The anterior mediastinal approach for management of tracheomalacia

Open and Thoracoscopic Aortopexy for Airway Malacia in Children: 15 Year Single Centre Experience

OBJECTIVES

The objective was to report and analyse the characteristics and results of open aortopexy and thoracoscopic aortopexy for the treatment of airway malacia in a paediatric population.

METHODS

We report a retrospective consecutive case series of paediatric patients undergoing aortopexy for the treatment of airway malacia at a quaternary referral centre between December 2006 and January 2021. Outcome measures included days to extubation, continued need for non-invasive ventilation, further intervention in the form of tracheostomy and death.

RESULTS

169 patients underwent aortopexy: 147 had open procedures (135 via median/limited median sternotomy and 12 thoracotomy) and 22 thoracoscopic. Mean follow up was 8.46 yrs (range 1-20 yrs). Most common site of airway malacia was the trachea (n = 106, 62.7 %), and 48 (28.4 %) had additional involvement at the bronchi with tracheobronchomalacia (TBM). 15 (8.9 %) had bronchomalacia (BM) only. Incidence of bronchial disease was lower in the thoracoscopic than open group (13.6 % vs 40.82 %; p < 0.0001). Mean time to extubation was 1.45 days, 2.59 days, 5.23 days in tracheomalacia, TBM and BM groups, respectively (p = 0.0047). Mean time to extubation was 1.35 days, 2 days, 3.67 days, and 5 days in patients with external vascular compression, TOF/OA, primary airway malacia, and laryngeal reconstruction, respectively (p = 0.0002). There were 21 deaths across the cohort, and all were in the open group. 71.4 % (n = 15) had bronchial involvement of their airway malacia.

CONCLUSIONS

Open and thoracoscopic aortopexy are effective treatments for airway malacia in children. We have identified that involvement of the bronchi is a risk factor for adverse outcomes, and the optimum treatment for this patient cohort is still debatable.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective Study.

Factors associated with success following transcervical innominate artery suspension

OBJECTIVE

Aortopexy including innominate artery suspension is a well-established treatment of anterior vascular compression and associated tracheomalacia. We report the results of our case series of cervical approach to innominate artery suspension and hypothesize that increased distance from the innominate to the sternum is predictive of superior symptomatic outcome.

STUDY DESIGN

Retrospective Case Series.

METHODS

All cases of cervical innominate artery suspension at our institution over the last 10 years were reviewed. CT scans of the neck and chest were reviewed to obtain anatomical measurements including anterior-posterior thoracic outlet distance, thymic thickness, and sternum-innominate artery distance. Measurements were compared with surgical outcomes as verified by follow up bronchoscopy and clinical course to determine factors predictive of success.

RESULTS

Ten cases of cervical innominate artery suspension were performed by the otolaryngology service at our institution over the last 10 years. Six patients had improvement in their symptoms. The average sternum-innominate artery distance (SID) was larger (14.4 mm (95% CI 9.1-19.7)) in patients who had improvement in clinical symptoms following innominate suspension compared to those that did not improve (6.3 mm (95% CI 2.5-10.1)) (p value = 0.02). Similarly, the anterior-posterior distance of the thoracic outlet was larger (34.9 mm (95% CI 27.4-42.4)) in patients who had improvement post-op compared to those that did not improve (22.6 mm (95% CI 18.2-27.2) (p value = 0.01). Two patients required spine surgery to achieve improvement in their symptoms.

CONCLUSION

Cervical innominate artery suspension is successful in carefully selected patients. More space in the thoracic outlet and larger distance from the innominate artery to the sternum is associated with symptomatic improvement.

Current concepts in tracheobronchomalacia: diagnosis and treatment

Airway collapse from dynamic tracheobronchomalacia (TBM), static compression from vascular compression, and/or tracheobronchial deformation are challenging conditions. Patients are best assessed and managed by a multidisciplinary team in centers specializing in complex pediatric airway disorders. Suspicion is made through clinical history and physical examination, diagnosis of location and severity by dynamic 3-phase bronchoscopy, and surgical treatment planning by MDCT and other studies as necessary to completely understand the problems. The treatment plan should be patient-based with a thorough approach to the underlying pathology, clinical concerns, and combined abnormalities. Patients should undergo maximum medical therapy prior to committing to other interventions. For those children considered candidates for surgical intervention, all other associated conditions, including vascular anomalies, chest wall deformities, mediastinal lesions, or other airway pathologies, should also be considered. Our preference is to correct the airway lesions at the same operation as other comorbidities, if possible, to prevent multiple reoperations with their attendant increased risks. We also strongly advocate for the use of recurrent laryngeal nerve monitoring in all cases of cervical or thoracic surgery to minimize the risks to vocal cord function and laryngeal sensation. Studies that evaluate the effect of these interventions on the patient and caregiver's quality of life are needed to fully grasp the impact of TBM on this challenging patient population.

The left-sided repair: An alternative approach for difficult esophageal atresia repair

PURPOSE

We describe a left-sided approach for long gap esophageal atresia (LGEA) repair in patients who have a large leftward upper pouch and no significant tracheomalacia, or as a salvage strategy after prior failed right-sided repairs.

METHODS

Retrospective review of patients who underwent repair via traction induced growth (Foker procedure [FP]) from 2014 to 2019 was performed. Surgical technique and post-operative outcomes were evaluated.

RESULTS

Of 47 LGEA patients, 18 (38%) were approached via the left side - 94% had a left aortic arch, and 22% had prior attempts at a right-sided anastomosis. More left-sided patients underwent minimally invasive repair (39% vs 7%, p = 0.007) and internal traction (50% vs 10%, p = 0.002) compared to right-sided patients. On multivariate analysis, internal traction was associated with a decreased length of paralysis (p<0.01); length of intubation and hospital stay were similar between groups. Anastomotic leak (17% vs 20%, p = 0.80) and stricture resection (6% vs 24%, p = 0.12) rates were similar. No left-sided FP patient required additional surgery for tracheomalacia, while six right-sided patients required intervention.

CONCLUSION

Left-sided FP can be considered for LGEA patients with a large leftward upper pouch or as a salvage pathway after a failed right chest approach, with similar outcomes to the right-sided approach.

Tracheobronchomalacia, Tracheobronchial Compression, and Tracheobronchial Malformations: Diagnostic and Treatment Strategies

Tracheobronchomalacia (TBM) is an excessive dynamic narrowing of the airway that is greatest with increased mediastinal pressure such as coughing, Valsalva, and forced expiration. Airway compression and/or cartilage malformation is a fixed or static narrowing of the airway typically caused by great vessel malposition and/or abnormalities and may also contribute to airway narrowing. Although imprecise and misleading, the term TBM is often used to represent both problems, static and dynamic airway narrowing, which only serves to confuse and may mislead the treatment team into ineffective therapies. The consequences of airway narrowing caused by dynamic TBM and/or static compression includes a range of clinical signs and symptoms, depending on the location, extent, and severity of the airway collapse. All patients with mild to severe TBM benefit from medical management to optimize airway clearance of mucus. The milder cases of TBM may become asymptomatic with this therapy, allowing time for the child to grow and the airway to enlarge without the consequences of recurrent infections. In cases of more severe TBM with clinical sequelae, more aggressive management may be warranted. Multiple options for surgical intervention are available. This article discusses the details of clinical presentation, evaluation, diagnosis, and a variety of treatments.

When to consider a posterolateral descending aortopexy in addition to a posterior tracheopexy for the surgical treatment of symptomatic tracheobronchomalacia

PURPOSES

The descending thoracic aorta typically crosses posterior to the left mainstem bronchus (LMSB). We sought to evaluate patient factors that may lead one to consider a posterolateral descending thoracic aortopexy (PLDA) in addition to a posterior tracheopexy (PT) in the surgical treatment of symptomatic tracheobronchomalacia (TBM) that involves the LMSB.

METHODS

Retrospective review of patients who underwent PT with or without PLDA between 2012 and 2017. Severity and extent of TBM were assessed using dynamic tracheobronchoscopy. Aortic positioning compared to the anterior border of the spine (ABS) at the level of the left mainstem bronchus was identified on computed tomography (CT). Factors associated with performing a PLDA were evaluated with logistic regression.

RESULTS

Of 188 patients who underwent a PT, 70 (37%) also had a PLDA performed. On multivariate analysis, >50% LMSB compression on bronchoscopy (OR 8.06, p < 0.001), >50% of the aortic diameter anterior to the ABS (OR 2.06, p = 0.05), and more recent year of surgery (OR 1.61, p = 0.003) were associated with performing a PLDA.

CONCLUSION

When performing a PT, a PLDA should be considered for patients who have >50% LMSB compression on dynamic bronchoscopy, and in those with a descending thoracic aorta located >50% anterior to the ABS.

LEVEL OF EVIDENCE

III TYPE OF STUDY: Retrospective comparative study.

Great vessel anomalies and their impact on the surgical treatment of tracheobronchomalacia

BACKGROUND

Tracheobronchial compression (TBC) from great vessel anomalies (GVA) can contribute to tracheobronchomalacia (TBM) symptoms. The frequency, impact on symptoms and optimal management of GVA in these patients, with or without a history of esophageal atresia (EA), are still unclear.

STUDY DESIGN

Patients who underwent surgery for TBM/ TBC between 2001 and 2017 were reviewed. Demographics, type of GVA, and operative interventions were collected. The frequency and treatment modalities of GVA between EA and non-EA patients were compared.

RESULTS

Overall, 209 patients met criteria; 120 (57.4%) patients had at least one GVA, including double aortic arches (n = 4, 1.9%), right aortic arches (n = 14, 6.7%), aberrant right subclavian arteries (n = 15, 7.2%), and innominate artery compression (n = 71, 34.0%). Non-EA patients were more likely to have surgery later in life (29.5 months versus 16 months, p = 0.0002), double aortic arch (p = 0.0174), right aortic arch (p < 0.0001), and undergo vascular reconstruction concurrently with their airway procedure (25% vs 8.4%, p = 0.002). Vessel reconstruction was performed in 25 patients; six required cardiac bypass.

CONCLUSION

The frequency of GVA in patients with symptomatic airway collapse is substantial. Multidisciplinary evaluation is imperative for operative planning as many require complex reconstruction and collaboration with cardiac surgery, particularly patients without a history of EA.

LEVEL OF EVIDENCE

Level III.

ERS statement on tracheomalacia and bronchomalacia in children

Tracheomalacia and tracheobronchomalacia may be primary abnormalities of the large airways or associated with a wide variety of congenital and acquired conditions. The evidence on diagnosis, classification and management is scant. There is no universally accepted classification of severity. Clinical presentation includes early-onset stridor or fixed wheeze, recurrent infections, brassy cough and even near-death attacks, depending on the site and severity of the lesion. Diagnosis is usually made by flexible bronchoscopy in a free-breathing child but may also be shown by other dynamic imaging techniques such as low-contrast volume bronchography, computed tomography or magnetic resonance imaging. Lung function testing can provide supportive evidence but is not diagnostic. Management may be medical or surgical, depending on the nature and severity of the lesions, but the evidence base for any therapy is limited. While medical options that include bronchodilators, anti-muscarinic agents, mucolytics and antibiotics (as well as treatment of comorbidities and associated conditions) are used, there is currently little evidence for benefit. Chest physiotherapy is commonly prescribed, but the evidence base is poor. When symptoms are severe, surgical options include aortopexy or posterior tracheopexy, tracheal resection of short affected segments, internal stents and external airway splinting. If respiratory support is needed, continuous positive airway pressure is the most commonly used modality either via a face mask or tracheostomy. Parents of children with tracheobronchomalacia report diagnostic delays and anxieties about how to manage their child's condition, and want more information. There is a need for more research to establish an evidence base for malacia. This European Respiratory Society statement provides a review of the current literature to inform future study.

Aortopexy for tracheomalacia via a suprasternal incision

AIM

Tracheomalacia is flaccidity of the tracheal wall leading to tracheal collapse, particularly on expiration. When severe it can warrant surgical intervention. Aortopexy is one surgical option and has been described using a variety of approaches. We report outcomes of aortopexy performed via a suprasternal incision in a single centre by a single surgeon.

METHODS

All patients undergoing aortopexy between February 2016 and May 2018 were prospectively included. Patients were managed by a multi-disciplinary team (MDT) and underwent standardized work-up, including dynamic flexible bronchoscopy (DFB) and contrast enhanced CT. Aortopexy was performed via a suprasternal skin crease incision. Surgery was guided by intra-operative flexible bronchoscopy. Data regarding pre-operative symptoms, degree of tracheomalacia, and outcomes were recorded.

RESULTS

Twenty-two patients were included, 18 boys, median age 5 months (range 1 month-5 years). Two aortopexy sutures were used in all cases, and three patients required an additional tracheopexy suture. Median operating time was 1 h 24 min (range 47 min-2 h 35 min). Median pre-operative tracheal collapse on DFB was 85% (range 80-95%), improving to 35% (35-80%) intra-operatively. Median length of stay was 4 days (range 1-118).

CONCLUSIONS

Aortopexy via a suprasternal incision is a useful treatment modality for tracheomalacia with short operating times and rapid recovery. Outcomes vary with the best results in the TOF and premature groups. Careful patient selection and MDT work-up are essential to optimize outcomes.

LEVEL OF EVIDENCE

Level 3 (Case Series).

Tracheomalacia and Tracheobronchomalacia in Pediatrics: An Overview of Evaluation, Medical Management, and Surgical Treatment

Tracheobronchomalacia (TBM) refers to airway collapse due to typically excessive posterior membrane intrusion and often associated with anterior cartilage compression. TBM occurs either in isolation or in association with other congenital or acquired conditions. Patients with TM typically present non-specific respiratory symptoms, ranging from noisy breathing with a typical barking cough to respiratory distress episodes to acute life-threatening events and recurrent and/or prolonged respiratory infections. There are no definitive standardized guidelines for the evaluation, diagnosis, and treatment of TBM; therefore, patients may be initially misdiagnosed and incorrectly treated. Although milder cases of TBM may become asymptomatic as the diameter of the airway enlarges with the child, in cases of severe TBM, more aggressive management is warranted. This article is an overview of the clinical presentation, evaluation, diagnosis, medical management, and surgical treatment options in pediatric tracheomalacia.

Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing

BACKGROUND

Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies.

METHODS

An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations.

RESULTS

The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing.

CONCLUSIONS

Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.

Complications in neonatal surgery

Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.

Tracheobronchial stents in children

Tracheobronchial obstruction is infrequent in children and still remains a challenging matter of concern. Management alternatives vary from conservative treatment to complex surgical techniques or endoscopic interventional procedures. Airway stenting in children is relatively recent and follows the trail of the experience in adult patients. Nevertheless, there are basic differences between both age groups like the benign nature of most obstructions and the small size of the pediatric airway. These specific features raise the issues of the precise role of tracheobronchial stenting in children and the selection of the most adequate device. Stents fall into four main categories according to the material they are made of: metallic, plastic, hybrid, and biodegradable. Each type has its own advantages and drawbacks so the ideal stent is not yet available. Despite increasing experience with stenting, definite clinical criteria for their use in children are yet to be established. Even so, there seems to be a basic general agreement that stents may play a role in particular clinical settings in which there are no other therapeutic options.

Treatment of severe porcine tracheomalacia with a 3-dimensionally printed, bioresorbable, external airway splint

IMPORTANCE

The study demonstrates use of a novel intervention for severe tracheobronchomalacia (TBM).

OBJECTIVE

To test a novel, 3-dimensionally (3D) printed, bioresorbable airway splint for efficacy in extending survival in a porcine model of severe, life-threatening TBM.

DESIGN AND PARTICIPANTS

A randomized, prospective animal trial was used to evaluate an external airway splint as treatment of severe, life-threatening TBM in a multi-institutional, multidisciplinary collaboration between a biomedical engineering department and an academic animal surgery center. Six 2-month-old Yorkshire pigs underwent tracheal cartilage division and inner tracheal lumen dissociation and were randomly assigned to splint treatment (n = 3) or control groups (n = 3). Two additional pigs had the splint placed over their normal trachea.

INTERVENTIONS

A 3D-printed, bioresorbable airway splint was assessed in a porcine animal model of life-threatening TBM. The open-cylindrical, bellow-shaped, porous polycaprolactone splint was placed externally and designed to suspend the underlying collapsed airway. Two additional animals were splinted without model creation.

MAIN OUTCOMES AND MEASURES

The observer-based Westley Clinical Croup Scale was used to assess the clinical condition of animals postoperatively. Animal survival time was noted.

RESULTS

Complete or nearly complete tracheal lumen collapse was observed in each animal, with resolution of symptoms in all of the experimental animals after splint placement. Using our severe TBM animal model, survival was significantly longer in the experimental group receiving the airway splint after model creation than in the control group (P = .0495).

CONCLUSIONS AND RELEVANCE

A multidisciplinary effort producing a computer-aided designed, computer-aided manufactured bioresorbable tracheobronchial splint was tested in a porcine model of severe TBM and was found to extend survival time. Mortality in the splinted group was ascribed to the TBM model based on the lack of respiratory distress in splinted pigs, long-term survival in animals implanted with the splint without TBM, and necropsy findings.

Resolution of opisthotonus in respiratory distress by aortopexy

We report a case of worsening respiratory distress associated with opisthotonus secondary to tracheomalacia, a rather unique pathophysiological phenomenon. A 2-month-old male baby was referred to our hospital for respiratory distress syndrome with a noticeable opisthotonus. Examination and investigation confirmed the presence of an aberrant innominate artery compressing the trachea. The infant underwent aortopexy and made a dramatic post-operative recovery. Of special note, the opisthotonus vanished soon after the operation. Opisthotonus is not always related to neurological impairment and may be a warning sign of mediastinal overcrowding in patients with respiratory distress syndrome secondary to vascular compression.

Tracheobronchomalacia in children: review of diagnosis and definition

Tracheobronchomalacia is characterised by excessive airway collapsibility due to weakness of airway walls and supporting cartilage. The standard definition requires reduction in cross-sectional area of at least 50% on expiration. However, there is a paucity of information regarding the normal range of central airway collapse among children of varying ages, ethnicities and genders, with and without coexisting pulmonary disease. Consequently, the threshold for pathological collapse is considered somewhat arbitrary. Available methods for assessing the airway dynamically--bronchoscopy, radiography, cine fluoroscopy, bronchography, CT and MR--have issues with reliability, the need for intubation, radiation dose and contrast administration. In addition, there are varying means of eliciting the diagnosis. Forced expiratory manoeuvres have been employed but can exaggerate normal physiological changes. Furthermore, radiographic evidence of tracheal compression does not necessarily translate into physiological or functional significance. Given that the criteria used to make the diagnosis of tracheobronchomalacia are poorly validated, further studies with larger patient samples are required to define the threshold for pathological airway collapse.

Minimally invasive innominate artery transection for tracheomalacia using 3-dimensional multidetector-row computed tomographic angiography: report of a case

We successfully performed transection of the innominate artery in a patient with a neuromuscular disorder through minimally invasive access after confirming the anatomical relationships of the vessel using 3-dimensional multidetector-row computed tomographic angiography. A 16-year-old girl with spinal muscular atrophy type 1 had been on long-term mechanical ventilation with a tracheostomy. She had scoliosis and tracheomalacia. Bronchoscopy showed a flattened and narrow lower trachea and an anterior pulsatile compression by the innominate artery. She underwent transection of the innominate artery to prevent tracheoinnominate artery fistula formation. Based on preoperative 3-dimensional multidetector-row computed tomographic angiography images, the innominate artery was transected through a small transverse curvilinear skin incision just below the suprasternal notch and an oblique partial manubriotomy from the suprasternal notch to the first left intercostal space.

Low cervical skin crease approach for superior sternal cleft repair

Superior sternal cleft repair aims to restore bony protection to mediastinal structures and to eliminate visible deformity. We describe a 4-day-old neonate with an isolated defect who successfully underwent primary repair using a low cervical skin crease incision. Such a novel approach combined optimal surgical exposure and excellent cosmesis.

Tracheobronchomalacia in infants and children: multidetector CT evaluation

Tracheobronchomalacia (TBM) is the most common congenital central airway anomaly, but it frequently goes unrecognized or is misdiagnosed as other respiratory conditions such as asthma. Recent advances in multidetector computed tomography (CT) have enhanced the ability to noninvasively diagnose TBM with the potential to reduce the morbidity and mortality associated with this condition. Precise indications are evolving but may include symptomatic pediatric patients with known risk factors for TBM and patients with otherwise unexplained impaired exercise tolerance; recurrent lower airways infection; and therapy-resistant, irreversible, and/or atypical asthma. With multidetector CT, radiologists can now perform objective and quantitative assessment of TBM with accuracy similar to that of bronchoscopy, the reference standard for diagnosing this condition. Multidetector CT enables a comprehensive evaluation of pediatric patients suspected of having TBM by facilitating accurate diagnosis, determining the extent and degree of disease, identifying predisposing conditions, and providing objective pre- and postoperative assessments. In this article, the authors present a step-by-step primer of multidetector CT imaging for evaluating infants and children with suspected TBM, including clinical indications, patient preparation, multidetector CT techniques and protocols, two- and three-dimensional processing of multidetector CT data, and image interpretation. The major aim of this article is to facilitate the reader's ability to successfully employ multidetector CT imaging protocols for evaluation of TBM in infants and children in daily clinical practice.

Tracheal Ceramic Rings for Tracheomalacia: A Review After 17 Years

BACKGROUND

Despite different support techniques, the surgical management of tracheomalacia is still a challenging problem. Satisfactory results after internal stenting are above 80%, whereas, when performing external stenting using biocompatible ceramic rings, results are reported at over 90%.

OBJECTIVE

The purpose of this study was to examine the efficiency of surgical treatment in patients with segmentary tracheomalacia using external ceramic ring grafts.

METHODS

In this retrospective study, we collected data from 12 patients who underwent surgery during the last 17 years for symptomatic segmentary tracheomalacia by use of biocompatible aluminum-oxide ceramic rings. All except one patient had undergone previous tracheostomy, six had a history of long-term intubation, two had previous trauma, and two patients had previous cancer treatment including radiotherapy. One of the patients still had an existing tracheostoma, which was closed when a ceramic ring was implanted. Tracheal wall collapse with pseudoglottis formation or flattened anterior-posterior tracheal diameter was documented with fiberoscopy at rest, and both pre- and postoperative airway resistance measurements were performed in all 12 patients using a spirometer. After malacic segments were found to be expandable using rigid tracheoscopy while the patient was under general anesthesia, preparation of the trachea was performed using a midline vertical incision in the neck. Subsequently, the malacic trachea was expanded by placing and suturing proper-sized ceramic ring(s) around it.

RESULTS

In all patients, surgical expansion of the malacic segment using ceramic rings was successfully carried out without major complications while inspiratory stridor was resolved. Airway resistance decreased significantly from an average of 0.62 to 0.385 kPascal.

CONCLUSION

Although the results of applying internal tracheal stents are encouraging, complications such as stent migration, granulation tissue and fistula formation, and mucociliary transport arrest are possible. Biocompatible ceramic rings do not cause foreign body reactions, remain stabile, and, with a proper suturing technique, provide a suitable long-term solution.

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 in esophageal atresia. Usefulness of preoperative imaging evaluation for tailored surgical correction

Tracheomalacia (TM) associated with esophageal atresia (OA) generally is located in the thoracic segment of the trachea, and the close anatomical relationships it has with the aortic arch and the other mediastinal structures play a remarkable role in the dynamic obstruction of the airways. Only correct preoperative imaging studies permit a precise anatomic description of TM, reducing the risk of incomplete treatment owing to the persistence of other undervalued problems. This report describes the usefulness of preoperative imaging by dynamic fiberoptic bronchoscopy and spiral multilayer computed tomography with 3-dimensional reconstruction in 7 symptomatic children with segmentary TM associated with esophageal atresia and treated surgically "case by case" based on dynamic fiberoptic bronchoscopy and computed tomography data.

The role of aortopexy in severe tracheomalacia

PURPOSE

Aortopexy is the accepted operative treatment for severe and localized tracheomalacia (TM). The standard surgical approach involves a left anterior thoracotomy, often under bronchoscopic control. We report the results of aortopexy in 28 children with severe and localized TM; 12 had a left lateral muscle-sparing approach and one had a thoracoscopic aortopexy.

METHODS

Retrospective review of patient notes was performed to note the indications, investigation findings, and postoperative course after aortopexy.

RESULTS

The median age at aortopexy was 5 months. The indications included acute life-threatening events in 22, failure to extubate in 5, and recurrent pneumonia in 1. Fifteen had associated esophageal atresia and 13 had primary TM. Symptoms of TM were abolished in 26 of the 28 patients after aortopexy.

CONCLUSIONS

Aortopexy is a safe and reliable procedure to treat localized intrathoracic TM presenting with acute life-threatening events. It is important to exclude associated problems such as vascular rings and to ensure that the tracheomalacic portion is segmental and does not significantly involve the main bronchi. The lateral muscle-sparing thoracotomy provides good access and is more cosmetic than the standard anterior approach. We would attempt the thoracoscopic approach in older infants and children.

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.

French experience of silicone tracheobronchial stenting in children

Silicone stents were inserted into the trachea or left main-stem bronchus in 14 children aged 2-69 months (median, 7 months). Indications were as follows: tracheomalacia or airway kinking (7 cases), vascular compression (5 cases), and surgically corrected congenital tracheal stenoses (2 cases). The best results were obtained in tracheomalacia. Overall, 6 cases out of 14 (43%) were considered successful, with a stent placement duration of 3-15 months (median, 7 months). Two cases were considered a technical success, although they were clinical failures. Five cases were considered failures primarily due to stent migration. A retrospective analysis of failures suggests that most of these could have been avoided by the use of larger stents. One patient died of stent obstruction. No wall erosion was observed, and the development of granulation tissue was infrequent. Endoscopic removal of the prostheses was uneventful. The biocompatibility of silicone stents appears to be better than what is reported for metal ones, although the stability of the former is less satisfactory. The present study shows the feasibility of silicone stent placement in infants. These stents should be considered as a possible therapeutic option in certain types of childhood airway disorders, although further studies are required.

Humans are born too soon: impact on pediatric otolaryngology

Humans are born 12 months too early. Gestation should be 21 months. Humans evolved to become the pre-eminent animal in the world, but our big brain, bipedalism, and small female pelvic outlet have caused us to pay the price of being born too soon with all of its disadvantages. Early birth has an impact on diseases and disorders encountered by the otolaryngologist, including otitis media, laryngomalacia, tracheomalacia, congenital vocal cord paralysis, subglottic and tracheal stenosis, gastroesophageal reflux, congenital micrognathia, and congenital nasal alar collapse. Many of these conditions improve or resolve completely in the first year of life as an infant's immune system and anatomy matures. Knowledge of this evolutionary process can help us understand why some infants will grow out of certain diseases and disorders encountered in pediatric otolaryngology, while others will not.

Adjusting the endotracheal tube tip in management of tracheomalacia in an infant

Tracheomalacia (TM) is an occult central airway problem that may block the endotracheal tube (ETT) tip and cause ventilation risk. Traditional physical examination, chest radiograph, end-tidal CO2 monitoring and blood gas analysis do not easily make the correct diagnosis. Ultra-thin flexible bronchoscopy (FB) is convenient and useful to verify this rare type of ETT obstruction and can also guide the adjustment of the ETT tip to a correct location. We report two TM infants who were successfully diagnosed and managed by FB to correctly reposition the ETT tip.

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.