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Cartilage grafts or biopsies of such grafts were obtained from six children who had undergone laryngo-tracheoplasty surgery at times ranging from 10 to 38 months after surgery. The histological appearance of the grafted cartilage was of gradual degeneration with chondrocyte necrosis and replacement of cartilage matrix by fibrous tissue.
The management of posterior glottic stenosis resulting from impaired crico-arytenoid joint (CAJ) mobility in infants and children presents a perplexing and frequently unrewarding surgical dilemma; any improvement in the airway is almost invariably at the expense of the voice. Progress in this area has been hampered not only by the rarity of cases, but also by the technical difficulty of achieving an accurate diagnosis at endoscopy. In order to address this problem we have undertaken a retrospective analysis of 35 infants and children, treated at Great Ormond Street between 1980 and 1991, with endoscopically confirmed impairment of CAJ mobility. Five cases of mild posterior glottic stenosis were successfully treated either conservatively or by laser scar division. Thirty cases of moderate or severe stenosis were identified, and 19 of these have undergone corrective surgery. Of these 19, 17 had a prior tracheostomy, and 12 have been decannulated. No problems with aspiration were encountered but five (i.e. 25%) of those treated surgically suffered a deterioration of voice quality.
Twelve cases of childhood subglottic stenosis diagnosed either acquired or congenital were treated using an endolaryngotracheal Montgomery T-tube. Stenting lasted on average 5.6 months. Tracheotomy closure was possible in 75% of cases on average 15.3 months after diagnosis. Tube-linked complications involved the child pulling out, forward migration of the tube out, lower tracheal migration of the tube, clogging and the formation of granulation tissue at its superior extremity. Comparison of outcomes with those for laryngeal surgery (cricoid split, laryngotracheal reconstruction) found in the literature, suggests that long-term T-tube stenting is the optimal treatment for subglottic stenosis where tracheomalacia precludes laryngeal surgery.
Physical illness in children is affected by a variety of factors unique to pediatrics. They include a child's developmental level, family environment and the presence of premorbid behavior patterns. Therefore, pediatric care requires special considerations pertaining to the patient-physician relationship and the potential for psychosocial dysfunction. Three case reports are presented to illustrate these concerns in treating children within the specialty of otolaryngology. Prompt identification of these factors and effective intervention in cases of psychosocial disturbance are challenging facets of the practice of pediatric otolaryngology.
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Reconstructive techniques for the stenotic pediatric airway have greatly enhanced the otolaryngologists ability to decannulate the tracheotomy-dependent child. Stents have played an important role in this process by both maintaining the reconstructed lumen and acting as a scaffold. However, decannulation is often not achieved after the first surgical intervention with some patients requiring two, three or more procedures. In an effort to improve upon the design of today's stents, an open stented tracheotomy tube was evaluated at our institution. This stent is designed to provide advantages of immediate postoperative voice and nutrition, and ease of evaluation, as well as to provide for safe and adequate healing. Four patients underwent laryngotracheal reconstruction with this stent over a 10-month period. All patients could vocalize and eat immediately postoperatively but recalcitrant granulation tissue and restenosis has prevented decannulation in three of the cases. The experience with this stent exemplifies the persistent difficulties of stent use in pediatric airway reconstruction. It also points out that progress is still needed in current reconstructive techniques as well as in the development of new techniques.
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.
The effects of a Rethi procedure upon the cricoid is investigated in young rabbits. An anterior and posterior cricoid split carried out upon the larynx of a young rabbit was demonstrated to result in an enlarged cricoid lumen in the adult stage due to an enhancement of both the anterior and posterior transversal diameter of the ring. These changes are ascribed to a release of interlocked stresses in the cricoid cartilage and the action of the cricopharyngeal and cricothyroid muscle.
After initial treatment of severe laryngotracheal stenosis (LTS), we evaluated subsequent airway function. Five children between 2 and 11 years were treated previously for severe LTS by T-tube stenting. One case underwent subsequent laryngotracheal reconstruction. All patients demonstrated dyspnea, the severity of which increased with age and duration of time after completion of stenosis treatment. In the most severe cases, magnetic resonance imaging and endoscopy revealed secondary subglottic stenosis. Ventilatory function tests disclosed obstruction of both extrathoracic and pulmonary origin. These findings raise questions regarding the treatment of the initial stenosing tissue and of the secondary stenoses.
Infection of the intubated subglottis is felt to be one of the many factors involved in the pathogenesis of acquired cicatricial subglottic stenosis. The precise role of infection is unclear and the microbial flora has not been established. An analysis of subglottic culture material, from 22 intubated pediatric patients undergoing tracheotomy, has been performed to establish the nature of the subglottic microbial flora. Fifty-nine isolates were found, including 19 types of organisms. The number of isolates per patient ranged from one to eight, with an average of 2.7 isolates per patient. The most common isolates in the 22 patients were alpha-hemolytic Streptococcus viridans (17 isolates-77%), Neisseria sp. (6 isolates-27%), Pseudomonas sp. (5 isolates-22%), and coagulase negative Staphylococcus sp. (5 isolates-22%). This data indicates that colonization of the subglottis in intubated pediatric patients is polymicrobial in nature. alpha-Hemolytic Streptococcus viridans and Neisseria sp. were most common, with a shift in cultured flora towards Pseudomonas sp. in patients intubated for more than 10 days. In view of this, antimicrobial therapy may be of benefit in preventing acquired cicatricial subglottic stenosis.
Thirty young patients with acquired laryngeal stenosis were treated by means of a laryngofissure and stenting. The age distribution suggested two subgroups: infants aged 0-2 years (n = 24), and children aged 6-16 years (n = 6). The causes of the stenosis and the treatment results were different in these subgroups. Treatment resulted in successful decannulation in 22 of 24 infants, and in 5 of 6 children. Treatment included a re-operation in two patients. In 1 patient the therapy failed, and 2 patients died after fatal complications. Decannulation rate, duration of the tracheotomy, and the number of re-operations compare favorably to the results of other centers. The longer duration of stenting, and the high mortality rate may be considered disadvantages.
The standards of treatment of subglottic hemangiomas are steroids and laser vaporization. If these methods do not provide a sufficient airway, a tracheotomy may be required. Analysis of the data available in the literature shows that there is a place for other therapeutic solutions. Open surgical excision could be one of them but is controversial. So far, it represented a 'last' resort procedure before tracheotomy. Our approach to open surgical excision is different. A prospective decision is taken in the initial therapeutic approach. Infants are considered candidates for excision in cases of large hemangiomas that extend beyond the limits of laser. Laser is, then, avoided in order not to damage the overlying mucosa. Interferon is not utilized because a rapid effect is not expected on the respiratory distress. Open surgical excision without tracheotomy is performed. A cricoid enlargement is associated at the end of the procedure. Risk for post-operative subglottic stenosis is limited. When conceived this way, open surgical excision seems effective to manage large life-threatening hemangiomas.
Posterior glottic stenosis resulting in limitation of vocal cord abduction is a difficult clinical problem. Usually secondary to intubation, mature posterior glottic stenosis is a difficult clinical problem better prevented than treated. We present a case of a patient with early, membranous posterior glottic stenosis successfully treated with a cricoid split procedure, lysis of the stenosis and planned postoperative intubation. This treatment allowed healing of the interarytenoid area and resulted in good vocal cord abduction. A literature review and rationale for the procedure are presented.
The campomelic syndrome is a rare osteochondrodysplasia which frequently leads to early death from pulmonary insufficiency. We describe a patient with anatomic compromise of the upper airway due to diffuse laryngotracheomalacia and a moderate subglottic stenosis, treated successfully with single-stage laryngotracheal reconstruction using a rib graft. To our knowledge this has not been previously described. A review of the current literature is included.
The possibility of subglottic stenosis in children with Down syndrome is well recognized. Nevertheless, this anomaly and its effect on laryngeal and respiratory function are frequently overlooked. When subglottic stenosis is present in a child with Down syndrome, the standard intubation technique may require modification. In these children, an endotracheal tube of a size appropriate to the patient's age may be too tight in the subglottic area. By aggravating a previously asymptomatic subglottic stenosis, long-term endotracheal intubation in this type of patient may be more likely to lead to a clinically significant subglottic stenosis. In our experience, subglottic stenosis in children with Down syndrome is more difficult to repair and is associated with a lower success rate of decannulation. Additionally, it is important in the management of these children not to create an even more severe subglottic stenosis.
The management of neonatal subglottic stenosis by the anterior cricoid split procedure (ACS) has evolved rapidly since this operation was first described by Cotton and Seid in 1980. Recent reports have specified criteria for the evaluation of patients for ACS, and adherence to these guidelines has increased the extubation rate and decreased the mortality rate in these series. Ninety-one patients have undergone anterior cricoid split at Children's Hospital Medical Center (Cincinnati, OH) since 1977. These cases were reviewed, emphasizing the 24 infants treated since January 1, 1988, and not previously reported. In comparison to our most recent report of 70% extubation and 10.4% mortality, 67% of the latest group were extubated, while mortality was reduced to 4.1%. These results were achieved despite some relaxation of strict patient-selection guidelines when this was appropriate in individual patients, emphasizing the need for careful clinical evaluation and close consultation between otolaryngologist and pediatrician in the selection of patients for ACS.