1
|
Ha TAN, Jain S, Schuman A, Ongkasuwan J. Pediatric Tracheotomy Stomal Maturation and Tracheocutaneous Fistulas. Laryngoscope 2024; 134:2941-2944. [PMID: 38265121 DOI: 10.1002/lary.31271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/02/2023] [Accepted: 12/22/2023] [Indexed: 01/25/2024]
Abstract
OBJECTIVE The purpose of this study is to determine whether tracheostomy stomal maturation affects the risk of tracheocutaneous fistula (TCF) in children. METHODS A retrospective chart review was conducted for all children who both underwent a tracheostomy and were decannulated between 2012 and 2021 at a tertiary children's hospital. Charts were analyzed for demographics, surgical technique, and development of a TCF. TCF was defined as a persistent fistula following 3 months after decannulation. RESULTS 179 children met inclusion criteria. The median (interquartile range) age at tracheostomy was 1.5 (82.4) months, average (standard deviation [SD]) duration of tracheotomy was 20.0 (20.6) months, and length of follow-up after decannulation (range; SD) was 39.3 (4.4-110.0; 26.7) months. 107 patients (60.0%) underwent stomal maturation and 98 patients developed a TCF (54.7%). Younger age at tracheostomy placement was significantly associated with increased risk of TCF, mean (SD) age 28.4 (51.4) version 80.1 (77.5) months (p < 0.001). Increased duration of tracheostomy was significantly associated with increased risk of TCF, 27.5 (18.4) version 11.0 (18.2) months (p < 0.001). Stomal maturation was not significantly associated with the risk of TCF, including on multivariable analysis adjusting for age at tracheostomy and duration of tracheostomy (p = 0.089). CONCLUSION Tracheostomy stomal maturation did not affect the risk of TCF in children, even after adjusting for age and duration of tracheostomy. LEVEL OF EVIDENCE 4 Laryngoscope, 134:2941-2944, 2024.
Collapse
Affiliation(s)
- Tu-Anh N Ha
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Samagra Jain
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Ari Schuman
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Julina Ongkasuwan
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
- Department of Otolaryngology, Texas Children's Hospital, Houston, Texas, U.S.A
| |
Collapse
|
2
|
Raynor T, Bedwell J. Pediatric tracheostomy decannulation: what's the evidence? Curr Opin Otolaryngol Head Neck Surg 2023; 31:397-402. [PMID: 37751378 DOI: 10.1097/moo.0000000000000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW Pediatric decannulation failure can be associated with large morbidity and mortality, yet there are no published evidence-based guidelines for pediatric tracheostomy decannulation. Tracheostomy is frequently performed in medically complex children in whom it can be difficult to predict when and how to safely decannulate. RECENT FINDINGS Published studies regarding pediatric decannulation are limited to reviews and case series from single institutions, with varying populations, indications for tracheostomy, and institutional resources. This article will provide a review of published decannulation protocols over the past 10 years. Endoscopic airway evaluation is required to assess the patency of the airway and address any airway obstruction prior to decannulation. There is considerable variability in tracheostomy tube modification between published protocols, though the majority support a capping trial and downsizing of the tracheostomy tube to facilitate capping. Most protocols include overnight capping in a monitored setting prior to decannulation with observation ranging from 24 to 48 h after decannulation. There is debate regarding which patients should have capped polysomnography (PSG) prior to decannulation, as this exam is resource-intensive and may not be widely available. Persistent tracheocutaneous fistulae are common following decannulation. Excision of the fistula tract with healing by secondary intention has a lower reported operative time, overall complication rate, and postoperative length of stay. SUMMARY Pediatric decannulation should occur in a stepwise process. The ideal decannulation protocol should be safe and expedient, without utilizing excessive healthcare resources. There may be variability in protocols based on patient population or institutional resources, but an explicitly described protocol within each institution is critical to consistent care and quality improvement over time. Further research is needed to identify selection criteria for who would most benefit from PSG prior to decannulation to guide allocation of this limited resource.
Collapse
|
3
|
Obayashi J, Fukumoto K, Yamoto M, Miyake H, Nomura A, Kanai R, Nemoto Y, Tsukui T. Safety evaluation of a stepwise tracheostomy decannulation program in pediatric patients. Pediatr Surg Int 2023; 39:260. [PMID: 37658905 DOI: 10.1007/s00383-023-05549-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE In the event of failed tracheostomy decannulation, patients might have a tragic course of events. We retrospectively evaluated our stepwise tracheostomy decannulation program and examined its safety. METHODS A 12-year retrospective study of pediatric patients was conducted. The decannulation program was performed on patients who had airway patency by laryngobronchoscopy and whose cannula could be capped during the day. A stepwise decannulation program was performed: continuous 48-h capping trial during hospitalization (Phase 1), removal of the tracheostomy tube for 48 h during hospitalization (Phase 2), and outpatient observation (Phase 3). If a persistent tracheocutaneous fistula existed, the fistula was closed by surgery (Phase 4). RESULTS The 77 patients in the study underwent 86 trials. The age at the first time of the decannulation program was 6.5 ± 3.6 years. Sixteen trials failed (18.6%): 8 trials in Phase 1, 2 trials in Phase 2, 4 trials in Phase 3, and 2 trials in Phase 4. Most decannulation failures were due to desaturation in Phase 1/2 and dyspnea in Phase 3/4. The time to reintubation after decannulation was 15-383 days in Phase 3/4. CONCLUSIONS Patients could fail at every phase of the program, suggesting that a stepwise decannulation program contributes to safety.
Collapse
Affiliation(s)
- Juma Obayashi
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan.
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Akiyoshi Nomura
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Risa Kanai
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Yuri Nemoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Takafumi Tsukui
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| |
Collapse
|
4
|
Almutairi N, Alshareef W, Almakoshi L, Zakzouk A, Aljasser A, Alammar A. Comparison Between Flap and Primary Closures of Persistent Tracheocutaneous Fistula: A Scoping Review. EAR, NOSE & THROAT JOURNAL 2023:1455613231179690. [PMID: 37291885 DOI: 10.1177/01455613231179690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
Objectives: To compare the susceptibility and complication rates between flap and primary closures for tracheocutaneous fistula (TCF). Methods: We searched 4 online databases (Web of Science, Cochrane Library, PubMed, and Scopus) for relevant articles published from study inception until August 2022. Studies including at least 5 adult or child patients with persistent TCFs who underwent closure surgery via primary or flap repair were included. All included studies reported outcomes of surgical repairs such as successful closure rates and complications. In addition, we performed single-arm meta-analyses for each surgical method using the Open Meta-Analyst software to calculate the pooled event rate with a 95% confidence interval (CI); compared the 2 surgical procedures using the Review Manager software using the risk ratio with 95% CI; and assessed study quality based on the National Heart, Lung, and Blood Institute criteria. Results: Overall, 27 studies with 997 patients were included. No significant difference was observed between the closure success and major complication rates of surgical methods. The primary and flap closures had overall success rates of 0.979 and 0.98, respectively. The overall major complication rates in primary and flap closures were 0.034 and 0.021, respectively; and that of minor were 0.045 and 0.04, respectively. In primary closure, a significant decrease in the success rate with increasing age at the time of decannulation was observed. In addition, the risk of major complications increased with increasing time from decannulation to closure. Conclusions: Both the primary and flap repairs of TCF are effective based on closure success and complication rates; therefore, they are both acceptable therapeutic alternatives, and flap repair can be considered when other techniques have failed. However, further prospective randomized studies comparing these 2 procedures are needed to support our results.
Collapse
Affiliation(s)
- Nasser Almutairi
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
- Department of Otolaryngology-Head and Neck Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Waleed Alshareef
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Latifah Almakoshi
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdulmajeed Zakzouk
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdullah Aljasser
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed Alammar
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
5
|
Teplitzky TB, Kou YF, Beams DR, Johnson RF, Chorney SR. Incidence of Persistent Tracheocutaneous Fistula After Pediatric Tracheostomy Decannulation. Laryngoscope 2023; 133:417-422. [PMID: 35546063 DOI: 10.1002/lary.30163] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/06/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence. STUDY DESIGN Prospective cohort. METHODS All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation. RESULTS A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05-0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06-0.99, p = 0.049) with failure to spontaneously close. CONCLUSIONS Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients. LEVEL OF EVIDENCE 3 Laryngoscope, 133:417-422, 2023.
Collapse
Affiliation(s)
- Taylor B Teplitzky
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Dylan R Beams
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| |
Collapse
|
6
|
Yosefof E, Tsur N, Boldes T, Najjar E, Mizrachi A, Shpitzer T, Hamzany Y, Bachar G. The Predictors of Persistent Posttracheostomy Tracheocutaneous Fistula and Successful Surgical Closure. Otolaryngol Head Neck Surg 2023. [PMID: 36856603 DOI: 10.1002/ohn.234] [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: 07/11/2022] [Revised: 11/16/2022] [Accepted: 11/30/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Persistent tracheocutaneous fistula is a well-described complication of prolonged tracheostomy, with a prevalence of about 70% when decannulation is performed after more than 16 weeks. Predictors of its occurrence and outcome of treatment in adults remain unclear. The aim of the study was to describe our experience with the treatment of persistent posttracheostomy tracheocutaneous fistula in adults and to investigate factors associated with its formation and with the success of surgical closure. STUDY DESIGN Retrospective cohort. SETTING Tertiary medical center. METHODS Patients who underwent open-approach tracheostomy between 2000 and 2020 were identified by database review. Data on background, need for surgical closure, and the surgical outcome was collected from the medical files and analyzed statistically between groups. RESULTS Of 516 patients identified, 127 with sufficient long-term follow-up data were included in the study. Compared to patients whose fistula closed spontaneously (n = 85), patients who required surgical closure (n = 42) had significantly higher rates of smoking, laryngeal or thyroid malignancy, and airway obstruction as the indication for tracheostomy, on both univariate and multivariate analysis. In a comparison of patients with successful (n = 29) or failed (n = 11) surgical closure, factors significantly associated with failure were prior radiotherapy and lower preoperative albumin level, on univariate analysis. CONCLUSION Smoking, thyroid or laryngeal malignancy, and airway obstruction indication are risk factors for persistent posttracheostomy tracheocutaneous fistula. Patients should be closely followed after tracheostomy and referred for surgery if the fistula fails to close. Before surgery, careful evaluation of the patient's nutritional status and consideration of prior radiation treatment is mandatory.
Collapse
Affiliation(s)
- Eyal Yosefof
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Tsur
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Boldes
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Esmat Najjar
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Mizrachi
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Shpitzer
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaniv Hamzany
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Bachar
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
7
|
Wong T, Macpherson O, Docherty S, Gray J, Clement WA, Kubba H. Outcomes and complications of simple layered closure of persistent tracheocutaneous fistula after tracheostomy in childhood. Int J Pediatr Otorhinolaryngol 2023; 164:111427. [PMID: 36577200 DOI: 10.1016/j.ijporl.2022.111427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/24/2022] [Accepted: 12/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Up to half of all children who have a tracheostomy will develop a persistent tracheo-cutaneous fistula (TCF) after decannulation. Surgical closure of the TCF is technically easy but post-operative complications can be immediate and life-threatening. These include air leak from the tracheal repair leading to massive surgical emphysema or pneumothorax. We reviewed our experience of TCF closure to try to identify potential risk factors for complications. METHOD Retrospective case record review of all children (0-16 years) who underwent surgical TCF closure between January 2010 and December 2021 following development of a persistent TCF after decannulation of a tracheostomy. RESULTS We identified 67 children. They ranged in age from 14 months to 16 years (median 3 years 10 months) at the time of the TCF closure. Major medical comorbidities were present in 90%. Pre-operative pulse oximetry with the fistula occluded was used in 29 children (43%). An underwater leak test was performed in 28 (42%). A non-suction drain was used in 29 children (43%). Prophylactic antibiotics were prescribed for 30 children (45%). Post-operative complications occurred in 15 children (22%). Life-threatening air leak occurred in the immediate post-operative period in 2 children (3%). Respiratory distress occurred in 3 children (4%) in the recovery area immediately after surgery. None required re-tracheostomy. Three children suffered post-operative pneumonia (4%), and wound infections occurred in 8 children (12%). We were unable to show a significant association between patient or surgical factors and complications. DISCUSSION Complications for TCF closure are unfortunately common and it is unclear from the available evidence how best to prevent them. Further research is required.
Collapse
Affiliation(s)
- Tiffany Wong
- Department of Paediatric Otolaryngology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, Scotland, UK
| | - Orla Macpherson
- Department of Paediatric Otolaryngology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, Scotland, UK
| | - Sophie Docherty
- Department of Paediatric Otolaryngology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, Scotland, UK
| | - Joyce Gray
- Department of Paediatric Otolaryngology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, Scotland, UK
| | - W Andrew Clement
- Department of Paediatric Otolaryngology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, Scotland, UK
| | - Haytham Kubba
- Department of Paediatric Otolaryngology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, Scotland, UK.
| |
Collapse
|
8
|
Azbell CH, Bakeman A, McCoy JL, Tobey ABJ. Primary versus secondary closure of tracheocutaneous fistula in pediatric patients. Am J Otolaryngol 2022; 43:103213. [PMID: 34823915 DOI: 10.1016/j.amjoto.2021.103213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Up to 50% of pediatric patients have a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Classically these fistula tracts were excised and completely closed in a multilayered fashion, but recently closure by secondary intention has become the standard of care. However, variations in postoperative care still exist. The primary objectives of this study were to compare outcomes between patients who had a primary closure versus closure by secondary intention after excision of a TCF in children with a tracheostomy placement at one year old or less and to determine if closure by secondary intention will be equally efficacious compared to traditional primary closure. METHODS Patients ages 0-21 years who had a primary or secondary closure of a TCF at a tertiary care children's hospital following decannulation of a tracheostomy tube were reviewed and those with a tracheostomy placement ≤1 year old were included. Demographic information, comorbidities, and surgical information were extracted from inpatient and outpatient charts. Mann-Whitney U test, Fisher's Exact test, and logistic regression to compare outcomes across the two TCF surgical groups. RESULTS A total of 64 patients met inclusion with primary closures in 25 (39.1%) patients and secondary closures in 39(60.9%) patients. Patients who underwent secondary closure had a significantly shorter surgery duration (p < .001), shorter ICU length of stay (p < .001), and shorter postop LOS (p < .001). There were no differences in cardiac complications, respiratory complications, and the need for additional closure surgery between the two techniques, p > .05. Time from decannulation to TCF in months increased with primary closure, p = .010. CONCLUSION Closure of tracheocutaneous fistula by secondary intention is safe and effective and can allow for shorter hospital stays in children with a tracheostomy placement at a year old or less.
Collapse
Affiliation(s)
- Christopher H Azbell
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Anna Bakeman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jennifer L McCoy
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Allison B J Tobey
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.
| |
Collapse
|
9
|
Xiao L, Kaspy K, Zielinski D, Amin R. Pediatric tracheostomy tube decannulation with or without polysomnography: A PRO-CON debate. Pediatr Pulmonol 2022; 57:609-615. [PMID: 34825785 DOI: 10.1002/ppul.25773] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 11/06/2022]
Abstract
Determining the timing for decannulation in children with a tracheostomy is a complex process, as the appropriate timing varies based on the initial indication for the tracheostomy tube as well as individual patient characteristics. The original condition for which a tracheostomy was created may improve over time with decannulation being a very important long-term goal for many families and multidisciplinary teams. However, decannulation is an inherently risky procedure associated with morbidity and mortality. Therefore, careful planning is required to ensure the safety of the procedure. Although routine airway endoscopy is an important component of decannulation protocols, guidelines are less prescriptive regarding the definition of a complete endoscopic airway evaluation and the routine use of polysomnography. This review will summarize the important PRO and CON arguments of integrating polysomnography into pediatric decannulation protocols.
Collapse
Affiliation(s)
- Lena Xiao
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Respiratory Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Kimberley Kaspy
- Division of Respiratory Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - David Zielinski
- Division of Respiratory Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Park SJ, Han SA, Kwon TK, Sung MW, Kwon SK. Primary versus modified secondary closure techniques for persistent tracheocutaneous fistula in pediatric patients. Pediatr Surg Int 2022; 38:123-131. [PMID: 34302512 DOI: 10.1007/s00383-021-04967-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aimed at compating two closure techniques for tracheocutaneous fistulas (TCFs) in pediatric patients. METHODS A total of 106 consecutive pediatric patients who underwent closure of a persistent TCF between April 2007 and February 2021 at a tertiary pediatric hospital were evaluated, and 103 pediatric patients aged between 12 months and 18 years were included. The clinical characteristics, perioperative outcomes, and postoperative outcomes were compared between TCF closure by primary closure (Group 1) and a modified secondary healing technique (Group 2). RESULTS Of the 103 patients, 58 were classified into Group 1, and 45 into Group 2. The mean age at tracheostomy and TCF closure was significantly younger in Group 2, and the interval between decannulation to TCF closure was significantly shorter in Group 2. Procedural time and hospital stay were significantly shorter in Group 2 than Group 1. Group 2 had a significantly lower complication rate, need for revision surgery, and recannulation rate than Group 1. CONCLUSIONS Modified secondary healing was more efficient in terms of procedural time and hospital stay, and safer (i.e., fewer complications). It is an effective surgical technique for closing a persistent TCF in younger patients more quickly after decannulation compared to primary closure.
Collapse
Affiliation(s)
- Sung Joon Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Sun A Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Tack-Kyun Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myung-Whun Sung
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seong Keun Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea. .,Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
11
|
Chorney SR, Stow J, Javia LR, Zur KB, Jacobs IN, Sobol SE. Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction. Ann Otol Rhinol Laryngol 2021; 130:948-953. [PMID: 33412912 DOI: 10.1177/0003489420987426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction. METHODS A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019. RESULTS A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy (P = .86), age at decannulation (P = .97), duration of tracheostomy (P = .43), or gestational age (P = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm, P = .03). Tracheostomy tube diameter (P = .02) and stent size (P < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up. CONCLUSIONS Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.
Collapse
Affiliation(s)
- Stephen R Chorney
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Joanne Stow
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luv R Javia
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Karen B Zur
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Ian N Jacobs
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Steven E Sobol
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
12
|
Chorney SR, Husain S, Sobol SE. Diagnostic considerations prior to pediatric tracheocutaneous fistula closure. Int J Pediatr Otorhinolaryngol 2020; 138:110357. [PMID: 32911241 DOI: 10.1016/j.ijporl.2020.110357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION An airway assessment often occurs prior to tracheocutaneous fistula (TCF) closure in children. Bronchoscopy (MLB) with or without fistula-occluded polysomnography (PSG) helps determine candidacy and localize potential obstruction. To date, little has been published on MLB or PSG findings in children before surgically closing a TCF. METHODS A case series with chart review of children between 2017 and 2020 who underwent repair of a TCF after tracheostomy decannulation. RESULTS Thirty-six children were included for review. Mean age was 5.9 years (95% CI: 4.5-7.3), 58.3% were male, and 50% had chronic lung disease. Surgery occurred 13.3 months (95% CI: 11.9-14.8) after decannulation, with 80.6% by primary closure and 19.4% by secondary intention. There was one unsuccessful closure and two patients (5.6%) presented with a postoperative complication. An MLB was performed in 97.2% of children, where 22.9% identified supraglottic pathology, 11.4% had grade 2 subglottic stenosis, and 11.4% had difficult exposure of the larynx. Further, one child had a non-obstructing subglottic cyst, one had a supraglottoplasty for redundant arytenoid mucosa, and two children had suprastomal granulomas requiring removal. A PSG was obtained in 36.1%, with a mean Apnea-Hypopnea Index of 2.4 events/hour (95% CI: 0.9-3.9), nadir Oxygen saturation of 90.5% (95% CI: 87.9-93.0), and peak end-tidal CO2 of 46.1 mmHg (95% CI: 43.7-48.5). CONCLUSION The selection of candidates for pediatric TCF closure requires careful evaluation of the airway. Surgeons should be familiar with the potential findings on MLB and PSG prior to closure.
Collapse
Affiliation(s)
- Stephen R Chorney
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA; Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Solomon Husain
- Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Steven E Sobol
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA; Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, 19104, USA.
| |
Collapse
|