Sensitivity and responsiveness of the medical research council dyspnoea scale to the presence and treatment of adult laryngotracheal stenosis

Objectives: To assess the sensitivity and responsiveness of the Medical Research Council (MRC) scale, a psychophysical dyspnoea assessment instrument to the presence and treatment of adult laryngotracheal stenosis. Design: Prospective observational study. Settings: Tertiary/National referral airway reconstruction centre. Participants: Fourty tracheostomy‐free patients undergoing endoscopic airway examination/laryngotracheoplasty. Main outcome measures: Demographic and clinical information, obtained from patient records, lesion severity, which was recorded intraoperatively, standard spirometry, which was measured preoperatively, and the MRC dyspnoea scale, which was administered preoperatively and at the first outpatient visit 4–6 weeks later. Results: There were 16 males and 24 females. Mean age at presentation was 44 ± 14 years (± SD). Postintubation stenosis was the commonest aetiology (73%) followed by idiopathic subglottic stenosis and Wegener’s Granulomatosis. Six patients were examined post‐treatment and had minimal residual stenosis and the remaining patients had glottic stenosis (n = 11) or Myer–Cotton Grade I (n = 8), II (n = 7) or III (n = 8) tracheal stenoses. Pre‐treatment MRC dyspnoea scores and the degree of change in the MRC score following treatment strongly correlated with pre‐treatment stenosis severity (r = 0.75 and r = ?0.71 respectively; P < .001). Moreover statistically significant correlations existed between preoperative peak expiratory flow and forced expiratory volume in 1 s and preoperative MRC dyspnoea scores (r = ?0.34 and r = ?0.35 respectively; P < 0.05). Discussion: Exertional dyspnoea is the hallmark symptom of laryngotracheal stenosis and for many patients it is the primary cause of disability. These findings confirm that the MRC dyspnoea scale is an appropriate outcome instrument for assessing dyspnoea associated with this condition.     

Single-stage laryngotracheoplasty in children

Objective

To review the outcomes of pediatric patients with laryngotracheal stenosis treated by single-stage laryngotracheoplasty.

Methods

A single surgeon personal series retrospective review of 15 children undergoing single-stage laryngotracheoplasty for laryngeal stenosis over 4-year period (2004–2008).

Results

15 patients (9 boys and 6 girls), with ages ranging from 1 month to 18 years, were operated. Using the Myer–Cotton grading system, 2 patients were diagnosed with grade 4 stenosis, 6 patients with grade 3 and 7 patients with grade 2. In10 cases, an LTP with anterior costal cartilage graft was performed; in one case an anterior and posterior LTP; in one case a partial cricotracheal resection and in 3 cases an anterior cricoids split. The overall success rate was 94%.

Conclusion

Single stage laryngotracheoplasty is a safe and effective method for laryngotracheal stenosis in children.     

Long‐term quality‐of‐life outcomes in children undergoing adenotonsillectomy for obstructive sleep apnoea: a longitudinal study

Clin. Otolaryngol. 2011, 36 , 475–481 Objectives: To assess a cohort of patients who underwent adenotonsillectomy for obstructive sleep apnoea, 4 years after surgery for evidence of continued and long‐term improvement in quality of life. We also sought to compare our results to Child Health Questionnaire scores obtained from our previous study. We also compared our data with a healthy UK children population from normative data available. Design: Longitudinal study. Settings: University Hospital Tertiary Referral Centre. Participants: A 4‐year follow‐up study of 37 children who underwent adenotonsillectomy for obstructive sleep apnoea confirmed on polysomnography. There were 19 boys and 18 girls from our initial cohort. The primary caregiver completed the validated Child Health Questionnaire Parental Form version‐28, 4 years after initial surgery. Our control group consist of 221 healthy children aged 6–18 that were included as ‘normal’ controls in a study looking at children with juvenile arthritis. The children were defined as healthy by a physician and/or after declaration by the parent. Main outcome measure: Child Health Questionnaire Parental Form version‐28 scores. Results: A total of 33 patients (89%) from our initial cohort were contacted. The mean age was 10.6 (median, 11; range, 5–16). When compared with results obtained 3 months postoperatively, the mean scores were higher in five domains and were statistically significant in three subscales (Role Limitations P < 0.00001; Bodily Pain P < 0.002; and Global Health P < 0.02). There was a significant deterioration in Behaviour subscale (P < 0.0007) in spite of surgery. Compared with controls, 4‐year follow‐up scores were higher in five domains with the Global Health domain (P < 0.0004) being statistically significant. When the 4‐year follow‐up scores were compared with preoperative values, these were higher in all 13 domains with statistically significant improvements in nine domains, indicating that improvements had persisted 4 years after surgery. At 4 years, however, the means scores in many domains remain lower when compared with controls. Conclusion: Quality‐of‐life data are an important measure when deciding on a specific clinical intervention. In the short term, quality‐of‐life measures have been shown to improve after adenotonsillectomy for obstructive sleep apnoea. Our study demonstrates that the benefits of surgery are still persistent and the children continue to improve in the long term.     

Modern management of laryngotracheal stenosis

OBJECTIVES: Laryngotracheal stenosis is a complex problem resulting most often from intubation, trauma,or autoimmune disease. Management options include dilation or airway reconstruction including laryngotracheoplasty (LTP), cricotracheal resection (CTR), and tracheal resection (TR). We describe our experience with management of this difficult problem. STUDY DESIGN: Retrospective chart review of patients treated for laryngotracheal stenosis between January 1995 and July 2005 at an academic, tertiary referral center. METHODS: A total of 127 patients were treated during the study period. Patients were followed, and hospital records were reviewed. RESULTS: There were 38 male and 89 female patients with an average age of 55.5 years treated for laryngotracheal stenosis resulting from intubation (64), idiopathic (25) or autoimmune disease (18), radiation (9), trauma (5), prior surgery (4), and relapsing polychondritis (2). Thirty-three percent were treated for grade I stenosis, 44% grade II, 19% grade III, and 4% grade IV. Seventy percent of patients undergoing initial dilation required a subsequent procedure. LTP, CTR, or TR was performed in 43%, 48%, 71%, and 100% of patients with grade I through IV stenosis, respectively. Among 76 patients undergoing LTP, CTR, or TR, 24 (32%) required a subsequent intervention. Among 36 patients treated with primary LTP, CTR, or TR, only 10 (28%) required further therapy. Twenty-two of 35 (63%) tracheostomy-dependent patients were ultimately decannulated. Three patients died in the immediate postoperative period. CONCLUSIONS: Patients undergoing dilation for laryngotracheal stenosis require multiple procedures. However, major reconstructive procedures are well tolerated and currently represent a viable primary treatment for laryngotracheal stenosis.     

Surgical management of scleromatous laryngotracheal stenosis

Objective

Scleroma is a chronic specific granulomatous disease of the upper respiratory tract caused by Klebsiella Rhinoscleromatis. It usually affects the subglottic region and upper trachea resulting in various degrees of stenosis. Patients with laryngotracheal stenosis may present with stridor, shortness of breath or exercise intolerance and may be tracheostomy dependent. In this work, we presented the experience of our Institute in the management of patients with scleromatous laryngotracheal stenosis using the already designed procedures for traumatic laryngotracheal stenosis.

Patients and methods

The study was a non controlled prospective study. It was conducted in Oto-Rhino-Laryngology and Head and Neck Surgery Department of Zagazig University Hospitals, Egypt. It included 38 patients with scleromatous subglottic stenosis and/or upper tracheal stenosis. The patients were classified into four grades according to Myer–Cotton's scale. The surgical treatment modalities included endoscopic CO₂ laser surgery with dilatation, laryngotracheal reconstruction, and partial cricotracheal resection with thyrotracheal anastomosis.

Results

The average follow-up period was 32.1 months. Twenty four patients (63%) had an excellent outcome. Nine patients (24%) had a good outcome. Five patients (13%) were still tracheostomy dependent. Eleven patients (29%) developed postoperative granulation tissue. The overall success rate was 87%.

Conclusion

Scleromatous laryngotracheal stenosis is considered a challenging surgical problem. It requires a multidisciplinary approach by well-trained personnel. The surgical techniques designed for cases of laryngotracheal stenosis of a traumatic etiology can be applied for cases of scleroma with approximately the same success rates.     

Psychometric validity of the 22‐item Sinonasal Outcome Test

Objectives: We set out to determine the psychometric validation of a disease‐specific health related quality of life instrument for use in chronic rhinosinusitis, the 22 item Sinonasal Outcome Test (SNOT‐22), a modification of a pre‐existing instrument, the SNOT‐20. Design, setting and participants: The National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis was a prospective cohort study collecting data on 3128 adult patients undergoing sinonasal surgery in 87 NHS hospitals in England and Wales. Data were collected preoperatively and at 3 months after surgery, and analysed to determine validity of the SNOT‐22. Test–retest reliability was assessed in a separate cohort of patients in a single centre. Main outcome measures: The SNOT‐22, a derivative of the SNOT‐20 was the main outcome measure. Patients were also asked to report whether they felt better, the same or worse following surgery. To evaluate the SNOT‐22, the internal consistency, responsiveness, known group differences and validity were analysed. Results: Preoperative SNOT‐22 scores were completed by 2803 patients. 3‐month postoperative SNOT‐22 scores were available for 2284 patients of all patients who completed a preoperative form (81.5% response rate). The Cronbach’s alpha scores for the SNOT‐22 were 0.91 indicating high internal consistency. The test–retest reliability coefficient was 0.93, indicating high reliability of repeated measures. The SNOT‐22 was able to discriminate between patients known to suffer with chronic rhinosinusitis and a group of healthy controls (P < 0.0001, t = 85.3). It was also able to identify statistically significant differences in sub‐groups of patients with chronic rhinosinusitis. There was a statistically significant (P < 0.0001, t = 39.94) decrease in patient reported SNOT‐22 scores at 3 months. At 3 months the overall effect size in all patients was 0.81, which is considered large. We found the minimally important difference that is the smallest change in SNOT‐22 score that can be detected by a patient, to be 8.9 points. Conclusions: We have found the SNOT‐22 to be valid and easy to use. It can be used to facilitate routine clinical practice to highlight the impact of chronic rhinosinusitis on the patient’s quality of life, and may also be used to measure the outcome of surgical intervention. The minimally important difference allows us to interpret scores in a clinical context, and may help to improve patient selection for surgery.     

Management of complex glottic stenosis in children with recurrent respiratory papillomatosis

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.     

Bacterial colonization of airway stents: a promoter of granulation tissue formation following laryngotracheal reconstruction

OBJECTIVE: To investigate whether airway granulation, a common occurrence during laryngotracheal reconstructive surgery and a common cause of delays in definitive treatment and treatment failure, is associated with a microbial etiology. DESIGN: Prospective case-control study. SETTING: Tertiary referral airway reconstruction unit. PATIENTS: Patients who had an airway stent as part of their treatment for laryngotracheal stenosis. INTERVENTIONS: All airway stents were sent for microbiological analysis. Information about patient demographics, lesion characteristics, and presence of airway granulation tissue at different times during treatment were obtained and correlated against the microbiological findings from airway stents. MAIN OUTCOME MEASURES: A chi2 test was used to correlate airway colonization with specific pathogens and occurrence of airway granulation. Logistic regression analysis was used to identify independent microbiological predictors of airway granulation. RESULTS: Thirty-one airway stents were removed from 26 patients. The mean (SD) age at presentation was 42 (18) years, and postintubation tracheal stenosis was the most common etiology. There were highly significant associations between stent colonization with Staphylococcus aureus and Pseudomonas aeruginosa and the occurrence of airway granulation (P<.02), and these microorganisms were independently associated with the risk of developing airway granulation. Furthermore, S aureus was associated with persistence of airway granulation on average 4 months following removal of the stent. CONCLUSIONS: Airway granulation seems to be associated not with polymicrobial airway colonization but with infection with specific pathogenic microorganisms. All patients undergoing laryngotracheoplasty should receive antibiotic prophylaxis to cover these microorganisms, and the development and use of antibiotic-impregnated airway stents should be explored.     

Management of subglottic stenosis in infancy and childhood

During the 12-year period between June 1987 and June 1999, 141 children underwent curative treatment for subglottic laryngeal stenosis at La Timone Children’s Hospital in Marseille, France. Ninety-six children (68%) were under the age of 5 years; 106 (75%) presented with acquired stenosis and 93 had narrowing involving over 70% of the subglottic lumen. Endoscopic laser surgery was performed in 25 cases and open surgery in 116. Open surgical techniques included laryngotracheoplasty with autologous cartilage interposition in 83 cases, laryngotracheal split in 22, and cricotracheal resection in 11. After decannulation, 132 children (94%) were able to breathe normally through the upper airway. Perspectives for development of new techniques and improvement of conventional methods are discussed. Received: 10 November 1999 / Accepted: 16 December 1999     

Surgical treatment for laryngotracheal stenosis in the pediatric patient

We report our experience with laryngotracheal stenosis (LTS) in children during the last 12 years. Documentation and follow-up were available for 115 patients who underwent surgery for acquired or congenital LTS. Most were severe cases according to Cotton's classification. Forty-six weighed less than 10 kg at the time of surgery; 45 had pure congenital subglottic stenosis; 70 had acquired subglottic stenosis, mainly due to endotracheal intubation. The surgical techniques used have been various. The three main types of procedure were castellated laryngotracheoplasty, anterior cartilage rib grafting, and anterior and posterior cricoid cuts with or without grafting. All cases but 1 (44/45) of congenital subglottic stenosis have been successfully decannulated, 7 requiring a second procedure. The decannulation rate for acquired SGS was 89% (62/70), but 14 patients required multiple procedures. Current trends in subglottic stenosis management in our institution are presented.     

Laryngotracheoplasty in early childhood

Because of increased risk of surgery in infancy and because surgery at this age may affect laryngotracheal growth it is preferable to postpone open surgical correction of congenital or acquired laryngotracheal stenoses until pre-school or even school age. However, early intervention by one of the surgical methods available today appears to be justified if a child with a tracheostomy has unsatisfactory home surroundings, if the tracheostomy impedes a rehabilitation programme or if the laryngeal stenosis does not allow voice production. Of 42 children with congenital (14) or acquired (28) laryngotracheal stenosis, 13 were operated between the ages of 3 months and 6 years. The following surgical methods were used, depending on the type and degree of stenosis: (1) submucosal scar resection (5 cases); (2) "stepped incision" as described by Evans and Todd (2 cases); (3) widening of the anterior wall by an autogenous cartilage graft as described by Cotton (2 cases); (4) laminotomy with interposition of an autogenous cartilage graft as described by Rethi (3 cases); (5) multiple-staged laryngotracheal reconstruction with regional skin flaps and repeated cartilage grafting (1 case). The soft silicon Montgomery T tube was preferred in all cases for stenting the reconstructed laryngotracheal lumen, because it seems to be the most convenient and safest method. The importance of painstaking postoperative intensive care is emphasized. Up to now 11 patients have been extubated, but 4 of them show a mild restenosis. The history of one child who has not yet been decannulated is reported in detail to demonstrate the limits of laryngotracheoplasty in early childhood.     

Laryngotracheoplasty using the Medpor implant: an animal model.

OBJECTIVE: The Medpor implant (Porex Surgical, College Park, GA) is a porous polyethylene that has been used safely in areas in the head and neck. Medpor allows the in-growth of capillaries and soft tissue and reduces the risk of infection and extrusion. This study was undertaken to evaluate the use of the Medpor implant in laryngotracheal reconstruction and to compare epithelialization of the trachea following two different methods at various intervals. METHODS: Eight beagles were divided into two groups. The first group underwent laryngotracheoplasty using the Medpor implant only, whereas the second group had the Medpor implant lined with a strap muscle flap. One animal from each group was sacrificed at 5-, 7-, 9-, and 12-month intervals. The degree of stenosis, inflammation, and epithelialization were compared. RESULTS: The Medpor implant can safely be used to reconstruct the trachea in this animal model. There is less stenosis and better epithelialization when the Medpor implant is lined with a strap muscle flap. CONCLUSION: The Medpor implant can safely be used in laryngotracheal reconstruction in beagles.     

The psychometric properties of the Tinnitus Handicap Questionnaire in a Dutch‐speaking population

Clin. Otolaryngol. 2011, 36 , 9–16 Objective: The aim of the study is to translate and validate the tinnitus handicap questionnaire (THQ) for a Dutch‐speaking population. The factor structure of the questionnaire, the reliability and the validity is determined. Furthermore, a statistical comparison with the original English version of the tinnitus handicap questionnaire is performed. Methodology: We assessed 101 patients at the Tinnitus Research Initiative clinic of Antwerp University Hospital. Twenty‐seven Dutch items from the tinnitus handicap questionnaire by Kuk et al. [(1990), Ear Hear 11 :434‐45.] were obtained by the process of translation and back translation. The factor structure, internal consistency, was evaluated using Cronbach’s alpha coefficient and item correlations were used to confirm reliability. The construct validity was confirmed with a visual analogue scale for loudness and distress, awareness, annoyance, the Tinnitus Questionnaire (TQ), the mini‐Tinnitus Questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI) and the Profile of Mood State (POMS), ensuring that this new instrument measures the tinnitus handicap. Results: This study demonstrates that the Dutch version of the tinnitus handicap questionnaire is a reliable (Cronbach’s alpha coefficient α = 0.93) and valid measure of self‐perceived tinnitus‐related distress [with visual analogue scale for loudness (r = 0.39) and distress (r = 0.45), awareness (r = 0.39), annoyance (r = 0.57), the Tinnitus Questionnaire (r = 0.82), the mini‐Tinnitus Questionnaire (r = 0.79), the Hospital Anxiety and Depression Scale (r = 0.62) and the Beck Depression Inventory (r = 0.32)]. The psychometric properties are in line with previous findings on the English version with regard to reliability and validity. However, the items in the subscales differ from the English version. While the English version has three subscales, our version has only two subscales. Yet, the English version reports that for the three factors, there is a low internal consistency and low correlation among the different items. For the Dutch‐speaking version, both factors show a very high reliability and validity. Conclusions: The tinnitus handicap questionnaire is suitable for assessing the handicapping effects of tinnitus among a Dutch‐speaking population in both clinical and research settings.     

The management of subglottic stenosis in patients with wegener's granulomatosis

Wegener's granulomatosis (WG) is a multisystem inflammatory disease characterized by vasculitis, granuloma formation, and necrosis. Among 158 patients treated at the National Institutes of Health during the past 24 years, 145 (92%) had an otolaryngologic manifestation of their disease and 25 (16%) had subglottic stenosis (SGS). SGS varied from asymptomatic to life-threatening. Sixteen (80%) of 20 patients with fixed SGS required surgical intervention, including manual dilations, carbon-dioxide laser resections, and laryngotracheoplasty (LTP). LTP was performed with and without microvascular reconstruction. Thirteen of the patients required tracheostomy and all 13 were ultimately decannulated. Five patients who repeatedly failed dilations and/or endoscopic laser surgery underwent LTP. Since 1987, two patients have undergone LTP with microvascular free flaps. Both patients were subsequently decannulated. The authors' experience demonstrates that management of SGS in WG is complex, requiring individualized frequent multimodality interventions to achieve satisfactory results. Microvascular laryngotracheal reconstruction should be considered in the surgical armamentarium for patients with persistent stenoses.     

Polyglycolic acid/poly-L-lactic acid copolymer use in laryngotracheal reconstruction: a rabbit model

Objective: To evaluate the tissue response and resorption of the polyglycolic acid/poly‐L‐lactic acid (PGA/PLLA) implant in laryngotracheal reconstruction and compare its dynamic stability with autologous cartilage grafts. Study Design: An interventional, before‐after trial. Methods: Twenty‐one white, female, New Zealand rabbits were divided into four groups. Groups A and B underwent laryngotracheoplasty using the PGA/PLLA implants of 3 and 4 mm widths. Group C received autologous ear cartilage grafts. Group D was the control group and did not undergo surgery. The subjects were sedated at 12 months, and the larynges were evaluated in vivo for stability and area measurements by way of endoscopy during spontaneous respiration. The subjects were then killed, the larynges harvested, and the negative intraluminal pressures applied to the laryngotracheal unit were measured in a closed‐system apparatus. The larynges were then evaluated for inflammatory reaction and implant resorption by way of histologic analysis. Results: All implanted subjects survived without complications and grew normally. There was no appreciable subglottic collapse during spontaneous respiration under anesthesia. Ex vivo examination of maximum negative intraluminal pressures (?50 cm H₂O) in a closed system demonstrated subglottic collapse of 78%, 72%, 61%, and 3% for groups A, B, C, and D, respectively, revealing the inherent weakness in the surgically manipulated airways regardless of grafting material. Histologically, the PGA/PLLA implants were essentially completely resorbed. Conclusions: PGA/PLLA appears to be a safe and effective synthetic material for use in laryngotracheal reconstruction in the rabbit model while avoiding donor site morbidity and additional operative time. Reconstructed airways maintained adequate strength and patency under physiologic conditions and are comparable with autologous cartilage grafts.     

Laryngotracheal Anastomosis: Primary and Revised Procedures

Objectives Acquired upper airway stenosis is usually associated with a complex of pathological conditions at the high tracheal and the subglottic levels. Reported reconstructive techniques include widening by incorporation of grafts, segmental resection, and anastomosis or combined procedures. The management of recurrent stenosis after reconstructive surgery is a major challenge and has rarely been discussed in the literature. The purposes of the present study are to compare the clinical course of primary versus revised reconstructive procedures and to analyze the effect of age, diabetes, chronic lung disease, grading of stenosis, extent of resection, and revised procedures on the operative rate of success. Study Design A cohort study in a tertiary referral medical center. Methods The clinical course of 23 consecutive patients undergoing laryngotracheal anastomosis was studied comparing a group of 13 primary with 10 revision procedures. Seventeen patients underwent cricotracheal and six patients thyrotracheal anastomoses. All patients but one were tracheotomized before the definitive reconstructive procedure. Suprahyoid release was routinely performed except for two cases, and only one patient required sternotomy. The Wilcoxon test was used to examine the relationship between preoperative clinical parameters and the postoperative success (i.e., airway patency). Results Twenty‐two of 23 patients (95.6%) had successful decannulation. Four patients required a revision procedure because of repeat stenosis at the site of the anastomosis (2) or distal tracheal malacia (2). Residual airway stenosis of less than 50% was noted in six patients, although only three complained of dyspnea during daily‐activity exertion. There was no associated mortality. Complications included subcutaneous emphysema (4), granulation tissue formation (3), pneumonia (2), cardiac arrhythmia (2), and one each of pneumomediastinum, neck hematoma, and urosepsis. Protracted aspirations were noted in one patient who had revision surgery. Age was the only parameter that correlated with postoperative airway patency (P <.07), whereas the presence of chronic obstructive lung disease and diabetes, grade of stenosis, type of surgery, and revision surgery were found to be insignificant. Conclusions The clinical course of laryngotracheal anastomosis in primary and revised procedures was similar in our group of patients. The operation can be performed safely, with an expected high rate of success and acceptable morbidity.     

Surgical management of laryngotracheal stenosis in adults

The purpose was to evaluate the outcome following the surgical management of a consecutive series of 26 adult patients with laryngotracheal stenosis of varied etiologies in a tertiary care center. Of the 83 patients who underwent surgery for laryngotracheal stenosis in the Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital of Lausanne, Switzerland, between 1995 and 2003, 26 patients were adults (16 years) and formed the group that was the focus of this study. The stenosis involved the trachea (20), subglottis (1), subglottis and trachea (2), glottis and subglottis (1) and glottis, subglottis and trachea (2). The etiology of the stenosis was post-intubation injury ( n =20), infiltration of the trachea by thyroid tumor ( n =3), seeding from a laryngeal tumor at the site of the tracheostoma ( n =1), idiopathic progressive subglottic stenosis ( n =1) and external laryngeal trauma ( n =1). Of the patients, 20 underwent tracheal resection and end-to-end anastomosis, and 5 patients had partial cricotracheal resection and thyrotracheal anastomosis. The length of resection varied from 1.5 to 6 cm, with a median length of 3.4 cm. Eighteen patients were extubated in the operating room, and six patients were extubated during a period of 12 to 72 h after surgery. Two patients were decannulated at 12 and 18 months, respectively. One patient, who developed anastomotic dehiscence 10 days after surgery, underwent revision surgery with a good outcome. On long-term outcome assessment, 15 patients achieved excellent results, 7 patients had a good result and 4 patients died of causes unrelated to surgery (mean follow-up period of 3.6 years). No patient showed evidence of restenosis. The excellent functional results of cricotracheal/tracheal resection and primary anastomosis in this series confirm the efficacy and reliability of this approach towards the management of laryngotracheal stenosis of varied etiologies. Similar to data in the literature, post-intubation injury was the leading cause of stenosis in our series. A resection length of up to 6 cm with laryngeal release procedures (when necessary) was found to be technically feasible.     

Irradiated homograft cartilage in laryngotracheal reconstruction--a preliminary experience

OBJECTIVE: To determine the suitability of irradiated homograft cartilage in pediatric laryngotracheal reconstruction (LTR). METHODS: Retrospective case series at a tertiary care children's hospital. Pediatric patients with subglottic stenosis who had LTRs performed using irradiated homograft costal cartilage. Data was collected on postoperative complications, findings at subsequent endoscopic examinations and final outcome. RESULTS: Minor degrees of graft resorption were observed that did not affect eventual decannulation. CONCLUSION: Irradiated homograft costal cartilage can serve as a successful alternative to the traditional autologous costal cartilage in lower grades of laryngotracheal stenosis.     

Cochlear implant outcomes and quality of life in the elderly: Manchester experience over 13 years1

Objectives: To objectively evaluate the clinical and functional outcomes of cochlear implantation in an elderly population. Design: Retrospective comparative study. Setting: Neurotology unit at Manchester Royal Infirmary, a supraregional tertiary referral centre in collaboration with Adult Cochlear Implant Programme at The University of Manchester. Participants: All cochlear implant procedures (38) undertaken on post‐lingually deafened elderly patients (age range at the time of implantation 65–80 years, n = 34) in the period from 1989 to 2002. Main outcome measures: Medical and surgical outcomes. Audiological performance outcomes for isolated words, words in sentences in quiet and noise. Functional outcome measures used are self‐reported measures of the social, psychological and emotional aspects of quality of life, and the differences between expectations for functional outcomes and the realization of functional outcomes. They included expectation profiles, Glasgow Benefit inventory (GBI) and Glasgow Health Status Inventory Questionnaire (GHSI). Results: There was statistically significant improvement post‐implantation of both open and closed set test scores (P < 0.01). Eighty‐two percentage of patients were completely satisfied with their cochlear implants. Patients judged that implantation restored half the loss of quality of life that they had experienced as a result of severe‐profound deafness with a highly significant (P < 0.001) improvement in overall quality of life after implantation. The commonest post‐operative observation was transient mild pyrexia. Conclusions: The age of a cochlear implant candidate should not be a factor in the candidacy decision‐making process. The quality of life of our elderly recipients was significantly improved after cochlear implant.     

Primary cricotracheal resection in children: indications, technique and outcome

OBJECTIVE: Treatment of subglottic stenosis has benefited greatly from development of grafting techniques such as larygontracheoplasty. Meanwhile, cricotracheal resection of the stenotic area and a major part of the cricoid cartilage have been shown to give excellent results in adults. PATIENTS AND METHODS: From June 1993 to June 2000, we performed cricotracheal resection, as the primary surgical procedure, for acquired (n=13), congenital (n=2) or mixed (n=l) subglottic stenosis in 16 pediatric patients comprising seven boys and nine girls. At the time of surgery, the mean weight was 16 kg and the mean age was 5 years. Degree of stenosis was classified as grade II in one case, grade III in 12, and grade IV in three. Eight patients underwent two-stage procedures with postoperative tracheostomy. A rolled reinforced silastic stent was placed for a mean period of 20 days and the tracheostomy tube was removed within a mean period of 44 days after stent removal. Eight patients underwent single-stage procedures. The Portex endotracheal tube was used for a mean period of 4 days. RESULTS: All patients underwent regular clinical and endoscopic postoperative examination. Mean follow-up was 38 months. No interference with laryngotracheal growth has been noted in any case, including the five with follow-ups longer than 5 years. CONCLUSIONS: The indications for laryngotracheoplasty and cricotracheal resection in children with subglottic stenosis are still unclear. Decisions must be made on a case-by-case basis. In this article the authors discuss decisional factors in terms of clinical findings, surgical techniques, potential complications, and outcome.