Cricotracheal resection in children weighing less than 10 kg

Case report: Idiopathic subglottic stenosis in a girl; successful treatment with macrolides

An 8-year-old girl presented with treatment-refractory cough and inspiratory stridor. Bronchoscopies showed progressive scarring leading to narrowing of the proximal trachea (Myer-Cotton Grade 2) and epithelial metaplasia of the tracheal and bronchial mucosa. After excluding other causes of congenital and acquired tracheal stenosis, an idiopathic subglottic tracheal stenosis (iSGS) was diagnosed. Because of the patient's young age, a judicious therapeutic approach seemed appropriate. Therapy with azithromycin, followed by roxithromycin, was started. Symptoms almost completely subsided, spirometry normalized, and endoscopic and histologic findings improved considerably. Therapy has been continued for more than 3 years with normal lung function values, and no compromise on physical activities and development. In instances of iSGS, therapy with macrolides is worth considering before more invasive procedures such as dilatation, laser, intralesional injections, or surgical resection are performed.

Subglottic Stenosis in Children: Preliminary Experience from a Tertiary Care Hospital

INTRODUCTION

This retrospective study describes our experience in the evaluation and management of infants with subglottic stenosis.

MATERIALS AND METHODS

The study included 10 patients aged between 1 wk and 18 months with 6 cases having congenital subglottic stenosis and 4 cases having acquired subglottic stenosis.

RESULTS

6 patients had grade I, 3 patients had grade II, and 1 patient had grade III subglottic stenosis. Tracheostomy was required in 4 patients at the time of presentation. 7 patients were treated successfully with Bougie dilation followed by topical application of mitomycin, whereas 1 patient who failed to serial dilation needed open reconstructive procedure. Laser excision of the anterior subglottic web was performed in one patient. Another patient with underlying cerebral palsy could not be operated upon and was managed with tracheostomy.

CONCLUSION

Subglottic stenosis may be effectively man-aged with endoscopic surgical techniques, although the number of such sittings required varies with the type and severity of stenosis. Open surgical procedures need to be individualised as per the needs of the patient only after all the other endoscopic possibilities have been exhausted.

Endoscopic Preoperative Assessment, Classification of Stenosis, Decision-Making

Pediatric Laryngo-Tracheal Stenosis (LTS) comprises different conditions that require precise preoperative assessment and classification. According to the guidelines, the optimal diagnostic work-up of LTS patients relies both on a comprehensive anamnesis and on endoscopic and radiological assessments. All the causes of LTS result in an impairment in airflow, mucociliary clearance, phonation, and sometimes in swallowing disorders. The main goals of treatment are to maintain an adequate respiratory space and restore the Upper Aero-Digestive Tract (UADT) physiology. The first step when dealing with LTS patients is to properly assess their medical history. The main causes of pediatric LTS can be divided into two groups, i.e., congenital and acquired. The most common causes of congenital LTS are: laryngomalacia (60%), vocal fold paralysis (15-20%), subglottic stenosis (SGS) (10-15%), laryngeal webs and atresia (5%), subglottic hemangioma (1.5-3%), and others. On the other hand, 90% of acquired pediatric LTS cases are subsequent to post-intubation injuries. Other less frequent causes are: iatrogenic complications from endoscopic laryngeal interventions, benign tumors, caustic or thermal injuries, external blunt force injury or trauma, chronic inflammatory disorders, or idiopathic causes. Diagnostic work-up consists in a step-by-step investigation: awake and asleep transnasal fiberoptic laryngoscopy (TNFL), direct laryngoscopy with 0° and angled telescopes to investigate the type of stenosis (arytenoid mobility, craniocaudal extension, involved anatomical sites, and active or mature scar tissue), and broncho-esophagoscopy to rule out associated mediastinal malformations. To date there are several available classifications for each of the involved sites: Cohen's classification for anterior glottic stenosis, Bogdasarian's for posterior glottic stenosis (PGS) and Myer-Cotton's for subglottic stenosis, even though others are used in daily practice (Lano-Netterville, FLECS, etc.). The European Laryngological Society recently proposed a new classification which is applicable in all LTS cases. In this chapter we deal with preoperative assessment and staging, reviewing the most relevant classifications applicable in patients affected by LTS, conditio sine qua non in order to tailor the best treatment modality to each subject. We'll also detail the comprehensive radiological, endoscopic and functional assessment for the correct use of each staging classification.

Pediatric airway reconstruction: results after implementation of an airway team in Brazil

INTRODUCTION

Since development of pediatric intensive care units, children have increasingly and appropriately been treated for complex surgical conditions such as laryngotracheal stenosis. Building coordinated airway teams to achieve acceptable results is still a challenge.

OBJECTIVE

To describe patient demographics and surgical outcomes during the first 8years of a pediatric airway reconstruction team.

METHODS

Retrospective chart review of children submitted to open airway reconstruction in a tertiary university healthcare facility during the first eight years of an airway team formation.

RESULTS

In the past 8 years 43 children underwent 52 open airway reconstructions. The median age at surgery was 4.1 years of age. Over half of the children (55.8%) had at least one comorbidity and over 80% presented Grade III and Grade IV subglottic stenosis. Other airway anomalies occurred in 34.8% of the cases. Surgeries performed were: partial and extended cricotracheal resections in 50% and laryngotracheoplasty with anterior and/or posterior grafts in 50%. Postoperative dilatation was needed in 34.15% of the patients. Total decannulation rate in this population during the 8-year period was 86% with 72% being decannulated after the first procedure. Average follow-up was 13.6 months. Initial grade of stenosis was predictive of success for the first surgery (p=0.0085), 7 children were submitted to salvage surgeries. Children with comorbidities had 2.5 greater odds (95% CI 1.2-4.9, p=0.0067) of unsuccessful surgery. Age at first surgery and presence of other airway anomalies were not significantly associated with success.

CONCLUSIONS

The overall success rate was 86%. Failures were associated with higher grades of stenosis and presence of comorbidities, but not with patient age or concomitant airway anomalies.

Cricotracheal Resection in Children 2 Years of Age and Younger

Objectives

We examine the surgical outcomes of cricotracheal resection in children 2 years of age and younger.

Methods

We performed a retrospective case study involving a single tertiary care children's hospital. All patients who underwent cricotracheal resection from 1993 through January 2006 were included. Patients 2 years old and younger were compared to patients more than 2 years of age (range, 2 to 44 years). The primary outcomes measured were decannulation and complication rates. We used X2 analyses for categorical variables to detect differences in proportions, Student's t-tests for continuous data, and logistical regression to explore for confounding. Significance was set at α = .05, 2-tailed.

Results

Fifteen children 2 years of age or younger were identified. Most patients underwent a single-stage operation (n = 12). The overall decannulation rate was 87% (2 failures). Two patients younger than 2 years had postoperative complications, including 1 patient who developed anastomosis dehiscence. When compared to the patients over 2 years of age, patients younger than 2 were more likely to undergo a single-stage procedure (p < .01). Additionally, the cricotracheal resection was more likely to be their first attempt at airway reconstruction (p = .002). Complication and decannulation rates were similar in both groups.

Conclusions

Cricotracheal resection can be performed safely and effectively in children less than 2 years old.

Pathologies of the larynx and trachea in childhood

Pathologies in the larynx and trachea in the pediatric age can be characterized in 4 main groups: airway stenosis, acute infections, benign neoplasia and foreign body aspiration. In this review main diagnostic strategies and therapeutic options are presented. Laryngomalazia is the most frequent condition of supraglottic stenosis. The term supraglottoplasty summarizes all different techniques used for it's repair using an endoscopic approach. Glottic stenosis is rare in children. Usually a compromise between voice preservation and airway restoration has to be sought. Type of reconstruction and timing are varying considerably in individual cases, endoscopic approaches should be preferred. Subglottic stenosis remains the largest group in paediatric airway pathology, with cicatrial stenosis being predominant. Today, cricotracheal resection is the most successful treatment option, followed by the classical laryngotracheal reconstruction with autologous cartilage. In early infancy subglottic stenosis is particularly demanding. Endoscopic treatment is possible in selected patients, but open reconstruction is superior in more severe cases. Tracheostomy is not a safe airway in early infancy, it's indication should be strict. Foreign body aspiration needs to be managed according to a clear algorhythm. Recurrent respiratory papillomatosis should be treated with emphasis on function preservation. The role of adjuvant medication remains unclear. Infectious diseases can be managed conservatively by a pediatrician in the majority of cases.

[Subglottic stenosis in the first year of life. Characteristics and treatment options]

Subglottic stenosis of congenital origin or acquired within the first 12 months of life are challenging in many aspects. Surgical reconstruction is difficult due to the small anatomic dimensions. Tracheostomy is an additional risk factor attributing to mortality and should be avoided, if possible. In this paper, the most important types of subglottic stenosis in the first year of life are discussed. Conservative, endoscopic, and open surgical treatment options are presented and evaluated. Laryngotracheal reconstruction with autologous thyroid cartilage is the treatment of choice for the majority of significant subglottic stenosis cases in this age group. This technique is comparatively less invasive, versatile, and allows all options for open reconstruction using other techniques in case of recurrent stenosis. Subglottic stenosis in early infancy requires expertise and experience in diagnosis and treatment. Considering the limited incidence, these cases should be managed in a referral center.

Gaslini's tracheal team: preliminary experience after one year of paediatric airway reconstructive surgery

BACKGROUND

Congenital and acquired airway anomalies represent a relatively common albeit challenging problem in a national tertiary care hospital. In the past, most of these patients were sent to foreign Centres because of the lack of local experience in reconstructive surgery of the paediatric airway. In 2009, a dedicated team was established at our Institute. Gaslini's Tracheal Team includes different professionals, namely anaesthetists, intensive care specialists, neonatologists, pulmonologists, radiologists, and ENT, paediatric, and cardiovascular surgeons. The aim of this project was to provide these multidisciplinary patients, at any time, with intensive care, radiological investigations, diagnostic and operative endoscopy, reconstructive surgery, ECMO or cardiopulmonary bypass. Aim of this study is to present the results of the first year of airway reconstructive surgery activity of the Tracheal Team.

METHODS

Between September 2009 and December 2010, 97 patients were evaluated or treated by our Gaslini Tracheal Team. Most of them were evaluated by both rigid and flexible endoscopy. In this study we included 8 patients who underwent reconstructive surgery of the airways. Four of them were referred to our centre or previously treated surgically or endoscopically without success in other Centres.

RESULTS

Eight patients required 9 surgical procedures on the airway: 4 cricotracheal resections, 2 laryngotracheoplasties, 1 tracheal resection, 1 repair of laryngeal cleft and 1 foreign body removal with cardiopulmonary bypass through anterior tracheal opening. Moreover, in 1 case secondary aortopexy was performed. All patients achieved finally good results, but two of them required two surgeries and most required endoscopic manoeuvres after surgery. The most complex cases were the ones who had already been previously treated.

CONCLUSIONS

The treatment of paediatric airway anomalies requires a dedicated multidisciplinary approach and a single tertiary care Centre providing rapid access to endoscopic and surgical manoeuvres on upper and lower airways and the possibility to start immediately cardiopulmonary bypass or ECMO.The preliminary experience of the Tracheal Team shows that good results can be obtained with this multidisciplinary approach in the treatment of complicated cases. The centralization of all the cases in one or few national Centres should be considered.

Endoscopic anterior cricoid split and balloon dilation in pediatric subglottic stenosis

OBJECTIVES

To analyze the outcome of a new endoscopic approach for the treatment of pediatric subglottic stenosis.

STUDY DESIGN

Case series.

SETTING

Tertiary care center.

MATERIAL AND METHODS

Eighteen pediatric cases of grade II to IV subglottic stenosis (8 congenital and 10 acquired) consecutively treated at our institutions by Endoscopic Anterior Cricoid Split (EACS) and balloon dilation between 2006 and 2010. Treatment protocol encompassed systematic postoperative laryngeal stenting (7 days of intubation or 1 month of Montgomery T-tube in previously tracheotomized patients) and endoscopic controls with possible additional balloon dilation every 15 days for at least 2 months.

RESULTS

Patients' ages ranged from 1 to 101 months. Postoperative follow-up ranged from 4 to 45 months (median value±SD: 15.3±11.9). The mean duration of the endoscopic procedure was 35.2±13.2 min. The number of days spent in PICU during the perioperative period varied between 2 and 15. Four patients (22.2%) needed one and 14 patients (77.7%) required several (from 4 to 7) additional balloon dilations during the postoperative endoscopic controls. No incident was observed during or immediately after EACS. Treatment was efficient in 83% of cases (n=15), with no residual respiratory symptoms and grade 0 to 1 SGS at the end of follow-up.

CONCLUSION

EACS is a safe and efficient technique to treat pediatric subglottic stenosis, regardless of their grade and length, provided to associate it with postoperative laryngeal stenting and regular endoscopic follow-up with possible additional balloon dilations. In our teams, it has become the first line treatment for most grades II to IV SGS. Its indications can be extended to congenital stenosis with cartilaginous involvement and to long-lasting acquired stenosis with firm fibrosis.

Partial Cricotracheal Resection in Children Weighing Less than 10 Kilograms

OBJECTIVES: To assess the long-term outcome, safety, and efficacy of partial cricotracheal resection (PCTR) for subglottic stenosis in a group of children and infants weighing less than 10 kg at the time of the surgery.

STUDY DESIGN: Historical cohort study.

SETTING: Academic tertiary medical center.

SUBJECTS AND METHODS: Thirty-six children weighing less than 10 kg at the time of the surgery were compared to a group of 65 children who weighed more than 10 kg. The Kaplan Meier method and Cox regression were carried out to detect differences in decannulation time and rates and to examine the influence of various parameters (i.e., comorbidities, type of surgery, and complications requiring revision surgery) at the time of decannulation. Evaluation of the long-term outcome was based on questionnaires assessing breathing, voice, and swallowing.

RESULTS: Decannulation rate was 92 percent (33/36) for the group of children weighing less than 10 kg. No significant differences were found between the two body weight groups with respect to the aforementioned covariates. The median follow-up period was nine years (range, 1–23 yrs). Questionnaire responses revealed completely normal breathing and swallowing in 72 percent and 90 percent of the children, respectively. Seventy-one percent of the patients considered their voice to be rough or weak.

CONCLUSION: PCTR in infants and children weighing less than 10 kg is a safe and efficient technique with similar long-term results when compared to results seen in older and heavier children.