Objectives/Hypothesis
Comparing Derkay anatomical score at time of procedure, disease characteristics, and mean treatment interval among adult and pediatric patients with recurrent respiratory ...papillomatosis (RRP).
Study Design
Restrospective study.
Methods
Retrospective review of juvenile‐onset (JO) and adult‐onset (AO) RRP patients treated longitudinally at pediatric and adult institutions from 1999 to 2019. Patients were included if they had a tissue diagnosis of papilloma and had at least a 12‐month follow‐up.
Results
One hundred and twelve patients met inclusion criteria (68 JO‐RRP and 44 AO‐RRP). All patients were stratified into either potassium titanyl phosphate (KTP) (n = 42), CO2 (n = 21), or microdebrider (n = 49) treatment groups. The Derkay score improved between first and last procedure in the KTP group (mean difference, 3.5; P < .001), CO2 group (mean difference, 4.4; P < .001), and microdebrider group (mean difference, 4.1; P < .001), but overall improvement did not differ across groups (P = .73). Baseline mean to last mean Derkay score improved for nine patients during bevacizumab treatments (mean difference, 3.0; P = .01) but did not improve for these same patients during an interval prior to receiving bevacizumab treatments. Baseline mean to last mean Derkay score improved for 19 patients during cidofovir treatments (mean difference, 3.84; P < .001) but did not improve for these same patients during the interval prior to receiving cidofovir treatments. The AO‐RRP population had more patients with dysplasia (50%) compared to JO‐RRP population (10%) (P < .001).
Conclusion
Various surgical modalities appear to be equally effective treatments for RRP. Adult and pediatric patients have decreased recurrent disease burden when receiving bevacizumab or cidofovir. AO‐RRP patients have more concomitant dysplasia.
Level of Evidence
3 Laryngoscope, 132:2420–2426, 2022
Objectives/Hypothesis
This study defines essential data elements to be recorded during an aerodigestive “triple endoscopy” to form the foundation of a standardized multicenter registry and to clearly ...define measurement of each consensus item.
Study Design
Modified Delphi process.
Methods
Modified Delphi consensus with six survey rounds. Twenty‐four expert pediatric otolaryngology, pulmonology, and gastroenterology aerodigestive clinicians from eight large academic pediatric aerodigestive programs formed the Delphi panel. After achieving consensus through the Delphi process, outside validation was performed at 2019 national Aerodigestive Society conference. Consensus, near‐consensus, or exclusion was obtained for each proposed data element. Concordance was then measured between expert panel conclusions and validation group conclusions.
Results
Overall response rate was 94.4%. 73/167 proposed items reached consensus in six domains (flexible bronchoscopy, bronchoalveolar lavage, microdirect laryngoscopy and bronchoscopy, esophagogastroduodenoscopy with biopsies, and esophageal impedance and pH probe). Measurement of all items was defined; classification/grading systems were selected for 11 items. Validation group endorsed importance of 82/167 data items; compared to expert consensus, overall, inclusion, and exclusion concordance rates were 94.5%, 98.7%, and 90.9%.
Conclusion
Triple endoscopy is a central component of aerodigestive care. This study identifies and defines data elements to be recorded for all triple endoscopy procedures. The list is of usable length, and clear definitions were created for all items, with explicit classification/grading systems selected for 11 items. Face validity was confirmed with an independent multispecialty sample of aerodigestive providers. This consensus provides the foundation for a triple endoscopy registry but also is immediately applicable to standardize clinical documentation in aerodigestive care.
Level of Evidence
5 Laryngoscope, 132:2251–2258, 2022
Objectives
Tracheal A‐frame deformity is a known consequence of tracheostomy that may lead to obstruction after decannulation. The goal of this study is to demonstrate the feasibility and success of ...endoscopic carbon dioxide (CO2) laser‐assisted tracheoplasty of tracheal A‐frame deformity in children.
Methods
Retrospective case series of symptomatic children with tracheal A‐frame deformity with no other site of airway obstruction (2016–2018). All patients underwent CO2‐laser assisted endoscopic resection tracheoplasty.
Results
Eight patients (six male) were included with a median age of 15.4 (IQR 12.3–17.9) years. Patients had a median of two previous open airway surgeries (IQR 1–2.5) and all patients had a history of tracheostomy with successful decannulation. Tracheal A‐frame deformity presented as dyspnea on exertion for all patients (n = 8, 100%). Obstructive sleep apnea was confirmed for all patients who underwent polysomnography (4/4, 100%). Median interval from decannulation to development of symptoms was 8.7 years (IQR 5.8–9.3). All patients sized with an age‐appropriate endotracheal tube despite the deformity. Endoscopic A‐frame tracheoplasty was successful for 7/8 (87.5%) patients and was performed with overnight observation for these patients (8/8, 100%). Unilateral A‐frame tracheoplasty was performed successfully for five patients (62.5%), bilateral A‐frame tracheoplasty was performed successfully for two patients (25.0%), and one patient (12.5%) did not have complete resolution of symptoms after bilateral A‐frame tracheoplasty due to multi‐level airway obstruction.
Conclusions
CO2 laser‐assisted tracheoplasty is an innovative endoscopic technique to relieve symptoms of airway obstruction for selected patients with tracheal A‐frame deformity although avoiding the morbidity and hospital stay duration associated with tracheal resection.
Level of Evidence
4 Laryngoscope, 131:E719–E723, 2021
Objectives/Hypothesis
Evaluate and compare surgical outcomes of slide tracheoplasty for the treatment of congenital tracheal stenosis in children with and without pulmonary malformations.
Study ...Design
Retrospective chart review at a tertiary care pediatric medical center.
Methods
We identified patients with tracheal stenosis who underwent slide tracheoplasty from 2001 to 2014, and a subset of these patients who were diagnosed with congenital pulmonary malformations. Hospital course and preoperative and postoperative complications were recorded.
Results
One hundred thirty patients (18 with pulmonary malformations, 112 with normal pulmonary anatomy) were included. Pulmonary malformations included unilateral pulmonary agenesis (61%) and hypoplasia (39%). Children with pulmonary malformations had a greater median age compared to their normal lung anatomy counterparts. Preoperatively, patients with pulmonary malformations more frequently required preoperative mechanical ventilation (55.6% vs. 21.3%, P = .007), extracorporeal membrane oxygenation (ECMO) (11% vs. 0.9%, P = .05), and tracheostomy (22.2% vs. 3.6%, P = .01). Postoperatively, patients with pulmonary malformations more frequently required mechanical ventilation >48 hours (78% vs. 37%, P =.005) and ECMO use (11% vs. 0.9%, P = .05). Pulmonary malformation patients and children with normal anatomy did not differ in terms of postoperative tracheostomy (16.7% vs. 4.4%, P > .05), dehiscence (6% vs. 0%, P > .05%), restenosis (11% vs. 6%, P > .05) or postoperative figure 8 deformity (6% vs. 3%, P > .05). Mortality, however, was significantly increased (22.2% vs. 3.6%, P = .01) in children with pulmonary malformations.
Conclusions
Although slide tracheoplasty can be successfully performed in patients with abnormal pulmonary anatomy, surgeons and families should anticipate a more difficult postoperative course, with possible associated prolonged mechanical ventilation, ECMO use, and higher mortality than in children with tracheal stenosis alone.
Level of Evidence
4. Laryngoscope, 127:1283–1287, 2017
Objectives/Hypothesis
Children with bilateral true vocal fold immobility (BTVFI) may present with significant airway distress necessitating tracheostomy. The objective of this study was to review our ...preliminary experience with the anterior–posterior cricoid split (APCS), an endoscopic intervention used as an alternative to tracheostomy in children with BTVFI.
Study Design
Multicenter review.
Methods
A review of patients undergoing endoscopic APCS for BTVFI at four institutions was performed. Patients were evaluated for the ability to ventilate without the requirement for tracheostomy or reintubation. Additional data extracted included the duration of intubation following APCS, the requirement for additional procedures, and demographics. Surgical success was defined as the ability to avoid tracheostomy and to cap or decannulate without respiratory symptoms if a tracheostomy was present prior to APCS.
Results
Nineteen APCS procedures were performed between October 2010 and June 2016. There were 12 male patients, the mean age at APCS was 4.7 months. BTVFI was primarily idiopathic (58%) and associated with other comorbidities (74%). All patients were candidates for tracheostomy prior to APCS. Fourteen patients (74%) were considered surgical successes. Of the unsuccessful patients, three (66%) required tracheostomy following APCS, and one was treated with a posterior cartilage graft. There was one nonsurgical mortality greater than 2 months after APCS and thought to be unrelated to the airway.
Conclusions
Endoscopic APCS appears to be a safe and effective intervention for pediatric BTVFI. Under the correct circumstances, this can be performed as a single procedure, obviating tracheostomy. Further study is warranted.
Level of Evidence
4. Laryngoscope, 128:257–263, 2018
To determine if time to tracheostomy decannulation differs among children by socioeconomic status.
Case series with chart review.
Tertiary pediatric medical center.
Patients (≤21 years old) who ...underwent tracheostomy from January 1, 2011, to December 31, 2016. Patients were divided into 2 groups based on their socioeconomic status (SES), low SES and high SES. Principal components analysis was used to create an index for SES using census data obtained by the US Census Bureau's American Community Survey 5 year data profile from 2013 to 2017. Statistical analysis was performed using a χ
for categorical variables and Wilcoxon rank-sum test for continuous variables. A general linear model was constructed to control for clinical factors to understand the independent effect of SES on time to decannulation.
In total, 215 patients were included; of these patients, 111 patients (52%) were included in the high-SES group and 104 patients (48%) were included in the low-SES group. There was a significant difference in the time to decannulation for children based on SES status, with those children in the low-SES group taking on average 10 months longer to decannulate (38.7 vs 28.0 months,
= .0007). Median follow-up was 44.1 months (interquartile range, 29.6-61.3 months).
Health care disparities appear to exist among children undergoing decannulation of their tracheostomy tube. Patients with lower SES had a significantly longer time to decannulation than those with higher SES.
Objectives/Hypothesis
Determine surgical and swallowing outcomes after surgery for type III laryngotracheoesophageal cleft (LTEC).
Study Design
Case series with chart review.
Methods
Chart review was ...performed on patients with type III LTEC between 2000 and 2019. Demographics, surgical outcomes, and swallowing outcomes were collected and analyzed.
Results
Thirty‐three patients met inclusion criteria (28 open and 5 endoscopic repairs). Mean age was 3.4 years for the open group and 0.9 years for the endoscopic group. Seventeen (51.5%) patients had a syndromic diagnosis, most commonly Opitz syndrome and Trisomy 21. Mean follow‐up was 33.6 months. Thirteen (39.4%) patients had a previous repair attempt prior to repair at our institution. Twenty‐four (70.6%) patients had a tracheostomy prior to or at the time of surgical repair and 13 (38.2%) remain tracheostomy‐dependent. Nine patients (27.3%) required a revision cleft repair and four (12.1%) required two revisions. Thirty‐one patients had an intact repair at last follow‐up (93.9). Two patients died outside the hospital over a year after surgery. Preoperatively 13 of 17 patients with swallowing evaluations aspirated. After repair, 11 of 20 patients were deemed safe for all consistencies and seven were safe for thickened. Endoscopic approaches were performed during the last 2 years of the study and had significantly lower operative time (354.4 minutes vs. 171.5 minutes).
Conclusions
Endoscopic and open approaches are effective for treatment of type III LTEC with 27.3% requiring revision and 93.9% of repairs intact at last follow‐up. Overall swallowing outcomes were good in patients who underwent postoperative instrumental swallow evaluation.
Level of Evidence
4 Laryngoscope, 132:1112–1117, 2022
Objectives Posterior glottic diastasis (PGD) is an underappreciated etiology of dysphonia in patients with prior airway reconstruction or prolonged intubation. In endoscopic posterior cricoid ...reduction (ePCR), cricoid is removed to minimize the posterior glottic gap. Dynamic voice computed tomography (DVCT) permits visualization of the posterior glottis, estimating the amount of cricoid to be removed. Posterior glottic gaps in patients undergoing ePCR were compared to non‐dysphonic patients to describe pediatric PGD and establish surgical parameters for ePCR. Methods DVCTs performed in non‐dysphonic patients and dysphonic patients undergoing ePCR from 2014 to 2023 were reviewed. EPCR operative reports were queried. Pre‐ and postoperative Pediatric Voice Handicap Index (pVHI) and Consensus Auditory‐Perceptual Evaluation of Voice (CAPE‐V) scores and aerodynamic measures were reviewed. Results Seventeen pediatric patients who underwent ePCR and 19 non‐dysphonic patients were included. Posterior glottic gaps were significantly larger in the dysphonic group (median 2.4 mm IQR: 2.0, 2.8 vs. 1.3 mm IQR: 1.1, 1.7, p < 0.001). Mean width of the cricoid removed was 1.6 mm (SD 0.4 mm). Mean (SD) pre‐ and postoperative pVHI scores were 55.5 (19.9) and 34.6 (16.0; p < 0.001). Mean (SD) pre‐ and postoperative CAPE‐V scores were 52.7 (15.4) and 36.5 (20.4; p < 0.001), respectively. Conclusions Children in this cohort tolerated an average 1.3 mm posterior glottic gap without dysphonia. Dysphonic patients with PGD had a median 2.4 mm gap and underwent cricoid reduction by 1.6 mm. All ePCR patients demonstrated improvement in dysphonia. Results seek to optimize the management of pediatric PGD and present a safe and effective amount of cricoid to remove during ePCR. Level of Evidence 4 Laryngoscope , 2024
This study documents the growth and course of repaired complete tracheal rings over time after slide tracheoplasty.
Case series with review.
Tertiary pediatric academic medical center.
Medical ...records of pediatric patients with confirmed tracheal rings on bronchoscopy who underwent slide tracheoplasty between January 2001 and December 2015 were reviewed. Patients who had operative notes documenting tracheal sizing over time were included. Exclusion criteria included tracheal stenosis not caused by complete tracheal rings, surgical repair prior to presentation at our institution, or lack of adequate sizing information. The postoperative follow-up was examined and airway growth over time documented.
Of 197 slide tracheoplasties performed during the study time period, 139 were for complete tracheal rings, and 40 of those children met inclusion criteria. The median age at time of surgery was 7 months, and the median initial airway size was 3.9 mm (n = 34). The median growth postoperatively was 1.9 mm over a median follow-up period of 57 months (0.42 mm/year), which is similar to growth rates of unrepaired complete tracheal rings (
= .53). Children underwent a median of 10 postoperative endoscopies, with time between endoscopies increasing further out from surgery. The most commonly performed adjunctive procedure was balloon dilation.
This is the first study documenting continued growth of repaired complete tracheal rings after slide tracheoplasty. Postoperative endoscopic surveillance ensures adequate growth. Intervals between airway endoscopies can be increased as the child gets older, as the airway increases in size, and as long as symptoms are minimal.
To compare the clinical outcomes of patients with prophylactic petiole suspension (PPS) at the time of laryngofissure and patients without PPS.
Retrospective case series.
Tertiary pediatric hospital ...from May 2003 to August 2017.
Patients included those undergoing airway reconstruction with complete laryngofissure. Patients in the study group had PPS at the time of laryngofissure, while control group patients did not.
Eighty-one patients underwent complete laryngofissure (22 study patients, 59 controls) at a median age of 4.8 years (interquartile range, 2.1-9.7). Patients in the control group were younger at the time of the surgery (3.7 vs 6.5 years,
= .04). Other demographic and clinical data, including subglottic stenosis (SGS) grades, were similar. For patients with SGS, 53.8% and 46.2% in the study group had a grade 1-2 and 3-4 SGS, respectively, as compared with 46.2% and 53.8% in the control group (
= .65). Manifestations of petiole prolapse included failure of decannulation (8.6%), exercise intolerance (16.0%), and obstructive sleep apnea (11.1%). After 4 years of follow-up, 4.5% of the study group versus 27.1% of the control group had prolapse of the petiole (
= .04). Petiole prolapsed affected >50% of patients with no PPS after 10 years of follow-up. Patients with petiole prolapse at the first surveillance microlaryngoscopy and bronchoscopy after stent removal had an odds ratio of 10.2 (95% CI, 1.1-94.8;
= .04) of becoming symptomatic.
Patients with PPS had significantly fewer symptoms after complete laryngofissure as compared with patients without PPS. PPS should be considered when a complete laryngofissure is being performed during airway reconstruction.
