Margins of partial cricotracheal resection in children.

OBJECTIVE: To review the surgical margins of partial cricotracheal resection in our series of patients. This includes specific anatomic detail as to each superior and inferior resection margin. To apply this information and access the utility of partial cricotracheal resection for the treatment of subglottic stenosis. STUDY DESIGN/METHODS: A retrospective review was performed of 38 children with severe subglottic stenosis who underwent partial cricotracheal resection. Information was obtained with regard to the specific anatomic location of the superior and inferior resection margins, the grade of subglottic stenosis preoperatively, the type of stenting material used postoperatively, and other surgical details specific to each procedure. RESULTS: The superior resection margins were generally to the superior aspect of the cricoid cartilage but as high as the undersurface of the true vocal folds in a minority of patients. Inferior resection margins were generally to the second tracheal ring. Length of resection varied, but was as long as 3.0 cm in one patient. Overall surgical success based on decannulation was > 86%. CONCLUSION: Partial cricotracheal resection is a safe and successful procedure for the treatment of subglottic stenosis. The margins and length of resection should be tailored specifically for each patient; and special considerations must be taken when extensive resection to the level of the true vocal folds is required. Safe airway management in the postoperative period is essential.     

Primary cricotracheal resection in children: indications, technique and outcome

OBJECTIVE: Treatment of subglottic stenosis has benefited greatly from development of grafting techniques such as larygontracheoplasty. Meanwhile, cricotracheal resection of the stenotic area and a major part of the cricoid cartilage have been shown to give excellent results in adults. PATIENTS AND METHODS: From June 1993 to June 2000, we performed cricotracheal resection, as the primary surgical procedure, for acquired (n=13), congenital (n=2) or mixed (n=l) subglottic stenosis in 16 pediatric patients comprising seven boys and nine girls. At the time of surgery, the mean weight was 16 kg and the mean age was 5 years. Degree of stenosis was classified as grade II in one case, grade III in 12, and grade IV in three. Eight patients underwent two-stage procedures with postoperative tracheostomy. A rolled reinforced silastic stent was placed for a mean period of 20 days and the tracheostomy tube was removed within a mean period of 44 days after stent removal. Eight patients underwent single-stage procedures. The Portex endotracheal tube was used for a mean period of 4 days. RESULTS: All patients underwent regular clinical and endoscopic postoperative examination. Mean follow-up was 38 months. No interference with laryngotracheal growth has been noted in any case, including the five with follow-ups longer than 5 years. CONCLUSIONS: The indications for laryngotracheoplasty and cricotracheal resection in children with subglottic stenosis are still unclear. Decisions must be made on a case-by-case basis. In this article the authors discuss decisional factors in terms of clinical findings, surgical techniques, potential complications, and outcome.     

Long-term voice outcome following partial cricotracheal resection in children for severe subglottic stenosis

Objective

To correlate the postoperative voice outcome to preoperative glottic involvement, following partial cricotracheal resection (PCTR) in children. The glottic involvement was analysed based on the extent of subglottic stenosis (SGS) in the endoscopic image and functional dynamic assessment using flexible endoscopy.

Methods

We conducted an interobserver study in which two ENT surgeons, blinded to one another's interpretation, independently rated the extent of SGS based on the endoscopic image along with the dynamic functional airway assessment, of 108 children who underwent PCTR for grade III or IV stenosis. Based on the observation, the glottic involvement was rated into 4 categories:

A.

SGS clear from vocal cords (3-4 mm below vocal cords).

B.

SGS reaching the free border of vocal cord and/or the posterior commissure with slightly limited abduction with no true posterior glottic stenosis (PGS).

C.

SGS with associated PGS or vocal cord fusion without cricoarytenoid ankylosis (CAA).

D.

Transglottic stenosis with/or without bilateral CAA.

Evaluation of the voice was based on a parent/patient proxy questionnaire sent in 2008 to assess the current functional status of the patient's voice.

Results

Among the 77 patients available for long-term outcome with a minimum 1-year follow-up, 31 patients had isolated SGS free from vocal cords (group A) and 30 had SGS reaching the under surface of vocal cords with partial or no impairment of abduction of vocal cords (group B). Twelve patients belonged to group C with posterior glottic stenosis and/or vocal cord fusion (without cricoarytenoid ankylosis) and 4 patients had transglottic stenosis and or/bilateral cricoarytenoid ankylosis (group D). The long-term voice outcome following PCTR as perceived by the parent or patient was normal in 18% (14 of 77 patients) and the remaining 63 patients demonstrated mild to severe dysphonia. Patients belonging to group A and B exhibited either normal voice or mild dysphonia. Patients in group C demonstrated dysphonia, which was moderate in severity in the majority (83%). All patients in group D with transglottic stenosis and/or CAA showed severe dysphonia.

Conclusion

Children with associated glottic involvement are at high risk for poor voice outcome following PCTR. The severity of dysphonia was found to be proportional to the preoperative glottic involvement. Preoperative rating of the extent of glottic involvement based on endoscopic image and dynamic assessment was found to be useful in prognosticating the voice outcome.     

Airway growth following cricotracheal resection in puppies

A canine animal model was developed to study the effects of cricoid resection on cricoid cartilage growth and subglottic lumen size. Twenty-four healthy, postweanling mongrel puppies, aged 5 to 7 weeks, were randomly divided into two groups. The first group, consisting of 13 puppies, underwent cricotracheal resection with primary anastomosis. A second group, consisting of 11 puppies, served as controls and did not have surgery. Animals from both groups were killed at age 13 weeks. Most of the animals, however, were allowed to mature to adulthood and were killed between age 26 to 28 weeks. Comparative histologic examinations of the laryngotracheal complexes of operated-on and control dogs showed uninterrupted cartilage growth at the anastomosis site after cricotracheal resection. There was no significant difference in the mean area of the cricoid lumen between the two groups when luminal area was adjusted for body weight. The results demonstrate that cricotracheal resection in this animal model does not interrupt cricoid luminal area or cricoid cartilage growth, and provides rationale for further investigation of cricoid resection with primary anastomosis in humans. Cricotracheal resection in growing puppies appears to be an excellent model for further studies in the surgical treatment of acquired subglottic stenosis in infants and children.     

Partial cricotracheal resection for congenital subglottic stenosis in children: The effect of concomitant anomalies

Objective

To review the surgical outcomes of partial cricotracheal resection in children with severe congenital subglottic stenosis and define the effect of concomitant anomalies or syndromes affecting outcome.

Methods

Forty-one children with subglottic stenosis of congenital and mixed (acquired on congenital) etiologies who underwent partial cricotracheal resection were identified from a prospectively collected database. Children with congenital subglottic stenosis and concomitant anomalies/syndromes were compared to children with congenital subglottic stenosis with no syndromes or concomitant anomalies. Operation-specific decannulation rates and complication rates were the primary outcome measures. We performed a two-sample test of proportion using the STATA-10 software for categorical variables to detect differences in proportions. Significance was set at p value < 0.05.

Results

Twenty-seven (66%) of 41 children had concomitant anomalies/syndromes and 14 (34%) had congenital subglottic stenosis without concomitant anomalies/syndromes. Four patients needed revision surgery in the concomitant anomaly group and two patients needed revision surgery in the non concomitant anomaly group before achieving decannulation. The operation-specific decannulation rate in the concomitant anomaly group was 85% and 86% in the non anomaly group. When compared to children without concomitant anomaly, children with concomitant anomalies were more likely to have delayed decannulation following partial cricotracheal resection. However, this difference was not found to be statistically significant. The complication and operation-specific decannulation rates after partial cricotracheal resection were comparable to children without concomitant anomalies. Mortality rate was 11% (three of 27 patients) in the group with associated congenital anomalies or syndromes. Two patients succumbed to the primary pathology and one patient died due to tracheostomy-tube obstruction. There was no post-operative death in the non anomaly group.

Conclusion

Partial cricotracheal resection can be done safely and effectively in children with concomitant anomalies/syndromes to achieve decannulation. The post-operative course may be prolonged but the decannulation and the complication rates are comparable to those children with congenital subglottic stenosis without concomitant anomalies.     

Partial cricotracheal resection for pediatric subglottic stenosis: a single institution's experience in 60 cases.

Ohne Zusammenfassung     

Partial cricotracheal resection for successful reversal of laryngotracheal separation in patients with chronic aspiration

OBJECTIVE: To present our experience with successful reversal of laryngotracheal separation in patients with chronic aspiration, to discuss our surgical technique, and to review the literature. STUDY DESIGN: Retrospective case review. METHODS: The medical records of two patients who underwent a successful reversal of laryngotracheal reversal after separation were reviewed. The two patients were evaluated clinically with videostroboscopy and videofluoroscopy. RESULTS: Both patients presented with intractable aspiration despite protective tracheostomy because of impairment of lower cranial nerve function. After laryngotracheal separation, swallowing rehabilitation was safely possible, and neurologic improvement allowed reversal of the separation procedure. For reversal, we present the use of a partial cricotracheal resection with tracheocricothyropexia similar to the technique used for subglottic stenosis. Both patients were successfully reversed.Satisfactory voice and swallowing function 7 and 10 years after reversal, respectively, could be assessed through our evaluation. Review of the literature revealed a total of 13 cases of successful reversal after laryngotracheal separation. Technical details of surgery and functional results are rarely reported.     

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.     

Lemierre's syndrome as a consequence of acute supraglottitis

Lemierre's syndrome comprises internal jugular vein thrombosis following oropharyngeal sepsis and is a rare and serious condition. It is most commonly caused by the anaerobe Fusobacterium necrophorum and typically presents as metastatic sepsis to the lungs and joints. Thrombosis is demonstrated by computed tomography (CT) of the neck, and it is routinely treated with intravenous antibiotics and anti-coagulation. We describe a case of Lemierre's syndrome following acute supraglottitis. The clinical features were of retrograde intracranial thrombosis, rather than the more usual metastatic sepsis.     

Ballooned trachea as a consequence of intubation.

A case of iatrogenic tracheal dilatation is presented. This potentially fatal complication of endotracheal intubation may escape early detection. It is well demonstrated by CT scanning.     

Cricotracheal resection in children

OBJECTIVE: To review our experience with cricotracheal resection in a pediatric population. DESIGN: Prospective case review of a cohort of patients undergoing cricotracheal resection. SETTING: Tertiary care pediatric hospital. PATIENTS: Forty-four consecutive patients undergoing cricotracheal resection between January 1, 1993, and December 31, 1998. MAIN OUTCOME MEASURES: Decannulation rates. RESULTS: Thirty-eight (86%) of the 44 children are decannulated. The ultimate decannulation rate was independent of the presenting grade of subglottic stenosis. Fourteen children (100%) had a primary cricotracheal resection; all are decannulated. Twenty-one children had a salvage cricotracheal resection, and 19 (90%) are decannulated. Nine children had an extended cricotracheal resection, of whom 5 (56%) are decannulated. A primary cricotracheal resection was performed on a child on whom no previous open airway procedure had been performed. A salvage cricotracheal resection was performed on a child on whom previous open airway reconstruction had not resulted in an adequate airway. An extended cricotracheal resection was performed on a child on whom the cricotracheal resection was combined with a second procedure, either additional expansion cartilage grafting or an open arytenoid procedure. Most of these children had complex airway pathologic conditions. CONCLUSION: Cricotracheal resection complements standard laryngotracheal reconstruction techniques in a pediatric population.     

Sensorineural hearing loss as a consequence of carbon monoxide intoxication

The authors describe the case of acute carbon monoxide intoxication in a 19 year old female patient, which caused, among other symptoms, bilateral sensorineural hearing loss. The symptoms, diagnostic methods and treatment with a particular regard to audiological examination were presented. Pathomechanism of carbon monoxide intoxication was also discussed. Despite the treatment, the effects of therapy have not been satisfactory.