To describe technical aspects and surgical outcomes of endoscopic resection and mucosal reconstitution with epidermal grafting (ie, the Maddern procedure) in the treatment of idiopathic subglottic ...stenosis.
Medical record abstraction.
Johns Hopkins Hospital.
Retrospective series of 9 adults with idiopathic subglottic stenosis who underwent the Maddern procedure by a single surgeon over a 5-year period. Prespecified outcomes included (1) perioperative outcomes (Clavien-Dindo grade 4/5 complications, need for staged tracheostomy, hospital length of stay), (2) postoperative outcomes (peak expiratory flow rate PEFR, need for subsequent airway surgery, tracheostomy at follow-up), and (3) patient-reported quality-of-life outcomes (Clinical COPD Questionnaire, Voice Handicap Index-10, Eating Assessment Tool-10, and 12-Item Short Form Version 2). Wilcoxon matched-pairs signed rank test and Kaplan-Meier analysis were performed.
There were no Clavien-Dindo grade 4/5 complications; 2 patients required unplanned staged tracheostomy; and the median length of stay was 3 days. Following endoscopic resection and stent removal, a median of 2 laser resurfacing procedures were required. Two patients developed recurrent stenosis requiring cricotracheal resection (CTR). There were significant improvements in PEFR, Clinical COPD Questionnaire, and Voice Handicap Index-10, without significant difference in Eating Assessment Tool-10. The 12-Item Short Form Version 2 approximated the population norm. Kaplan-Meier analysis demonstrated significant improvement in time to surgery after the final laser resurfacing.
The Maddern procedure has a low complication rate and offers durable physiologic improvement in PEFR, limiting need for additional procedures. Risks included need for CTR salvage, temporary tracheostomy, phlegm accumulation, and laryngospasm. It is a surgical option for patients with short dilation intervals who prefer to avoid the risks of CTR.
A 59-year-old man presented to the emergency department with recent onset biphasic stridor, dyspnoea and increased work of breathing on the background of prolonged intubation for the novel COVID-19 2 ...months previously. Flexible laryngoscopy revealed bilateral vocal fold immobility with a soft tissue mass in the interarytenoid region. The patient’s symptoms improved with oxygen therapy, nebulised epinephrine (5 mL; 1:10 000) and intravenous dexamethasone (3.3 mg). The following morning, the patient was taken to theatre, underwent suspension microlaryngoscopy and found to have bilateral fixation of the cricoarytenoid joints and a large granuloma in the interarytenoid area. He underwent cold steel resection of the granuloma and balloon dilatation between the arytenoids, with the hope of mobilising the joints. This failed and CO2 laser arytenoidectomy was performed on the left side. The stridor had resolved postoperatively, with normalisation of work of breathing and the patient was discharged home on the first postoperative day.
Introduction
Informed consent for any surgical intervention is necessary, as only well-informed patients can actively participate in the decision-making process about their care, and better ...understand the likely or potential outcomes of their treatment. No consensus exists on informed consent for suspension microlaryngoscopy (SML).
Materials and methods
Informed consent procedures in nine countries on five continents were studied.
Results
Several risks can be discerned: risks of SML as procedure, anesthesiologic risks of SML, specific risks of phonosurgery, risks of inadequate glottic exposure or unexpected findings, risks of not treating. SML has recognized potential complications, that can be divided in temporary (minor) complications, and lasting (major) complications.
Conclusion
SML is a safe procedure with low morbidity, and virtually no mortality. Eleven recommendations are provided.
Written by recognized international experts, this book provides practicing professionals with an up-to-date, accessible reference text for managing stenosis of the larynx, trachea or bronchi. The ...editors have treated a significant number of patients with this condition and have collected objective and scientifically validated outcome measures, thus establishing a balanced and scientific approach to literature review and the material presented.
Objective/Hypothesis
The study's objective was to determine the utility of expiratory disproportion index (EDI), the ratio of forced expiratory volume in 1 second (FEV1) to peak expiratory flow rate ...(PEFR) (EDI = FEV1L/PEFRL/s × 100), in differentiating between laryngotracheal stenosis (LTS) and other respiratory diagnoses. LTS is an uncommon complication of mechanical ventilation or vasculitis or a manifestation of airway compression or malignancy. It frequently masquerades as asthma and evades timely diagnosis, causing prolonged morbidity and airway‐related mortality.
Study Design
Observational study.
Methods
We compared spirometry results of 9,357 healthy subjects and nonstenosis pulmonary patients with 217 cases of LTS. Bootstrap analysis, receiver‐operating characteristic (ROC) statistics, and Pearson correlation were used to assess the diagnostic utility of the EDI and its correlation with stenosis severity.
Results
Mean EDI values were 36 ± 7 in nonstenosis cases, 76 ± 17 in benign stenoses, and 69 ± 23 in tracheal cancer (P < .0001). A significant correlation existed between anatomic stenosis severity and EDI (P < .0001; R = 0.61). Area under the ROC curve was 0.98, and at a threshold of >50, EDI had a sensitivity of 95.9% and a specificity of 94.2% in differentiating between stenosis and nonstenosis cases.
Conclusions
EDI can reliably diagnose LTS using routine lung function data. Its simplicity and clinical utility, first recognized by Duncan Empey, are underpinned by a unique physiology whereby PEFR, being determined by total tracheobronchial tree resistance, falls disproportionately compared with FEV1, which is determined within small intrathoracic airways. EDI provides valuable information about the presence and extent of LTS particularly in nonspecialist clinical settings and its routine inclusion within standard lung function reports could prevent the prolonged morbidity and mortality that currently result from missed and delayed diagnoses.
Level of Evidence
3b. Laryngoscope, 123:3099–3104, 2013
Objectives/Hypothesis
To perform a national review of the incidence and treatment of primary tracheal cancer and to identify gaps in service provision and factors associated with survival.
Study ...Design
Retrospective analysis of Hospital Episode Statistics data for England between 1996 and 2011.
Methods
Information about age, sex, morbidity, provider trust, diagnostic delay, nature of hospital admission and treatment, and palliation‐free survival were recorded. The relationship between variables and survival was explored with Cox regression.
Results
There were 874 patients, giving an incidence of 0.9 per million. Mean age at diagnosis was 66 ± 13, and there were 456 (52%) males. Mean presentation to diagnosis latency was 2.5 ± 8 months, and 40% of patients presented as emergency admissions. There were 19 cases of oesophageal involvement and 241 cases of bronchopulmonary involvement; and 188 patients developed distant metastases. There were 60 curative resections (6.9%), which was the most significant predictor of palliation‐free survival (hazard ratio: 0.23; 95% confidence interval 0.13–0.38). Other prognostic variables included age, sex, emergency admission, interventional bronchoscopy, chemotherapy, oesophageal involvement, and distant metastases. Ten‐year palliation‐free survival was 60.8% with curative resection and 19.5% overall. Eighty‐six percent of patients were treated in units that treated fewer than one patient per year.
Conclusion
Tracheal cancer is under‐recognized and under‐treated. Early diagnosis, access to interventional bronchoscopy, and surgical treatment in specialist units may improve the survival of patients with this condition.
Level of Evidence
4. Laryngoscope, 124:145–150, 2014
The larynx in cough Sandhu, Guri S; Kuchai, Romana
Cough (London, England),
06/2013, Letnik:
9, Številka:
1
Journal Article
Recenzirano
Odprti dostop
About 40% of the population will experience chronic cough at some point during their lives and it tends to be more common in women (Thorax 58:901-7, 2003). Post-nasal drip (or upper airway cough ...syndrome), gastro-esophageal reflux disease and asthma are considered the most common causes. Yet only a small percentage of patients with these common conditions experience chronic cough. Also there is no agreed measure of post-nasal drip and controversy exists about the diagnosis of reflux above the upper esophageal sphincter (laryngopharyngeal reflux) based on observable changes to the larynx. The approach of the otolaryngologist is to consider the upper and lower airways as a continuum and that a common pathology can have an impact on all these anatomical sites.A multidisciplinary approach is advocated, utilising the skills of the respiratory physician, otolaryngologist, gastroenterologist and speech pathologist.
Objectives/Hypothesis
Delivering evidence‐based patient care is predicated on the availability of objective and validated outcome measures. We aimed to calculate physiology‐based minimum clinically ...important difference (MCID) values for adult laryngotracheal stenosis (LTS).
Study Design
Prospective observational study.
Methods
Patient demographics, morbidities, and stenosis severity were assessed preoperatively. Flow‐volume loops and Medical Research Council (MRC) dyspnea grades were measured in 21 males and 44 females before and 6 to 8 weeks after airway surgery, and before treating recurrent disease in 10 patients. Anchor and distribution‐based methodologies were used to calculate MCIDs for treatment efficacy and disease recurrence respectively.
Results
The mean age at treatment was 46 ± 16 years. The most common etiology was idiopathic subglottic stenosis (38%). Most lesions (66%) obstructed >70% of the lumen. There were strong correlations between treatment‐related changes in total peak flow (TPF) (ΔTPF) (peak expiratory flow + |peak inspiratory flow|) and the ratio of area under the flow‐volume loop (AUC) to forced vital capacity (FVC) (ΔAUCTotal/FVC), and treatment‐related changes in the MRC grade (ΔMRC) (r = −0.76 and r = −0.82, respectively). Both TPF and AUCTotal/FVC discriminated between effective (ΔMRC <0) and ineffective (ΔMRC ≥0) interventions, yielding MCID values of 4.2 L/s for TPF and 2.1 L2/s for AUCTotal/FVC, respectively. Ten patients required airway treatment for recurrent disease, and TPF and AUCTotal/FVC levels had distribution‐based MCID values of 0.9 and 0.6, respectively.
Conclusions
Flow‐volume loops provide a quantitative method of objectively assessing outcomes in LTS. TPF is the most convenient index for this purpose, but AUCTotal/FVC provides marginally greater sensitivity and specificity.
Level of Evidence
4 Laryngoscope 124:2313–2320, 2014
Objectives/Hypothesis: To assess the results of primary endoscopic treatment of adult postintubation tracheal stenosis, to identify predictors of a successful outcome, and better define the scope and ...limitations of minimally‐invasive surgery for this condition.
Methods: Sixty‐two consecutive patients treated between April 2003 and 2006 with initial endoscopic surgery were prospectively studied. Patient and lesion characteristics, treatment details, complications, decannulation, and open surgery rates were recorded. Actuarial analysis and Cox regression were used to identify predictors of decannulation and freedom from external surgery.
Results: There were 34 male patients and the average age was 45 ± 16 years. The average stenosis height was 18 mm (range: 5–55 mm), and 82% of lesions were Myer‐Cotton grades III or IV. Lesion height and intubation‐to‐treatment latency independently predicted success of endoscopic surgery. Ninety‐six percent of patients with lesions <30 mm in height were treated endoscopically, but the success rate fell to 20% for lesions longer than 30 mm. Patients with recalcitrant lesions underwent airway augmentation (n = 11) or resection (n = 3), with a 79% success rate. All patients were decannulated, but some, predominantly morbidly obese patients, required long‐term stents for dynamic airway compromise. Ninety‐eight percent of re‐interventions occurred within 6 months.
Conclusions: Minimally invasive treatment is effective in postintubation airway stenosis and obviates the need for open cervicomediastinal surgery in most patients. Patients with old and long lesions are less likely to be cured endoscopically. For most patients in this subgroup, endoscopic surgery makes airway augmentation a viable, less invasive alternative to resection. Patients were unlikely to require further therapy after 6 months of symptom‐free follow‐up.
Objectives/Hypothesis
To evaluate the efficacy of endoscopic resection tracheoplasty (ERT) for treating post‐tracheotomy stomal stenosis caused by inward collapse of tracheal ring remnants.
Study ...design
Prospective observational study.
Methods
Between 2007 and 2012, we treated 40 patients with “lambdoid” tracheal deformity with a two‐staged minimally invasive procedure undertaken using suspension microtracheoscopy and high‐frequency jet ventilation. The first procedure entailed CO2 laser photoablation of collapsed tracheal rings and dilatation. The second procedure, performed 6 to 8 weeks later, involved ablation of residual structural obstruction, removal of granulation tissue, and intralesional corticosteroid injection. Perioperative patient and lesion characteristics and results of treatment were assessed.
Results
There were 22 males and 18 females, and mean age at first treatment was 59 years. There were 17 cases of scarring at the postero‐lateral tracheal groove (trachealis blunting), and 22 patients had age‐adjusted Charlson comorbidity scores greater than 4. All patients without trachealis blunting were successfully managed endoscopically, with only one patient requiring one additional endoscopic treatment. Seven patients with trachealis blunting needed additional treatment, and four patients had tracheal resection (P = 0.013). All patients were decannulated, and 75% of patients achieved good dyspnea outcomes. Patients with low morbidities were significantly more likely to achieve good dyspnea outcomes (P < 0.027). There were no treatment‐related worsenings of voice or swallowing.
Conclusions
ERT is an effective minimally invasive treatment for intubation‐related lambdoid tracheal stenosis. It achieves a successful outcome while avoiding the risks associated with open surgery. We recommend its more widespread use for treating patients with this condition.
Level of Evidence
4. Laryngoscope, 2012
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