Single-stage laryngotracheal reconstruction for the treatment of subglottic stenosis in children

Int. Arch. Otorhinolaryngol. 2012;16(2):217-221. DOI: 10.7162/S1809-97772012000200010 Original Article Single-stage laryngotracheal reconstruction for the treatment of subglottic stenosis in children Reconstrução laringotraqueal em único estágio para tratamento de estenose subglótica em crianças Mariana Magnus Smith1, Cláudia Schweiger2, Denise Manica3, Camila Degen Meotti4, Larissa Valency Eneas5, Gabriel Kuhl6, Paulo Jose Cauduro Marostica7. 1) Master. Medical Residency Preceptor of Otolaryngology of Hospital São Lucas of PUCRS / Sao Lucas Hospital of PUC/RS - Catholic University, Rio Grande do Sul State, Brazil. 2) Master. Medical Residency Preceptor of Otolaryngology of Hospital de Clínicas of Porto Alegre/Clinical Hospital of Porto Alegre, Rio Grande do Sul State, Brazil. 3) Otolaryngologist. Fellowship in Laryngology of Hospital de Clínicas of Porto Alegre/ Clinical Hospital of Porto Alegre, Rio Grande do Sul State, Brazil. 4) Otolaryngologist. Fellowship em Rhinology of Hospital de Clínicas of Porto Alegre/ Clinical Hospital of Porto Alegre, Rio Grande do Sul State, Brazil. 5) Otolaryngologist. Medical Residency Preceptor of Otolaryngology of Hospital São Lucas of PUCRS/ Sao Lucas Hospital of PUC/RS - Catholic University, Rio Grande Do Sul State, Brazil. 6) Otolaryngologist. Professor of Otolaryngology and Ophthalmology Department of UFRGS. Medical Residency Preceptor of Otolaryngology of HCPA- Clinical Hospital of Porto Alegre. 7) Post-Ph.D. Professor of Pediatrics Department of UFRGS - Federal University of Rio Grande do Sul State. Medical Residency Preceptor of Pediatrics of HCPA - Clinical Hospital of Porto Alegre. Institution: Hospital of Clinicas de Porto Alegre. Porto Alegre / RS – Brazil. Mailing address: Cláudia Schweiger - Ramiro Barcelos Street, 2350 - Zona 19 - Porto Alegre / RS - Brazil - Zip-code: 90035-903 - E-mail: Article received in September 7, 2011. Article approved in October 12, 2011. SUMMARY RESUMO Introduction: In recent decades, airway reconstruction has become the treatment of choice for subglottic stenosis (SGS) in children, which is performed in either single or multiple stages. However, there is evidence in the literature that singlestage surgery is more effective. Objective: To evaluate the success rate of single-stage laryngotracheoplasty (LTP) and cricotracheal resection (CTR) in patients that were treated in our hospital. Materials and Method: We performed a retrospective study of children undergoing laryngotracheal reconstruction. Results: Twenty-four children were included. The etiology of SGS was postintubation in 91.6% and congenital in 8.3%. One patient (4.2%) had grade 4 SGS, 17 (70.8%) presented with grade 3 SGS, 4 (16.6%) had grade 2 SGS, 1 (4.2%) had grade 3 SGS associated with glottic stenosis, and 1 (4.2%) had grade 3 SGS with tracheal stenosis. We performed 26 LTPs and 3 CTRs. Decannulation rates were 66% in the CTR procedures and 85.7% in the LTP procedures; the overall decannulation rate was 83.3%. All children presented with fever in the postoperative period, but were afebrile after the tube was removed. Conclusion: Our series showed a decannulation rate of 83.3%. Keywords: larynx, child, laryngostenosis. Introdução: Nas últimas décadas, a reconstrução da via aérea tornou-se o tratamento de escolha para estenose subglótica (ESG) na criança, realizada em único ou múltiplos estágios. Há indícios na literatura de que a cirurgia em um só tempo é mais efetiva. Objetivo: Avaliar o índice de sucesso da laringotraqueoplastia (LTP) e ressecção cricotraqueal (RCT) em único estágio nos pacientes tratados no nosso hospital. Método: Estudo retrospectivo de crianças submetidas à reconstrução laringotraqueal. Resultados: Foram incluídos 24 pacientes. As causas da ESG foram pós-intubação endotraqueal em 91,6% e congênita em 8,3%. Diagnosticamos ESG grau 4 em 1 paciente (4%), grau 3 em 16 (66,6%), grau 2 em 4 (16,6%), grau 3 associada com estenose glótica em 1 (4%), grau 3 associada com estenose traqueal em 1 (4%). Foram realizadas 26 LTP e 3 RCT. O índice de decanulação foi de 66% nos pacientes submetidos à RCT e de 85,7% nos pacientes submetidos à LTP; o índice total de decanulação foi de 83,3%. Todos apresentaram febre persistente no pós-operatório, que cessou após a extubação. Conclusão: Nossa série mostrou índice de decanulação de 83,3%. Palavras-chave: laringe, criança, laringoestenose. Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.2, p. 217-221, Apr/May/June - 2012. 217 Single-stage laryngotracheal reconstruction for the treatment of subglottic stenosis in children. INTRODUCTION Over the last 3 decades, airway reconstruction has become the treatment of choice for subglottic stenosis (SGS) in children. Two surgical procedures are commonly used in the management of SGS: laryngotracheoplasty (LTP), in which a cartilage graft is used to expand the luminal diameter of the airway, and cricotracheal resection (CTR), in which the stenosed segment is resected and an end-to-end anastomosis is performed. LTP was first described by EVANS and TODD (1) in 1974, but gained popularity with Cotton in the late 70s with the widespread use of costal cartilage grafts (2). CTR is the preferred option for children with severe stenosis (MyerCotton grades III and IV) (3). Laryngotracheal reconstruction can be performed at a single stage, using the endotracheal tube (ETT) as a temporary stent after surgery, or in multiple stages, with a tracheostomy inserted (if not already in place) to safeguard the airway postoperatively. There is evidence in the literature that the single-stage procedure is more effective, as the ETT is used as a stent of the airway, which also helps to prevent obstructive granulation (10,11). Single-stage laryngotracheal reconstruction has become a worldwide trend, and it is our treatment of choice for patients undergoing open surgery for SGS. Our aim was to evaluate the success rate of singlestage LTP and CTR procedures that were performed in pediatric patients in our hospital, to describe the characteristics of our sample, and to compare our results to those reported in the literature. METHOD We performed a retrospective study by reviewing the medical records of patients who underwent laryngotracheal reconstruction in the period between June 2005 and November 2009. We included all pediatric patients with laryngeal and/or proximal tracheal stenosis who underwent a single-stage procedure. The project was approved by the Ethics Committee of our hospital (approval #09-568). The data were analyzed with PASW 17.0. Below, we describe the procedures in detail. Single-stage LTP Patients were intubated, unless a tracheostomy tube Smith et al. was present, in which case they were ventilated through the tracheostomy during surgery. Patients were positioned in cervical hyperextension, and the operative sites (anterior cervical region and costal cartilage) were infiltrated with a 1% lidocaine solution containing (...truncated)