Pearson's General Thoracic
Subglottic Resection: Infants and Children
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Key Points
- Perform a thorough preoperative endoscopy with assessment of vocal fold mobility and potential extralaryngeal sites of obstruction (e.g., nasopharynx, oropharynx, tracheostoma).
- Evaluate for gastroesophageal reflux.
- Do not plan any surgery before a mature, cicatricial stenosis has been obtained.
- Use a single-stage partial cricotracheal resection (PCTR) for grade III and IV subglottic stenoses without glottic involvement in an otherwise healthy child.
- A double-stage PCTR in children with associated congenital anomalies or impaired cardiopulmonary or neurologic functions is preferred.
- Do not identify the recurrent laryngeal nerves but stay in close contact with the cartilaginous rings when dissecting the lateral tracheal wall.
- Stay anterior to the cricothyroid joint and place the stitches in a subperichondrial plane on the outer surface of the cricoid plate to avoid injury to the recurrent laryngeal nerves.
- Perform a laryngeal release procedure when resection of five or more tracheal rings is necessary.
- Follow the airway carefully for any sign of stridor after extubation for single-stage PCTR.
- Perform a control endoscopy at the third postoperative week to assess patency of the anastomotic site after double-stage PCTR without stenting.
The principle of subglottic resection in infants and children is basically identical to that described for adults. However, a child’s airway is smaller, thus the postoperative management is more challenging. Furthermore, pediatric subglottic stenosis is often associated with glottic scarring (e.g., posterior glottic stenosis, cicatricial fusion of the vocal cords) and sometimes laryngeal and mediastinal malformations significantly add to the therapeutic challenge. However, the worst situations seen in this group of pathologic processes always result from the following:
- Previously failed laryngotracheal reconstructions (LTRs) that can distort the laryngeal framework
- Inappropriate overuse of the laser
- Misplacement of the tracheostoma that unnecessarily damages the normal trachea
The best chance for the patient lies in a successful first surgery. This implies that the surgeon be fully trained in pediatric upper airway endoscopy and laryngotracheal surgery because inappropriate initial management of subglottic stenosis may lead to permanent, intractable sequelae.
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Key Points
- Perform a thorough preoperative endoscopy with assessment of vocal fold mobility and potential extralaryngeal sites of obstruction (e.g., nasopharynx, oropharynx, tracheostoma).
- Evaluate for gastroesophageal reflux.
- Do not plan any surgery before a mature, cicatricial stenosis has been obtained.
- Use a single-stage partial cricotracheal resection (PCTR) for grade III and IV subglottic stenoses without glottic involvement in an otherwise healthy child.
- A double-stage PCTR in children with associated congenital anomalies or impaired cardiopulmonary or neurologic functions is preferred.
- Do not identify the recurrent laryngeal nerves but stay in close contact with the cartilaginous rings when dissecting the lateral tracheal wall.
- Stay anterior to the cricothyroid joint and place the stitches in a subperichondrial plane on the outer surface of the cricoid plate to avoid injury to the recurrent laryngeal nerves.
- Perform a laryngeal release procedure when resection of five or more tracheal rings is necessary.
- Follow the airway carefully for any sign of stridor after extubation for single-stage PCTR.
- Perform a control endoscopy at the third postoperative week to assess patency of the anastomotic site after double-stage PCTR without stenting.
The principle of subglottic resection in infants and children is basically identical to that described for adults. However, a child’s airway is smaller, thus the postoperative management is more challenging. Furthermore, pediatric subglottic stenosis is often associated with glottic scarring (e.g., posterior glottic stenosis, cicatricial fusion of the vocal cords) and sometimes laryngeal and mediastinal malformations significantly add to the therapeutic challenge. However, the worst situations seen in this group of pathologic processes always result from the following:
- Previously failed laryngotracheal reconstructions (LTRs) that can distort the laryngeal framework
- Inappropriate overuse of the laser
- Misplacement of the tracheostoma that unnecessarily damages the normal trachea
The best chance for the patient lies in a successful first surgery. This implies that the surgeon be fully trained in pediatric upper airway endoscopy and laryngotracheal surgery because inappropriate initial management of subglottic stenosis may lead to permanent, intractable sequelae.
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