Tracheal ring-graft reinforcement in lieu of tracheostomy for tracheomalacia

The Management of Cyanotic Spells in Children with Oesophageal Atresia

Cyanotic spells, also known as blue spells, dying spells, or apparent life-threatening events, refer to a bluish tone visible in the mucosal membranes and skin caused by an oxygen decrease in the peripheral circulation. Although this decrease may be transient and benign, it may also be indicative of a severe underlying problem that requires immediate intervention. Children with oesophageal atresia (OA) are at risk for a number of coexisting conditions that may trigger cyanotic spells. This current article will focus on the management of cyanotic spells both in children with innominate artery compression and those with tracheomalacia.

Pre-expanded Supraclavicular Artery Perforator Flap

The supraclavicular artery perforator (SAP) flap is a versatile flap for the reconstruction of head and neck defects. Recently, the authors have modified the SAP flap by using an anterior branch of the transverse cervical artery. The anterior SAP flap allows the harvest of a tissue island in the deltopectoral fossa, which is even thinner, is more pliable, and shows a superior color match to the face and neck compared with the original SAP flap. Pre-expansion increases flap size considerably, enabling the coverage of extended defects without the need of microsurgery.

A new technique for treatment of tracheal compression by the innominate artery: external reinforcement with autologous cartilage graft and muscle flap suspension

We report a new technique for treatment of tracheomalacia or tracheal compression caused by the innominate artery, utilized in two patients with neuromuscular disorders. Both cases developed a chest deformity in the setting of severe scoliosis. Computed chest tomography and fiberoptic bronchoscopy showed that the cervical trachea was compressed between the innominate artery and the cervical spine in the setting of deformity of the thoracic cavity. Both patients required prolonged mechanical ventilation prior to the operative procedure. To relieve compression by the innominate artery, the superior mediastinum was exposed by resection of part of the manubrium allowing a greater space, and external stenting of the cervical trachea with a reinforcing autologous cartilage graft and tracheopexy, as well as anterior suspension of the innominate artery with a sternohyoid muscle flap were carried out. Both patients were successfully weaned from prolonged mechanical ventilation. Resection of the manubrium sterni, tracheal stenting with rib segments and use of the strap muscle to elevate the innominate artery off of the trachea offer potential long-term release of airway obstruction.

Multistage Approach for Tracheobronchomalacia Caused by a Chest Deformity in the Setting of Severe Scoliosis

We present a case of tracheobronchomalacia caused by thoracic morphologic changes associated with severe scoliosis. The patient underwent fundoplication for gastroesophageal reflux. After the operation, the patient developed clinically significant tracheobronchomalacia. Tracheobronchial reinforcement and splinting with autologous cartilage grafts was initially performed to externally stent the trachea. Next, tracheopexy of the intrathoracic trachea and sternal elevation was performed using a pectus bar to correct the tracheal compression between the sternum and the spine. Because the cervical trachea was compressed between the innominate artery and the cervical spine, external stenting and tracheopexy of the cervical trachea as well as anterior suspension of the innominate artery were performed. At present, the patient has a Tracheostoma Retainer in place and is being followed as an outpatient without the need for mechanical ventilation. Multistaged techniques for tracheobronchomalacia because of an abnormal chest configuration therefore offer the potential to achieve the long-term release of airway obstruction.

Tracheomalacia secondary to obstructive sleep apnea

Tracheomalacia (TM) is abnormal flaccidity of the trachea caused by inadequate cartilaginous support by the C-shaped tracheal rings. This defect generally results in various degrees of dynamic narrowing of the airway lumen. TM usually presents with expiratory stridor, wheeze, and respiratory obstruction. TM is usually associated with tracheoesophageal fistula and esophageal atresia or with other thoracic lesions of vascular rings and tumors. We report a well-documented case of a 20-month-old boy who presented to our institution with a severe history of obstructive sleep apnea and adenotonsillar hypertrophy. On direct laryngoscopy/bronchoscopy, severe TM was noted. Tonsillectomy and adenoidectomy was performed, and by the 37th postoperative day, the TM had completely resolved. We review the literature, discuss the differential diagnosis and clinical evaluation, and propose a new pathophysiological mechanism by which obstructive sleep apnea causes TM.

Tracheomalacia and Tracheobronchomalacia in Children and Adults

Tracheomalacia and tracheobronchomalacia are disorders that are encountered in both pediatric and adult medicine. Despite increasing recognition of these disease processes, there remains some uncertainty regarding their identification, causes, and treatment. This article is intended to be a comprehensive review of both the adult and pediatric forms of the diseases, and includes sections on the historical aspects of the disorders, and their classification, associated conditions, histopathology, and natural history. We also review the various modalities that are used for diagnosis as well as the state of the art of treatment, including airway stent placement and surgical intervention.

Aortic suspension (aortopexy) for severe tracheomalacia in infants and children

BACKGROUND

Tracheomalacia with anterior great vessel compression is a common disorder in infants and children, which can lead to life-threatening airway occlusion. In this study, a large number of patients underwent anterior aortopexy to provide a more normal distal airway.

METHODS

Thirty-two infants and children with tracheomalacia associated with esophageal atresia-tracheoesophageal fistula (18), vascular ring (8), abnormal innominate artery takeoff (4), and primary (2) were evaluated with bronchoscopy, magnetic resonance imaging, and pulmonary functions. Aortopexy was accomplished through left thoracotomy and suture fixation of the aorta and innominate artery to the posterior sternum.

RESULTS

Intraoperative bronchoscopy showed marked improvement in airway caliber and rigidity, and no patients had further obstructive episodes. Forced expiratory volume improved from 52% +/- 4% of predicted to 82% +/- 3%.

CONCLUSIONS

Aortopexy is a simple procedure for the treatment of distal tracheomalacia that is immediately effective and provides permanent relief of obstructive episodes.

The anterior mediastinal approach for management of tracheomalacia

BACKGROUND

Tracheomalacia occurs as a primary developmental defect or may be secondary to vascular compression. It is common in association with esophageal atresia and tracheoesophageal fistula. Collapse of the weak trachea is a cause of recurrent respiratory symptoms but may be severe and life threatening.

METHODS

Between 1978 and 1999 at Sheffield Children's Hospital and The Royal Manchester Children's Hospital, of 16 children with clinically significant symptoms of tracheomalacia 8 underwent combined aortopexy and tracheopexy, 1 had aortopexy alone, 4 only had a tracheopexy, and 3 had tracheal reinforcement with free costal cartilage ring grafts. The surgical approach was limited to a low cervical skin crease incision with a midline manubrial split providing extrapleural access to the anterior mediastinum and allowing for all surgery under direct unimpaired vision.

RESULTS

Ten children did not require postoperative ventilatory support. Four underwent ventilation for a few hours or days. One child required CPAP for 4 months for residual tracheomalacia and a further child, who had 3 operations to insert 11 costal cartilage ring grafts, underwent ventilation intermittently for 6 months. Adequate tracheal patency could be verified by intraoperative tracheoscopy and was sustained postoperatively so that only 1 child with associated bilateral vocal cord paralysis came to tracheostomy. Four children required prolonged hospitalization because of residual tracheomalacia, 2 for bronchomalacia and 2 because of esophageal narrowing leading to further surgery. All other children were fit for discharge within 10 to 30 days of surgery. Long-term follow-up has confirmed sustained tracheal improvement and resolution of the life-threatening features of tracheomalacia.

CONCLUSIONS

The authors recommend the low skin crease transmanubrial approach, as described by Vaishnav and MacKinnon, for tracheopexy, aortopexy and for tracheal reconstruction for tracheomalacia. The approach gives excellent access for surgery under direct vision through a relatively avascular plane. It is associated with less morbidity than a conventional thoracotomy and leaves a more acceptable aesthetic scar.

Advances in the management of major airway collapse: the use of airway stents

The management of major airway collapse in the pediatric age group has evolved and continues to evolve over time. Tracheobronchomalacia, either primary or secondary, is still the most frequent cause of major airway collapse. This article reviews tracheobronchomalacia and discusses several treatment options; from traditional aortopexy to the more recent introduction of tracheobronchial stenting. Various types of stents are discussed and the authors' preferences are included.