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Cricotracheal Resection in Children
Michael J. Rutter, FRACS;
Benjamin E. J. Hartley, FRCS;
Robin T. Cotton, MD
Arch Otolaryngol Head Neck Surg. 2001;127:289-292.
ABSTRACT
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Objective To review our experience with cricotracheal resection in a pediatric
population.
Design Prospective case review of a cohort of patients undergoing cricotracheal
resection.
Setting Tertiary care pediatric hospital.
Patients Forty-four consecutive patients undergoing cricotracheal resection between
January 1, 1993, and December 31, 1998.
Main Outcome Measures Decannulation rates.
Results Thirty-eight (86%) of the 44 children are decannulated. The ultimate
decannulation rate was independent of the presenting grade of subglottic stenosis.
Fourteen children (100%) had a primary cricotracheal resection; all are decannulated.
Twenty-one children had a salvage cricotracheal resection, and 19 (90%) are
decannulated. Nine children had an extended cricotracheal resection, of whom
5 (56%) are decannulated. A primary cricotracheal resection was performed
on a child on whom no previous open airway procedure had been performed. A
salvage cricotracheal resection was performed on a child on whom previous
open airway reconstruction had not resulted in an adequate airway. An extended
cricotracheal resection was performed on a child on whom the cricotracheal
resection was combined with a second procedure, either additional expansion
cartilage grafting or an open arytenoid procedure. Most of these children
had complex airway pathologic conditions.
Conclusion Cricotracheal resection complements standard laryngotracheal reconstruction
techniques in a pediatric population.
INTRODUCTION
OVER THE LAST 30 years reconstruction of the pediatric airway has rapidly
evolved, fueled by the advent of prolonged neonatal intubation and the subsequent
dramatic increase in the incidence of acquired subglottic stenosis.1, 2 While many different techniques for
reconstruction of the pediatric airway have been used, expansion laryngotracheal
reconstruction (LTR) using cartilage grafts has stood the test of time and
should be considered the standard criterion against which other techniques
should now be measured.3 Our unit has vast
experience with expansion LTR using cartilage grafts.4
Cricotracheal resection (CTR) is an alternative technique for managing
subglottic stenosis and has been an established technique in the adult population
for many years.5, 6 The pediatric
series was described by Monnier et al7 in 1993.
Between January 1, 1993, and December 31, 1995, our unit performed 4 CTRs.
The initial results were encouraging, and since 1996 we have performed between
10 and 15 pediatric CTRs each year, with initial results published in 1997.8 Subsequent reports have also been encouraging.9, 10 Our increasing experience with CTR
includes children with complex airway pathologic conditions, and with time
the indications, limitations, and complications of CTR are becoming more established.
The technique of CTR involves the resection of the anterior cricoid
arch and thinning of the posterior cricoid plate with preservation of a posterior
mucosal flap. The transected normal trachea is then telescoped into the posterior
cricoid plate and anastomosed to the mucosal flap and thyroid cartilage. This
technique has been previously well described.7, 8
Cricotracheal resection is more technically challenging than standard expansion
LTR and there are recognized complications associated with the procedure including
recurrent laryngeal nerve damage and anastomotic dehiscence.
MATERIALS AND METHODS
A prospective database analysis was undertaken of all patients in whom
CTR had been performed between January 1, 1993, and December 31, 1998. No
patients were lost to follow-up. A minimum of 12 months' follow-up information
was available for all patients. The data collected included the surgical airway
history prior to CTR, the preoperative grade of the subglottic stenosis, the
decannulation status of each patient, and whether the patient had required
a further procedure prior to decannulation.
The patients were further subdivided into primary, salvage, and extended
CTR. A primary CTR was defined as a CTR performed on a child on whom no previous
open airway procedure had been performed. A salvage CTR was defined as a CTR
performed on a child on whom previous open airway reconstruction had not resulted
in an adequate airway. An extended CTR was defined as a CTR performed on a
child on whom the CTR was combined with a second procedure, either additional
expansion cartilage grafting or an open arytenoid procedure.
RESULTS
Between January 1, 1993, and December 31, 1998, 44 (19 females and 25
males) consecutive children underwent CTR. The follow-up period ranged between
12 and 67 months. The patients' ages at the time of CTR ranged from 13 months
to 19 years (mean age, 73 months). Forty children were operated on since 1996.
Twenty-four children were former premature infants, 14 children were receiving
antireflux medication at the time of CTR, and 6 more children had a history
of previous Nissen fundoplication.
This cohort of 44 children included 3 with a history of laryngotracheoesophageal
clefting. All 3 had required previous LTR, using expansion cartilage grafting
techniques. Two are decannulated. An additional child with a Wegener granulomatosis,
is decannulated and symptom free 56 months following CTR.
A variety of stenting techniques were used, with 22 patients having
single-stage procedures, 16 patients requiring a T tube, 4 patients having
a suprastomal stent, and 2 patients having no stent. Of the 4 children with
suprastomal stents, 3 remain tracheotomy dependent, all of whom had extended
CTRs.
Ten patients had a grade 4 subglottic stenosis (Myer-Cotton grading
scale).11 Nine are decannulated, although 1
required an LTR with expansion cartilage grafting 8 months following CTR to
achieve decannulation. A second child required a subglottic laser procedure
to achieve decannulation. The 10th patient has had a revision LTR and awaits
decannulation.
Thirty-two children had a grade 3 subglottic stenosis, of whom 27 (84%)
are decannulated. Of these 27, 3 required a subsequent LTR with expansion
cartilage grafting to achieve decannulation.
Two children could not be adequately graded as they had subglottic collapse
due to preexisting damage to the anterior cricoid cartilage resulting from
a previous LTR rather than fixed subglottic stenosis. Using the endotracheal
tube method, one of these children could be sized as having a grade 2 subglottic
stenosis, but both children functionally behaved as if they had a grade 3
subglottic stenosis due to the subglottic collapse of the airway. Both children
were decannulated following CTR.
The indications for, and outcomes of, performing CTR should not be considered
merely in terms of the grade of subglottic stenosis. We have attempted to
address this by retrospectively assigning patients into 1 of 3 groups, namely,
primary CTR, salvage CTR, and extended CTR.
Primary CTR is defined as a CTR performed on a child who has not had
a previous open airway procedure. Fourteen children were included in this
group, all of whom are decannulated. In this group 4 children required a subsequent
LTR using expansion cartilage grafting to achieve decannulation.
Salvage CTR is defined as a CTR performed on a child who has had at
least 1 prior open airway reconstruction. Twenty-one children fulfilled this
criterion, with a range of between 1 to 8 previous LTRs (mean, 2.8 previous
LTRs). This includes previous anterior cricoid splits. Of these 21 children,
19 (90%) have been decannulated. Two of these children required temporary
replacement of their T tube following single-stage CTR prior to ultimate decannulation.
Extended CTR is defined as a CTR performed on a child when an additional
open airway procedure is required. Nine children in the series had an extended
CTR. Seven were salvage procedures; 2 were primary procedures (with both of
the extended primary procedures still being tracheotomy dependent). The additional
procedures comprised 2 posterior cricoid splits, a posterior cricoid graft,
an anterior cartilage graft, 4 arytenoid lateralizations, and 1 arytenoidectomy.
Five (56%) of these children are decannulated.
The most common complication we encountered was webbing at the anastomotic
site. This was present in most cases and was usually minor and asymptomatic.
In 9 cases restenosis occurred and 5 of these children are still tracheotomy
dependent. The sixth tracheotomy-dependent child had subglottic collapse rather
than stenosis. Four children required a subsequent LTR to achieve decannulation.
Two children had significant postoperative wound infections with resultant
grade 4 subglottic stenosis. Injury to the recurrent laryngeal nerve unilaterally
may have occurred in 2 children in the series. In 1 child this was not appreciated
interoperatively, but a vocal cord palsy was noted postoperatively that had
not been noted preoperatively. In the other child there was concern that the
right recurrent laryngeal nerve had been partially severed while dissecting
in thick scar tissue. However, this could not be confirmed postoperatively
as the child did not have an identifiable vocal cord present on that side.
Both of these children had single-stage CTRs and were able to be decannulated.
In 20 of the 44 patients, arytenoid prolapse was noted postoperatively when
it had not been noted preoperatively. Twelve of these children were asymptomatic,
but 8 required laser partial arytenoidectomy with all of these children being
decannulated. Two of these children require continuous positive airway pressure
for moderate supraglottic collapse. In this series there were no cases of
dehiscence at the anastomotic site.
The overall decannulation rate for the series is 86%, with 38 of 44
children being decannulated. The 6 children who are still tracheotomy dependent
are described in Table 1. Three
of these children (patients 1, 4, and 6) have a markedly improved airway following
CTR, but will still require another airway procedure prior to decannulation.
One child with a history of a laryngotracheoesophageal cleft (patient 2) and
a very deficient posterior cricoid continues to have subglottic collapse following
CTR, as he did prior to CTR. He maintains an excellent lumen with a T tube
in situ, but the airway collapses on removal of the T tube. He also requires
additional airway reconstruction. The final 2 children (patients 3 and 5)
are the only 2 examples in our series in which the airway was not improved
following CTR. In one case a grade 3 stenosis was converted to a grade 4 stenosis,
and in the other case a grade 4 stenosis remained grade 4 following CTR. In
both cases a significant postoperative wound infection was believed to be
responsible, Pseudomonas species in one case and
methocillin-resistant Staphylococcus aureus in the
other case. One has already had a further reconstruction and is awaiting decannulation;
the other awaits further surgery.
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Children Still Tracheotomy Dependent Following Cricotracheal Resection
(CTR)*
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COMMENT
Over the period of this review there has been an evolution, not only
of surgical technique, but also a better appreciation of the indications,
limitations, and complications of CTR. In the initial stages of the series
we routinely performed a suprahyoid release. This occurs in less than 50%
of cases as long as there is no undue tension on the anastomosis. Similarly,
chin to chest sutures were routine initially, and more recently less than
30% of children had required chin to chest suturing. However, although there
have been no anastomotic dehiscences in our series, subsequently we have had
experience with anastomotic dehiscence and have returned to using chin to
chest sutures in most cases. In this series most children had a tracheostomy
preoperatively. Intraoperatively, the stoma may be included in the resected
tracheal specimen, or maybe left intact. The key is to anastomose healthy
trachea to the thyroid cartilage whether above or below the level of the preexisting
tracheostomy stoma. We have also become more selective about the drilling
of the posterior cricoid plate, and in almost half of our current cases minimal
drilling or no drilling is performed, dependent on the amount of scar tissue
present.
We have used a variety of different stenting techniques, from using
no stent at all in 2 children to using an endotracheal tube as part of a single-stage
CTR in 22 children. In our opinion the choice of stent does not critically
influence outcome. Our current preference is for a single-stage reconstruction
with 7 to 10 days of postoperative intubation if the child is initially seen
without a T tube, or if the child has a grade 3 subglottic stenosis. We rarely
use T tubes smaller than 8-mm outer diameter to minimize the risk of secretions
obstructing the lumen, and this usually requires the child to be at least
4 years old. In a child older than 4 years, who is already tracheotomy dependent,
our preference is to use a T tube. In a child too small to use a T tube, and
in whom we do not wish to use a single-stage technique, we place a suprastomal
Cotton-Lorenz stent. We would not normally perform a single-stage CTR in a
child with a grade 4 subglottic stenosis, or in a child requiring an extended
CTR. In this series, 3 of the 4 children in whom a suprastomal stent was used
remained tracheotomy dependent. However, all 3 of these children had extended
CTRs, and we do not consider that the form of stenting influenced outcome.
The complications encountered in the series included recurrent laryngeal
nerve palsy, postoperative infection, anastomotic webbing, or restenosis and
arytenoid prolapse. Minor anastomotic webbing was virtually universal and
usually asymptomatic. Significant restenosis occurred in 9 of 44 patients,
severe enough to receive or required further airway reconstruction. Only 2
children had a worse airway following CTR and both of these children had postoperative
infections following extended CTRs. These were the only 2 significant postoperative
infections in the series. Arytenoid prolapse was a common postoperative finding,
though it could present very late, and was asymptomatic in most patients.
Eight patients required laser partial arytenoidectomy, and while efficacious,
this procedure should be done as conservatively as possible, as there is an
attendant risk of supraglottic stenosis or collapse. This occurred in 2 of
our patients who require nocturnal continuous positive airway pressure. In
this series there were no cases of anastomotic site dehiscence, though subsequently
we have noted this in 2 patients operated on after 1998.
This series is unusual in that 9 (90%) of the 10 children with a grade
4 subglottic stenosis have been decannulated, and the other awaits decannulation,
while only 84% of the children with grade 3 subglottic stenosis are decannulated.
There are 2 possible explanations for this. First, most grade 4 stenoses occur
low in the subglottis, and these children are, therefore, ideal CTR candidates.
Meanwhile many grade 3 lesions occur higher in the subglottis and may even
involve the vocal cords, making them less ideal CTR candidates. The alternative
explanation, and the one that we favor, is that this result reflects the small
sample size rather than the disease. Similarly, the 100% decannulation rate
for the primary CTRs is likely to represent the small sample size rather than
the disease, and it is notable that in 4 of these cases a subsequent LTR was
required prior to decannulation.
In our experience we have found that CTR had particular utility for
salvaging airways where a previous LTR with expansion cartilage grafting had
failed. Several children had multiple failed LTR procedures, yet 90% of the
salvage CTRs were able to be decannulated, with none requiring further airway
reconstruction. This figure, however, does not include the 7 extended CTRs
that were salvage procedures, of whom only 5 achieved decannulation.
The results of extended CTR were more disappointing with only 56% achieving
decannulation. However, it is our opinion that this reflects the severity
of the presenting problem rather than the reconstructive procedure itself.
Most of these children had pathologic airway conditions affecting multiple
levels.
In this sense, our series has differences to the experience in other
centers performing pediatric CTR, in that we have primarily used CTR for the
most challenging cases of subglottic stenosis. This series includes children
referred to us with airway burns, laryngotracheoesophageal clefts, Wegener
granulomatosis, multiple failed LTRs, and children with second airway lesions
including glottic stenosis, arytenoid prolapse, arytenoid fixation, and bilateral
true vocal cord paralysis.
This experience has helped to refine our indications for CTR. We believe
that CTR is particularly well suited to manage grade 4 subglottic stenosis,
grade 3 subglottic stenosis with concentric low subglottic scarring (
3 mm below the vocal cords), airway salvage following failed LTR, inflammatory
scarring of the subglottis, and airway collapse due to cartilage damage of
the anterior cricoid. While these are the ideal candidates, CTR need not necessarily
be limited to these patients, but on an individualized basis may be applied
to children with multiple level pathology, a deficient posterior cricoid plate,
and where the stenosis is closer to vocal cord level. While a limitation,
vocal cord involvement is not an absolute contraindication.
Cricotracheal resection has not replaced LTR techniques using cartilage
extension in our practice. In fact, we still perform more than twice the number
of LTRs for subglottic stenosis as we do CTRs. Cricotracheal resection is
more technically challenging than LTR and we do not believe that CTR is justified
where an anterior cricoid graft would suffice. Most grade 2 subglottic lesions
and many grade 3 lesions respond adequately to anterior cricoid grafting alone.
Anterior and/or posterior cartilage grafting remains ideal for the management
of grade 3 subglottic stenosis due to lateral shelving. Laryngotracheal reconstruction
also remains the first consideration for subglottic stenosis that involves
the vocal folds, unless there is a good reason to consider CTR (such as failure
following multiple previous LTRs).
CONCLUSIONS
Cricotracheal resection is a valuable addition to the management options
for severe laryngotracheal stenosis in children. It does not so much replace
LTR using cartilage expansion techniques, as it is to be considered as complementing
LTR. It is particularly suited to the management of grade 4 subglottic stenosis,
severe grade 3 subglottic stenosis particularly with concentric scarring in
the low subglottis, and salvage of the airway when standard LTR techniques
have failed.
AUTHOR INFORMATION
Accepted for publication June 29, 2000.
Presented at the annual meeting of the American Society of Pediatric
Otolaryngology, Orlando, Fla, May 18, 2000.
From the Division of Otolaryngology, Children's Hospital Medical Center,
Cincinnati, Ohio. Dr Hartley is now with the Hospital for Sick Children, London,
England.
Corresponding author and reprints: Michael J. Rutter, FRACS, Department
of Otolaryngology, Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati,
OH 45229-3039 (e-mail: ruttm0{at}chmcc.org).
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