Suprastomal Granulation Research Articles

CoblationTM-assisted excision of suprastomal granulation tissue.

Suprastomal granulation tissue is a common complication of long-term tracheostomy. It may be associated with bleeding, aphonia, airway obstruction and delayed decannulation. This study describes the experience of a tertiary paediatric medical centre with CoblationTM-assisted suprastomal granulation tissue excision. Thirteen children (mean age, 5.7 years) who underwent the procedure from 2013 to 2019 because of delayed decannulation or aphonia were included. Lumen obstruction ranged from 50 to 90 per cent, with a mean of 68.8 per cent. After the procedure, decannulation was successfully performed in 7 patients, and voice quality improved in 10 patients. There were no peri- or post-operative complications. This is the largest series to date that describes Coblation used for the treatment of suprastomal granuloma. Coblation has advantages of high precision, relatively low temperature (thereby avoiding thermal injury to adjacent tissue), haemostatic resection and feasibility for use for even large granulomas. The promising results should prompt further studies in larger samples.

BRONCHOSCOPIC CRYOTHERAPY IN MANAGEMENT OF POST TRACHEOSTOMY TRACHEAL STENOSIS: AN UNCONVENTIONAL NOVEL APPROACH

Abstract: Post tracheostomy / Post intubation -tracheal stenosis is a relatively rare but a serious problem which warrants a precise diagnosis and a multimodality-multidisciplinary approach for successful outcome. Traditionally, depending upon the type and site of stenosis, such cases are managed by open surgical approach and occasionally by endoscopic approach with dilatation. We report a case, a post traumatic quadriplegic on tracheostomy tube with suprastomal granulation and web like brous stenosis, which w a s m a n a g e d s u c c e s s f u l l y b y bronchoscopiccryotherapy.Bronchoscopiccryot herapy can be considered as primary modality treatment in select group of cases. Key words: bronchoscopy, cryotherapy, cryoadhesion, suprastomal granulation, tracheal stenosis

Combined trans-stomal endotracheal approach to peri-stomal tracheal pathologies in children

ImportancePeristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved. ObjectiveWe evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies. MethodsThe medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed. ResultsIn total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p = .03) and tracheal stenosis (p = .02) were significantly associated with decannulation failure. ConclusionCombined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies.

Surveillance endoscopy after tracheostomy placement in children: Findings and interventions.

The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions. Retrospective case series. This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ2 tests and logistic regression were used to identify risk factors for the development of abnormal changes. There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%). The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation. 4 Laryngoscope, 130:1327-1332, 2020.

Airway findings in children with tracheostomies: When is diagnostic bronchoscopy and laryngoscopy indicated?

ObjectivesTo determine the utility of diagnostic laryngoscopy and bronchoscopy in children with tracheostomies and to describe the incidence of airway findings. MethodsRetrospective cohort study examining children with tracheostomies who underwent direct laryngoscopy and bronchoscopy (DLB) at Duke University Hospital between 2008 and 2016. ResultsA total of 81 patients who underwent 114 bronchoscopies met inclusion criteria. The median time between tracheostomy and first DLB was 13 months (IQR 4.25–14.75). Sixty-six patients were diagnosed with findings on DLB (81.5%). Suprastomal granulation tissue was the most common complication (59.0%), followed by increased tracheal secretions (23%), stomal and peristomal granulation (13.2%), tracheal ulcer (3.3%), and suprastomal collapse (1.6%). The proportion of patients with airway findings who underwent endoscopy >6 months post-tracheostomy was higher than those <6 months post-tracheostomy, although this did not reach statistical significance (90.6% vs. 75.5%, p = 0.087). However, when examining tracheostomy-related findings, the proportion of patients with airway findings who underwent DLB >6 months post-tracheostomy (61%) compared to <6 months post-tracheostomy (36%) was significantly different (p = 0.026). Patients who were symptomatic before bronchoscopy were more likely to have positive findings (91.9% vs. 72.7%, p = 0.027) and patients were more likely to be symptomatic if they had DLB >6 months after tracheostomy versus <6 months after tracheostomy (68.8% vs. 30.6%; p < 0.001). ConclusionThe high incidence of airway findings, especially tracheostomy-related findings, noted on DLB supports the continued use of airway endoscopies in children post-tracheostomy. Timing of DLB may play a role in determining utility with evaluation and symptomatic patients should be more closely monitored as they demonstrate higher rates of airway findings.

Suprastomal granulation tissue and pediatric tracheotomy decannulation

Suprastomal granulation tissue and pediatric tracheotomy decannulation

Routine airway surveillance in pediatric tracheostomy patients

ObjectivesThe aim of this study is to review airway findings in children with tracheostomies who underwent surveillance direct laryngoscopy and bronchoscopy (DLB) to determine the yield of routine airway evaluation in these patients. Study designRetrospective chart review at tertiary referral children's hospital. MethodsA retrospective chart review was conducted of all of the children with tracheostomies who underwent DLB after tracheostomy between 1984 and 2015. ResultsA total of 303 patients met inclusion criteria. The median time interval between tracheostomy and first follow-up DLB was 12.0 months (IQR 4.8–28.9 months). There was no significant difference in the incidence of airway lesions between patients who underwent endoscopy <6 months post tracheostomy versus those who had a longer time interval between tracheostomy and DLB (p = 0.16). One hundred sixty seven patients (55.1%) were diagnosed with lesions, with suprastomal granulation (39.9%) being the most common. Symptomatic patients were significantly more likely to have an airway lesion identified (69.9% versus 42.0%; p < 0.001). Ventilator dependent patients and those with either cardiopulmonary disease or traumatic injury as indications for tracheostomy were significantly more likely to have an airway lesion (p = 0.01). ConclusionsThe high incidence of airway lesions noted during surveillance DLB support the utility of routine airway endoscopy in pediatric tracheostomy patients. Symptomatic patients, those with ventilator dependence, or cardiopulmonary or trauma indications for tracheostomy are more likely to have airway lesions and should be monitored closely. The ideal time interval between surveillance endoscopies needs to be examined further.

Tracheostomy Complications in Institutionalized Children with Long-term Tracheostomy and Ventilator Dependence.

(1) To identify tracheostomy complications in institutionalized children with chronic tracheostomy. (2) To determine factors that predispose to development of tracheostomy complications in institutionalized children with chronic tracheostomy. Case series with chart review over 10 years. Tertiary children's hospital. Children were included if they underwent tracheostomy before 21 years of age and resided at a pediatric nursing facility. Most children were ventilator dependent and had severe comorbid medical conditions, including developmental delay and cerebral palsy. The number of tracheostomy complications and unplanned hospital admissions were recorded. Interventions for tracheostomy complications were also reviewed. Thirty-two institutionalized children with chronic tracheostomy were included. The mean age at time of tracheostomy was 5.4 years, with a mean duration of institutionalization of 9.1 years. Twenty-seven children (84%) experienced tracheostomy complications. The total number of complications was 79. The most common tracheostomy complications identified were peristomal granulation (n = 13) and suprastomal granulation (n = 12). Age at time of tracheostomy, duration of institutionalization, and ventilator dependence did not predict the likelihood of developing a complication. Of 32 patients, 20 were evaluated in the emergency room during the study, and there were 48 unplanned admissions for tracheostomy-related complications during the study. Forty-five urgent direct laryngoscopy and bronchoscopy procedures were performed in a total of 20 children with tracheostomy complications. Tracheostomy complications are common in institutionalized children with chronic tracheostomy and are challenging to manage. Further research is necessary to determine novel ways to reduce tracheostomy complications in this population.

Developing a Standard of Care for Pediatric Tracheostomy Decannulation

Objectives: 1) Recognize which diagnostic modalities are helpful to facilitate safe decannulation. 2) Provide data-driven conclusions about pediatric tracheostomy management, given the recent American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) Consensus Statement on Tracheostomy Management (January 2013), which was based on expert opinion alone. 3) Define a pediatric tracheostomy decannulation protocol that can be extended to a large subset of patients. Methods: Study type: 10-year retrospective review of one surgeon’s pediatric tracheotomy decannulation methods. Inclusion criteria: Patients less than 18 years old. Setting: Tertiary care pediatric hospital. Outcome measurements: Airway endoscopy findings, sleep study results, capping trial tolerance, successful decannulation, and tracheocutaneous fistula repair and management. Results: 167 patients underwent tracheotomy during this period, and 52 were decannulated. Of these, 22 had suprastomal granulation tissue removed and 4 patients had tonsillectomies, adenoidectomies, epiglottopexies, and/or supraglottoplasties prior to decannulation. Seventeen patients had subglottic stenosis; 9 underwent laryngotracheal reconstruction. Twenty-five patients developed tracheocutaneous fistulas; 24 patients elected repair with 100% success rate. Conclusions: Decannulation of the pediatric patient requires a starkly different approach compared to the adult population, as many require surgical intervention prior to decannulation, and a much higher percentage of pediatric patients will keep a tracheocutaneous fistula. Our decannulation protocol includes daytime capping, rigid airway endoscopy to detect anatomic airway abnormalities, flexible endoscopy during simulated sleep to detect dynamic airway problems, and capped sleep studies. We also describe our novel trapdoor stomal flap technique, which has a 100% success rate for closure of tracheocutaneous fistulas.

Powered debridement of suprastomal granulation tissue to facilitate pediatric tracheotomy decannulation

Objective To compare suprastomal granulation tissue (SSGT) removal using the microdebrider with other common methods of excision. Methods Retrospective review ( n = 21) of SSGT excision at a tertiary care pediatric hospital (2004–10). Outcome measures included intraoperative blood loss, operative time, decannulation rates, and complications. Results 10 children underwent excision of SSGT via powered SSGT debridement and 8 were decannulated (80% success rate). Of the other 11 patients who had manually non-powered techniques (kerrison rongeur, laryngeal microinstruments, or optical forceps), 7 were decannulated (63% success rate). Operative time was on average shorter than all other procedures, but not significantly ( p = 0.101). There was no significant difference in blood loss when powered debridement was compared to other techniques ( p = 0.872). There were no significant complications encountered in our patients who received SSGT powered debridement. Conclusions Endoscopic powered SSGT debridement is a simple and useful tool in the process of pediatric tracheotomy decannulation with superior decannulation rate, shorter operative time, and comparable blood loss to other techniques.

Flexible CO2Laser Fiber in the Pediatric Airway

Objective. Our institution has been using a novel flexible laser fiber in pediatric surgical airway procedures, which has been quite successful. The purpose of this paper is to present our preliminary experience in the treatment of pediatric airway lesions using this laser technique.Methods.A case series reviewing 40 patients undergoing 95 laser procedures is reported. Indications included removal of suprastomal granulation tissue, removal of granulation after laryngotracheal reconstruction, subglottic and supraglottic stenoses, recurrent respiratory papillomas, subglottic hemangioma, laryngeal cleft, and left main stem bronchus stenosis. Procedures were performed via microdirect laryngoscopy and bronchoscopy.Results. No complications including postoperative glottic webs, concentric scar formation, or airway fires occurred in any of the patients (after the series was completed, we did experience an airway fire. It was a flash flame that was self-limited and caused no long-term tissue injury).Conclusions. The endoscopic application of a new flexible carbon dioxide laser fiber for management of pediatric airways lesions provides good outcomes in selected patients. Distal respiratory papillomas, subglottic stenosis, and granulation tissue are, in our experience, appropriate indications.

Impact of Stoma Maturation on Pediatric Tracheostomy-Related Complications

To assess the impact of stoma maturation on pediatric tracheostomy-related complications and to report the incidence of pediatric tracheostomy-related complications. Retrospective medical chart review and data analysis. Tertiary care children's hospital. A total of 172 consecutive patients who underwent tracheotomy during a 4-year period. Tracheotomy with or without stoma maturation at the time of surgery was performed by 8 pediatric otolaryngologists. Stoma maturation was based solely on individual surgeon preference, not on patient factors. Early and late tracheostomy-related complications; correlation between stoma maturation and complication rate. The patients' mean (SD) age was 4.9 (6.6) years, with a mean follow-up of 35.4 (24.5) months. Of 156 patients for whom stoma maturation data were available, 48 (30.8%) underwent stoma maturation and 108 (69.2%) did not. Nineteen of 172 patients (11.0%) had an early complication (within the first 7 days), including accidental decannulation, bleeding, false tract, pneumonia, and tracheitis. Late complications included suprastomal tracheal granulation tissue (48.8%), tracheitis (48.8%), peristomal granulation tissue (26.7%), accidental decannulation (11.6%), and mucus plugging (9.9%). Among the 62 patients (36.0%) who were decannulated, 23 of 62 (37.1%) developed a persistent tracheocutaneous fistula. Younger patients had a higher rate of suprastomal granulation tissue, tracheitis, tracheocutaneous fistula, and repeated surgical procedures (P < .05). Patients with stoma maturation were incidentally older than patients without stoma maturation (P < .05). When corrected for age, stoma maturation did not have an impact on the incidence of any of the tracheostomy-related complications. There was no relationship between stoma maturation and tracheostomy-related complications, including rate of tracheocutaneous fistula and development of granulation tissue.

Kryoextraktion bei unterschiedlichen Formen einer Atemwegsobstruktion: Vier exemplarische Fälle

With the development of mechanically stable cryoprobes, direct endoscopic removal of tissue from the bronchial system with cryotherapy is now possible. Tissue is frozen to the tip of the probe and removed by pulling on the probe together with the fiberscope. This procedure, also referred to as cryoextraction, additionally provides good quality biopsy specimens for histopathological examination. We report here on four patients with different forms of bronchial obstruction, in whom cryoextraction was performed for rapid recanalization. In addition to the immediate effect, the procedure has few complications and is cost-effective. Indications were mucoid impaction, foreign body aspiration, removal of suprastomal granulation tissue prior to decannulation after prolonged mechanical ventilation, and obstruction of the trachea and the main bronchi by a carcinosarcoma. In the latter case, the diagnosis was additionally based on a specimen obtained by cryobiopsy.

Pediatric Laryngotracheal Obstruction: Current Perspectives on Stridor

To assess how medical advances have impacted the diagnosis, management, and outcomes of pediatric laryngotracheal obstruction, and to describe the advantages of audio-video documentation of stridorous children. Retrospective. 268 patients were referred for suspected laryngotracheal obstruction during the 30 months between September 1, 1995 and March 1, 1998: 173 had 206 flexible fiberoptic laryngoscopies, and 160 had 273 direct laryngoscopies. One hundred and forty-one children were identified with laryngotracheal obstruction, yielding 40 different diagnoses that could be classified into 9 major categories. Thirty-six children (25.5%) had multiple sites of upper airway obstruction. 138 children had follow-up >1 month. Twelve children died (8.7%), leaving 126 survivors (mean follow-up=21.1 months). Outcomes were classified as resolved (44.2%), improved (37.0%), stable (9.4%), failed (0.7%), or death (8.7%). Better outcomes were seen in more readily treated diagnostic categories, such as tracheobronchial foreign body, chronic laryngitis, and suprastomal granulation tissue; laryngeal stenosis, tracheomalacia, and recurrent respiratory papillomatosis, had less favorable outcomes (P<.001). The former group also showed superior outcome compared to laryngomalacia (P<.001) and vocal cord mobility disorders (P=.004). Ninety-four patients (68.1%) had comorbidities complicating their management. Comorbid conditions were universal among deceased patients and least common in the resolved outcomes category (56.7%), supporting the premise that patients with poor outcomes are more likely to have comorbidities than patients with resolution of laryngotracheal symptoms (P=.034). Audio-video recording of pediatric laryngotracheal obstruction offers numerous advantages. Children classified into an array of diagnostic categories usually have favorable outcomes, but opportunities for continued advances exist, particularly regarding management of comorbidity and chronic obstruction.

Is tracheotomy decannulation possible in oxygen-dependent children?

Objective: The goal was to determine whether decannulation can be safely achieved in children with persistent oxygen requirements. Design: The study was a prospective evaluation of 12 oxygen-dependent children at a tertiary care academic children's medical center. Methods: Twelve tracheotomy-dependent children with persistent oxygen requirements were evaluated for decannulation. Patients requiring more than 35% FiO were not considered. Direct laryngoscopy and bronchoscopy were performed in all patients. Two required single-stage laryngotracheoplasty to correct subglottic stenosis, 1 required tracheal resection, and 7 required removal of suprastomal granulation tissue. Oxygen was administered after decannulation through a nasal cannula. Results: Decannulation was successful in 92% (11 of 12) of patients. At final follow-up, oxygen requirements decreased in 58% of patients after decannulation. Conclusions: Decannulation can be successful in children who remain oxygen dependent; conversion to a more physiologic airway may be an adjunct to reducing or eliminating their oxygen demand. (Otolaryngol Head Neck Surg 2000;123: 263–8.)

Totally obstructing tracheotomy-associated suprastomal granulation tissue

Although tracheotomy-associated suprastomal granulation tissue is quite common, suprastomal granulation tissue that totally obstructs the airway is relatively rare and can be associated with serious complications. In this report the complications and management of six cases of totally obstructing suprastomal granulation tissue (TOSGT) are presented. Complications associated with the presence or management of TOSGT included progression of subglottic stenosis, development of posterior laryngeal stenosis, development of supraglottic stenosis following CO 2 laser supraglottoplasty, and dislodgement of the TOSGT with distal tracheal obstruction resulting in anoxic brain injury. It is recommended that the tracheotomy tube remains in position at all times during attempted removal, and that if endoscopic removal is not possible, that open tracheoplasty is the safest method for removal. Measures that may decrease the chances of recurrence include diligent diagnosis and treatment of gastroesophageal reflux disease (GERD) and bacterial infection. TOSGT may be a marker for some patients with abnormal wound healing.

Obstructive suprastomal granulation tissue following percutaneous tracheostomy.

Percutaneous dilatational tracheostomy is frequently performed as an alternative to traditional surgical open tracheostomy with many reported benefits. Despite its relative safety and widespread acceptance, complications can be associated with the procedure itself or long-term. We present four cases where there was difficulty with decannulation because of exuberant obstructive granulation tissue. In each case, the percutaneous tracheostomy involved the cricoid cartilage.

Suprastomal granulation tissue and pediatric tracheotomy decannulation.

Although numerous decannulation techniques have been reported, often involving costly sleep studies, repetitive laser procedures, and tracheotomy tube "downsizing," no established standard of care exists. We advocate the following simple, minimally invasive decannulation protocol. After excluding concomitant airway lesions, suprastomal granulation is removed transtomally by an endoscopically guided rongeur. A tracheotomy tube is then fashioned with a fenestration centered in the tracheal lumen. Decannulation occurs if the patient maintains adequate ventilation over a 12- to 24-hour observation period with the fenestrated tracheotomy capped. Over 18 months we prospectively followed 10 consecutive children presenting as potential decannulation candidates. Using the aforementioned technique, nine of 10 patients were successfully decannulated (average follow-up, 11.5 months). The postoperative capped fenestrated tracheotomy trial provides a realistic assessment of preparedness for decannulation. We recommend this protocol as a rapid, efficient, and cost-effective means of achieving decannulation.

Ventilating Tracheal Resectoscope

The ventilating tracheal resectoscope (Karl Storz) combines the advantages of a ventilating bronchoscope and the resecting cytoscope for removal of soft tissue from the airway. The resectoscope offers several distinct advantages over other methods of granulation tissue removal. The procedure is done under direct vision with magnification and illumination of a rod-lens optical system. Suprastomal granulation tissue is resected cleanly, without tearing or stripping adjacent mucosa. Hemorrhage is readily controlled with the coagulating mode. The resectoscope can also be used for removing benign tumors (such as recurrent respiratory papillomatosis) from the trachea and bronchi. Its use in the efficient removal of malignant tumors and subglottic soft tissue has also been described.

Excision of suprastomal granulation tissue

Excision of suprastomal granulation tissue