Lathyrogenic agents as therapy for subglottic stenosis--a pilot study.

The surgical repair of subglottic stenosis (SGS) is often unsuccessful because of recurrence of the scar contracture. Over the past few years, two lathyrogenic agents (compounds that inhibit collagen cross-linking) have been shown effective in prevention of stenosis in animal models that have deep caustic esophageal burns. Since the principles of induced lathyrism have not been applied to the treatment of laryngotracheal stenosis, a pilot study using a canine model was conducted to test the efficacy of penicillamine and N-acetyl-L-cysteine in reduction of the rate of reformation of SGS. In all six animals used, a complete, 10 to 15 mm thick, mature SGS was induced experimentally, then opened with a CO2 laser. The dogs that were treated with lathyrogenic agents exhibited a lower rate of re-stenosis (one maintained patency throughout the 5 weeks of treatment) when compared to the two control dogs. Histologic sections of the subglottis in each dog revealed severe cricoid collapse, necrosis, and scarring, and thus demonstrated similarities to SGS in human beings. The two lathyrogenic agents used in this study are already approved for human use and may represent a valuable form of adjunctive therapy in the surgical management of SGS.

Right middle lobe syndrome in children.

Right middle lobe syndrome (RMLS) is characterized by a spectrum of diseases from recurrent atelectasis and pneumonitis to bronchiectasis of the middle lobe. It has been described among all age groups, although the diagnosis in pediatrics may be delayed or missed because of non-specific symptoms or findings. Twenty-one children with RMLS were evaluated during the past 10 years with particular attention to the history, bronchoscopic and pathologic findings. Most of these patients had asthma or a family history of atopic disorders; 3 patients had a family history of RMLS. Only two of the 21 patients had sufficient obstruction on bronchoscopy to account for their disease. Four had evidence of concomitant laryngeal pathology. The various theories of pathogenesis are discussed. In this series, the non-obstructive (impaired collateral ventilation) theory appeared to be most plausible. Bronchoscopy was performed in all instances to rule out obstruction due to foreign body or tumor. It was therapeutic in two-thirds of the cases. Resolution occurred promptly in one-third, and eventually in another third. Of the remaining patients, 4 required lobectomy and were cured; two have decreased but persistent symptoms. An aggressive medical management following bronchoscopy is warranted in all cases, especially when there is a possibility of asthma.

Anterior cricoid split: the Chicago experience with an alternative to tracheotomy.

Twenty-six infants and children underwent anterior cricoid split (ACS) in an attempt to avoid tracheotomy. Twenty (77%) were extubated successfully without tracheotomy;six (23%) failed and required tracheotomy. Our experience corroborates that reported in the literature. To date, 106 (77%) of 138 patients who have undergone ACS have been extubated successfully without tracheotomy. These results substantiate the validity of the operation when done for the proper indications. Substantive glottic and tracheal pathology indicate a high likelihood of failure of ACS.