2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Reprinted by permission of Laryngoscope. 2017; 127(1):191-198.

The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Systematic Review

Systematic Review for Surgical Treatment of Adult and Adolescent Laryngotracheal Stenosis

Sean Lewis, MD; Marisa Earley, MD; Richard Rosenfeld, MD, MPH; Joshua Silverman, MD, PhD

Objectives/Hypothesis: To determine if open surgical treatment options for adult and adolescent laryngotracheal stenosis are more successful than endoscopic procedures. Study Design: Systematic review. Methods: Embase and MEDLINE were searched for publications on adult and adolescent patients ( > 13 years old) with laryngotracheal stenosis. Cause of stenosis (intubation, idiopathic, or trauma) and treatments (open laryngotracheal resection with anastomosis, open laryngotracheal reconstruction with expansion grafting, or endoscopic procedures) were included. Primary outcomes are decreased additional surgery performed and success of decannulation, if previously tracheostomy. Results: There were 297 abstracts reviewed, 104 articles selected for full-text review, and 39 articles, with 834 pooled patients, included in the analysis. Patients who had an open procedure (resection with anastomosis or reconstruction with expansion grafting) had significantly different outcomes rates; 32% versus 38% ( P < .001) received additional surgery and 89%and 83% ( P < .001) were decannulated, respectively. For patients who had endoscopic repair, 44% received additional surgery, and 63% were decannulated. Patients with idiopathic stenosis were more likely to receive additional surgery than those with traumatic (54% vs. 25%) and intubation/tracheostomy etiologies (54% vs. 35%). Etiology of stenosis did affect decannulation rates, patients with intubation/tracheostomy etiology had decannulation rates of 88%, compared to traumatic etiologies (78%, P < .001) and idiopathic stenosis (63%, P < .001). Risk of bias did not impact study results and was assessed using a validated instrument, Methodological Index for Non-randomized Studies criteria. Conclusions: Patients with adult laryngotracheal stenosis who undergo laryngotracheal resection with anastomosis receive less surgery compared to those who undergo endoscopic treatment or laryngotracheal reconstruction with augmentation/grafting. Patients with idiopathic stenosis are less likely to receive further surgery compared to those from trauma or intubation/tracheostomy, but have the lowest rate of decannulation. Key Words: Laryngotracheal stenosis, subglottic stenosis, laryngotracheal reconstruction. Level of Evidence: NA Laryngoscope , 127:191–198, 2017

notic airway or resect the region of stenosis. 1–34,40 Frequently, an endoscopic approach in addition to an open procedure is necessary to relieve obstruction. 33 We have undertaken this systematic review to compare these tech- niques and determine if one approach is superior for treat- ment of LTS. Etiology of LTS is multifactorial. In adults and adoles- cents it is mostly acquired, where in children in may be acquired or congenital. 41 Acquired LTS can result from pre- vious intubation or tracheostomy, systemic disease, trauma, infection, or idiopathic causes. 41 Historically, infec- tious etiology was common. Currently, LTS most frequently results from prolonged intubation or trauma from intuba- tion itself. 42 The most straightforward treatment for upper airway obstruction continues to be tracheostomy. 44 How- ever, long-term tracheostomy requires continual mainte- nance and can lead to additional airway problems. To pursue decannulation of patients with LTS, surgical man- agement at the stenosis site is typically required. 41 Surgery for LTS can be grouped into three categories: endoscopic procedures, open laryngotracheal resection with anastomosis, and laryngotracheal reconstruction (LTR)

INTRODUCTION Laryngotracheal stenosis (LTS) is a condition that can cause severe patient morbidity, as airway obstruction causes respiratory distress and difficulty breathing. 1–40 LTS continues to provide significant challenges for treating specialists, primarily due to regrowth of granulation tissue at the site of intervention or at the anastomotic site. 40 A range of endoscopic and open techniques are available to treat LTS. 1–44 Open neck procedures can augment the ste- Additional Supporting Information may be found in the online version of this article. From the Department of Otolaryngology, State University of New York Downstate Medical Center, Brooklyn, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication June 1, 2016. Presented at the Triological Society Meeting, Coronado, California, U.S.A., January 23, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Sean Lewis, MD, SUNY Downstate HSC, 450 Clarkson Avenue, Box 126, Brooklyn, NY 11203. E-mail: seanlewis210@gmail.com.

DOI: 10.1002/lary.26151

Laryngoscope 127: January 2017

Lewis et al.: Surgical Treatment of Adult LTS

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