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Laryngotracheal reconstruction with autogenous thyroid cartilage (Illustration: courtesy of Sonja Burger)
Source publication
Pathologies in the larynx and trachea in the pediatric age can be characterized in 4 main groups: airway stenosis, acute infections, benign neoplasia and foreign body aspiration. In this review main diagnostic strategies and therapeutic options are presented.
Laryngomalazia is the most frequent condition of supraglottic stenosis. The term supraglot...
Context in source publication
Context 1
... this method, the cricoid cartilage, the cranial trachea and caudal thyroid cartilage are exposed via an external access similar to the established procedure of the cricoid split, then the cricoid cartilage, as well as the first and second tracheal cartilage if necessary, are incised. An approximately 2x3 mm wide piece of cartilage is obtained from the free top edge of the thyroid cartilage ( Figure 9). This is an el- egant way of reconstruction with autologous tissue in the same area of operation and does not require an additional incision. ...
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Introduction:
Many objects were described in the literature as causes of upper airway obstruction including seeds, nuts and household particles but fragmented tracheostomy tube is a rarely reported cause of airway obstruction. We report a case of foreign body aspiration in the tracheobronchial tree due to a fragmented and migrated tracheostomy tub...
Citations
... The types of reconstruction were categorized into LTR, CTR, and extended CTR (eCTR). 14) The costal cartilage was harvested for the free-graft reconstruction of LTR. The graft was oriented in place with the perichondrium facing the airway lumen. ...
Background and Objectives Airway reconstruction surgery in children is still challenging, especially in cases of combined subglottic and posterior glottic stenosis (PGS). The aim of this study was to review the underlying reasons of failure in open airway reconstruction surgeries performed for children with combined subglottic and PGS.Subjects and Method We reviewed medical records of seven children who received more than two open airway reconstruction surgeries to finally achieve and maintain decannulation status for more than one year. Twenty-two reconstructive surgeries were performed and they consisted of 19 laryngotracheal reconstruction (LTR), 2 cricotracheal resection with end-toend anastomosis (CTR) and one extended CTR. For each patient, the following potential causes of failure were evaluated; preoperative evaluation (PE), type of reconstruction (TR), single vs. double staging (SDS), type of stent (TS), and perioperative optimization (PO).Results The median age of patients at the time of surgery was 32 months (range, 4-64 months). Successful decannulation was achieved after the median open surgery of three (range, 2-5 times for each patient). Recognized causes of failure were as follows: 8 insufficient PE, 10 inadequate TR, 3 improper SDS, 8 ill-chosen TS, and 2 inappropriate PO.Conclusion PE of dynamic airway is important, especially vocal fold mobility and tracheomalacia. Types of reconstruction should be carefully decided after full consideration of potential causes of failure, and adequate laryngotracheal stent is essential.
... In some rare cases, however, a significant airway narrowing remains resulting in respiratory failure and distress necessitating intervention. Common recommended treatment options for long-established stenosis favour significant surgical treatments [1][2][3], stent insertion [4] or balloon dilatation with an associated long-term morbidity and possible mortality [5,6]. Topical corticosteroids are reported to limit the scarring process [7]; however, there is currently no published evidence for the treatment of severe subglottic lesions in children. ...
Purpose
Surgical treatment is generally recommended for severe subglottic lesions following traumatic endotracheal intubation in children. An alternative approach is early transglottic corticosteroid administration to reduce scar formation and prevent the need for subsequent surgical intervention. This technique has been practiced successfully for several decades at the Children’s Hospital of Cologne and the outcomes of 26 subsequent patients reviewed in this analysis.
Methods
All patients who underwent transglottic corticosteroid injection for treatment of post-intubation stridor and dyspnoea between 2012 and 2018 were identified and their records and endoscopy images analysed. Severity of the endoscopic findings was assessed using the Myer–Cotton classification (MCC) and an Expected Need for Surgical Intervention (ENSI) score (1 = inevitable; 2 = very likely necessary; 3 = probably avoidable and 4 = most likely not necessary) was recorded. Treatment was considered successful if the children had a complete resolution of clinical symptoms.
Results
A total of 26 patients with a median (range) age of 1.9 (0.02–7.2) years and weight of 9.8 (1.8–25) kg were identified and included into the analysis. Endoscopic images were available for 22 children. All children underwent transglottic corticosteroid injection prior to any potential surgical treatment. A total of 22 patients (85%) improved following transglottic corticosteroid injection including 4 of 5 patients with a MCC = 3 and ENSI = 1 avoiding surgical intervention. None of the patients experienced a deterioration of clinical symptoms or endoscopic findings.
Conclusion
Transglottic corticosteroid injections as first-line treatment in children with severe post-endotracheal intubation trauma can successfully resolve symptoms and prevent invasive surgery.
... Clinically, RRP can manifest as dysphonia that progresses to aphonia; dyspnea and dysphagia can also develop and become progressively worse until the affected person can no longer breathe and dies. [6][7][8] The incidence of RRP has been reported to be 1.9 and 7.0 cases per 100 000 population, depending on the geographical area. 6,9 It has been hypothesized that HPV can be transmitted vertically from mother to the neonate during passage through the birth canal. ...
Background
Recurrent respiratory papillomatosis (RRP) or laryngeal papillomatosis is a disease caused by papillomavirus infection.
Methods
In this phase I/II clinical trial, we evaluated the efficacy of the modified vaccinia Ankara (MVA) E2 virus in the treatment of RRP. Twenty‐nine patients (18 female and 11 male) underwent injection of MVA E2 directly into the borders of the vocal cords where lesions were seen and were monitored by direct laryngoscopy. The immune response was assessed by the determination of CD3⁺, CD4⁺, and CD8⁺ lymphocytes counts. The presence of papillomavirus was determined by polymerase chain reaction analysis.
Results
Lesions were completely eliminated in 13 patients (44.8%). In 16 patients (55.2%), lesions recurred between 6 and 18 months after treatment; these patients received a second round of treatment with MVA E2, and they are not seen with new recurrences.
Conclusion
The MVA E2 vaccine has excellent potential for generating complete regression of RRP lesions.
Wstęp
Laryngomalacja jest najczęstszą wrodzoną wadą krtani. Odpowiada za około 65–75% przypadków wrodzonego stridoru. Etiologia choroby pozostaje niejasna. Skutkiem laryngomalacji jest zapadanie się podczas wdechu wiotkich chrząstek górnego piętra krtani. Laryngomalacja w większości przypadków ustępuje samoistnie, a interwencji chirurgicznej wymaga około 10% dzieci z bardzo ciężkim przebiegiem choroby. Rozpoznanie opiera się na wywiadzie i laryngoskopii bezpośredniej bez intubacji. Obecnie coraz częstsze zastosowanie ma wideolaryngoskopia.
Cel pracy
Celem pracy była analiza obrazu krtani uzyskanego w badaniu wideolaryngoskopowym u niemowląt diagnozowanych w Klinice Audiologii i Foniatrii Instytutu Fizjologii i Patologii Słuchu z powodu podejrzenia laryngomalacji.
Materiał i metody
Niemowlęta z laryngomalacją wyselekcjonowano z 910 dzieci, które w latach 2009–2014 zgłosiły się do Kliniki Audiologii i Foniatrii IFPS z objawami zaburzeń oddychania lub/i zaburzeń głosu. Grupę badaną stanowiło 20 niemowląt (5 dziewczynek i 15 chłopców, 2–9 m.ż.). Wszystkich pacjentów poddano kompleksowemu badaniu laryngologiczno-foniatrycznemu, ze szczególnym uwzględnieniem badania wideonasolaryngoskopowego. Endoskopię wykonano z dojścia przez nos, przy użyciu fiberoskopu firmy Xion o średnicy 3,2 mm. Wyniki badań oraz filmy i zdjęcia poddano analizie retrospektywnej oraz porównawczej.
Wyniki
Przeprowadzone badania pozwoliły na rozpoznanie laryngomalacji u wszystkich pacjentów. Objawy uwidocznione w badaniu wideonasofiberoskopowym to, występujące w różnych zestawieniach, zapadanie się fałdów nalewkowo-nagłośniowych, zapadanie się chrząstek nalewkowatych oraz nagłośnia zwinięta w kształcie litery Ω. Zaobserwowano, że tylko jeden objaw endoskopowy występował u 9 pacjentów, u 9 obecne były jednocześnie dwa z nich, natomiast u 2 potwierdzono współwystępowanie wszystkich 3 objawów. Dodatkowo u 2 niemowląt stwierdzono, nieopisywany dotąd w literaturze, przerost fałdów rzekomych.
Wnioski
W przebiegu laryngomalacji występują zarówno izolowane, jak i współistniejące zaburzenia strukturalno-anatomiczne. Endoskopia umożliwia klasyfikację wrodzonej wiotkości krtani na podstawie anatomicznych przyczyn jej występowania. Stosowane obecnie klasyfikacje laryngomalacji zawierają jedynie najczęstsze izolowane zaburzenia anatomiczne. Wykorzystanie obrazów uzyskanych podczas nasofiberoskopii u pacjentów, którzy nie wymagają interwencji chirurgicznej, mogłoby posłużyć stworzeniu nowego systemu klasyfikacji, uwzględniającego zarówno zaburzenia izolowane, jak i złożone.
Introduction . Definition " upper respiratory tract stenosis " (URTS) includes a large number of nosologies. The most common are cicatricial stenoses, in particular, post-intubation ones as well as bilateral paralysis of the larynx. An important issue for nowadays is choosing the curative modality for such patients.
Purpose . To compare outcomes after treating children with URTS.
Material and methods . The authors have assessed results of treatment of 110 patients who had reconstructive surgery in 2010-2019. Patients were divided into two groups depending on the nosology: stenosis of the upper respiratory tract (n = 71) and bilateral paralysis of the larynx (n-39). In each group, four types of surgeries were performed: costal cartilage plasty, plasty with T-tube (TT), a modified version of plasty with TT, plasty with a stent. The choice of treatment technique was determined mostly by the tendency to make this or that type of surgery in authors' departments, as well as by the nosology, severity of the disease and patient's age. Decannulation terms, surgical time, early and late postoperative complications as well as relapse-free period were assessed.
Results . 66% patients were decannulated in Group 1; in Group 2 - 69%. Group 1 a statistically reliable comparison was possible between the following techniques: costal cartilage plasty and laryngeal stent plasty (p > 0.005) as well as plasty with TT implantation and the proposed modified technique (p > 0.005). While using Mann-Whitney test and Log Rank, the authors found out that in Group 1 there were no significant difference in surgical time, relapse-free period and stenosis degree (p > 0.005). However, decannulation terms after plastic surgery of the larynx with costal cartilage implantation are longer than after plastic surgery with stent implantation (p < 0.005). In Group 2, the authors compared three abovementioned curative modalities, excluding laryngeal plasty with TT implantation. Thus, surgical time for costal cartilage plasty is longer, if to compare to other two techniques (p < 0.005). There is also no significant difference in decannulation terms and relapse-free periods between all three techniques (p > 0.005).
Conclusion . The results obtained have demonstrated the effectiveness of long-term stenting with TT placement in children, mainly with cicatricial stenoses, and in older children. The trial also revealed that laryngoplasty with costal cartilage in children with bilateral laryngeal paralysis is an effectiveness choice too.
Zusammenfassung
Der Übersichtsartikel beinhaltet eine Zusammenstellung seltener Erkrankungen von Larynx, Trachea und Schilddrüse. Im Speziellen werden angeborene Fehlbildungen, seltene Formen der entzündlichen Larynxerkrankungen, gutartige und bösartige epitheliale sowie nicht-epitheliale Tumoren, laryngeale und tracheale Manifestationen von Allgemeinerkrankungen und schließlich seltene Erkrankungen der Schilddrüse besprochen. Die einzelnen Kapitel beinhalten eine Übersicht über die Datenlage in der Literatur, das jeweilige klinische Erscheinungsbild, wichtige Stichpunkte zur Diagnostik und zur Therapie und eine abschließende Stellungnahme zur Prognose der Erkrankung. Des Weiteren finden sich Hinweise zu Studienregistern und Selbsthilfegruppen.
Introduction . One of the urgent problems in pediatric surgery and otorhinolaryngology is stenosis of the upper respiratory tract in children. Among many causes leading to airway narrowing , basic ones are: cicatricial stenosis, bilateral vocal cord paralysis and volumetric formations.
Diagnostics . Currently, fibroscopy of the upper respiratory tract is a gold standard of this pathology examination.
Methods . There are many surgical techniques to treat upper airway stenosis, but currently there is no any unified approach to the choice of surgical tactics. The given article presents an overview on modern techniques of reconstructive surgery which have demonstrated good and excellent results and a high percentage of decannulation. Among them, there are two basic ones - endoluminal surgery and open surgery. Recently, reports on the effectiveness of microsurgical interventions have been published , namely, reinnervation of the larynx to restore vocal cords. The most effective endoscopic surgeries in pediatrics are balloon dilation, bougienage and CO2- laser treatment. Patients with stenosis of stages III-IV, with extended stenosis, marked laryngomalacia, larynx and trachea deformity because of unsuccessful previous surgeries are recommended to have open reconstructive surgery. Laryngoplasty, laryngoplasty with T-tube and crico-tracheal resection are regarded as a choice option in case of ineffective previous surgeries.
Conclusion . Thus, type of surgical intervention, indications and patient’s age for surgery are chosen individually for each patient with upper respiratory tract stenosis.
Endotracheal intubation injuries are rare, but may be devastating-mostly among the pediatric patients or when these occur in the distal trachea. Such complications typify a therapeutic challenge, which, besides requiring intellectual and technical resources, takes a long time to reach a resolution. The authors present the case of a 15-year-old girl admitted with an abnormal state of consciousness due to diabetic ketoacidosis. She was submitted to endotracheal intubation with hyperinflation of the tube cuff, which rendered tracheal necrosis and detachment of the tracheal mucosa, and consequent obstruction. Later, she developed scarring retraction and stenosis. The patient was successfully treated with an endotracheal prosthesis insertion. The aim of this report is to illustrate a preventable complication.
Airway malformations include a wide range of conditions that generally manifest early in life. These malformations usually present with upper and lower airway obstruction symptoms, which fluctuate in their intensity depending on how serious is the compromise. They may progress seriously during the neonatal period, exposing the patient to vital compromise, but clinical progression could be prolonged and mild during infancy. The principal congenital malformations of the airway are laryngomalacia, tracheomalacia, tracheal stenosis, bronchomalacia, and vascular rings.
Objectives:
Subglottic stenosis is the most common laryngeal anomaly necessitating tracheostomy in early childhood. Crico- and laryngotracheal resection and laryngotracheal reconstruction-usually with autologous cartilage graft implantation-are the most effective treatments. These surgical techniques are obviously challenging in neonatal age and infancy. However, a reconstructive surgery performed at early age may prevent the sequel of complications.
Methods:
The authors present their novel surgical method for congenital subglottic stenosis. Seven infants had inspiratory stridor; two of them had to be intubated and one required tracheostomy. Laryngotracheoscopy, CT or MRI revealed subglottic stenosis: Cotton-Myer grade II in one, and grade III in six cases. Slide laryngotracheoplasty was performed before 5 months of age (10-130 days), with a follow-up period of average 36 months (4-80 months). Phoniatry and quality of life questionnaire were used for evaluation of postoperative results.
Results:
Slide laryngotracheoplasty in the neonatal age made the temporary tracheostomy unnecessary. All babies remained intubated for 3 to 10 days with an uncuffed tracheal tube. After extubation, no dyspnea or swallowing disorder occurred. A subjective quality of life questionnaire, laryngotracheoscopy, clinical growth charts showed satisfactory functional results.
Conclusions:
Single-stage slide laryngotracheoplasty might be a favorable solution for subglottic stenosis, even in early childhood. In one step, the airway can be maintained without stenting and tracheostomy.
Level of evidence:
4 Laryngoscope, 2019.
