Microlaryngoscopy And Bronchoscopy Research Articles

Post-extubation laryngitis in children: diagnosis, management and follow-up

ObjectivesTo describe the occurrence of post-extubation laryngitis, analyze its one-year evolution, and correlate laryngeal lesions with clinical outcomes. MethodsRetrospective study including children up to 13 years old at a tertiary hospital between March 2020 and March 2022 with diagnosis of post-extubation laryngitis confirmed by endoscopic examination. Exclusion criteria were prior history of intubation or anatomical airway abnormalities. Medical records were reviewed to characterize patients, underlying diagnosis, laryngeal lesions, treatment, and outcomes at 12-month follow-up. ResultsThe study included 38 endoscopically confirmed post-extubation laryngitis cases, corresponding to 86.4% of suspected cases. The mean age was 13.24 months, and 60.5% were male. Acute respiratory failure was the leading cause of intubation. Initial treatment was clinical, and initial diagnosis was defined by nasopharynoglaryngoscopy and/or Microlaryngoscopy and Bronchoscopy (MLB) findings. Initial diagnostic MLB was performed in 65.7% of the patients. Approximately half (53%) of the patients exhibited moderate or severe laryngeal lesions. When compared to mild cases, these patients experienced a higher rate of extubation failures (mean of 1.95 vs. 0.72,p = 0.0013), underwent more endoscopic procedures, and faced worse outcomes, such as the increased need for tracheostomy (p = 0.0001) and the development of laryngeal stenosis (p = 0.0450). Tracheostomy was performed in 14 (36.8%) children. Patients undergoing tracheostomy presented more extubation failures and longer intubation periods. Eight (21%) developed laryngeal stenosis, and 17 (58.6%) had complete resolution on follow-up. ConclusionPost-extubation laryngitis is a frequent diagnosis among patients with clinical symptoms or failed extubation. The severity of laryngeal lesions was linked to a less favorable prognosis observed at one-year follow-up. Otolaryngological evaluation, follow-up protocols, and increased access to therapeutic resources are essential to manage these children properly. Level of evidenceLevel 4.

Transtracheal Pressure for Evaluation of Decannulation Readiness.

Pediatric tracheostomy decannulation protocols vary among institutions and may include toleration of Passy Muir Valve (PMV), microlaryngoscopy and bronchoscopy (MLB) findings, and polysomnography evaluation. Transtracheal pressure (TTP) is an objective measurement utilized to evaluate PMV toleration. We aimed to investigate the role of TTP in decannulation candidates and compare TTP measurements with polysomnography and MLB findings. A retrospective cohort study of children who underwent TTP measurement during PMV trial between December 2012 and November 2022. A total of 79 patients underwent TTP measurement and MLB evaluation; of these, 16 (20.3%) patients had a capped polysomnography. Twenty-eight (35.4%) patients had TTPs ≤10 cm H2 O, and 51 (64.6%) patients had TTPs >10 cm H2 O. The most common indication for tracheostomy was upper airway obstruction (n = 41, 51.9%), followed by a need for mechanical ventilation (n = 24, 30.4%). Twenty-five (31.6%) patients were decannulated. Patients with TTPs ≤10 cm H2 O had a mean Apnea-Hypopnea Index of 0.17 ± 0.26/h compared with 6.93 ± 7.67/h in those with TTPs >10 cm H2 O, p = 0.0365. Patients with TTPs >10 cm H2 O were found to have a significantly higher occurrence of airway obstruction (96.1% vs. 46.4%, p < 0.0001) and multilevel airway obstruction (70.6% vs. 21.4%, p < 0.0001) on MLB. Neither TTP measured at time of PMV assessment nor capped polysomnography was associated with successful decannulation. TTP measurements at time of PMV evaluation are associated with polysomnography and MLB findings. One-time PMV measurements were not indicative of decannulation success. 4 Laryngoscope, 2024.

Predictors of the need for tracheostomy in the neonatal intensive care unit

ObjectivesMany infants in the neonatal intensive care unit (NICU) require prolonged periods of respiratory support. Microlaryngoscopy and bronchoscopy (MLB) is performed to evaluate for airway pathology and facilitate decision-making regarding further airway interventions or tracheostomy. The objectives of this study are to describe the operative findings of MLB performed on infants in the NICU and determine which pre-operative characteristics or operative findings are predictive of the need for tracheostomy. MethodsThe medical records of preterm inpatients in the NICU at a single tertiary care hospital who underwent MLB between January 1, 2013 and January 7, 2016 were reviewed. Baseline and demographic characteristics and intra-operative findings were compared between patients who underwent tracheostomy and those who were successfully weaned from respiratory support. ResultsSeventy-three preterm patients underwent MLB for respiratory failure, of whom 41 (56.2%) underwent tracheostomy. Patients who underwent tracheostomy had lower mean gestational age (27.4 vs. 30.5 weeks), higher prevalence of bronchopulmonary dysplasia (73.2% vs. 37.5%), lower mean birth weight (1.1 kg vs. 1.6 kg), and a greater number of extubation events (5.2 vs. 3.0) than those who weaned from respiratory support. Abnormal MLB findings were common in both groups, though no single MLB finding differed significantly between groups. ConclusionsPreterm infants in the NICU with gestational age ≤30 weeks, birth weight <1.5 kg, severe pulmonary disease, and who have failed more than 3 extubation attempts are more likely to require tracheostomy.

Timing of Initial Posttracheostomy Surveillance Endoscopy in Pediatric Patients.

To determine the optimal timing of the first posttracheostomy microlaryngoscopy and bronchoscopy (MLB). Case series with chart review. Tertiary pediatric medical center. Patients (<21 years of age) who underwent tracheostomy placement from January 1, 2011, to December 31, 2016. Patients were divided into early and late posttracheostomy surveillance groups (<6 weeks vs 6 to 14 weeks, respectively) based on the timing of their first posttracheostomy MLB. The primary outcome was to ascertain the clinical yield of the initial posttracheostomy MLB by documenting whether a medical or surgical treatment decision was made based on MLB findings. In total, 202 patients were included; of these patients, 162 met criteria for placement in the early group and 40 met criteria for the late group. There was no significant difference between the early and late groups regarding whether a medical or surgical decision was made at the time of the first MLB (21.5% vs 19%, respectively; P = .49). Multiple logistic regression identified that the presence of tracheostomy-related symptoms prior to MLB (odds ratio, 6.75; 95% confidence interval, 2.78-16.39) was the sole predictor of a medical or surgical decision being made at the first posttracheostomy MLB. The presence of tracheostomy-related symptoms was predictive of a medical or surgical decision being made using information obtained at the time of the first posttracheostomy MLB. We thus recommend that surveillance endoscopy be initiated when tracheotomized children start to develop tracheostomy-related symptoms.

A Simple Mandibular Distraction Protocol to Avoid Tracheostomy in Patients With Pierre Robin Sequence.

Recent treatment goals for Pierre Robin sequence (PRS) focus on avoiding tracheostomy through modalities such as mandibular distraction osteogenesis (MDO). We primarily evaluated the efficacy of our straightforward MDO treatment protocol for resolution of PRS-associated airway obstruction while secondarily analyzing patient characteristics associated with success or failure of MDO. A retrospective chart review before and after treatment. Tertiary institutional center and private practice setting. All patients were diagnosed with PRS and treated with MDO, according to the MDO treatment protocol, by a single surgeon with the same operative technique from 1999 to 2013. A sample size of n = 38 met the inclusion criteria. Data assessed included tracheostomy status (pre-MDO, post-MDO, or none), microlaryngoscopy and bronchoscopy (MLB) findings, multipositional airway study results, clinical resolution of airway obstruction following MDO, and patient characteristics. Resolution of airway obstruction with avoidance of a tracheostomy. Prior to referral for MDO, five patients required urgent tracheostomy. Of patients without a pre-MDO tracheostomy (n = 33), two patients required tracheostomy post-MDO, while 94% avoided tracheostomy with clinical resolution of airway obstruction (n = 31). On secondary analysis, anatomic abnormalities diagnosed by MLB were associated with a higher rate of tracheostomy (P = .037), confirming the utility of preoperative evaluation with MLB; otherwise, no patient characteristics demonstrated significance in patient selection. Follow-up ranged from 6 months to 10 years (mean = 6.45 years, median = 7.61 years). Our treatment protocol demonstrates MDO is highly effective for resolving severe airway obstruction related to PRS. Based on secondary analysis, our simplified protocol does not require amendment.

Validation of the Airway-Dyspnoea-Voice-Swallow (ADVS) scale and Patient-Reported Outcome Measure (PROM) as disease-specific instruments in paediatric laryngotracheal stenosis.

To validate the Airway-Dyspnoea-Voice-Swallow (ADVS) instrument as a disease-specific Patient-Reported Outcome Measure in paediatric laryngotracheal stenosis. Prospective observational study. A quaternary referral centre for complex airway disease. Forty-eight patients (30 males) with a mean age of 49 ± 49 months who underwent laryngotracheal surgery or microlaryngoscopy and bronchoscopy (MLB) following laryngotracheal surgery. Airway-Dyspnoea-Voice-Swallow summary scale and Patient-Reported Outcome Measure (PROM), Paediatric Quality of Life (PedsQL) scale, Paediatric Voice Handicap Index (pVHI) and Lansky performance scale were administered to patients before and 6-8 weeks following airway examination/surgery. Most patients (73%) had intubation-related subglottic stenosis, and 60% of patients had prior airway treatments. The majority of patients (77%) had more than one major chronic morbidity, and the commonest procedures were diagnostic MLB (49%), followed by airway dilation (29%). Cronbach-α value for the ADVS PROM was 0.71 overall and 0.85, 0.86 and 0.64 for the dyspnoea, voice and swallow domains, respectively. Rank correlations between Dyspnoea, Voice and Swallow summary scale and PROM scores were 0.83, 0.71 and 0.81, respectively (P < 0.0001). For those patients undergoing diagnostic MLB, pre- and post-examination scores were highly correlated (intraclass correlations >0.75). There was a significant rank correlation between ADVS PROM score and Lansky performance score (r = -0.68; P < 0.0001). There were significant correlations between PROM score and PedsQL (r = -0.57; P < 0.0001) and between voice domain of the PROM and pVHI (r = 0.78; P < 0.0001). There were strong correlations between Myer-Cotton stenosis severity and dyspnoea scale and PROM score (r = 0.68; P < 0.0001). There were significant differences in voice and swallow ADVS scales and PROM scores between patients with and without concomitant laryngeal/oesophageal pathology. Patient age and presence of high dyspnoea and swallowing PROM scores were independently associated with poorer quality of life and performance status. These series of observations validate the ADVS instrument as a disease-specific outcome measure for paediatric laryngotracheal stenosis. Dyspnoea and swallowing dysfunction appear to have the greatest impact on quality of life. More widespread adoption of the ADVS instrument could help create a shared language for outcomes communication and benchmarking for children with this complex condition.

Conservative management of laryngeal dog bite*

Dog bites represent an important public health issue, causing injuries from trivial to fatal. The true incidence is unknown due to the lack of national and local reporting system. School children, mostly male, are more commonly affected with the majority of injuries occurring in the head and neck area, followed by the limbs and trunk. The conservative management of a 6-year-old girl who sustained a fracture of her laryngeal structure from an attack by her neighbours' dog is described. Only a 1 cm visible puncture wound in the midline of her neck with air escaping through the wound was seen at presentation. Ten days were spent in hospital including the first four in intubated Paediatric Intensive Care Unit. Initial microlaryngoscopy and bronchoscopy (MLB) showed a swelling in the right anterior subglottis not reducible by manipulation. She was re-intubated with progressively larger naso-tracheal tube until the fracture was fully reduced on her 3rd MLB. Three months post-injury, there is no evidence of airway narrowing. The literature advocates early surgical management of laryngeal trauma including dog bites. Conservative management of laryngeal fracture from a dog bite is feasible and associated with a good outcome and no long-term sequela.

Accuracy and Safety of Tracheoscopy for Infants in a Tertiary Care Clinic

To assess the diagnostic accuracy and safety of office-based tracheoscopy when combined with flexible fiberoptic laryngoscopy (FFLT). Flexible laryngoscopy on infants is routinely performed by otolaryngologists in the clinic. The addition of tracheoscopy may improve overall airway assessment but is rarely performed due to the suspected risk of airway compromise. A 6-year retrospective medical record review. Tertiary care hospital. Thirty-one infants younger than 1 year with complete data from preoperative FFLT and microlaryngoscopy and bronchoscopy (MLB) were examined. Results from 241 MLB procedures were reviewed. Laryngomalacia (LM) and tracheomalacia (TM) were identified more often by FFLT than by MLB. In particular, the detection rate for LM and TM by MLB, as seen preoperatively by FFLT, was 79% and 61%, respectively. Compared with FFLT, MLB accurately diagnosed the severity of LM and TM only 55% and 65%, respectively, of the time. Fiberoptic laryngoscopy revealed synchronous airway lesions in 62% of infants with LM, while MLB discovered synchronous airway lesions in 54%. Static airway lesions were more frequently diagnosed with MLB. No respiratory events occurred during FFLT. In an appropriate patient, FFLT is a safe and effective diagnostic tool for common infant tracheal and laryngeal abnormalities. Detection and characterization of dynamic airway lesions is better achieved by FFLT than by MLB.

Blue episodes in a neonate

In September, 2007, a 9-day-old baby girl presented to the emergency department with increased respiratory eff ort and weight loss. She was delivered by elective caesarean section for breech presentation. At birth, she was fl oppy, cyanosed, and bradycardic. Her Apgar score was 5 and 9 at 1 and 5 min, respectively. On examination she had a grade II systolic murmur. Blood pressure and oxygen saturation were normal. On day 3, she was noted to have some weight loss due to poor feeding. Following successful supervised feeding and some weight gain, she was discharged the following day, in good condition, with an echocardiogram planned for day 9. On day 6, however, the mother raised concerns about her baby’s rapid breathing and continuing feeding diffi culties but was reassured by the community midwife. When we saw the baby in the emergency department she was cyanosed (SaO2 88% on room air), with a respiratory rate of 30–40/min, intercostal recession, and grunting. She had noisy breathing with intermittent episodes of desaturation and bradycardia. Her nasal passages were patent. The rest of the clinical examination was unremarkable. Capillary blood gas showed respiratory acidosis (ph 7·28, PO2 6·5 kPa, PCO2 9·1 kPa, HCO3 31 mmol/L, and base excess +1·6 mmol/L). Septic screen was negative. Chest radiography showed a boot shaped heart, suggestive of congenital cyanotic heart disease. She was transferred immediately to a specialist unit for a cardiology opinion. Echocardiography showed a small posteromuscular ventricular septal defect which did not account for the clinical presentation. Her noisy breathing was attributed to inspiratory stridor, and subsequent microlaryngoscopy and bronchoscopy (MLB) showed a large cyst arising from the vallecula (fi gure A). Aspiration of the cyst failed because of the viscosity of the contents; the cyst was incised and de-roofed successfully (fi gure B). Histological examination showed a squamous epi thelium lined cyst with a smooth muscle-containing wall. She was discharged home on the 10th post-operative day with intermittent soft stridor, and on demand feeds. When the baby was reviewed 6 weeks later in clinic, she had gained weight and was well, with no stridor or breathing diffi culty, and feeding well. Congenital tumours of the oropharynx are rare. Laryngeal cysts are broadly classifi ed as ductal (75%) or saccular (25%). Ductal cysts arise because of obstruction in the collecting ducts; vallecular cysts are a form of ductal cyst. The vallecula is the groove between the epiglottis and the base of the tongue; during swallowing food enters the vallecula and passes around the epiglottis either side into the pyriform aperture and then into the oesophagus. Although vallecular cysts are benign, a mortality rate of 40% has been reported because of major airway obstruction. They arise because of obstruction in mucous glands at the base of the tongue. Vallecular cysts can be detected in pregnancy as early as 25 weeks’ gestation. They can present antenatally as polyhydramnios, tracheal compression, or compression of cervical vessels or hypoglossal nerve. Postnatally, they can present as respiratory distress. Other clinical features are intercostal recession, failure to thrive, cough, dysphonia, dysphagia, and cyanosis. MLB and rigid endoscopy are the mainstay of diagnosis. A fi bre-optic review of the upper airway and bronchus is mandatory to rule out laryngo/bronchomalacia. The defi nitive treatment of these cysts is marsupialisation with CO2 laser or electrocautery. The prognosis is generally good with no risk of recurrence. Cyanosis in neonates is often caused by congential heart problems or lung pathology; our case shows that investigating non-cardiac causes of cyanosis in neonates can be a life-saving measure.

Multilevel Esophageal Biopsy in Children with Airway Manifestations of Extraesophageal Reflux Disease

Extraesophageal reflux disease (EERD) is a recognized cause of upper airway symptoms in children. Direct microlaryngoscopy and bronchoscopy (MLB) is performed for diagnostic information as to the extent and severity of the inflammation caused by gastric refluxate. Esophagoscopy with multilevel biopsy performed at the time of MLB may provide the clinician with additional information to assist in the management of EERD. We undertook to determine the role of multilevel esophageal biopsy in children who have airway manifestations secondary to EERD. We performed a retrospective chart review of 139 esophagoscopies with multilevel biopsy done at the time of MLB by a single provider for evaluation of symptoms highly associated with EERD at a tertiary care children's hospital. The histopathologic presence of esophagitis was analyzed by site and compared to the presence and location of tracheolaryngeal abnormalities. Tracheolaryngeal abnormalities associated with EERD were found in 97% of patients when evaluated by MLB. Concomitant esophagitis was found in 59% of these patients. Of patients who had 0, 1, 2, 3, 4, or 5 positive findings on MLB, 75% (3 of 4), 58% (7 of 12), 57% (20 of 35), 62% (32 of 51), 56% (18 of 32), and 80% (4 of 5), respectively, had at least 1 positive biopsy. We found that EERD that affects the pediatric upper airway was associated with esophagitis in more than half of the patients. The usefulness of 4-level biopsies during esophagoscopy and concomitant airway endoscopy will be discussed.

Subglottic cysts: the Great Ormond Street experience

Objective: Subglottic cysts are a relatively rare, non-malignant cause of airway obstruction. In this study we reviewed the details of the patients who were treated for subglottic cysts in our department in order to evaluate the presentation and treatment of patients with this condition. Methods: We performed a retrospective case note analysis of 55 patients with subglottic cysts. Case notes were examined to determine the following details for each patient: date of birth, gestational age at birth, history and length of intubation, age at presentation, presenting symptoms, findings on endoscopy, treatment given for subglottic cysts, recurrence(s) of cysts after initial treatment, and follow up for a minimum of 6 months post diagnosis. Results: Fifty five patients were identified, 35 male, 20 female. Ninety four percent were born prematurely at 24–31 weeks gestation. All patients were intubated in the neonatal period. The median duration of intubation for all patients was 10 days (range 1–126). Fifty one patients underwent intervention for their subglottic cysts at their initial, diagnostic microlaryngoscopy and bronchoscopy (MLB), and recurrent cysts occurred in 22 cases. A total of 82 procedures for cyst removal were performed, using either the carbon dioxide laser or microinstruments. Subglottic stenosis was a commonly associated feature in our series of patients, being present in 38 patients. Eleven of the 14 patients who presented to our department with tracheostomies in situ were decannulated after removal of their subglottic cysts. Conclusions: This review of the largest series of patients with subglottic cysts reported to date, reinforces our view that such cysts are rare but potentially reversible causes of upper airway obstruction, and that they result from injury to the larynx as a result of endotracheal intubation. Treatment of the cysts will often be sufficient to correct the obstructed airway allowing successful extubation or decannulation of a tracheostomy. Patients who have had subglottic cysts treated should have access to long-term follow up as there is a tendency for these cysts to recur.