Tracheotomies: a 10-year experience in 319 children

Acquired laryngeal stenosis in infants and children treated by laryngofissure and stenting

Thirty young patients with acquired laryngeal stenosis were treated by means of a laryngofissure and stenting. The age distribution suggested two subgroups: infants aged 0-2 years (n = 24), and children aged 6-16 years (n = 6). The causes of the stenosis and the treatment results were different in these subgroups. Treatment resulted in successful decannulation in 22 of 24 infants, and in 5 of 6 children. Treatment included a re-operation in two patients. In 1 patient the therapy failed, and 2 patients died after fatal complications. Decannulation rate, duration of the tracheotomy, and the number of re-operations compare favorably to the results of other centers. The longer duration of stenting, and the high mortality rate may be considered disadvantages.

A twenty year (1971-1990) review of tracheostomies in a major paediatric hospital

Changing trends in the indications for paediatric tracheostomies, with decreasing numbers of tracheostomies being performed, have been reported in the literature. In a retrospective analysis of the period 1971 to 1990 the experience of tracheostomies in children under the age of 15 at Our Lady's Hospital (Dublin) is reviewed. Only 29 tracheostomies were performed during this time with an increase in numbers (90%) performed during the second 10 year period. The major underlying indication for tracheostomy in both 10 year periods was for the management of an airway problem secondary to congenital abnormalities (65%). In 14 children the operation was performed during the first year of life. However, while 90% of the children were under the age of one in the period 1971-1980 this fell to 26% during 1981-1990. Complications occurred in 41% overall, however, in the under 1 year old group 64% developed complications. There were no deaths as a direct result of the tracheostomy or its complications, but six children died because of the severity of the underlying disease. The average length of time before decannulation was 2.1 years, with decannulation difficulties occurring infrequently (11%).

Mortality in the pediatric patient with tracheotomy

BACKGROUND

The mortality rate of children with tracheotomies is estimated to be between 11% and 40%, although the incidence of tracheotomy-related deaths is only between 0% and 3.4%. The purpose of this report was to analyze the mortality rate in children with tracheotomies.

METHODS

A review of the medical records of children at the University of Iowa Hospitals and Clinics who underwent tracheotomy over a 15-year period ending in 1989 was performed. Data were analyzed in 5-year time blocks (Block 1, 1975 to 1979; Block 2, 1980 to 1984; and Block 3, 1985 to 1989).

RESULTS

Fifty-two patients died with tracheotomy tubes in place. In 4 patients, the cause of death was tracheotomy related. Three of these patients were under 5 years of age and died secondary to tracheotomy tube displacement or obstruction; one patient, an 18-year-old, developed a fatal tracheotomy-related vascular hemorrhage. The average age of patients who died with tracheotomies decreased significantly from Block 1 to Block 3; in Block 3, mean age at the time of tracheotomy was significantly lower in patients who died than in patients who survived. A comorbidity score (CS) based on the number of airway diagnoses showed that higher CSs were associated with a poorer prognosis.

CONCLUSIONS

Mortality does not seem to be strongly related to the presence of the tracheotomy tube. Overall, two diagnostic groups were found to be independently associated with a poorer prognosis, ie, mechanical ventilation and pulmonary disease. Tracheotomies performed to provide airway access during other surgical procedures were associated with a better prognosis.

Airway Obstruction in Children with Infectious Mononucleosis

Epstein-Barr Virus (EBV) infection generally has a benign clinical course. Upper airway obstruction is a known complication requiring the otolaryngologist's attention. EBV is usually associated with adolescence but has been increasingly documented in younger children. We review 36 pediatric admissions for infectious mononucleosis over a 12-year period at our institution, 11 of which required consultation for airway obstruction. Airway management was based on clinical severity and ranged from monitored observation, with or without nasopharyngeal stenting, to prolonged intubation or emergent tonsilloadenoidectomy. A rare case of a four-year-old with near total upper airway obstruction secondary to panpharyngeal and transglottic inflammatory edema prompted this review and is reported. The otolaryngologist must recognize the potential severity of EBV-related airway compromise and be prepared to manage it.

Paediatric laryngotracheal reconstruction: Melbourne experience at the Royal Children's Hospital

A retrospective study was carried out to evaluate the outcome following laryngotracheal reconstruction (LTR) performed in 15 children for the treatment of severe laryngotracheal stenosis between 1989 and 1993. The age ranged from 18 months to 19 years with all but one patient being tracheostomy-dependent. The tracheostomy tube was successfully removed in 12 children who remain free of obstructive symptoms at follow up. One patient was successfully decannulated but required repeat tracheostomy 8 months later for intermittent severe supraglottic/pharyngeal obstruction. There were two failures, with one of these undergoing repeat LTR with successful decannulation. Surgery was complicated in one child by aspiration which improved spontaneously. These findings suggest that LTR is a safe and effective procedure for the management of severe paediatric laryngotracheal stenosis.

The safety of home tracheostomy care for children

Home tracheostomy care avoids prolonged hospitalization for tracheostomized children who must remain cannulated for a long time; however the safety aspects of this form of management are still under discussion. Since 1987 the authors have tutored parents in tracheostomy care. Once parental training was complete and the necessary equipment (aspirator, humidifier, etc) provided, children in stable condition were discharged and had period follow-up as outpatients. Thirty-four children had a total of 710 months in home care; 11 of them had decannulation. The only reported complications were two partial obstructions of the cannula and two accidental decannulations. The low number of documented accidents and the parents' profound appreciation in having their children at home indicate that patients with a tracheostomy in need of long-term care can be safely managed at home.

Trends in the use of tracheotomy in the pediatric patient: the Iowa experience

BACKGROUND

The role of tracheotomy in airway management in children has been widely discussed. Improved medical care and technology have resulted in improved survival rates, and increased survival rates have been associated with changes in the indications for and the use of tracheotomy. The purpose of this review was to evaluate trends in the use of tracheotomy over a 15-year period.

METHODS

We reviewed the medical charts of patients who underwent tracheotomy from 1975 to 1989 and analyzed them over three 5-year time intervals: Block 1, 1975-79; Block 2, 1980-84; and Block 3, 1985-89.

RESULTS

In the defined age group, 305 patients underwent tracheotomy during the study period. Records from 281 patients were analyzed; the remaining charts either were unavailable for review or did not contain adequate documentation of the tracheotomy. We observed an increase in the number of tracheotomies over time, especially in the younger population. Across blocks, median age decreased, duration of tracheotomy increased, and indications for tracheotomy changed.

CONCLUSIONS

Mean age, duration of tracheotomy, and indications for tracheotomy changed over the 15-year period. Additionally, these parameters were strongly related.

Current trends in pediatric tracheotomy

A retrospective analysis was performed on 103 pediatric patients, less than 5 years of age, undergoing tracheotomy at New York Hospital between 1980 and 1990. Charts were reviewed with respect to primary diagnosis, indication for tracheotomy, duration of the tracheotomy, complication rate and mortality rate. Approximately 62% of the tracheotomies were performed in patients less than 12 months of age, with the most common indication being an acquired or congenital airway abnormality. The number of patients receiving tracheotomies for neurological disorders, however, increased more than threefold over the course of this review. Approximately one-third of the patients experienced immediate, early or delayed complications. There was a significant correlation between the complication rate and weight at the time of the tracheotomy as well as the degree of prematurity of the child. Over one half of the infants under 2000 g suffered complications. A mortality rate of 2.9% was noted in our study with mucous plugging of the tracheotomy being the most common etiology of death.

Evaluation of horizontal and vertical tracheotomy healing after short-duration tracheostomy in dogs

PURPOSE

The purpose of the study was to assess healing of horizontal and vertical tracheotomy after short-duration tracheostomy in dogs using clinical, radiographic, endoscopic, and histologic methods.

MATERIALS AND METHODS

Horizontal tracheotomy (n = 6) between the third and fourth tracheal rings or vertical tracheotomy (n = 6) across tracheal rings three through five was performed for airway management during laryngoplasty. Tracheostomy tubes were maintained for 6 hours with low-pressure cuff inflation time limited to the first 1.5 hours. Cervical radiographs and tracheoscopy were performed preoperatively and at postoperative weeks 2, 4, 8, and 12. Ten of the 12 dogs were killed 12 weeks after tracheostomy.

RESULTS

There was no significant difference in preoperative and postoperative tracheal diameter or change in endoscopic tracheal circumference at the tracheostomy site when dogs were compared based on type of tracheotomy. Three dogs with horizontal tracheotomies had evidence of scar (web) within the tracheal lumen 12 weeks after surgery. All vertical tracheotomies had a mild, ventral, triangular deformity. Histologic examination of vertical tracheotomy sites showed complete restoration of the pseudostratified columnar epithelium. Horizontal tracheotomies healed with a single layer of columnar epithelium. Intraluminal scar was composed primarily of loose connective tissue.

CONCLUSION

Based on the results of this study, vertical tracheotomy shows more consistent healing compared with horizontal tracheotomy after short-duration tracheostomy. No evidence was found to support the preferential recommendation of horizontal tracheotomy for short-duration tracheostomy airway management.

Therapeutic reintubation for post-intubation laryngotracheal injury in preterm infants

The failure to extubate a preterm infant after prolonged intubation is often caused by laryngotracheal injury. This condition is treated by tracheotomy, anterior cricoid split, or often, by reintubation and subsequent extubation attempts in a later stage. To assess the value of reintubation as treatment of post-intubation injury, we retrospectively studied a group of preterm infants from the neonatal intensive care unit in the Sophia Children's Hospital. Three categories of injury were distinguished according to the findings at laryngobronchoscopy: (a) edema or superficial lesions, (b) ulcerations and edema and (c) granulations. Twenty-three infants were therapeutically reintubated after post-intubation injury was diagnosed, for a mean period of 17 days. The therapy was successful in 22 patients, and a failure in one. The follow-up period was a mean 34 months. The result and the duration of the treatment vary with the category of the injury and the condition of the patient. Therapeutic reintubation is compared with alternatives such as anterior cricoid split and tracheotomy. We conclude that reintubation is a valuable therapy that should precede the decision for surgery.

Percutaneous dilational tracheostomy in children and teenagers

Percutaneous dilational tracheostomy (PDT) is a new technique that has been successfully performed in adult patients who required long-term mechanical ventilation, but it has not been used in children. The authors report their initial experience with PDT in 11 children and teenagers. The procedure is as follows. Using Seldinger's technique, the trachea is cannulated with a guide-wire. It is then progressively dilated, to an appropriately sized tract, with dilators from a commercially available kit. Then, a tracheostomy tube can be inserted into the trachea, loaded over a dilator. Eleven children, aged 10 to 20 years, underwent PDT in an average of 20 minutes. In eight cases, PDT was performed at the bedside. One intraoperative and one postoperative complication developed in the same patient; both complications were easily recognized and treated. Tracheal stenosis has not developed in eight decannulated patients at an average of 43 +/- 30 weeks after decannulation. PDT appears to be a safe, potentially cost-effective alternative to open tracheostomy in young patients.

Experience with anterior cricoid split for infantile subglottic stenosis

A retrospective study of infants undergoing anterior cricoid split (ACS) from 1989 to 1993 was performed to evaluate our unit's experience with ACS in the management of infantile subglottic stenosis (SGS). Twelve children were identified ranging in age from 10 to 30 weeks and weighing between 1200 and 6500 g. Nine were born at or less than 30 weeks' gestation. Indications for surgery were endotracheal tube dependency, nasopharyngeal continuous positive airway pressure dependency and recurrent croup. All had varying degrees of SGS. Eleven of the 12 patients were extubated successfully following surgery. Two of these required subsequent repeat ACS 6 and 9 months later with one patient eventually requiring tracheostomy. These results suggest that ACS can be safely employed as an alternative to tracheostomy for a variety of clinical presentations of infantile SGS, with a relatively high rate of successful extubation.

An analysis of the inferior based tracheal flap for pediatric tracheotomy

In the past, various tracheotomy incisions have been used at the Children's Hospital of Michigan with the occurrence of complications related to accidental decannulation and immediate recannulation. Since that time the inferior based tracheal cartilage flap has been used to minimize early complications. A retrospective study of 126 pediatric tracheotomies performed at the Children's Hospital of Michigan from June 1986 to January 1991 was reviewed. Only tracheotomies performed by a staff otolaryngologist utilizing the inferior based tracheal cartilage flaps were reviewed. This study includes patients with a 6 month to 5 year follow up. The early complication rate was 4%, while the late was 50%. Stomal granulation tissue was comparatively increased in this series of patients but did not hinder decannulation. We consider the use of the inferior based tracheal cartilage flap in the pediatric population a safe and effective technique without increasing the morbidity of long-term tracheotomy.

Pediatric tracheotomy referrals to speech-language pathology in a children's hospital

The pattern of referral of infants and children with tracheotomy to speech-language pathology (SLP) was studied through a retrospective review. Less than half (29/62) were referred to SLP with no difference by surgical service (otolaryngology vs pediatric surgery) or length of time with tracheotomy. Younger children were referred far less frequently than older children. Furthermore, more than half of all children referred to SLP showed moderate to severe communication deficits. Central nervous system abnormalities were documented in 66% of the subjects. In the majority tracheotomies were in place longer than 12 months. On the basis of the findings, a protocol was established for early routine involvement of SLP with infants and children with tracheotomy.

Paediatric tracheostomy: persistent tracheo-cutaneous fistula following decannulation

A retrospective analysis of 101 children with tracheostomies, all performed for upper airway obstruction and who were decannulated in a single department, is reported. Persistent tracheo-cutaneous fistula occurred in 43% of patients and this was significantly related to age at tracheostomy and duration of tracheostomy. The operation of tracheo-cutaneous fistula closure is described.

Tracheotomy in the first year of life

Much has been written concerning complications of pediatric tracheotomies, but few studies have reviewed the complication rates of tracheotomies performed in the first 12 months of life. We reviewed the records of 60 patients who underwent tracheotomy in the first year of life between 1976 and 1988. This study includes 30 full-term infants and 30 premature infants, 16 of whom were very low birth weight preterm infants (less than or equal to 32 weeks' gestation and less than 1,500 g birth weight). Overall complication rates were 3% intraoperative, 13% early postoperative, and 38% late postoperative. The early postoperative complication rate in preterm infants was nearly double that of full-term infants. The late postoperative complication rate of patients undergoing tracheotomy for airway obstruction was more than double that of patients requiring tracheotomy for pulmonary indications. Duration of tracheotomy, however, was felt to be the most important factor in the development of a late postoperative complication.

Posttracheotomy granulation tissue managed by carbon dioxide laser excision

The problem of accumulation of granulation tissue and scar at the superior edge of the tracheostoma is a frequent problem in the management of chronic tracheotomy patients. This traditionally has been managed by cup forceps excision or by eversion through the tracheostoma with a skin hook and blind resection. These methods often lead to hemorrhage, and incomplete removal in a bloody field. We have used the carbon dioxide laser via a bronchoscope for ablation of the granulation tissue and/or scar at the stomal edge and at the tracheotomy tube proximal tip without morbidity in 13 pediatric cases. With experience, removal with the laser often proceeds more quickly than conventional methods. The scar and granulation tissue are excised under direct vision with minimal hemorrhage. We believe this to be a reasonable alternative in the management of this recurring problem.