Skip to Main Content

++

YOUR PATIENT

++

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.

++

PREOPERATIVE CONSIDERATIONS

++

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.

++

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.

++

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.

++

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.

++

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.

++

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.

++

ANESTHETIC MANAGEMENT

++

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.

++

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

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.