Robin T. Cotton

Proposed grading system for subglottic stenosis based on endotracheal tube sizes.

The classification of airway stenoses has been a problem for many years. As a result, both intradepartmental and interdepartmental comparisons of airway sizes remain difficult. It follows that comparisons of therapeutic maneuvers are even more difficult. A system is proposed that is simple, reproducible, and based on a readily available reference standard. Endotracheal tubes, which are manufactured to high standards of precision and accuracy, can be used to determine the size of an obstructed airway at its smallest point. The endotracheal tube that will pass through the lumen, if one exists, and tolerate normal leak pressures (10 to 25 cm H2O), can be compared to the expected age-appropriate endotracheal tube size. By using the outside diameters of the endotracheal tubes, the maximum percentage of airway obstruction can be determined. We present a conversion of tube size to the proposed grading scale: grade I up to 50% obstruction, grade II from 51% to 70%, and grade III above 70% with any detectable lumen. An airway with no lumen is assigned to grade IV.

Pediatric Laryngotracheal Stenosis

Severe laryngotracheal stenosis (LTS) in children is a problem of increasing incidence in the past 15 years, following the widespread adoption of prolonged endotracheal intubation for respiratory support. Rarer cases of stenosis secondary to external trauma, high tracheotomy, thermal and chemical burns, and dystrophic cartilage are seen. In contrast to congenital subglottic stenosis, where conservative therapy is generally indicated, severe, mature LTS often requires surgical correction--either endoscopic or external reconstruction. The prevailing attitude has been to perform a tracheotomy and hope for decannulation after 1 or 2 years, due to the expected growth of the larynx. This attitude developed from experience with congenital subglottic stenosis. Unfortunately, acquired LTS tends to be a much more severe problem than congenital subglottic stenosis; the degree of obstruction is usually greater and loss of cartilaginous support of the airway commonly occurs. Some of the acquired lesions are so severe that often no lumen is demonstrable. In such cases no amount of growth will allow extubation. A variety of endoscopic methods such as dilation, with or without resection using diathermy, cryotherapy, or laser, or steroid injection are certainly helpful in the early phases of wound healing while granulation tissue is still present or while the scar tissue is still soft and pliable. To deal with the mature, hard, fibrous unresponsive scar, various authors have proposed different approaches both endoscopic and external reconstruction. The present study discusses a unique experience of external laryngotracheal reconstruction (LTR) in 100 children. In the evaluation of LTS, a thorough endoscopic evaluation is required using both flexible and rigid endoscopic techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of the extubation problem in the premature child. Anterior cricoid split as an alternative to tracheotomy.

Long-term endotracheal intubation is a widely established means of giving ventilatory support in the newborn period. Though such long-term intubation is well tolerated by the premature infant, laryngeal complications do occur and extubation may be impossible even though the initial disease process for which the intubation was performed has resolved. In such a situation, careful endoscopic evaluation of the upper respiratory tract is advocated to identify the site of the problem. If subglottic edema or mucosal ulceration in the subglottic area is the site of the damage and if, during endoscopic evaluation immediately following removal of the endotracheal tube, the subglottic area starts to narrow because of edema formation or edema fluid filling up compressed granulation tissue, then a split of the cricoid in the midline anteriorly, leaving the endotracheal tube in as a stent, appears to be a preferable alternative to performing a tracheotomy. Of 12 consecutive patients, 9 have been successfully extubated.

Management of Subglottic Stenosis in Infancy and Childhood Review of a Consecutive Series of Cases Managed by Surgical Reconstruction

The management of mature subglottic stenosis secondary to endotracheal intubation in infancy and childhood remains a controversial issue. If treated similarly to congenital subglottic stenosis by tracheotomy and a “wait-and-see” period then there is a considerably higher mortality and morbidity for the acquired disease compared with the congenital. Eighteen children with severe acquired subglottic stenosis managed by surgical reconstruction are presented; 17 have been successfully extubated. The longest follow-up is 5½ years. No evidence of interference with laryngeal growth is evident.

Epiglottoplasty for the Treatment of Laryngomalacia

Laryngomalacia is the most common congenital laryngeal anomaly. Patients present with different degrees of stridor and feeding problems that usually resolve by 18 months of age. A small number present with severe feeding problems, failure to thrive, stridor with cyanosis, and apnea, which may result in cardiopulmonary disease. These infants require surgical intervention, usually a hyomandibulopexy or tracheotomy. We present a new procedure, epiglottoplasty, that is performed endoscopically and involves excision of redundant mucosa over the lateral edges of the epiglottis, aryepiglottic folds, arytenoids, and corniculate cartilages. Ten patients have undergone this procedure with good results. Epiglottoplasty represents an alternative to tracheotomy in severe laryngomalacia. Indications, techniques, postoperative management, and complications are presented.

Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: The single‐stage approach

Laryngotracheal reconstruction (LTR) comprises five stages: 1, characterization of the stenosis; 2, expansion of the lumen; 3, stabilization of the enlarged lumen framework; 4, healing of the surgical site; and 5, decannulation. Single‐stage LTR (SS‐LTR) combines and compresses stages 3 through 5 (stabilization, healing, and decannulation) into a brief period of postoperative intubation.

MANAGEMENT OF SUBGLOTTIC STENOSIS

Evaluation and management of pediatric subglottic stenosis is complex and technically challenging. Laryngotracheal reconstruction has become the standard of care for symptomatic subglottic stenosis in children. Careful preoperative planning, meticulous surgery, and dedicated postoperative care are essential for a successful outcome. Early recognition and management of intraoperative and postoperative complications minimize their impact.

Surgical correction of subglottic stenosis of the larynx in infants and children. Progress report.

A survey of 25 consecutive cases of severe subglottic stenosis in children and infants, managed conservatively, revealed an unexpectedly high 24% mortality rate. A three year ongoing experimental study in infant primates indicated the feasibility of operative correction of subglottic stenosis without interference with usual laryngeal growth potentials. Initial results in the surgical correction of subglottic stenosis in two patients are very encouraging. For surgical correction of subglottic stenosis we recommend division of the cricoid and upper trachea anteriorly with interposition of autogenous cartilage, without removal of scar tissue, and without internal laryngeal stenting.

The problem of pediatric laryngotracheal stenosis: a clinical and experimental study on the efficacy of autogenous cartilaginous grafts placed between the vertically divided halves of the posterior lamina of the cricoid cartilage.

Acquired laryngotracheal stenosis is a well-documented complication of endotracheal intubation. Severe acquired laryngotracheal stenosis in children responds to surgical reconstruction, including the use of grafts and stents. The most commonly described graft material is autogenous cartilage, placed in the anterior laryngotracheal complex. The role of autogenous cartilaginous grafts sewn between the divided lamina of the posterior cricoid cartilage is less well established. Several authors report good clinical results using autogenous cartilaginous grafts to the posterior larynx; the single reported animal study of grafts to the posterior larynx failed to show significant benefit. This study was undertaken to examine the hypothesis that there is no difference in survival of anteriorly placed or posteriorly placed cartilaginous grafts in the larynx of growing rabbits, and to report on 61 pediatric patients with laryngotracheal stenosis treated with autogenous cartilaginous grafts placed between the vertically divided posterior lamina of the cricoid cartilage. The animal study showed that posteriorly placed grafts survived with viability equal to or better than that of anteriorly placed grafts. The clinical study showed that 59 of the 61 patients were decannulated with satisfactory vocal quality, good exercise tolerance and sleep patterns, and with no mortality.

Congenital laryngeal anomalies. Laryngeal atresia, stenosis, webs, and clefts.

The physician who is called upon to evaluate stridor in the newborn must be familiar with common congenital lesions of the larynx. Congenital stridor is a symptom of an underlying problem that must be accurately diagnosed to be properly and effectively managed. This requires a complete history and physical examination to discover the type of stridor and its association with feeding difficulties or cyanosis. Careful evaluation of the cry is important. Radiologic examinations are of great value in providing additional information concerning laryngeal anomalies. The mainstay of diagnosis is endoscopic examination. Familiarity with these anomalies, their symptoms, diagnostic methods, and treatment will provide for better care of the pediatric patient with stridor.