Laryngeal and tracheal stents in children

Recalcitrant Stenosis Following Pediatric LTR: Contributing Factors and Clinical Impact

OBJECTIVES

Laryngotracheal reconstruction (LTR) has revolutionized the management of pediatric subglottic stenosis (SGS). However, postoperative stenosis remains a difficult hurdle to overcome. Our goal is to determine the clinical impact of recalcitrant stenosis after LTR and the factors contributing to postoperative stenosis.

STUDY DESIGN

Retrospective review of 181 open LTR patients between 2008 and 2021.

SETTING

Stand-alone tertiary children's hospital.

METHODS

Recalcitrant stenosis was defined as new or worsening stenosis despite open LTR. Fisher's exact and Mann-Whitney tests were used to detect differences in categorical and continuous clinical data between patients with and without treatment-resistant stenosis. Time-to-decannulation analysis of both groups was performed using Kaplan-Meier analysis and evaluated with log-rank and Cox proportional hazards regression. Multivariate logistical regression was used to assess the validity of associations found in univariate analysis.

RESULTS

As expected, the 27 patients with postoperative stenosis were less likely to be decannulated (P < .001, Fisher's Exact), more likely to require a postoperative tracheostomy (P < .001, Fisher's Exact) or revision LTR (P < .001, Fisher's Exact) and had prolonged time to decannulation (P < .001, Log-rank). Children with Grade IV SGS (P = .004, Fisher's Exact), and those with longer suprastomal stent duration (P = .03, Fisher's Exact) were more likely to suffer from recalcitrant stenosis. Stent duration longer than 4 weeks (P = .01) contributed to refractory stenosis when controlling for all aforementioned variables using multivariable logistic regression. Interposition grafts had a protective effect (P = .005).

CONCLUSION

Maintaining suprastomal stents over 4 weeks after LTR increases the risk for postoperative stenosis and its sequelae.

LEVEL OF EVIDENCE: 4

A modified procedure of T-tube maneuver to treat tracheal total obstruction involving ablative bronchoscopy sparing open surgical intervention

Objectives

The study objectives were to test an innovative T-tube procedure involving ablative bronchoscopy for the treatment of total airway occlusion and to orchestrate a safe and nontraumatic maneuver to treat intricate subglottic stenosis amenable for substituting the conventional surgical intervention.

Methods

This was an uncontrolled single-center cohort study on 1254 patients from January 2001 to June 2021. Patients underwent the modified T-tube procedure treatment for tracheal stenosis. Only 42 patients were included in the study because they had full records for subglottic total occlusion sitting tracheostomy. The ablative bronchoscopy, aided by a fixed suspending laryngoscope, was applied to retunnel their total airway occlusion. T-tube revision and removal were conducted under general anesthesia with laryngeal mask airway aid during follow-up.

Results

The primary outcome was 90-day mortality. The secondary outcome was 90-day morbidity. The 42 patients included in the study had a mean age of 52.29 years (range, 9-84 years) with 22 men (52.38%). Their mean length of hospital stay was 13.67 days (range, 2-45 days). Their mean operation time was 73 minutes (range, 43-256 minutes). Their mean length of the tracheal stenosis was 2.8 cm (range, 0.8-6.3 cm). Outcomes were good in 29 patients (69.05%), satisfactory in 10 patients (23.81%), and considered failures in 3 patients (7.14%). A total of 16 patients (38.10%) underwent decannulation, and 3 patients (7.14%) were shifted to a Shiley tracheostomy. All 42 patients had a median follow-up of 6.2 years (range, 1.5-16.3 years).

Conclusions

The modified T-tube procedure, which offered both resilience and versatility, improved the conventional technique in treating those patients experiencing total tracheal stenosis and who were unqualified for conventional open surgery.

A refashioned foley catheter: novel cost-effective available stent in pediatric laryngotracheal reconstruction

PURPOSE

Pediatric laryngotracheal reconstruction (LTR) for laryngotracheal stenosis (LTS) mandates stenting in certain situations. This study presents a novel commercially available and cost-effective stent, a refashioned foley catheter.

METHODS

This prospective clinical study was performed on pediatric cases with LTS up to 8 years. The study was performed in a tertiary referral center. The selection of the proper foley catheter size for age was explained. The atraumatic insertion maneuver of the stent was also shown in detail in different situations of LTS. The endoscopic removal of the stent was also described. The mean follow-up was 6.45 ± 1.3 months.

RESULTS

The study included 31 cases using the refashioned foley catheter stents. The study included 17 males and 14 females with a mean age of 3.45 ± 1.09. Subglottic stenosis was the most common cause of LTR in the study (74.2%) cases. The mean duration of stenting was 40.5 ± 3.7 days. Decannulation was achieved in 96.8% of cases. No stent complications were encountered like stent migration, excess granulation tissue, intractable aspiration, or pressure necrosis.

CONCLUSION

The refashioned foley catheter is a novel, available, and inexpensive stent that can be utilized for LTR cases for pediatric LTS. The newly described stent is soft, pliable with atraumatic insertion and easy endoscopic removal with minimal complications.

The surgical treatment of acquired subglottic stenosis in children with double-stage laryngotracheal reconstruction

OBJECTIVES

The aim of this study is to report our experience with double-stage laryngotracheal reconstruction with anterior or antero-posterior cartilage grafting in the management of acquired laryngotracheal stenosis in children. Patients were treated by the same surgeon at the UMC National Research Center for Maternal and Child Health of Astana (Kazakhstan), and Sfendiyarov Kazakh National Medical University, Almaty (Kazakhstan).

METHODS

From November 2011 to September 2019, 9 children underwent surgery for grade III and IV laryngotracheal stenosis according to the European Laryngological Society classification (mean age of 6 years, range of 2-12 years).

RESULTS

Six patients underwent double-stage laryngotracheal reconstruction with anterior and posterior cartilage graft, and 3 patients underwent double-stage laryngotracheal reconstruction with single anterior cartilage graft. In all patients, a T-tube was used to stabilize the airway (mean time of 5.8 months, range of 5-9 months). One patient required additional dilation with bougies to obtain a viable laryngotracheal diameter. No postoperative complications were observed. One patient experienced recurrence of the stenosis 5 months after double-stage laryngotracheal reconstruction with double anterior and posterior cartilage grafts and is waiting for revision surgery. After a mean follow-up of 14 months (range of 4-36 months), 8 patients are tracheostomy-free, and all patients are feeding tube-free.

CONCLUSIONS

Double-stage laryngotracheal reconstruction with a single or double cartilage grafting represents a safe and effective option in the management of complete or severe laryngotracheal stenosis.

Short- versus Long-term Stenting in Children with Subglottic Stenosis Undergoing Laryngotracheal Reconstruction

Objectives Suprastomal stents are routinely used in laryngotracheal reconstruction (LTR) to stabilize grafts and provide framework to sites of repair. However, the duration of stenting varies according to patient history and physician preference. We examined outcomes of short- versus long-term stenting in children with subglottic stenosis (SGS) undergoing LTR. Study Design Case series with chart review. Setting Tertiary care pediatric hospital. Subjects and Methods Thirty-six children <18 years old who underwent double-stage LTR for SGS from January 2012 to January 2015 were included. Demographic data, stenosis grade, and decannulation rates were compared between children with short-term stenting (≤21 days; n = 14) and those with long-term stenting (>21 days; n = 22). Results No significant difference between groups was seen for sex, age, race, or previous repair. Children in the short-term group were stented for 10.9 ± 4.9 days, compared with 44.0 ± 10.6 for those long-term ( P < .0001). A similar number of children with short- versus long-term stents had grade 3/4 stenosis preoperatively (71.4% vs 77.2%). Although time to decannulation was not significantly different, 72.7% of children with long-term stents were decannulated, as opposed to 35.7% with short-term stents ( P = .03). After adjusting for grade at surgery and age, children with long-term stents had 4.3 greater odds (95% CI, 1.0-18.3) of decannulation than children with short-term stents. Conclusions Children with long-term stenting were more likely to be successfully decannulated. Although long-term stenting improved outcomes for children with SGS, additional research is needed to better define ideal candidates for short- versus long-term stenting.

Is T-tube treatment effective in Meyer-Cotton grade 3 tracheal stenosis: long-term outcomes

OBJECTIVES

To present retrospective experience in Meyer-Cotton grade 3 tracheal stenosis of 17 patients treated by T-tube, considering the characteristics of the treated stenosis, surgical procedures performed, and post-operative outcomes and complications.

METHODS

All demographic and clinical data were collected retrospectively. Chest and neck computed tomography scans were performed to assess the stenosis, including length, location, and glottic involvement. The stenotic area was evaluated endoscopically according to an adapted Meyer and Cotton grading scale.

RESULTS

The aetiology of the tracheal stenosis was intubation-related in all cases. The duration of intubation ranged between 1 hour to 40 days. According to the Myers-Cotton classification, all patients were at stage 3. Mean length of the stenosis was 26.58 ± 12.02 (range =15-70) mm. Mean follow-up for the study group was 60.16 ± 34.10 (range =18-137) months. Two patients died during follow-up, one due to stroke, one due to chronic lymphocytic leukemia; no deaths were attributable to TS. The remaining 15 patients could be evaluated up to the present time. Post-operative decannulation was achieved in three of 15 patients (20%), and decannulation was not achieved in 12 of 15 patients (80%).

CONCLUSION

T-tube is not an effective treatment of tracheal stenosis.

Endotracheal Nitinol Stents

Objective

To reflect on lessons learned placing endotracheal nitinol stents in children.

Study Design

Case series with chart review.

Setting

Tertiary care children’s hospital.

Subjects and Methods

All children who underwent nitinol cervical tracheal stenting were included. Records were carefully reviewed for intraoperative and postoperative complications, management choices, outcomes, and factors that influenced results.

Results

Between 1999 and 2011, 7 children underwent 13 stent placements. Median follow-up was 5 years (range, 1-12 years). Six patients underwent stenting as a salvage procedure following open attempts at airway reconstruction. Four patients remain decannulated with their stent in place (median follow-up 7 years). The fifth patient had his stent removed endoscopically after 50 days because it became apparent that his obstruction was primarily laryngeal. The sixth child had his stent removed via a tracheal fissure after 14 months because of recalcitrant subglottic inflammation at the superior stent border. The seventh patient was decannulated for over 2 years but ultimately required tracheotomy replacement because of stenosis with the stent lumen. Complications included stent migration (23%), restenosis (29%), edema (29%), and granulation (57%).

Conclusion

Endotracheal nitinol stents provide a realistic opportunity for decannulation in children for whom other options have failed but should be reserved only as a salvage procedure in severely complicated airways. Our experience has taught valuable lessons about stent indications, sizing, characteristics, and deployment, as well as means to avoid and manage their complications.

Larynx: implants and stents

In the human larynx, implants a primarily used for the correction of glottis insufficiency. In a broader sense laryngeal stents may be considered as implants as well. Laryngeal implants can be differentiated into injectable and solid. The most important representatives of both groups are discussed in detail along with the respective technique of application. Laryngeal stents are primarily used perioperatively. Different types and their use are presented.

Anesthetic management of patients with tracheal T-tubes

AIMS

To better inform the preoperative anesthesia assessment, we review the rationale of tracheal T-tubes and the maintenance they require. We then describe specific intraoperative techniques to administer inhalational agents and maintain respiration in patients with tracheal T-tubes.

BACKGROUND

Tracheal T-tubes maintain airway patency in the healing phases of laryngotracheal reconstruction or in the setting of extrinsic or intrinsic airway collapse. The T-tube comprises a superior limb, an inferior limb, and an anterior limb projecting from a tracheotomy site. Negotiating tracheal T-tubes may present significant anesthetic challenges in both elective and emergent circumstances.

METHODS

The intraoperative ventilation techniques in patients with tracheal T-tubes are reviewed as well as pre and postoperative T-tube maintenance strategies.

RESULTS

Twelve techniques to connect anesthetic circuitry to tracheal T-tubes in different perioperative clinical scenarios are detailed.

CONCLUSIONS

T-tubes are a well-established method for supporting the airway in both adults and children. However, the very design of the T-tube poses unique anesthetic management issues before, during, and after the operation. Anesthetic administration and gas exchange may be effectively achieved through a variety of methods, which we describe in detail.

Duration and extent of dysphagia following pediatric airway reconstruction

OBJECTIVE

Patients who undergo open airway reconstruction procedures are likely to experience some degree of post-operative dysphagia. This retrospective review describes the duration of post-operative dysphagia and the use of compensatory strategies in a group of 30 pediatric patients.

METHODS

A retrospective chart review of pediatric patients referred for post-operative swallowing assessment following airway reconstruction during a six-month period was completed. Age, sex, surgical procedure, stent type, co-morbid factors, duration of dysphagia, and use of compensatory dietary modifications and swallowing strategies was summarized and compared.

RESULTS

Dysphagia was generally of short duration (1-5 days) in patients undergoing single stage procedures with anterior or anterior/posterior grafts. Duration of swallowing difficulty was increased in patients undergoing posterior grafts in combination with T tubes (10-14 days). The longest duration of difficulty (>2 weeks) occurred in patients who had anterior and posterior grafting with T tubes, combined with additional procedures such as vocal fold lateralization, epiglottic petiole repositioning, and/or arytenoidectomy. There was a greater likelihood of oral feeding difficulty post-operatively in patients presenting with pre-operative feeding issues such as oral aversion or specific texture refusal, and the pre-morbid need for supplemental tube feeding to supplement oral intake. Compensatory swallowing strategies were effective in decreasing aspiration associated with swallowing in oral feeders post-operatively, and in facilitating return to baseline swallowing skills.

CONCLUSIONS

The duration of dysphagia overall was increased in patients undergoing anterior/posterior grafts in conjunction with in-dwelling T tubes, especially when combined with additional procedures. Compensatory strategies to assist with swallowing were found to be effective in the post-operative phase and included the use of a modified supraglottic swallowing sequence to assist with compensatory airway closure during swallowing in conjunction with diet modifications. Post-operative feeding difficulty occurred in patients with pre-existing feeding issues such as oral aversion and/or texture resistance regardless of reconstructive surgical procedure type.

The role of endoluminal self-expanding stents in the management of pediatric tracheal stenosis

OBJECTIVE

Review of our experience in the management of pediatric tracheal stenosis using endoscopic techniques and self-expanding intraluminal stents.

METHODS

Thirteen children (aged 1 week to 14 years) with various causes of tracheal stenosis were treated. A total of 15 stents were used, 13 self-expanding nitinol stents and 3 silicone self-expanding stents. Follow-up ranged from 6 month to 8 years.

RESULTS

There were no stent related mortalities. Serious complications occurred in 4 patients [30.7%] but all were managed successfully. The most frequent problem was granulation tissue formation. Patient follow-up ranged from 6 months to 8 years. In the short-term (18-24 months) 12 stents remained patent and functional. On the longer term (5 years) 3 stents required removal, one required replacement and another resulted in stenosis.

CONCLUSION

Endoluminal stenting can have an increasing role in the management of selected cases pediatric tracheal stenosis with acceptable morbidity and stable long-term results.