Voice Quality in Laryngotracheal Stenosis

Hillel, Alexander T.; Karataylı-Özgürsoy, Selmin; Benke, James R.; Best, Simon R.; Pacheco-Lopez, Paulette; Teets, Kristine; Starmer, Heather M.; Akst, Lee M.

doi:10.1177/0003489414564249

Cited by 39 publications

(30 citation statements)

References 28 publications

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“…Patients demonstrated significant improvement in laryngeal resistance, vital capacity, and V-RQOL and DI surveys, whereas no change in acoustic or perceptual evaluation of voice quality was found. These results confirm findings from multiple retrospective studies on voice and dyspnea outcomes after endoscopic airway surgery 6,7 and contribute to the development of a panel of outcome measures in the evaluation and treatment of LTS.…”

Section: Discussionsupporting

confidence: 82%

“…Perceptual voice quality evaluation using the CAPE-V assessment did not demonstrate improvement in our sample population, a result that is consistent with those of previous perceptual voice evaluation studies. 5,6 The lack of concordance between improvement in CAPE-V and V-RQOL scores may be because the patient’s self-rated V-RQOL improvement reflects that they no longer run out of breath or that they are less anxious and/or depressed about their airflow related to voice, rather than the quality of voice grade, roughness, breathiness, asthenia, or strain that perceptual raters assess. Acoustic and aerodynamic measures evaluated largely remained unchanged, although maximum phonation time and maximal high-pitch frequency improved after the airway intervention.…”

Section: Discussionmentioning

confidence: 99%

“…4–13 A few studies 4–6 have retrospectively demonstrated improved voice QOL after endoscopic balloon dilation in patients with LTS. None of the published studies evaluating voice outcomes in LTS have been prospective.…”

mentioning

confidence: 99%

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Evaluation of Dyspnea Outcomes After Endoscopic Airway Surgery for Laryngotracheal Stenosis

Samad

Akst

Karataylı-Özgürsoy

et al. 2016

JAMA Otolaryngol Head Neck Surg

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IMPORTANCE Endoscopic airway surgery is a frequently used procedure in the management of laryngotracheal stenosis (LTS); however, no established outcome measures are available to assess treatment response. OBJECTIVE To assess acoustics and aerodynamic measures and voice- and dyspnea-related quality of life (QOL) in adult patients with LTS who undergo endoscopic airway surgery. DESIGN, SETTING, AND PARTICIPANTS This case series compared preoperative measures and postoperative outcomes among adult patients who underwent endoscopic airway surgery for LTS from September 1, 2013, to September 30, 2015, at the tertiary care Johns Hopkins Voice Center. Patients were excluded if they did not undergo balloon dilation or if they had multilevel or glottic stenosis. The Phonatory Aerodynamic System was used to quantify laryngotracheal aerodynamic changes after surgery. Final follow-up was completed 2 to 6 weeks after surgery. MAIN OUTCOMES AND MEASURES The voice-related QOL instrument (V-RQOL), Dyspnea Index, and Clinical Chronic Obstructive Pulmonary Disease Questionnaire were completed before and after endoscopic surgery. Consensus auditory perceptual evaluation of voice, acoustic measurements, and aerodynamic outcomes were also assessed. RESULTS Fourteen patients (1 man and 13 women; mean [SD] age, 45.4 [4.3] years) were enrolled. The mean postoperative V-RQOL scores (n = 14) increased from 74.3 to 85.5 (mean of difference, 11.3; 95%CI, 2.2 to 20.3). The mean postoperative Dyspnea Index (n = 14) decreased from 26.9 to 6.6 (mean of difference, −20.3; 95%CI, −27.9 to −12.7); the mean postoperative Clinical Chronic Obstructive Pulmonary Disease Questionnaire scores (n = 9) decreased from 3.2 to 1.0 (mean of difference, −2.2; 95% CI, −3.4 to −0.9). Postoperative mean vital capacity (n = 14) increased from 2.5 to 3.1 L (mean of difference, 0.6 L; 95%CI, 0.3–1.0 L), whereas mean laryngeal resistance (n = 14) decreased from 73.9 to 46.4 cm H2O/L/s (mean of difference, −27.5 cm H2O/L/s; 95%CI, −44.8 to −10.3 cm H2O/L/s) postoperatively. CONCLUSIONS AND RELEVANCE Patients demonstrate statistically clinically significant improvement in dyspnea-related QOL, whereas a few patients showed a clinically significant improvement in V-RQOL. Dyspnea-related QOL outcomes should be added to airway surgeons’ regular assessment of patients with LTS to measure treatment response and inform the decision to perform a second operation, whereas V-RQOL outcomes need additional prospective study with a larger sample size. The Phonatory Aerodynamic System is not an optimal method to quantify changes in laryngotracheal aerodynamics after intervention in LTS.

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Section: Discussionsupporting

confidence: 82%

Section: Discussionmentioning

confidence: 99%

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Evaluation of Dyspnea Outcomes After Endoscopic Airway Surgery for Laryngotracheal Stenosis

Samad

Akst

Karataylı-Özgürsoy

et al. 2016

JAMA Otolaryngol Head Neck Surg

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“…1,2 The stenosis usually occurs within the larynx or proximal trachea, though it can occur more distally in the trachea as well. Surgical decision-making incorporates the characteristics of the stenosis on flexible laryngoscopy and bronchoscopy, subjective complaints of dyspnea, and at times CT Scan and/or pulmonary function tests.…”

Section: Introductionmentioning

confidence: 99%

Laryngotracheal Stenosis: Risk Factors for Tracheostomy Dependence and Dilation Interval

Gadkaree

Pandian

Best

et al. 2016

Otolaryngol.--head neck surg.

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Objective Laryngotracheal stenosis (LTS) is a fibrotic process that narrows the upper airway and has a significant impact on breathing and phonation. Iatrogenic injury from endotracheal and/or tracheostomy tubes is the most common etiology. This study investigates differences in LTS etiologies as they relate to tracheostomy dependence and dilation interval. Study Design Case series with chart review Setting Single-center tertiary care facility Subjects and Methods Review of adult patients with LTS was performed between 2004–2015. The association of patient demographics, comorbidities, disease etiology, and treatment modalities with patient outcomes was assessed. Multiple logistic regression analysis and Kaplan-Meier analysis was performed to determine factors associated with tracheostomy-dependence and time to second procedure respectively. Results 262 patients met inclusion criteria. Iatrogenic patients presented with greater stenosis (p=0.023), greater length (p=0.004), and located further from the vocal folds (p<0.001) compared with other etiologies. Iatrogenic patients were more likely to be African-American and have obstructive sleep apnea, type II diabetes, hypertension, COPD, stroke, and use tobacco. Iatrogenic LTS (OR=3.1, CI= 1.2–8.2), Cotton-Myer Grade 3–4 (OR=2.6, CI=1.1–6.4), and lack of intraoperative steroids (OR=2.9, CI=1.2–6.9) were associated with tracheostomy-dependence. Non-smokers, patients without tracheostomy, and idiopathic LTS patients had a significantly longer time to second dilation procedure. Conclusion Iatrogenic LTS presents with a greater disease burden and higher risk of tracheostomy dependence compared to other etiologies of LTS. Co-morbid conditions promoting microvascular injury, including smoking, COPD, and diabetes, were prevalent in the iatrogenic cohort. Changes in hospital practice patterns to promote earlier tracheostomy in high risk patients could reduce the incidence of LTS.

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“…1,2 The multiple consequences of LTS include communication handicap and airway obstruction, a potentially life-threatening complication if not managed appropriately. 1,3 The contemporary management of LTS is primarily surgical and includes serial dilation, tracheal or cricotracheal resection, laryngotracheoplasty, and/or permanent tracheostomy. 4,5 Medical therapies available for the management of LTS are limited, reflecting a need for improved understanding of disease pathogenesis.…”

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confidence: 99%

Interferon-γ Treatment of Human Laryngotracheal Stenosis–Derived Fibroblasts

Motz

Samad

Yin

et al. 2017

JAMA Otolaryngol Head Neck Surg

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IMPORTANCE Laryngotracheal stenosis (LTS) is a fibroproliferative disorder of the glottis, subglottis, and trachea. In models of fibrosis from other organ systems, the CD4+T-cell response has been shown to regulate extracellular matrix deposition. Specifically, helper T cell 2 (TH2) promotes fibrosis, whereas TH1 and associated cytokines have been shown to be antifibrotic. However, this antifibrotic effect of the TH1 response has not been demonstrated in LTS. OBJECTIVE To determine whether the TH1 cytokine interferon-γ inhibits the function of LTS-derived fibroblasts in vitro. DESIGN, SETTING, AND PARTICIPANTS This in vitro controlled study included 6 patients with iatrogenic LTS undergoing routine surgical subglottic and tracheal dilation at a single institution. Fibroblasts were isolated from biopsy specimens of laryngotracheal scar and normal-appearing trachea. The presence of fibroblasts was confirmed by an immunohistochemical analysis. Laryngotracheal stenosis–derived fibroblasts were treated with interferon-γ and compared with untreated controls (2 sets of untreated, LTS-derived fibroblasts [media did not contain interferon-γ]) and normal airway fibroblasts (fibroblasts isolated from normal trachea). Data were collected from August 2015 through June 2016. INTERVENTIONS Treatment with interferon-γ, 10 ng/mL. MAIN OUTCOMES AND MEASURES Cellular proliferation, fibrosis gene expression (using quantitative reverse transcription polymerase chain reaction analysis), soluble collagen, and cellular histologic features were assessed. RESULTS Among the 6 patients (6 women; mean [SD] age, 38.3 [17.2] years), LTS-derived fibroblast proliferation was reduced in patients who received interferon-γ treatment compared with untreated controls on days 3 (mean difference, −6515 cells; 95% CI, −10 630 to −2600 cells) to 6 (mean difference, −47 521 cells; 95% CI, −81285 to −13 757 cells). Interferon-γ treatment reduced collagen types I and III gene expression by 86% and 68%, respectively, and resulted in lower total collagen production (10.94 vs 14.89 μg/mL). In addition, interferon-γ treatment resulted in a 32% reduction in expression of transforming growth factor β in LTS-derived fibroblasts. CONCLUSIONS AND RELEVANCE Interferon-γ reduced proliferation, soluble collagen production, and collagen expression in LTS-derived fibroblasts while also reducing the expression of the profibrotic cytokine transforming growth factor β. These findings suggest that therapeutics aimed at increasing interferon-γ and the TH1 response could attenuate LTS.

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Voice Quality in Laryngotracheal Stenosis

Abstract: Laryngotracheal stenosis is associated with dysphonia. Patients with glottic involvement have significantly worse voice quality of life than those with tracheal/subglottic stenosis. Endoscopic balloon dilation improves V-RQOL in patients with subglottic/tracheal stenosis.

Cited by 39 publications

References 28 publications

Evaluation of Dyspnea Outcomes After Endoscopic Airway Surgery for Laryngotracheal Stenosis

Evaluation of Dyspnea Outcomes After Endoscopic Airway Surgery for Laryngotracheal Stenosis

Laryngotracheal Stenosis: Risk Factors for Tracheostomy Dependence and Dilation Interval

Interferon-γ Treatment of Human Laryngotracheal Stenosis–Derived Fibroblasts

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