Effects of supramaximal balloon dilatation pressures on adult cricoid and tracheal cartilage: A cadaveric study.

OBJECTIVES/HYPOTHESIS: Cricoid fracture is a serious concern for balloon dilatation in airway stenosis. Furthermore, there are no studies examining tracheal rupture in balloon dilatation of stenotic segments. The aim of this study was to evaluate the effect of supramaximal pressures of balloons on the cricoid and tracheal rings. STUDY DESIGN: Prospective cadaveric study. METHODS: Seven cadaveric laryngotracheal complexes of normal adults with intact cricothyroid membranes were acquired. Noncompliant vascular angioplasty balloons (BARD-VIDA) were used for dilatation. The subglottis and trachea were subjected to supramaximal dilatation pressures graduated to nominal burst pressure (NBP) and, if necessary, rated burst pressure (RBP). Larger-diameter balloons, starting from 18 mm size to 24 mm, were used. Dilatations were maintained for 3 minutes. RESULTS: The cricoid ring was disrupted by larger-diameter balloons (22 mm and 24 mm) even at lower pressures (less than NBP) in six cases. Tracheal cartilages were very distensible, and external examination after supramaximal dilatation (24 mm close to RBP) revealed no obvious cartilage fractures or trachealis tears. Histopathological examination revealed sloughing of mucosa in the areas corresponding to balloon placement, but no microfractures or disruption of the perichondrium of tracheal ring cartilages. CONCLUSIONS: These results indicate that the cricoid is vulnerable to injury from larger balloons even at lower dilatation pressures. The tracheal cartilages and the membranous wall of the trachea remained resilient to supramaximal dilatation and larger balloons. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1304-1309, 2018.

Oropharyngeal Dysphagia in children: mechanism, source, and management.

Oropharyngeal dysphagia (OPD) is a challenging and relatively common condition in children. Both developmentally normal and delayed children may be affected. The etiology of OPD is frequently multifactorial with neurologic, inflammatory, and anatomic conditions contributing to discoordination of the pharyngeal phase of swallowing. Depending on the severity and source, OPD may persist for several years with significant burden to a patient's health and family. This article details current understanding of the mechanism and potential sources of OPD in children while providing an algorithm for managing it in the acute and chronic setting.

Supraglottoplasty outcomes in neurologically affected and syndromic children.

IMPORTANCE: Supraglottoplasty (SGP) failure is frequently attributed to coexistent medical comorbidities, but studies specifically evaluating outcomes in these populations are lacking. OBJECTIVE: To assess SGP outcomes in patients with neurologic and syndromic comorbidities and severe laryngomalacia (LM). DESIGN, SETTING, AND PARTICIPANTS: Case series with retrospective review of medical records of 54 patients with neurologic and/or syndromic comorbidity and severe LM who underwent SGP between 2004 and 2012 at a tertiary care pediatric institution. INTERVENTIONS: Patients presented with severe LM that required SGP. Supraglottoplasty failure necessitated revision SGP, tracheostomy, or gastrostomy tube insertion, or LM and obstructive sleep apnea that required assisted ventilation (continuous positive airway pressure and bilevel positive airway pressure). MAIN OUTCOMES AND MEASURES: Medical records were reviewed with a focus on patient factors, surgical timing, complications, and surgical and dysphagia outcomes. Patients were grouped based on their age at the time of SGP as infants (aged ≤12 months) and children (aged >12 months). Statistical comparisons were performed with SGP outcomes of infants with LM and no comorbidities. RESULTS: Fifty-four patients met the inclusion criteria. Thirty-one (13 infants, 18 children) had a neurologic condition and 23 (15 infants, 8 children) had syndromes. The overall success rate of SGP was 67% (36 of 54) in these populations. Neurologic (P = .003) and syndromic (P < .001) comorbidities were associated with significant reduction in SGP success rates vs no comorbidities. Among SGP failures (18 of 54 [33%]), 13% (7 of 54) required tracheostomy, 9% (5 of 54) needed assisted ventilation, 7% (4 of 54) required a postoperative gastrostomy tube, and 4% (2 of 54) required revision SGP. In the neurologic comorbidities group, patients with cerebral palsy had significantly higher tracheostomy rates compared with those who had other neurologic pathologies constituting comorbidities (2 of 11 [18%] vs 0 of 20; P = .049). In infants, acute airway obstruction was the most common indication for SGP in the neurologically comorbidity and syndrome populations (success rates, 69% and 67%, respectively). In children, obstructive sleep apnea was the most common indication for SGP in the neurologic comorbidity and syndrome populations (success rates, 78% and 50%, respectively). CONCLUSIONS AND RELEVANCE: Supraglottoplasty remains useful and outcomes were better in patients with neurologic comorbidity than in patients with syndromic comorbidity.

Supraglottoplasty in premature infants with laryngomalacia: does gestation age at birth influence outcomes?

PURPOSE: Prematurity is thought to be to be an independent risk factor for supraglottoplasty (SGP) failure. The purpose of this study was to compare the outcomes of supraglottoplasty in premature infants with congenital laryngomalacia (LM) with that of term infants. STUDY DESIGN: Case series with chart review. SETTING: Tertiary-care pediatric institution. METHODS: Analysis was performed on 325 consecutive patients undergoing SGP between 2004 and 2012. Patients older than 12 months age or with syndrome, neurologic, or cardiac comorbidities were excluded. Resolution of airway symptoms after SGP was considered successful while revision SGP and tracheostomy were considered failures. The rates of secondary airway lesions (SAL), dysphagia, and gastrostomy tube (GT) placement were also compared. RESULTS: A total of 176 infants (136 term, 40 preterm) were identified. SGP was successful in 92.7% term and 90% preterm infants with no significant difference (P = .5865). Incidence of revision SGP and tracheostomy was similar among the groups. The outcomes of SGP were the same in all groups stratified by age. Incidence of SAL was significantly higher in preterm (72.5%) compared to term infants (34.6%, P = .0002). Dysphagia rates in the follow-up were higher in preterm (32.5%) versus term infants (6.6%, P < .001). The rate of GT insertion was significantly greater (P = .003) in preterm (27.5%) than term infants (6.6%). The preoperative dysphagia, persistent dysphagia, and GT in follow-up was significantly higher when gestation age <32 weeks (25%, P = .0168). CONCLUSION: Supraglottoplasty outcomes in term and preterm infants were similar irrespective of gestation age. Higher rates of dysphagia in follow-up are seen when gestation age <32 weeks.

Intralesional cidofovir as adjuvant for the successful management of aggressive respiratory papillomatosis in an infant.

Recurrent respiratory papillomatosis (RRP) in young children is frequently characterized by a recalcitrant course and need for multiple surgeries. Periodic surgical debulking and ablation is the mainstay of therapy as a cure for RRP rarely occurs. Benefits of adjuvant treatment with local injection of cidofovir in aggressive cases of RRP have been reported in both children and adults. However, a consensus on initiation, dosage, or scheduling of this drug has not been established in the very young patient. Literature on successful remission in children less than 1 year of age is not available. One such case of an infant with aggressive RRP treated with local adjuvant cidofovir is described herein.