Slide 1 - Dayton Children`s Hospital

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Acquired Subglottic Stenosis
Granulation
48 hours
Ulceration
72 hours -10 days
Furrow
10-30 days
Interarytenoid Scar
10-30 days
Acquired Subglottic Stenosis
Pathogenesis
• Intrinsic Factors:
o Shape and size of larynx
o Infection
o Wound healing
o Malnutrition
o Chronic Disease
o Activity/ movement
o GERD/ LPR
• Extrinsic Factors:
oEndotracheal tube
• Size
• Traumatic intubation/
Multiple reintubations
• Duration of intubation
oTracheostomy
oNasogastric Tube trauma
• Chronic inflammation will
exacerbate changes induced by
ETT
• Higher rate of GER in patients
with SGS than the general
population
Gould SJ, Young M. Sublgottic ulceration and healing following endotracheal tube intubation in
the neonate. Annals ORL; 1992, 101: 815.
Acquired Subglottic Stenosis
Pathogenesis
• Endotracheal Tube Factors:
o Size of ETT
• < 20 cm H2O pressure air leak appropriate
o ETT material
• Silicone or Polyvinyl chloride tubes safest
o Duration of Intubation
• Adults <7-10 days
• Longer for premature infants
o Shearing motion of ETT
• Increased trauma to mucosa  Increases traumatic changes
o Maintenance and care of ETT and patient
• Aggressive suctioning, endoscopy, reintubation
Subglottic Stenosis
Cotton Myer Grading System
Myer CM, O’Connor DM, Coton RT. Proposed grading system for subglottic stenosis based on
endotracheal tube sizes. Ann Otol Rhinol Laryngol, 1994; 103: 319-323.
Grading Subglottic Stenosis
ETT
Size
Patient Age
Premature
No
Detectable
Lumen
0-3 ½ mos
3 ½- 9 ½ mos
9 ½- 2 yrs
2 yrs
4 yrs
6 yrs
Grade
IV
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
40
58
68
75
80
84
86
89
30
48
59
67
74
78
81
26
41
53
62
68
73
22
38
50
57
64
20
35
45
54
19
32
43
17
30
16
Grade
III
Grade
II
Grade
I
6.0
Subglottic Stenosis
Grade I: <50% Stenosis
Grade II: 50-70% Stenosis
Grade III: 70-99% Stenosis
Grade IV: No Detectable
Lumen
Subglottic Stenosis- Treatment
• Grade I and low Grade II
o Can usually be observed
o Close follow up, endoscopy for surveillance
• High Grade II
o May require surgical repair
o Endoscopic dilation
o Open surgical repair
• Grade III and IV
o Require surgical repair
o Open surgical repair
o Tracheostomy as temporizing measure
Surgical Treatment- Dilation
Anterior Cricoid Split
• Described in 1980 by Cotton as
alternative to tracheostomy for patients
with acquired subglottic stenosis
• Patient selection:
o
o
o
o
> 2 failed extubations due to SGS
Weight >1500 grams
Off ventilator support for 10 days
<30% O2 requirement
• Airway improved by:
o Improved circulation to the cricoid and
decreased edema
o Opening the cricoid allows it to “spring
open”
Laryngotracheal Reconstruction
• Anterior Graft
o Use for lower grade and
primarily anterior stenoses
• Anterior and Posterior
Grafts
o Use for posterior glottic
stenosis, circumferential
stenosis, or near total/ total
subglottic stenosis
Single Stage Laryngotracheal
Reconstruction
• Traditional LTR with cartilage grafts and simultaneous
tracheal decannulation
• Indications:
o
o
o
o
SGS without associated tracheal stenosis or tracheomalacia
Weight greater than 4 kg
Gestational age > 30 weeks
No craniofacial or vertebral anomalies
• Aim to avoid complications of long term stenting and
tracheostomy
• Postoperative care critical!
o Nasotracheal tube “stenting”
o Titrated sedation versus Paralysis
“Mini” Laryngotracheal Reconstruction
• Anterior cricoid split with thyroid
ala cartilage graft
• Small retrospective series show
shortened operative time
compared with costal cartilage
graft and no significant difference
in operative outcomes
• Expands the age group for LTR to
younger patients
Endoscopic Posterior Cricoid Split
• Described by Inglis et al in 2003 for management of
posterior glottic stenosis with or without subglottic
stenosis
o 5/ 7 children decannulated within a year after
surgery
• Posterior cricoid lamina is endoscopically divided and
expanded with a costal cartilage graft
Inglis AF, Perkins JA, Manning SC, Mouzakes J. Endoscopic posterior cricoid split and
rib grafting in 10 children. Laryngoscope
2003; 113(11):2004-2009.
Conclusions
• The most common causes of congenital stridor include
laryngomalacia, subglottic stenosis.
o Tracheomalacia is the most common cause of lower airway
stridor, however is much less common than laryngomalacia
• Diagnostic work up should include careful history and physical
examination.
o Office laryngoscopy and/ or direct laryngoscopy and
bronchoscopy should be used to make definitive diagnosis
• Many congenital airway lesions can be treated expectantly or
medically
• Surgical treatment options are available, and should be
tailored to the individual patient.
Thank You!
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