A survey of patients with laryngotracheal stenosis on future clinical trial design

Background/Aims Laryngotracheal stenosis is a rare but devastating proximal airway fibrosis that restricts a patient’s ability to breathe. Treatment is primarily surgical and to date, there has never been a multi-institutional, randomized, prospective, and interventional clinical trial for a medical therapy to treat laryngotracheal stenosis. Therefore, we aimed to obtain patient feedback to guide successful trial design, recruitment, retention, and for identifying potential barriers to study participation. Methods Over 1000 members of an international laryngotracheal stenosis online support community (the Living with Idiopathic Subglottic Stenosis Facebook group) were sent two questionnaires for a proposed interventional double-blinded, randomized, placebo-controlled clinical trial. Results A total of 317 and 558 participants responded to the first and second surveys, respectively. The majority of participants (77%) were willing to consider enrollment, regardless of having a 50% chance of receiving placebo versus treatment (78%). The majority (84%) of participants were willing to travel 200 miles to participate for up to six in-person visits over 50 days. Specific side effects, including anemia/thrombocytopenia (72%) or risk of infection (69.3%) had the greatest impact on clinical trial participation with other side effects (peripheral edema (53%), oral ulcers (51%), and gastrointestinal side effects (41%)) having less impact. Conclusion Patients with laryngotracheal stenosis possess nuanced insight into their disease and treatment options. As a group, they are extremely motivated for better therapies. Future laryngotracheal stenosis clinical trials should focus on providing excellent side effect -related education and utilizing feedback from online advocacy groups to optimize recruitment and retention.

Subglottic Stenosis (SGS) Pasca Trauma Inhalasi

Latar Belakang: Laryngotracheal stenosis (LTS) terjadi pada 24-53% pasien pasca trauma inhalasi1. Insiden komplikasi pasca pembedahan LTS adalah 33- 34% dan mortalitas pasca pembedahan adalah 1,5-2%2. SGS sering terjadi pada cedera inhalasi pasca intubasi1. Laporan Kasus: Pasien dengan luka bakar pada area wajah dan keempat ekstremitas, akibat ledakan tabung gas pada ruangan tertutup. Sembilan jam pasca trauma, pasien mengeluhkan kesulitan bernapas. Pasien diintubasi selama 2 hari pasca trauma dan 5 kali intubasi lainnya dengan ETT cuff 6,5 mm untuk tindakan operasi. Tidak ada data tekanan cuff pasien. Hari ke-38 perawatan di rumah sakit, pasien mengeluh suaranya serak dan terkadang merasa sulit bernapas. Hasil fiber optic laryngoscopy (FOL) pasien menunjukan 30% penyempitan pada subglotis. Pasien didiagnosis dengan SGS stadium 1. Pasien tidak membutuhkan tindakan pembedahan dan hanya diobservasi. Diskusi: Evaluasi FOL perlu dilakukan sejak awal cedera inhalasi3. Evaluasi FOL pada pasien kami baru dilakukan setelah muncul gejala SGS. Risiko LTS meningkat sesuai dengan keparahan cedera inhalasi, keparahan reaksi inflamasi, durasi intubasi (lebih dari 10 hari), ukuran ETT yang besar, dan intubasi berulang. Tekanan cuff pada ETT dapat mengakibatkan pembentukan skar dan stenosis pada subglotis1. Tekanan cuff yang direkomendasikan adalah 20-30 cmH2O. Tekanan cuff perlu diukur dan disesuaikan tiap 4-12 jam4. Pasien kami diintubasi sebanyak 6 kali, tanpa pengukuran tekanan cuff. Stadium SGS yang sering digunakan adalah Cotton Meyer staging. Stadium 1 SGS tidak membutuhkan tindakan pembedahan5. Kesimpulan: Sekuel cedera inhalasi pada subglotis dapat dicegah dengan melakukan intubasi sesuai indikasi dan menggunakan ETT ukuran kecil dengan tekanan cuff yang tidak terlalu tinggi.

“A Major Quality of Life Issue”: A Survey-Based Analysis of the Experiences of Adults With Laryngotracheal Stenosis with Mucus and Cough

Objectives: To investigate how the symptoms of mucus and cough impact adults living with laryngotracheal stenosis, and to use this information to guide future research and treatment plans. Methods: A survey was developed with the support of patient advisors and distributed to people suffering with laryngotracheal stenosis. The survey comprised 15 closed and open questions relating to mucus and cough and included the Leicester Cough Questionnaire (LCQ). Descriptive statistics, X2 and thematic analyses were completed. Results: In total, 641 participants completed the survey, with 83.62% (n = 536) reporting problems with mucus; 79% having daily issues of varying severity that led to difficulties with cough (46.18%) and breathing (20.90%). Mucus affected voice and swallowing to a lesser degree. Respondents described a range of triggers; they identified smoky air as the worst environmental trigger. Strategies to manage mucus varied widely with drinking water (72.26%), increasing liquid intake in general (49.35%) and avoiding or reducing dairy (45.32%) the most common approaches to control symptoms. The LCQ showed a median total score of 14 (interquartile range 11-17) indicative of cough negatively affecting quality of life. Thematic analysis of free text responses identified 4 key themes—the Mucus Cycle, Social impact, Psychological impact, and Physical impact. Conclusion: This study shows the relevance of research focusing on mucus and cough and its negative impact on quality of life, among adults with laryngotracheal stenosis. It demonstrates the inconsistent advice and management strategies provided by clinicians for this issue. Further research is required to identify clearer treatment options and pathways.

Laryngotracheal stenosis: A more common problem in the COVID era

Laryngotracheal stenosis (LTS) is a rare cause of dyspnoea. It is associated with emergency or prolonged intubation and with tracheostomy. It is expected to increase in incidence following the coronavirus 2019 (COVID-19) pandemic, due to the increased numbers of prolonged intensive care admissions. Presentation may be weeks or even years after the acute episode. A variety of symptoms may be present, and include dyspnoea, cough, dysphagia, stridor or voice change. LTS can be confused with commoner respiratory diseases such as asthma. Awareness of the condition is important to facilitate a timely referral to Otolaryngology for diagnosis and management.

Subglottic Stenosis as an Isolated Clinical Manifestation in Relapsing Polychondritis – A Case Report

Relapsing Polychondritis is a rare, multisystem autoimmune disease still of unknown origin, characterized by recurrent inflammation of the hyaline cartilages. The involvement of Laryngotracheal cartilages in polychondritis is one of the most serious known complications, observed in 50% of patientswith worse prognosis. Among the causesof death, laryngotracheal stenosis associated with pneumonia or severe respiratory failure stands out, and may be found in 10% to 50% of patients with the disorder. We describe a case of relapsing polychondritis in a female patient, with dyspnea as an initial manifestation, in which Grade III Cotton-Myer Laryngotracheal Stenosis was later confirmed. During the 10 years of investigation, clinical treatment stabilized the disease, but the respiratory distress persisted, which prompted the patient to be submittedto surgical correction of laryngotracheal stenosis.

Management of Laryngotracheal Stenosis in Obesity. Is This Another Co-morbidity that Can Be Improved with Weight Loss Following Bariatric Surgery?

Purpose Bariatric surgery improves several obesity-related comorbidities. Laryngotracheal stenosis is a rare condition that is usually managed with repeated endoscopic airway interventions and reconstructive airway surgery. The outcome of these definitive operations is worse in individuals with obesity. There are no studies investigating the effect of weight loss following bariatric surgery in the management of laryngotracheal stenosis. Materials and Methods In an observational study, consecutive patients with a BMI over 35 kg/m2 and laryngotracheal stenosis were prospectively recruited to a bariatric and airway stenosis database in two tertiary care centres. Patients were treated with laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy and control subjects were managed conservatively. Results A total of eleven patients with an initial body mass index of 43 kg/m2 (37–45) were enrolled to this study. Six patients underwent bariatric surgery and five subjects were treated conservatively. After 12 months, the total weight loss of patients undergoing bariatric surgery was 19.4% (14–24%) whilst 2.3% (1–3%) in the control group. The annual number of endoscopic airway interventions following bariatric surgery reduced (p = 0.002). Higher weight loss in patients led to less frequent interventions compared to control subjects (p = 0.004). Patients undergoing laryngotracheal reconstruction following bariatric surgery needed less endoscopic intervention, an annual average of 1.9 interventions before vs 0.5 intervention after. Conservatively managed control subjects required more frequent endoscopic intervention, 1.8 before vs 3.4 after airway reconstruction. Conclusion Bariatric surgery reduced the number of endoscopic airway interventions and enabled patients to undergo successful definitive airway reconstructive surgery.

Preliminary Experience With a Novel Metallic Segmented Transcordal Stent Modified With Three-Dimensional Printing for Inoperable Malignant Laryngotracheal Stenosis

BackgroundThis study aims to assess the feasibility of a novel metallic segmented transcordal stent modified with three-dimensional (3D) printing for treating inoperable malignant laryngotracheal stenosis and the tolerability of the stent.MethodsThis was a retrospective study. The stents were individually customized with the aid of 3D printing model based on the anatomic features of each patient’s airway. The stent was composed of two separate segments that corresponded to the larynx and the upper trachea. The stents were barrel-shaped at the proximal end to prevent migration. The proximal end of the stent was located slightly above the vocal cord. The technical and clinical success of stenting procedure, patient tolerability, and stent-related complications of patients were evaluated.ResultsTen patients with dyspnea caused by malignant laryngotracheal stenosis underwent implantation of such stents. Technical and clinical success of the stenting procedure were achieved in all patients. For all patients, basic communication in life could be maintained by speaking softly. During follow-up, one patient showed intolerance to the stent, and the stent was retrieved 2 weeks after stenting. Stent migration was found in one patient, and the position of the stent was readjusted. Granulation tissue proliferation was found in two patients and was treated with cryotherapy by bronchoscopy. There were no deaths associated with stenting.ConclusionsThe individually customized metallic segmented transcordal stent is feasible and tolerable for patients with inoperable malignant laryngotracheal stenosis. The implantation of this stent may serve as a novel alternative treatment for patients who are not suitable for surgery or tracheotomy.