Laryngotracheoplasty in early childhood

Because of increased risk of surgery in infancy and because surgery at this age may affect laryngotracheal growth it is preferable to postpone open surgical correction of congenital or acquired laryngotracheal stenoses until pre-school or even school age. However, early intervention by one of the surgical methods available today appears to be justified if a child with a tracheostomy has unsatisfactory home surroundings, if the tracheostomy impedes a rehabilitation programme or if the laryngeal stenosis does not allow voice production. Of 42 children with congenital (14) or acquired (28) laryngotracheal stenosis, 13 were operated between the ages of 3 months and 6 years. The following surgical methods were used, depending on the type and degree of stenosis: (1) submucosal scar resection (5 cases); (2) "stepped incision" as described by Evans and Todd (2 cases); (3) widening of the anterior wall by an autogenous cartilage graft as described by Cotton (2 cases); (4) laminotomy with interposition of an autogenous cartilage graft as described by Rethi (3 cases); (5) multiple-staged laryngotracheal reconstruction with regional skin flaps and repeated cartilage grafting (1 case). The soft silicon Montgomery T tube was preferred in all cases for stenting the reconstructed laryngotracheal lumen, because it seems to be the most convenient and safest method. The importance of painstaking postoperative intensive care is emphasized. Up to now 11 patients have been extubated, but 4 of them show a mild restenosis. The history of one child who has not yet been decannulated is reported in detail to demonstrate the limits of laryngotracheoplasty in early childhood.