Tertiary center experience with primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and literature review

Abstract

Background and objectivesTo share our experience with primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and critically review the previously published studies.SettingTertiary Referral Centers, King Abdulaziz Medical City, Riyadh, Saudi Arabia.Patients and methodsA retrospective case series study was conducted, where the case notes of all pediatric patients who underwent endoscopic management as a primary surgical intervention for acquired subglottic stenosis (SGS) from 2004 to 2014 were reviewed. All patients who underwent surgical correction with primary open laryngoplasty for congenital subglottic stenosis had been excluded.ResultsA total of 60 patients with a workable diagnosis of subglottic stenosis were reviewed. Forty-five patients were included in the study and 15 patients were excluded because they underwent open laryngoplasty as a primary treatment modality for congenital subglottic stenosis. The majority of the patients were males 29 (64%), with 16 (36%) females. The main presentation was stridor and intercostal recession. Thirty-nine (86%) patients had subglottic stenosis due to prolonged intubation; 5 (11%) patients were idiopathic and one patient (3%) had inflammatory reasons. The site of stenosis was isolated SGS in 41 while 4 patients had glottic-subglottic stenosis (GSGS). In terms of the grade of stenosis: 13 patients had grade I; 23 had grade II and 9 had grade III. The character of stenosis was soft except in 5 patients with hard (mature) scar. The number of dilatation procedures ranged from 1 to 6 with a mean of 2. The endoscopic management was considered to be successful when the patient is completely asymptomatic after the follow up period of one year. No major complications were recorded among the patients. Thirty-seven (82.3%) patients had a benign course post endoscopic intervention without complications and 8 (17.7%) underwent a secondary open surgical management due to re-stenosis (P value < 0.01).ConclusionOur study showed that primary endoscopic management was successful in 82.3% of cases of acquired subglottic stenosis including those with high grade stenosis and long segment of more than 12 mm in terms of the craniocaudal length. CO2 laser was an important tool to convert mature hard stenotic segment into a soft one. The latter yielded to the lateral pressure created by balloon dilatation better.

Ongoing Laryngeal Stenosis: Conservative Management and Alternatives to Tracheostomy

“…After review of the full-length articles, 14 were excluded, due to its use for chronic stenoses (15,(17)(18)(19)(20), due to its lack of differentiation between acute or chronic stenosis (16,19,(21)(22)(23)(24)(25)(26)(27), and/or because the paper did not differentiate between rigid or balloon dilations (27,28). The 10 remaining papers were selected for this review (3,(29)(30)(31)(32)(33)(34)(35)(36)(37).…”

“…Some authors used the INSPIRA AIRTM balloon (Acclarent Inc., CA, U.S.A.) (33,37). Other authors do not mention the brands of their balloons and/or use many different brands (3,(29)(30)(31)(32)(34)(35)(36).…”

“…An inflation/deflation handle mounted with a syringe and gauge assembly designed to monitor and maintain the pressure was used by all authors (29)(30)(31)(32)(33)(34)(35)(36)(37)(38). The balloon was inflated to rated burst pressure by some authors (33,36,37). Other authors specifically mentioned pressures between 2 and 15 atm, (3) 2 atm, (29,31,34), 4 atm, (32), 7 atm (30).…”

“…Other authors specifically mentioned pressures between 2 and 15 atm, (3) 2 atm, (29,31,34), 4 atm, (32), 7 atm (30). The balloon was maintained inflated for 30-60 s or until the patient's oxygen saturation level dropped below 90-92% (3,(29)(30)(31)(32)(33)(34)(35)(36)(37). Some authors repeated the procedure 2-3 times during each session (31)(32)(33)(34)(35)(36)(37).…”

“…The 10 case reports and series (nine retrospectives, one prospective), published between 2007 and 2017, included 109 pediatric patients who underwent 1-6 dilations each, with an average 1.8 dilations per patient. Follow-up ranged from 5 days to 7 years (3,(29)(30)(31)(32)(33)(34)(35)(36)(37). Included studies are summarized on Table 3.…”