Management of tracheomalacia in association with congenital tracheo-oesophageal fistula

Familial and genetic factors in laryngeal cleft: Have we learned anything?

INTRODUCTION

Laryngeal clefts are rare congenital anomalies characterized by failed fusion of the posterior cricoid lamina or incomplete development of the tracheoesophageal septum. While most cases are sporadic, laryngeal cleft may be associated with other congenital anomalies or syndromes. Though not frequently reported, familial occurrence of laryngeal cleft has been noted in our clinical experience. The goal of this research is to describe the existing literature and our own experience surrounding familial occurrence of laryngeal cleft that may help elucidate its underlying genetic basis.

METHODS

Comprehensive literature search was conducted and retrospective chart review was performed on 8 sets of siblings diagnosed at our institution. Data assessed included demographics, type of cleft, and genetic findings.

RESULTS

Laryngeal cleft appears to be mostly sporadic. We evaluated data at our institution over a 10-year period and identified 19 patients from 8 families demonstrating familial occurrence of laryngeal cleft. Six (75%) families had two affected siblings, one family (12.5%) had three affected siblings, and one family (12.5%) had four affected siblings. There was no evidence of sex predilection, with half the patients being male (10/19, 52.6%). Fourteen patients (73.7%) had Type 1 clefts and five (26.3%) had Type 2 clefts. Genetic findings were available for review in five patients from three families.

CONCLUSION

Beyond a few known syndromes, laryngeal cleft has largely been thought to be sporadic. However, findings from the existing literature and our own experience with familial laryngeal cleft in eight families suggest additional genetic factors are yet to be elucidated.

Prevalence of Laryngeal Cleft in Pediatric Patients With Esophageal Atresia

Importance

Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), and laryngeal cleft are rare congenital anomalies that often occur together. Previous reports have established a link between EA/TEF and laryngeal cleft, but there have been no large case series to further characterize this relationship.

Objectives

To assess the prevalence of laryngeal cleft among patients with EA/TEF, identify associations between types of laryngeal cleft and EA/TEF, and identify factors associated with the timing of diagnosis for both conditions.

Design, Setting, and Participants

Retrospective analysis of 270 patients. The Esophageal Atresia database was used to identify patients seen at the Esophageal and Airway Treatment (EAT) Center at Boston Children's Hospital, Boston, Massachusetts, a tertiary referral hospital, from August 1, 2009, to August 1, 2016. Patients were included if they were younger than 18 years at the time they were diagnosed with EA, TEF, or both and had undergone a procedure or examination by a surgeon from the EAT Center. Patients with acquired airway or esophageal problems were excluded.

Main Outcomes and Measures

Data regarding patient demographics, primary diagnoses, dates of diagnosis, comorbidities, and airway/esophageal surgical interventions were collected and analyzed. Association between type of EA/TEF and laryngeal cleft type was evaluated. Secondary outcomes were age at diagnosis between patients who resided in Massachusetts and those who resided outside the state.

Results

Of 270 patients diagnosed with EA/TEF during the 7-year period, 138 (51.1%) were male, and the median age at diagnosis of EA/TEF was 1.0 years (IQR, 0.4-2.0) and at diagnosis of laryngeal cleft was 1.1 years (interquartile range [IQR], 0.6-2.8). Laryngeal cleft was diagnosed in 53 of the 270 patients (19.6%) (95% CI, 14.9%-24.4%). No apparent difference was found in the distribution of types of laryngeal cleft by type of EA/TEF. Among patients with EA/TEF type A or B, 9 patients (56%) had a type I cleft, 6 (38%) had a type II cleft, and 1 (6%) had a type III cleft. Among those with EA/TEF type C or D, 20 (57%) had a type I cleft, 11 (31%) had a type II cleft, and 3 (9%) had a type III cleft. Out-of-state patients were more likely to be diagnosed with EA/TEF at an older age than in-state patients (mean difference, 1.5 years; 95% CI, 0-2.9 years).

Conclusions and Relevance

Pediatric patients with EA/TEF have a much greater prevalence of laryngeal cleft than the general population. Multidisciplinary esophageal and airway programs serve as an ideal clinical setting for management of EA/TEF.

Upper Airway Anomalies in Congenital Tracheoesophageal Fistula and Esophageal Atresia Patients

Objective:

To examine the prevalence of upper airway anomalies in patients diagnosed with congenital tracheoesophageal fistula and esophageal atresia (TEF/EA).

Methods:

A retrospective review was conducted of all TEF/EA patients seen at a tertiary pediatric hospital between January 2008 and December 2013. Inclusion criteria included evaluation by the otolaryngology service. Exclusion criteria included age >18 years, acquired TEF/EA, subsequent rule out of TEF/EA, and otolaryngology evaluation for reasons not pertaining to the airway. Data collected and analyzed included demographics, comorbidities, presenting symptoms, surgical interventions, laryngoscopic and bronchoscopic examinations, and subsequent medical and surgical management.

Results:

Four hundred and thirty patients were diagnosed with TEF/EA at our institution. In all, 32.3%, or 139 children, were included in the analysis; 56.1% (n = 78) male, 43.9% (n = 61) female. Of the analyzed patients, 4.3% (n = 6) were diagnosed with laryngomalacia. Eighteen patients (12.9%) were diagnosed with subglottic stenosis. Thirty (21.6%) had vocal fold paresis or immobility. Laryngeal cleft was diagnosed in 25.9% (n = 36). Tracheomalacia was the most common airway finding, diagnosed in 37.4% (n = 52) patients.

Conclusion:

Patients diagnosed with congenital TEF/EA have a high rate of secondary upper airway anomalies. Consideration should be given to perform a complete airway evaluation in all of these patients.

Tracheomalacia and Tracheobronchomalacia in Children and Adults

Tracheomalacia and tracheobronchomalacia are disorders that are encountered in both pediatric and adult medicine. Despite increasing recognition of these disease processes, there remains some uncertainty regarding their identification, causes, and treatment. This article is intended to be a comprehensive review of both the adult and pediatric forms of the diseases, and includes sections on the historical aspects of the disorders, and their classification, associated conditions, histopathology, and natural history. We also review the various modalities that are used for diagnosis as well as the state of the art of treatment, including airway stent placement and surgical intervention.

Tracheomalacia and bronchomalacia in children: pathophysiology, assessment, treatment and anaesthesia management

Tracheomalacia and bronchomalacia are becoming increasingly well recognized. Although pathologically benign conditions, they are responsible for considerable morbidity, occasional mortality and significant difficulties in the operating theatre and intensive care unit. We performed an extensive literature search to identify causal associations, methods of clinical and investigative assessment, treatment modalities and anaesthetic experience with these conditions.

[Acute gastric distension necessitating gastrostomy after anesthetic induction for surgical correction of type III esophageal atresia]

IPPV during anaesthesia for management of oesophageal atresia with tracheo-oesophageal fistula (TOF) can cause gastric insufflation. We report such a complication in a one-day-old newborn, who developed, 15 min after induction, a distension of the abdomen, hypoxia and bracdycardia. An emergency gastrostomy was performed. His status improved rapidly and surgery could be completed. TOF was located at the carina and had a large calibre. To avoid gastric distension in such cases, the tip of the tube is located just proximal to the carina, but distal to the fistula to prevent intubation of the latter. Difficulties are due to position of the fistula (carina, main bronchi) or its large bore. Gastric distension carries a risk of regurgitation and inhalation of gastric contents, elevation of hemidiaphragm and lung compression, decreased tidal volume, decreased venous return, cardiovascular collapse and cardiac arrest. When insufflation peak pressures are low, gastrostomy is benefitful, as in our case, as the tidal volume loss through the stomach is acceptable. In case of high insufflation pressures because of co-existing lung disease, gastrostomy is better avoided, as most if not all the tidal volume may be lost through the stomach.