Endoscopic treatment of subglottic stenosis in children

Introduction. Subglottic stenosis is one of the most common causes of upper airway obstruction. The incidence of post-intubation stenosis ranges from 0.9% to 3% (Rodríguez H. et al.), or from 0.2% to 20% (Haranal M.Y. et al.). Currently, there is no consensus on the choice of surgical tactics due to a large number of modalities for surgical restoration of the laryngeal lumen.Material and methods. 44 patients with postintubation laryngeal stenosis were treated in the surgical thoracic department of the National Medical Research Center of Children’s Health subordinate to the Ministry of Health of the Russian Federation during 2019-2021. The average age of patients in this group was 4 years 8 months ± 3 years 8 months. Endoscopic treatment was done to 24 patients (54.5%). Laryngoscopy, fibrobronchoscopy, multispiral computed tomography and, if necessary, barium esophagogram were done for additional diagnostics.Results. The average number of endoscopic procedures per patient was 2.9 ± 1.5 (range from 1 to 7). Good results were seen in 20 patients (83.3%).Conclusions. Endoscopic techniques are alternative options to open reconstructive surgery. These techniques give good results in treating stenoses in the subglottic space and give a good chance to avoid tracheostomy in a certain group of patients, which, according to the results of our study, was as large as 79.1%.

Selective digestive decontamination solution used as “lock therapy” prevents and eradicates bacterial biofilm in an in vitro bench-top model

Background Most preventing measures for reducing ventilator-associated pneumonia (VAP) are based mainly on the decolonization of the internal surface of the endotracheal tubes (ETTs). However, it has been demonstrated that bacterial biofilm can also be formed on the external surface of ETTs. Our objective was to test in vitro the efficacy of selective digestive decontamination solution (SDDs) onto ETT to prevent biofilm formation and eradicate preformed biofilms of three different microorganisms of VAP. Methods We used an in vitro model in which we applied, at the subglottic space of ETT, biofilms of either P. aeruginosa ATCC 15442, or E. coli ATCC 25922, or S. aureus ATCC 29213, and the SDDs at the same time (prophylaxis) or after 72 h of biofilm forming (treatment). ETT were incubated during 5 days with a regimen of 2 h-locks. ETT fragments were analyzed by sonication and confocal laser scanning microscopy to calculate the percentage reduction of cfu and viable cells, respectively. Results Median (IQR) percentage reduction of live cells and cfu/ml counts after treatment were, respectively, 53.2% (39.4%—64.1%) and 100% (100%–100.0%) for P. aeruginosa, and 67.9% (46.7%–78.7%) and 100% (100%–100.0%) for E. coli. S. aureus presented a complete eradication by both methods. After prophylaxis, there were absence of live cells and cfu/ml counts for all microorganisms. Conclusions SDDs used as “lock therapy” in the subglottic space is a promising prophylactic approach that could be used in combination with the oro-digestive decontamination procedure in the prevention of VAP.

Comparison of Endoscopic and Ultrasonographic Measurements of the Subglottic Airway in Children

Objective To compare measurements of the pediatric subglottis obtained by surgeon-performed ultrasound and endoscopy. Study Design Prospective observational comparison-of-methods study. Setting Tertiary care pediatric hospital. Subjects and Methods Thirty-one patients who underwent direct laryngoscopy from May 2017 to July 2018 were recruited. Transcervical ultrasound was used to visualize the vocal folds, subglottis, and cervical trachea. The anterior-posterior (AP) and transverse (TV) diameter of the subglottic space were measured endoscopically and via ultrasound by 2 independent evaluators. Measurements were compared for correlation, bias, and agreement. A clinically acceptable bias for subglottic diameter was assumed to be 0.5 mm or less. Results The median age of enrolled patients was 2.6 years (range, 4 months–13.3 years). Endoscopic subglottic AP and TV measurements ranged from 3.33 mm to 14.81 mm and from 4.44 mm to 11.65 mm, respectively, while ultrasonographic AP and TV measurements ranged from 4.57 mm to 9.85 mm and from 3.77 mm to 8.96 mm. Pearson coefficient showed strong a correlation for both endoscopic and ultrasound AP ( R = 0.8081, P < .0001) and TV ( R = 0.8796, P < .001) measurements of the subglottis. Bland-Altman plots revealed a bias (average discrepancy) for AP measurements of 0.22 mm and 0.11 mm for TV measurements. Conclusion Endoscopic and ultrasonography measurements of the pediatric subglottic airway were strongly correlated. The discrepancy between AP and TV measurements was less than 0.5 mm. Ultrasound of the subglottis may be an alternative to endoscopic assessment of the airway for measurement of the subglottic airway in children in select cases.

Impact of Subglottic Saline Irrigation on Reducing Bacterial Contamination for Oral Surgery Patients

This study investigated the effectiveness of subglottic irrigation (SI) with 100 mL of saline on reducing bacterial contamination in the subglottic space during oral surgery procedures without the use of throat packs. Subglottic lavage and irrigation were performed through the suction lumen located on specialized endotracheal tubes (ETTs) with capabilities of permitting evacuation from the subglottic space. Fifty-three patients who were scheduled for oral surgery procedures under general anesthesia while intubated with specialized ETTs at Kyushu Dental University Hospital were enrolled in this study. Subglottic irrigation was performed, and the sample fluid was collected through the ETT suction lumen for smear and culture bacterial examinations after 3 points in time: immediately after intubation, after completing the surgical procedure, and again after SI. Oral surgery without a throat pack significantly increased bacterial contamination in the subglottic lavage (p &lt; .001), and SI decreased bacterial contamination (p &lt; .001) similarly to levels found after tracheal intubation. Subglottic irrigation with 100 mL of saline was effective in reducing bacterial load in the subglottic space to levels similarly noted immediately after intubation for patients undergoing intraoral surgical procedures without the use of a throat pack.

Internal Laryngocele: Unusual onset in a 91-year-old female patient

While internal laryngoceles rarely cause major clinical complaints, they may lead to airway obstruction and require emergency intervention on rare occasions. We report a 91-year-old patient who was referred to the Ear, Nose & Throat Clinic of the Policlinico Santa Maria alle Scotte, Siena, Italy, in 2017 due to recurrent episodes of severe dyspnoea. A flexible nasopharyngolaryngoscopic examination revealed an internal laryngocele of approximately 1.5 cm in diameter that moved up and down the glottic plane, occasionally invading the subglottic space during inspiration and impeding airflow. This caused cyanosis and dyspnoea so severe that an emergency tracheotomy was considered. Luckily, after considerable effort, the patient was able to cough, causing the mass to move above the vocal plane and allowing normal breathing. The laryngocele was subsequently removed via laryngomicrosurgery. Although the incidence of internal laryngoceles is quite rare, physicians should consider this potentially life-threatening condition among patients with dyspnoea.

The Role of Airway and Endobronchial Ultrasound in Perioperative Medicine

Recent years have witnessed an increased use of ultrasound in evaluation of the airway and the lower parts of the respiratory system. Ultrasound examination is fast and reliable and can be performed at the bedside and does not carry the risk of exposure to ionizing radiation. Apart from use in diagnostics it may also provide safe guidance for invasive and semi-invasive procedures. Ultrasound examination of the oral cavity structures, epiglottis, vocal cords, and subglottic space may help in the prediction of difficult intubation. Preoperative ultrasound may diagnose vocal cord palsy or deviation or stenosis of the trachea. Ultrasonography can also be used for confirmation of endotracheal tube, double-lumen tube, or laryngeal mask placement. This can be achieved by direct examination of the tube inside the trachea or by indirect methods evaluating lung movements. Postoperative airway ultrasound may reveal laryngeal pathology or subglottic oedema. Conventional ultrasound is a reliable real-time navigational tool for emergency cricothyrotomy or percutaneous dilational tracheostomy. Endobronchial ultrasound is a combination of bronchoscopy and ultrasonography and is used for preoperative examination of lung cancer and solitary pulmonary nodules. The method is also useful for real-time navigated biopsies of such pathological structures.