Sonia Ayari

Cidofovir plasma assays after local injection in respiratory papillomatosis

Objective: To assess cidofovir plasma concentration after intralesional airway administration for recurrent respiratory papillomatosis.

Natural History of Adult-Onset Laryngeal Papillomatosis following Multiple Cidofovir Injections:

Objectives: A prospective study was performed to assess the intermediate and long-term efficacy of intralesional cidofovir therapy associated with surgical excision in laryngeal papillomatosis in adults. Methods: Endoscopy with intralesional injection of cidofovir 5 mg/mL was performed 3 times at 4-week intervals. The concentration was later increased to 7.5 mg/mL and the interval between injections shortened to 2 weeks. Further treatment was performed at 3 or 6 months, depending on the evolution of the papillomas. After complete remission, the treatment was stopped and the patients were reviewed every 6 months. Results: Nineteen patients completed the protocol, with a mean of 4.5 injections each. Complete remission was obtained in 17 cases (89%) after a mean of 3.8 procedures. Remission was stable after a mean follow-up of 24 months (range, 8 to 57 months). With higher cidofovir concentrations at shorter intervals, patients needed fewer injections to achieve remission (mean, 2.1 versus 4.7 injections). Conclusions: The effectiveness of intralesional cidofovir therapy in adult-onset recurrent respiratory papillomatosis was impressive. Once obtained, complete remission was stable on intermediate or long-term follow-up. The concentration and the interval between injections seemed to influence the number of injections necessary to achieve remission.

Pathophysiology and diagnostic approach to laryngomalacia in infants

Laryngomalacia is defined as collapse of supraglottic structures during inspiration. It is the most common laryngeal disease of infancy. Laryngomalacia presents in the form of stridor, a high-pitched, musical, vibrating, multiphase inspiratory noise appearing within the first 10 days of life. Signs of severity are present in 10% of cases: poor weight gain (probably the most contributive element), dyspnoea with permanent and severe intercostal or xyphoid retraction, episodes of respiratory distress, obstructive sleep apnoea, and/or episodes of suffocation while feeding or feeding difficulties. The diagnosis is based on systematic office flexible laryngoscopy to confirm laryngomalacia and exclude other causes of supraglottic obstruction. Rigid endoscopy under general anaesthesia is only performed in the following cases: absence of laryngomalacia on flexible laryngoscopy, presence of laryngomalacia with signs of severity, search for any associated lesions prior to surgery, discrepancy between the severity of symptoms and the appearance on flexible laryngoscopy, and/or atypical symptoms (mostly aspirations). The work-up must be adapted to each child; however, guidelines recommend objective respiratory investigations in infants presenting signs of severity.

Management of laryngomalacia

Laryngomalacia is the most common laryngeal disease of infancy. It is poorly tolerated in 10% of cases, requiring assessment and management, generally surgical. Surgery often consists of supraglottoplasty, for which a large number of technical variants have been described. This surgery, performed in an appropriate setting, relieves the symptoms in the great majority of cases with low morbidity. However, few data are available concerning the objective results: preoperative and postoperative objective assessment of these infants is therefore necessary whenever possible. Noninvasive ventilation (NIV) may be indicated in some infants with comorbid conditions or failing to respond to surgical management.

Minimizing surgical management through the use of adjuvant medical therapies

INTRODUCTION Much has been achieved since the introduction of laryngotracheoplasty for surgical correction of subglottic stenosis of the larynx in infants and children in 1974. Current techniques include both open and endoscopic surgical approaches, with the aim of avoiding tracheostomy and decreasing the time to decannulation. Concurrent advancements have focused on preserving both respiration and voice. Adjuvant pharmacotherapy has changed the management of a number of otolaryngologic conditions. For example, a major step forward was achieved when propranolol was reported to induce the regression of proliferating hemangiomas, including those affecting the airway. Over the past two decades, the management of this vascular anomaly has gone from a wait-and-see approach, including tracheostomy until sufficient involution occurred, to surgical excision (both open and endoscopic), to administering propranolol. Although the same degree of improvement has not yet been achieved in other conditions affecting the airway, outcomes have been improved by combining surgery and medications. Mitomycin-C has been used to limit recurrence of scar tissue, whereas cidofovir has been used to control papillomatosis.