Objectives/Hypothesis
To identify any potential barriers for decannulation in children undergoing double‐staged laryngotracheal reconstruction (dsLTR) beyond the severity of disease itself.
Study ...Design
Case series with chart review.
Methods
We performed a retrospective chart review from 2008 to 2018 of 41 children who had undergone dsLTR as primary treatment for laryngotracheal stenosis at a stand‐alone tertiary children's hospital. We examined the effect of demographic, medical, and surgical factors on successful decannulation and time to decannulation after dsLTR.
Results
Of the 41 children meeting inclusion criteria who underwent dsLTR, 34 (82%) were decannulated. Age, gender, race, insurance status, medical comorbidity, and multilevel stenosis did not predict overall decannulation. Insurance status did not impact time to decannulation (P = .13, Log‐rank). Factors that increased length of time to decannulation were the use of anterior and posterior cartilage grafts (P = .001, Log‐rank), history of pulmonary disease (P = .05, Log rank), history of cardiac disease (P = .017, Log‐rank), and race/ethnicity (P = .001 Log‐rank).
Conclusion
In a cohort with a similar decannulation rates to previous dsLTR cohorts, we identified no demographic or medical factors that influenced overall decannulation. We did observe that pulmonary comorbidity, cardiac comorbidity, and race/ethnicity lengthens time to decannulation.
Level of Evidence
4 Laryngoscope, 131:2141–2147, 2021
Oropharyngeal squamous carcinoma (OPSC) continues to increase in incidence secondary to human papillomavirus (HPV) infection. Despite the good overall prognosis for these patients, treatment with ...chemoradiation is associated with morbidity and treatment failure. Better predictors for disease outcome are needed to guide de-intensification regimens. We hypothesized that estrogen receptor α (ERα), a prognostic biomarker in oncology with therapeutic implications, might have similar utility in OPSC.
To investigate associations among ERα and demographics, HPV status, and survival, we analyzed ERα mRNA expression of head and neck squamous carcinomas (HNSC) from The Cancer Genome Atlas (TCGA) and immunohistochemistry (IHC) of pretreatment biopsy specimens from an independent group of 215 OPSC patients subsequently treated with primary chemoradiation (OPSC-CR). Associations among variables were evaluated with Fisher exact tests and logistic regression; associations with survival were evaluated with log-rank tests and Cox proportional hazards regression.
Among 515 patients in TCGA, ERα mRNA expression was highest in HPV-positive OPSC. High ERα mRNA expression was associated with improved survival among those receiving chemoradiation (hazard ratio adjusted for HPV status = 0.44, 95% confidence interval = 0.21 to 0.92). In OPSC-CR, ERα was positive by IHC in 51.6% of tumors and was associated with improved overall, disease-specific, progression-free, and relapse-free survival (log-rank tests: P < .001, P < .001, P = .002, P = .003, respectively); statistically significant associations of ERα positivity with improved survival were maintained after adjusting for clinical risk factors including HPV status.
In two independent cohorts, ERα is a potential biomarker for improved survival that also may represent a therapeutic target in OPSC.
We present an unusual case of vocal fold mobility disorder in a child resulting from a PDA aneurysm. A bedside ultrasound was suggestive of intermittent left vocal fold immobility and the decision ...was made to monitor the aneurysm towards spontaneous regression through serial radiology. The serial ultrasounds showing reduction in thrombus size mirrored the improvement of vocal cord mobility. Although Ortner's syndrome has been described previously to our knowledge this is the first report of a child without a full left-sided vocal fold paralysis. This case highlights the importance of radiologic investigation of unilateral vocal immobility in children.
The airway transcriptome includes genes that contribute to the pathophysiologic heterogeneity seen in individuals with asthma.
We analyzed sputum gene expression for transcriptomic endotypes of ...asthma (TEA), gene signatures that discriminate phenotypes of disease.
Gene expression in the sputum and blood of patients with asthma was measured using Affymetrix microarrays. Unsupervised clustering analysis based on pathways from the Kyoto Encyclopedia of Genes and Genomes was used to identify TEA clusters. Logistic regression analysis of matched blood samples defined an expression profile in the circulation to determine the TEA cluster assignment in a cohort of children with asthma to replicate clinical phenotypes.
Three TEA clusters were identified. TEA cluster 1 had the most subjects with a history of intubation (P = 0.05), a lower prebronchodilator FEV1 (P = 0.006), a higher bronchodilator response (P = 0.03), and higher exhaled nitric oxide levels (P = 0.04) compared with the other TEA clusters. TEA cluster 2, the smallest cluster, had the most subjects that were hospitalized for asthma (P = 0.04). TEA cluster 3, the largest cluster, had normal lung function, low exhaled nitric oxide levels, and lower inhaled steroid requirements. Evaluation of TEA clusters in children confirmed that TEA clusters 1 and 2 are associated with a history of intubation (P = 5.58 × 10(-6)) and hospitalization (P = 0.01), respectively.
There are common patterns of gene expression in the sputum and blood of children and adults that are associated with near-fatal, severe, and milder asthma.
Objective
To understand the etiology of tracheotomy‐induced tracheal stenosis by comparing the differences in techniques and mechanical force applied with open tracheotomy (OT) versus percutaneous ...tracheotomy (PCT) placement.
Methods
This study is an unblinded, experimental, randomized controlled study in an ex‐vivo animal model. Simulated tracheostomies were performed on 10 porcine tracheas, 5 via a tracheal window technique (OT) and 5 using the Ciaglia technique (PCT). The applied weight during the simulated tracheostomy and the compression of the trachea were recorded at set times during the procedure. The applied weight during tracheostomy was used to calculate the tissue force in Newtons. Tracheal compression was measured by anterior–posterior distance compression and as percent change.
Results
Average forces for scalpel (OT) versus trocar (PCT) were 2.6 N and 12.5 N (p < 0.01), with the dilator (PCT) it was 22.02 N (p < 0.01). The tracheostomy placement with OT required an average force of 10.7 N versus 23.2 N (p < 0.01) with PCT. The average change in AP distance when using the scalpel versus trocar was 21%, and 44% (p < 0.01), with the dilator it was 75% (p < 0.01). The trach placement with OT versus PCT had an average AP distance change of 51% and 83% respectively (p < 0.01).
Conclusion
This study demonstrated that PCT required more force and caused more tracheal lumen compression when compared to the OT technique. Based on the increased force required for PCT, we suspect there could also be an increased risk for tracheal cartilage trauma.
Level of Evidence
NA Laryngoscope, 134:103–107, 2024
This study demonstrates that percutaneous tracheostomy techniques require more force than open tracheostomy techniques, and thus have an increased risk for trauma and tracheal injury.
Objective
Standard methods to evaluate tracheal pathology in children, including bronchoscopy, may require general anesthesia. Conventional dynamic proximal airway imaging in noncooperative children ...requires endotracheal intubation and/or medically induced apnea, which may affect airway mechanics and diagnostic performance. We describe a technique for unsedated dynamic volumetric computed tomography angiography (DV‐CTA) of the proximal airway and surrounding vasculature in children and evaluate its performance compared to the reference‐standard of rigid bronchoscopy.
Methods
Children who had undergone DV‐CTA and bronchoscopy in one‐year were retrospectively identified. Imaging studies were reviewed by an expert reader blinded to the bronchoscopy findings of primary or secondary tracheomalacia. Airway narrowing, if present, was characterized as static and/or dynamic, with tracheomalacia defined as >50% collapse of the tracheal cross‐sectional area in exhalation. Pearson correlation was used for comparison.
Results
Over a 19‐month period, we identified 32 children (median age 8 months, range 3–14 months) who had undergone DV‐CTA and bronchoscopy within a 90‐day period of each other. All studies were unsedated and free‐breathing. The primary reasons for evaluation included noisy breathing, stridor, and screening for tracheomalacia. There was excellent agreement between DV‐CTA and bronchoscopy for diagnosis of tracheomalacia (κ = 0.81, p < 0.001), which improved if children (n = 25) had the studies within 30 days of each other (κ = 0.91, p < 0.001). CTA provided incremental information on severity, and cause of secondary tracheomalacia.
Conclusion
For most children, DV‐CTA requires no sedation or respiratory manipulation and correlates strongly with bronchoscopy for the diagnosis of tracheomalacia.
Level of Evidence
3 Laryngoscope, 133:410–416, 2023
Normative trachea dimensions and aerodynamic information during development was collected to establish clinical benchmarks and showed that airway development seems to outpace respiratory demands. ...Infants and toddlers' trachea exhibit higher aerodynamic stress that significantly decreases by teenage years. This implies large airway pathology in younger children may have a more substantial clinical impact.
A 28-year-old previously healthy male presented with 3 months of swelling of the right upper gingiva and lower gingiva and right palate (Figures 1 and 2). He initially presented to dentistry with ...concern for a tooth abscess and subsequently failed 2 rounds of clindamycin. The patient reported unprotected sexual activity with males and females and endorsed a 13 pack-year smoking history and marijuana use, but denied IV drug use. He underwent biopsy with oral surgery which revealed vascular spindle cell proliferation with local hemosiderin deposition and reactive lymphoplasmacytic infiltration, as well as CD31, CD34, and HHV-8 positivity.
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