Tracheostomy in children

S-shaped tracheostoma in pediatric tracheostomy using three-dimensional sigma-plasty--a novel technique to possibly reduce procedure related complications

OBJECTIVES

We have designed a technique of tracheostomy in pediatric patients with S-shaped incision on the tracheal wall which we think, provides a larger cross-sectional area of stoma and facilitates easier insertion of tracheostomy tube and thus helped in reducing early and late complications associated with it in our series.

TECHNIQUE

The trachea was exposed in midline by a vertical skin incision. In order to make S-shaped tracheostoma, second tracheal ring was identified. The conventional vertical incision was made in second tracheal ring and then extended at both its ends laterally in the inter-cartilaginous space parallel to the tracheal cartilage in the opposite direction to make the incision S-shaped. The trachea was dilated with tracheal dilator and appropriate size of tracheostomy tube was then placed into the trachea.

RESULTS

S-shaped tracheostomy was performed in 40 children with mean age of 6.36 years (age range is 2-12) required for airway maintenance or prolonged ventilatory support. The incidence of early complications was quite less in our patients (ranged from 0 to 5%). There was no incidence of excessive intra-operative bleeding or injury to surrounding structures causing subcutaneous emphysema or vocal cord palsy. One patient developing pneumothorax after the procedure was managed conservatively. There was no incidence of tracheo-esophageal fistula, suprastomal collapse or difficulty in decannulation on 9 months of follow up related to our technique. However, one of the patients developed early trachietis and cutaneous peristomal granulomas and 2 patients developed late trachietis which was treated conservatively.

CONCLUSION

S-shaped tracheoplasty, a new pediatric tracheotomy technique has resulted in a quantifiable reduction in the risk of the early and late complications in our series. Hence, we feel that this new technique is a better alternative to existing methods but larger randomized controlled studies are required before universal adoption of this technique.

A single-center 6-year experience with two types of pediatric tracheostomy

OBJECTIVE

Among a wide variety of tracheostomy techniques, a vertical tracheal incision and a horizontal incision with creation of an inferior base tracheal flap have been favorized in children in the past. The aim of this study was to determine surgical and postoperative stoma complications after performing these two types of tracheal incision in tracheostomy in children.

METHODS

A 6-year, prospective, observational cohort study was undertaken in 24 children (range, 0.03 month-15 years) at the Department of Otorhinolaryngology, University of Ulm. All children who underwent an elective tracheostomy were included in this study. Early and late local disorders in wound healing of the tracheal stoma and the clinical follow-up of both groups (Flap group and Vertical group) were analyzed.

RESULTS

Formation of granulation tissue and tracheal stenosis were the most observed local disorders in both groups. Granulation tissue at the level of the stoma was the most frequently observed complication in the Flap group (4/12; 33%), whereas in the Vertical group only one child showed granulation tissue around the stoma (1/7; 14%). The difference between both groups was statistically not significant. The overall mortality rate 1 year after tracheostomy was 25% (6/24) and the tracheostomy-related death rate was 4% (1/24). An association of wound healing disorders with a feasible lethal outcome was not found after both tracheostomy types. There were no differences in the outcome between both tracheal incision types.

CONCLUSIONS

Both types of tracheal incision proved to be a suitable surgical procedure for temporary or permanent tracheostomy in pediatric patients.

Topographic variations in anatomical structures of the anterior neck of children: an ultrasonographic study

OBJECTIVE

Tracheostomies in children are frequently used for temporary airway support during surgical procedures. In pediatric patients with congenital craniofacial malformations, preoperative assessment of the delicate anatomy of the airway is necessary. The purpose of this study was to assess the ultrasonographic anatomy of the anterior neck with regard to the performance of tracheostomy.

STUDY DESIGN

Ultrasonographic investigation was done in 50 pediatric patients (age range, 6 to 15 years) to analyze the relationships among the anatomical structures that are of practical interest with respect to tracheostomy.

RESULTS

The data reveal that information concerning variations in anatomical structures lying in the immediate vicinity of the tracheostomy site was readily obtainable with the techniques used.

CONCLUSIONS

In pediatric patients requiring tracheostomy for surgical treatment of severe congenital craniofacial malformations, preoperative ultrasonography may be used to diagnose individual anatomical variations at the tracheostomy site.

The superiorly based flap long-term tracheostomy in pediatric patients

PURPOSE

Tracheostomy is commonly used to provide control of the upper airway in pediatric patients. The traditional approach, which uses a midline vertical incision in the anterior tracheal wall, is associated with relatively high rates of complications when it is used on a long-term basis. Alternative approaches, such as removing tracheal window or creating tracheal flaps, have been avoided in the pediatric patient because of the risk of tracheal stenosis and the potential for the subsequent effect on tracheal growth. The superiorly based flap tracheostomy (SBFT) has greatly reduced these risks in adults and offers better stomal maintenance, safety, and patient acceptance, but it has not been widely evaluated in pediatric patients.

METHODS

We reviewed 21 superiorly based flap tracheostomies performed in children at our institution between 1986 and 1993. Routine follow-up assessments included fixed and flexible laryngotracheoscopy. Average follow-up was 17 months.

RESULTS

The most common indication for performing the SBFT was bilateral vocal cord paralysis. Short-term complications included wound infection and granuloma in 2 patients. Long-term complications were not observed. One patient died from lower respiratory tract causes. Five of the patients were eventually decannulated, and the stoma closed without laryngotracheal stenosis. Morbidity rates were less and mortality was comparable to those of traditional tracheostomy.

CONCLUSION

We conclude that the SBFT is promising a technique for establishing long-term control of the airway in pediatric patients.

Ultrasonographic anatomy of the anterior neck: implications for tracheostomy

PURPOSE

Tracheostomy is the preferred intervention for surgical establishment of an upper airway in the treatment of certain elective maxillofacial procedures. Complication rates associated with surgical tracheostomy are largely related to the restricted possibilities in diagnosis of anatomic variations. Therefore, endoscopic-guided tracheostomy is increasingly being used to enhance precision and safety. The purpose of this study was to assess the ultrasonographic anatomy of the anterior neck with regard to the performance of tracheostomy.

PATIENTS AND METHODS

Fifty patients underwent ultrasonographic investigation to analyze the relationship of anatomic structures lying in the immediate vicinity of the tracheostomy site.

RESULTS

The data presented demonstrate the feasibility and advantage of preoperative ultrasonography to visualize the structures of the infrahyoid region.

CONCLUSION

Preoperative ultrasonography may be of great importance in diagnosing individual anatomic variations at the site of tracheostomy and in avoiding complications.

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.

Acute epiglottitis treated by intubation

Acute epiglottitis is a severe disease which is especially common in children and may be fatal if not treated. The main problem in these patients is to secure a free airway. During the last decade there has been much debate as to whether one should perform a tracheotomy or secure the airway by means of long-term intubation. During the last 12 years we have treated 86 patients with acute epiglottitis by long-term intubation to secure the airway. Three of these patients have been tracheotomized. All patients have been investigated by direct laryngotracheoscopy about 3 months after recovery. During the last 8 years we have had no complications whatsoever and we consider long-term intubation to be a safe and convenient way of securing the airway in acute epiglottitis.

Pediatric tracheostomy. Experience during the past decade

A retrospective review of a decade of experience with pediatric tracheostomy encompassed 420 children. Analysis was performed with respect to primary diagnosis, age, duration of tracheostomy and hospitalization, early and late complications and mortality. While the incidence of tracheostomy per hospital admission decreased over the period of review, there was substantial increase in duration of tracheotomy. Approximately half of the patients sustained complications. While overall mortality approached 28%, tracheostomy-related deaths occurred in only eight patients (2%). Almost one fifth of children with tracheostomies were discharged to home care, and 3% were involved in our home ventilator program.