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YOUR PATIENT

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A 4-year-old male with congenital subglottic stenosis and a tracheotomy presents for laryngotracheal reconstruction. He has inspiratory and expiratory stridor that is always present.

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PREOPERATIVE CONSIDERATIONS

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Congenital subglottic stenosis results from embryologic failure that includes laryngeal atresia, stenosis, and webs. In its mildest form, congenital subglottic stenosis shows a normal-appearing cricoid with a smaller-than-average diameter, usually with an elliptical shape. Infants and children with mild subglottic stenosis may present with a history of recurrent upper respiratory infections, often diagnosed as croup, in which minimal glottic swelling precipitates airway obstruction. The location of the stenosis is usually 2-3 mm below the true vocal cords.

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Severe congenital subglottic stenosis can be a life-threatening airway emergency that manifests immediately after the infant is delivered. Tracheotomy at the time of delivery can be lifesaving.

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Neonatal subglottic stenosis that is unresponsive to nonoperative therapy may require tracheotomy or an anterior cricoid split procedure. After tracheotomy and without an endotracheal tube to act as a stent, the stenosis may become more severe. Over the next few years, the airway may heal, allowing for decannulation, but laryngotracheal reconstructive (LTR) surgery may be necessary to allow for decannulation.

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The five stages of laryngotracheal reconstruction are characterization of the stenosis, expansion of the tracheal lumen, stabilization of the framework, healing of the airway, and decannulation.

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An anterior cartilage graft with a tracheotomy left in place without a stent is indicated primarily for an isolated anterior subglottic stenosis with no or relatively mild posterior subglottic components. A variation of this procedure is to remove the tracheotomy at the time of surgery and perform a single-stage laryngotracheoplasty. Posterior division of the cricoid plate and the introduction of a cartilage graft between the cut ends are indicated particularly for children with persistent posterior glottic pathology or primarily posterior subglottic pathology.

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Single-stage LTR uses cartilage grafts to provide stability for the reconstructed airway. Single-stage LTR may include an anterior cartilage graft, a posterior cartilage graft, or both, and reconstruction often includes a cartilage graft at the former stoma site. The grafts are supported temporarily by a full-length endotracheal tube fixed in position through the nasal route. Children usually remain intubated for 7-10 days for anterior cartilage grafts alone, and for 12-14 days if a posterior and anterior graft is required.

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ANESTHETIC MANAGEMENT

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The patient may be anesthetized by the intravenous route or with inhalation anesthesia through a tracheotomy cannula. The patient is placed in the tracheotomy position with the shoulders elevated and the neck hyperextended. A tracheotomy tube is replaced with a sterile cuffed armored (anode) endotracheal tube through the tracheostomy stoma and is covered under an adhesive drape to minimize contamination of the surgical field.

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An auricular or septal rib cartilage is used for grafting. Toward the conclusion of surgery, the ...

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