2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

with expansion grafting/augmentation. 43 One of the diffi- culties in comparing these procedures is that the specific type of operation varies by surgeon, both between institu- tions and within the same institution. 1–39 Many patients receive multiple surgeries to permanently reduce LTS. Thus, an important goal for definitive management of LTS is the least number of surgical interventions. Conse- quently, there are multiple definitions of success in man- agement of LTS. In reviewing the scientific literature, two measures for success become apparent: 1) additional sur- gery following intervention, 1–39,41 and 2) decannulation for tracheostomy patients. 44 Another variable in the manage- ment of LTS is the site of stenosis. LTS can encompass different subsites of the airway. Stenosis may range from the larynx alone (supraglottis, glottis, or subglottis) to the larynx and trachea, or the trachea alone. 41 We reviewed articles that managed patients with subglottic stenosis with or without tracheal extension. The treatment of supraglottic and glottic stenosis is frequently different than subglottic stenosis, preventing direct comparison to management of the subglottis. 41 This systematic review sought to determine which surgical treatment option resulted in the fewest additional procedures and success of decannulation. In addition, the study sought to determine whether surgical treatment success varied based on the etiology of stenosis, because the underlying pathophysiol- ogy of the stenosis may determine which procedure could be most beneficial. This study is reported as a systematic review based on the statements from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. 45,46 An a priori protocol was established to define the hypothesis, methodology, and objectives of the study. The following PICO question (identifies the patient problem or population [P], intervention [I], compari- son [C], and outcome(s) [O]) was formulated: “In adult and ado- lescent patients over 13 years with LTS, are there different outcomes for patients treated with open laryngotracheal resec- tion with anastomosis, open LTR with augmentation grafting, and endoscopic procedures in need for further additional surgi- cal procedures, and decannulation success if the patient had a previous tracheostomy.” Separate forms for data collection and quality assessment were produced. These were not published or registered. Eligibility Criteria The systematic review included strict inclusion and exclu- sion criteria. The population defined is adults and adolescents aged > 13 years. Inclusion criteria comprised 1) surgical treatment of adult and adolescent LTS or subglottic stenosis; 2) etiology of stenosis as idiopathic, traumatic, or postintubation/tracheostomy; 3) two or more cases per publication; and 4) English language. Exclusion criteria comprised 1) stent placement as sole treatment for LTS; 2) age < 13 years; 3) etiology of stenosis other than idiopathic, traumatic, postintubation/tracheos- tomy, or not listed; 4) case report; 5) no discussion of decan- nulation or need for additional surgery; and 6) duplicate patient series. MATERIALS AND METHODS Protocol and Registration

Information Sources and Search A systematic review using multiple databases was used. MEDLINE (January 1966–December 2013) and Embase (January 1974–December 2013) were searched using search terms, included Medical Subject Headings terms: laryngotracheal stenosis, surgi- cal procedures/operative, device removal, adult, voice outcomes. “All field” terms included adult, laryngotracheal, laryngostenosis, subglottic stenosis, tracheal stenosis, reconstruction, treatment, surgery, and adult. In addition, reference sections were used to include studies not present on database searches. The last search was completed in December 2013. Study Selection Identification of studies was conducted by one reviewer ( S . L .). All titles and abstracts were screened by two independent reviewers ( S . L .) and ( M . E .) using the strict inclusion and exclu- sion criteria. Eligible articles were then assessed in full text by the two independent reviewers. Studies matching eligibility criteria were included in the systematic review. Data Collection Process Data were extracted independently by two reviewers through a data collection form. Quality was assessed using Methodological Index for Non-randomized Studies (MINORS) criteria. 47 Authors of publications were not contacted for indi- vidual data, as the study design was intended as a systematic review rather than an individual data meta-analysis. Data Items Study characteristics included year of publication, loca- tion, study design, inclusion criteria, and exclusion criteria. Population data included age range, gender, cause of stenosis, length of stenosis, and grade of stenosis. Interventions included surgical treatment, endoscopic procedure with dilation or CO 2 laser, LTR with expansion grafting, and laryngotracheal resec- tion with anastomosis. Different surgical treatment procedures were compared. Outcomes Primary endpoints were of additional surgery performed or received and open or endoscopic surgery. Open surgery included any patient who had another laryngotracheal resection with anastomosis or reconstruction with augmentation grafting. Endoscopic procedures included bronchoscopy for surveillance with dilation, excision of granulation tissue, or any other endo- scopic procedure. The secondary endpoint was success of decan- nulation if the patient previously had a tracheostomy. Other endpoints and outcomes we attempted to evaluate were time to decannulation from procedure, voice outcome, complications, and need for further endoscopic versus open surgical procedure. Risk of Bias in Individual Studies MINORS criteria were used to evaluate quality and level of bias. MINORS criteria is a validated instrument to assess for bias among observational studies, especially studies involving surgical intervention. There are two sets of criteria for MINORS criteria, those for noncomparative studies, which include eight items. For comparative studies, there are an addi- tional four items. Items are scored 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). The global ideal score for noncomparative studies are 16 and 24 for comparative

Laryngoscope 127: January 2017

Lewis et al.: Surgical Treatment of Adult LTS

274