Pediatric Airway Surgery (eBook)

Since 1991, Professor Monnier is the Chairman and Head of the Otolaryngology, Head & Neck Surgery Department of the University Hospital CHUV in Lausanne, Switzerland.He is internationally recognized for the management of pediatric airway problems and is the pioneer of pediatric cricotracheal resection for the management of subglottic stenosis in infants and children. For the past 10 years he has given around 5 to 6 guest lectures each year to audiences around the world on this topic.

Pediatric Airway Surgery 2
Copyright Page 3
Dedication 4
Preface 5
Acknowledgments 6
Contents 7
Contributors 9
Abbreviations 10
Part I: Evaluation of the CompromisedPaediatric Airway 13
1: The Compromised Paediatric Airway: Challenges Facing Families and Physicians 14
References 16
2: Applied Surgical Anatomy of the Larynx and Trachea 18
2.1 Position of the Larynx and Trachea in the Neck 19
2.2 Laryngotracheal Framework(Fig. 2.4) 20
2.3 The Larynx’s Intrinsic Musculature (Fig. 2.7) 22
2.4 Innervations of the Larynx (Fig. 2.9) 23
2.5 Vascular Supply of the Larynx and the Trachea 25
2.6 Endoscopic Anatomy (Fig. 2.13) 26
2.7 Morphometric Measurements of the Larynx and Trachea 27
2.7.1 Larynx Morphometry 27
2.7.1.1 Subglottic Luminal Diameter and Recommended ET-Tube Sizes 27
2.7.1.2 Cricoid Cartilage Diameter Compared to Recommended Sizes of Rigid Bronchoscopes 28
2.7.2 Trachea Morphometry 29
2.8 Laryngeal Stents 30
2.8.1 Aboulker Stent (Fig. 2.17) 30
2.8.2 Montgomery T-Tube (Fig. 2.18) 31
2.8.3 Healy Paediatric T-Tube (Fig. 2.20) 32
2.8.4 Montgomery LT-Stent (Fig. 2.21) 33
2.8.5 Eliachar LT-Stent (Fig. 2.22) 33
2.8.6 Monnier LT-Mold (Fig. 2.23) (Table 2.6) 34
2.9 Tracheal Stents 35
2.10 Appendix 1 38
2.11 Appendix 2 38
2.12 Appendix 3 38
References 39
3: Clinical Evaluation of Airway Obstruction 41
3.1 Degree of Respiratory Distress 42
3.2 Site and Cause of Airway Obstructions 43
3.2.1 Pathological Respiratory Sounds (Fig. 3.1) 43
3.2.2 Variable Extrathoracic Obstruction (Fig. 3.2) 44
3.2.3 Variable Intrathoracic Obstruction (Fig. 3.3) 44
3.2.4 Fixed Airway Obstruction 44
3.3 Assessment of Laryngeal Functions (Fig. 3.4) 45
3.4 Medical History 46
3.5 Physical Examination 47
3.5.1 In-Office Transnasal Flexible Laryngoscopy (TNFL) 47
3.5.2 Indication for Endoscopy Under General Anaesthesia 47
3.6 Radiological Evaluation 48
3.7 Anaesthetic Techniques for MRI in Children with Obstructive Dyspnoea 50
3.7.1 Pre-anaesthetic Assessment 50
3.7.2 Anaesthesia for MRI in Children with Mild (Stage I and II) Obstruction (See Table 3.5) 50
3.7.3 Anaesthesia for MRI in Children with a Fixed (³70%) Tracheal Stenosis 51
3.7.4 Anaesthesia for MRI in Children with Stage III and IV Collapsible Upper Airway 52
3.7.5 Sedation for MRI in Children with Compressible Intrathoracic Airway 52
3.8 Assessment of the Patient’s General Condition 52
References 53
4: Equipment and Instrumentation for Diagnostic and Therapeutic Endoscopy 55
4.1 Endoscopy Suite 56
4.2 Laryngoscopes 56
4.2.1 Parsons Laryngoscopes (Fig. 4.3) 57
4.2.2 Benjamin–Lindholm Laryngoscopes (Fig. 4.4) 57
4.2.3 Kleinsasser Laryngoscopes (Fig. 4.5) 57
4.2.4 Holinger–Benjamin Laryngoscopes (Fig. 4.7) 58
4.2.5 Suspension Microlaryngoscopy 58
4.2.6 Ancillary Instruments 59
4.3 Bronchoscopes 62
4.3.1 Rigid Bronchoscopes 62
4.3.2 Flexible Bronchoscopes 63
4.4 Oesophagoscopes 64
4.4.1 Rigid Oesophagoscopes (Fig. 4.19) 64
4.5 Documentation and Training 65
4.6 Lasers in Paediatric Airway Management 66
4.6.1 Laser Principles 67
4.6.2 Properties of Laser Light 68
4.6.3 Laser–Tissue Interactions 68
4.6.3.1 Laser Wavelength 69
4.6.3.2 Absorption Characteristics of the Tissue 69
4.6.3.3 Tunable Laser Parameters 70
4.6.4 Light Delivery Systems 72
4.6.4.1 Articulated Arm 72
4.6.4.2 Micromanipulator 73
4.6.4.3 Waveguide (Fig. 4.32) 74
4.7 Laser Safety 75
4.7.1 Eye and Skin Hazards (Fig. 4.36) 76
4.7.2 Skin Protection 77
4.7.3 Fire Hazards 78
4.7.3.1 Source of Ignition 78
4.7.3.2 Combustible Material 78
4.7.3.3 Combustion-Supporting Gas Mixture 78
4.7.4 Fire Prevention 79
4.7.4.1 Closed Circuit Anaesthesia with a Laser-Safe ET Tube 79
4.7.4.2 Intermittent Apnoeic Technique 79
4.7.4.3 Tubeless Anaesthesia in Spontaneous Respiration 79
4.7.4.4 Jet Ventilation Anaesthesia 80
4.7.5 Laser-Induced Accidents 80
4.7.6 Safety Recommendations 80
4.8 Ancillary Therapeutic Means 81
4.8.1 Dilation 81
4.8.1.1 Tapered Bougies 81
4.8.1.2 Balloon Dilators 82
4.8.2 Microdebrider 82
4.9 Appendix 1 84
References 84
5: Endoscopic Assessment of the Compromised Paediatric Airway 86
5.1 Emergency Airway Support for Severe Respiratory Distress 87
5.1.1 Transnasal Fibre-Optic Laryngoscopy (TNFL) 88
5.1.2 Rigid Bronchoscopy 89
5.1.3 Emergency Surgical Airway Access 89
5.2 Noisy Child with or Without Respiratory Distress and Undiagnosed Disease 89
5.2.1 Anaesthetic Techniques for Endoscopy in Spontaneous Respiration 90
5.2.1.1 Dynamic Evaluation of the Upper Airway 90
5.2.2 Asleep Transnasal Fibre-Optic Laryngoscopy (TNFL) 91
5.2.3 Direct Laryngoscopy with the Bare 0° Rod-Lens Telescope 93
5.3 Tracheotomised Child with Known Airway Obstruction 94
5.3.1 Transnasal Flexible Laryngoscopy 94
5.3.2 Direct Laryngotracheobronchoscopy with a Rod-Lens Telescope 94
5.3.3 Suspension Microlaryngoscopy 94
5.3.3.1 Craniocaudal Measurements of Airway Stenoses 95
5.3.3.2 Bilateral Vocal Cord Paralysis (BVCP) Versus Posterior Glottic Stenosis (PGS) 95
Type I: Interarytenoid Adhesion (Fig. 5.11a) 95
Type II: Interarytenoid and Posterior Commissure Scarring Adhesion (Fig. 5.11b) 95
Type III: Posterior Commissure Scarring with Unilateral Cricoarytenoid Joint Fixation (Fig. 5.11c) 95
Type IV: Scarring of Posterior Commissure with Bilateral Cricoarytenoid Joint Ankylosis (Fig. 5.11d) 96
5.3.3.3 Myer–Cotton Airway Grading System 96
5.3.3.4 New Grading System 98
5.3.4 Broncho-oesophagoscopy 99
5.3.4.1 Bronchoscopy Below the Tracheostoma 99
5.3.4.2 Oesophagoscopy 100
5.4 Treatment Plan for Laryngotracheal Stenosis 100
5.4.1 Primary Endoscopic Treatment 101
5.4.2 Laryngotracheal Reconstruction with Cartilage Expansion (LTR) 102
5.4.3 Partial Cricotracheal Resection (PCTR) 102
5.4.4 Extended Partial Cricotracheal Resection 102
References 102
Part II: Congenital Anomalies of the Larynxand Trachea 105
Introduction 105
References 105
6: Laryngomalacia (LM) 106
6.1 Pathogenesis 107
6.2 Symptoms 107
6.3 Patient Assessment 107
6.4 Endoscopy Under General Anaesthesia 108
6.5 Indications for Surgical Intervention 108
6.6 Supraglottoplasty in Suspension Microlaryngoscopy 108
6.6.1 Type I Laryngomalacia (Fig. 6.2a) 110
6.6.2 Type II Laryngomalacia (Fig. 6.2b) 110
6.6.3 Type III Laryngomalacia (Fig. 6.4) 111
6.7 Postoperative Care 111
6.8 Complications and Results 112
References 112
7: Vocal Cord Paralysis (VCP) 114
7.1 Unilateral Vocal Cord Paralysis (UVCP) 115
7.1.1 Surgical Intervention 116
7.2 Bilateral Vocal Cord Paralysis (BVCP) 116
7.2.1 Aetiology of BVCP 117
7.2.2 Surgical Treatment for BVCP 117
7.2.2.1 Open Surgical Techniques 118
Postero-lateral Approach to the Larynx 118
Laryngofissure Approach 118
7.2.2.2 Endoscopic Surgical Techniques 118
CO2 Laser Arytenoidectomy (Fig. 7.4) 119
Endoscopic CO2 Laser Posterior Cordotomy 120
Endoscopic Vocal Cord Lateralization 120
Endoscopic Posterior Cricoid Split and Rib Grafting 121
Reinnervation of the Posterior Cricoarytenoid Muscle 122
References 123
8: Congenital Subglottic Stenosis (C-SGS) 125
8.1 Pathogenesis and Classification 126
8.2 Symptoms 127
8.3 Endoscopic Assessment 127
8.4 Indications for Surgery 128
8.4.1 Soft Tissue Versus Cartilaginous C-SGS 128
8.4.2 Isolated C-SGS Versus Glotto-Subglottic Stenosis 128
8.4.3 Mild Versus Severe Grade C-SGS 128
8.4.4 Congenital Versus Acquired on Congenital SGS 129
8.5 Surgery for C-SGS 130
References 130
9: Laryngeal Web and Atresia 131
9.1 Patient Assessment 132
9.1.1 Symptoms 132
9.1.2 Endoscopic Assessment 132
9.1.3 Additional Examinations 133
9.2 Management of Laryngeal Webs 133
9.2.1 Type I Web (< 35% of Glottic Length)
9.2.2 Type II Web (35–50% of Glottic Length) (Fig. 9.3) 134
9.2.3 Type III Web (50–75% of Glottic Length) 136
9.2.4 Type IV Web (75–90% of Glottic Length) 137
References 137
10: Subglottic Haemangioma (SGH) 138
10.1 Clinical Course 139
10.2 Patient Assessment 140
10.3 Management of SGH 140
10.3.1 Medical Treatment 140
10.3.1.1 Observation 140
10.3.1.2 Systemic Steroids 141
10.3.1.3 Interferon a-2a 141
10.3.1.4 Propanolol 141
10.3.2 Endoscopic Treatment 141
10.3.2.1 Intralesional Steroid Injections 141
10.3.2.2 Laser Resection 141
10.3.2.3 Microdebrider Submucosal Resection 142
10.3.3 Open Surgery 142
10.3.3.1 Tracheostomy 142
10.3.3.2 Open Excision of SGH Through a Laryngofissure 142
References 144
11: Ductal Cysts, Saccular Cysts and Laryngoceles 145
11.1 Ductal Cysts 146
11.2 Saccular Cysts 146
11.3 Laryngoceles 146
11.4 Treatment of Ductal Cysts, Saccular Cysts and Laryngoceles 148
References 149
12: Laryngeal and Tracheal Clefts 150
12.1 Pathogenesis and Definition 151
12.1.1 Four Syndromes Are Encountered with LTOC 151
12.2 Classification 151
12.3 Symptoms 152
12.4 Diagnosis 152
12.5 Management 153
12.5.1 Airway Control 153
12.5.2 Control of Aspiration and Lung Infection 154
12.5.3 Endoscopic Repair 154
12.5.4 Open Surgical Repair 156
12.5.4.1 Extrathoracic LTOC 156
12.5.4.2 Intrathoracic LTOC 157
References 159
13: Congenital Tracheal Anomalies 160
13.1 Tracheomalacia 162
13.1.1 Primary Diffuse TM or Posterior Membranous Dyskinesia 162
13.1.2 Secondary Localised Tracheomalacia 163
13.1.2.1 Incomplete Vascular Rings 164
Aberrant Innominate Artery (Fig. 13.2) 164
Aberrant Right Subclavian Artery (Fig. 13.3) 164
Anomalous Left Pulmonary Artery Sling (Fig. 13.4) 164
13.1.2.2 Complete Vascular Rings (Fig. 13.5) 166
13.1.2.3 Cardiac Anomalies 167
13.1.2.4 Tracheal Compression due to Mediastinal Masses 167
13.1.2.5 Treatment of Extrinsic Vascular and Tumoural Compressions of the Tracheobronchial Tree 167
13.1.3 Oesophageal Atresia with Tracheo-Oesophageal Fistula 168
13.1.3.1 Symptoms 169
13.1.3.2 Patient Assessment 169
13.1.3.3 Management 169
13.1.3.4 Postoperative Endoscopic Management 170
13.2 Intrinsic Anomalies of the Trachea 170
13.2.1 Congenital Tracheal Stenosis 170
13.2.1.1 Symptoms and Patient Assessment 171
13.2.1.2 Classification of CTS 171
13.2.1.3 Management 171
Primary Resection with End-to-End Anastomosis 172
Anterior Patch Tracheoplasty 173
Tracheal Autografts 174
Slide Tracheoplasty 175
Tracheoplasty with Cadaveric Tracheal Homografts 178
13.2.2 Tracheal Agenesis and Atresia 178
References 180
Part III: Acquired Laryngeal and Tracheal Stenoses 183
References 183
14: Acquired Post-Intubation and Tracheostomy-Related Stenoses 185
14.1 Acute Lesions and Cicatricial Intubation Sequelae 187
14.2 Prevention of Acute Intubation Lesions 188
14.3 Treatment of Acute Intubation Lesions 191
14.3.1 Treatment of Soft-Tissue Stenosis without Mucosal Necrosis 191
14.3.2 Anterior Cricoid Split (ACS) 192
14.3.3 Treatment of Obstructive Granulation Tissue 193
14.3.3.1 Treatment Is as Follows 195
14.3.3.2 The Procedure Is Performed as Follows 196
14.3.4 Correct Tracheostomy Placement in case of Impending Laryngotracheal Stenosis 196
14.4 Acquired Tracheal Stenosis 197
14.4.1 Tracheal Incision-Related Stenosis 198
14.4.2 Cannula-Related Stenosis 199
References 200
15: External Laryngeal Trauma 201
15.1 Blunt and Penetrating Laryngeal Injuries 202
15.1.1 Mechanisms of Injury 202
15.1.2 Traumatic Lesion Sites (Fig. 15.2) 203
15.1.2.1 Impact on the Thyrohyoid Membrane (Fig. 15.2a) 203
15.1.2.2 Impact on the Thyroid Cartilage (Fig. 15.2b) 203
15.1.2.3 Impact on the Cricoid Cartilage (Fig. 15.2c) 203
15.1.2.4 Impact on the Thorax (Fig. 15.5) 203
15.1.3 Clinical Presentation and Diagnosis 205
15.1.3.1 Conscious Patient with Minor to Moderate Laryngeal Trauma 205
15.1.3.2 Conscious Patient with Moderate to Severe Laryngeal Trauma 205
15.1.3.3 Intubated or Tracheostomised Patient 206
15.1.3.4 Penetrating Trauma 206
15.1.4 Radiological Evaluation 207
15.1.5 Management 207
15.1.5.1 Arytenoid Dislocation 208
15.1.5.2 Supraglottic Disruption 208
15.1.5.3 Thyroid Cartilage Fracture 209
15.1.5.4 Laryngotracheal Disruption 209
15.2 Inhalation Injuries 211
15.3 Caustic Ingestion 211
15.3.1 Patient Assessment 212
15.3.2 Endoscopic Assessment 212
15.3.3 Management 213
15.3.4 Late Cicatricial Sequelae 214
References 216
16: Neoplastic Lesions of the Larynx and Trachea 218
16.1 Recurrent Respiratory Papillomatosis (RRP) 221
16.1.1 Epidemiology and Pathogenesis 221
16.1.2 Clinical Course 222
16.1.3 Management 223
16.1.3.1 Voice Improvement for Limited Laryngeal Disease (Fig. 16.7) 223
16.1.3.2 Prevention of Tracheostomy for Moderately Invasive Laryngeal Disease 225
16.1.3.3 Need for Tracheotomy due to Recurrent Aggressive Disease 225
16.1.4 Adjuvant Medical Therapy 226
16.1.4.1 Indol-3-carbinol (I3C) 227
16.1.4.2 Alpha-2A Interferon 227
16.1.4.3 Cidofovir 227
References 228
Part IV: Surgery for laryngotracheal stenosis 229
References 230
17: Preoperative Assessment, Indications for Surgery and Parental Counselling 231
17.1 Medical History 232
17.2 Patient’s General Condition 232
17.3 Preoperative Endoscopic Workup 233
17.4 Modified Myer–Cotton Airway Grading System 234
17.5 Indications for Surgery 234
17.5.1 Grade I SGS (£50% Luminal Obstruction) 234
17.5.2 Grade II SGS (51%–70% Luminal Obstruction) 234
17.5.3 Grade III and IV SGSs 235
17.5.4 Isolated Posterior Glottic Stenosis (PGS) 236
17.6 Timing for Surgery 238
17.7 Preoperative Planning 239
17.8 Preparation for Surgery 239
References 240
18: Endoscopic Techniques for Laryngotracheal Stenosis 241
18.1 Anaesthesia for Endoscopic Airway Procedures 242
18.1.1 Tubeless Microlaryngeal Surgery under Spontaneous Respiration Anaesthesia 242
18.1.1.1 Volatile Anaesthesia 242
18.1.1.2 Total Intravenous Anaesthesia 242
18.1.2 Apnoeic Anaesthesia with Intermittent Ventilation and Oxygenation 243
18.1.3 Anaesthetic Techniques for Airway Endoscopies under Controlled Ventilation 244
18.1.3.1 Anaesthetic Drugs 244
18.1.3.2 Specific Monitoring 244
18.1.4 Jet Ventilation 245
18.2 Indications for Endoscopic Airway Procedures 246
18.2.1 Primary Endoscopic Techniques 246
18.2.1.1 Cicatricial Subglottic Stenosis (SGS) 246
18.2.1.2 Subglottic Ductal Cysts 247
18.2.1.3 Posterior Glottic Stenosis (PGS) 249
Type I Interarytenoid Adhesion 249
Type II PGS with Bilateral Preservation of “Active” Arytenoid Mobility 249
18.2.1.4 Subacute Lesions of Intubation Evolving into Incipient LTS 249
18.2.2 Secondary Endoscopic Techniques 250
18.2.2.1 Postoperative Optimisation of Open Surgical Results 250
18.3 Mitomycin C (MMC) 251
18.3.1 Mitomycin C Dosage for Topical Application 252
18.3.2 Duration of Topical MMC Application 252
18.3.3 Rinsing the Wound after Topical MMC Application 253
18.3.4 Risks of Multiple Topical MMC Applications 253
18.3.5 Indications and Contraindications of Topical MMC Applications 253
Box 18 Surgical Highlights of Endoscopic LTS Management 254
References 254
19: Laryngotracheoplasty and Laryngotracheal Reconstruction 257
19.1 Laryngotracheoplasty 257
19.2 Laryngotracheal Reconstruction 258
19.3 Historic Review of Paediatric Laryngotracheal Reconstruction 258
19.3.1 Milestones in Paediatric Laryngotracheal Reconstruction 258
19.3.2 Paediatric Cricoid Framework Expansion Without Graft 259
19.3.3 Paediatric Cricoid Framework Expansion with Grafts 259
19.4 Laryngotracheoplasty Without Cartilage Expansion 260
19.5 Laryngotracheal Reconstruction (LTR) with Cartilage Expansion 262
19.5.1 Surgical Steps for LTR 262
19.5.1.1 Cervical Exposure of the Larynx and Trachea 262
19.5.1.2 Anterior Laryngotracheofissure 262
19.5.1.3 Posterior Cricoid Split 262
19.5.1.4 Costal Cartilage Graft Harvesting 263
19.5.1.5 Carving the Posterior Costal Cartilage Graft 264
19.5.1.6 Fixing the Posterior Costal Cartilage Graft (Fig. 19.7) 265
19.5.1.7 Selecting Appropriate Stent Materials 266
19.5.1.8 Stent Fixation and Closure of Laryngofissure 266
19.5.1.9 Carving and Positioning the Anterior Costal Cartilage Graft 267
19.5.1.10 Positioning and Fixing the Anterior Costal Cartilage Graft 267
19.5.1.11 Neck Closure 267
19.6 Single-stage Laryngotracheal Reconstruction (SS-LTR) 268
19.6.1 Surgical Steps of Single-Stage Laryngotracheal Reconstruction (SS-LTR) 269
Box 19.3 and 19.4 Surgical Highlights for LTR 270
19.7 Postoperative Care and Complications 271
19.8 Results of Laryngotracheal Reconstruction (LTR) 271
References 275
20: Partial Cricotracheal Resection 278
20.1 Historical Review of Paediatric Partial Cricotracheal Resection (PCTR) 281
20.1.1 Milestones in Paediatric PCTR 281
20.2 Anaesthesia for PCTR 282
20.2.1 Anaesthesia for Single-Stage PCTR in Non-tracheostomised Children 283
20.2.1.1 Ventilation Through the Tracheal Stump with a Sterile ET Tube 283
20.2.1.2 High Frequency Jet Ventilation 283
20.2.1.3 Spontanous Respiration Anaesthesia with an Opened Trachea 284
20.2.2 Anaesthesia for Single-Stage PCTR in Tracheostomised Children 284
20.3 Surgical Technique for Simple PCTR 284
20.3.1 Position of the Patient and Incisions 285
20.3.2 Tracheal Dissection 285
20.3.3 Laryngeal Dissection 286
20.3.4 Resection of Subglottic Stenosis 286
20.3.5 Reshaping of the Subglottic Space 287
20.3.6 Anastomosis 288
20.3.6.1 Single-Stage Versus Double-Stage PCTR 290
20.1 Box 20.1 Surgical Highlights for Simple PCTR 291
20.4 Surgical Technique for Extended PCTR 292
Box 20.2 Surgical Highlights for Extended PCTR 296
20.5 Surgical Technique for Extended PCTR with Intussusception of Thyrotracheal Anastomosis 296
Box 20.3 Surgical Highlights for Extended PCTR with Intussusception of Thyro-tracheal Anastomosis 299
20.6 Management of Supraglottic Stenosis 299
20.7 Decision-Making Process in the Operating Theatre 299
20.7.1 Extent of Airway Resection 299
20.7.2 Laryngeal and Tracheal Release Manoeuvres 301
20.7.3 Management of Malacic Tracheal Segments 301
20.8 Perioperative Intensive Care After Major Laryngotracheal Surgery in Infants and Children: The Intensivist’s Perspective 302
20.8.1 Developmental Anatomy and Physiology of the Pharyngolarynx and Trachea During Childhood 303
20.8.2 General Aspects of Peri-operative Intensive Care Management After Laryngotracheal Surgery 303
20.8.3 Post-Extubation Respiratory Care Management 305
20.8.3.1 Non-Invasive Ventilation in Infants and Children 305
20.8.3.2 Use of Helium–Oxygen Gas Mixture During the Peri-operative Period 307
20.9 Postoperative Management After Single-Stage PCTR 308
20.9.1 Initial Intensive Care Management Following SS-PCTR 308
20.9.2 Continuing PostOperative Care for SS-PCTR 309
20.9.3 Follow-Up Care for SS-PCTR 309
20.10 Postoperative Management After Double-Stage PCTR 310
20.10.1 Initial Intensive Care Management Following DS-PCTR 310
20.10.2 Continuing Postoperative Care for DS-PCTR 310
20.10.3 Follow-Up Care for DS-PCTR 311
20.11 Complications of PCTR 312
20.11.1 Anastomotic Dehiscence 312
20.11.2 Recurrent Laryngeal Nerve Injury After PCTR 314
20.11.3 Delayed Recurrent Stenosis After PCTR 314
20.11.4 Tracheostomy-Related Stenosis After DS-PCTR 314
20.12 Results of Paediatric PCTR 314
20.12.1 Surgical Data on PCTR for Severe Grades III and IV LTS 315
20.12.1.1 Overall and Operation-Specific Decannulation Rates 315
20.12.1.2 Single-Stage PCTR (N.=.62) 316
20.12.1.3 Double-Stage PCTR (N.=.38) 316
20.12.1.4 Children Weighing Less Than 10 kg at the Time of Surgery 316
20.12.1.5 Glotto-subglottic Stenosis 316
20.12.1.6 Revision Open Surgery 317
20.12.1.7 Delayed Decannulation Group (> 1 year)
20.12.1.8 Long-Term Follow-Up 317
Breathing 317
Voice 317
Swallowing 318
Global Satisfaction 318
References 318
Part V: Tracheal Surgery and Revision Surgery 321
References 321
21: Tracheotomy 322
21.1 Indications 323
21.2 Technique of Tracheotomy 323
21.2.1 Location of Tracheotomy (Table 21.2) 323
21.2.2 Operative Technique for Tracheotomy 324
Box 21.1 Surgical Highlights for Tracheotomy 325
21.3 Complications (Table 21.3) 326
21.3.1 Early Complications 326
21.3.2 Late Complications 327
21.3.2.1 Closure of TOF with Tracheal Resection (Fig. 21.5) 329
21.3.2.2 Closure of TOF Without Tracheal Resection (Fig. 21.6) 330
21.4 Decannulation and Tracheostoma Closure 331
21.4.1 Surgical Closure of the Tracheostoma 332
References 333
22: Tracheal Resection and Anastomosis 334
22.1 Isolated Post-Intubation Stenosis 335
22.1.1 Tracheal Resection with End-to-End Anastomosis 335
22.1.2 Cervical Slide-Tracheoplasty (Fig. 22.6) 337
22.2 Isolated Post-Tracheostomy Stenosis and Tracheostoma-Related Stenosis 338
22.3 Tracheal Stenosis in a Tracheostomised Child 339
Box 22.1 Surgical Highlights for Tracheal Resection and Anastomosis 339
22.4 Postoperative Management of Single-Stage Tracheal Resection and Anastomosis 341
22.5 Complications of Tracheal Resection and Anastomosis 341
22.5.1 Anastomotic Separation 341
22.5.2 Granulation Tissue at Anastomosis 342
22.5.3 Recurrent Laryngeal Nerve (RLN) Injury 342
22.6 Tracheoplasty 342
22.7 Results of Tracheal Resection 342
References 343
23: Revision Surgery 345
23.1 Insufficient Preoperative Assessment 346
23.1.1 Incorrect or Incomplete Airway Assessment 347
23.1.2 Poor Evaluation of the Patient’s Comorbidities 347
23.1.3 Inadequate Parental Counselling 347
23.1.4 Inappropriate Selection of the Operative Procedure 348
23.2 Failure of Surgical Technique 348
23.2.1 Laryngotracheal Reconstruction with CCG 348
23.2.2 Tracheal Resection and PCTR 349
23.2.2.1 Anastomotic Separation 349
23.2.2.2 Tracheal Stenosis 349
23.2.2.3 Anastomotic Granulation Tissue and Restenosis 349
23.2.2.4 Recurrent Laryngeal Nerve Injury 350
23.3 Factors Unrelated to the Child’s Primary Medical Condition 350
23.4 Late Failures 350
23.4.1 Suprastomal Collapse and Granuloma 350
23.4.2 A-Frame Tracheal Deformity 351
23.4.3 Arytenoid Prolapse 351
23.4.4 Recurrent Posterior Glottic Stenosis 351
23.4.5 Epiglottic Petiole Prolapse 351
23.5 Unresolved Issues 351
23.5.1 Bilateral Cricoarytenoid Joint Fixation 352
23.5.2 Extensive Tracheal Damage 352
References 352
Appendix 354
Manufacturer Information 354
Index 356