatric airway after laryngotracheal reconstruction.

Administration, Topical↗
PubMed2001

Dynamic tissue expansion of the larynx in a canine model.

OBJECTIVES: To test whether staged, progressive, monitored, dynamic tissue expansion is possible in the larynx and to evaluate its effectiveness in dilating and augmenting constricting cicatricial lesions. DESIGN: Animal study. SETTING: Research facility, tertiary care medical center. SUBJECTS: Thirteen dogs, 3 with laryngotracheal stenosis. INTERVENTIONS: Dogs underwent laryngeal splits, tracheostomy, and insertion of inflatable stents. In 7 normal dogs, stents were progressively inflated by air in predetermined increments during 11 days. In 3 normal dogs and 3 with laryngotracheal stenosis, stents were gradually expanded by water. Stents were kept in place for 21 days. After removal, dogs were observed for 25 days. Five died of complications of tracheostomy. MAIN OUTCOME MEASURES: Airway diameter measured by endoscopy before the induction of stenosis, before the laryngeal splitting procedure, after stent removal, and before euthanasia. RESULTS: The lumen increased, then shrank somewhat after stent removal. In 2 surviving dogs with laryngotracheal stenosis and water-expanded stents, the lumen was 82.5% larger than baseline at stent removal and 71.0% larger at euthanasia. In 2 surviving normal dogs with water-expanded stents, lumen size increased by 50.0% at stent removal, and in 1 dog surviving to day 46, it was 17.0% larger. In 5 surviving dogs with air-inflated stents, lumen size was 39.0% larger at stent removal and 8.0% larger at day 46. Histologically, fibrous tissue developed in the gaps between the splayed margins of the laryngeal cartilages. CONCLUSIONS: The larynx may be dynamically expanded. Although the maximal diameter is not maintained, final cross-sectional areas are larger.

Animals↗
PubMed2001

Laryngotracheal reconstruction in canines: fixation of autologous costochondral grafts using polylactic and polyglycolic acid miniplates.

OBJECTIVE: To examine the feasibility of a new method of laryngotracheal reconstruction (LTR) that uses a bioabsorbable plating system consisting of polylactic and polyglycolic acid and provides some advantages over currently used methods. DESIGN AND INTERVENTIONS: Anterior subglottic stenosis was created in 10 beagles that then underwent LTR using an autologous costochondral graft. External laryngotracheal framework and cartilage grafts were secured using a sheet and screws made from a copolymer composed of polylactic and polyglycolic acid. Animals were humanely killed at 40, 60, and 90 days, and specimens were submitted for pathological examination. Histologic analysis included evaluation for inflammatory reaction, polylactic and polyglycolic acid incorporation into cartilage, cartilage necrosis, cartilage remodeling, and graft epithelialization. RESULTS: All animals underwent LTR after creation of a subglottic stenosis without episodes of airway compromise. After LTR, all airways were returned to prestenosis diameter without significant complication, and all animals were immediately extubated after surgery without difficulty. After the animals were killed, distraction of the stenotic cricoid area was demonstrated in 100% of the cases. Significant necrosis was noted in 2 of 10 grafts grossly; however, histologic analysis demonstrated significant areas of viable cartilage, areas of cartilage remodeling, and good epithelialization despite graft necrosis. Complete epithelialization of grafts was noted in the other 8 specimens. CONCLUSIONS: Using a canine model, we demonstrated a bioabsorbable plating system that offers an effective method for LTR. This model has the advantages of providing external support to the operated laryngeal and tracheal framework, elimination of the difficulties of suture placement, and potential future failure while offering rigid external fixation of a cartilage graft.

Absorbable Implants↗