© Borgis - New Medicine 2/2001, s. 8-10
Mieczysław Chmielik, Małgorzata Dębska, Anna Bielicka, Anna Gabryszewska
Treatment of laryngeal stenosis in children
Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw
Head of Department: Prof. Mieczysław Chmielik, MD.
The number of children with laryngeal stenosis has increased as a result of congenital defects and prolonged int-bation. In the Department of Paediatric Otorhinolaryngology of Warsaw Medical School, during the last ten years (1990-1999), 52 children suffering from laryngeal stenosis have been diagnosed. Among the 36 diagnosed or treated children, 21 were decannulated, 3 died, 4 are still under treatment, and we have no information on 8 of them. Children with laryngeal stenosis are treated using a laryngeal incision performed with a laryngotome, on a silastic seperator on an endless thread. The treatment is difficult and prolonged in children with the 3 rd and 4th degree of stenosis. Intralaryngeal incision is an efficient method in the treatment of postintubation laryngeal stenosis. It allowed the decannulation of 58% of cases.
Since the mid – seventies, we have seen an increase in the number of children with postintubation laryngeal stenosis. This is connected with the prolonged intubation of small children in intensive care with circulatory and respiratory insufficiency.
Factors which may influence the occurence of postintubation complications include: imperfect intubation technique, tissue infection during the introduction of the tube, and the age of the child (premature infants and new – borns tolerate intubation better than older children). They also include the duration of the intubation, tube size and material, method of sterilisation, tissue anoxia caused by respiratory disorders, bleeding, metabolic disturbances, and the drugs used.
The mechanism of generation of postintubation complications depends on the compression of the laryngeal mucous membrane by the intubation tube. In the subglottic area, which consists of a full ring of cricoid cartilage, inelastic during compression, this results in localised anaemia followed by necrosis caused by ischaemia. An inflammatory state, petechiae, ulceration covered by fibrin and granulation, cicatricial infiltration, and adhesions result.
The subglottic area is the most frequent site of postintubation strictures. Postintubation changes are rarely found at the level of the glottis. Symptoms of postintubation laryngeal stenosis most often appear between 7 and 21 days after the removal of the tube. At this time, inspiratory or mixed dyspnoea, laryngeal stridor, and voice changes can occcur.
The child requires endoscopic examination of the respiratory tract, and specialist therapeutic management.
We evaluated the degree of stenosis on a four – point scale;
1st degree – stenosis of up to 70% of the lumen of the larynx
2nd degree – stenosis of up to 90% of the lumen of the larynx
3rd degree – stenosis of up to 97% of the lumen of the larynx
4th degree – stenosis greater than 97% of the lumen of the larynx, or laryngeal atresia.
Children with laryngeal stenosis have frequently been found to have concomitant diseases; for example: anomalies of the facial skeleton, congenital heart disease, intracerebral haemorrhage, epilepsy, or chromosomal abnormalities.
In the Department of Paediatric Otolaryngology of Warsaw Medical School, children with laryngeal stenosis are treated using a laryngeal incision performed with a laryngotome, on a silastic separator on an endless thread. In the most frequent cases, a tracheotomy should be performed; this allows proper ventilation, and is vital for the introduction and fixing of a separator at the site of the incision.
AIM OF THE STUDY
The purpose of this study was to assess the effectiveness of treatment of postintubation laryngeal stenosis using intralaryngeal incisions.
MATERIALS AND METHODS
During the last ten years (1990-1999), 52 children suffering from laryngeal stenosis have been diagnosed and treated. These were 25 girls and 27 boys, aged from 1 month to 10 years. The average age at recognition of the stricture was 2 years and 1 month. We examined the age of the child at the time of recognition of the stricture, the reason for intubation, and co – existing diseases. We also recorded the location and degree of laryngeal stenosis.
In estimating the effectiveness of treatment, we disregarded the number of laryngeal incisions, the type and date of application of a separator, the treatment time from diagnosis to decannulation, and any complications after treatment.
In all 36 children, laryngeal stenosis was caused by prolonged translaryngeal intubation. The time ranged from 3 to 90 days, with a mean of 28 days. In 12 cases prolonged intubation was caused by respiratory and circulatory failure during inflammatory diseases of the respiratory tract, in 2 cases by a foreign body in the bronchum, in 4 cases due to sepsis, and in 17 cases due to prematurity or congenital disease of the larynx and trachea (laryngomalacia – 7 cases, cyst – 2 cases, vocal chord paralysis – 1 case, tracheo – oesophageal fistula – 1 case, web – 1 case, dysplasia of the cricoid cartilage – 1 case, Pierre – Robin syndrome accounted for 1 case, palatoschisis – 1 case; operation for congenital heart disease – 1 case, and the result of multi – organ trauma – 1 case).
Six children were found to have intracerebral haemmorhage, 3 to have congenital heart disease, 2 to have infantile cerebral palsy, 1 to have congenital hypothreosis and severe sensory hearing loss, 1 to have cardiomyopathy, 1 to have epilepsy, 1 to have macrocephaly, 1 to have Down´s Syndrome, and 1 to have genotype 48XXXX. In total, concommitant diseases were found in 26 children (72.2%) (table 1).
Table 1. Co-existing diseases.
|Co-existing diseases ||Number of children |
|Prematurity ||7 |
|Anomaly of facial skeleton, macrocephaly ||3 |
|Congenital heart disease, cardiomiopathy ||4 |
|Intracerebral haemorrhage, epilepsy, infantile
cerebral palsy ||9 |
|Hypothyreosis ||1 |
|Chromosomal abnormalities ||2 |
|Total ||26 |
The most common location of stenosis was the subglottis in 23 cases, followed by the upper cervical trachea with 7 cases, stenosis at the glottis in 2 children, and 4 were found to have stenosis at both glottis and subglottis levels (table 2).
Table 2. Location of stenosis.
|Location ||Number of children |
|Subglottis ||23 |
|Upper cervical trachea ||7 |
|Glottis ||2 |
|Multilevel stenosis (glottis and subglottis) ||4 |
The degree of stenosis was – 4th degree, 8 cases; 3rd degree, 14 cases; 2nd degree, 8 cases, and 1st degree, 6 cases (table 3).
Table 3. Degree of stenosis.
|Degree of stenosis ||Number of cases |
|4 ||8 |
|3 ||14 |
|2 ||8 |
|1 ||6 |
In 15 cases a silastic separator was used, and a T- tube in 18. A separator was not used in 13 cases. The range of intralaryngeal incisions was from 1 to 30, with an average of 5. The separator was retained for from 2 to 21 days, with an average of 16. In 6 cases general sterydotherapy (Encortone or Hydrocortisone) was applied. After cicatricotomy in the larynx and during the period of use of a separator, pneumonia was recognised in 4 cases, upper respiratory tract infection in 4, pneumothorax in 1, and in several cases vomiting required changing of the separator fixing.
Among the 36 diagnosed or treated children, 21 were decannulated, 3 died, 4 are still under treatment, and we have no information on 8 of them.
Decannulation was carried out at between 1 month and 4 years after recognition of stenosis and after tracheotomy, with an average time of 14.5 months.
In the group with 1st or 2nd degree laryngeal stenosis there was an average of 1.8 incisions, and the treatment time was an average of 7.6 months. In the 3rd degree group there was an average of 2.9 incisions, and a treatment time of 17 months. In the 4th degree group, the average number of incisions was 11.3, and treatment lasted for an average of 30 months (table 4).
Table 4. Results.
|Degree of stenosis ||Number of cases ||Average time of treatment (months) ||Average number of incisions ||Number of decannulations ||Notes |
|1 and 2 ||14 ||7.6 ||1.8 ||12 (86%) ||1 death |
|3 ||14 ||17 ||2.3 ||7 (50%) ||3 children in the process of treatment, 1 death |
|4 ||8 ||30 ||11.3 ||2 (28%) ||1 child in the process of treatment, 1
Of the 36 children with laryngeal stenosis, 21 (58.3%) were decannulated, 3 (8.3%) died, 4 (11.1%) are still being treated, and there is no information concerning 8 (22.3%).
1. Intralaryngeal incision is an efficient method in the treatment of postintubation laryngeal stenosis. It allowed the decannulation of 58.3% of cases.
3. Third or fourth degree stenosis was seen in 22 cases.
4. The most common area for postintubation laryngeal stenosis is the subglottal area.
5. In the 3rd and 4th degree groups, the treatment is difficult and prolonged; 11.3 incisions and 30 months for 4th degree, 2.3 incisions and 17 months for 3rd degree.
6. In children with postintubation laryngeal stenosis we frequently find other coexisting general diseases, which have an effect on treatment and on the prognosis in relation to the health of the child.
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