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Coccidioidomycosis of the larynx in infants and adults.

Coccidioidomycosis is a fungal disease endemic to the southwestern United States. The primary form of the disease is relatively benign and many patients, after exposure by inhalation of the sapyrophytic form of the organism, convert from negative to positive skin testing without significant clinical symptoms. The less common disseminated form represents a serious life-threatening disease and can present with granulomatous changes in the larynx. The authors' experience with disseminated coccidioidomycosis presenting in the larynx of adults and infants successfully treated with amphotericin B are presented and discussed.

Amphotericin B↗
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Long-term stenting in the treatment of subglottic stenosis.

Long-term stenting (3 to 12 months) with silicone rubber stents was found successful in 12 of 14 cases (86%) with severe subglottic stenosis. A new silicone rubber stent is described that is suitable for long-term stenting in infants or adults.

Adult↗
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Experimental animal model of subglottic stenosis.

An animal model of subglottic stenosis has been developed. The results of this pilot study show evidence to suggest that injury to the cricoid cartilage leading to perichondritis is the important factor in the development of subglottic stenosis.

Animals↗
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Subglottic stenosis of the larynx in the infant and child. Methods of management.

This presentation is a ten-year retrospective study on all patients with proven subglottic stenosis admitted to the Department of Otolaryngology, Hospital for Sick Children, Toronto. Some of these patients have required no treatment, others one or two dilatations of the stenosis only; others tracheotomy only; some tracheotomy plus dilatations; some the Fearon-Cotton operation, and a few who had very extensive stenosis of the larynx and trachea, extensive reparative surgery. In this presentation, the authors describe the different types of management, and the results of treatment are assessed and compared.

Dilatation↗
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Management of subglottic stenosis in infancy and childhood. Review of a consecutive series of cases managed by surgical reconstruction.

The management of mature subglottic stenosis secondary to endotracheal intubation in infancy and childhood remains a controversial issue. If treated similarly to congenital subglottic stenosis by tracheotomy and a "wait-and-see" period then there is a considerably higher mortality and morbidity for the acquired disease compared with the congenital. Eighteen children with severe acquired subglottic stenosis managed by surgical reconstruction are presented; 17 have been successfully extubated. The longest follow-up is 5 1/2 years. No evidence of interference with laryngeal growth is evident.

Adolescent↗
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Epidermolysis bullosa associated with laryngeal stenosis.

A boy with epidermolysis bullosa developed progressive laryngeal obstruction after age six months, with tracheotomy necessary at age three years. By eight years, the larynx was completely occluded by web and scar. Stenosis recurred repeatedly over the next seven years, three to six months after each corrective procedure, but laryngeal patency has been better-maintained since age 15. Laryngeal stenosis, presumably secondary to epithelial detachment, although a rare complication of epidermolysis bullosa, can be serious and life-threatening.

Child↗
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Endoscopic Teflon keel for anterior glottic web.

Anterior glottic webs are generally repaired with a McNaught keel placed and removed by laryngofissure. Attempts have been made since 1922 to repair these webs endoscopically. An endoscopic technique using a Teflon keel which has been successful in properly selected cases is presented.

Adult↗
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Acquired stenosis of the upper airway in neonates. An increasing problem.

Thirty neonates with acquired airway stenosis were treated between 1975 and 1979 at the C. S. Mott Children's Hospital of the University of Michigan. Neonates surviving a period of ventilation are at risk of developing subglottic stenosis (8.3%). The stenosis is often severe. Children with respiratory distress syndrome and/or neurologic disorders were particularly prone to developing a stenosis (37%). Following treatment, 43% were successfully decannulated and decannulation occurred in a biphasic pattern. Thirty-seven percent were still tracheostomy-dependent but had a voice and were developing normal speech patterns. The mean decannulation time was 92.5 weeks, confirming that acquired subglottic stenosis in the neonate is a serious problem with long-term disability.

Female↗
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Long-term stenting for laryngotracheal stenosis.

The use of an inert stent as an adjunct to surgical procedures to correct laryngotracheal stenoses remains somewhat controversial. It is the purpose of this report to describe the use of long-term stents in seven patients with either acute or chronic laryngotracheal stenoses. The conclusion from this series is that stenting for prolonged periods of time represents a valuable adjunctive technique in the correction of the more severe airway reconstruction problems.

Child↗
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Repair of supraglottic laryngeal stenosis with postcricoid involvement. A case report.

A supraglottic stenosis with postcricoid stenosis was successfully corrected in a single stage procedure by excising the scar tissue and the arytenoid cartilage and the use of mucosal flaps to recover the right side of the larynx and postcricoid area. By obtaining good mucosal approximation without tension the need for a free skin graft or mucosal graft was avoided.

Adult↗
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Histopathology of acquired subglottic stenosis. A documented case report.

The history of a 2,900 g infant who had no stridor at birth and developed subglottic stenosis is presented in detail. The laryngeal lumen, which accepted a 3 mm endotracheal tube at one day of age, diminished to total occlusion at 15 months of age. There was an 8-day intubation and tracheotomy at nine months. At 19 months the patient expired from associated cardiac problems; the larynx was obtained at autopsy and was serially sectioned in the horizontal plane. A series (Imm-Tracer) of 12 sections through the stenotic area is presented. It demonstrates gross distortion of the cricoid cartilage with ossification extending into the right paraglottic larynx.

Glottis↗
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Epiglottic laryngoplasty for complicated laryngeal stenosis.

The technique of epiglottic laryngoplasty, previously described for reconstruction following near total laryngectomy for glottic carcinoma, has been used in selected patients with severe glottic and subglottic stenosis. Our experience in four patients suggests that it is useful for 1) laryngeal stenosis in which there is loss or collapse of the external cartilaginous framework, and 2) laryngeal stenosis which is refractory to the usual forms of therapy. The technique is a technically simple, one-stage procedure which provides its own endolaryngeal mucosal lining, as well as autogenous cartilaginous support. It has been successful in restoring adequate airway and preserving voice without interfering with deglutition or laryngeal competence in most patients.

Adult↗
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Pseudolaryngeal paralysis: a postintubation complications.

Seven patients in the pediatric age group who had severe posterior glottic stenosis are reported. All of these patients had been misdiagnosed as having bilateral vocal cord paralysis because of errors in observing the actual findings in the larynx. On cursory examination of the larynx, the findings resembled vocal cord paralysis, thus the name "pseudolaryngeal paralysis" was given to this disease entity. This paper describes in some detail the case histories, the endolaryngeal findings, and the therapy which was instituted and followed. The difficulties in managing this problem are also reviewed. Three of the seven patients were decannulated, two with persistent stress, stridor and reduced exercise tolerance. Four other patients have improved, but are still in the process of being treated. The success of the therapy appears to be dependent on the severity of the scarring, whether there was fibrosis of the interarytenoideus muscle, and whether the cricoarytenoid joints were involved. It is hoped that by reporting this difficult problem, a more rapid and successful form of management will be developed.

Adolescent↗
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Treatment of laryngeal stenosis. A conservative new approach.

One of the most perplexing problems in laryngology is the treatment of laryngeal scar tissue. This can be supraglottic, glottic, or infraglottic. Two acceptable methods of treatment have been surgical and endoscopic. Endoscopic treatment consists of dilatation, excision of scar tissue with a laser, removal of scar tissue with insertion of a stent, and removal and scar tissue with injection of intralesional cortisone. Twelve cases are reported, treated with microscopic removal of scar tissue followed by voice rest and beclomethasone dipropionate (Vanceril) inhalations, a topical steroid. All twelve cases showed marked improvement measured by improved glottic opening and improvement of voice quality. Further evaluation of this method of treatment should be done as an auxiliary treatment to our present accepted regime of treatments in this troublesome condition.

Adult↗
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Laryngotracheal reconstruction in children. Five-year follow-up.

Congenital and acquired subglottic stenosis is a commonly encountered problem in the pediatric population. In acquired cases endotracheal intubation is responsible for its development in the great majority of cases, but high tracheotomy, laryngeal burns, external neck trauma, and tumors, both intrinsic and extrinsic, are occasionally seen. The management of mature subglottic stenosis in children remains a controversial issue. The prevailing attitude of otolaryngologists is to perform a tracheotomy and hope for decannulation after one or two years, due to the expected growth of the larynx. Unfortunately, some of the acquired lesions are so severe that often no lumen is demonstrable. In such cases no amount of growth will allow extubation. A variety of endoscopic methods, such as dilation with or without resection using diathermy or laser, are certainly helpful in the early phases of wound healing while the scar tissue is soft and pliable. To deal with the mature, hard, fibrous, unresponsive scar various authors have proposed differing laryngotracheal reconstructive techniques. The authors discuss a unique experience of laryngotracheal reconstruction in 103 children. They define their indications for the three procedures that are most widely used, and address the issue raised by opponents of laryngotracheal reconstruction in children, namely the consideration that laryngeal growth potential may be adversely affected by such external operations. The authors have evidence that this has not occurred in 35 cases followed for a minimum of five years.

Cartilage↗