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At least 649 records · Page 36Linked to original sources
PubMed1996

Laryngotracheal reconstruction using microplates in a porcine model with subglottic stenosis.

Current techniques of laryngotracheal reconstruction require a choice between prolonged stenting (conventional technique) or short-term stenting with maintenance of sedation and paralysis until the airway has stabilized (single-stage laryngotracheal reconstruction). An alternative method is proposed using microplates to provide immediate airway stabilization without stenting. This study was designed to evaluate the long-term effects of microplate repair of stenosis of the subglottis and trachea on the growing larynx. Subglottic stenosis was produced in piglets using a transoral endoscopic technique. Eight animals underwent repair of the stenosis using an anterior cricoid split with microplate distraction and stabilization of the cricoid cartilage and first tracheal ring. The distraction was maintained and airway growth continued for the duration of this study. However, with growth of the larynx the plates migrated away from their original position. In 50% of the animals followed up for 90 days the plates migrated into the airway lumen. This study suggests that rigid distraction of the stenotic airway with microplates is a viable alternative to more traditional methods of repair. However, plate removal at some interval after surgery is required in the growing larynx in order to prevent migration of the plate into the airway.

Animals↗
PubMed1997

Tenuous airway in children with trisomy 21.

Multiple congenital anomalies are closely linked to Down syndrome (trisomy 21). Cardiac malformations are found in 40% of patients, a large number of whom will require a major surgical procedure. The importance of postextubation stridor in these children is frequently underestimated. A retrospective review of 99 trisomy 21 patients who underwent cardiovascular surgery revealed postextubation stridor in 24 (24.2%). Significant factors for the development of stridor included younger age (P=0.04), lower growth percentile for weight (P=0.03), and increased frequency of reintubation (P=0.04). Subglottic stenosis was found in 6 (6.1%). In 4 of these patients, an endotracheal tube of larger diameter than predicted for age was used. All 6 patients were less than the 10th percentile for weight. We conclude that Down syndrome patients deserve special considerations and modifications of standard intubation techniques for successful airway management.

Age Factors↗
PubMed1997

Posterior glottic stenosis mechanism and surgical management.

Posterior glottic stenosis with arytenoid fixation is an uncommon complication of laryngeal injury. Though etiologies vary; the most common is prolonged intubation. Patients with this problem are tracheotomy dependent and have compromised voice production. There has been no acceptable approach to reconstruction of the larynx, the majority of patients being treated with some type of vocal fold lateralization. The success rate with this approach varies, and this procedure does not take advantage of the intact neuromuscular status of the larynx. Over the past 3 years we have utilized an alternative approach, to repair the stenosis and mobilize the arytenoids in 10 patients. Our surgical technique involves laryngeal exposure via a laryngofissure, the removal of posterior glottic cicatricial tissues, and the application of an autologous graft. Subsequently, all but one of the patients were able to be decannulated. Subjective postoperative voice analysis showed improved voice production. The pathophysiology for this disorder and a review of different treatment modalities are discussed.

Adolescent↗
PubMed1997

Malformation and stenosis of the cricoid cartilage in association with Larsen's syndrome.

Three patients with the typical features of Larsen's syndrome are described. All three developed severe respiratory symptoms caused by a congenital subglottic stenosis. Tracheotomy and treatment of the stenosis by means of laryngotracheoplasty resulted in complete collapse of the cricoid cartilage and the proximal tracheal skeleton. Lack of rigidity of the laryngeal and tracheal cartilages in patients with Larsen's syndrome could well be responsible for this failure. Surgical treatment consisted of resection of the stenotic and collapsed areas and end-to-end anastomosis. This therapy was eventually successful in all three patients.

Abnormalities, Multiple↗
PubMed1999

Measuring in situ central airway resistance in patients with laryngotracheal stenosis.

OBJECTIVES: To evaluate a newly developed bronchoscopic technique for the assessment of intratracheal pressures. STUDY DESIGN: In situ measurement of central airway resistance in 20 consecutive spontaneously breathing subjects. Thirteen patients had benign glottic or subglottic stenosis. Seven patients without central airway disease served as normal control subjects. METHODS: A pressure catheter was introduced into the trachea via the working channel. The pressure swing was measured upstream and downstream of the stenosis. Central airflow was monitored simultaneously using a commercial pneumotachograph attached to a mouthpiece. Data acquisition frequency was 500 Hz. Prestenotic and poststenotic inspiratory and expiratory resistances could be calculated and displayed from the raw data off-line. RESULTS: Inspiratory and expiratory resistances measured in mid-trachea or below the stenosis (subglottic) were 0.36 +/- 0.13 and 0.35 +/- 0.13 kPa.s/L for the control subjects (C), 1.11 +/- 0.47 and 0.65 +/- 0.26 kPa.s/L for patients who did not need to be operated on (NOOP), 7.11 +/- 7.19 and 3.35 +/- 2.25 kPa.s/L respectively for those who required surgical correction (OP). Supraglottic inspiratory and expiratory resistances for C were 0.22 +/- 0.09 and 0.25 +/- 0.06 kPa.s/L, for NOOP 0.15 +/- 0.10 and 0.14 +/- 0.11 kPa.s/L, and for OP 0.26 +/- 0.13 and 0.24 +/- 0.07 kPa.s/L respectively. The cut-off point for surgical correction was estimated to be > 2.5 kPa.s/L of inspiratory resistance. Concurrent expiratory values showed a considerable overlap between OP and NOOP. No correlation could be established between local resistance values and dyspnea score. CONCLUSIONS: In situ subglottic flow-pressure tracing in spontaneously breathing patients who present with benign obstruction of the upper airways is well tolerated and may help to identify patients who need surgical correction.

Adult↗
PubMed1999

Can topical mitomycin prevent laryngotracheal stenosis?

OBJECTIVES/HYPOTHESIS: Early topical application of mitomycin to a laryngotracheal lesion may prevent or reduce laryngotracheal stenosis (LTS). STUDY DESIGN: Prospective controlled animal study. METHODS: LTS was induced in 60 dogs randomly assigned to four groups. Controls received an immediate topical application of normal saline. The suction-control group received an immediate application of normal saline followed by suction of secretions on day 2. The mitomycin group received immediate application of 0.7 mL mitomycin (0.2 mg/mL). The repeat-mitomycin group received an immediate application of mitomycin and a second application on day 2, after secretions were suctioned. The laryngeal lumens were measured endoscopically at baseline, day 12, and day 21. Animals were euthanatized if stenosis approximated 95% or at day 21. RESULTS: All dogs in the mitomycin groups survived to day 21, compared with 12 in the suction group and only 2 controls. No side effects of mitomycin were observed. At day 21, surviving controls had 85% and 95% stenosis. In the mitomycin group, median stenosis was 27% (interquartile range, 29% to 42%); in the repeat-mitomycin group, 30% (22% to 40%); and in the suction-control group, 84.5% (72.5% to 93.5%). The mitomycin group differed significantly from controls on day 12 (median difference = 85%, 95% CI = 80%-94%, P < .0001) and day 21 (difference = 63.9%, 95% CI = 58%-85%, P = .031). CONCLUSION: A single topical application of mitomycin significantly reduces the severity of LTS in dogs. Reapplication after 2 days does not improve results. Prospective clinical studies are warranted to assess the efficacy in humans.

Administration, Topical↗
PubMed1999

Margins of partial cricotracheal resection in children.

OBJECTIVE: To review the surgical margins of partial cricotracheal resection in our series of patients. This includes specific anatomic detail as to each superior and inferior resection margin. To apply this information and access the utility of partial cricotracheal resection for the treatment of subglottic stenosis. STUDY DESIGN/METHODS: A retrospective review was performed of 38 children with severe subglottic stenosis who underwent partial cricotracheal resection. Information was obtained with regard to the specific anatomic location of the superior and inferior resection margins, the grade of subglottic stenosis preoperatively, the type of stenting material used postoperatively, and other surgical details specific to each procedure. RESULTS: The superior resection margins were generally to the superior aspect of the cricoid cartilage but as high as the undersurface of the true vocal folds in a minority of patients. Inferior resection margins were generally to the second tracheal ring. Length of resection varied, but was as long as 3.0 cm in one patient. Overall surgical success based on decannulation was > 86%. CONCLUSION: Partial cricotracheal resection is a safe and successful procedure for the treatment of subglottic stenosis. The margins and length of resection should be tailored specifically for each patient; and special considerations must be taken when extensive resection to the level of the true vocal folds is required. Safe airway management in the postoperative period is essential.

Cricoid Cartilage↗
PubMed2000

Airway growth after cricotracheal resection in a rabbit model and clinical application to the treatment of subglottic stenosis in children.

OBJECTIVE: To evaluate the effects of a partial resection of the anterior cricoid arch on the growth of the laryngotracheal complex in an animal model and to study the lumen caliber and cross sectional surface area following resection as the animals are allowed to grow. Laryngeal, subglottic, and tracheal measurements in the infant and pediatric larynges in autopsy specimens are also investigated. DESIGN: A controlled animal study was done comparing the operated rabbit group to the nonoperated group. Twenty-nine infant rabbits were compared to a control group of ten rabbits. In addition, autopsy dissections were performed on infant and pediatric larynges to obtain measurements of various laryngeal and cricoid relationships. METHODS: Thirty-nine pasteurella-free New Zealand white female rabbits between the ages of 8 and 11 weeks were used in this study. In the experimental group, cricotracheal resections were performed by removing the anterior cricoid cartilage and the first tracheal ring. A primary anastomosis was then performed. The animals were kept alive for 4 months and then humanely euthanized. The laryngeal complex was then removed and histological sections of the cricotracheal region were mounted on glass slides and stained with H&E. Measurements were taken of the cricoid and upper tracheal lumen and cross-sectional area. RESULTS: Twenty-seven of the study group survived until the time of sacrifice. All of the control group survived during the study period. The two groups were comparable in regard to weight, lumen size, and cross-sectional area There were no statistical differences between the groups. CONCLUSIONS: The experimental data support the hypothesis that partial cricotracheal resections can be performed safely and effectively in young rabbits. The potential clinical significance is described in light of the autopsy data.

Age Factors↗
PubMed2000

Laryngotracheal reconstruction and the hidden airway lesion.

OBJECTIVE: Single-stage laryngotracheal reconstruction (SSLTR) is an increasingly common technique to achieve decannulation of patients with laryngotracheal stenosis. In a proportion of cases airway distress on extubation may be attributed to a dynamic second airway lesion not diagnosed before surgery. Our aim is to describe our recent experience with these frustrating patients. METHODS: Between July 1997 and July 1999 we prospectively followed patients who underwent SSLTR and experienced difficulty after extubation owing to an unsuspected second airway lesion. RESULTS: During this 24-month period we performed 80 SSLTRs. In six surgeries performed on five patients, a second airway lesion complicated extubation. In five patients the second lesion was not diagnosed before surgery because there was significant airway stenosis and tracheotomy. The sixth patient was transferred to our care intubated. In all cases the airway surgery for the dominant lesion was technically successful, but revealed a second dynamic lesion. There were three cases of tracheomalacia, two cases of laryngomalacia, and one case of arytenoid prolapse. All patients required intervention. Tracheotomy was required in four patients. CONCLUSIONS: Failure to achieve extubation after SSLTR may be caused by a dynamic second airway lesion that was previously disguised by a more dominant airway lesion. Surgical repair of the dominant lesion will allow manifestation of the dynamic lesion due to the Bernoulli effect. The combination of a tracheotomy and a dominant airway lesion limits airflow and potentially disguises the situation.

Child, Preschool↗
PubMed2000

Effect of mechanical reinforcement on stability of the rotary door flap laryngotracheal reconstruction: a canine study.

OBJECTIVE/HYPOTHESIS: The rotary door flap (RDF) laryngotracheal reconstructive procedure uses a 180 degrees rotation of the sternohyoid muscle into a laryngofissure. Despite excellent clinical results, there are concerns of flap inspiratory prolapse. This study examined RDF stability and the efficacy of ancillary materials in providing additional support. METHODS: Seventeen dogs underwent endoscopic induction of subglottic stenosis and delayed RDF reconstruction. Animals received 1) traditional RDF (control), 2) RDF with titanium screen implant, 3) RDF with porous polyethylene implant, or 4) RDF with hydroxyapatite cement (HAC) injection. Four weeks postoperatively the flaps were tested for stability. On qualitative assessment, endoscopic visualization was completed with quiet respiration and then following endotracheal tube occlusion. On quantitative assessment, after animals were killed, the RDF segment was isolated and subjected to negative pressure (maximum pressure, -50 mm Hg). The pressure-causing collapse was measured. RESULTS: In the traditional RDF animals (control), five of six flaps were stable in vivo and with negative pressures. In the titanium screen, porous polyethylene group, and HAC groups, respectively, four of four, three of four, and two of three flaps were stable in vivo and under negative pressure. Flaps that demonstrated instability had granulation, dehiscence, and poor healing. These occurred in 1 of 6 animals in the traditional RDF group and in 2 of 11 animals in the implant groups. In addition, 13 of 24 animals assigned to the implant groups died, compared with 2 of 8 of those in the traditional RDF group. CONCLUSIONS: The RDF is stable and maintains the airway under physiological conditions. Support materials did not improve stability, render flap harvest more difficult, or increase morbidity and mortality.

Animals↗
PubMed2001

Neonatal subglottic stenosis--incidence and trends.

OBJECTIVE/HYPOTHESIS: Neonatal subglottic stenosis is a known entity arising from endotracheal tube intubation. In the 1970s and 1980s, estimates of the incidence of subglottic stenosis were in the range of 0.9% to 8.3% of intubated neonates. Because of improved techniques of handling neonates who require ventilatory support, we thought the actual incidence of neonatal subglottic stenosis in the late 1990s was much lower. STUDY DESIGN: We retrospectively reviewed all neonatal intensive-care unit (NICU) admissions from 1997 at our institution, which serves as a level 3 NICU. We also performed a MEDLINE search of the reported incidence of neonatal subglottic stenosis between 1960 and 1999. METHODS: Analysis was performed to identify all children who developed subglottic stenosis at our institution. Data were also collected and analyzed with regard to average gestational age, average birth weight, average duration of intubation, and the number of children requiring tracheostomy. The reports identified in the literature were reviewed as to the incidence of subglottic stenosis. RESULTS: A total of 544 neonates were admitted to the unit. Of these, 281 were intubated for an average of 11 days. No patients developed subglottic stenosis. Three patients required tracheostomies for other reasons. All studies published after 1983 reported an incidence of neonatal subglottic stenosis as less than 4.0%, and all studies published after 1990 reported an incidence of neonatal subglottic stenosis as less than 0.63%. CONCLUSIONS: Although our report applies to only a single institution in a single year, after reviewing the literature we think a downward trend exists in the incidence of neonatal subglottic stenosis in the late 1990s. The current incidence of neonatal subglottic stenosis is likely between 0.0% and 2.0%.

Birth Weight↗