International Journal of Pediatric Otorhinolaryngology Extra
Volume 3, Issue 1 , Pages 39-43, January 2008

The cutting balloon for endoscopic dilatation of pediatric subglottic stenosis

  • K. Watters

      Affiliations

    • Corresponding Author InformationCorresponding author at: 8 Eglinton Wood, Eglinton Road, Donnybrook, Dublin 4, Ireland. Tel.: +353 87 8101731.
    • ,
  • J. Russell

Department of Pediatric Otorhinolaryngology, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland

Received 6 August 2007; received in revised form 26 September 2007; accepted 28 September 2007. published online 12 November 2007.

Article Outline

Summary 

In recent years, the increasing use of endoscopic techniques for management of pediatric subglottic stenosis has become evident. However, two problems encountered with conventional balloon dilatation are that of re-stenosis and distal balloon migration. We report a novel technique of endoscopic dilatation using the Peripheral Cutting Balloon™ Microsurgical Dilatation Device in a 4-year-old child with symptomatic Cotton Grade 2 subglottic stenosis. The presence of microsurgical blades on the balloon allows for more secure placement of the balloon at the level of the stenosis, preventing migration and allowing for more accurate dilatation under less pressure decreasing re-stenosis rates. We recommend that the cutting balloon be used as first line treatment in pediatric subglottic dilatation.

Keywords: Pediatric subglottic stenosis, Endoscopic dilatation, Cutting balloon

 

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1. Introduction 

Following the re-introduction of prolonged endotracheal support in 1965, the management of pediatric laryngotracheal stenosis (LTS) has undergone great advances, with surgery being very much tailored to the individual needs of the patient [1]. The management of LTS continues to evolve, ranging from dilatation, laryngotracheoplasty, cricoid split, laryngotracheal reconstruction with cartilage grafts and partial cricotracheal resection. Previously, endoscopic techniques had a very limited role in the correction of LTS, however, in the recent years, increasing use of endoscopic techniques with successful outcomes, either as primary or salvage surgery, has become evident, preventing the need for open reconstructive surgery. We continue to advocate the guidelines for endoscopic surgery previously proposed by Simpson et al. in 1982; the stenosis must not be longer than 1cm, the cartilage framework must be intact, no tracheomalacia, no chronic infection, and no circumferential scarring [2]. At our institution we have experience in successfully managing subglottic stenosis (Cotton Grade 2 – 51–70% stenosis) with endoscopic techniques – carbon dioxide laser or balloon dilatation, using conventional angioplasty balloons, followed by the application of mitomycin C [3].

Two problems encountered with conventional balloon dilatation in the airway are that of re-stenosis and distal migration of the balloon at the time of inflation. We describe a new technique of endoscopic airway dilatation using the Peripheral Cutting Balloon™ Microsurgical Dilatation Device (InterVentional Technologies Europe Ltd. (IVT®), a subsidiary group of Boston Scientific, Letterkenny, County Donegal, Ireland) which helps to overcome these issues. The balloon is available in Europe and the United States. The cutting balloon is a relatively new device for coronary angioplasty that by the combination of incision and dilatation of the coronary plaque, has been shown to reduce the incidence of re-stenosis [4], [5], [6]. Cutting balloons are now accepted for use in the vascular system, especially for dialysis-related arteriovenous fistulas and venous anastomotic strictures after failed high-pressure balloon angioplasty [4]. There are also reports on their successful use in the management of resistant ureteral and biliary strictures [7]. We report the case of a 4-year-old child with acquired symptomatic subglottic stenosis Cotton grade 2 (51–70% stenosis) that was successfully treated with the Peripheral Cutting Dilatation balloon. The use of the cutting balloon in the airway has not been previously reported.

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2. Methods 

The Peripheral Cutting Balloon™ Microsurgical Dilatation Device consists of a non-compliant balloon with four longitudinally mounted, 1-cm long microsurgical blades, orientated at the four quadrants of the circumference of the balloon, that are exposed during inflation (Fig. 1). During dilatation, the device produces four surgical incisions, increasing the circumference of the lumen but limiting the degree of mucosal trauma encountered in conventional balloon dilatation, and consequently reducing the rate of re-stenosis.

Following confirmation of the diagnosis at microlaryngobronchoscopy and grading of the stenosis using the Cotton grading system for subglottic stenosis, an appropriate size cutting balloon is chosen based on the expected normal cricoid diameter of the age of the patient [8]. We use a cutting balloon with an inflated balloon lumen equivalent to the expected cricoid diameter of the patient according to their age (Table 1). For example, for a 3–6-year-old patient with an expected normal internal cricoid diameter of 7.4–8.2mm, we would use a 8mm cutting balloon. We also recommend using a guide-wire appropriate to the size of the catheter when placing the balloon, as the catheter is very flexible. The cutting balloon is placed at the level of the stenosis (Fig. 2) and inflated and deflated slowly (1atm/5s) using the Encore™ 26 Advantage Kit Inflation Device Kit (Ref: 588862, Boston Scientific Corporation, Sragh Industrial Estate, Tullamore, Ireland). An airway pledget soaked in mitomycin C at a concentration of 0.25mg/ml is then applied to the dilated segment for 5min. The area is then washed with a pledget soaked in normal saline.

Table 1. Recommended cutting balloon size based on expected normal cricoid diameter according to patient age
Patient age
<1 month1–6 months6–18 months18 months –3 years3–6 years6–9 years9–12 years>12 years
Cricoid AP diameter i.d. (mm)3.5–4.34.3–5.85.8–6.56.5–7.47.4–8.28.2–99–10.710.7
Recommeded cutting balloon size (mm)4466/888/101010

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3. Results 

A 4-year-old girl was referred to our service from a peripheral institution following failure to intubate at the time of an elective dental procedure, resulting in the procedure being abandoned. She was born at 25 weeks gestation, and was intubated for 5 months as a neonate. Although clinical examination revealed failure to thrive and inspiratory stridor, she had not previously been referred by her primary pediatric physician for airway assessment. At microlaryngobronchoscopy a Cotton Grade 2 subglottic stenosis (51–70% stenosis) was diagnosed. She initially underwent routine dilatation of the stenosis using a 8mm conventional angioplasty balloon (Ref. CBVP8X20/70, BALT, Extrusion Fabrication de Cathèters, 10, Rue Croix-Vigneron, 95160 Montmorency, France), followed by the application of mitomycin C (0.25mg/ml). Following dilatation the stenosis was graded as a Cotton 1 subglottic stenosis (0–50% stenosis).

At microlaryngobronchoscopy 4 weeks later, there was evidence of subglottic re-stenosis, measured as a Cotton Grade 2 subglottic stenosis (Fig. 3). At this stage, a 6mm Peripheral Cutting Balloon™ Microsurgical Dilatation Device (Ref: BP906010B InterVentional Technologies Europe Ltd. (IVT®)) was used to dilate the stenosis, followed by further application of mitomycin C (0.25mg/ml). The mucosal cuts were evident in the mucosa following cutting balloon dilatation (Fig. 4). Microlaryngobronchoscopies at 6 and 12 weeks following dilatation showed no evidence of re-stenosis. At 9 months post-dilatation the child remains asymptomatic—her stridor has resolved and she is gaining weight. No further dilatation has been necessary.

  • View full-size image.
  • Fig. 3. 

    An image taken at microlaryngobronchoscopy 4 weeks following conventional balloon dilatation showing evidence of re-stenosis. Subglottic stenosis (Cotton grade 2) was diagnosed.

  • View full-size image.
  • Fig. 4. 

    An image taken at microlaryngobronchoscopy following dilatation with the Peripheral Cutting Balloon™ Microsurgical Dilatation Device. The incisions created by the microsurgical blades on the balloon are visible in the mucosa.

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4. Discussion 

The cutting balloon is a novel technique for dilatation of subglottic stenosis. The presence of the microsurgical blades on the balloon allows for more accurate and secure placement of the balloon at the level of the stenotic segment, preventing balloon migration with subsequent more precise dilatation of the affected area.

The cutting balloon produces longitudinal microsurgical incisions in the subglottic mucosa before dilatation. It has been reported in the vascular literature that these controlled surgical incisions induce less neutrophil activation, an indicator of less balloon-induced vessel wall injury and inflammatory reaction than conventional balloon angioplasty, reducing re-stenosis and improving long-term outcome [9], [10]. We suggest that the blades have a similar action on subglottic mucosa, inducing a smaller degree of mucosal wall injury localized to the area of the incisions and sparing the inter-incisional segments, thus re-stenosis is less likely. The blades are small enough not to excessively disrupt the mucosa, but sufficiently large to break tissue at the stenosis and allow dilatation in cases in which conventional balloons fail. The blades also concentrate the dilatation force allowing for greater dilatation at lower pressures, enabling more resistant stenoses to be overcome. The cutting balloon not only dilates the subglottic lumen, the microsurgical incisions also lengthen the circumference of the lumen giving a better result.

The cutting balloon should be used with caution when the stenosis begins immediately below the level of the vocal cords as the blades may cause trauma to the vocal cords. The upper limit of the balloon must be clearly identified with direct vision prior to inflation of the balloon to prevent inadvertent damage to the vocal cords. We routinely use the cutting balloon in cases where conventional balloon dilatation has failed. Despite the higher cost of the cutting balloon compared with conventional angioplasty balloons, we suggest that the cutting balloon has a role as first line treatment in subglottic dilatation and should not only be reserved for those cases where conventional balloon dilatation has failed.

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5. Conclusion 

We report a new technique of endoscopic dilatation of pediatric subglottic stenosis using the Peripheral Cutting Balloon™ Microsurgical Dilatation Device. This technique allows for more accurate dilatation of the subglottis under less pressure reducing the risk of circumferential scarring. Dilatation with the cutting balloon is particularly useful when conventional balloon dilatation has failed.

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Conflict of interest 

We wish to state that the authors have no personal or financial relationships with the products or organizations mentioned in this manuscript.

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Acknowledgment 

We would like to thank Dr. Kevin Walsh, Consultant Cardiologist at Our Lady's Hospital for Sick Children in Crumlin, Dublin, Ireland for introducing us to the cutting balloon and suggesting its use in the airway.

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References 

  1. McDonald IH, Stocks J. Prolonged nasotracheal intubation. Br. J. Anaesth. 1965;37:161–165
  2. Simpson GT, Strong MS, Healy GB. Predictive factors of success or failure in the endoscopic management of laryngeal and tracheal stenosis. Ann. Otol. Rhinol. Laryngol. 1982;91:384–388
  3. Rabhar R, Jones DT, Nuss RC, Roberson DW, Kenna MA, McGill TJ, et al. The role of Mitomycin in the prevention and treatment of scar formation in the pediatric aerodigestive tract: friend or foe?. Arch. Otolaryngol. Head Neck Surg. 2002;128(4):401–406
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  9. Inoue T, Sakai Y, Hoshi K, Yaguchi I, Fujito T, Morooka S. Lower expression of neutrophil adhesion molecule indicates less vessel wall injury and might explain lower re-stenosis rate after cutting balloon angioplasty. Circulation. 1998;97:2511–2518
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PII: S1871-4048(07)00077-9

doi:10.1016/j.pedex.2007.09.006

International Journal of Pediatric Otorhinolaryngology Extra
Volume 3, Issue 1 , Pages 39-43, January 2008

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