Adult Subglottic Stenosis: Management With Laser Incisions and Mitomycin-C

Article (PDF Available)inThe Laryngoscope 118(9):1542-6 · October 2008with125 Reads
DOI: 10.1097/MLG.0b013e318179247a · Source: PubMed
Abstract
To assess the efficacy of endoscopic laser radial incisions with mitomycin-C application (ELRM) in managing adult subglottic stenosis (SGS). Retrospective case series review. Fifteen consecutive cases of adult SGS treated with ELRM at a single tertiary referral center over three years were reviewed. Subjects with SGS secondary to Wegener's granulomatosis (WG) and idiopathic SGS were included. Patients with cartilaginous SGS were excluded. The primary outcome measure was postoperative reduction in symptoms. Secondary outcome measures included total number of procedures required to relieve symptoms, interval between procedures, and improvement in pulmonary function tests when available. In addition to surgery, 14 of 15 patients were treated medically for reflux. Ten women and five men with average age 48 years were identified. Ten patients had idiopathic SGS and five had WG. The predominant presenting symptom was dyspnea on exertion in all patients. All subjects reported at least a temporary postoperative reduction in symptoms. Six patients (40%) required only one ELRM and nine patients (60%) required repeat ELRM at an average interval of 9 months. The average interval for the six patients with idiopathic etiology requiring a second procedure was 9 months. One subject with WG required four procedures. His interval improved from 2.5 to 7 months between procedures. Evidence of extrathoracic airway obstruction resolved in three of four patients with pre and postoperative pulmonary function tests. ELRM is an effective method of managing SGS associated with idiopathic causes. In patients with WG, ELRM reduced airway associated symptoms and avoided need for tracheotomy.

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The Laryngoscope
Lippincott Williams & Wilkins
© 2008 The American Laryngological,
Rhinological and Otological Society, Inc.
Adult Subglottic Stenosis: Management
With Laser Incisions and Mitomycin-C
Frederick C. Roediger, MD; Lisa A. Orloff, MD; Mark S. Courey, MD
Objectives/Hypothesis: To assess the efficacy of
endoscopic laser radial incisions with mitomycin-C appli-
cation (ELRM) in managing adult subglottic stenosis
(SGS).
Study Design: Retrospective case series review.
Methods: Fifteen consecutive cases of adult SGS
treated with ELRM at a single tertiary referral center
over three years were reviewed. Subjects with SGS sec-
ondary to Wegener’s granulomatosis (WG) and idiopathic
SGS were included. Patients with cartilaginous SGS were
excluded. The primary outcome measure was postopera-
tive reduction in symptoms. Secondary outcome mea-
sures included total number of procedures required to
relieve symptoms, interval between procedures, and im-
provement in pulmonary function tests when available.
In addition to surgery, 14 of 15 patients were treated
medically for reflux.
Results: Ten women and five men with average
age 48 years were identified. Ten patients had idio-
pathic SGS and five had WG. The predominant pre-
senting symptom was dyspnea on exertion in all pa-
tients. All subjects reported at least a temporary
postoperative reduction in symptoms. Six patients
(40%) required only one ELRM and nine patients
(60%) required repeat ELRM at an average interval
of 9 months. The average interval for the six patients
with idiopathic etiology requiring a second procedure
was 9 months. One subject with WG required four
procedures. His interval improved from 2.5 to 7
months between procedures. Evidence of extratho-
racic airway obstruction resolved in three of four
patients with pre and postoperative pulmonary func-
tion tests.
Conclusions: ELRM is an effective method of
managing SGS associated with idiopathic causes.
In patients with WG, ELRM reduced airway associ-
ated symptoms and avoided need for tracheotomy.
Key Words: Subglottic stenosis, Wegener’s granulo-
matosis, endoscopic laser radial incisions, mitomycin-C.
Laryngoscope, 118:1542–1546, 2008
INTRODUCTION
The most common cause of adult subglottic stenosis
(SGS) in the modern era is mechanical trauma from pro-
longed intubation or tracheotomy.
1
Acquired SGS may
also be caused by respiratory infections, external trauma,
or rheumatologic disease, such as Wegener’s granuloma-
tosis (WG), a systemic vasculitis characterized by inflam-
mation of the upper and lower respiratory tracts and
kidneys.
2
SGS occurs in up to 20% of patients with WG
and may be the presenting clinical feature.
2
Other, rarer,
etiologies include scleroma, amyloidosis, and osteochon-
droid hamartoma.
3
Finally, multiple studies demon-
strate that laryngopharyngeal reflux (LPR) is strongly
associated with SGS regardless of etiology
4
and these
studies suggest that LPR may be the primary etiology in
some cases.
Because of multiple associated comorbidities and var-
ied etiologies, adult SGS remains a challenging disease for
the otolaryngologist to diagnose and treat. The primary
difficulty for the surgeon is determining what structures
are involved. The region of stenosis may involve only soft
tissue scarring, only cartilage remodeling or some combi-
nation of both. Until recently, methods of assessing carti-
lage involvement were difficult as neither the commonly
available methods of computed tomography (CT) scanning
nor magnetic resonance imaging reliably image the carti-
laginous framework of the airway. Therefore, patient his-
tory, related disease and direct endoscopy with palpation
were considered the preferred method for determining
cartilage involvement. When associated with external or
internal trauma SGS is most likely to be associated with
cartilage remodeling. When due to inflammatory condi-
tions, such as WG or LPR, SGS is most commonly due
primarily to soft tissue scar. The key to successful man-
agement is determining the degree of cartilage involve-
ment. The recent advent of high resolution CT scanning
with three dimensional reconstruction and virtual endos-
copy is beginning to show promise in airway evaluation.
5
However, these types of studies are not widely available.
From the Department of Otolaryngology, Head and Neck Surgery,
University of California, San Francisco, California, U.S.A.
Editor’s Note: This Manuscript was accepted for publication April
4, 2008.
Presented at Western Section Meeting, Triological Society, Rancho
Mirage, California, U.S.A., January 31–February 2, 2008.
Send correspondence to Mark S. Courey, MD, Division of Laryngol-
ogy, UCSF Voice and Swallowing Center, 2330 Post Street, 5th Floor, Box
1809, San Francisco, CA 94115. E-mail: mcourey@ohns.ucsf.edu
DOI: 10.1097/MLG.0b013e318179247a
Laryngoscope 118: September 2008 Roediger et al.: Adult Subglottic Stenosis
1542
A wide array of surgical techniques for the manage-
ment of SGS have been employed. These include various
endoscopic and open operations. Endoscopic dilatation
alone has proven to be ineffective in the majority of cases.
6
Segmental resection with primary anastomosis can achieve
decannulation in the majority of patients with preexisting
tracheotomy tubes
7–9
yet seems an aggressive option in pa-
tients with unknown causes of SGS, in those with ongoing
sources of inflammation, or in those without cartilage in-
volvement. Therefore, endoscopic techniques for this group
of patients were developed to avoid the morbidity of open
surgery and have evolved over time.
10 –12
Early work by Simpson et al.
13
demonstrated that
endoscopic management was most successful in treating
laryngotracheal stenoses that were not completely circum-
ferential (CS), less than 1.0 cm in the vertical dimension,
and not associated with significant loss of cartilage or
remodeling. Ossoff and coworkers
14
introduced the use of
laser radial incisions and dilation, and later, the adjunc-
tive use of mitomycin-C, an antineoplastic agent that in-
hibits fibroblast proliferation and activity was reported
first by Shapshay and coworkers.
15
Mitomycin-C is now
routinely used in the endoscopic management of laryngo-
tracheal stenosis. The concentration is usually 0.4 mg/mL
and is applied topically on a cottonoid pledget. The length
of application varies from two to three repeat applications
of 2 minutes each to a single application of 5 minutes. The
handling and disposal of the mitomycin-C should be per
the hospital protocol for chemotherapeutic agents. Care
should be taken to avoid contact with unprotected skin.
Again, patients with idiopathic SGS (IS) or those
with SGS due to the inflammation of WG are more likely
to have primarily soft tissue disease amenable to endo-
scopic management. Therefore, the present study was de-
signed to assess the efficacy of endoscopic laser radial
incisions and mitomycin-C application (ELRM) in treating
adult SGS in these populations.
MATERIALS AND METHODS
A retrospective chart review was performed including all
patients 18 years of age or older with SGS treated with ELRM at
the University of California, San Francisco (UCSF) Department
of Otolaryngology, Head and Neck Surgery between October 1,
2004, and January 21, 2008. Patients with IS and WG were
included while those with cartilaginous SGS were excluded.
Fourteen of 15 patients were treated with twice daily proton
pump inhibitors (PPIs) perioperatively. All patients underwent
ELRM as described in the next paragraph with the following
exceptions: the rigid bronchoscopic dilation step was not per-
formed in one patient, and balloon dilation to 13.5 mm was
performed instead of rigid bronchoscopic dilation in two other
cases. Postoperative symptoms were recorded during routine
follow-up. The total number of procedures and the interval be-
tween surgeries were noted. Four patients had pre and postoper-
ative pulmonary function tests (PFTs) available for review.
Surgical Technique (ELRM)
General anesthesia with jet ventilation was used to provide
adequate exposure for the intervention. After the induction of
general anesthesia, an initial survey of the larynx and pharynx
was performed with a monocular laryngoscope. Then an adult
male or female subglottiscope was inserted into the larynx, posi-
tioned just above the true vocal folds, and suspended. Jet venti-
lation controlled by the anesthesiologist commenced. Photodocu-
mentation of the stentotic segment was obtained with 0 degree
and 70 degree Hopkins rod telescopes. The distance from the
superior surface of the true vocal folds to the start of the lesion
and the vertical length of the stenotic segment were measured by
marking the telescope as it passed the edge of the viewing end of
the subglottiscope.
The subglottiscope was rotated 90 degrees as it was care-
fully negotiated through the true vocal folds and advanced until it
was seated just above the stenotic segment and resuspended. The
patient’s face was protected with saline-soaked towels and the
microscope was positioned to view the larynx at 6.8 times mag-
nification. A carbon dioxide (CO
2
) laser with an AcuBlade
TM
micromanipulator (Lumenis, Santa Clara, CA) was attached to
the operating microscope. Laser energy was delivered in a pulsed
(Ultrapulse
TM
) mode. The Acublade
TM
employs a computer to
generate either a circular or linear pattern. The pulsed laser
beam pattern is chosen by the surgeon and then shuttered to
minimize overlapping areas of laser tissue impact and enhance
surgical precision. Radial incisions were made through stenotic
segments using the pattern generator to generate a line with a
length of 1 to 3 mm and 0.5 to 1.0 mm deep. Delivery continued
with the chosen pattern until the length of the entire stenotic
segment was incised. Incisions were deep enough to reach the
plane of the normal lumen of the adjacent trachea and larynx.
Great care was taken to preserve intervening mucosa between
the incisions (Fig. 1). Cottonoids soaked with mitomycin-C in a
concentration of 0.5 mg/mL were then applied for 3 minutes to the
incisions. Excess medication was wiped free using saline-soaked
cottonoids.
Finally, the subglottiscope was removed, ventilation was
maintained by the anesthesia team with mask-assisted respira-
tion, and then size 6, 7, and 8 rigid bronchoscopes were sequen-
tially passed through the segment for controlled dilation at the
incision sites. The largest size bronchoscope that passed through
the stenosis was noted.
RESULTS
Ten women and five men with average age 48 years
were identified (Table I). Ten patients had IS (2 men, 8
women) and five had WG (3 men, 2 women). Presenting
symptoms included dyspnea on exertion (all 15 patients),
cough (3), dysphonia (3), stridor (2), globus sensation (2),
and vocal fatigue (1). Most IS patients reported months to
years of progressive dyspnea on exertion, and one pa-
tient’s symptoms worsened during pregnancy. All five WG
patients had previously been diagnosed with the rheuma-
tologic disorder and were referred for suspected subglottic
involvement or management of known SGS. Two IS pa-
tients had known gastroesophageal reflux disease and one
of the two was taking twice daily PPIs before consultation.
Four patients had a history of prior surgical inter-
vention. One IS patient had undergone 19 prior microtrap-
door flap procedures. A second IS patient had been dilated
once. One WG patient had been treated with multiple
dilations, and a second WG patient had been unsuccess-
fully dilated once and had undergone tracheal resection
with temporary relief. No patients had an indwelling tra-
cheotomy tube at the time of consultation.
Twenty-eight total ELRMs were performed. All sub-
jects in all cases reported at least a temporary postopera-
tive reduction in symptoms. Overall, six patients (40%)
required only one ELRM for symptomatic relief during the
study period. The average follow-up for the entire study
Laryngoscope 118: September 2008 Roediger et al.: Adult Subglottic Stenosis
1543
group was 18 months (range 3–39 month). Nine patients
(60%) required repeat ELRM at an average interval of 9
months. The percentage of patients requiring a second
procedure was preserved within each group: 6/10 (60%) IS
patients and 3/5 (60%) WG patients. Second procedures
were performed at an average interval of 9 months for the
six IS patients and 7 months for the three WG patients
with recurrence of symptoms. The four IS patients who
TABLE I.
Patient Data.
Pt Age Sex Dx History ELRMs (no.) INT (mo.) FU (mo.)
1 51 F IS Nineteen prior microtrapdoor flaps, most recently
every 2–3 mo
34,410
2 66 M IS Six-month history of progressive DOE and known
history of GERD
1 n/a 21
3 63 F IS Several-year history of slowly progressive DOE 1 n/a 18
4 42 F IS Five-year history of slowly progressive DOE 1 n/a 11
5 33 F IS Prior history of DOE and one prior dilation at an
outside institution
1 n/a 9
6 49 M IS Several-year history of slowly progressive DOE 2 10 16
7 57 F IS Several-year history of slowly progressive DOE 2 2 3
8 49 F IS Nine-month history of slowly progressive DOE 2 7 8
9 29 F IS Presented during pregnancy with a three-month
history of progressive DOE
21328
10 70 F IS Six-month history of slowly progressive DOE 3 21, 14 39
11 47 F WG Known WG with recurrent DOE after prior dilation
and open tracheal resection
21318
12 32 M WG Known WG with slowly progressive DOE 2 6 32
13 28 M WG Known WG with slowly progressive DOE and
prior dilations
1 n/a 14
14 83 F WG Known WG with rapidly progressive DOE over
one week
1 n/a 20
15 28 M WG Known WG with slowly progressive DOE 4 2.5, 7, 7 21
Pt Patient; Dx diagnosis; IS idiopathic subglottic stenosis; WG Wegener’s granulomatosis; DOE dyspnea on exertion; GERD gastroesophageal
reflux; ELRM endoscopic laser radial incisions and mitomycin-C application; INT interval between procedures; FU total follow-up.
Fig. 1. (A–D) Endoscopic laser radial in-
cisions. (A) Circumferential subglottic
stenosis viewed with a 0-degree Hop-
kins telescope passed through a sub-
glottiscope positioned just above the
true vocal folds. (B) Closer view of the
same stenotic segment. (C) Appearance
after laser radial incisions have been
made at 12, 3, 6, and 9 o’clock (where
12 o’clock is anterior) with preservation
of intervening mucosa. (D) Enlargement
of the incisions after controlled dilation.
Laryngoscope 118: September 2008 Roediger et al.: Adult Subglottic Stenosis
1544
did not require a second ELRM were followed for an av-
erage of 15 months (range 9 –21 month). One subject with
WG (patient #15) required four procedures during the
study period. His interval improved from 2.5 to 7 months
from his first to his third procedures. The interval be-
tween his third and fourth procedures was also 7 months.
No patients progressed to require tracheotomy or open
surgical intervention. Overall, each patient underwent an
average of 1.9 0.9 procedures.
All first procedures (15) were analyzed for factors
predictive of surgical success, defined as not requiring a
second procedure, because all patients showed an im-
provement in symptoms. The average length of stenosis
(LOS) measured at the beginning of each case for the
entire group was 1.46 0.58 cm (range, 0.8–2.7 cm). Only
two patients had a stenotic segment less than 1.0 cm in
length. The mean LOS for IS patients, 1.7 0.6 cm, was
significantly greater than the mean LOS for WG patients,
1.0 0.1 cm (P .03), however, as noted previously, the
percentage of patients proceeding to a second surgery was
the same for both groups. The character of the stenosis
was CS in 8 and eccentric (ES) in 7. Although the mean
LOS for patients with ES (1.64 0.60 cm) showed a trend
toward being longer than those with CS (1.30 0.55 cm)
(P .3), only 3/7 (43%) patients with ES underwent a
second procedure compared with 6/8 (75%) patients with
CS. Five first procedures were performed urgently for
patients with critical airway narrowing on initial exami-
nation and evidence of extrathoracic airway obstruction
on preoperative PFTs with flow volume loops. Three of
these patients required a second procedure at an average
interval of 3.3 months.
Four patients underwent PFTs before and after sur-
gery. Evidence of extrathoracic airway obstruction re-
solved in three of four patients. The fourth patient was the
gentleman with WG who required four procedures in the
study period. He had PFTs between his first and second
procedures which showed normal flow volume loops. He
then stopped taking his PPIs and his WG medications.
PFTs 1 year later (6 months after the most recent ELRM)
showed the development of extrathoracic upper airway
obstruction, reflecting progression of the underlying
disease.
The majority of procedures (17/28, 61%) were per-
formed on an outpatient basis. The remainder (11/28,
39%) required a one-night hospital stay, largely because of
the extensive catchment area of UCSF; these patients
resided an average distance of 175 miles from the medical
center. Only one patient stayed for medical reasons, a
73-year-old woman with IS (patient #10, who also lives
200 miles away from UCSF) who developed postoperative
nausea and subsequently, increased pulmonary secretions
with difficulty clearing the secretions. She was treated
with intravenous steroids and racemic epinephrine with
complete resolution of her symptoms by postoperative day
four, and she was discharged home breathing more easily
than she had been preoperatively. A second patient (#7),
was admitted urgently from clinic for severe airway nar-
rowing, underwent an uncomplicated ELRM, and stayed
one night in the hospital. She was discharged home then
returned to a scheduled visit on postoperative day 6 with
mild dyspnea, stably improved from her preoperative con-
dition, and subglottic crusting that required a two-night
stay in the hospital for monitoring while corticosteroids
were administered. The patient’s symptoms resolved com-
pletely before discharge. The prolonged hospital stay and
the readmission were the only complications that occurred
in all 28 procedures (7%). No cervical emphysema, bleed-
ing, infection, or loss of cartilaginous support was seen in
any of the study patients.
DISCUSSION
Determining the proper management of adult laryngo-
tracheal stenosis has intrigued otolaryngologists throughout
modern history. Our recent evaluation and management of
two patients referred for recurrent disease after only tempo-
rary relief from open tracheal resection spurred our interest
in evaluating our own outcomes. Despite a wide array of
approaches described in the literature, no single method has
been proven to be significantly more effective than the oth-
ers. Conversely, with the exception of dilation, which has
been proven to be ineffective,
6
many approaches have shown
acceptable rates of success, variably defined as symptomatic
relief or decannulation of previously tracheotomy-dependent
patients.
Several prior studies have reported heterogeneous
patient populations with varying degrees of glottic, sub-
glottic, and tracheal stenosis. The present series focused
on a subset of adult laryngotracheal stenosis patients with
SGS secondary to either unknown inflammatory causes or
WG and no cartilaginous contribution to the stenosis. All
patients were managed effectively with ELRM and treat-
ment of reflux, with 60% of patients requiring a second
procedure, an acceptable mean interval between proce-
dures (9 month) for patients with idiopathic causes, and
no requirement of tracheotomy or open surgical interven-
tion. These results compare favorably with other pub-
lished case series of endoscopic management.
10 –19
In 1982, Simpson et al. described five factors predic-
tive of poor results or failure with endoscopic management
of laryngotracheal stenosis: CS scarring with cicatricial
contracture, scarring longer than 1 cm in vertical dimen-
sion, tracheomalacia and loss of cartilage, previous history
of severe bacterial infection associated with tracheostomy,
and posterior laryngeal inlet scarring with arytenoid fix-
ation.
13
The design of the present study excluded patients
with the latter three factors but allowed for examination
of the first two: the pattern and length of the stenotic
segment. Our data support Simpson’s first conclusion,
that CS lesions lead to poorer outcomes, because more
patients with CS stenosis required a second ELRM than
those with ES stenosis (75% vs. 43%). However, the ma-
jority of patients in this study had stenotic segments
exceeding 1 cm in length but still reported an improve-
ment in symptoms postoperatively and did not progress
to require open surgery or tracheotomy. In addition, one
of the two patients with short (1.0 cm) LOS required a
second ELRM. Therefore, although LOS has been shown
previously to be an important factor to consider in en-
doscopic management,
13
predominantly soft tissue ste-
noses such as those in IS and WG may be treated
effectively even when longer than 1.0 cm. In addition,
Laryngoscope 118: September 2008 Roediger et al.: Adult Subglottic Stenosis
1545
the use of mitomycin-C to inhibit fibroblast prolifera-
tion and modulate wound healing has been shown to
improve success rates, even in complex lesions.
18
The complication rate in the present study (7%) was
acceptably low. One patient had postoperative nausea and
increased secretions which resolved with conservative
management and observation, whereas a second patient
required readmission for two nights of observation and
corticosteroid administration. This finding has significant
implications when considering open surgical intervention
and the attendant perioperative risks of edema or granu-
lation tissue formation requiring reintubation or trache-
otomy, cervical emphysema, anastomotic dehiscence, re-
current laryngeal nerve injury, tracheoesophageal fistula,
and death.
7–9
Despite these risks, cricotracheal resection and pri-
mary thyrotracheal anastomosis have been shown to be
highly effective in managing laryngotracheal stenosis
secondary to prolonged intubation or trauma.
7–9
Open
surgery as the primary treatment modality in patients
with ongoing inflammatory diseases, such as IS or WG,
has not been studied in a large series. Recent studies of
airway reconstruction continue to report predominantly
intubation-related disease, with idiopathic and autoim-
mune diseases as additional subsets.
20
Although not
utilized in the present study, open surgical manage-
ment is a reasonable consideration for patients who fail
endoscopic management of SGS. However, the criteria
that define failure of endoscopic management continue
to be debated. Valdez and Shapshay reported their al-
gorithm of offering primary resection and reanastomo-
sis to patients with disease refractory to three endo-
scopic procedures,
15
whereas Dedo and Catten describes
repeated microtrapdoor flap procedures for “palliation”
of what he terms idiopathic progressive SGS.
19
Furthermore, the best treatment modality for any
given patient with SGS is predicated on the results of
upper aerodigestive tract endoscopy. Office-based indirect
laryngoscopy, high resolution CT scans, and PFTs give
supportive evidence but only the detailed view afforded by
intraoperative microdirect laryngoscopy, subglottoscopy,
and tracheoscopy can accurately diagnose the location,
extent, and character of the stenosis. The initial endos-
copy should not be limited to diagnostic maneuvers; inter-
vention should be considered for all patients, since ELRM,
as the current series demonstrates, can be highly success-
ful with a low complication rate.
CONCLUSION
Adult SGS remains a challenging disease to treat.
Endoscopic management continues to evolve, providing an
effective alternative to open surgical approaches for pa-
tients with inflammatory causes of SGS, such as IS and
WG. Airway-associated symptoms are reduced and trache-
otomy can be avoided. Endoscopic management can be
performed safely, with an acceptably low complication
rate, in the outpatient setting or with an overnight stay
for patients traveling long distances to the hospital. Fur-
ther study of this treatment modality is warranted.
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    • "The choice of treatment is based on the patients characteristics and on evaluation of the merits of each procedure . The surgical interventions can be endoscopic or open depending on the type, site and severity of stenosis [1, 2, 4]. Endoscopic methods include mechanical dilatation, excision with cold steel or CO2 laser excision and balloon dilatation. "
    [Show abstract] [Hide abstract] ABSTRACT: Laryngeal stenosis is one of the most complex and challenging problems in the field of head and neck surgery. The management involves a multidisciplinary approach with multiple complex procedures. In this study we discuss our experience of laryngeal stenosis with regards to patient characteristics, cause and management. A retrospective analysis of 35 patients of laryngeal stenosis treated at a tertiary care centre was evaluated. Inclusion criteria were all patients with laryngeal stenosis who required surgical intervention. Exclusion criteria were patients with associated tracheal stenosis and laryngeal stenosis due to cancer. Demographic data was recorded and findings relating to aetiology, characteristics of stenosis and the various aspects of therapeutic procedures performed are discussed with review of literature. Among 35 patients, 24 were males and 11 females of the age group 2–79 years. 2 (5.7 %) patients had supraglottic stenosis, 11 (31.4 %) had glottis stenosis, 16 (45.7 %) had subglottic stenosis and 6 (17.1 %) had combined multiple sites stenosis. Each patient underwent an average of 3.22 surgical procedures like microlaryngoscopy and excision with cold instrument, CO2 laser excision or open procedures like laryngofissure and excision and laryngoplasty. Montgomery t tube insertion was a common procedure in 17 patients (48.6 %). Of the total 35 patients with severe LS, 27 (77.1 %) patients were successfully decanulated. The results of glottic (100 %) and supraglottic stenosis (100 %) are excellent as compared to subglottic (68.8 %) and combined stenosis (50 %) of multiple sites. Laryngeal stenosis with airway compromise causes significant morbidity to the patients and is a difficult condition to treat in both adult and pediatric population. The need for multiple surgical procedures is common in the treatment of laryngeal stenosis with the t-tube being an important aid in the management of this condition. Trauma especially post intubation trauma is the commonest cause of laryngeal stenosis and the involvement of subglottis has poor outcome as compared to other subsites.
    Article · Dec 2015
    • "Furthermore, the results of mitomycin-C application are very promising, although our studied group needs further investigation . The protective role in laryngeal wound healing was described previously [14]. Although we did not manage to present significant results concerning the impact of surgeon's experience or the accessibility of modern anaesthesiological or surgical equipment on the results of our operations, a clear trend could be seen. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Surgery of the thyroid gland remains the main cause of bilateral vocal cord palsy (VCP). Ventilation problem is the main problem in such situations. There are a couple of corrective surgical procedures in the case of VCP. The aim of our study was to show the possibility of widening of the glottis, and to evaluate the techniques and effects of surgical treatments due to bilateral VCP resulting from thyroid gland surgery. Material and methods: Five methods of surgical treatment were used: laser-assisted posterior cordectomy, according to Denis and Kashima; laser-assisted bilateral medial arytenoidectomy, as proposed by Crumley; laser-assisted posterior ventriculocordectomy, as described by Pia; laser-assisted total arytenoidectomy with posterior cordectomy, as presented by Ossoff; and laterofixation, according to Lichtenberger. The postoperative patient's subjective improvement was assessed using visual analogue scale. Results: Between 1998 and 2014 we operated on 270 patients with bilateral VCP. Paresis occurred as the result of the iatrogenic effect of thyroid gland surgery in 255 patients (94.4%) vs. 15 (7.6%) from other causes. The majority of our patients (77.6%) had undergone laser arytenoidectomy with posterior partial cordectomy, and in 13.7% of them Lichtenberger laterofixation had been performed. Ossoff 's surgery gives good ventilation results: successful decannulation (62.9% after first surgery; 97.6% final rate) and significant subjective ventilation improvement in 96% of patients. Conclusions: Ossoff 's laser arytenoidectomy with posterior cordectomy is a safe procedure that gives acceptable ventilation improvement. Patients report satisfactory quality of life and the possibility of returning to active professional life. Laterofixation should be considered as an alternative for tracheotomy rather than permanent procedure. (Endokrynol Pol 2015; 66 (5): 412-416).
    Article · Oct 2015
    • "Strict precautions should be followed during its preparation, handling and application. (Roediger et al 2008, Wong et al 2010  Brachytherapy: (Rahman et al 2010) High-dose rate endobronchial brachytherapy was advocated to prevent granulation tissue formation and restenosis. It is administered as a single application of a total 10 Gy along the stent using a brachytherapy remote after loader with a 192 Ir source. "
    [Show abstract] [Hide abstract] ABSTRACT: Tracheal stenosis is one of the most challenging problems facing a variety of medical specialists. This entity is usually confounded with laryngeal stenosis. However solitary tracheal lesions are even commoner. Although post-intubation stenoses are the commonest many other causes can lead to tracheal stenosis. Various lesions can occur singly or in combination. Although preventive measures should be enforced to prevent intubation injuries, this is far from satisfactory and many patients end with post-intubation sequels. The proper evaluation of the airway problems and tailoring of the most suitable management strategy is a lifelong commitment for both patient and physician.
    Full-text · Book · Feb 2012 · Endokrynologia Polska
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