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Respiratory Medicine Oct 2021Histologically benign airway strictures are frequently misdiagnosed as asthma or COPD and may present with severe symptoms including respiratory failure. A clear... (Review)
Review
Histologically benign airway strictures are frequently misdiagnosed as asthma or COPD and may present with severe symptoms including respiratory failure. A clear understanding of pathophysiology and existing classification systems is needed to determine the appropriate treatment options and predict clinical course. Clinically significant airway strictures can involve the upper and central airways extending from the subglottis to the lobar airways. Optimal evaluation includes a proper history and physical examination, neck and chest computed tomography, pulmonary function testing, endoscopy and serology. Available treatments include medical therapy, endoscopic procedures and open surgery which are based on the stricture's extent, location, etiology, morphology, severity of airway narrowing and patient's functional status. The acuity of the process, patient's co-morbidities and operability at the time of evaluation determine the need for open surgical or endoscopic interventions. The optimal management of patients with benign airway strictures requires the availability, expertise and collaboration of otolaryngologists, thoracic surgeons and interventional pulmonologists. Multidisciplinary airway teams can facilitate accurate diagnosis, guide management and avoid unnecessary procedures that could potentially worsen the extent of the disease or clinical course. Implementation of a complex airway program including multidisciplinary clinics and conferences ensures that such collaboration leads to timely, patient-centered and evidence-based interventions. In this article we outline algorithms of care and illustrate therapeutic techniques based on published evidence.
Topics: Bronchoscopy; Constriction, Pathologic; Evidence-Based Medicine; Humans; Laryngostenosis; Patient Care Team; Patient-Centered Care; Pulmonary Surgical Procedures; Receptor, Endothelin A; Respiratory Function Tests; Respiratory System; Tracheal Stenosis
PubMed: 34481304
DOI: 10.1016/j.rmed.2021.106582 -
Indian Journal of Otolaryngology and... Dec 2020Schwannomas are a frequent cause of swellings in the head and neck region. Due to the abundance of peripheral, cranial and autonomic nerves in this region, schwannomas...
Schwannomas are a frequent cause of swellings in the head and neck region. Due to the abundance of peripheral, cranial and autonomic nerves in this region, schwannomas can present in variety of locations, posing a diagnostic and therapeutic challenge to the surgeon. Unusual sites in head and neck region can have varied presentation depending on the site of origin. We identified unusual extracranial locations of head and neck schwannomas, their presenting features and surgical management. Retrospective review of cases of extracranial head and neck schwannomas operated in the Department of Otolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, a tertiary referral centre between July 2015 and June 2019. A total of 42 cases of extracranial head and neck schwannomas were operated. Among them, 9 cases were found to arise from uncommon sites, such as parotid gland (n = 1), infratemporal fossa (n = 2), external auditory canal (n = 1), subglottis (n = 1), false vocal cord (n = 1), frontal recess (n = 1), maxillary sinus (n = 1) and retromolar trigone (n = 1). All patients underwent excision via relevant approaches. Nerve of origin was identified in 4/9 cases. One case had postoperative neurological deficit. No recurrences were noted in mean follow-up of 19 months. Schwannomas ought to be considered as a differential diagnosis for swellings/ mass in any part of head and neck region. Comprehensive evaluation with appropriate imaging and histology should be done in all cases. Preoperative counselling and consent regarding neurological deficit pertaining to possible nerve of origin is required in each case.
PubMed: 33088768
DOI: 10.1007/s12070-020-01820-1 -
Surgical Endoscopy Aug 2021We investigated a novel minimally invasive surgical platform for use in the oropharynx, hypopharynx, and larynx for single-port transoral surgery used in concert with...
BACKGROUND
We investigated a novel minimally invasive surgical platform for use in the oropharynx, hypopharynx, and larynx for single-port transoral surgery used in concert with standard transoral laryngeal and pharyngeal instrumentation.
METHODS
The preclinical investigational device by Fortimedix Surgical B.V. (Netherlands) features two channels for manually controlled flexible articulating surgical instruments. A third central channel accepts both rigid and flexible endoscopes. The system is coupled to a standard laryngoscope for transoral access. In three cadaver models, we evaluated the surgical capabilities using wristed grasping instruments, microlaryngeal scissors, monopolar cautery, and a laser fiber sheath. Procedures were performed within the oropharynx, supraglottis, glottis, subglottis, and hypopharynx.
RESULTS
Within the oropharynx, we found adequate strength, range of motion, and dexterity to perform lateral oropharyngectomy and tongue base resection. Within the larynx, visualization was achieved with a variety of instruments including a flexible, 0° and 30° rigid endoscope. The glottis, supraglottis, pyriform sinuses, post-cricoid space, and esophageal inlet were readily accessible. Visualization and manipulation of grasping, laser, and monopolar cautery instruments were also possible within the subglottis. Instrument reach and accuracy facilitated completion of a delicate micro-flap on the true vocal fold. Other procedures included vocal fold resection, cricopharyngeal myotomy, and resection of subglottic mucosa.
CONCLUSIONS
From this initial proof of concept experience with this novel platform, we found a wide range of procedures within the oropharynx, larynx, and hypopharynx to be feasible. Further work is needed to evaluate its applicability to the clinical setting. The ability of this platform to be used with conventional instrumentation may provide an opportunity for complex transoral surgery to be performed in a facile manner at greatly reduced cost.
Topics: Endoscopes; Humans; Hypopharynx; Laryngoscopes; Microsurgery; Minimally Invasive Surgical Procedures; Robotic Surgical Procedures
PubMed: 33712940
DOI: 10.1007/s00464-021-08420-2 -
Anaesthesia Nov 2020Tracheal tubes are routinely used in adults undergoing elective surgery. The size of the tracheal tube, defined by its internal diameter, is often generically selected... (Review)
Review
Tracheal tubes are routinely used in adults undergoing elective surgery. The size of the tracheal tube, defined by its internal diameter, is often generically selected according to sex, with 7-7.5 mm and 8-8.5 mm tubes recommended in women and men, respectively. Tracheal diameter in adults is highly variable, being narrowest at the subglottis, and is affected by height and sex. The outer diameter of routinely used tracheal tubes may exceed these dimensions, traumatise the airway and increase the risk of postoperative sore throat and hoarseness. These complications disproportionately affect women and may be mitigated by using smaller tracheal tubes (6-6.5 mm). Patient safety concerns about using small tracheal tubes are based on critical care populations undergoing prolonged periods of tracheal intubation and not patients undergoing elective surgery. The internal diameter of the tube corresponds to its clinical utility. Tracheal tubes as small as 6.0 mm will accommodate routinely used intubation aids, suction devices and slim-line fibreoptic bronchoscopes. Positive pressure ventilation may be performed without increasing the risk of ventilator-induced lung injury or air trapping, even when high minute volumes are required. There is also no demonstrable increased risk of aspiration or cuff pressure damage when using smaller tracheal tubes. Small tracheal tubes may not be safe in all patients, such as those with high secretion loads and airflow limitation. A balanced view of risks and benefits should be taken appropriate to the clinical context, to select the smallest tracheal tube that permits safe peri-operative management.
Topics: Adult; Elective Surgical Procedures; Equipment Design; Humans; Intubation, Intratracheal; Postoperative Complications
PubMed: 32415788
DOI: 10.1111/anae.15041 -
Children (Basel, Switzerland) Oct 2022(1) Background: Contrary to a tenet of the funnel-shaped pediatric larynx with the cricoid level being narrowest, recent studies show the glottis and subglottis as the...
(1) Background: Contrary to a tenet of the funnel-shaped pediatric larynx with the cricoid level being narrowest, recent studies show the glottis and subglottis as the narrowest levels. To locate the functionally narrowest level of the larynx, we reported normal laryngeal dimensions and their croup-related changes in young children. (2) Methods: We reviewed normal plain neck radiographs recorded for the evaluation of minor trauma or foreign bodies in 504 children aged ≤4 years who visited the emergency department from 2016 through 2021. Using computed tomography-based localization of the glottis, we radiographically defined the subglottis and cricoid. At these levels, we measured diameters and calculated cross-sectional areas (CSAs) on the radiographs. The values were compared to the equivalent values of a 1:1 age-matched population with croup. (3) Results: In the study population (n = 401), the narrowest diameter and CSA were observed in the glottis. In detail, the mean anteroposterior/transverse diameters were 9.8/3.4 mm at the glottis, 8.5/5.6 mm at the subglottis, and 7.4/6.8 mm at the cricoid (p < 0.001), respectively. In the same order, the mean CSAs were 26.5, 38.1, and 40.5 mm2 (p < 0.001). All dimensions were narrower in the croup population (p < 0.001). We found croup-related narrowing, namely reductions in the transverse diameter and CSA that were more severe closer to the glottis (p < 0.001), without differences per level in the anteroposterior diameter. (4) Conclusions: This study confirms the glottis as the narrowest level of the larynx in young children. In addition, level-based differences in croup-related narrowing suggest some point between the glottis and subglottis as the functionally narrowest level.
PubMed: 36291468
DOI: 10.3390/children9101532 -
Otolaryngologia Polska = the Polish... Sep 2023<br><b>Introduction:</b> Malignant minor salivary gland tumors are rare, accounting for fewer than 1% of all laryngeal cancers.</br>...
<br><b>Introduction:</b> Malignant minor salivary gland tumors are rare, accounting for fewer than 1% of all laryngeal cancers.</br> <br><b>Aim:</b> This study aims to share our experiences regarding clinical, radiological, pathological profiles and their management.</br> <br><b>Materials and methods:</b> The current study reviews 11 cases of malignant minor salivary gland tumors of the larynx treated surgically at our Institute between 2005 and 2019.</br> <br><b>Results:</b> The mean age of the patients was 54 years (range 38-75 years) with six females and five males in the series (1.2:1). Subglottis and trachea were the sites of origin in 54% of the cases, and hoarseness with dyspnea were the most common presenting symptoms. There were nine Adenoid cystic and two Mucoepidermoid carcinoma patients. Surgery was the primary mode of treatment.</br> <br><b>Conclusions:</b> Most of the larynx's malignant minor salivary gland tumors are submucosal in origin. The outcome and prognosis vary considerably based on the tumor's histology, grade, and stage.</br>.
Topics: Female; Male; Humans; Adult; Middle Aged; Aged; Adenoids; Hoarseness; Laryngeal Neoplasms; Larynx; Salivary Gland Neoplasms
PubMed: 38032326
DOI: 10.5604/01.3001.0053.4040 -
European Archives of... Dec 2020To describe the technique and outcomes of percutaneous tracheostomy under laryngosuspension.
PURPOSE
To describe the technique and outcomes of percutaneous tracheostomy under laryngosuspension.
METHODS
A consecutive series of patients who underwent percutaneous tracheostomy under laryngosuspension were reviewed for outcomes. The procedure is performed under general anesthesia and laryngosuspension. An 8.5 oral endotracheal tube is inserted and the cuff is inflated in the supraglottis, allowing access to the whole trachea and subglottis. The tube is taped to the laryngoscope. A rigid endoscope is inserted in the endotracheal tube through a swivel connector connected to the tube and the ventilation circuit. Percutaneous tracheostomy kit is used to perform dilatational tracheostomy at the desired level of the trachea under direct visual endoscopic control.
RESULTS
Forty-eight patients underwent percutaneous tracheostomy under laryngosuspension. Thirty-two cases were performed in an emergency after securing the airway with endotracheal intubation. In all other cases, tracheostomy was performed as a part of an elective procedure affecting the airway or in patients requiring prolonged ventilation. More than half of patients were considered high risk by virtue of one or more of the following: morbid obesity, prior neck surgery, prior neck radiotherapy, progressive head and neck cancer, or laryngotracheal stenosis. Complications occurred in seven cases.
CONCLUSION
Percutaneous tracheostomy under laryngosuspension has the advantage of optimal control of patient ventilation and hemostasis throughout the procedure. High-quality endoscopic vision and easy access to the airway under laryngosuspension allow tracheostomy to be performed with maximum safety.
Topics: Dilatation; Humans; Intubation, Intratracheal; Laryngoscopes; Trachea; Tracheostomy
PubMed: 32577900
DOI: 10.1007/s00405-020-06141-1 -
JAMA Otolaryngology-- Head & Neck... Nov 2017Laryngotracheal stenosis (LTS) is a fibroproliferative disorder of the glottis, subglottis, and trachea. In models of fibrosis from other organ systems, the CD4+ T-cell...
IMPORTANCE
Laryngotracheal stenosis (LTS) is a fibroproliferative disorder of the glottis, subglottis, and trachea. In models of fibrosis from other organ systems, the CD4+ T-cell response has been shown to regulate extracellular matrix deposition. Specifically, helper T cell 2 (TH2) promotes fibrosis, whereas TH1 and associated cytokines have been shown to be antifibrotic. However, this antifibrotic effect of the TH1 response has not been demonstrated in LTS.
OBJECTIVE
To determine whether the TH1 cytokine interferon-γ inhibits the function of LTS-derived fibroblasts in vitro.
DESIGN, SETTING, AND PARTICIPANTS
This in vitro controlled study included 6 patients with iatrogenic LTS undergoing routine surgical subglottic and tracheal dilation at a single institution. Fibroblasts were isolated from biopsy specimens of laryngotracheal scar and normal-appearing trachea. The presence of fibroblasts was confirmed by an immunohistochemical analysis. Laryngotracheal stenosis-derived fibroblasts were treated with interferon-γ and compared with untreated controls (2 sets of untreated, LTS-derived fibroblasts [media did not contain interferon-γ]) and normal airway fibroblasts (fibroblasts isolated from normal trachea). Data were collected from August 2015 through June 2016.
INTERVENTIONS
Treatment with interferon-γ, 10 ng/mL.
MAIN OUTCOMES AND MEASURES
Cellular proliferation, fibrosis gene expression (using quantitative reverse transcription polymerase chain reaction analysis), soluble collagen, and cellular histologic features were assessed.
RESULTS
Among the 6 patients (6 women; mean [SD] age, 38.3 [17.2] years), LTS-derived fibroblast proliferation was reduced in patients who received interferon-γ treatment compared with untreated controls on days 3 (mean difference, -6515 cells; 95% CI, -10 630 to -2600 cells) to 6 (mean difference, -47 521 cells; 95% CI, -81 285 to -13 757 cells). Interferon-γ treatment reduced collagen types I and III gene expression by 86% and 68%, respectively, and resulted in lower total collagen production (10.94 vs 14.89 μg/mL). In addition, interferon-γ treatment resulted in a 32% reduction in expression of transforming growth factor β in LTS-derived fibroblasts.
CONCLUSIONS AND RELEVANCE
Interferon-γ reduced proliferation, soluble collagen production, and collagen expression in LTS-derived fibroblasts while also reducing the expression of the profibrotic cytokine transforming growth factor β. These findings suggest that therapeutics aimed at increasing interferon-γ and the TH1 response could attenuate LTS.
Topics: Cell Proliferation; Collagen; Fibroblasts; Humans; In Vitro Techniques; Interferon-gamma; Laryngostenosis; Reverse Transcriptase Polymerase Chain Reaction; Tracheal Stenosis; Transforming Growth Factor beta
PubMed: 28715559
DOI: 10.1001/jamaoto.2017.0977 -
Laryngoscope Investigative... Dec 2022The primary aim of this study was to identify expression of TRPV3 and TRPV4 chemoreceptors across perinatal and adult stages using a murine model with direct comparisons...
OBJECTIVE
The primary aim of this study was to identify expression of TRPV3 and TRPV4 chemoreceptors across perinatal and adult stages using a murine model with direct comparisons to human laryngeal mucosa. Our secondary aim was to establish novel cell expression patterns of mechanoreceptors PIEZO1 and PIEZO2 in human tissue samples.
STUDY DESIGN
In vivo
METHODS
We harvested murine laryngeal tissue to localize and describe TRPV3/4 endogenous protein expression patterns via immunofluorescence analyses across two developmental (E16.5, P0) and adult (6 weeks) timepoints. Additionally, we obtained a 60-year-old female larynx including the proximal trachea and esophagus to investigate TRPV3/4 and PIEZO1/2 protein expression patterns via immunofluorescence analyses for comparison to murine adult tissue.
RESULTS
Murine TRPV3/4 expression was noted at E16.5 with epithelial cell colocalization to supraglottic regions of the arytenoids, aryepiglottic folds and epiglottis through to birth (P0), extending to the adult timepoint. Human TRPV3/4 protein expression was most evident to epithelium of the arytenoid region, with additional expression of TRPV3 and TRPV4 to proximal esophageal and tracheal epithelium, respectively. Human PIEZO1 expression was selective to differentiated, stratified squamous epithelia of the true vocal fold and esophagus, while PIEZO2 expression exhibited selectivity for intermediate and respiratory epithelia of the false vocal fold, ventricles, subglottis, arytenoid, and trachea.
CONCLUSION
Results exhibited expression of TRPV3/4 chemoreceptors in utero, suggesting their importance during fetal/neonatal stages. TRPV3/4 and PIEZO1/2 were noted to adult murine and human laryngeal epithelium. Data indicates conservation of chemosensory receptors across species given similar regional expression in both the murine and human larynx.
PubMed: 36544955
DOI: 10.1002/lio2.968