Early Intervention for the Treatment of Acute Laryngeal Injury After Intubation.

Importance: Patients with laryngeal injury after endotracheal intubation often present long after initial injury with mature fibrosis compromising cricoarytenoid joint mobility and glottic function. Objective: To compare functional outcomes between early and late intervention for intubation-related laryngeal injury. Design, Setting, and Participants: This retrospective cohort study involved 29 patients with laryngeal injury resulting from endotracheal intubation who were evaluated at a tertiary care center between May 1, 2014, and June 1, 2018. Ten patients with intubation injury to the posterior glottis who received early treatment were compared with 19 patients presenting with posterior glottic stenosis who received late treatment. Statistical analysis was performed from May 1 to July 1, 2019. Exposures: Early intervention, defined as a procedure performed 45 days or less after intubation, and late treatment, defined as an intervention performed greater than 45 days after intubation. Main Outcomes and Measures: Patient-specific and intervention-specific covariates were compared between the 2 groups, absolute differences with 95% CIs were calculated, and time to tracheostomy decannulation was compared using log-rank testing. Results: The 2 groups had similar demographic characteristics and a similar burden of comorbid disease. Ten patients who received early intervention (7 women [70%]; median age, 59.7 years [range, 31-72 years]; median, 34.7 days to presentation [IQR, 1.5-44.8 days]) were compared with 19 patients who received late intervention (11 women [58%]; median age, 53.8 years [range, 34-73 years]; median, 341.9 days to presentation [IQR, 132.7-376.3 days]). Nine of 10 patients (90%) who received early intervention and 11 of 19 patients (58%) who received late interventions were decannulated at last follow-up (absolute difference, 32%; 95% CI, -3% to 68%). Patients who received early treatment required fewer total interventions than patients with mature lesions (mean, 2.2 vs 11.5; absolute difference, 9.3; 95% CI, 6.4-12.1). In addition, none of the patients who received early treatment required an open procedure, whereas 17 patients (90%) with mature lesions required open procedures to pursue decannulation. Conclusions and Relevance: This study suggests that early intervention for patients with postintubation laryngeal injury was associated with a decreased duration of tracheostomy dependence, a higher rate of decannulation, and fewer surgical procedures compared with late intervention. Patients who underwent early intervention also avoided open reconstruction. These findings may bear relevance to the management of patients requiring extended durations of endotracheal intubation during recovery for critical illness related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Emergency presentation of iatrogenic airway stenosis following intubation in a patient with COVID-19 and its management.

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.