A comparative analysis of open surgery vs endoscopic balloon dilation for pediatric subglottic stenosis

Alison Maresh, Diego A Preciado, Ashley P O'Connell, George H Zalzal
JAMA Otolaryngology—Head & Neck Surgery 2014, 140 (10): 901-5

IMPORTANCE: Minimally invasive endoscopic techniques are an appealing alternative to open surgical management of pediatric subglottic stenosis (SGS), but more information is needed to understand the comparative risks, benefits, and limitations of such interventions.

OBJECTIVE: To compare the effectiveness of endoscopic balloon dilation (EBD) and laryngotracheoplasty (LTP) in pediatric patients with SGS and to identify patient and disease factors that are associated with successful EBD.

DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical record review of children undergoing EBD and LTP for SGS in a tertiary care children's hospital from 2006 through 2012.

MAIN OUTCOMES AND MEASURES: Success was defined as decannulation or tracheotomy avoidance. Additional outcomes were total number of procedures and number of unplanned procedures. Univariate χ2 analyses and multivariate regression analyses were performed to identify patient and disease factors statistically associated with success within treatment groups.

RESULTS: Overall, 86 of 90 patients (96%) successfully avoided tracheotomy or were decannulated. Fourteen patients were successfully treated with EBD, but for 13 patients, EBD failed, and they underwent LTP. A total of 76 patients underwent LTP. In univariate analyses, patients for whom EBD was successful were more likely to have mild (grade 1 or 2; n = 10) than severe (grade 3 or 4; n = 4) SGS compared with patients for whom EBD failed (grade 1 or 2, n = 0 vs grade 3 or 4, n = 13) (P < .001). Three patients who underwent initial EBD had worsening stenosis. Patients initially treated with EBD were more likely to require unplanned surgical intervention during their treatment (6 of 27; 22%) than patients initially treated with LTP (3 of 63; 5%) (P = .01). Patients initially treated with EBD had a lower number of airway interventions and/or evaluations under anesthesia (mean, 6.7) during their course of treatment than patients initially treated with LTP (mean, 9.2) (P = .003). In multivariate analyses, only severe SGS was significantly associated with failure of initial EBD (13 of 13 [100%] with type 3 or 4 vs 4 of 14 with type 1 or 2 [29%]) (P = .002).

CONCLUSIONS AND RELEVANCE: For severe SGS, EBD has limited application compared with LTP, and in some cases failed EBD is even detrimental, increasing the risk of unplanned urgent interventions compared with LTP.

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