Extended cricotracheal resection with posterior costochondral grafting for complex pediatric subglottic stenosis

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.

Posterior glottic stenosis: management and outcomes

PURPOSE OF REVIEW

Pediatric posterior glottic stenosis (PGS) is a challenging clinical entity with multiple treatment options. This review describes the evaluation of patients with PGS and discusses existing surgical techniques.

RECENT FINDINGS

PGS secondary to a distinct scar band between the vocal folds can often be effectively managed with endoscopic division and surveillance. More advanced glottic scarring that also involves the interarytenoid mucosa, cricoarytenoid joints, or subglottis merits a more thorough investigation and repair. A postcricoid mucosal advancement flap can be employed in select adolescent or adult PGS, but long-term cricoarytenoid joint mobility is difficult to restore once it has been fixed. Younger pediatric patients have smaller airways and frequent concurrent subglottic stenosis which is better addressed with cartilage grafting.

SUMMARY

Surgical success in pediatric PGS depends on careful preoperative airway assessment and the accurate characterization of airway stenosis. A surgical technique should be chosen based on the severity and extent of stenosis.

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.

Pediatric airway reconstruction: results after implementation of an airway team in Brazil

INTRODUCTION

Since development of pediatric intensive care units, children have increasingly and appropriately been treated for complex surgical conditions such as laryngotracheal stenosis. Building coordinated airway teams to achieve acceptable results is still a challenge.

OBJECTIVE

To describe patient demographics and surgical outcomes during the first 8years of a pediatric airway reconstruction team.

METHODS

Retrospective chart review of children submitted to open airway reconstruction in a tertiary university healthcare facility during the first eight years of an airway team formation.

RESULTS

In the past 8 years 43 children underwent 52 open airway reconstructions. The median age at surgery was 4.1 years of age. Over half of the children (55.8%) had at least one comorbidity and over 80% presented Grade III and Grade IV subglottic stenosis. Other airway anomalies occurred in 34.8% of the cases. Surgeries performed were: partial and extended cricotracheal resections in 50% and laryngotracheoplasty with anterior and/or posterior grafts in 50%. Postoperative dilatation was needed in 34.15% of the patients. Total decannulation rate in this population during the 8-year period was 86% with 72% being decannulated after the first procedure. Average follow-up was 13.6 months. Initial grade of stenosis was predictive of success for the first surgery (p=0.0085), 7 children were submitted to salvage surgeries. Children with comorbidities had 2.5 greater odds (95% CI 1.2-4.9, p=0.0067) of unsuccessful surgery. Age at first surgery and presence of other airway anomalies were not significantly associated with success.

CONCLUSIONS

The overall success rate was 86%. Failures were associated with higher grades of stenosis and presence of comorbidities, but not with patient age or concomitant airway anomalies.