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Acquired subglottic stenosis in children.

Subglottic stenosis is a disorder characterized by narrowing of the airway below the glottis or apposing edges of the true vocal cords. In a broad definition, the term may be used to describe airway compromise in the regions of the larynx or the trachea or both. In children, the stenosis is usually due to scar formation secondary to prolonged airway intubation, rather than to external trauma. The location and extent of the stenosis are highly variable; consequently, corrective measures need to be selected to suit the individual problem. In the present series of children, conservative treatment was adequate for lesser degrees of stenosis; those with more severe scarring required external laryngeal surgery. The preoperative evaluation and treatment plans are reviewed.

Adolescent↗

Adjunctive measures for successful laryngotracheal reconstruction.

The field of reconstructive surgery of the laryngotracheal complex has been the object of considerable enthusiasm in recent years. New surgical techniques, better surgical tools, and improved diagnostic skills all have contributed to a more confident approach to severe laryngotracheal stenosis. Just as the surgeon's judgment is crucial for a successful primary laryngotracheal reconstruction, so are his or her skill and judgment vitally important in managing the various problems that frequently are found following reconstructive surgery of the larynx and trachea. These problems, although seemingly minor, may prevent successful decannulation if not managed appropriately. This paper discusses the various problems that have been encountered while achieving decannulation following laryngotracheal reconstruction. An approach to such frustrating problems as suprastomal collapse, granulation tissue, and the inability to decannulate are presented.

Catheterization↗

Cricothyroidotomy: a decade of experience in Denver.

In an attempt to evaluate cricothyroidotomy as described by Brantigan and Grow in 1976, the authors have reviewed the literature and compared it to the decade of experience following Brantigan and Grow's report. The records of over 1,000 patients requiring ventilatory assistance were reviewed. A comparison of this experience with Brantigan and Grow's original series and subsequent reports was used to establish the criteria and technique for cricothyroidotomy. It appears that while cricothyroidotomy has specific advantages, it also has disadvantages and a higher incidence of airway stenosis than either of the procedures it was designed to replace (low tracheotomy or endotracheal intubation). For this reason, its use has been severely restricted in Colorado, where it was popularized.

Adolescent↗

Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation.

Five patients with severe fibrous subglottic and tracheal stenosis were treated by endoscopic radial laser incision and dilation using both carbon dioxide and neodymium:yttrium aluminum garnet lasers. Good results were noted without complications in all patients in a follow-up period of at least 1 year. Careful selection of patients, excluding those with tracheal collapse or tracheomalacia, and preservation of tracheal epithelium with minimal heat and mechanical trauma are considered essential for good results.

Adult↗

Laryngotracheal reconstruction for subglottic stenosis in children.

The experience with laryngotracheal reconstruction in 20 children in Chicago is reviewed. Nine of the 20 children (45%) operated upon had congenital subglottic stenosis. Ten (50%) had acquired stenosis. One child was classified as having combined types. All patients underwent laryngotracheal reconstruction with autogenous costal cartilage grafts. Eight patients had both anterior and posterior costal cartilage grafts with stent insertion. One had a posterior costal cartilage graft only. Sixteen of the 20 children (80%) have been decannulated. Midtracheal or lower tracheal disease concomitant with laryngotracheal stenosis is an indication that endoscopic management of severe subglottic stenosis is likely to fail. Early laryngotracheal reconstruction is indicated for patients with a high likelihood of failure of endoscopic management and for those with severe cricoid cartilage deformities. Our results support the use of laryngotracheal reconstruction as an alternative to conservative (endoscopic) management of severe subglottic stenosis in carefully selected patients.

Cartilage↗

Risk factors for intubation injury of the larynx.

The endolaryngeal structures are subjected to insult from prolonged endotracheal intubation. Factors that may exacerbate this injury include intubation technique, duration of intubation, tube geometry and constitution, frequency of reintubation, and patient-related factors such as concomitant medical diseases. The contribution of underlying medical disease to laryngeal intubation injury was studied prospectively by sequential endoscopy from the time of tracheotomy. Diabetes mellitus, congestive heart failure, and a history of stroke or tuberculosis increased the likelihood of severe laryngeal injury. The association of these disorders with severe laryngeal injury should lead to consideration of earlier tracheotomy in such patients.

Adult↗

Traumatic innominate pseudoaneurysm rupture during laryngeal dilatation.

Endotracheal hemorrhage from the innominate artery is, fortunately, a rare problem encountered by the otolaryngologist. We present a patient with a tracheal-innominate artery fistula secondary to delayed rupture of a traumatic innominate artery aneurysm. The differential diagnosis of innominate artery hemorrhage is discussed, as is the management of this potentially lethal event. We propose, as the treatment of choice, cessation of hemorrhage through the use of a cuffed endotracheal tube, followed by ligation of the innominate artery using cardiopulmonary bypass. These techniques were used in this patient with a successful outcome.

Adult↗

Protocol for management of the interposition cartilage graft laryngotracheoplasty.

This report presents the results of laryngotracheoplasty surgery using both the Evans and Cotton techniques on 27 children with congenital or acquired subglottic stenosis. Failure to obtain early decannulation after surgery has resulted in the formulation of a new protocol for the operative and postoperative management of infants undergoing cartilage graft tracheoplasty. Excision and closure of the tracheostoma at surgery, with postoperative nasoendotracheal intubation providing the necessary support for the graft, now has reduced this period to approximately 2 weeks. A series of six infants for whom this protocol was followed is presented.

Cartilage↗

Development of congenital laryngeal atresias and clefts.

Congenital supraglottic laryngeal obstruction still is being described as subglottic stenosis. There are three clearly defined types of congenital laryngeal atresia, which result from arrest at consecutive developmental stages. Type 1 consists of a supraglottic obstruction, absent vestibule, and stenotic infraglottis, and type 2 is a supraglottic obstruction that separates a shallow primitive vestibule above from a nonstenotic infraglottis. These two types usually are accompanied by other defects, many of them severe. In type 3, a perforated membrane partly obstructs the glottis. Arrest of the dorsal advance of the chondrifying cricoid before the ends meet to form the dorsal lamina results in a complete laryngeal cleft, and incomplete fusion of the ends may leave a notch and/or foramen within the lamina. Failure of the interarytenoid tissue to develop will produce a local cleft, and maldevelopment of the cricoid cartilage or infraglottic submucosa can result in true subglottic stenosis without supraglottic obstruction.

Humans↗

Rib cartilage grafts for the treatment of posterior glottic and subglottic stenosis in children.

Posterior glottic and subglottic stenosis from endotracheal intubation in children can be managed endoscopically with varying success. Open surgical treatment offers a better potential for correction with a single procedure in moderate and severe cases. The open method consists of splitting the scar and cricoid cartilage posteriorly to the level of the interarytenoid muscle, then stenting the incised cricoid open with a rib cartilage graft. Use of this method is described, and results in 12 cases are reported. Decannulation was achieved in ten patients. In all patients who were decannulated, good exercise tolerance, freedom from aspiration, and an adequate voice quality were achieved.

Adult↗

Advantages of the rotary door flap in laryngotracheal reconstruction: is skeletal support necessary?

Most attempts at laryngeal reconstruction have sought to reestablish skeletal support. Bone and cartilage grafts have been used for this purpose, but they have often failed to maintain position in the larynx and/or trachea following reconstruction, and they tend to be reabsorbed. The rotary door flap can provide an undelayed, one-stage epithelial resurfacing of the larynx and trachea while simultaneously restoring luminal support without the need for transfer of cartilage or bone. Luminal support for the trachea is provided by the bulk, turgor, and anterior traction of the intact sternohyoid muscle, which serves as the carrier for the rotated skin island. During inspiration the intact muscle, whose points of attachment are anterior to the plane of the larynx and trachea, contracts and tends to open the airway to provide dynamic luminal support. The need for internal stenting is minimized. The technique is described and experience in 20 patients is presented.

Adolescent↗

Laryngotracheal reconstruction with composite nasal septal cartilage grafts.

The composite nasal septal graft has been used successfully by us to reconstruct patients with high tracheal and laryngotracheal stenosis. We have treated ten patients and have been able to decannulate seven of these patients. When these ten cases are added to the six original cases presented in an earlier report (1981), certain conclusions can be drawn. The success or failure of these procedures, which is judged by the ability to decannulate the patient, appears to be related to the extent of the initial injury. We discuss the indications for the composite nasal septal graft and the use of additional treatment, including stents, steroid injections, dilatations, and flaps. In conclusion, the addition of these ten cases to the original six cases of composite nasal septal grafts now provides the opportunity to review indications and contraindications for the use of this graft in the management of advanced laryngotracheal stenosis.

Adult↗

Congenital subglottic stenosis: the elliptical cricoid cartilage.

Various malformations of the cricoid cartilage produce congenital subglottic stenosis. The elliptical cricoid cartilage first was demonstrated histopathologically in horizontal sections of six postmortem specimens and now has been identified clinically in ten patients. The clinical diagnosis of the elliptical cricoid cartilage, suggested by anteroposterior soft tissue neck films, is confirmed at direct laryngoscopy. Delineation of the precise location, extent, and histopathology of subglottic stenosis provides the basis for rational management.

Child, Preschool↗

Hydroxylapatite for laryngotracheal framework reconstruction.

Hydroxylapatite plates and rings were employed for reconstruction of the laryngotracheal framework in 12 patients. The cause of the framework defect was surgery for stenosis in nine cases and removal of malignancy in the other three. The trough method associated with a two-stage procedure was tolerated in all 12 cases. Hydroxylapatite plates or rings were used to reconstruct the framework during the second stage. The implant was well taken in all cases, without any infection or rejection. Nine of the 12 cases resulted in excellent airways.

Adult↗

Ferret model for acquired subglottic stenosis.

Researchers continue to look for an improved animal model for the study of acquired subglottic stenosis. This report describes a ferret model that reliably produces 40% to 60% stenosis with a method analogous to the pathophysiology of prolonged endotracheal intubation. Unlike some previously developed animal models, this model has a low morbidity and a perioperative mortality of less than 5%. Ferrets are small, hardy animals that are inexpensive and easy to house, handle, and anesthetize. They are readily available from breeders in a uniform size, age, and sex. Their airway is disproportionately large for their body size, making them particularly well suited for the study of acquired subglottic stenosis and subsequent surgical therapy.

Animals↗

Sliding flap tracheoplasty.

The optimal method for surgical management of subglottic stenosis is based upon careful assessment of the location, caliber, length, and maturity of the stenotic segment, as well as associated conditions. For patients with a mature stenosis of short length, excision of the anterior arch of the cricoid and first ring and immediate reconstruction by means of a sliding flap of the next two to three rings of trachea offer a one-stage definitive treatment without the need for grafting. We report four cases of subglottic stenosis and one case of cricoid chondroblastoma in which reconstruction of the airway was successful and prompt. For carefully selected cases, sliding flap tracheoplasty may be a useful alternative to procedures in which the airway is expanded by means of grafting.

Adolescent↗

Effect of laryngeal stenting in a rabbit model.

A short length of oversize endotracheal tube was sutured in the undamaged subglottis of 22 rabbits to explore the effect of laryngeal stents. The stent was secured to lie beneath the vocal cords. The histologic changes were minimal irrespective of the type of tube used and how long it remained in situ. These findings are consistent with the theory that tube movement is necessary to produce stenosis and are encouraging given the widespread use of stents in pediatric laryngeal reconstruction. The role of gastric acid in producing subglottic stenosis is discussed.

Animals↗