Pediatric laryngotracheal stenosis*

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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. Information obtained from the flexible examination relates to the dynamics of vocal cord function and the upper airway including the trachea. Rigid bronchoscopy allows a thorough study of the area of stenosis with subsequent planning of surgical repair, thus tailoring operative repair to the specific lesion. The results of experiences with these patients support the following conclusions: (1) Dilation is a useful modality in the first few weeks following injury but has limited value in the management of a lesion where dense collagen tissue formation is advanced. (2) In 100 cases of severe, mature LTS, 95 were extubated without airway limitation and there has been no mortality. Of these 100 cases, 69 represented failures of previous procedures both either endoscopic (55) or external LTR (14). (3) LTR is not associated with clinical, radiological, endoscopic, or functional evidence of change in laryngeal growth patterns. (4) The costal cartilage graft without scar resection or stenting is the method of choice for isolated anterior subglottic stenosis severe enough to prevent decannulation. The posterior cricoid split and Aboulker stent with or without anterior costal cartilage graft is the currently preferred method of LTR if there is combined glottic and sugglottic stenosis or severe subglottic stenosis and upper tracheal stenosis with loss of cartilage and cricoid arch support. In particular, LTR has been successful where other methods have failed. Continued work is necessary to improve techniques of LTR. (5) Further research is required to prevent LTS as a complication of endotracheal intubation.

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    *

    Presented before the 15th Annual Meeting of the American Pediatric Surgical Association, Marco Beach, Florida, May 9–12, 1984.

    1

    From the Department of Otolaryngology and Maxiffofacial Surgery, University of Cincinnati College of Medicine.

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