Efficacy of Cricotracheal Stenosis Resection (CTSR) Among Children with Congenital vs. Acquired Sub-glottic Stenosis.

Sub-glottic Stenosis (SGS) treatment in children is challenging because there is no standard algorithm to follow; however, the use of endoscopic techniques in SGS treatment has emerged over the last decades and has advanced. The aim of this study was to assess the efficacy of Cricotracheal Stenosis Resection (CTSR) among children with congenital vs. acquired SGS. In this retrospective study, we reviewed the charts of 22 patients who underwent endoscopic intervention as the primary modality of treatment for SGS at King Abdulaziz Medical City from January 1, 2011 to October 31, 2019. Successful treatment was defined as: resolution of symptoms, restoration of a normal patent airway with no stenosis, and decannulation. Out of 22 patients, 14 cases were acquired and 8 were congenital SGS. Most of the patients had grade 3 stenosis before surgery 15 (68%), followed by grade 1 stenosis among 4 (18.2%) and grade 2 stenosis was present in 3 (13.6%) patients. Postoperatively, 17 (77.3%) patients improved to grade zero, whereas grade 3 stenosis was not reported in any patient. The Mc-Nemar's test showed significant improvement between pre- and post-operative stenosis grade with test value = 22, and P value = 0.003. This technique was successful among 18 (82%) patients with P value ≤ 0.01. Irrespective of the differences in the age of patients, length, and character of stenosis among congenital and acquired groups, the endoscopic CTSR technique proved to be successful in both groups. We achieved a success rate of 86% in the acquired series, and 75% in the congenital series, which is a very promising result.

Long-term results of slide laryngotracheoplasty for congenital subglottic stenosis in newborns and infants.

OBJECTIVES: Slide laryngotracheoplasty is an effective, single-step procedure without tracheostomy and stenting for treating high-grade congenital subglottic stenosis in neonates and infants. Long-term outcomes were evaluated to assess the reliability of the procedure performed in this age of rapid development of the laryngeal structures. METHODS: We report five children who underwent slide laryngotracheoplasty before the age of 4 months, each with >3 years follow-up. Increases of length and bodyweight were systematically assessed. Breathing, swallowing, voice, and overall satisfaction was assessed by a quality of life questionnaire. Voice quality was objectively evaluated by measuring shimmer, jitter, fundamental frequency, and the harmonics-to-noise ratio. RESULTS: All patients had a stable and adequate airway during follow-up without any additional open airway surgery. The patients' voices were physiological, and the intervention had no negative impact on speech development. Swallowing function was optimally retained, and the patients' bodyweight gain and length were satisfactory. During at least 3 years of observation, the anastomosis remained stable and grew dynamically with the patient. CONCLUSIONS: Slide laryngotracheoplasty (as a single-step procedure) provides an adequate airway without tracheostomy, grafting, or stenting with good long-term functional results in selected neonates and infants with congenital subglottic stenosis.

Slide laryngotracheoplasty for treating congenital subglottic stenosis: a case report and follow-up / 中华实用儿科临床杂志

The data of a case of congenital subglottic stenosis (C-SGS) who underwent slide laryngotracheoplasty in the Center for Respiratory Intervention, Children′s Hospital Affiliated to Shandong University in December 2021 was analyzed retrospectively.The patient was a girl aged 2 months and 15 days.She visited the hospital 23 days after tracheotomy due to dyspnea for more than 2 months.The bronchoscopy and annular cartilage B ultrasound results suggested subglottic stenosis and no scar hyperplasia.Based on the medical history, the child was diagnosed with C-SGS.Slide laryngotracheoplasty was performed 2 weeks after admission, and the tracheotomy tube was removed after surgery.The child was followed up 2 months after surgery, and she recovered well with no dyspnea.The study results suggest that early and safe slide laryngotracheoplasty after definite diagnosis can provide immediate and sufficient airway space for C-SGS patients, and protect their voice and swallowing function.

Congenital airway anomalies.

Congenital airway anomalies (CAA) include a variety of conditions that cause respiratory distress in neonates and infants. These malformations occur at various anatomic levels and manifest in a wide spectrum of airway symptoms, with presentation significantly influenced by the level at which obstruction occurs as well as by the severity of obstruction. The prevalence of congenital airway malformations has been estimated to range between 0.2 and 1 in 10,000 live births. The most frequent CAA are laryngomalacia, bilateral vocal cord paralysis, subglottic stenosis, laryngeal webs, subglottic hemangioma, tracheomalacia, congenital tracheal stenosis, laryngotracheal cleft, and tracheal agenesis.

Surgical Management of Anterior Glottic Webs.

Congenital webs are rare and represent <5% of all congenital laryngeal anomalies. They are usually a partial laryngeal atresia rather than a true web, and present as a thick and fibrotic web with subglottic extension and associated subglottic stenosis. All patients with a congenital anterior glottic web should be evaluated for chromosome 22q11.2 deletion syndrome. Management strategies are mainly based on the severity of airway obstruction and the anatomical extension of the webs. Simple division of the web endoscopically may be adequate for rare thin webs, however, an open approach is usually warranted for thick glottic webs regardless of Cohen grades. Open repair can be either with keel placement or reconstruction of the anterior commissure.

Airway Anomalies.

This article reviews congenital anomalies involving the larynx and trachea, including congenital subglottic stenosis, laryngeal webs, laryngeal cleft, and tracheal stenosis. Presenting signs and symptoms, prevailing surgical repair techniques, and postoperative care are discussed.

Subglottic Stenosis.

The subglottis is a narrow region of the pediatric airway that is exquisitely susceptible to the development of airway stenosis. The incidence of acquired subglottic stenosis in the setting of prolonged intubation has significantly decreased because of improved endotracheal tube management protocols. Advances in otolaryngology interventions, such as balloon dilation and endoscopic cricoid split techniques, may allow the avoidance of tracheostomy in patients with mild to moderate subglottic stenosis. However, patients with severe subglottic stenosis are often tracheostomy dependent. Open surgical techniques to treat severe disease, such as laryngotracheal reconstruction and cricotracheal resection, offer high rates of tracheostomy decannulation.

Endoscopic cricoid split in a tertiary referral paediatric centre.

BACKGROUND: Anterior cricoid split is performed for grade 2 and 3 subglottic stenosis, which can be a cause of extubation failure. It can be performed endoscopically or as an open procedure. This paper describes a case series of endoscopic cricoid split procedures performed using a bespoke sickle knife. METHOD: Nine patients (six pre-term infants) underwent endoscopic cricoid split in a tertiary referral paediatric unit between August 2012 and March 2015. RESULTS: Six patients (67 per cent; four pre-term and two term infants) were on oxygen pre-operatively. Mean age at operation was 30 weeks (range, 11-104 weeks). Mean number of days' intubation was 5.6 days (range, 4-9 days). All five patients intubated pre-operatively were extubated. Seven patients required repeat dilatations. One patient required tracheostomy. CONCLUSION: The extubation rates for endoscopic cricoid split are comparable to the open procedure. It is a safe and efficient method for managing subglottic stenosis, whether acquired or congenital. The main advantage is the shorter operative time, in addition to the avoidance of an external scar and drain.

Safe balloon sizing for endoscopic dilatation of subglottic stenosis in children.

OBJECTIVES: To describe our experience and provide guidelines for maximum safe balloon sizes according to age in children undergoing balloon dilatation. METHOD: A retrospective review was conducted of children undergoing balloon dilatation for subglottic stenosis in a paediatric tertiary unit between May 2006 and February 2016. RESULTS: A total of 166 patients underwent balloon dilatation. Mean ( ± standard deviation) patient age was 4.5 ± 3.99 years. The median balloon size was 8 mm, the median balloon inflation pressure was 10 atm, and the mean balloon inflation time was 65.1 ± 18.6 seconds. No significant unexpected events occurred. The Pearson correlation co-efficient for the relationship between patient age and balloon size was 0.85 (p = 0.001), suggesting a strongly positive correlation. CONCLUSION: This study demonstrated that balloon dilatation is a safe procedure for airway stenosis. The results suggest using a balloon diameter that is equal to the outer diameter of the age-appropriate endotracheal tube +1 mm for the larynx and subglottis and +2 mm for the trachea.

Subglottic stenosis.

Subglottic stenosis (SGS) is a congenital or acquired condition characterized by a narrowing of the upper airway extending from just below the vocal folds to the lower border of the cricoid cartilage. With the introduction of prolonged intubation in neonates (mid 1960s), acquired SGS became the most frequent cause of laryngeal stenosis; unlike congenital SGS, it does not improve with time. Laryngeal reconstruction surgery evolved as a consequence of the need to manage these otherwise healthy but tracheotomized children. Ongoing innovations in neonatal care have gradually led to the salvage of premature and medically fragile infants in whom laryngeal pathology is often more severe, and in whom stenosis often involves not only the subglottis, but also the supraglottis or glottis-causing significant morbidity and mortality. The primary objective of intervention in these children is decannulation or preventing the need for tracheotomy. The aim of this article is to present a more detailed description of both congenital and acquired SGS, highlighting the essentials of diagnostic assessment and familiarizing the reader with contemporary management approaches.

Diagnóstico y tratamiento de las estenosis subglóticas en pediatría: experiencia en un hospital de alta complejidad / Diagnosis and treatment of pediatric subglottic stenosis: experience in a tertiary care center

La estenosis subglótica es una de las causas más frecuentes de obstrucción de la vía aérea en pediatría. El 90% son secundarias a la intubación endotraqueal. El diagnóstico se sustenta en la clínica del paciente, la evaluación radiológica, la laringoscopía flexible y la endoscopía rígida de la vía aérea bajo anestesia general. Debe sospecharse en niños con dificultad respiratoria posextubación. La conducta terapéutica dependerá de la gravedad de la estenosis subglótica y de la sintomatología del paciente. Describimos nuestra experiencia en cuanto a las etiologías de las estenosis subglóticas, el diagnóstico, el tratamiento y la evolución de pacientes con esta patología.

Subglottic stenosis is among the most common causes of airway obstruction in children, 90% of which resulting from endotracheal intubation. The diagnosis is based on the patient's clinical, radiologic evaluation, flexible laryngoscopy and rigid airway endoscopy under general anesthesia. It must be suspected in children with respiratory distress after extubation. The therapeutic approach depends on the severity of the subglottic stenosis and the patient's symptoms. We describe our experience with the subglottic stenosis etiologies, diagnosis, treatment and outcome of patients with this condition.

Diagnóstico y tratamiento de las estenosis subglóticas en pediatría: experiencia en un hospital de alta complejidad / Diagnosis and treatment of pediatric subglottic stenosis: experience in a tertiary care center

La estenosis subglótica es una de las causas más frecuentes de obstrucción de la vía aérea en pediatría. El 90% son secundarias a la intubación endotraqueal. El diagnóstico se sustenta en la clínica del paciente, la evaluación radiológica, la laringoscopía flexible y la endoscopía rígida de la vía aérea bajo anestesia general. Debe sospecharse en niños con dificultad respiratoria posextubación. La conducta terapéutica dependerá de la gravedad de la estenosis subglótica y de la sintomatología del paciente. Describimos nuestra experiencia en cuanto a las etiologías de las estenosis subglóticas, el diagnóstico, el tratamiento y la evolución de pacientes con esta patología.(AU)

Subglottic stenosis is among the most common causes of airway obstruction in children, 90% of which resulting from endotracheal intubation. The diagnosis is based on the patients clinical, radiologic evaluation, flexible laryngoscopy and rigid airway endoscopy under general anesthesia. It must be suspected in children with respiratory distress after extubation. The therapeutic approach depends on the severity of the subglottic stenosis and the patients symptoms. We describe our experience with the subglottic stenosis etiologies, diagnosis, treatment and outcome of patients with this condition.(AU)

Anaesthetic management of a child with multiple congenital anomalies scheduled for cataract extraction.

SUMMARY: In infants & children variety of conditions and syndromes are associated with difficult Airway. Anaesthetic management becomes a challenge if it remains unrecognized until induction and sometimes results in disaster, leading to oropharyngeal trauma, laryngeal oedema, cardiovascular & neurological complications. A 4-month-old child with multiple congenital anomalies was posted for cataract extraction for early and better development of vision. He had history of post birth respiratory distress, difficulty in feeding, breath holding with delayed mile stones. He was treated as for Juvenile asthma. This child was induced with inhalation anaesthesia. There was difficulty in laryngoscopic intubation and could pass much smaller size of the tube than predicted. He developed post operative stridor and desaturation. The problems which we faced during the anaesthetic management and during postoperative period are discussed with this case.

Unanticipated Difficult Intubation in a Patient with Asymptomatic Congenital Subglottic Stenosis Caused by a Laryngeal Web and Thyroid Cartilage Anomaly: A case report / 대한마취과학회지

Both a laryngeal web and thyroid cartilage anomaly are rare airway abnormalities and can cause the obliteration of the tracheal diameter, which may be asymptomatic or symptomatic. In asymptomatic patients, the presence of unsuspected obliteration of the tracheal diameter may be problematic if endotracheal intubation is indicated. We report a case of unsuspected difficult intubation caused by a combined laryngeal web and congenital anomaly of the thyroid cartilage. A 14-year-old female was scheduled for corrective surgery for idiopathic scoliosis of the spine. After injection of IV induction agent and muscle relaxant, most of the vocal cords were exposed clearly by laryngoscopy, but a 6.0 mm internal diameter (ID) endotracheal tube could not be advanced below the level of the vocal cords because of resistance. Intubation was re-attempted with smaller tube (5.0 mm ID) only to fail. We awakened the patient and consulted an otolaryngologist. An Otolaryngologic examination and radiologic study revealed the narrowing of the trachea was caused by a laryngeal web and congenital anomaly of the thyroid cartilage. Later, a tracheotomy was performed under local anesthesia and then the laryngeal web and anomalous portion of the thyroid cartilage were removed under general anesthesia.

Congenital Subglottic Stenosis of the Larynx Associated with Tracheoesophageal Fistula: 1 autopsy case

Congenital subglottic stenosis of the larynx is one of the most common cause of chronic airway obstruction im infancy and childhood. It is defined as narrowing of the space bounded inferiorly by the inferior margin of the cricoid cartilage amd superiorly by the insertion of the fibers of the conus elasticus into the true vocal cords. In case we experienced was a female full-term baby delivered by Cesarean section. The stenosis was believed by hypertrophy of stromal soft tissue and cricoid cartilage in the subglottic area. The lesion was associated with tracheoesophageal fistula of H1 type. A brief review of the literature was done.