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Objectives: To describe our management of complex glottic stenosis in tracheotomy dependent children with severe recurrent respiratory papillomatosis., Methods: Retrospective chart review at a tertiary care children's hospital., Results: Three children with complex glottic stenosis secondary to severe recurrent respiratory papillomatosis were treated at our institution since 2011. Two patients had complete stenosis, and the third had near-complete stenosis. Two patients were managed using balloon dilation alone, and the third also underwent laryngotracheal reconstruction with posterior costal cartilage grafting. Two patients have been successfully decannulated and the third has been tolerating continuous tracheotomy capping for greater than twelve months. All three patients underwent aggressive debridement of papillomatosis and balloon dilation every 4-6 weeks until their burden of disease was controlled. In two patients, the glottic airway was patent, and the third continued to have complete restenosis between procedures and required laryngotracheoplasty with multiple post-operative dilation procedures to establish an adequate glottic airway., Conclusions: Severe laryngeal stenosis is a well-described complication of recurrent respiratory papillomatosis, but its management is not well-defined. Aggressive management of papillomatosis with frequent debridement is critical in successfully managing laryngeal stenosis. Balloon dilation alone may be surprisingly effective in these patients, and laryngotracheoplasty can be used as an adjunct procedure in those patients who fail balloon dilation. Given the quality of life issues and concerns regarding distal spread of disease with tracheotomies in these patients, we feel that aggressive management and early decannulation is in the patient's best interest., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: An operative technique is described as a salvage treatment for severe subglottic and supraglottic laryngeal stenosis. In addition to expansion of the laryngeal framework with an anterior cartilage graft, as used in a classical laryngotracheal reconstruction, the scar tissue obliterating the airway lumen is excised and a mucosal graft is placed to reconstruct the inner lining of the airway. The graft is harvested from buccal mucosa., Methods: The operative technique is outlined. Three cases, 2 paediatric and one adult, with complete or near complete laryngeal stenosis are presented where this operative technique was employed. In all patients several surgeries had been performed previously which were unsuccessful., Results: In all 3 patients a patent airway was achieved with decannulation of the tracheostomy in the 2 paediatric patients., Conclusions: In patients with severe subglottic or supraglottic airway stenosis where other surgeries have failed, excision of endoluminal scar tissue and placement of a buccal mucosal graft, in addition to conventional laryngotracheal reconstruction, is a promising technique. In revision cases of subglottic stenosis cricotracheal resection might not be an option because of scarring from previous surgeries. This operation is an alternative, which allows an increase in the airway lumen by excising the scar tissue then re-lining the exposed internal lumen. The buccal mucosa reduces granulation formation and re-stenosis., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Examine outcomes of varied postoperative sedation management in pediatric patients recovering from single stage laryngotracheal reconstruction., Design: Retrospective review of 34 patients treated with single stage laryngotracheal reconstruction from 2001 through 2011., Setting: Tertiary children's hospital., Methods: Patients were divided into 2 groups: those managed postoperatively with sedation, with or without paralysis (group 1), and those managed awake with narcotic pain medication as needed for primary management (group 2). Outcomes were measured as a function of sedation management. Outcomes investigated focused on those related to the success of the airway reconstruction, and those related to sedation management., Results: Out of 68 cases of laryngotracheal reconstruction reviewed from 2001 to 2011, 34 were single stage reconstructions. Nineteen patients were sedated postoperatively (group 1) and fifteen patients were left awake (group 2). There were no significant differences between groups in airway-related outcomes, including risk of accidental decannulation, revision rates, and need for secondary airway procedures such as balloon dilation. Sedation-related outcomes, specifically focusing on differences in medical management, showed significant increases in rates of withdrawal (p<0.0001), nursing concerns of withdrawal (p<0.0001) and sedation level (p<0.0001), pulmonary complications (OR 7.7, p=0.008), and prolonged hospital stay due to withdrawal (p=0.0005) in patients managed with sedation with or without paralysis. Multivariable regression analysis revealed that duration of sedation was the primary risk factor for increased postoperative morbidity, while younger age, lower weight, and use of a posterior graft were also significant variables assessed., Conclusion: Avoiding sedation as the standard for postoperative management of single stage laryngotracheal reconstruction airway patients leads to an overall decreased risk of morbidity without increasing risk of airway-specific morbidity. This is specifically as related to withdrawal, pulmonary complications, concerns about sedation level and prolonged hospital course, all of which increase significantly with increased level and duration of sedation., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: There's no greater challenge in pediatric laryngology than diagnosis and treatment of chronic dysphonia following laryngotracheal reconstruction of acquired subglottic stenosis. Videolaryngoscopy with stroboscopy provides incomparable diagnostic information to fiberoptic endoscopy. Unfortunately, this pediatric subpopulation which would benefit the most from videolaryngoscopy with stroboscopy infrequently does. We present the unique videolaryngostroboscopic patterns with their diagnostic and treatment implications in this complex population., Methods: From a total database of 113 children with histories of subglottic stenosis and/or airway reconstruction between January 1, 2000 and September 30, 2011, successive frames of recorded videolaryngostroboscopies in twenty-three dysphonic children were reviewed. These stroboscopies were compared to age and gender matched controls with dysphonia due to vocal nodules consecutively analyzed from the time period 2009-2011. To validate the similarity of our patient population to others previously reported, we also collected the standardized perceptual, acoustic, and aerodynamic measures of voice analysis and parent/patient reported quality of life., Results: The voices of patients' pre- and post-airway reconstruction are typically moderately breathy and harsh in voice quality with the majority exhibiting a restricted pitch range and vocal strain. Reduced vocal volume intensity and low habitual speaking pitch were common. Overall, the severity of voice fell within the moderately dysphonic range. Despite universal glottic aperture incompetence, muscle tension dysphonia of the true vocal cords was seen. The glottic muscle tension was confirmed indirectly by noting a consistent "posterior cricoarytenoid bulge." In addition, our group termed a unique pattern of "circumferential supraglottic squeeze" which included both lateral plica ventricularis (false vocal folds) and anteroposterior squeeze opposing the arytenoids to the epiglottic petiole (termed by our group as "arytenoid hooding"). In no patients were the true vocal cords fully visualized. While superficially appearing as hyperfunction, these findings paradoxically represented compensation for laryngeal hypofunction marking the hyperfunction not the problem but a symptom. Actual "mucosal waves" were seen involving the false vocal cords., Conclusions: Videolaryngoscopy with stroboscopy results in patterns that are not only unique to patients after airway reconstruction for subglottic stenosis but are also critical for both surgical and non-surgical treatment of chronic dysphonia in these children., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Exercise-induced laryngomalacia (EIL) is characterized by inspiratory stridor that is brought on by exercise (i.e. competitive sports) and fails to respond to treatment with bronchodilators (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541). During exercise, (1) spirometric flow volume loops show evidence of variable extrathoracic obstruction, and (2) laryngoscopy shows inspiratory prolapse of supraglottic structures with partial glottic obstruction. Only five cases of probable EIL have been reported in the literature (Smith et al., Ann Otol Rhinol Laryngol 1995;104:537-541; Lakin et al., Chest 1984;86:499-501; Bittleman et al., Chest 1994;106:615-616; Bent et al., Ann Otol Rhinol Laryngol 1996;105:169-175; Chemery et al., Rev Mal Respir 2002;19:641-643). Here, a case of laryngomalacia induced by exercise in a previously asymptomatic 10-year-old athlete with a remote history of laryngomalacia in infancy is presented, and a review of previously reported cases is provided.

In contrast to skin, mucosal wound healing has not been extensively studied. Subglottic stenosis (SGS) is an excellent model for such investigation. The main objective of this pilot study was to develop a chronic model of SGS in a small animal (i.e. rabbit). In so doing, a serendipitous observation was made that the development of SGS is directly related to depth of the injury and is independent of circumferential extent. Animals with deep injury (i.e. deep to the lamina propria, reaching the perichondrium), independent of age and circumferential extent, experienced respiratory obstruction resulting from edema and granulation tissue formation and died or had to be sacrificed in the acute period. This was in contrast to no risk of mortality in the more superficially injured group. Histology was used to characterize this model of SGS. In the mucosal epithelium, or mucosa, changes of inflammation, squamous metaplasia, basal cell hyperplasia, necrosis and ulceration were only seen acutely and total regeneration of the epithelium was achieved by the end of the study period. In contrast, changes within the lamina propria, including chronic inflammatory cellular infiltrates and fibroplasia, were lasting and resulted in fibrotic repair, not regeneration. These findings are quite similar to the healing events in skin and suggest that SGS is the mucosal equivalent of a 'keloid' or, perhaps more appropriately, a 'hypertrophic scar.' Likewise, cartilage degeneration and deformation were persistent markers of the chronic phase of healing. Like the lamina propria, the response to injury was reparative. Therefore, injury to the connective tissue is a critical component of development of SGS.

This study assesses the effect of pediatric laryngotracheoplasty on voice quality. A group of ten children who underwent laryngotracheoplasty with thyrotomy and anterior cartilage graft were examined two or more times after decannulation and their voices were compared to those of sex- and age-matched controls. Each examination included a laryngoscopy, evaluation by a speech/language pathologist and measurement of maximum phonation times and fundamental frequencies using the Signalyse program. The strength of the voices and the maximum phonation times gradually improved. The fundamental frequency became lower with age, as in the controls. The data suggest that laryngotracheoplasty does not hamper the development of voice with age in children and that the voice improves without any further surgery, although hoarseness remains.

After initial treatment of severe laryngotracheal stenosis (LTS), we evaluated subsequent airway function. Five children between 2 and 11 years were treated previously for severe LTS by T-tube stenting. One case underwent subsequent laryngotracheal reconstruction. All patients demonstrated dyspnea, the severity of which increased with age and duration of time after completion of stenosis treatment. In the most severe cases, magnetic resonance imaging and endoscopy revealed secondary subglottic stenosis. Ventilatory function tests disclosed obstruction of both extrathoracic and pulmonary origin. These findings raise questions regarding the treatment of the initial stenosing tissue and of the secondary stenoses.

Non-invasive procedures are proposed to aid the diagnosis of childhood laryngotracheal pathology and to monitor the course of such disease. The procedures capitalize on the one-to-one relationship which exists between the acoustic phenomena (stridors) associated with respiration and the configuration of the respiratory tract. Careful analysis of these acoustic patterns can thus assist in identifying and localizing constrictions, in diagnosis, and in monitoring disease severity. Based on the acoustical analysis of the stridor generated by children with congenital stridor, subglottal laryngitis, and trachea stenosis, the present paper demonstrates that a close relationship exists between the specific pathology and the spectrum of the associated respiratory stridor.

In young rabbits (4-week-old) the growth of the subglottis was studied after an endolaryngeal soft tissue trauma. The injury induced the formation of a subglottic stenosis. In contrast to earlier observations on endolaryngeal trauma extending into the cricoid cartilage, the cricoid developed normally to the adult size and shape at 24 weeks. Similar to the earlier findings, the subepithelial layer showed considerable thickening as the result of formation of scar tissue, ectopic cartilage and fatty tissue with interruption of the elastic tunica (= conus elasticus). It was concluded that after endolaryngeal trauma in rabbits two types of subglottic stenosis can develop, determined by the depth of the injury.