© Borgis - New Medicine 4/2013, s. 111-113
*Lidia Zawadzka-Głos, Iwona Krajewska
Treatment of subglottic stenosis in children
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
Subglottic stenosis of the larynx are currently the most common indication for tracheostomy in children. Treatment of postintubation laryngeal stenosis has been modificated for many years. Methods of treatment of postintubation stenosis of the larynx can be divided into two groups: endoscopic and open surgical methods. Below presented review of these methods of treatment are based on the literature and our own experience.
In 1930, Chevalier Jackson noted that children with chronic stenosis of the larynx did not grow out of their problem while ageing but require treatment. Acquired stenosis of the larynx was the result of trauma caused by the surroundings or infectious diseases such as syphilis, tuberculosis, and typhoid fever (1). These children were treated by tracheotomy. Often too high tracheostomy itself provoked the process of fibrosis and drove to secondary stenosis of the larynx at the cricoid cartilage. During this period, there was no method of reconstruction of the respiratory tract, and many children were treated by expansion, with virtually no major effects, leaving them dependent on a tracheotomy for life.
Acquired subglottic stenosis of the larynx has started to be well recognized since 1965, when McDonald and Stocks initiated prolonged intubation as a treatment for infants requiring respirator (2). The increase in the occurrence of postintubation stenosis of the larynx and the high risk of mortality of children with tracheostomy of as much as 24% resulting in the development of new methods of treatment and reconstruction of the respiratory tract (3, 4).
METHODS FOR OPEN SURGERY
In 1971, the first cut was described by Grahn of Rethie procedure of cricoid cartilage (5). This procedure was based on the intersection of the vertical rear wall of cricoid cartilage and scar excision and stent type of Aboulker. In 1974 Evans and Todd developed the first laryngotracheoplastic by using the characteristic stepped front notches of cricoid cartilage and upper tracheal rings that were left open, and stented it by stent made from silastic for about 6 weeks (6).
In 1980, Cotton and Seid proposed a method of anterior cricoid cartilage called cricoid split (CS) (7). The method has been used for infants with stenosis of the front of the glottis and stenosis of the subglottic region. The concept involved decompression of cricoid cartilage in exchange for a tracheotomy. According to data from 1987 Holinger successfully intubated off 77% of patients in the 138 children without performing a tracheotomy (8).
Severe laryngotracheal stenosisstarted to heal with the use of cartilage grafts. Fearon and Cotton in 1972 described a procedure for the use of cartilage graft to expand the light of the larynx in children (4, 9). The implant used part of the thyroid cartilage. In subsequent studies they used the cartilage of the nasal septum, the cartilage of the ear, the cartilage of the ribs, but also part of the hyoid bone or piece of muscle sterno-clavicular-mastoideus. They also tried to enter the conserved cartilage, but due to the very high risk of resorption of the cartilage, they discontinued its use (10). The largest use of autogenic cartilage has been found in the patient’s ribs. The implants were introduced in the front or rear part of the cricoid cartilage, or in both parts simultaneously. This type of treatment is called laryngo-tracheal reconstruction (LTR). In 1989 Cotton analyzed more than 200 cases that were treated with the use of LTR and acquired 92% decannulation of the trachea after an average of 1.23 procedures for each patient (11). Zalzal passed about 90% of the decannulation of the trachea after the application of the front and back of the cartilage implant (12). All children after medical intervention were stented for a minimum of six weeks.
Quadrilateral cuts cricoid cartilage in the LTR was started in 1992 as one of the treatment options for severe subglottic stenosis of the larynx (13). The procedure provides for cutting not only the front and back wall of cricoid cartilage, but also to the side walls. This technique is often combined with the use of cartilage implant.
Treatments type LTR in the 90’s were divided into two groups: one-step (single-stage) or SS-LTR and two-stage (double-stage) – DS-LTR. SS-LTR technique involves the simultaneous removal of a tracheotomy during reconstructive surgery of the larynx and trachea (14, 15). Currently the procedure is dominated by resection of cricothyroid-tracheal (CTR). Partial cricothyroid-tracheal resection (PCTR) is increasingly being performed by surgery in severe narrowing of the larynx. It involves resection of the narrowed section of the respiratory tract and end-to-end anastomosis. Monnier among surgical patients rated their efficacy of this method as of 93% (16).
METHODS OF ENDOSCOPIC SURGERY
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