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Coblation-assisted Excision of Suprastomal Granulation Tissue. The Journal of Laryngology & Otology 2021; 136:930-933. [PMID: 34583797 DOI: 10.1017/s0022215121002589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Koizumi M, Ishimaru M, Matsui H, Fushimi K, Yamasoba T, Yasunaga H. Factors associated with the occurrence of stomal stenosis after tracheostomy in adults. Auris Nasus Larynx 2021; 48:973-977. [PMID: 33926785 DOI: 10.1016/j.anl.2021.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/21/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Although tracheal stomal stenosis can be life-threatening, factors associated with the occurrence of stomal stenosis remain unknown. This study was performed to evaluate these factors in adult patients. METHODS We retrospectively identified adult patients who underwent tracheostomy from 2010 to 2016 using a Japanese national inpatient and outpatient database. We performed Cox proportional hazard regression analyses to evaluate factors associated with the occurrence of tracheal stomal stenosis. RESULTS We obtained data on 25,436 eligible patients. The proportion of tracheal stomal stenosis was 0.9%. Tracheal stomal stenosis was significantly less likely to occur in patients with regular use of oral steroids [hazard ratio (HR), 0.28; 95% confidence interval (CI), 0.09-0.88; P = 0.03] and in male patients (HR, 0.75; 95% CI, 0.57-0.97; P = 0.03). The occurrence of tracheal stomal stenosis was significantly associated with use of a mechanical ventilator at home (HR, 2.54; 95% CI, 1.55-4.15; P < 0.001) and a body mass index of <18.5 kg/m2 (HR, 1.45; 95% CI, 1.06-1.99; P = 0.02). CONCLUSION Our study revealed several factors that are associated with tracheal stomal stenosis. These findings may help physicians to manage tracheal stomas.
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Affiliation(s)
- Megumi Koizumi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Department of Otolaryngology and Head and Neck Surgery, Sanraku Hospital, 2-5 Kandasurugadai, Chiyoda-ku, Tokyo 101-8326, Japan.
| | - Miho Ishimaru
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Tatsuya Yamasoba
- Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population. Int J Pediatr Otorhinolaryngol 2020; 139:110427. [PMID: 33120101 DOI: 10.1016/j.ijporl.2020.110427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/03/2020] [Accepted: 10/03/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation. OBJECTIVE Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy. METHODS Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method. RESULTS Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: CONCLUSION: This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.
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Onder SS, Ishii A, Sandu K. Surgical options in suprastomal collapse-induced severe airway obstruction. Eur Arch Otorhinolaryngol 2020; 277:3415-3421. [PMID: 32914258 PMCID: PMC7647974 DOI: 10.1007/s00405-020-06339-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 08/28/2020] [Indexed: 11/30/2022]
Abstract
Purpose A single institutions experience with various surgical options in the treatment of severe suprastomal collapse (SSC). Methods The study included 18 tracheostomized children with SSC treated between January 2012 and December 2018. Data included: patient demography, initial airway lesions, comorbidities, indication and age at tracheostomy, prior airway surgery, stomal demography, type of surgery, postoperative management, complications and treatment outcomes. Results Four techniques were used to correct SSC. The surgical choice was dependent on stoma demography and associated airway lesions. Excision was done in eight patients and rib cartilage augmentation in five. Three patients had single stage tracheal resection and anastomosis. Two patients received stomal rigidification and temporary placement of Montgomery T tube. Three patients with anterior rib graft augmentation required additional lateral tracheal wall rigidification. Three patients (two with cartilage augmentation, and one with stomal rigidification) developed minimal granulation tissue in the postoperative period. Complete SSC resolution was seen in all except two patients who had a partial response to the treatment. All patients were successful decannulated and are currently asymptomatic. Conclusion Decannulation failures may be due to severe suprastomal collapse that could be either unique or associated with obstructing laryngotracheal lesions. Therefore, it is essential to select the most appropriate surgical treatment to obtain overall favorable outcomes. Electronic supplementary material The online version of this article (10.1007/s00405-020-06339-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Serap Sahin Onder
- University of Health Science Umraniye Education and Research Hospital, Istanbul, Turkey
| | - A Ishii
- Lausanne University Hospital, Lausanne, Switzerland
| | - K Sandu
- Lausanne University Hospital, Lausanne, Switzerland.
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Surgical management of suprastomal tracheal collapse in children. Int J Pediatr Otorhinolaryngol 2019; 118:188-191. [PMID: 30641306 DOI: 10.1016/j.ijporl.2019.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/06/2019] [Accepted: 01/06/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Suprastomal collapse is a complication of pediatric tracheotomy with a potential impact on decannulation success. The aim of this study was to review the experience in the management of pediatric suprastomal collapse in a tertiary-care center, detailing the surgical technique employed. METHODS This study included 12 tracheotomised children with the diagnosis of suprastomal collapse in the last 5 years. All patients of the study underwent surgical intervention to manage suprastomal collapse to achieve tracheotomy decannulation. The surgical procedure entailed dissection of the pre-existing tracheotomy tract down to the trachea, then excision of the tract flush with the anterior tracheal wall. The tracheal opening was closed transversely with 3-4 interrupted absorbable sutures placed in craniocaudal direction. RESULTS At the end of treatment all patients were decannulated successfully. No intraoperative complications were reported. Minor postoperative complications were reported in 3 children in the form of mild surgical emphysema (n = 2) and wound infection (n = 1). Those patients were successfully managed conservatively. CONCLUSION This technique is a simple and effective procedure enabling immediate decannulation with very low morbidity. In a long term follow up period, no recurrence has been reported and all patients returned to their usual quality of life.
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Abstract
OBJECTIVES This study was aimed to evaluate the utility and benefits of flexible fiberoptic bronchoscopy (FFB) prior to tracheostomy decannulation. METHODS Besides demographic data, initial cause of tracheostomy, primary diagnosis, pre-tracheostomy and pre-decannulation bronchoscopic findings and duration of tracheostomy were collected from medical charts. The type of active intervention following bronchoscopy and outcome after decannulation were recorded. Departmental decannulation policy and procedure were used in all patients. RESULTS Forty-nine tracheostomized patients who underwent decannulation attempt were included. The median age of the children at the time of decannulation was 3 years (range 4 months-16 years). The median duration of tracheostomy was 8 months (range 1-86 months). Prolonged mechanical ventilation was the commonest indication for tracheostomy. There were 45 abnormal findings on FFB in 36 patients. Airway granulation was the commonest abnormality (23/45, 51%). Successful decannulation without any intervention was possible in 23 (46.9%) cases. 12 of these had normal bronchoscopy. Fifteen (30.6%) patients required surgical interventions before attempting decannulation. In five patients decannulation failed, while in six children decannulation was not attempted after FFB. CONCLUSION Pre-decannulation flexible fiberoptic bronchoscopy in children with tracheostomy helps in identifying the possible causes of decannulation failure and helps in deciding the appropriate intervention.
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Brown CS, Ryan MA, Ramprasad VH, Karas AF, Raynor EM. Coblation of suprastomal granulomas in tracheostomy-dependent children. Int J Pediatr Otorhinolaryngol 2017; 96:55-58. [PMID: 28390614 PMCID: PMC5433249 DOI: 10.1016/j.ijporl.2017.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Suprastomal granulomas pose a persistent challenge for tracheostomy-dependent children. They can limit phonation, cause difficulty with tracheostomy tube changes and prevent decannulation. We describe the use of the coblator for radiofrequency plasma ablation of suprastomal granulomas in five consecutive children from September 2012 to January 2016. METHOD Retrospective case series at a tertiary medical center. RESULTS The suprastomal granuloma could be removed with the coblator in all 5 cases. Three were removed entirely endoscopically and 2 required additional external approach through the tracheal stoma for complete removal. There were no intraoperative or postoperative complications. One patient was subsequently decannulated and 2 patients have improved tolerance of their speaking valves. Two patients remain ventilator dependent, but their bleeding and difficulty with tracheostomy tube changes resolved. Three of the patients have had subsequent re-evaluation with bronchoscopy, demonstrating resolution or markedly decreased size of the granuloma. This technique is time efficient, simple and minimizes risks associated with other techniques. The relatively low temperature and use of continuous saline irrigation with the coblator device minimizes the risk of airway fires. Additionally, the risk of hypoxia from keeping a low fractional inspiratory oxygen level (FIO2) to prevent fire is avoided. The concurrent suction in the device decreases blood and tissue displacement into the distal airway. CONCLUSION Coblation can be used safely and effectively with an endoscopic or external approach to remove suprastomal granulomas in tracheostomy-dependent children. More studies that are larger and have longer follow-up are needed to evaluate the use of this technique.
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Affiliation(s)
- C Scott Brown
- Duke University Medical Center, Division of Otolaryngology-Head and Neck Surgery & Communication Sciences, Department of Surgery, 40 Duke Medicine Circle, DUMC 3805, Durham, NC 27710, USA.
| | - Marisa A. Ryan
- Duke University Medical Center, Division of Otolaryngology-Head and Neck Surgery & Communication Sciences, Department of Surgery. 40 Duke Medicine Circle, DUMC 3805, Durham, NC 27710, USA
| | - Vaibhav H. Ramprasad
- Duke University School of Medicine, 8 Duke University Medical Center Greenspace, Durham, NC 27703, USA
| | - Anatoli F. Karas
- Duke University Medical Center, Division of Otolaryngology-Head and Neck Surgery & Communication Sciences, Department of Surgery. 40 Duke Medicine Circle, DUMC 3805, Durham, NC 27710, USA
| | - Eileen M. Raynor
- Duke University Medical Center, Division of Otolaryngology-Head and Neck Surgery & Communication Sciences, Department of Surgery. 40 Duke Medicine Circle, DUMC 3805, Durham, NC 27710, USA
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Gupta A, Cotton RT, Rutter MJ. Pediatric Suprastomal Granuloma: Management and Treatment. Otolaryngol Head Neck Surg 2016; 131:21-5. [PMID: 15243552 DOI: 10.1016/j.otohns.2004.02.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE: Suprastomal granulomas (SSG) are a common complication of pediatric tracheotomy. Occasionally excision is indicated for obstructive granulomas. We report on our experience on the management of SSG requiring excision. STUDY DESIGN AND SETTING: A retrospective chart review of 68 patients who underwent SSG excision at a tertiary referral pediatric hospital between July 1997 and November 2002. The medical charts were reviewed for excision techniques and outcomes. RESULTS: A total of 106 excisions of SSG were performed on 68 patients. Of the patients, 25 (36.8%) required multiple excisions. Removal techniques included sphenoid punch (34.9%), optical forceps (34.0%), open excision (22.6%), electrocautery (4.7%), and hook and eversion (3.8%). CONCLUSION: The majority of SSG do not require removal. If excision is indicated, we recommend using optical forceps for soft and friable lesions and the sphenoid punch for fibrous and firm granulomas. For granulomas that have a broad base, are very large, or where endoscopic instrumentation is not possible, we recommend open excision.
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Affiliation(s)
- Akash Gupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Managing dysphonia in paediatric patients with complex airway conditions. The Journal of Laryngology & Otology 2015; 129:820-4. [PMID: 26080854 DOI: 10.1017/s0022215115001553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To suggest a phonosurgical management strategy that can be used for children who have previously undergone laryngotracheal reconstruction. METHODS This cases series describes three children who presented with complex, multi-level airway stenosis and marked dysphonia. Phonosurgical intervention involved endoscopic and open approaches, and was combined with voice therapy. A phonosurgical reconstruction management algorithm is suggested for evaluating and treating these complex conditions. RESULTS Pre-operative assessment is critical, and should involve voice analysis and glottal anatomy assessment using office laryngoscopy and stroboscopy. The risks must be weighed up against the benefit of vocal improvement. Surgical intervention should involve combined endoscopic and open approaches. CONCLUSION Voice restoration after paediatric airway reconstruction is a complex challenge. Surgical intervention should be conducted in a step-by-step manner to reduce the risk of worsening dysphonia and airway compromise. The risks and benefits must be carefully explored and discussed.
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Mathur NN, Sohliya LM. Pre-decannulation Peristomal Findings in Tracheostomized Cases and Their Effect on the Success of Decannulation. Indian J Otolaryngol Head Neck Surg 2014; 67:91-7. [PMID: 25621261 DOI: 10.1007/s12070-014-0785-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/15/2014] [Indexed: 11/25/2022] Open
Abstract
Decannulating a patient on a tracheostomy is a procedure that has to be dealt with vigilantly. This study evaluated both external and telescopic/bronchoscopic findings at the peristomal level of subjects being considered for decannulation. The patients did not undergo any intervention after above observations and before attempting decannulation. Thereafter peristomal findings and their contribution towards failure to decannulate were correlated. Thirty subjects were studied prospectively, of whom 21 (70 %) demonstrated peristomal complications including granulation tissue, ulceration, mucopurulent discharge, suprastomal granulations, suprastomal collapse and suprastomal flap. Complications were more common in the younger age group (p = 0.007) as well as in tracheostomies of longer duration with mean duration >20 months (p = 0.045). However there was no statistically significant correlation between the success of decannulation and various peristomal findings. Therefore the success of decannulation in a particular case cannot always be correctly predicted by peristomal assessment.
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Affiliation(s)
- N N Mathur
- VMMC & Safdarjung Hospital, #456, OPD Block, New Delhi, 110029 India
| | - L M Sohliya
- VMMC & Safdarjung Hospital, #456, OPD Block, New Delhi, 110029 India
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Hammoudeh J, Bindingnavele VK, Davis B, Davidson Ward SL, Sanchez-Lara PA, Kleiber G, Mobin SSN, Francis CS, Urata MM. Neonatal and Infant Mandibular Distraction as an Alternative to Tracheostomy in Severe Obstructive Sleep Apnea. Cleft Palate Craniofac J 2012; 49:32-8. [DOI: 10.1597/10-069] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Context Surgical management for severe obstructive sleep apnea has been tracheostomy, which has significant morbidity. Objective To determine the efficacy of internal mandibular distraction in treating severe obstructive sleep apnea in infants and neonates. Design Retrospective review of medical records of 29 patients who underwent internal mandibular distraction for obstructive sleep apnea secondary to micrognathia. Setting Nonprofit, academic, pediatric medical center. Patients A total of 29 infants with obstructive sleep apnea were studied. Nine were included in the respiratory failure group requiring intubation prior to distraction surgery. The other 20 were included in the respiratory distress group and underwent preoperative polysomnography that assessed the severity of obstructive sleep apnea as measured by the apnea-hypopnea index. One patient expired following surgery; the remaining 28 underwent postoperative polysomnography determining their postoperative apnea-hypopnea index. Interventions Bilateral mandibular distraction with internal microdistractors. Main Outcome Measure Improvement in the apnea-hypopnea index or extubation. Results The nine respiratory failure patients avoided tracheostomy and were successfully extubated postdistraction. Eight in this group had postoperative polysomnographies showing a mean apnea-hypopnea index of 3.13 (range, 0 to 13.9). All 20 patients in the respiratory distress group underwent polysomnography and showed improved apnea-hypopnea indices ( p < .001). The mean pre-op apnea-hypopnea index was 39.7 (range, 4.5 to 177), and the mean post-op apnea-hypopnea index was 5.8 (range, 0 to 34). Average improvement in the apnea-hypopnea index was 33.9. The mean follow-up period was 18.7 months (1.6 to 45.2 months). Conclusions Infants with micrognathia and obstructive sleep apnea may avoid tracheostomy and its inherent risks and complications by undergoing internal mandibular distraction, which is a viable alternative to tracheostomy.
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Affiliation(s)
- Jeffrey Hammoudeh
- Keck School of Medicine, University of Southern California (USC), and Director–Jaw Deformities, Children's Hospital Los Angeles (CHLA), Los Angeles, California
| | | | - Brian Davis
- University of California Los Angeles, Los Angeles, California
| | - Sally L. Davidson Ward
- Keck School of Medicine, University of Southern California, and Division Head for Pediatric Pulmonology and Medical Director, Sleep Laboratory, Children's Hospital Los Angeles, Los Angeles, California
| | - Pedro A. Sanchez-Lara
- Keck School of Medicine, University of Southern California, and Director of Craniofacial Genetics at Children's Hospital Los Angeles, Los Angeles, California
| | - Grant Kleiber
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Cameron S. Francis
- Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Mark M. Urata
- Keck School of Medicine, University of Southern California, and Division Head, Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California
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Kitsko DJ, Chi DH. Coblation removal of large suprastomal tracheal granulomas. Laryngoscope 2009; 119:387-9. [PMID: 19172629 DOI: 10.1002/lary.20035] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Dennis J Kitsko
- Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Surgical management of severe suprastomal cricotracheal collapse complicating pediatric tracheostomy. Int J Pediatr Otorhinolaryngol 2008; 72:179-83. [PMID: 18001847 DOI: 10.1016/j.ijporl.2007.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Revised: 10/01/2007] [Accepted: 10/01/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Suprastomal tracheal collapse may interfere with decannulation in tracheostomized patients. The purposes of the study are to evaluate the role of tracheotomy technique in the ethiology of suprastomal cricotracheal collapse and to report our results in the treatment of this complication. METHODS A retrospective review of children showing severe suprastomal collapse during the period 1990-2007, in a tertiary care children's hospital, was performed. Medical records were assessed for the following data: sex, age, original indication for tracheotomy, surgical technique, endoscopic findings, type of surgical correction, complications, result, and follow-up. RESULTS Fourteen patients were included in the study, nine girls and five boys. Average age at tracheotomy was 17 months (range: 21 days-8 years), and prolonged ventilatory support was the most common indication (57%). Horizontal H-type tracheotomy was the most frequent technique in patients with suprastomal collapse (n=9), whereas only one patient with a vertical tracheotomy showed this complication (p<0.05). In every case bronchoscopy disclosed a suprastomal tracheal obstruction of at least 50% of the lumen. Mean age at surgical decannulation was 38 months (range: 12-147 months). Two surgical techniques have been used in the treatment of suprastomal collapse: anterior cricotracheal suspension (n=13) and reconstruction with autologous cartilage graft (n=1). All the patients were successfully decannulated although in one case two procedures were required. No recurrence has been observed during long-term follow-up (mean: 8.6 years). CONCLUSIONS Endoscopical examination is essential for the diagnosis of suprastomal collapse and to rule out other causes of decannulation failure. In our experience, the tracheotomy technique seems to have an ethiologic role, and anterior cricotracheal suspension is a simple and effective procedure in the treatment of this tracheostomy related complication.
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Dellweg D, Barchfeld T, Haidl P, Appelhans P, Kohler D. Tracheostomy decannulation: Implication on respiratory mechanics. Head Neck 2007; 29:1121-7. [PMID: 17685452 DOI: 10.1002/hed.20653] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Tracheostomy decreases airway resistance and work of breathing. No comprehensive data are available on respiratory mechanics after tracheostomy decannulation. We evaluated respiratory mechanics after decannulation. METHODS Twenty-five patients with tracheostomy were included. Measurement of arterial blood gases, air-flow, and esophageal pressure during spontaneous breathing were evaluated. RESULTS Overall arterial blood gas parameters as well as flow and pressure measurements including work of breathing and airway resistance were not affected by the intervention. Inspiratory time fraction increased from 40.0 + or - 0.04 to 43% + or - 0.05% (p = .007). We observed marked individual differences. Postdecannulation change in work of breathing is best predicted by change in airway resistance (R = 0.869, R(2) = 0.755, p < .0001) CONCLUSION Inspiratory time increased after decannulation, and arterial blood gas levels and respiratory mechanics did not change for the whole cohort. Individual changes in work of breathing are considerable and correlate closely to changes in airway resistance.
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Affiliation(s)
- Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft, Annostr. 1, 57392 Schmallenberg, Germany.
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Abstract
Long-term tracheostomy in infants and children is associated with significant morbidity. The majority of paediatric patients experience tracheostomy-related complications during cannulation and/or after decannulation. A large proportion of these complications are, however, preventable or may be minimised by good tracheostomy care and clinical evaluation of the patients at regular intervals, tailored to the needs of the individual child. By and large, infants and children benefit from a specialist tracheostomy service. In this article, we review different aspects of hospital-based care, covering a wide range of topics including the selection of tracheostomy tubes and adjuncts, clinical evaluation, speech/communication, and late complications and their prevention.
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Affiliation(s)
- Ernst Eber
- Respiratory and Allergic Disease Division, Paediatric Department, Medical University of Graz, Auenbruggerplatz 30, A-8036 Graz, Austria.
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Mandell DL, Yellon RF. Endoscopic KTP laser excision of severe tracheotomy-associated suprastomal collapse. Int J Pediatr Otorhinolaryngol 2004; 68:1423-8. [PMID: 15488975 DOI: 10.1016/j.ijporl.2004.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2004] [Revised: 06/14/2004] [Accepted: 06/25/2004] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the feasibility, safety, and clinical utility of potassium-titanium-phosphate (KTP) laser bronchoscopy for excision of severe, obstructing tracheotomy-associated suprastomal collapse. METHODS A retrospective review was performed of six children at a tertiary care children's hospital with severe tracheotomy-associated collapse of the suprastomal anterior tracheal wall cartilage, precluding decannulation. All subjects had undergone KTP laser endoscopic excision of the collapsed segment of suprastomal tracheal cartilage. Medical records were assessed for: (1) endoscopic demonstration of relief of suprastomal collapse, and (2) successful tracheotomy decannulation. RESULTS All six patients had endoscopic evidence of relief of suprastomal airway obstruction after KTP laser therapy. Five of six (83%) subsequently underwent successful decannulation. There was one case of minimal thermal airway injury associated with a laser fire during use of the KTP laser, the effects of which were fortunately transient. CONCLUSIONS KTP laser bronchoscopic excision of severe tracheotomy-associated suprastomal collapse: (1) is a feasible technique; (2) results in relief of suprastomal obstruction with subsequent successful decannulation in selected patients; and (3) avoids the need for more extensive open neck procedures. However, risks of KTP laser therapy are not negligible and strategies must be in place to minimize the occurrence of complications.
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Affiliation(s)
- David L Mandell
- Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Eliashar R, Gross M, Attal P, Hocwald E, Sichel JY. "Starplasty" prevents tracheotomy complications in infants. Int J Pediatr Otorhinolaryngol 2004; 68:325-9. [PMID: 15129943 DOI: 10.1016/j.ijporl.2003.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The average age of children undergoing tracheotomy has declined over the years and the indications for tracheotomy have changed from acute airway obstruction due to infection, to treatment of chronically ill children. Tracheotomy-related complication rates are more numerous in younger children and in certain cases have proved to be fatal. A variety of operative techniques have been advocated for reducing the rate of tracheotomy-related morbidity and mortality. This manuscript reports on our experience with a new technique--starplasty tracheotomy (SPT)--and assesses the value of this procedure in preventing tracheotomy-related complications in infants (under 6 months old), in whom complications are more frequent and more dangerous. METHODS Children less than 6 months old who underwent tracheotomy in the Department of Otolaryngology/Head and Neck Surgery, Hadassah University Hospital, Jerusalem, between the years 1999 and 2003 were studied. They were divided into two groups according to the surgical technique preferred and performed by the senior surgeon on call. Children in group 1 underwent tracheotomy by means of a regular technique and children in group 2 underwent SPT. All events related to the tracheotomy were recorded and a comparison was made between the two groups. RESULTS Eleven of a total of 26 pediatric tracheotomy patients were less than 6 months old. Five underwent regular tracheotomy (RT) and six underwent SPT. Three complications were encountered in the RT group and none in the SPT group. Accidental decannulation and failure to re-insert the cannula resulted in severe hypoxemic brain damage in one patient with RT. No tracheotomy-related deaths occurred. CONCLUSION Our experience supports the existing data regarding the superiority of SPT over RT in preventing dangerous tracheotomy-related complications in infants. We, therefore, recommend performing SPT in all infants undergoing tracheotomy, even at the price of having to perform surgical closure of TCF after decannulation in some cases.
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Affiliation(s)
- Ron Eliashar
- Department of Otolaryngology/Head and Neck Surgery, Hadassah University Hospital, Jerusalem, Israel.
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Sharp HR, Hartley BEJ. KTP laser treatment of suprastomal obstruction prior to decannulation in paediatric tracheostomy. Int J Pediatr Otorhinolaryngol 2002; 66:125-30. [PMID: 12393245 DOI: 10.1016/s0165-5876(02)00217-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Decannulation following tracheostomy in the paediatric patient is often complicated by the development of secondary suprastomal obstruction. We describe the technique of bronchoscopic KTP laser therapy in the management of such conditions, and have audited the results of this treatment with 12 children treated with this modality before attempted decannulation over the last 2 years at Great Ormond Street Hospital for Children (GOSH). METHOD Via a retrospective record review. RESULTS Eight (67%) were successfully decannulated, with four being unsuccessful. All children with less than 50% suprastomal obstruction were successfully decannulated following bronchoscopic KTP laser treatment. CONCLUSIONS Bronchoscopic KTP laser therapy is a useful tool in the abolition of suprastomal obstruction prior to decannulation following paediatric tracheostomy. Children with greater than 50% obstruction are likely to require an open procedure.
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Affiliation(s)
- H R Sharp
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK.
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19
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Park JY, Suskind DL, Prater D, Muntz HR, Lusk RP. Maturation of the pediatric tracheostomy stoma: effect on complications. Ann Otol Rhinol Laryngol 1999; 108:1115-9. [PMID: 10605914 DOI: 10.1177/000348949910801204] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The pediatric tracheostomy stoma can be matured via a technique that places 4-quadrant sutures from the tracheal cartilage to the dermis. This has the potential of decreasing the risk of accidental decannulation and the formation of granulation tissue. A retrospective analysis of 149 tracheostomies performed between January 1989 and December 1996 was done for the following factors: age, underlying diagnosis, indication for tracheostomy, type of tracheal incision, maturation of stoma, duration of tracheostomy, and early and late (>7 days) complications. Maturation of the stoma was performed in 88 (59.1%) of the 149 tracheostomies. There was an overall complication rate of 21.5% (32/149, not including granulation tissue formation). There were 9 (6.0%) early complications and 23 (15.4%) late complications. The overall incidence of tracheocutaneous fistulas occurred in 11 (11.2%) of the 98 decannulated patients: 6 (10.2%) of the 59 matured stomas and 5 (12.8%) of the 39 nonmatured stomas. Granulation tissue was found on subsequent laryngoscopy in 24 (27.3%) of the 88 matured stomas versus 23 (37.7%) of the 61 nonmatured stomas. There were no tracheostomy-related mortalities. Maturing the tracheostomy stoma resulted in a decreased morbidity from accidental decannulations and did not increase the incidence of tracheocutaneous fistulas or granulation tissue formation.
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Affiliation(s)
- J Y Park
- Division of Pediatric Otolaryngology, St Louis Children's Hospital, Missouri 63110, USA
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Eliashar R, Eliachar I, Esclamado R, Gramlich T, Strome M. Can topical mitomycin prevent laryngotracheal stenosis? Laryngoscope 1999; 109:1594-600. [PMID: 10522927 DOI: 10.1097/00005537-199910000-00009] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES/HYPOTHESIS Early topical application of mitomycin to a laryngotracheal lesion may prevent or reduce laryngotracheal stenosis (LTS). STUDY DESIGN Prospective controlled animal study. METHODS LTS was induced in 60 dogs randomly assigned to four groups. Controls received an immediate topical application of normal saline. The suction-control group received an immediate application of normal saline followed by suction of secretions on day 2. The mitomycin group received immediate application of 0.7 mL mitomycin (0.2 mg/mL). The repeat-mitomycin group received an immediate application of mitomycin and a second application on day 2, after secretions were suctioned. The laryngeal lumens were measured endoscopically at baseline, day 12, and day 21. Animals were euthanatized if stenosis approximated 95% or at day 21. RESULTS All dogs in the mitomycin groups survived to day 21, compared with 12 in the suction group and only 2 controls. No side effects of mitomycin were observed. At day 21, surviving controls had 85% and 95% stenosis. In the mitomycin group, median stenosis was 27% (interquartile range, 29% to 42%); in the repeat-mitomycin group, 30% (22% to 40%); and in the suction-control group, 84.5% (72.5% to 93.5%). The mitomycin group differed significantly from controls on day 12 (median difference = 85%, 95% CI = 80%-94%, P < .0001) and day 21 (difference = 63.9%, 95% CI = 58%-85%, P = .031). CONCLUSION A single topical application of mitomycin significantly reduces the severity of LTS in dogs. Reapplication after 2 days does not improve results. Prospective clinical studies are warranted to assess the efficacy in humans.
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Affiliation(s)
- R Eliashar
- Department of Otolaryngology/Head & Neck Surgery, Hadassah University Hospital, Jerusalem, Israel
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21
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22
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Brown MT, Montgomery WW. Microbiology of tracheal granulation tissue associated with silicone airway prostheses. Ann Otol Rhinol Laryngol 1996; 105:624-7. [PMID: 8712633 DOI: 10.1177/000348949610500807] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Granulation tissue formation and contraction is inevitable during the healing of open wounds. The presence of infection and a foreign body, such as a silicone airway prosthesis or other tracheotomy tube, magnifies this response. In airway reconstruction, wound contraction secondary to chronic inflammation is a liability. Cultures of granulation tissue were taken from 12 patients with silicone cannulas of T-Tubes. Polymicrobial colonization predominated, with variable combinations of gram-positive, gram-negative, and anaerobic organisms being present. On the basis of sensitivity data, amoxicillin-clavulanate potassium and ciprofloxacin hydrochloride were chosen as empirical antimicrobials. Anecdotally, impressive decreases in the quantity of granulation tissue were seen. We recommend a prospective trial to more accurately define the role of antibiotics in this setting.
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Affiliation(s)
- M T Brown
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA
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Rhee CK, Miller FR, Tucker HM, Eliachar I. The superiorly based flap long-term tracheostomy in pediatric patients. Am J Otolaryngol 1996; 17:251-6. [PMID: 8827290 DOI: 10.1016/s0196-0709(96)90090-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Tracheostomy is commonly used to provide control of the upper airway in pediatric patients. The traditional approach, which uses a midline vertical incision in the anterior tracheal wall, is associated with relatively high rates of complications when it is used on a long-term basis. Alternative approaches, such as removing tracheal window or creating tracheal flaps, have been avoided in the pediatric patient because of the risk of tracheal stenosis and the potential for the subsequent effect on tracheal growth. The superiorly based flap tracheostomy (SBFT) has greatly reduced these risks in adults and offers better stomal maintenance, safety, and patient acceptance, but it has not been widely evaluated in pediatric patients. METHODS We reviewed 21 superiorly based flap tracheostomies performed in children at our institution between 1986 and 1993. Routine follow-up assessments included fixed and flexible laryngotracheoscopy. Average follow-up was 17 months. RESULTS The most common indication for performing the SBFT was bilateral vocal cord paralysis. Short-term complications included wound infection and granuloma in 2 patients. Long-term complications were not observed. One patient died from lower respiratory tract causes. Five of the patients were eventually decannulated, and the stoma closed without laryngotracheal stenosis. Morbidity rates were less and mortality was comparable to those of traditional tracheostomy. CONCLUSION We conclude that the SBFT is promising a technique for establishing long-term control of the airway in pediatric patients.
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Affiliation(s)
- C K Rhee
- Department of Otolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Korea
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Froehlich P, Seid AB, Kearns DB, Pransky SM, Morgon A. Use of costal cartilage graft as external stent for repair of major suprastomal collapse complicating pediatric tracheotomy. Laryngoscope 1995; 105:774-5. [PMID: 7603286 DOI: 10.1288/00005537-199507000-00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- P Froehlich
- Département d'Oto-Rhino-Laryngologie et de Chirurgie Cervico-Faciale, Hôptial E. Herriot, Lyon France
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Prescott CA. Factors that influence successful decannulation after surgery for laryngo-tracheal stenosis in children. Int J Pediatr Otorhinolaryngol 1994; 30:183-8. [PMID: 7836031 DOI: 10.1016/0165-5876(94)90059-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The process to decannulation requires attention to details from the time of initial tracheostomy, through the pre- and peri-operative period up until the decannulation event. Important points to consider during this process are: a formal tracheostomy rather than a tracheotomy; other potential sites of obstruction than the laryngeal stenosis; gastroesophageal reflux; prevention and control of infection and the use of prophylactic antibiotics; method and type of suture material; stenting; movement and method of feeding. Decannulation itself requires attention to removal of granulation tissue and control of tracheomalacia and tracheostenosis.
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Affiliation(s)
- C A Prescott
- Department of Otolaryngology, University of Cape Town, South Africa
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al-Saati A, Morrison GA, Clary RA, Bailey CM. Surgical decannulation of children with tracheostomy. J Laryngol Otol 1993; 107:217-21. [PMID: 8509699 DOI: 10.1017/s0022215100122674] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Over a five-year period during which 99 children underwent successful ward decannulation, 14 other children were deemed unsuitable and underwent surgical decannulation. The technique of surgical decannulation involves excision of the tracheostomy tract with any granuloma and splinting of the anterior tracheal wall by the use of an indwelling nasotracheal tube for 48 hours post-operatively. It is indicated in carefully selected patients whose tracheostomies are complicated by large suprastomal granulomas, anterior tracheal wall collapse or previous anterior rib graft collapse into the airway. Nine of the 14 decannulations were successful. Success is dependent upon accurate prior endoscopic assessment and satisfactory previous reconstruction surgery in cases of subglottic stenosis. The five failures (4.42 per cent of all decannulations) represent some of the most demanding airway problems encountered.
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Affiliation(s)
- A al-Saati
- Department of Otolaryngology, Hospital for Sick Children, London
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