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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 ...

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