49 Laryngotracheal Revision Surgery in Children Major reconstructive procedures on the airway, such as laryngotracheal reconstruction, will not always provide a good airway without any further therapy. It is important for the discussion to distinguish between the “usual cares” which are considered to be adjunctive measures and failures or postoperative problems that need revision surgery. The aim of this chapter is to describe failures and revision surgery. Many pathologies such as laryngeal dyskinesia and vocal cord paralysis (in neonates), or subglottic stenosis, subglottic hemangioma, and even tumors (in children), can be responsible of laryngeal dyspnea. This chapter is devoted to examining this particular problem in the revision management of pediatric subglottic stenosis, which is the most frequent pathology needing a revision surgical procedure. Even in the hands of the most experienced surgeons, primary laryngotracheal surgery can result in a less than satisfactory outcome in the short term with respect to the correction of the airway. Failure in the correction of the laryngotracheal lumen after primary laryngotracheal reconstruction by an external or endoscopic approach or the reappearance of a dyspnea following a successful surgery results in the option to perform laryngotracheal revision surgery. Short- and long-term failures occur despite a multitude of improvements and refinements that have been accomplished in pediatric laryngotracheal surgery since its inception. The goals of laryngotracheal surgery in children are to eliminate primary disease, choose the best operative procedure for the individualized case to prevent recurrent disease, restore the theoretical airway diameter, andrestore serviceable voice and feeding. When surgery for a laryngotracheal pathology fails, it usually can be ascribed to either improper selection of the technical procedure and/or technical failures or improper preoperative evaluation. Gastroesophageal reflux (GER) is a common occurrence in children,1 especially when they have a breathing problem.2 Experienced authors recommend reflux investigation and treatment before operating for subglottic stenosis.1,3,4 Antireflux treatment is always given before and after laryngeal surgery because, first, reflux is very common, and, second, it has been shown that patients with uncontrolled GER have a higher rate of failure in laryngotracheal reconstruction.4 It is very important to determine the patient’s nutritional status prior to revision surgery. Several postoperative complications, such as healing defects, often occur in malnourished children. In all cases, topical steroids given by aerosol technique and antimicrobial agents (oral or intravenous) are used postoperatively, as proposed by several authors.4 At the present time, laryngotracheal reconstruction via augmentation with graft cartilage is the mainstay of treatment. Cricotracheal resection is becoming the alternative option for managing subglottic stenosis. For Ochi et al, in a 10-year experience, ~30% of laryngotracheal reconstruction cases required revision surgery to achieve decannulation, implying that insufficient airway was obtained.3 The various problems that can occur after reconstruction procedures will be evaluated from the less to the most important. For each one, prevention and management will be described. Granulomas are very usual and can be considered as one of the events that need further therapy in the initial plan. They often occur in the suprastomal region and can interfere with decannulation. Many factors can induce granulomas. Whatever the surgical procedure—cricotracheal resection or laryngotracheal reconstruction—suturing has to be performed under the mucosa. The use of stenting can generate granulomas because the stent represents a foreign object. In most cases, granulomas are caused by the vocal cords or false cords trying to close over the stent. The same phenomenon can occur if the epiglottis is scarred. Long-term stenting has to be placed through the false and true vocal cords without contact with the epiglottis. When possible, it is better to perform a single-stage procedure because of need for short-term stenting. Granulomas can be treated by surgical removal with or without mitomycin-C in topical agents.1,5 This product is an antineoplastic antibiotic that acts as an alkylating agent by inhibiting deoxyribonucleic acid (DNA) and protein synthesis. Surgery can be performed under telescope or microscope with microsurgical instruments or laser. In children, potassium titanyl phosphate (KTP) laser has been used successfully and easily with 400 μm fiber and 0-degree telescope.6 This procedure allows for very precise removal in anatomical regions that are often difficult to reach. Mitomycin-C is used by topical application of a 20% solution in saline during 2 to 4 minutes at the surgical site. Tracheocutaneous fistulas are frequent but minor problems in the epithelialization of the tracheostomy tract. Tracheocutaneous fistulas occur in ~50% of patients with tracheotomy, but most of them have been decannulated in the third year.7 Preventing fistulas requires short-term tracheotomy when possible, along with occlusive and compressive bandaging after decannulation. For this period, the child is restricted from swimming, and parents have to be careful during bathing. Surgical closure is indicated if the fistula persists 6 months after decannulation.7 It begins with removal of the epithelialized tract from the skin to the trachea. The tracheal opening is sutured, and subhyoidian muscles are stitched to each other on the midline. The skin is sutured. A compressive bandage is then made.
General Considerations
Subglottic Stenosis Revision Surgery
Granulomas
Prevention
Treatment
Tracheocutaneous Fistulas
Prevention
Treatment
Suprastomal Collapse
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