Marilena Trozzi

Symptomatic vocal cord paresis/paralysis in infants operated on for esophageal atresia and/or tracheo-esophageal fistula

OBJECTIVES To describe the prevalence and pathogenesis of symptomatic vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA), tracheo-esophageal fistula (TEF) or both. STUDY DESIGN Retrospective study of all patients treated for EA/TEF in our center (1995 to 2009). Patients with and without symptomatic VCP were compared for gestational age, birth weight, associated anomalies, referrals, long-gap EA (> 3 cm or 3 vertebral bodies), cervical esophagostomy, anastomotic leakage, length of ventilation, and major cardiac surgery. Prevalence or median (IQR) is reported. RESULTS Of 174 patients, 7 (4%) had symptomatic VCP. Prevalence of referrals (5/7 versus 21/167; P = .0009), long gap (5/7 versus 41/167; P = .0146), previous cervical esophagostomy (5/7 versus 7/167; P < .0001), and anastomotic leakage (3/7 versus 10/167; P = .0097) was higher, and ventilation longer (8.5 days [7.0 to 15.5] versus 6.0 days (5.0 to 7.0); P = .0072) in patients with VCP. CONCLUSIONS In infants treated for EA/TEF, VCP should be ruled out in case of persistent respiratory morbidity or, when present, cautiously monitored. Surgical risk factors should be actively controlled. Further studies are needed to define the prevalence of acquired and congenital VCP in patients with EA/TEF.

Head and neck vascular anomalies in children

Vascular lesions are the most common congenital and neonatal abnormalities. The aim of this work is to point out differences between various vascular anomalies, in order to define accurate diagnosis, and to present different therapeutic options now used for the treatment of the vascular lesions in children. According to biological classification described by the work of Mulliken and Glowacki there are two major types of vascular abnormality: haemangioma and vascular malformation. Haemangioma is a distinct biologic tumour entity characterised by rapid endothelial proliferation shortly after birth. The lesion is absent at birth and growth in early infancy, followed by a spontaneous resolution in childhood. Vascular malformations are structural anomalies that have a normal growth rate and endothelial turnover. According to the morphology of the vessels and the flow rate we distinguish: slow-flow and fast-flow vascular malformation. The authors document their personal experience in diagnosis, clinical evaluation, treatment and follow-up of the vascular lesions.

Imaging modalities in children with vascular ring and pulmonary artery sling

Our aim is to compare new non‐invasive imaging modalities in the evaluation of vascular ring (VR) and pulmonary artery sling (PAS) and to understand the role of bronchoscopy in comparison with them in assessing tracheobronchial tree.

Dehiscence of bronchial anastomosis after lung transplantation: a successful unconventional treatment

Anastomotic airway complications, including the dehiscence of the bronchial anastomosis, are a severe cause of morbidity after lung transplantation. We present a case of dehiscence treated by placing an uncovered metal stent into the main bronchus. We usually use this procedure for bronchial stenosis, but in this case, the stent favored the growth of granulation tissue and so the closure of the dehiscence. This procedure was minimally invasive and may be an alternative to an open repair, without precluding open repair in case of failure.

Vocal cord paralysis appears to be an acquired lesion in children with repaired esophageal atresia/tracheoesophageal fistula

OBJECTIVES Determine whether vocal cord paresis or paralysis (VCP/P) following surgical repair of congenital esophageal atresia/tracheoesophageal fistula (EA/TEF) is generally a primary anomaly, or is secondary to EA/TEF repair. METHODS We carried out a retrospective study based on a recently published protocol, which included the systematic performance of a laryngo-tracheo-bronchoscopy before and after EA/TEF repair. RESULTS There were 105 patients with EA/TEF referred for multidisciplinary follow-up, between 2010 and 2015. Sixty-four of the 105 patients included in the study underwent EA/TEF repair at the referral center and had pre-operative bronchoscopy; the others had their initial surgery elsewhere. No included patient had VCP/P detected pre-operatively. Six patients (4 initially managed at the referral center) were diagnosed with VCP/P during the follow-up period (6/105, 5.7%). CONCLUSION VCP appears to be an acquired lesion in this population.

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.

Changing Breathing Pattern in Laryngomalacia after Surgery

Objective: Most of the studies on the surgical treatment of severe laryngomalacia have aimed to describe the efficacy of the treatment in terms of improvement of clinical symptoms or anatomical findings. The aim of this study is to analyze the changes in breathing patterns following aryepiglottoplasty for severe laryngomalacia. Method: A series of retrospective cases at a tertiary referral children’s hospital. Between 2005 and 2010, 40 infants with severe laryngomalacia were studied before (T1) and after surgery (T2). Breathing patterns were studied using an ultrasonic flow-meter measuring: tidal volume, respiratory rate, time to peak and mean expiratory flow/expiratory time ratio. Results: The surgical procedure was well tolerated in all the infants and no perioperative and long-term complications were present. In T1, the breathing pattern is characterized by low tidal volume and high flow/expiratory time ratio (tPTEF/Te) and mean expiratory/mean inspiratory flow ratio (MEF/MIF), suggesting a severe reduction in upper airways patency for all patients. After surgery (T2), all above mentioned variables significantly improved, reaching normal values for the age. Conclusion: Pulmonary function test in this study showed the diagnostic value of testing respiratory functionality in severe laryngomalacia and comparing them to clinical and endoscopic data. Moreover, we also propose the use of this available test to verify the therapeutic effects and to monitor future respiratory development in these infants.

Second Step of LTP: A New Technique for Stoma Closure

Objective: To present our protocol and propose a new surgical technique for the closure of the tracheocutaneous fistula in patients admitted for laryngotracheal reconstruction. Method: We present a modified surgical technique to close the tracheocutaneous fistula performed on patients around 6 months after laryngotracheoplasty and decannulation. The procedure involves the closure of the stoma of the tracheal anterior wall by placing the suture along the longitudinal axis and approaching the tracheal margins in craniocaudal direction. Results: Eight closures were performed in accordance with this technique without complications in the short and long term. Max follow-up was 3 years with no evidence of tracheal stenosis, tracheomalacia, tracheal pouch, or caliber irregularities on the site of the previous stoma. Although the modified closure technique slightly reduces the length of the trachea, it has proven to effectively enlarge the transverse diameter, reduce the risk of an extraluminal or intraluminal invagination of the flaps, and prevent secondary tracheal stenosis or pouch. Conclusion: Based on our protocol for decannulation after LTP, we recommend postponing fistula treatment until the grafts have been well established, the stomal scar has reduced spontaneously, and the traumatic effect of intubation has been minimized. Our method for surgical closure has shown to reduce problems associated with these fragile tracheae.

Endoscopic surgery for treatment of paediatric upper airway diseases

Abstract In September 2005, the 3rd OPBG/Mayo Clinic Joint Conference was held in Rome to highlight current views in paediatric medicine. After an overview of the various pathologies, the Otolaryngology Unit of the Bambino Gesu Childrens Hospital of Rome described their own experience with endoscopic surgery for the treatment of upper airway diseases between 2002 and 2004. During this period, 1500 paediatric endoscopies were performed for obstructive upper airway disease. A total of 80% of patients were under 2 years of age. The aetiological causes of upper airway obstruction most frequently cited were: foreign bodies (the most frequent reason for urgent endoscopic treatment), choanal atresia, severe laryngomalacia, laryngeal cysts, neurological lesions (vocal fold paralysis), laryngeal clefts, laryngeal haemangiomas, recurrent respiratory papilloma, tracheoesophageal fistula, tracheal granuloma and tubercular adenobronchial fistula. In all the patients, stridor disappeared following surgery. No complications, such as aspiration or supraglottic stenosis, were identified and no revision surgeries were required. Stenting was necessary in only three cases. This study described the OPBG management of paediatric airway obstruction and outcomes during a 3-year period and was the starting point for reflection on this topic.