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PubMed2007

Combined endoscopic and open approach to the removal of expandable metallic tracheal stents.

OBJECTIVES: To review complications of indwelling tracheal stents and to describe a technique of stent removal using a combined open and endoscopic approach. DESIGN: Descriptive case series. SETTING: Medical University of South Carolina. PATIENTS: Six patients were identified who had undergone combined open and endoscopic removal of indwelling tracheal stents. Coated (4 patients) and uncoated (2 patients) expandable metal stents had been present for an average time of 24 months (range, 5-60 months) before removal. MAIN OUTCOME MEASURES: Medical comorbidities, characteristics of the underlying airway lesion (origin, type, and length), stent characteristics (type and duration), and the presentation and management of stent-related complications. RESULTS: All patients presented with worsening dyspnea and/or stridor, with 3 requiring intubation. Stent removal was performed in the operating room and consisted of initial exposure of the trachea for emergency airway access, removal of the indwelling stent under bronchoscopic and transtracheal guidance, and tracheotomy. Two patients experienced desaturations of more than 25% during the procedure, and 2 patients had stents that could be only partially removed. Five patients subsequently received Montgomery T-tubes without complications after a mean follow-up of 23 months (range, 6-40 months). CONCLUSIONS: Indwelling tracheal stents are becoming increasingly common in the management of benign airway stenosis. The stents frequently occlude with granulation tissue and may require removal. A combined open and endoscopic removal maximizes airway protection and minimizes potential complications.

Adolescent↗
PubMed1975

Innominate artery compression of the Trachea.

We review innominate artery compression of the trachea in 60 surgically corrected patients and 30 in patients who did not undergo surgery. The symptoms and radiologic features are correlated with the degree of tracheal narrowing at bronchoscopy and with associated defects that may exist. From this study, a history of respiratory distress with "reflex apnea" associated with tracheal narrowing is a strong indication for surgery. Stridor and recurrent respiratory infections are not an indication in themselves, and must be assessed with the severity of tracheal narrowing and presence or absence of associated defects. Surgery resulted in complete or moderate relief in most patients, although the results were less gratifying when subglottic stenosis or a repaired tracheoesophageal fistula existed.

Brachiocephalic Trunk↗
PubMed1976

Congenital complete tracheal rings. Report of a case.

An unusual congenital tracheal anomaly is described. Complete (closed) tracheal rings, occupying the entire length of the trachea, have seldom been reported. Most affected patients succumb to respiratory infections in early infancy. Diagnosis of this anomaly is difficult during life, but radiographic and endoscopic examinations may be revealing. There is no known definitive treatment, although the airway may be managed long enough for body growth to relieve the obstruction. This rare anomaly should be considered in those cases of intermittent respiratory obstruction that are not associated with other more common causes of stridor.

Humans↗
PubMed1981

Functional upper airway obstruction. A new syndrome.

Functional airway obstruction is an uncommon condition that must be considered in adults with apparent airway distress. The disorder is characterized by stridor without abnormal physical findings on laryngeal examination other than intense vocal cord adduction. Three patients had functional upper airway obstruction documented by objective criteria. In each case the respiratory embarrassment was severe enough to warrant tracheostomy. A thorough search for systemic causes did not reveal an organic etiologic factor. Psychiatric evaluation demonstrated psychological disorders in each case. Functional airway obstruction represents an important consideration in the differential diagnosis of airway obstruction in the adult.

Adult↗
PubMed1981

Bacterial tracheitis.

Bacterial tracheitis is a recently described clinical entity characterized by high fever, stridor, and airway obstruction. Laryngoscopy shows membraneous inflammation with notable subglottic edema and copious mucopus in the trachea. Staphylococcus aureus is the most common bacterium to be cultured. Subglottic narrowing can be seen on lateral soft-tissue roentgenograms of the neck. Bacterial tracheitis should be treated by establishing a controlled airway by endotracheal intubation or tracheotomy, rather than by usual modalities used for the treatment of croup. Bacterial tracheitis seems to be similar to croup but is more likely to be fatal. Two of the five patients described herein died.

Child↗
PubMed1983

Laryngeal problems in the scimitar syndrome.

The scimitar syndrome is a congenital anomaly of the venous system of the right lung. This diagnosis is suspected when a scimitarlike shadow is found on the thoracic roentgenogram; the definitive diagnosis is made by angiography when an abnormal outflow of the venous system of the right lung is found. Dyspnea and recurrent infections are the most prominent clinical feature. In a child with the scimitar syndrome, a laryngeal anomaly was found that caused stridor from birth onwards. A right-sided arytenoidectomy was performed with relief of all the symptoms. The follow-up period has been two years.

Abnormalities, Multiple↗
PubMed1984

Congenital vascular anomalies causing tracheoesophageal compression.

Congenital vascular anomalies of the great vessels causing marked tracheoesophageal compression are rare. Notable symptoms usually manifest in the neonatal period and include stridor, repeated cyanotic attacks, recurrent pneumonia, and dysphagia. Although the diagnosis can often be made from barium swallow studies, the preoperative examination should nevertheless include an endoscopy. This is essential if the degree of tracheomalacia is to be adequately assessed and other tracheobronchial abnormalities are to be identified. Possible airway problems can then be anticipated, thus minimizing postoperative respiratory difficulties.

Aorta, Thoracic↗
PubMed1988

The anterior cricoid split. Clinical experience with extended indications.

A recommended approach to postextubation infant subglottic stenosis secondary to subglottic edema employs the recently described anterior cricoid split (ACS) procedure. This technique provides an expanded subglottic airway with minimal paratracheal dissection and does not require concomitant tracheotomy. We applied this procedure in managing extubation difficulty in pediatric as well as neonatal patients. Five of ten patients in our series did not fulfill the traditional criteria for ACS. Relief of stridor and avoidance of tracheotomy were accomplished in nine of ten patients. One patient in whom mechanical ventilation was reinstituted developed an interesting complication. In properly selected infants with subglottic airway compromise, the ACS appears to be an effective adjunct in facilitating extubation.

Child, Preschool↗
PubMed1989

Hereditary agenesis of nasal cartilage. Surgical implications.

In the evaluation of a patient for cosmetic surgery, an underlying congenital origin for the deformities noted, with possible expression in multiple organ systems, should always be considered. In this case, a 19-year-old woman requesting rhinoplasty exhibited facial anomalies: lack of quadrangular and lower lateral cartilages, small bony dorsum, underdeveloped aural cartilage, and infantile larynx and trachea. Otherwise healthy, she recalled having recurrent bouts of croup until she was 15 years old, exercise limitation secondary to stridor, and a family history of nasal hypoplasia. Genetic referral diagnosed her condition as Opitz-BBB/G compound syndrome (oculogenitolaryngeal syndrome), and we here review its head and neck manifestations. Suspected agenesis of nasal cartilage, unreported in previous literature (to our knowledge), was confirmed intraoperatively and presented a unique challenge for reconstruction, including a restricted choice of anesthesia and a need for banked cartilage.

Abnormalities, Multiple↗
PubMed1990

Subglottic cysts in the premature infant.

Supraglottic cysts in the newborn are a well-recognized entity, but subglottic cysts have been rarely reported. Over the past 6 years we have observed subglottic cysts in nine patients with relatively long intubations from the neonatal intensive care unit of two university hospitals. Most frequently the patients were extubated and did well for weeks or months, but then they had progressive biphasic stridor. On endoscopy the patients had a subglottic stenosis that was irregular but with a smooth mucosal lining. Usually the cysts were apparent, but in two patients the mucosa was thickened and the patients were treated as a subglottic stenosis with tracheostomy. These subglottic cysts were recognized at the time of laryngotracheoplasty. In six patients the cysts were managed either by marsupialization with cup forceps, endoscopic diathermy, or carbon dioxide laser without recurrence. It is our belief that this condition is most likely due to scarring and obstruction of mucus glands of the subglottic area from prolonged intubation. This entity should be recognized and looked for in the neonate who has an acquired subglottic stenosis and should first be treated conservatively with endoscopic marsupialization.

Child, Preschool↗
PubMed1991

Endoscopic repair of supraglottic laryngeal clefts.

We describe the technique of endoscopic diagnosis and endoscopic surgical repair used in the management of supraglottic interarytenoid laryngeal clefts in 11 children seen between 1981 and 1988 at the Hospital for Sick Children, London, England. Six of the children had primary type I clefts that required endoscopic repair. The symptoms included inspiratory stridor, choking during eating, and aspiration. Five of the children had previous transcervical repair of type II clefts that had partial breakdown in the interarytenoid area causing symptoms of aspiration, which required secondary repair endoscopically. All the patients had successful microlaryngoscopic closure; in two children, however, the breakdown of the repair necessitated repeated endoscopic correction. The only complication occurred in a case of postoperative supraglottitis, which was successfully managed with intubation and antibiotics. We conclude that endoscopic repair is a useful and reliable technique and an elegant alternative to the open transcervical approach for the closure of supraglottic laryngeal clefts.

Adolescent↗
PubMed1992

Vertically fused tracheal cartilage. An underrecognized anomaly.

Anterior vertical fusion of the tracheal cartilages with normal pars membranacea is a rarely described tracheal anomaly. We report four cases of this anomaly, three associated with craniosynostosis syndromes and one with Goldenhar's syndrome. The anomaly was documented at postmortem examination in one case, both endoscopically and at tracheotomy in two cases, and endoscopically in one case. Documentation from gross postmortem photographs, photomicrographs, and intraoperative endoscopic photographs is presented so that the anatomical aspects of this anomaly can be thoroughly understood and recognized. All four newborn patients developed recurrent lower respiratory tract infections, reactive airway disease, and chronically retained secretions attributable to this anomaly. Neither tracheal stenosis nor stridor was encountered. In the three surviving patients, the infections grew less frequent and less severe in later childhood. These observations suggest that this tracheobronchial anomaly may be associated with a variety of craniofacial syndromes and may alter airflow dynamics in a way that predisposes to retained secretions and chronic pulmonary disease.

Abnormalities, Multiple↗
PubMed1993

Herpes laryngitis and tracheitis causing respiratory distress in a neonate.

A newborn presented 1 week after birth with the sudden onset of stridor and respiratory distress. At endoscopy, the supraglottic and subglottic tissues were edematous and erythematous, and numerous plaquelike ulcers were seen on the mucosal surface. Cultures of the lesions yielded herpes simplex virus type 2. The infant required a prolonged course of acyclovir and remained intubated for 31 days, but ultimately had both virological and clinical cure. Evaluation and further treatment of this unusual presentation of herpes simplex virus are discussed, as are the implications of herpes infections in neonates.

Acyclovir↗
PubMed1993

Carbon dioxide laser serial microtrapdoor flap excision of subglottic stenosis.

The recent development of microspot micromanipulators for the carbon dioxide laser with 250-microns spot sizes has greatly facilitated the extension of endolaryngeal procedures to children and neonates. It is possible to accurately develop microtrapdoor flaps within the limited exposures in the pediatric subglottis. We have used serial microtrapdoor flaps in the excision of subglottic scar tissue in eight children. In five children, the stenosis was improved with relief of stridor. In three children, the flaps were used as an adjunct to laryngotracheoplasty. The surgical techniques of this procedure are detailed in this report.

Child↗
PubMed1994

Congenital tracheal stenosis. The otolaryngologist's perspective.

Congenital tracheal stenosis is a rare congenital anomaly, with less than 70 reported cases in the literature. The presenting signs and symptoms of stridor, recurrent pneumonia, and respiratory distress are commonly seen in other conditions. The rarity of congenital tracheal stenosis and the diverse presentations make accurate early diagnosis difficult and frequently lead to inappropriate treatment. We treated three patients with congenital tracheal stenosis who presented with different sites of stenosis. Each patient displayed different symptoms and required individualized management. The treatment of congenital tracheal stenosis depends on identifying the site and extent of the stenosis. We reviewed the embryogenesis and treatment of this abnormality and developed a new classification system that will aid in the management of congenital tracheal stenosis.

Female↗
PubMed1994

Acquired subglottic cysts in infancy.

OBJECTIVE: To evaluate the presentation and treatment of infants with acquired subglottic cysts. DESIGN: Case series seen over 12 years. SETTING: Academic tertiary referral pediatric medical center. PATIENTS: Eleven patients had subglottic cysts diagnosed. INTERVENTION: Four patients were treated with rupture with the tip of the endoscope. Seven patients underwent endoscopic marsupialization by means of carbon dioxide laser (n = 5) and by cup forceps (n = 2). OUTCOME MEASURES: Intraoperative cyst control. Symptomatic cyst recurrence. RESULTS: Initial cyst management was successful in all cases. There was one symptomatic recurrence in a patient who was managed with cyst rupture. There were no symptomatic recurrences in the group treated by marsupialization. The mean follow-up period was 6 years. CONCLUSIONS: Subglottic cysts should be considered in the ex-premature infant with a history of neonatal intubation who presents with stridor or respiratory difficulty. These ductal retention cysts can develop after periods of intubation of less than 24 hours. Endoscopic marsupialization is the recommended form of treatment.

Child, Preschool↗
PubMed1995

Management of posterior laryngeal and laryngotracheoesophageal clefts.

OBJECTIVE: To review the clinical features, associated congenital abnormalities, management, and morbidity of infants presenting with posterior laryngeal and laryngotracheal clefts. DESIGN: Case series. SETTING: Great Ormond Street Hospital for Sick Children NHS Trust, London, England. PATIENTS: Consecutive sample of 44 patients presenting with posterior laryngeal and laryngotracheal clefts between December 10, 1979, and January 30, 1992. MAIN OUTCOME MEASURES: Clinical features, incidence of surgery, and associated morbidity and mortality related to different types of airway cleft. RESULTS: The main presenting features were stridor and aspiration, which were more evident with the more extensive clefts. Twenty-five patients (56%) had associated congenital abnormalities. Fourteen patients (32%) were treated conservatively. Sixteen patients (36%) underwent primary endoscopic surgical repair. Eight patients (18%) underwent primary repair via an anterior laryngofissure; and six patients (14%) underwent primary repair via a lateral pharyngotomy. Eight patients (18%) required revision surgery, two (4%) of them on more than one occasion. Ten patients (23%) required fundoplication to control gastroesophageal reflux. Six patients (14%) died. CONCLUSIONS: The identification of an airway cleft requires a high index of suspicion. Morbidity and mortality are reduced by securing the airway, controlling gastroesophageal reflux, and using a multidisciplinary pediatric team. We recommend the anterior laryngofissure because of the ease of surgical access.

Abnormalities, Multiple↗
PubMed1997

Brief bilateral vocal cord paralysis after insecticide poisoning. A new variant of toxicity syndrome.

We describe a new variant of life-threatening organophosphate toxicity syndrome that produces a brief bilateral vocal cord paralysis. There are 3 recognized types of toxicity syndrome: acute (instantaneous), intermediate (slightly delayed, i.e., hours to days), and delayed (weeks to months). Ingestions of large doses of insecticides lead to a cholinergic crisis and possible death (acute-type syndrome). Exposures to lower doses may cause the intermediate- or delayed-type syndrome. The intermediate-type syndrome is characterized by slightly delayed polyneuropathy and generalized weakness. Transient vocal cord paralysis has also been reported in association with other neurologically profound findings. The delayed-type syndrome can produce muscle weakness for months. Our patient, a 2-year-old boy, was found eating a substance later found to be contaminated with insecticide. Within minutes, fever and somnolence developed, followed by progressive respiratory distress and stridor, without generalized weakness. The child's condition progressed to complete airway obstruction, and intubation was necessary. Emergency laryngoscopy and bronchoscopy were performed to rule out epiglottitis or a foreign body. Instead, a bilateral vocal cord paralysis was found. The paralysis lasted 2 days before completely resolving. Insecticide poisoning was suspected. We theorize that our patient manifested a combination of the acute-type syndrome, because of the immediacy of the onset of the symptoms (i.e., fever and somnolence), and the intermediate-type syndrome, because of the transient vocal cord paralysis. Because of the potential dangers involved, we wish to familiarize physicians concerning organophosphate poisoning; to alert the medical community to this variant of toxicity syndrome, which involves transient bilateral vocal cord paralysis; and to demonstrate the benefit of early otolaryngological consultation for the prevention and treatment of airway obstruction in patients with suspected organophosphate poisoning, be it from insecticides or poison gas.

Child, Preschool↗