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Age, Experience Factors in Predicting Failure of Subglottic Stenosis Procedures

From: ENT Today, September 2008

by Ed Susman

Physicians have suggested that the likelihood of failure of surgery to correct subglottic stenosis appears to be related to the age of the child at the time of treatment and whether the child is being treated at a tertiary care facility.

The worst case for risk of a surgical failure would be a nine-year-old child with neurological disorders operated on by a surgeon inexperienced in pediatric otolaryngology, said Richard Nicollas, MD, a pediatric otolaryngologist in the Ear, Nose and Throat Department at Hôpital d'Enfants La Timone in Marseille, France.

On the other hand, Dr. Nicollas determined in his study that the best-case scenario would be a three-year-old child without associated neurological disorders who is operated on by an experienced pediatric otolaryngologist.

Richard Nicollas, MDWhat we don't know is why these operations fail. That is what we wanted to discover with this study. So the question was, can we predict when something will go wrong?
-Richard Nicollas, MD

Dr. Nicollas and his research team, led by Jean-Michel Triglia, MD, head of the department of pediatric otolaryngology at the hospital, reviewed outcomes in which children underwent procedures to correct subglottic stenosis at Hôpital d'Enfants La Timone and at Armand Trousseau Children's Hospital in Paris.

We all know how to perform this operation, and although it can be challenging, in most cases it is successful, Dr. Nicollas said during the 23rd Annual Meeting of the American Society of Pediatric Otolaryngology, conducted during the Combined Otolaryngology Spring Meeting. What we don't know is why these operations fail. That is what we wanted to discover with this study. So the question was, can we predict when something will go wrong?

Subglottic Stenosis Study

The researchers identified 262 children who underwent subglottic stenosis repair procedures. There were 138 boys and 124 girls in the study population, who had undergone procedures at the two institutions from 1988 through 2008. Dr. Nicollas compared the 224 children who required one procedure with the 38 children who required a second operation. In the second group, 17 were boys and 21 were girls.

The researchers considered the patients' sex, age, weight, whether the condition was congenital or not, the type of initial procedure, the use of stenting, associated pathology-whether there were neurological or cardiological or other conditions, and whether the children were referred to the tertiary hospitals after treatment in a nonpediatric ear, nose, and throat facility.

The initial severity of the stenosis was similar between the groups, except for Grade 4 subglottic stenosis. Dr. Nicollas said 37 of the patients in the group that required just one procedure (16%) had Grade 4 stenosis, whereas 12 of the children who would require a second procedure were identified with Grade 4 stenosis-about 32.4% (p = 0.009).

The median age of the children who had just one operation was 42 months, compared with an average age of 110 months for a child who required a second procedure (p < 0.001).

Dr. Nicollas said that eight of the 38 children who required a second operation were initially treated at the tertiary hospitals, whereas the other 30 children who needed the second procedure were referred from nonpediatric specialty facilities (p < 0.001).

There were 56 children in the group that required just one procedure who also were diagnosed with a neurological disorder-about 25% of the total group. But 16 of the 38 children requiring the second operation-42% of that group-were found to have neurological comorbidities (p = 0.0049).

Aside from those factors, the researchers did not find that other variables-including sex of the children-had an impact on whether the initial procedure failed.

We hope that one day this information will help us determine which children require special attention so that we do not have to perform a second procedure, said Dr. Nicollas. For us and the children who are our patients, failure is not an option.

Udayan Shah, MD, Pediatric Otolaryngologist at Nemours Children's Clinic at the Alfred I. duPont Hospital for Children in Wilmington, DE, said the study offered by Dr. Nicollas provides interesting information for clinicians.

These data support the concept of interdisciplinary subspecialty care for children with airway stenosis. Such an approach benefits children and their families by involvement of pediatric gastroenterologists, pulmonologists and respiratory therapists, speech and swallowing specialists, and a safe home care regimen, said Dr. Shah. Further studies from other centers would be helpful to expand, as well as to confirm and to clarify, the data presented by Dr Nicollas and colleagues at ASPO.

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