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Seidl E, Kramer J, Hoffmann F, Schön C, Griese M, Kappler M, Lisec K, Hubertus J, von Schweinitz D, Di Dio D, Sittel C, Reiter K. Comorbidity and long-term clinical outcome of laryngotracheal clefts types III and IV: Systematic analysis of new cases. Pediatr Pulmonol 2021; 56:138-144. [PMID: 33095514 DOI: 10.1002/ppul.25133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/08/2020] [Accepted: 10/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Long segment laryngotracheoesophageal clefts (LTECs) are very rare large-airway malformations. Over the last 40 years mortality rates declined substantially due to improved intensive care and surgical procedures. Nevertheless, long-term morbidity, comorbidity, and clinical outcomes have rarely been assessed systematically. METHODS In this retrospective case series, the clinical presentation, comorbidities, treatment, and clinical outcomes of all children with long-segment LTEC that were seen at our department in the last 15 years were collected and analyzed systematically. RESULTS Nine children were diagnosed with long segment LTEC (four children with LTEC type III and five patients with LTEC type IV). All children had additional tracheobronchial, gastrointestinal, or cardiac malformations. Tracheostomy for long-time ventilation and jejunostomy for adequate nutrition was necessary in all cases. During follow-up one child died from multiorgan failure due to sepsis at the age of 43 days. The clinical course of the other eight children (median follow-up time 5.2 years) was stable. Relapses of the cleft, recurrent aspirations, and respiratory tract infections led to repeated hospital admissions. CONCLUSIONS Long-segment LTECs are consistently associated with additional malformations, which substantially influence long-term morbidity. For optimal management, a multidisciplinary approach is essential.
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Affiliation(s)
- Elias Seidl
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Johanna Kramer
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Florian Hoffmann
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Carola Schön
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Matthias Griese
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Matthias Kappler
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Kristina Lisec
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jochen Hubertus
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dietrich von Schweinitz
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Diana Di Dio
- Department of Otorhinolaryngology Head and Neck Surgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Christian Sittel
- Department of Otorhinolaryngology Head and Neck Surgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Karl Reiter
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
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Jáuregui EJ, Propst EJ, Johnson K. Current management of type III and IV laryngotracheoesophageal clefts: the case for a revised cleft classification. Curr Opin Otolaryngol Head Neck Surg 2020; 28:435-442. [PMID: 33109943 PMCID: PMC8966410 DOI: 10.1097/moo.0000000000000669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the paediatric laryngotracheoesophageal cleft (LTEC) literature, with an emphasis on recent trends, evaluation and management, surgical techniques, postoperative care of Type III and IV LTECs, and to propose a revised cleft classification system that more accurately reflects our current understanding of these anomalies. RECENT FINDINGS There are a number of techniques described to address Type III and IV LTEC, from endoscopic to open approaches with thoracotomy. The surgical approach should be tailored to the length of the cleft and its proximity to important anatomical structures. On the basis of review of the literature, we propose a modified Benjamin-Inglis classification (MBI) with subcategories to address this issue. Postoperative complications are common, namely, tracheoesophageal fistulae and tracheomalacia, which may necessitate subsequent procedures or prolonged tracheostomy dependence. SUMMARY The medical and surgical management of Type III and IV LTEC is challenging with a high rate of morbidity and mortality. The rarity and difficulties in management of these malformations have made large cohort studies difficult, thus generalizable recommendations have been elusive. Experience and patient selection are critical for successful endoscopic repair. Anterior cervical approach, often with complete laryngofissure, appears to be the most common and preferred method for open repairs, though some use a lateral approach. The proposed MBI classification appears to be a useful adjunct to aid in surgical decision-making for deeper LTEC.
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Affiliation(s)
- Emmanuel J. Jáuregui
- University of Washington, Department of Otolaryngology—Head & Neck Surgery and Seattle Children’s Hospital, Seattle, Washington, USA
| | - Evan J. Propst
- Department of Otolaryngology—Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kaalan Johnson
- University of Washington, Department of Otolaryngology—Head & Neck Surgery and Seattle Children’s Hospital, Seattle, Washington, USA
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3
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Tambucci R, Wautelet O, Haenecour A, François G, Goubau C, Scheers I, Halut M, Menten R, Schmitz S, de Toeuf C, Pirotte T, D'hondt B, Reding R, Poncelet A. Esophageal Trachea, a Unique Foregut Malformation Requiring Multistage Surgical Reconstruction: Case Report. Front Pediatr 2020; 8:605143. [PMID: 33330293 PMCID: PMC7714922 DOI: 10.3389/fped.2020.605143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/26/2020] [Indexed: 11/13/2022] Open
Abstract
Abnormal connections between the esophagus and low respiratory tract can result from embryological defects in foregut development. Beyond well-known malformations, including tracheo-esophageal fistula and laryngo-tracheo-esophageal cleft, rarer anomalies have also been reported, including communicating bronchopulmonary foregut malformations and tracheal atresia. Herein, we describe a case of what we have called "esophageal trachea," which, to our knowledge, has yet to be reported. A full-term neonate was born in our institution presenting with a foregut malformation involving both the middle esophagus and the distal trachea, which were found to be longitudinally merged into a common segment, 3 cm in length, located just above the carina and consisted of esophageal tissue without cartilaginous rings. At birth, the esophagus and trachea were surgically separated via right thoracotomy, the common segment kept on the tracheal side only, creating a residual long-gap esophageal atresia. The resulting severe tracheomalacia was treated via simultaneous posterior splinting of such diseased segment using an autologous pericardium patch, as well as by anterior aortopexy. Terminal esophagostomy and gastrostomy were created at that stage due to the long distance between esophageal segments. Between ages 18 and 24 months, the patient underwent native esophageal reconstruction using a multistage traction-and-growth surgical strategy that combined Kimura extra-thoracic esophageal elongations at the upper esophagus and Foker external traction at the distal esophagus. Ten months after esophageal reconstruction, prolonged, refractory, and severe tracheomalacia was further treated via anterior external stenting using a semitubular ringed Gore-Tex® prosthesis, through simultaneous median sternotomy and tracheoscopy. Currently, 2 years after the last surgery, respiratory stabilization, and full oral feeding were stably achieved. Multidisciplinary management was crucial for assuring lifesaving procedures, correctly assessing anatomy, and planning for multiple sequential surgical approaches that aimed to restore long-term respiratory and digestive functions.
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Affiliation(s)
- Roberto Tambucci
- Pediatric Surgery and Transplantation Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Océane Wautelet
- Pediatric Surgery and Transplantation Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Astrid Haenecour
- Pediatric Intensive Care Unit, Emergency Department, Saint-Luc University Clinics, Brussels, Belgium
| | - Geneviève François
- General Pediatric Unit, Department of Pediatrics, Saint-Luc University Clinics, Brussels, Belgium
| | - Christophe Goubau
- Pediatric Pneumology Unit, Department of Pediatrics, Saint-Luc University Clinics, Brussels, Belgium
| | - Isabelle Scheers
- Pediatric Gastroenterology and Hepatology Unit, Department of Pediatrics, Saint-Luc University Clinics, Brussels, Belgium
| | - Marin Halut
- Pediatric Radiology Unit, Department of Radiology, Saint-Luc University Clinics, Brussels, Belgium
| | - Renaud Menten
- Pediatric Radiology Unit, Department of Radiology, Saint-Luc University Clinics, Brussels, Belgium
| | - Sandra Schmitz
- Otolaryngology Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Caroline de Toeuf
- Otolaryngology Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Thierry Pirotte
- Pediatric Anesthesiology Unit, Emergency Department, Saint-Luc University Clinics, Brussels, Belgium
| | - Beelke D'hondt
- Pediatric Surgery and Transplantation Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Raymond Reding
- Pediatric Surgery and Transplantation Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
| | - Alain Poncelet
- Pediatric Cardiac and Thoracic Surgery Unit, Department of Surgery, Saint-Luc University Clinics, Brussels, Belgium
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4
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Revision repair of type IV laryngotracheoesophageal cleft using multiple long tapered engaging grafts. Int J Pediatr Otorhinolaryngol 2017; 103:80-82. [PMID: 29224771 DOI: 10.1016/j.ijporl.2017.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 11/20/2022]
Abstract
An 8 year-old female with esophageal atresia and a type IV laryngotracheoesophageal cleft underwent tracheostomy, gastric pull-up and fundoplication with G-tube insertion at birth. She remained nil per os due to aspiration. The trachealis was separated from the esophagus that was reapproximated and clavicular periosteum was placed. A long posterior costal cartilage graft that engaged behind the cricoid plate and tapered inferiorly was inserted. A second thin cartilage graft was sutured to it distally to extend the length of the repair. This allowed for removal of the tracheostomy and oral feeding while providing a four-layer closure to prevent aspiration.
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Vuncannon J, Albanna M, Evans AK. The adaptive use of a hand-crafted endotracheal-endobronchial tube for airway management in laryngo-tracheo-esophageal cleft type IV. Int J Pediatr Otorhinolaryngol 2017; 98:71-74. [PMID: 28583508 DOI: 10.1016/j.ijporl.2017.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/27/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
| | | | - Adele K Evans
- Wake Forest School of Medicine, Department of Otolaryngology, United States.
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6
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Propst EJ. Repair of short type IV laryngotracheoesophageal cleft using long, tapered, engaging graft without need for tracheotomy. Laryngoscope 2015; 126:1006-8. [DOI: 10.1002/lary.25472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/25/2015] [Accepted: 06/08/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Evan J. Propst
- Department of Otolaryngology-Head and Neck Surgery; Hospital for Sick Children; Toronto Ontario Canada
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto; Toronto Ontario Canada
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7
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Ryan DP, Doody DP. Management of congenital tracheal anomalies and laryngotracheoesophageal clefts. Semin Pediatr Surg 2014; 23:257-60. [PMID: 25459009 DOI: 10.1053/j.sempedsurg.2014.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Congenital obstructions and anomalies of the pediatric airway are rare problems that may be associated with mild symptoms or critical stenoses that may be life threatening in the first few days of life. This review provides an overview of the embryologic development of the airway, different congenital anomalies associated with airway development, and surgical correction that may be associated with good long-term outcome.
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Affiliation(s)
- Daniel P Ryan
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, Massachusetts 02114.
| | - Daniel P Doody
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, Massachusetts 02114
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8
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Johnston DR, Watters K, Ferrari LR, Rahbar R. Laryngeal cleft: evaluation and management. Int J Pediatr Otorhinolaryngol 2014; 78:905-11. [PMID: 24735606 DOI: 10.1016/j.ijporl.2014.03.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/14/2014] [Accepted: 03/15/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Review the latest diagnostic and treatment modalities for laryngeal and laryngotracheoesophageal clefts as they can be a major cause of respiratory and feeding morbidity in the infant and pediatric population. METHODS Literature review of published reports. RESULTS The presentation of laryngeal cleft usually involves respiratory symptoms, such as stridor, chronic cough, aspiration, and recurrent respiratory infections. Clefts of the larynx and trachea/esophagus can occur in isolation, as part of a syndrome (Opitz-Frias, VATER/VACTERL, Pallister Hall, CHARGE), or with other associated malformations (gastrointestinal, genitourinary, cardiac, craniofacial). This publication reviews the presenting signs/symptoms, diagnostic options, prognosis, and treatment considerations based on over a decade of experience of the senior author with laryngeal clefts. CONCLUSIONS Type I laryngeal clefts can be managed medically or surgically depending on the degree of morbidity. Types II, III, and IV require endoscopic or open surgery to avoid chronic respiratory and feeding complications.
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Affiliation(s)
- Douglas R Johnston
- Division of Otolaryngology, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, United States.
| | - Karen Watters
- Department of Pediatric Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, United States
| | - Lynne R Ferrari
- Department of Anesthesiology, Boston Children's Hospital, Boston, MA, United States
| | - Reza Rahbar
- Department of Pediatric Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, United States
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9
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[Malformations of the esophagus: diagnosis and therapy]. DER PATHOLOGE 2013; 34:94-104. [PMID: 23423505 DOI: 10.1007/s00292-012-1733-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Esophageal malformations are rare and can occur sporadically or as a component of various syndromes. The variations and classifications are manifold. With the available modern operation techniques most malformations can be resolved with good results. However, esophageal malformations are often combined with further malformations which limit the prognosis. The separation of the trachea and esophagus after gastrulation is not yet completely researched. The results so far indicate that the localized expression of various homeodomain transcription factors is essential for normal development of the trachea and esophagus.
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10
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Propst EJ, Ida JB, Rutter MJ. Repair of long type IV posterior laryngeal cleft through a cervical approach using cricotracheal separation. Laryngoscope 2013; 123:801-4. [DOI: 10.1002/lary.23660] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2012] [Indexed: 11/07/2022]
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Ongkasuwan J. In Search of the Elusive Laryngotracheal Cleft. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2012; 25:143-149. [DOI: 10.1089/ped.2012.0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Julina Ongkasuwan
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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12
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Leboulanger N, Garabédian EN. Laryngo-tracheo-oesophageal clefts. Orphanet J Rare Dis 2011; 6:81. [PMID: 22151899 PMCID: PMC3261097 DOI: 10.1186/1750-1172-6-81] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 12/07/2011] [Indexed: 01/09/2023] Open
Abstract
A laryngo-tracheo-esophageal cleft (LC) is a congenital malformation characterized by an abnormal, posterior, sagittal communication between the larynx and the pharynx, possibly extending downward between the trachea and the esophagus. The estimated annual incidence of LC is 1/10,000 to 1/20,000 live births, accounting for 0.2% to 1.5% of congenital malformations of the larynx. These incidence rates may however be underestimated due to difficulty in diagnosing minor forms and a high mortality rate in severe forms. A slightly higher incidence has been reported in boys than in girls. No specific geographic distribution has been found. Depending on the severity of the malformation, patients may present with stridor, hoarse cry, swallowing difficulties, aspirations, cough, dyspnea and cyanosis through to early respiratory distress. Five types of laryngo-tracheo-esophageal cleft have been described based on the downward extension of the cleft, which typically correlates with the severity of symptoms: Type 0 laryngo-tracheo-esophageal cleft to Type 4 laryngo-tracheo-esophageal cleft. LC is often associated with other congenital abnormalities/anomalies (16% to 68%), mainly involving the gastro-intestinal tract, which include laryngomalacia, tracheo-bronchial dyskinesia, tracheo-bronchomalacia (mostly in types 3 and 4), and gastro-esophageal reflux disease (GERD). The syndromes most frequently associated with an LC are Opitz/BBB syndrome, Pallister Hall syndrome, VACTERL/VATER association, and CHARGE syndrome. Laryngeal clefts result from failure of fusion of the posterior cricoid lamina and abnormal development of the tracheo-esophageal septum. The causes of the embryological developmental anomalies leading to LC are not known but are thought to be multifactorial. LC appears to be mostly sporadic although some familial cases with suspected autosomal dominant transmission have been reported. The age of diagnosis depends mainly on the severity of the clinical symptoms and therefore on the extent of the LC. Diagnosis is made either based on clinical manifestations or on investigations, such as endoscopy, X-ray, CT scan, performed for other conditions. Differential diagnoses include tracheo-bronchial fistula, gastro-esophageal reflux disease and neurological swallowing disorders, as well as laryngomalacia and laryngeal palsy. Prenatal diagnosis of LC has never been reported, although associated anomalies may be detected on fetal ultrasonography. Once the cleft is diagnosed, it is essential to determine its length to orient the management and treatment approach. Management involves maintenance of satisfactory ventilation, prevention of secondary pulmonary complications as a result of repeated aspirations, and adequate feeding. Endotracheal intubation may be required for respiratory distress in severe cases. Treatment requires endoscopic or external surgery to close the cleft. Surgery should be performed as early as possible to avoid complications related to aspiration and gastric reflux, except in type 0 and type 1 cases in which conservative measures must first be attempted. The prognosis is variable depending on the severity of the LC and associated malformations. Early diagnosis and appropriate treatment and management help to reduce mortality and morbidity.
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Affiliation(s)
- Nicolas Leboulanger
- Paediatric Otolaryngology-Head and Neck surgery Department, UPMC-Paris VI University, Armand-Trousseau Children's Hospital, Paris, France.
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Owusu JA, Sidman JD, Anderson GF. Type IV laryngotracheoesophageal cleft: report of long-term survivor successfully decannulated. Int J Pediatr Otorhinolaryngol 2011; 75:1207-9. [PMID: 21752479 DOI: 10.1016/j.ijporl.2011.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 06/12/2011] [Accepted: 06/16/2011] [Indexed: 10/18/2022]
Abstract
Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly that results from failed posterior fusion of the cricoid cartilage and incomplete development of the tracheoesophageal septum. LTEC presents with increased secretions, respiratory distress, aspiration and recurrent pulmonary infections. The severity of presenting symptoms is dependent on the type of cleft. LTEC is most commonly classified into four types (I, II, III and IV) based on the inferior extent of the cleft. Types III and IV LTEC are associated with high morbidity and mortality and require timely diagnosis and repair for survival. Most patients who survive repair of Type IV LTEC have long-term tracheotomy dependency with minimal chance of decannulation. We report on a case of a long-term survivor of Type IV who has been safely decannulated.
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Affiliation(s)
- James A Owusu
- Department of Otolaryngology, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, United States.
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15
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Pezzettigotta SM, Leboulanger N, Roger G, Denoyelle F, Garabédian EN. Laryngeal Cleft. Otolaryngol Clin North Am 2008; 41:913-33, ix. [DOI: 10.1016/j.otc.2008.04.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mathur NN, Peek GJ, Bailey CM, Elliott MJ. Strategies for managing Type IV laryngotracheoesophageal clefts at Great Ormond Street Hospital for Children. Int J Pediatr Otorhinolaryngol 2006; 70:1901-10. [PMID: 16901551 DOI: 10.1016/j.ijporl.2006.06.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Revised: 06/24/2006] [Accepted: 06/27/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To review our strategy for the treatment of patients with Type IV laryngotracheoesophageal cleft-a very rare congenital malformation. METHODS Retrospective review of nine cases of Type IV laryngotracheoesophageal cleft managed between October 1994 and January 2004 at Great Ormond Street Hospital for Children, London. RESULTS Three children were not operated upon (Group A) because of serious co-morbidity and parental decision not to opt for repair; they died at the ages of 2, 7 and 14 days, respectively. Six cases were repaired (Group B) at ages ranging from 2 to 53 days, all using an anterior cervico-thoracic approach. Two cases were operated upon using conventional ventilation, three using cardiopulmonary bypass and one using extracorporeal membrane oxygenation. There was no intra-operative mortality. The number of operative and diagnostic procedures varied from 4 to 37. Two operated cases expired at the ages of 11 days and 25 months; both were operated upon using cardiopulmonary bypass and had significant cardiac co-morbidity. Post-operative microlaryngoscopy and bronchoscopy showed dehiscence in the cleft repair ranging from 1mm to 2cm in five cases. This was observed at the distal end in three patients and just below the vocal cords in two cases. Three cases underwent further repair which was successful. The most recent case repaired using extracorporeal membrane oxygenation required less heparin when compared with those done on cardiopulmonary bypass and had the best post-operative result. Two patients were finally decannulated. The total duration of diagnostic and operative procedures ranged from 9 to 26h and 30min. The hospital stay in the operated cases varied from 9 days to 2 years 2 months 3 days, and their ICU stay ranged from 9 days to 10 months 7 days. All four of our patients with clefts which ended above the carina are alive after multiple repairs whereas all five cases with clefts extending all the way to the carina died (repair was attempted in two). CONCLUSION Early diagnosis and repair are essential for successful treatment of Type IV laryngotracheoesophageal clefts. We believe it is best to repair this defect via an anterior cervico-thoracic approach, with or without a median sternotomy, and extracorporeal membrane oxygenation is now our preferred method of gas exchange during such repair. The longest Type IV clefts extending all the way to the carina have the worst prognosis. The decision to operate or not should be based upon the associated co-morbidity and fully informed parental choice, since treatment entails significant morbidity and mortality.
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Affiliation(s)
- Neeraj N Mathur
- Department of Paediatric Otolaryngology, Head & Neck Surgery, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK.
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Abstract
OBJECTIVES The objectives of this study are to present the technique and results of endoscopic repair of laryngotracheoesophageal clefts (LTEC) extending caudally to the cricoid plate into the cervical trachea and to revisit the classification of LTEC. METHODS The authors conducted a retrospective case analysis consisting of four infants with complete laryngeal clefts (extending through the cricoid plate in three cases and down into the cervical trachea in one case) treated endoscopically by CO2 laser incision of the mucosa and two-layer endoscopic closure of the cleft without postoperative intubation or tracheotomy. RESULTS All four infants resumed spontaneous respiration without support after a mean postoperative period of 3 days with continuous positive airway pressure (CPAP). They accepted oral feeding within 5 postoperative days (range, 3-11 days). No breakdown of endoscopic repair was encountered. After a mean follow up of 48 months (range, 3 mos to 7 y), all children have a good voice, have no sign of residual aspiration, but experience a slight exertional dyspnea. CONCLUSION This limited experience on the endoscopic repair of extrathoracic LTEC shows that a minimally invasive approach sparing the need for postoperative intubation or tracheotomy is feasible and safe if modern technology (ultrapulse CO2 laser, endoscopic suturing, and postoperative use of CPAP in the intensive care unit) is available.
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Affiliation(s)
- Kishore Sandu
- Department of Otorhinolaryngology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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18
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Kawaguchi AL, Donahoe PK, Ryan DP. Management and long-term follow-up of patients with types III and IV laryngotracheoesophageal clefts. J Pediatr Surg 2005; 40:158-64; discussion 164-5. [PMID: 15868578 DOI: 10.1016/j.jpedsurg.2004.09.041] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly that occurs when the trachea and esophagus fail to separate during fetal development. The 2 most severe forms of LTEC are type III, with extension of the cleft from the larynx to the carina, and type IV, with extension of the cleft into one or both mainstem bronchi. METHODS Over the past 25 years, we have accumulated an experience caring for 9 patients with severe LTEC, including 4 with type III and 5 with type IV. RESULTS Morbidity and mortality from severe LTEC often result from aspiration and chronic lung disease. Patients with types III (1/4) and IV (5/5) LTEC have an extremely high incidence of microgastria with a shortened esophagus for which fundoplication is ineffective. Because gastric feeding often does not initially increase stomach volume and may cause severe aspiration, we suggest early gastric division with later reconstruction of intestinal continuity in patients with microgastria. Postoperative tracheoesophageal fistulas have occurred in 6 of 9 patients. CONCLUSIONS Generous interposition of vascularized tissue with a multiple-layer closure has helped to prevent further recurrences. Postoperative tracheomalacia may be managed with continuous positive airway pressure and may require customized endotracheal tubes. Evaluation of respiratory and digestive function, school performance, and quality of life for the surviving patients is described.
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Affiliation(s)
- Akemi L Kawaguchi
- Department of Pediatric Surgery, Mass General Hospital for Children, Massachusetts General Hospital, Boston, MA 02114, USA
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Chitkara AE, Tadros M, Kim HJ, Harley EH. Complete laryngotracheoesophageal cleft: complicated management issues. Laryngoscope 2003; 113:1314-20. [PMID: 12897552 DOI: 10.1097/00005537-200308000-00010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES/HYPOTHESIS Laryngotracheoesophageal clefts are rare developmental anomalies of the upper aerodigestive tract. They range in severity from being virtually asymptomatic throughout life (type I) to being incompatible with life (type IV). The timing of diagnosis is crucial to the successful treatment of severe clefts. Treatment is complicated and requires a multi-team approach. The case report discusses the elements involved in diagnosing and treating this severe airway anomaly. STUDY DESIGN Case report. METHODS Review of a case at a tertiary care center. RESULTS A case of a complete laryngotracheoesophageal cleft with left-side pulmonary agenesis in a newborn is reported. Rigid bronchoscopy revealed a common tracheoesophageal lumen from the larynx to the stomach with a single bronchus supplying the right-side lung. Management of this patient included establishment and maintenance of a tenuous airway, maintenance of nutrition, and anesthetic and surgical planning for upper aerodigestive tract reconstruction. CONCLUSIONS Although severe laryngotracheoesophageal clefts are rare, they require prompt, team-oriented management for the best outcome possible. The diagnosis, sustenance, and treatment options of these patients depend on varied and complicated factors, which are discussed.
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Affiliation(s)
- Ajay E Chitkara
- New York Center for Voice and Swallowing Disorders, and the St. Luke's-Roosevelt Hospital, New York, NY, USA.
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20
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Abstract
We report the case of a newborn baby with a type IV laryngotracheo-oesophageal cleft and the anaesthetic management during the rigid bronchoscopy that was performed at 5 days of age. After anaesthetic induction with sevoflurane and atropine, the child was maintained with sevoflurane 2-2.5% and remifentanil at an infusion rate of 0.5 microg.kg(-1).min(-1). Ventilation was managed through the lateral port of the bronchoscope. The patient breathed sevoflurane and oxygen/N2O spontaneously via a Jackson-Rees circuit. To prevent the stomach from filling up with anaesthetic gases, a Foley catheter was placed orally into the stomach. The Foley balloon was inflated and retracted until it sealed the gastro-oesophageal junction. Tracheal intubation was performed after bronchoscopy to allow suture of the stomach into two chambers. Oxygenation was adequate with no air leakage, with spontaneous ventilation. The Foley catheter was removed afterwards and the patient awakened. We review the literature on different ways of managing the airway in these cases and protecting it from gastric aspiration during ventilation.
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Affiliation(s)
- A Fernández
- Paediatric Anaesthesiology Division, University Hospital Doce de Octubre, Madrid, Spain.
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21
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Shehab ZP, Bailey CM. Type IV laryngotracheoesophageal clefts -- recent 5 year experience at Great Ormond Street Hospital for Children. Int J Pediatr Otorhinolaryngol 2001; 60:1-9. [PMID: 11434948 DOI: 10.1016/s0165-5876(01)00464-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This article summarises a 5 year experience of type IV laryngotracheoesophageal clefts from Great Ormond Street Hospital for Children, London. We present six infants who had type IV clefts, two of whom are long-term survivors, and we review the literature. The recognition of specific complicating issues may lead to a standardised approach, which can result in successful repair and long-term survival. Increased awareness of the condition and early diagnosis combined with aggressive, planned surgical intervention in centres of paediatric expertise should result in a significant reduction of current mortality.
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Affiliation(s)
- Z P Shehab
- Manchester Children's Hospital-Booth Hall, Charlestown Road, Blackley, Manchester M9 2DD, UK.
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22
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Herman TE, Siegel MJ. Concurrent type 1 laryngotracheoesophageal cleft and H-type tracheoesophageal fistula. J Perinatol 2001; 21:341-2. [PMID: 11536033 DOI: 10.1038/sj.jp.7200214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- T E Herman
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
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23
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Abstract
Diagnostic flexible endoscopy for pediatric respiratory diseases is performed in many centers. Technical advances have resulted in performance of interventional bronchoscopies, and new diagnostic indications are being explored. Indications with documented clinical benefit include congenital or acquired progressive or unexplained airway obstruction. Pulmonary infections in immunodeficient children who do not respond to empirical antibiotic treatment may be diagnosed by bronchoscopy and bronchoalveolar lavage (BAL). The potential usefulness of bronchoscopy and BAL for managing chronic cough, wheeze, or selected cases with asthma or cystic fibrosis requires further study. The use of transbronchial biopsies (TBB) is established in pediatric lung transplantation. The role of TBB in the diagnosis of chronic interstitial lung disease in children remains to be determined. For a number of interventional applications, rigid endoscopy is required, and pediatric bronchoscopists should be trained in its use. Complications in pediatric bronchoscopy are rare, but severe nosocomial infection or overdosing with local anesthetics has occurred. The issues of quality control, video documentation, interobserver variability of findings, and educational standards will have to be addressed in the future as bronchoscopy use becomes less restricted to only large pediatric pulmonary units.
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Affiliation(s)
- T Nicolai
- Universität Kinderklinik München, Dr. von Haunerschen Kinderspital, Munich, Germany.
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24
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Iskit SH, Senyüz OF, Sander S. Type IV laryngotracheoesophageal clefts: surgical management for long-term survival. J Pediatr Surg 1998; 33:1733. [PMID: 9856908 DOI: 10.1016/s0022-3468(98)90645-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Noorily MJ, Farmer DL, Flake AW. The association of complete laryngotracheoesophageal cleft with left lung agenesis: pathophysiological clues provided by an experiment of nature. J Pediatr Surg 1998; 33:1546-9. [PMID: 9802811 DOI: 10.1016/s0022-3468(98)90495-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The authors present a patient with complete laryngotracheoesophageal cleft and concurrent left lung agenesis and microgastria. Prenatal ultrasound scan showed polyhydramnios and a hypertrophic right lung. The authors propose that the combination of right lung hypertrophy, polyhydramnios, and microgastria in the absence of a competent laryngeal mechanism may suggest that the preferential path for swallowed amniotic fluid was into the lung, rather than the normal route through the stomach. This case illustrates the prenatal findings suggestive of complete laryngotracheoesophageal cleft and lung agenesis, and suggests a potential causal relationship between shunting of swallowed amniotic fluid into the bronchial tree and prenatal lung hypertrophy and microgastria.
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Affiliation(s)
- M J Noorily
- Department of General Surgery, Children's Hospital of Michigan, Wayne State University, Detroit 48201, USA
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26
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Abstract
Congenital laryngotracheo-oesophageal cleft is a rare anomaly which presents a challenge to the anaesthetists because of the potential problems of establishing and maintaining an airway. We report the anaesthetic management of a one-month old baby with complete or type IV laryngotracheo-oesophageal presenting for the repair of the defect. The management of the precarious airway is presented and the various techniques of managing the airway are reviewed.
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Affiliation(s)
- S K Lim
- Department of Anaesthesia & Intensive Care, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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