Laryngotracheal reconstruction in infants and children: are single-stage anterior and posterior grafts a reliable intervention at all pediatric hospitals?

Complications associated with costal cartilage harvest in pediatric laryngotracheal reconstruction

Objective

We aimed to determine the rate of complications associated with autologous costal cartilage graft harvest for pediatric laryngotracheal reconstruction (LTR). Secondarily, we sought to identify risk factors associated with the harvest of autologous costal cartilage, as well as evaluate management strategies.

Data Sources

An electronic database search of Ovid MEDLINE, Ovid EMBASE, and PubMed was completed for articles pertaining to complications in autologous costal cartilage harvest for pediatric LTR.

Review Methods

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The study characteristics, operative information, and patient demographics were collected. The data concerning postoperative complications, risk factors, and management strategies were collected and analyzed for patterns.

Results

A total of 31 manuscripts representing 745 patients were included for analysis. The reported donor site complications included pneumothorax (n = 13, 1.74%), pleural tear (n = 5, 0.67%), infection (n = 8, 1.07%), and scar-related problems (n = 2, 0.26%). There were no reported cases of seroma, persistent pain, or chest wall deformity. Only five studies discussed the management of donor site complications, with intervention in 11 (39.28%) patients including chest tube drainage and steroid injection.

Conclusion

There is significant variability in the literature regarding complication rates in autologous costal cartilage harvest for pediatric LTR. The incidence of major postoperative complications is low and supports the use of autologous costal cartilage as graft material for pediatric LTR.

Level of Evidence

NA.

Complications and outcomes following open laryngotracheal reconstruction: A 15 year experience at an Australian paediatric tertiary referral centre

OBJECTIVE

To report on our experience with open pediatric laryngotracheal reconstruction (LTR) with cartilage interposition grafts over the past 15 years and document setbacks and factors that affect postoperative outcomes.

METHOD

A retrospective chart review was performed on all pediatric patients who underwent single and double-stage LTR at The Children's Hospital in Westmead between August 2004 and July 2019. The outcomes measured include the overall decannulation rate, rates of postoperative complications, need for subsequent procedures and postoperative functional results (dyspnea, stridor, voice impairment).

RESULTS

Between August 2004 and July 2019, a total of 51 open LTRs were performed on 46 patients, with mean age 3.9 years (range 1 month to 12.1 years), including 11 revision operations (11.8%). The most common indication for surgery was subglottic stenosis, followed by bilateral vocal cord motion impairment followed by anterior glottic web. 13 cases (25.5%) were complicated by ventilator associated pneumonia in the postoperative period and 11 patients (21.6%) experienced wound complications ranging from localised wound abscess to wound dehiscence and graft failure. Patients with viral infections had an increased risk of wound dehiscence and graft failure (OR 1.8, 95% CI 1.01 - 3.23). Patients with a greater decrease in albumin in the postoperative period were more likely to have wound complications (OR 1.8; 95% CI 1.17 -2.83). Ten patients failed extubation and required a subsequent tracheostomy. Severity of stenosis, age at time of surgery, history of prematurity and revision LTR were not predictors for need for reintubation and/or tracheostomy after surgery. 23 cases (45.1%) underwent subsequent endoscopic procedures such a balloon dilatation to manage restenosis following LTR. Though 45.7% had a very good outcome, a significant group of 21% had ongoing voice issues.

CONCLUSION

Good outcomes were achieved following open LTR for pediatric laryngotracheal stenosis despite postoperative complications. At final follow up, 33 patients (71.7%) had good exercise tolerance with no or mild stridor. Forty-one of the forty-six patients (89.1%) were successfully decannulated.

Therapeutic effectiveness of costal cartilage grafting into both anterior and posterior walls for laryngotracheal reconstruction in acquired subglottic stenosis

BACKGROUND

We have reviewed the surgical procedures performed and outcomes for low-birth-weight infants with acquired subglottic stenosis.

METHODS

The gestational age at birth, birth weight, age at Laryngotracheal reconstruction, and therapeutic outcome over the past 26 years were reviewed. Laryngotracheal reconstruction was initially performed by costochondral grafting involving only the anterior wall for the first operation, but since 2010 a costal cartilage was also inserted into the posterior wall of the cricoid cartilage using the BENSON pylorus spreader to split the cartilage.

RESULTS

There were 21 patients. The mean gestational age was 29.6 weeks, the mean birth weight was 1127 g, and the first surgery was performed at a mean age of 37.0 ± 21.8 months. Extubation was possible in 11 of 21 patients (52.3%) after the first surgery and in 7 of 7 patients after re-operation. The total extubation rate reached 100% (18/18) excluding three patients (one who suffered sudden death, and two who were lost to follow-up).

CONCLUSION

Sufficient dilatation of the subglottic space could not be achieved by costochondral grafting involving the anterior wall alone. The extubation rate was improved by dilatation of the posterior wall and the insertion of costal cartilage into both the anterior and posterior walls.

Association Between Red Blood Cell Distribution Width and Outcomes of Open Airway Reconstruction Surgery in Adults

Importance

Airway reconstruction for adults with laryngotracheal stenosis (LTS) is directed toward improving airway caliber to mitigate the patient's dyspnea and achieve prosthesis-free breathing (ie, without tracheostomy, intraluminal stent, or T-tube). Despite the importance of preoperative risk stratification to minimize postoperative complications, consensus on an objective predictive algorithm for open airway reconstruction is lacking.

Objective

To determine whether the ability to achieve a prosthesis-free airway in adults after open airway reconstruction is associated with red blood cell distribution width (RDW) at the time of surgery.

Design, Setting, and Participants

Case series study investigating 92 consecutive patients 18 years and older with laryngotracheal stenosis who underwent open airway reconstruction at a US tertiary care hospital from January 1, 2006, to January 1, 2017.

Main Outcomes and Measures

The main outcome was a prosthesis-free airway (absence of tracheostomy, intraluminal stent, or T-tubes) at last follow-up. Multivariate logistic regression modeling was used to identify independent factors associated with this outcome.

Results

Of the 92 patients who met inclusion criteria, the median (interquartile range) age was 44 (33.0-60.3) years; 50 (53%) were female, and 82 (89%) were white. In all, 74 patients (80%) were prosthesis free at the last follow-up (mean, 833 days; 95% CI, 10-4229 days). In multivariate analyses, airway decannulation was significantly correlated with reduced RDW (odds ratio [OR], 0.40; 95% CI, 0.19-0.84) and the absence of posterior glottic stenosis (OR, 0.12; 95% CI, 0.04-0.37).

Conclusions and Relevance

These data suggest that surgical success in open airway reconstruction is significantly associated with RDW and whether the patient had posterior glottic stenosis. The RDW is a routine laboratory parameter that may provide some insight to the preoperative probability of prosthesis removal, facilitate risk stratification, promote informed patient decision making, and optimize health care resource management.

Slide laryngotracheoplasty for congenital subglottic stenosis in newborns and infants

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, 130:E199-E205, 2020.

Optimal Management of a 2-Hour-Old Newborn With Severe Congenital Subglottic Stenosis and Multiple Congenital Heart Diseases

Introduction:

Congenital subglottic stenosis (C-SGS) is the third most common congenital anomaly of the larynx. It necessitates tracheotomy in newborns if it causes severe airway obstruction. When the negative impact of tracheostomy cannot be tolerated, as in presence of congenital heart disease requiring further surgical intervention, other alternative procedures are required. This case report is the first of its kind reporting airway expansion in a neonate in the first few hours after birth.

Case Report:

A 38-week-fetus male was born with multiple congenital heart anomalies and C-SGS of grade III. Single-stage laryngotracheoplasty (SS-LTP) with anterior thyroid alar cartilage (TAC) grafting was performed. Our team was fully aware of all potential risks during SS-LTP procedure in such debilitated patient.

Discussion:

Treatment of C-SGS in premature neonates is tracheostomy to avoid prolonged intubation. In some cases, tracheostomy is not a good option as in presence of congenital heart disease necessitating urgent further surgical interventions. Among all surgical procedures to augment the airway without tracheostomy, SS-LTP with placement of anterior TAC graft was our choice.

Conclusion:

This case report demonstrated that SS-LTP with anterior TAC graft can be performed in a newborn with severe C-SGS and congenital heart disease. It can alleviate the need for tracheostomy and avoid unnecessary delay for subsequent cardiac interventions. However, further study is likely needed to make a definitive statement of its safety and efficacy.

Management of congenital tracheal anomalies and laryngotracheoesophageal clefts

Congenital obstructions and anomalies of the pediatric airway are rare problems that may be associated with mild symptoms or critical stenoses that may be life threatening in the first few days of life. This review provides an overview of the embryologic development of the airway, different congenital anomalies associated with airway development, and surgical correction that may be associated with good long-term outcome.

Management of laryngotracheal stenosis in infants and children: the role of re-do surgery in cases of severe subglottic stenosis

Although many advances have improved the treatment of congenital and acquired laryngotracheal stenosis in children over the past two decades, the therapeutic decision-making process remains challenging for pediatric surgeons and otolaryngologists. Severe subglottic stenosis is a complex laryngeal injury that necessitates multiple airway procedures, and the approach depends on the exact nature of the cicatricial lesion and its effect on the vocal cord mobility. Therefore, it is imperative that the pediatric surgeons and otolaryngologists dealing with this situation should be well trained in endoscopy and laser treatment, in addition to open surgical intervention. Open re-do surgery remains the best choice in cases of severe congenital stenosis, glottic immobility, or after two to three endoscopic procedures have been performed without any significant improvement.

Novel Method for Laryngotracheal Reconstruction: Combining Single- and Double-Stage Techniques

Objectives:

Traditional open techniques for laryngotracheal reconstruction are either single- or double-stage procedures. Some patients may benefit from the presence of a long, single-tube stent, such as an endotracheal tube, but their predicted need for a 2-stage procedure and a persistent tracheostomy is high. We describe a novel technique for airway reconstruction that combines the methods of both single- and double-stage procedures.

Methods:

We present a retrospective review of 4 patients. All patients underwent laryngotracheal reconstruction by a single surgeon. After the operation, the airway was stented with nasotracheal intubation. A small stent, fashioned from an endotracheal tube, was placed in the tracheostoma to keep it patent. The patients subsequently underwent extubation and replacement of the tracheostomy tube.

Results:

The study included 1 patient with grade 4 subglottic stenosis, 2 patients with grade 3 subglottic stenosis, and 1 patient with a posterior glottic scar. All were tracheostomy tube-dependent. Serial bronchoscopy was used to follow the patients for a minimum of 9 months after the operation. All 4 patients have since met the criteria for decannulation.

Conclusions:

This hybrid reconstruction merges the advantages of both the single- and double-stage procedures. It adds versatility to the surgical toolbox for airway reconstruction.