Search

The management of laryngeal and tracheal stenosis continues to challenge us, despite advances in surgical techniques and better understanding of the wound healing process. Injury to the airway mucosa is the inciting event, regardless of the cause of the stenosis. Mitomycin-C is an antineoplastic antibiotic that acts as an alkylating agent by inhibiting DNA and protein synthesis. It can inhibit cell division, protein synthesis, and fibroblast proliferation. Topical application of mitomycin-C (0.4 mg/mL) was used as an adjuvant treatment in the endoscopic laser management of laryngeal and tracheal stenosis in 15 patients. Fourteen patients (93%) have shown improvement of their airway and resolution of their preoperative symptoms. After a mean follow-up of 18 months, no complication was noted with regard to the application of mitomycin-C. This study gives promising findings on the efficacy and safety of mitomycin-C as an adjuvant treatment in the management of selected cases of laryngeal and tracheal stenosis.

Malignant laryngeal neoplasms in children are uncommon and present diagnostic and therapeutic challenges. A 15-year retrospective review of laryngeal tumors at our institution identified four patients with malignant neoplasms. These children, 7 months to 16 years of age, were treated for squamous cell carcinoma, choriocarcinoma, rhabdomyosarcoma, and primitive neuroectodermal tumor. This report details these cases, emphasizing diagnostic approaches, treatment decisions (medical oncologic management, surgical resection), and rehabilitation measures for postlaryngectomy communication. A multi-institutional pediatric head and neck tumor registry would be a useful reference to assist with individual treatment decisions.

Innominate artery compression of the trachea in infants can cause severe biphasic stridor, cyanosis, and respiratory arrest. These episodes are sometimes referred to as "dying spells." In the past, aortopexy has been used for the treatment of this problem, but since many have questioned its success, its use has not been popularized or generally accepted. Over the past 4 years, 12 children have been successfully treated for innominate artery compression of the trachea with aortopexy. These children all initially presented with significant respiratory and/or feeding difficulties. Preoperative and postoperative videos were obtained to document the degree of tracheal compression and/or lumen size before and after surgery. Since treatment, all patients have been without further feeding problems or cyanosis. When performed in selected patients, aortopexy is successful in relieving tracheal obstruction from innominate artery compression. This article discusses proper patient selection, operative technique, and follow-up care. The management of compression in patients with less severe symptoms will also be addressed.

Patients with subglottic hemangioma present with biphasic stridor during infancy. The natural history of this lesion is characterized by progressive airway obstruction during the proliferative phase of the lesion, followed by resolution of symptoms during the subsequent involutive phase. Although this is a benign neoplasm, it can be associated with a fatal outcome. Treatment options have been directed at maintaining airway patency during the proliferative phase. The senior author (G.B.H.) originally described the role of the carbon dioxide laser in management of these patients in 1980. Thirty-one patients were treated for subglottic hemangioma at The Children's Hospital, Boston, between 1980 and 1990. The 10-year experience of management of subglottic hemangioma with endoscopic vaporization using the carbon dioxide laser is reviewed to assess the efficacy of this technique.

Hemangioma is a well-recognized cause of airway obstruction in the infant with stridor. Corticosteroid and laser therapy are effective in stabilizing the airway in most cases. There are, however, some extensive airway lesions that are not adequately managed by these modalities. This report describes the use of recombinant interferon alfa-2a in 15 patients with life-threatening airway hemangiomas. All patients had failed corticosteroid and/or laser therapy. Multiple upper airway sites were involved, including the base of the tongue, supraglottis, subglottis, trachea, and mediastinum. Eleven patients have completed therapy and are doing well. Four patients have resolving lesions on the drug regimen. Life-threatening airway lesions unresponsive to conventional treatment should be considered for a trial of interferon alfa-2a.

Tracheobronchial foreign bodies continue to be a source of morbidity and mortality in the pediatric population. Technical advances in anesthesia and equipment have made the removal of these troublesome objects more feasible. Diligence must still be exercised and a coordinated team effort must be employed in order to achieve a satisfactory and safe outcome for the patient. The appropriate use of diagnostic studies and management techniques are discussed.

Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

Recurrent respiratory papillomatosis is most common in childhood but it affects all age groups; it represents a diathesis of the aerodigestive tract so that lesions amy develop at various sites - the nares, lips, pharynx, nasopharynx, larynx, tracheobronchial tree, approximately one-third of patients for one year or more; since relapses amy occasionally occur 2 to 20 years later, cure can never be assumed. At the present time, management is directed towards total ablation of all visble papilloma consistent with preservation of the airway and voice; reduction of the tumor burden to minimal proportions is thought to allow the maximum opportunity for remission. As the host-papilloma relationship is unraveled, it may be possible in the future to provoke an immune response so that remissions can be predicted and produced consistently.

Topical chemotherapy with the antimetabolite 5-fluorouracil (5-FU) has been used as an adjunct to surgical laser excision of squamous papillomas arising in the larynx and in the tracheobronchial tree. The drug has been administered intensively to eight patients with tracheotomies and disease in both anatomic regions. These patients received repeated instillations of 5-FU at concentrations from 0.5 to 5% into the larynx and tracheobronchial tree while in the hospital and at home. More than 4,500 doses of the drug have been administered during our phase 1 study. There has been no significant toxicity associated with repeated 5-FU instillation into the airway. Several patients developed blood-tinged tracheal secretions after the repeated use of high concentrations of the agent. Other complications included coughing, bronchospasm, and peristomal irritation. These symptoms all disappeared after temporary discontinuation of the drug. No patient has developed a systemic hypersensitivity response to the drug either detectable clinically or by repeated skin testing. There were no adverse effects on the hematologic or hepatic systems. Use of 5-FU was associated with inhibition of papilloma regrowth in six of eight patients. The major limitation to drug effectiveness is the requirement for its frequent administration.

Congenital choanal atresia frequently demands immediate recognition in the newborn, and provision of a nasal airway as soon as possible. A variety of techniques are available to correct this problem, but none is entirely satisfactory. Transpalatal procedures are associated with significant morbidity in the newborn, and transnasal microsurgical procedures are less predictable when a thick bony plate is present in the choanal obstruction. Transnasal resection with the CO2 laser has been carried out in seven patients (ten sides), whose ages ranged from 16 hours to 14 years. From this early experience, it appears that the procedure is entirely feasible and convenient. It seems to have significant advantages over conventional microsurgical techniques. Eight out of ten choanae have remained patent for four months or more. A lumen keeper is needed during the immediate postoperative period for at least two to three weeks. The procedure is associated with minimal morbidity.

Infection of the supraglottic larynx is a well-recognized clinical entity in both adults and children. The anatomical relationships of the various components of the larynx have been studied extensively, especially as they relate to the spread of malignant disease. However, the relationship of these spaces and compartments in inflammatory disease has not been heretofore appreciated. This report describes for the first time histologic evidence that infection of the supraglottic larynx may spread to the paraglottic space, thus causing compromise of the glottic region. This potential carries significant implications for planning the appropriate therapeutic measures.

Congenital subglottic hemangioma is a potentially life-threatening lesion which frequently presents before the age of 6 months. Many forms of therapy have been advocated for the treatment of this difficult lesion. The use of the carbon dioxide laser has been advocated in the past and this report represents an update in treating 31 patients from 1975 to 1983. The success rate was 94% and the complication rate was 6.5%. This form of therapy is an effective and valuable addition to those already available for this troublesome lesion.

Segmental tracheal stenosis in children may be either acquired or congenital in nature. Acquired injuries usually involve a previous tracheostomy site or an area just superior to the carina. Congenital stenosis may occur in any location and often is associated with pulmonary agenesis. Surgical correction may be undertaken relatively safely in children of any age by segmental resection. We report three patients ranging in age from 4 weeks to 3 years who were corrected successfully. The use of cardiopulmonary bypass may be indicated, especially in young infants, to facilitate resection.

Benign lesions of the airway in infants and children may endanger the airway and compromise laryngeal function. The CO2 laser provides an elegant method of transoral surgical excision without compromising laryngeal function or airway competence. It avoids the risks of such other treatment modalities as external surgical approaches, prolonged steroid therapy, and radiation. It is applicable to a wide variety of lesions without the necessity of tracheotomy. Hospitalization is minimized. Ten cases are presented to show the wide applicability of this technique. Gross pathology and pre- and postoperative findings are demonstrated and discussed, as is the safety and efficacy of the laser soft-tissue interaction.

A new microlaryngeal instrument set has been developed for phonatory surgery in adults and for pediatric laryngology. This 20-instrument set consists of forceps (cupped and alligator type) and scissors with 1-mm distal grasping and cutting tips. Open tip and whistle tip variety suction instruments with tip diameters of 1.0, 1.5, and 2 mm are also available. Included as well are fine (1.0-mm) probes for palpation and laser welding and smoke evacuation double-action grasping forceps. This microlaryngeal instrument set has been extremely useful in more than 80 clinical applications.

Acute epiglottitis is a true pediatric emergency. The intense inflammation of the supraglottic larynx may completely obstruct the larynx within several hours. This infection is secondary to infiltration of Hemophilus influenzae type b (HIB), and 90% to 95% of patients have positive blood cultures. During this period of generalized septicemia HIB involvement of other soft tissue sites may occur. The goal of this article is to alert otolaryngologists to the possibility of extraepiglottitic HIB involvement. In particular, HIB meningitis, concurrent with supraglottitis, will be discussed. Although the overall incidence of multiple site involvement is relatively low, it is important to be aware of the possibility, since the outcome may be significantly altered.

Congenital and acquired lesions of the pediatric airway may lead to significant morbidity and mortality. A review of 616 endoscopic procedures, carried out over a 2-year period, was undertaken. Of these procedures, 270 were diagnostic and 346 were therapeutic. This paper outlines the clinical indications, the role of radiology, and the diagnoses revealed by this retrospective review. Of particular interest was the fact that 11.5% of the patients had lesions in more than one anatomic site in the upper aerodigestive tract. The complications were divided into intraoperative, immediate postoperative, and delayed. In total, there was a 1.6% complication rate.

Cystic fibrosis (mucoviscidosis; fibrocystic disease of the pancreas) is an inherited autosomal recessive disorder that results in generalized dysfunction of exocrine glands. Chronic pansinusitis with nasal polyposis occurs frequently in this disease. Polypectomy and sinus drainage procedures are often required in those cases refractory to medical therapy. Recurrence of nasal polyps following removal is common. Controversy exists regarding the timing and extent of surgery. The management of 40 children with cystic fibrosis who underwent nasal polypectomy, intranasal ethmoidectomy, and Caldwell-Luc procedures to treat extensive sinusitis and nasal polyposis forms the basis for this report. Follow-up data indicate that fewer recurrences and longer symptom-free intervals result when intranasal ethmoidectomy and Caldwell-Luc procedures are combined with polypectomy.

A controversy has existed in recent years regarding the ideal method of establishing and maintaining an airway in the pediatric patient with acute supraglottitis. Nasotracheal intubation has been used as the sole method of airway management of acute supraglottitis at The Children's Hospital, Boston, since 1970. This paper reviews our experience with 80 children with acute supraglottitis presenting at our institution during the years 1980 to 1985.

Flexible endoscopy is assuming a role of increasing importance in the evaluation and diagnosis of upper aerodigestive tract disorders. With improved fiberoptic capabilities and miniaturization, these techniques are gaining in applicability to the pediatric population. At Children's Hospital, Boston, a newly designed Machida 1.9-mm bronchoscope has been employed in the evaluation of the upper airway. The use of this small caliber instrument has been investigated in 1) evaluation of endotracheal or tracheotomy tube position, thus decreasing the need for repeated chest radiographs to confirm location; 2) bedside evaluation of possible tracheal disease (eg, mucous plug, granuloma, tracheitis) in the intensive care unit patient to determine treatment plans and/or need for further rigid bronchoscopy, and 3) evaluation of airway dynamics in the awake patient. Our experience with the flexible fiberoptic minibronchoscope is reviewed, with a discussion of indications for its use, as well as possible limitations. Case studies are presented to demonstrate the usefulness of the instrument.

The carbon dioxide laser was used to treat a group of pediatric patients with benign lesions of the upper aerodigestive tract exclusive of the larynx. Prior to development of the CO2 laser, excision of these lesions by conventional means often resulted in incomplete removal, significant bleeding, and postoperative edema resulting in airway obstruction. The CO2 laser, with its unique properties of precise excision, hemostatic effect, and minimal postoperative edema, has become the instrument of choice in the removal of these lesions.

A variety of congenital and acquired lesions of the larynx are now managed effectively with the use of the carbon dioxide laser. This instrument seems to be the most effective of all available lasers for this type of therapy. Argon and neodymium:yttrium aluminum garnet lasers do not appear appropriate for such lesions for several reasons. On occasion, patients with congenital and acquired subglottic stenosis, as well as those afflicted with rare tumors of the larynx, require open procedures as part of their treatment regimen. The need for appropriate equipment and competent pediatric anesthesia is paramount when undertaking cases of this type. These patients offer unique challenges to a laryngologist, but correction of their problems is effectively managed by appropriate application of current technology.