David L. Walner

Partial Cricotracheal Resection with Primary Anastomosis in the Pediatric Age Group

The traditional approach to severe subglottic stenosis (SGS) in the pediatric age group is laryngotracheal reconstruction (LTR). This approach may be complex and multistaged, with variable and unpredictable success rates in the individual patient. Excellent results have been reported in adults who had severe SGS and underwent partial resection of the cricoid and primary thyrotracheal anastomosis. This procedure has not been widely reported in infants and children. We report our experience with this procedure in 16 pediatric patients with grade III or IV SGS. Eleven patients had multiple previous LTR operations. The preoperative evaluation, surgical techniques, postoperative care, complications, and final results are described and discussed. Fourteen patients were decannulated after the procedure, 1 patient needed a second open procedure prior to decannulation, and 1 patient with concomitant bronchopulmonary dysplasia remains cannulated, for an overall 94% decannulation rate. Fourteen patients have no limitation of respiration, and 1 patient has moderate exercise intolerance. The results of this series suggest that partial cricotracheal resection with primary anastomosis is a relatively safe and effective procedure for pediatric patients with severe SGS.

Utility of radiographs in the evaluation of pediatric upper airway obstruction.

The evaluation of children with airway obstruction always involves a history and physical examination. The definitive diagnosis is most often made with microlaryngoscopy and bronchoscopy (MLB), and in cases of extrinsic compression, information is gained from magnetic resonance imaging. Although plain radiographs of the airway are often used as a primary diagnostic modality in children with airway obstruction, the accuracy of plain radiographs in predicting specific airway abnormalities has not previously been evaluated. This study was designed to correlate the findings of plain airway radiographs with the diagnosis made at the time of MLB. Medical records from 1991 to 1996 were reviewed to identify patients that had MLB and airway radiographs within 2 days of one another. One hundred forty-four cases were identified and divided into diagnostic categories. Statistical analysis showed a high sensitivity (>86%) for the accuracy of the radiologic diagnoses of exudative tracheitis, airway foreign body, and innominate artery compression. Laryngomalacia and tracheomalacia had a much lower sensitivity (5% and 62%, respectively). We believe that plain radiographic evaluation of the airway provides important information to the diagnostician. However, plain radiographs can be inaccurate and must be considered along with a history, physical examination, and clinical suspicion. Microlaryngoscopy and bronchoscopy remains the ultimate diagnostic test for airway disorders.

Role of laryngoscopy, dual pH probe monitoring, and laryngeal mucosal biopsy in the diagnosis of pharyngoesophageal reflux

There is no standard for determining significant pharyngoesophageal reflux. This prospective blind comparison study compared dual pH probe studies, direct laryngoscopy, and mucosal biopsy in children without symptoms of gastroesophageal reflux who underwent airway evaluation. Significant reflux to the lower esophageal probe did not correlate with statistical significance with reflux to the upper probe. In this group of asymptomatic patients, a positive lower pH probe finding did not correlate with upper or lower esophageal mucosal inflammation. Eosinophilia in the esophageal mucosa is diagnostic of gastroesophageal reflux disease, and was seen in 5 of the laryngeal biopsies. A weak correlation was seen between positive findings at laryngoscopy and positive posterior cricoid biopsy in this group. There may be no consistent way to predict significant pharyngoesophageal reflux in asymptomatic patients. Single-probe pH testing will not predict significant pharyngoesophageal reflux with mucosal changes. Laryngoscopy and upper pH probe findings only weakly correlate with significant histologic findings. Laryngeal and posterior cricoid biopsy may be the only sensitive test for mucosal injury. Clinical trials of empiric antireflux therapy should be used to determine whether the laryngeal changes seen in these patients are reversible.

Correlation between computed tomography and surgical findings in retropharyngeal inflammatory processes in children.

Retropharyngeal abscess (RPA) in children is a potentially life-threatening process which often requires immediate surgical intervention. Contrast enhanced computed tomography (CT) is utilized frequently to determine abscess versus cellulitis/phlegmon and aids in determining cases needing surgical drainage. The purpose of this retrospective study was to determine the accuracy of CT in distinguishing retropharyngeal abscess from cellulitis in children. The medical records of 32 children from 1989 to 1997 suspected of having a retropharyngeal abscess were reviewed. All patients included in the study underwent a CT scan as well as surgical exploration within 48 h of the scan. Two patients required two surgical procedures (n = 34). A comparison between CT results and operative findings was made to determine the accuracy of CT imaging in confirming the presence of RPA versus cellulitis. Suspected diagnosis of abscess or cellulitis/phlegmon on CT was confirmed at surgery in 25 of 34 cases (73.5%). The false positive rate of CT scan was 11.8% (4/34), while the false negative rate was 14.7% (5/34). Based on our results, CT is accurate in differentiating abscess from cellulitis in 73.5% of cases. Clinical findings, as well as radiologic findings, must be considered together prior to surgical drainage of a suspected retropharyngeal abscess in children.

Laryngeal mask airway versus endotracheal tube in pediatric adenotonsillectomy

Evaluation of safety and postoperative outcomes of the laryngeal mask airway (LMA) during pediatric tonsil surgery compared to use of the endotracheal tube (ETT).

Margins of Partial Cricotracheal Resection in Children

Objective: To review the surgical margins of partial cricotracheal resection in our series of patients. This includes specific anatomic detail as to each superior and inferior resection margin. To apply this information and access the utility of partial cricotracheal resection for the treatment of subglottic stenosis.

Model for evaluating the effect of growth factors on the larynx

Growth factors are proteins that help regulate the inflammatory response and wound healing in tissues. After laryngotracheal surgery, proper wound healing is important in maintaining the reconstructed airway. The application of growth factor to the respiratory mucosa of the larynx and its effect on wound healing within the airway have not been studied. This study was designed to establish a model for the evaluation of wound healing after the application of growth factor to composite respiratory mucosa and cartilage surfaces at the time of laryngotracheoplasty. Forty rabbits underwent anterior cricoid cartilage split with or without the use of a cartilage graft. Platelet-derived growth factor or a placebo substance was applied to the wound at the time of surgery. This study offers a model for studying wound healing in the airway that is reproducible with limited morbidity. (Otolaryngol Head Neck Surg 1999;120:78-83.)

Lobular Capillary Hemangioma of the Neonatal Larynx

OBJECTIVE To describe a previously unreported condition of the neonatal larynx. DESIGN Case series of 4 neonates with an uncommon laryngeal lesion. SETTING Tertiary care childrens hospital. PATIENTS Four neonates in the first 10 days of life with stridor, hoarseness, and respiratory distress. INTERVENTION The patients were examined using flexible fiberoptic laryngoscopy, and laryngeal lesions were identified and subsequently removed using microlaryngoscopy. Photodocumentation of the lesions was performed. Microscopic evaluation of biopsy specimens by a pathologist followed. MAIN OUTCOME MEASURES Each patients medical record was carefully reviewed for prenatal history, birth history, neonatal history, pathologic findings, and office follow-up. RESULTS All 4 neonates were delivered atraumatically and developed symptoms of upper airway obstruction within the first few minutes to days of life. Each neonate was found to have an obstructive laryngeal lesion requiring surgical intervention. No child had other congenital abnormalities or a history of obvious laryngeal trauma. Pathologic review of each laryngeal specimen revealed inflammatory lesions with characteristic features of a lobular capillary hemangioma (or a pyogenic granuloma). CONCLUSIONS The diagnosis of a lobular capillary hemangioma of the larynx should be considered in the differential diagnosis of a newborn with stridor, hoarseness, or respiratory distress. The cases seem to be of congenital origin, although acquired pathogenesis cannot be ruled out. Treatment of these lesions includes microscopic surgical excision.

Management of Persistent Tracheocutaneous Fistula in the Pediatric Age Group

Different surgical methods have been advocated for closure of persistent tracheocutaneous fistula (TCF) in children. The objective of this study was to compare different methods of repair and postoperative care that were used for management of TCF in children. The charts of 98 children with persistent TCF who were surgically managed in our department between January 1990 and April 1997 were reviewed retrospectively. Excision of the fistulous tract and healing by secondary intention was employed in 18 patients. Eighty patients were managed by tract excision followed by primary closure. Sixty-three patients remained intubated for 18 to 24 hours postoperatively, while 17 patients were extubated in the recovery room. One patient had a large tracheal granuloma on follow-up endoscopy. Three patients needed a second procedure. No significant correlation was found between the method of surgical repair or the length of postoperative intubation and outcome. In our experience, TCF repair, either by primary closure or secondary intention, is a relatively safe and effective procedure in the pediatric age group. Preoperative evaluation and possible indications for selecting the method of repair are discussed.

Potential role of growth factors and extracellular matrix in wound healing after laryngotracheal reconstruction

Laryngotracheal reconstruction (LTR) has been used for more than 20 years to treat infants and children with subglottic stenosis. Results after pediatric LTR have been satisfactory; however, approximately 10% of children have recurrent airway narrowing after LTR. The purpose of our study was to determine whether a correlation existed between specific growth factors and extracellular matrix in patients with adequate wound healing capability as compared with patients with poor wound healing capability. Histologic sections from 27 patients who underwent LTR were cut, and immunohistochemical staining was performed for transforming growth factor-β, platelet-derived growth factor, fibronectin, tenascin, transforming growth factor-α, and vascular endothelial growth factor. Results showed that patients with adequate wound healing capability had a positive correlation with vasculature fibronectin, vasculature tenascin, and stromal fibronectin. Patients with poor wound healing capability had a positive correlation with stromal vascular endothelial growth factor.