Laryngotracheal reconstruction in infants and children: are single-stage anterior and posterior grafts a reliable intervention at all pediatric hospitals?

Objective

To review outcomes of pediatric laryngotracheal stenosis treated by single-stage laryngotracheal reconstruction with anterior and posterior cartilage grafts and compare decannulation rate for single-stage laryngotracheal reconstruction with rates published at larger (>200 beds) pediatric tertiary care hospitals.

Methods

A 4-year retrospective chart review (2004–2008) of all patients undergoing procedures coded with 2008 CPT codes 31582 (laryngoplasty for laryngeal stenosis with graft or core mold, including tracheotomy) and 31587 (laryngoplasty, cricoid split) for a pediatric, tertiary-care hospital. Interventions were single-stage laryngotracheal reconstruction with anterior and posterior cartilage grafts, and the main outcome measure was the decannulation rate after single-stage laryngotracheal reconstruction.

Results

We identified 44 patients with subglottic stenosis, of whom 13 underwent single-stage laryngotracheal reconstruction with anterior and posterior cartilage grafts. The mean age at surgery was 2.2 years (range, 5 months to 4 years). Twelve of 13 children had Cotton-Myer grade III stenosis. Ninety-two percent (12 of 13) of children remain decannulated. The mean follow up was 52 months.

Conclusions

Single-stage laryngotracheal reconstruction with anterior and posterior cartilage grafts appears to be a safe and effective technique for managing patients with high-grade subglottic stenosis at intermediate size children's hospitals. Our overall decannulation rate of 92% compares favorably to that reported in the literature (84–96%).     

探讨肋软骨瓣移植成形术治疗重症喉气管狭窄成败原因

目的探讨应用肋软骨移植喉气管成形术治疗重症喉气管狭窄成败原因,提高喉气管狭窄成形术技术.方法回顾分析第四军医大学唐都医院1983～2001年采用喉气管裂开移植肋软骨治疗重症喉气管狭窄患者36例病情及治疗结果,研究其成败原因及解决方法.结果 36例中29例(80.5%)一次成形术成功治愈,拔除气管切开套管,恢复正常呼吸,经1～10年随访,疗效巩固.7例失败未愈.失败原因局部皮肤血循环差(大剂量放射治疗后,反复多次手术局部瘢痕重),伤口感染软骨坏死排出,T形管损伤黏膜形成新的瘢痕狭窄和瘢痕体质.结论用肋软骨瓣移植术治疗严重或比较严重的喉气管狭窄方法简单,带T形管时间短,疗效好.缺点是增加一个手术切口,游离肋软骨容易发生缺血性坏死,颈部皮肤放射治疗后及瘢痕体质者慎用此法.选择好适应证,术后加强护理,正确应用支撑器可以提高疗效.     

探讨肋软骨瓣移植成形术治疗重症喉气管狭窄成败原因

目的 探讨应用肋软骨移植喉气管成形术治疗重症喉气管狭窄成败原因，提高喉气管狭窄成形术技术。方法 回顾分析第四军医大学唐都医院1983－2001年采用喉气管裂开移植肋软骨治疗重症喉气管狭窄患者36例病情衣治疗效果，研究其成败原因及解决方法。结果 36例中29例（80．5％）一次成形术成功治愈，拔除气管切开大管，恢复正常呼吸，经1－10年随访，疗效巩固。7例失败未愈。失败原因：局部皮肤血管循环差（大剂量放射治疗后，反复多次手术局部瘢痕重），伤口感染软骨坏死排出，T形管损伤黏膜形成新的瘢痕狭窄和瘢痕体质。结论 用肋软骨瓣移植术治疗严重或比较严重的喉气管狭窄方法简单，带T形管时间短，疗效好。缺点是增加一个手术切口，游离肋软骨容易发生缺血性坏死,颈部皮肤放射治疗后及瘢痕体质者慎用此法。选择好适应证，术后加强护理，正确应用支撑器可以提高疗效。     

Study of mechanisms of lightening aspiration and increasing decannulation rate in anastomosis of cricoid cartilage and base of tongue (epiglottis)]

OBJECTIVE: To study laryngopharyngeal anastomosis and fixing methods of super-cricoid laryngectomy with reconstruction of functions in lightening aspiration and increasing decannulation rate. METHODS: Recovering conditions of laryngeal functions in 66 patients who underwent supracricoid laryngectomy and anastomosis of cricoid cartilage and base of tongue (epiglottis) in recent eight years were summarized. Some relevant caliber distances in 21 residual larynges were measured. RESULTS: All cases restored their phonation. In 36 cases that underwent anastomosis of cricoid cartilage and base of tongue, 15 cases without aspiration, 18 with mild aspiration, 3 moderates. Decannulation rate is 94.4%. In 30 cases who underwent anastomosis of cricoid cartilage and base of tongue, 10 with mild aspiration, 17 moderate, 3 serious. All cases overcame aspiration within 3 weeks. 7 cases were cannulated. 3, 5, 10 year survival rates were 80.3%, 74.4%, and 3/7. The longitudinal and transverse calibers of epiglottis were 1.5-2.0 times longer than that of the entrance of cricoid cartilage. After anastomosis of cricoid cartilage and base of tongue (epiglottis), the epiglottis can exactly cover the entrance of cricoid cartilage to prevent aspiration fully and increase decannulation rate. Previously the cricoid cartilage was anatomized and fixed under the hyoid bone. Because some spaces exist between cricoid cartilage, base of tongue and epiglottis, aspiration is likely to occur. That hyoid bone covers the entrance of cricoid cartilage will bring constriction of the new laryngeal orifice and make decannulation difficult. Hyoidectomy and anastomosis of cricoid cartilage and base of tongue (epiglottis) overcame the two shortcomings and had good effects. CONCLUSION: Cricoid-hyoid-anastomosis was the main reason of severe aspiration and low decannulation rate. The ideal methods to lighten aspiration and increase decannulation rate are hyoidectomy and anastomosis of cricoid cartilage and base of tongue (epiglottis).     

环舌根会厌吻合术对减轻误咽提高拔管率的探讨

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Laryngotracheal reconstruction with autogenous rib cartilage graft for complex laryngotracheal stenosis and/or anterior neck defect

To study the effectiveness of laryngotracheal reconstruction with rib cartilage graft for complex laryngotracheal stenosis and/or anterior neck defect, 62 patients with complex laryngotracheal stenosis and/or anterior neck defect underwent laryngotracheal reconstruction with autogenous rib cartilage graft. The surgical procedures were laryngotracheotomy with rib cartilage graft interposition and silicon-tube stent placed in the region of laryngotracheal stenosis and/or anterior neck defect for the period of between 10 days and 12 months. Three patients with complex subglottic stenosis and anterior neck defects underwent a single-stage reconstruction with a combined rib cartilage graft interposition and fasciocutaneous flap reparation. One patient with a complex subglottic and superior thoracic tracheal stenosis underwent a staged operation. Of the 62 patients, 46 patients (74.1 %) were successfully decannulated. One patient had combined subglottic stenosis, which was healed, and superior thoracic tracheal stenosis, which is undergoing treatment. 15 patients (24.2 %) had failure in decannulation due to either wound infection followed by rib cartilage necrosis, or granulation tissue formation and restenosis. Of these 15 patients, ten required revision operations and delayed healing. The duration of follow-up ranged from 1 to 10 years. Of 46 patients, who were successfully decannulated, 36 had a satisfactory airway and a functional voice; two had restenosis due to partial laryngectomy for laryngocarcinoma recurrence 1 year after decannulation; eight were lost to follow-up after successfully decannulated. We conclude that this method can provide effective treatment for complex laryngotracheal stenosis and/or anterior neck defects. It is relatively simple with a high decannulation rate in selected patients.     

Cricotracheal resection as a primary procedure for laryngotracheal stenosis in children

OBJECTIVE: Cricotracheal resection (CTR) is being increasingly used in the treatment of children with severe laryngotracheal stenosis. In this institution the majority of children are treated with CTR as a salvage procedure having undergone previous unsuccessful laryngotracheal reconstruction (LTR). Selected children have undergone CTR as a primary procedure (without previous LTR). The objective of this study is to examine the outcome for children undergoing cricotracheal resection as a primary procedure for severe laryngotracheal stenosis. METHOD: analysis from prospectively collected database. RESULTS: 17 patients underwent CTR without previous LTR or anterior cricoid split between October 1994 and September 1998. All the patients had grade 3 or 4 stenosis. After a minimum of 1 year follow up 15 children are decannulated. Five children required further surgery to achieve this. Two children still have tracheostomies. Both had extended procedures. One included bilateral arytenoid abduction for bilateral vocal cord paralysis in a patient with quadraparesis following transverse myelitis. The other child, who suffered from multiple congenital anomalies, underwent a concurrent posterior cricoid cartilage graft. Nine patients had good voice post-operatively, five had acceptable voice and three had weak or no voice. CONCLUSION: the early experience for CTR in children as a primary procedure achieved an overall decannulation rate of 88% after 1 year follow up in children with severe laryngotracheal stenosis. Five children required further surgery to achieve this. The voice outcome was variable. CTR is an alternative primary procedure to LTR for severe laryngotracheal stenosis in children. The relative indications for these procedures are discussed.     

Acquired total (grade 4) subglottic stenosis in children

Pediatric acquired total subglottic stenosis (SGS) is a challenging problem. The management of these patients has evolved at our institution over the past 25 years. We conducted a retrospective study to evaluate the surgical management and outcomes of children with grade 4 SGS. Fifty-six patients have presented with acquired grade 4 SGS since 1981. The causes included previous surgery (34), prolonged intubation (15), bums (1), and unknown causes (6). Of the 56 patients, 44 (79%) were decannulated; 120 total procedures were performed, and 39 patients (70%) required more than 1 procedure for decannulation. The decannulation rate has risen from 67% in the 1980s to 86% in the 1990s. Patients who underwent cricotracheal resection (CTR) had a higher decannulation rate than patients who underwent laryngotracheal reconstruction (LTR) with anterior and posterior costal cartilage grafting (CCG) (92% versus 81%), and were less likely to need additional open procedures to achieve decannulation (18% versus 46%). The decannulation rate for children with grade 4 SGS has improved because of advances in surgical technique. Currently, the principal operations used at our institution are 1) CTR and 2) LTR with anterior and posterior CCG. There was a trend toward a higher decannulation rate in patients who underwent CTR, and they were less likely to require further reconstructive surgery before decannulation.     

Pediatric airway reconstruction at Great Ormond Street: a ten-year review. II. Revisional airway reconstruction.

One hundred eight consecutive patients with pediatric laryngotracheal stenosis requiring airway reconstruction over a 10-year period were reviewed. Thirty-two patients required revisional airway reconstruction in an attempt to achieve decannulation. Patients underwent from one to four revisional airway reconstructions, most often laryngotracheal reconstruction with costal cartilage grafting. In the Cotton grading scheme of preoperative stenosis, those patients requiring revisional airway surgery tended to come from the more severely affected categories. Twenty-two patients of 32 (69%) achieved decannulation with revisional airway reconstruction. Thus, revisional airway reconstruction is indicated if the first attempt fails.     

喉气管狭窄重建术20年经验

为了提高喉气管狭窄的重建技术。总结２０年来２６１例喉气管狭窄的治疗，８８．８％患者术前都依靠气管切开套管呼吸。主要手术方法：声门重建术、栅栏状喉气管重建术，喉气管切开加自体或人工合成移植重建术等。结果：２６１例，９例未愈，５例失访，２４７例（９４．６％）已拔管治愈。１９２例随访１￣１８年，４例３年后再狭窄，其中３例再手术治愈。１０例未愈，１８２例（９４．７％）疗效巩固。结论：喉气管狭窄的治疗应根据     

喉气管狭窄重建术20年经验

为了提高喉气管狭窄的重建技术。总结２０年来２６１例喉气管狭窄的治疗。８８．８％患者术前都依靠气管切开套管呼吸。主要手术方法：声门重建术；栅栏状喉气管重建术；喉气管切开加自体或人工合成移植物重建术等。结果：２６１例中，９例未愈，５例失访；２４７例（９４．６％）已拔管治愈。１９２例随访１～１８年，４例３年后再狭窄，其中３例再手术治愈。１０例未愈，１８２例（９４．７％）疗效巩固。结论：喉气管狭窄的治疗应根据病情选择手术方法和移植物；栅栏状喉气管重建术具有方法简单，抗感染力强优点；严重喉气管狭窄、闭锁或合并气管大面积缺损以双蒂肌皮瓣、复合肋软骨和人工气管环重建术效果较好；支撑器的应用在喉气管重建中有重要作用。     

Update on the use of auricular cartilage in laryngotracheal reconstruction

The pediatric otolaryngologist is often called upon to aid in the diagnosis and management of subglottic stenosis. This report contains an update of our experience using auricular cartilage in laryngotracheal reconstruction. A retrospective review of the medical records at St Louis Children's Hospital identified 43 children with subglottic stenosis. Thirty-one children were treated by use of auricular cartilage with a success rate of 84%, and an overall 94% success rate after revision surgery. Eight children in whom an anterior cricoid split initially failed were secondarily treated with auricular cartilage with a success rate of 75%. Two children initially treated with costochondral cartilage underwent multiple reconstructive procedures with either auricular cartilage or costochondral cartilage with an overall success rate of 50%. The remaining 2 children had long-segment tracheal stenosis and underwent repair with auricular cartilage with a 50% success rate. We find that auricular cartilage grafts are highly effective when used in a primary single-stage procedure in children with grade I or II stenosis. We have had limited success with auricular cartilage in patients with grade III stenosis and are reluctant to use it in grade IV stenosis, long-segment tracheal stenosis, staged reconstruction, or revision of an auricular or costal cartilage graft laryngotracheal reconstruction.     

Laryngotracheal Reconstruction Using Microplates in a Porcine Model With Subglottic Stenosis

Current techniques of laryngotracheal reconstruction require a choice between prolonged stenting (conventional technique) or short-term stenting with maintenance of sedation and paralysis until the airway has stabilized(single-stage laryngotracheal reconstruction). An alternative method is proposed using microplates to provide immediate airway stabilization without stenting. This study was designed to evaluate the long-term effects of microplate repair of stenosis of the subglottis and trachea on the growing larynx. Subglottic stenosis was produced in piglets using a transoral endoscopic technique. Eight animals underwent repair of the stenosis using an anterior cricoid split with microplate distraction and stabilization of the cricoid cartilage and first tracheal ring. The distraction was maintained and airway growth continued for the duration of this study. However, with growth of the larynx the plates migrated away from their original position. In 50% of the animals followed up for 90 days the plates migrated into the airway lumen. This study suggests that rigid distraction of the stenotic airway with microplates is a viable alternative to more traditional methods of repair. However, plate removal at some interval after surgery is required in the growing larynx in order to prevent migration of the plate into the airway.     

Characteristics and surgical outcome of 98 infants and children surgically treated for a laryngotracheal stenosis after endotracheal intubation: Excellent outcome for higher grades of stenosis after SS-LTR

Introduction

To describe the characteristics and surgical outcome of 98 infants and children treated for an acquired laryngeal stenosis after intubation for respiratory support.

Material and methods

We retrospectively reviewed our data from the last 18 years (1994–2013) concerning infants and children with an acquired laryngotracheal stenosis who were treated in our hospital with a laryngotracheal reconstruction or a cricotracheal resection. Outcome was defined by decannulation ratio.

Results

Of the 98 infants and children who were studied, 54% were preterm, 18% neonates, 13% infants and 14% children. Ninety-one SS-LTR’s, two DS-LTR’s and five CTR’s were performed as primary surgery; three revision operations were performed (DS-LTR). Seventy-seven children had a tracheostomy prior to surgery; decannulation ratio was 93% after primary surgery and 95% after inclusion of revision surgery. For SS-LTR, the decannulation ratio was 93%, including grade III stenosis with comorbidities. Male sex and glottic involvement of the stenosis are correlated to failure of decannulation. Intubation in the term neonatal period is correlated to complicated post-operative course after SS-LTR.

Conclusions

Excellent results of surgery for acquired laryngotracheal stenosis can be obtained with a high decannulation rate. Even for higher grades of stenosis with comorbidities and glottic involvement, an SS-LTR is an effective surgical treatment for acquired laryngeal stenosis.     

Surgical treatment for laryngotracheal stenosis in the pediatric patient

We report our experience with laryngotracheal stenosis (LTS) in children during the last 12 years. Documentation and follow-up were available for 115 patients who underwent surgery for acquired or congenital LTS. Most were severe cases according to Cotton's classification. Forty-six weighed less than 10 kg at the time of surgery; 45 had pure congenital subglottic stenosis; 70 had acquired subglottic stenosis, mainly due to endotracheal intubation. The surgical techniques used have been various. The three main types of procedure were castellated laryngotracheoplasty, anterior cartilage rib grafting, and anterior and posterior cricoid cuts with or without grafting. All cases but 1 (44/45) of congenital subglottic stenosis have been successfully decannulated, 7 requiring a second procedure. The decannulation rate for acquired SGS was 89% (62/70), but 14 patients required multiple procedures. Current trends in subglottic stenosis management in our institution are presented.     

游离舌骨重建环状软骨治疗获得性声门下狭窄的疗效评估

目的 探讨儿童获得性声门下狭窄诊断及治疗方法.方法 对2017年6月～2019年6月因获得性声门下狭窄行喉气管重建术治疗的15例中重度的病例资料进行分析,所有患儿均行喉气管重建术.症状功能评分采用视觉模拟量表(VAS)由监护人评分,包括吞咽功能、肺炎的频率及严重性、语音质量,评估其治疗效果.结果 评估声门下狭窄按Cot...     

喉全切除环咽吻合喉重建术式的改进

为改进Ａｒｓｌａｎ手术，减轻术后误咽、提高拔管率，总结１９８９年￣１９９５年我院行喉全切除环咽吻合喉重建术２７例，按ＵＩＣＣ１９８７年标准Ｔ１ｂＮｏ８例，Ｔ２Ｎ０１７例，Ｎ３Ｎ０２例，全部病例均为双侧声带病变，病变较轻一侧声带受累在１／２以上。     

Irradiated homograft cartilage in laryngotracheal reconstruction--a preliminary experience

OBJECTIVE: To determine the suitability of irradiated homograft cartilage in pediatric laryngotracheal reconstruction (LTR). METHODS: Retrospective case series at a tertiary care children's hospital. Pediatric patients with subglottic stenosis who had LTRs performed using irradiated homograft costal cartilage. Data was collected on postoperative complications, findings at subsequent endoscopic examinations and final outcome. RESULTS: Minor degrees of graft resorption were observed that did not affect eventual decannulation. CONCLUSION: Irradiated homograft costal cartilage can serve as a successful alternative to the traditional autologous costal cartilage in lower grades of laryngotracheal stenosis.     

Management of severe congenital laryngeal webs – a 12 year review

ObjectiveThe aim of this study was to investigate respiratory and voice outcomes after open surgery for severe congenital laryngeal web.MethodsIncluded were all patients treated for severe congenital glottic web (Cohen type 3 and 4) between 2002 and 2014. Demographic data, symptoms, endoscopic findings, type of operation, outcome and complications were analyzed. Open surgery was performed with division of the web and enlargement of the subglottis by a laryngotracheal reconstruction or an extended partial cricotracheal resection.ResultsFourteen patients were included. Information on the pre-operative voice was available in 11 patients. Aphonia was present in 6 patients (55%), dysphonia was severe in 1 (9%), moderate in 2 (18%) and mild in 2 (18%). Median age at operation was 19.3 months. As a first line treatment, laryngotracheal reconstruction was performed in 12 patients, and an extended partial cricotracheal resection in 2. Median follow-up was 9.5 months. All patients were successfully decannulated in a median time of 4 months after first surgery. Voice was improved in 10/11 (91%). Post-operatively, 3 patients (27%) had good voice. Dysphonia was severe in 2 (18%), moderate in 3 (27%) and mild in 3 patients (27%).ConclusionOpen surgery for Cohen type 3 and 4 glottic web allowed establishing a patent airway with successful decannulation in all cases. Quality of voice was improved in 91%, however, voice results were variable. In our opinion a delicate operative technique described in the paper is important for optimal voice results.     

外伤性喉气管狭窄63例临床分析

目的 探讨外伤喉气管狭窄的手术方式与选择原则.方法 回顾性分析解放军总医院耳鼻咽喉头颈外科1993至2006年共收治外伤性喉气管狭窄患者63例的手术方法与治疗效果.结果 63例患者在该院共行99次针对喉气管狭窄治疗的手术(不包括气管切开、拔管及拔管后的气管造口封闭手术),每例患者平均经历1.9次手术;经1次手术者40例(占63.5%),经2次手术者15例(23.8%),3次手术者5例(7.9%),4次手术者2例(3.2%),经历6次手术者1例(1.6%).对首次入院时判断为喉软骨支架完整而行支撑喉镜手术15例,11例1次手术成功.软骨支架骨折、狭窄严重者,首次单纯喉气管裂开T管置入36例,经单次手术成功拔管者20例(55.6%);喉气管裂开、腔内植皮+T管置人术10例,拔管7例(70%);喉气管裂开T管置入、带蒂舌骨喉气管软骨缺损修复共6例,拔管4例(4/6).声门下及气管的局限性狭窄采用狭窄部气管或环状软骨部分切除、端端吻合术9例,7例单次手术拔管(7/9).2例卢门下狭窄并气管食管瘘修补均一次成功,拔除气管套管.患者随访6个月～5年,57例拔管后均呼吸通畅,无误吸,无再狭窄,但嗓音沙哑;6例拔管失败,拔管率为90.5%.结论 外伤性喉气管狭窄治疗比较困难,需根据术前伞面检查,准确评估喉气管支架缺损情况、狭窄的程度和受累的范围,选择恰当的手术方式.