Release: May 12, 2000
Contact: Kenneth Satterfield, 407-238-4161 (as of 5/12/2000)
A Recently Developed Surgical Procedure is Found to Expedite Normal Breathing for
Children with a Totally Blocked Airway
Cincinnati otolaryngologists prove that in most cases, a cricotracheal resection allows removal of the tracheotomy tube following one procedure.
Orlando, FL -- Pediatric acquired subglottic stenosis is a narrowing of a child's airway in the region below the vocal cords ("voice box"). The more severe the stenosis, the more trouble children have with breathing and performing normal activity. In advanced cases, a tracheotomy tube is placed in the neck in order to facilitate safe breathing.
Correction of complete stenosis of the airway is especially important as these patients are reliant on a tracheotomy tube that is placed below the level of the restricted airway. If this tube becomes blocked, these children have no alternative airway and the situation can be fatal. Historically, correction of complete stenosis has been difficult with successful repair (defined as being able to remove the tracheotomy tube, or decannulation) ranging from 50%-74%. In addition, many children required multiple operations over several years in order to have their tubes removed.
Despite considerable advancements in the management of this severe medical disorder, there has few studies conducted to measure the effectiveness of surgical repair for children with complete stenosis. Now, a retrospective study has evaluated surgical management and outcomes of children presenting grade 4 acquired total subglottic stenosis.
The authors of the study, "Management of Complete Acquired Laryngotracheal Stenosis in Children," are L. Mark Gustafson, M.D., Benjamin E. J. Hartley, MD, and Robin T. Cotton, MD, all from the Department of Otolaryngology-Head and Neck Surgery, Children's Hospital Medical Center, Cincinnati OH. Their findings were presented at the Spring Meeting of the American Broncho-Esophagological Association, Orlando FL, May 16, 2000.
Methodology: Since 1981, the department of pediatric otolaryngology at Children's' Hospital, Cincinnati has maintained an ongoing database of all operative airway procedures. A retrospective review was undertaken to identify all children, since 1981, who presented with acquired complete (Cotton grade 4) SGS at the Children's Hospital in Cincinnati (Cotton grade 4 stenosis is defined as the lack of any identifiable opening in the subglottis). Patients with laryngeal atresia or congenital complete subglottic or tracheal stenosis were specifically excluded from this study. Only those children with at least one year of follow-up were included in our analysis.
Patient demographics were collected from the database and patient charts. The cause of the SGS was identified as prolonged intubation, previous surgery, burns, or unknown. The number and type of prior airway operations was noted. The initial procedure performed by our department to correct the stenosis was recorded along with any additional procedures performed after that initial surgery. Decannulation rates, time to decannulation and the number of operations required were also recorded. Statistical analysis was performed using Chi-squared tests for categorical data.
Results: Fifty-six patients presented with acquired grade 4 SGS since 1981. Twenty-one were initially treated in the 1980's and 35 have been seen since 1990. There were 24 females and 32 males. The mean age was 4.8 years (range 2 months-16.8 years). The causes of the stenoses included prolonged intubation (15), previous surgery (34), unknown (6), and burns (1).
The study revealed that for patients in the 1980s, laryngotracheal reconstruction (LTR) with anterior and posterior division of the trachea , anterior and posterior costal cartilage graft (CCG), and with posterior, were the most common initial surgical procedures utilized. In the 1990s, cricotracheal restriction (CTR) was introduced and since then, become the predominant method of correcting complete SGS (this procedure involves removal of the narrowed section of the airway including a portion of the cricoid cartilage that forms the lower part of the larynx or voice box).
Other key findings included:
ï Forty-three of the 56 patients (76%) have had their tracheotomy tube removed (decannulated). For the entire group, 120 procedures were performed; 17 patients were decannulated following one procedure; 12 after two procedures; six after three procedures, two after four procedures; three after five procedures; and one each following six, seven, and nine operations. The mean time to decannulation was 28 months. The decannulation rate in the 1980s was 66% and in the 1990s was 85%.
ï Thirteen of the 16 patients (81%) who underwent LTR with anterior and posterior CCG have been decannulated. Six of those patients (46%) required more than one open airway procedure to be decannulated. Ten of the twelve patients (83%) who underwent CTR have been decannulated. Only two of that group (22%) required an additional operation before being decannulated.
ï Cricotracheal resection (CTR) cannot be used for children in whom the stenosis is too near the vocal cords. For these children, other techniques are used, primarily division of the airway in the front and back and placement of cartilage grafts from a rib to maintain the larger size of the airway.
Conclusions: The majority of patients in the study required more than one operation to have their tracheotomy tubes permanently removed. However, CTR has enhanced the life of children with total subglottic stenosis as evidenced by the fact that 83% of the children undergoing CTR in the study have been decannulated and 78% of them required only one procedure. Accordingly, cricotracheal restriction (CTR) has improved the surgeon's ability to successfully decannulate these children in a timely manner.
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