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Predictive factors of success or failure in the endoscopic management of laryngeal and tracheal stenosis.

Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

Adolescent↗
PubMedDate not supplied

Treatment of severe subglottic stenosis without tracheotomy: a preliminary report.

Subglottic stenosis in neonates, infants and children is one of the most challenging problems confronting the pediatric otolaryngologist today. Small patients with congenital or acquired stenosis were enough to require tracheotomy must undergo repeated endoscopic procedures or laryngotracheal reconstruction; weeks, months, or years may be required to attain a lumen large enough to permit decannulation. During 1981, six infants and children with severe subglottic stenosis were managed without tracheotomy. The surgical technique employed involves endoscopic excision of the offending subglottic tissue using the CO2 laser and suspension microlaryngoscopy. Intraoperative intubation is avoided by using an insufflation technique for general anesthesia which permits unobstructed visualization of the larynx, thereby avoiding laryngeal trauma and edema.

Female↗
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Chevalier Jackson Lecture. Congenital laryngeal webs.

Congenital laryngeal web is not as common as has been previously believed, and thorough clinical, radiographic, and endoscopic assessment is needed before any form of surgical treatment is undertaken. It is important to detect associated anomalies in the larynx, the respiratory tract, or in other organ systems. The results of treatment with regard to voice quality are good only in thin, membranous, uncomplicated webs. Treatment for thick webs with or without associated congenital subglottic stenosis remains unsatisfactory.

Child↗
PubMedDate not supplied

Antibiotics and steroids in the treatment of acquired subglottic stenosis. A canine model study.

The efficacy of a combination of systemic antibiotics and a steroid in the prevention of acquired subglottic stenosis (ASGS) was evaluated employing a previously developed canine animal model. Thirty-five healthy, postweanling mongrel puppies aged 5 weeks were each intubated for 14 days with an uncuffed polyvinyl endotracheal tube. Twenty puppies received intramuscular dexamethasone (1 mg) daily, and procaine penicillin (100,000 IU) and dihydrostreptomycin (0.125 g) in two divided doses on the day of intubation and each day thereafter until the completion of the study. The remaining 15 puppies served as a control group and received no medical therapy. Animals from both groups were killed at 5, 7, 12, 15, 20, 30, and 56 days following intubation. Comparative examinations of the laryngotracheal complexes of treated and control dogs showed that there was no significant difference between the two groups in the ultimate degree of ASGS attained, as determined by intraluminal cross-sectional area analysis, or in the extent of the lesion as documented by gross and microscopic histology. This investigation showed that the specific systemic combination of two antibiotics and a steroid used in the study was not efficacious in the prevention of ASGS in a canine animal model; for this reason we question the benefit of analogous medical regimens employed to prevent ASGS in infants and children who require long-term endotracheal intubation.

Animals↗
PubMedDate not supplied

Congenital laryngeal atresia. Histopathologic study of two cases.

Two specimens of laryngeal atresia were studied. In the first case stenosis was hard due to noncanalization of the anterior cricoid cartilage. In the second case there was a soft stenosis from limited canalization of the endoluminal soft tissue. Additionally, the first case had a posterior cleft with a persistent pharyngotracheal duct. The stenotic soft-tissue elements in both cases contained striated muscle fibers that interdigitated across the midline. The mucosa on the inferior surface of the hard stenosis was grossly thickened and contained large mucous glands. The embryologic significance of these anomalies is discussed. Presumably these cases represent anomalies caused by different embryologic events.

Epiglottis↗
PubMedDate not supplied

Endotracheal tube movement in the preterm neonate: oral versus nasal intubation.

Endotracheal intubation of a preterm infant cadaver was performed both orally and nasally to assess the relative movement of the endotracheal tube with changes in head position. For each method of intubation, anteroposterior radiographs were obtained with the head in neutral, flexed, extended, and laterally rotated positions. The results indicate slightly increased movement of the nasotracheal tube with flexion and rotation, and markedly increased movement with extension. The possible relationship between tube movement and the development of subglottic stenosis is discussed.

Head↗
PubMedDate not supplied

Chronic laryngeal stenosis.

The results of treatment of 82 patients with chronic laryngeal stenosis during a 20-year period are presented. Road traffic accidents accounted for 30% of the cases and iatrogenic disease for 40%. Of the stenoses 10% were supraglottic, 20% glottic, 50% subglottic, and 15% combined. Virtually all patients with supraglottic stenosis had a good result as regards voice and airway, and we describe the use of a laryngeal widening operation for this group of patients. Over 80% of patients with glottic stenosis achieved good results. However, patients with a subglottic stenosis did badly, and only 60% were relieved of their tracheostomies. Patients with stenosis due to previous tracheostomy or to systemic disease such as Wegener's granuloma did badly.

Adolescent↗
PubMedDate not supplied

Epiglottis in reconstruction of the larynx and trachea.

Many methods have been proposed for reconstruction of the larynx and trachea. An ideal method would utilize tissue which is native to the area, highly viable, convenient to the surgeon, and expendable to the patient. This tissue should be composite, that is, containing both epithelium and skeletal support. This paper describes the use of epiglottis in repair of laryngeal and tracheal defects due to cancer or trauma. The methods of repair include 1) pedicled composite epiglottic flap, 2) free composite epiglottic graft, and 3) pedicled epiglottic mucosal flap. Results in 15 patients are discussed and indicate that use of the epiglottis is an effective method for one-stage laryngotracheal reconstruction.

Adolescent↗
PubMedDate not supplied

High frequency ventilation through a small catheter for laser surgery of laryngotracheal and bronchial disorders.

One-lung and two-lung high frequency ventilation (HFV) through a 2-mm internal diameter catheter was evaluated in 22 patients during endoscopic laser excision of stenotic lesions of larynx, trachea, and bronchi. High frequency ventilation at 80 to 250 breaths per minute using air during two-lung HFV and using air-oxygen at an inspired oxygen concentration of 25% during one-lung HFV maintained adequate alveolar ventilation and oxygenation in all patients. The use of HFV through a catheter allowed continuous control of ventilation and provided maximal surgical exposure for endoscopic laser surgery. The continuous outflow of HFV gases through the endoscope also prevented lung contamination with blood and debris. The potential of HFV polyvinylchloride catheter ignition by laser was also evaluated in the laboratory during continuous flow of air-oxygen and oxygen-nitrous oxide. The laser ignited polyvinylchloride tubes in all the mixtures of oxygen and nitrous oxide within 3 to 7 seconds. Oxygen at 30% mixed with nitrogen 70% was safe and all such tubes were not ignited by the laser. The ability of HFV to provide adequate oxygenation during endoscopic laser surgery using air-oxygen at an FiO2 below 30% also avoids the hazard of catheter and airway fire.

Aged↗
PubMedDate not supplied

Laryngeal stenosis following carbon dioxide laser in subglottic hemangioma. Report of three cases.

Recent reports recommend carbon dioxide laser as the safest and the most effective treatment for subglottic hemangioma in infants. Though one report mentions the development of a small amount of subglottic scarring in an 8-month-old girl after resection of a subglottic hemangioma, there is insufficient emphasis in the literature with respect to stenosis as a complication of CO2 laser therapy. The authors present three cases of severe laryngotracheal stenosis developing in infants treated with the CO2 laser for subglottic hemangioma. The presentation of these three cases should be a warning to the otolaryngologist that the use of the CO2 laser is not without significant risk of scar tissue formation.

Carbon Dioxide↗
PubMedDate not supplied

Carbon dioxide laser management of laryngeal stenosis.

A retrospective review of 20 cases of laryngeal stenosis treated with the carbon dioxide laser was conducted at the Medical College of Wisconsin and Northwestern University. The stenoses were grouped into four categories: supraglottic, glottic, subglottic, and combined glottic-subglottic. Twenty patients had 21 lesions excised by 40 laser procedures. Eleven of 21 stenoses were successfully managed by carbon dioxide laser endoscopy: 3 of 3 supraglottic, 6 of 10 glottic, 2 of 4 subglottic, and 0 of 4 combined laryngeal/tracheal stenoses. Eleven of the 20 patients had significant airway improvement or decannulation. Soft tissue stenoses of the supraglottic area respond favorably to carbon dioxide laser excision. In other regions of the larynx, the use of supplemental stents, steroid injections, dilatations, and the micro-trapdoor surgical flap technique in scar stenosis may increase the rate of success. The lower success rate in the posterior commissure, subglottic, and combined laryngotracheal stenoses is due to the circumferential, thick stenosis with a vertical depth of more than 1 cm and the fibrotic fixation of the arytenoid cartilages. Small cicatrices appear to respond better to laser vaporization than the large ones which frequently recur.

Adolescent↗
PubMedDate not supplied

Cricoid resection and thyrotracheal anastomosis in the growing primate.

Although many procedures have been described for the correction of subglottic stenosis in the infant and child, none has been universally satisfactory. Cricoid resection and thyrotracheal anastomosis have been successful in adults, and we considered that the same techniques could be applied to correct subglottic stenosis in infants and children. A feasibility study was undertaken using young primates as a surgical model. The operation in each was accomplished uneventfully, although one animal later developed a complication possibly due to the use of a tissue adhesive. In practice, this complication could have been corrected without compromising the surgical outcome.

Animals↗
PubMedDate not supplied

Experience with partial cricoid resection and thyrotracheal anastomosis.

Since 1973, 28 patients have undergone tracheal and subglottic resection with reconstruction by primary laryngotracheal anastomosis. Nine patients had postintubation stricture, eight had blunt trauma with cricotracheal disruption, seven had a neoplasm, two had an inhalation burn, and two had idiopathic stenosis. In all cases, the anterior cricoid arch was completely resected and a submucosal segment of the posterior cricoid plate was partially resected. A posterior shell of cricoid plate was preserved in 21 patients with intact laryngeal nerve function. Postoperatively, a Montgomery T-tube was used to stent the anastomosis and subglottic area in ten patients, all of whom had residual injury or disease at or immediately below the level of the cords. The proximal arm of the T-tube was positioned above the vocal cords. The tube was removed within 1 month in eight patients and remained for 3 and 18 months in the other two. The extent of resection varied from 2.5 to 7 cm. Tension-relieving procedures were added in 13 cases. Fourteen patients have been followed longer than 5 years, and five patients for more than 10 years. A widely patent anastomosis was maintained in 26 patients. In two patients, a partial restenosis resulted in some limitations of exercise tolerance. Voice and exercise tolerance have not deteriorated with the passage of time. Recurrent laryngeal nerve function was completely preserved in 20 of the 21 patients whose nerve function was intact before operation.

Adolescent↗
PubMedDate not supplied

Staged repair of extensive tracheal and laryngotracheal stenoses.

The usual operative procedures (primary tracheal anastomosis, cricotracheal anastomosis, skin grafting and stenting, pedicle cartilage grafts, or free rib grafts) used to correct stenoses of great length involving the trachea or laryngotrachea have a high incidence of failure. An alternative method of reconstruction is the open technique, which requires three stages. The initial stage creates a trough after resection of the stenotic area, followed by subcutaneous embedding of a rigid material adjacent to the trough, and finally closure of the trough by reformation of the anterior wall. This staged procedure has been used in adult patients with tracheal stenoses greater than 4 cm, in patients with tracheal stenoses involving the cricoid, and in patients whose primary corrective operative procedures have failed. This paper critically assesses 30 patients who have had a staged reconstruction with a minimum follow-up of 12 months. The indications, number of procedures performed, time required for decannulation, complications, and analysis of failures are presented. The incidence of success in this series of patients is 76% (23/30).

Adolescent↗
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Risk factors for neonatal acquired subglottic stenosis.

Endotracheal intubation has proven to be a relatively safe and effective means of securing the airway in neonates. Some concern remains, however, regarding airway management in critically ill infants who require assisted ventilation for extended periods. Among the various risk factors associated with the complication of acquired subglottic stenosis in neonates, the one most frequently cited has been "prolonged" intubation, although opinion varies regarding the definition of this term. Various recommendations exist that attempt to establish the limits of "safe" periods of intubation for infants. Some feel that tracheotomy is indicated when airway support is required beyond those limits. In an attempt to define important risk factors involved in the development of neonatal subglottic stenosis, a retrospective analysis of infants admitted to the Neonatal Intensive Care Unit of Columbus Children's Hospital who required intubation during a 3-year period from 1977 to 1980 was undertaken. Of 343 infants who survived hospitalization, five patients were identified as having acquired subglottic stenosis. The average duration of intubation for these five patients was 56.2 days. The incidence of subglottic stenosis for infants whose duration of intubation ranged from 3 to 50 days was 0.4% (1/245). Infants with birth weights less than 1,500 g appeared more susceptible to the development of intubation-related laryngeal injury. The conclusion of this study is that endotracheal intubation is an appropriate means of long-term airway management in neonates hospitalized in a pediatric intensive care unit, providing other known risk factors are minimized.

Birth Weight↗
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Subglottic stenosis: retrospective analysis and proposal for standard reporting system.

A retrospective analysis was undertaken reviewing management of 67 patients treated for subglottic stenosis (SGS) at the Children's Hospital National Medical Center (CHNMC) between 1980 and 1985. Forty-seven (90%) of the patients were followed for at least 18 months from the time diagnosis was made. Twenty-three (66%) of the patients followed for at least 18 months were successfully decannulated or had an adequate airway without tracheotomy. To compare efficacy of management of SGS at the CHNMC with management outcomes previously reported, a review of medical literature was undertaken and data from the most significant reports on management of SGS were collated and tabulated. Since analysis of published reports did not yield a consensus regarding optimal methods for management, and statistics in many published reports were absent or unclear, authors of the previously published reports were contacted personally by means of a letter and survey questionnaire. Results of the survey show that many authors have not performed a statistical review of their case data to determine relative efficacy of different surgical procedures. Thus, retrospective review of cases managed at the CHNMC as well as information obtained from leading experts in management of SGS indicate that there is no single optimal procedure or technique for management of all cases of SGS. Further, the way in which surgical procedures for management of SGS are being reported makes difficult the process of meaningfully comparing results reported by different surgeons. A reporting system is proposed that uses specific terms and objective parameters.

Adolescent↗
PubMedDate not supplied

Pathogenesis of subglottic stenosis from endotracheal intubation.

Subglottic stenosis is more likely to develop secondary to endotracheal intubation if one or more trauma-related risk factors are involved. Ulcerations occur most often in the posterior-lateral cricoid ring. They vary in size and may involve the entire circumference of the subglottic area. The ulcerations heal with fibrous scarring which, if extensive enough, results in subglottic stenosis.

Glottis↗