Partial Cricotracheal Resection for Severe Pediatric Subglottic Stenosis: Update of the Lausanne Experience

Abstract

Until recently, severe pediatric subglottic stenosis (SGS) has been treated almost exclusively by laryngotracheoplasty procedures. Even in the most experienced centers, the results of single-stage operations for Cotton's grade III and IV stenoses have been disappointing. This paper reports our experience on 31 partial cricotracheal resections for severe SGS in infants and children. The stenosis was congenital in 6 cases and acquired after prolonged intubation in 25 cases. Twenty-seven patients were tracheotomy-dependent at the time of surgery. Twenty-two cases were classified as grade III and 9 cases as grade IV stenoses according to Cotton. The decannulation rate was 97% (30 of 31 cases) after an open procedure. There were no fatalities and no lesions to the recurrent laryngeal nerves, but there was 1 complete restenosis. Twenty-seven patients show no exertional dyspnea, 3 have a slight stridor with some dyspnea while exercising, and 1 patient is not decannulated. The voice is normal in 21 cases, a dysphonia is present in 9 cases, and the patient with complete restenosis acquired an esophageal voice. Postoperative follow-up is longer than 10 years in 8 cases and longer than 5 years in an additional 6 cases. All patients who reached adulthood show normal growth of the larynx and trachea. Considering the excellent results obtained in this consecutive series of 31 cases, partial cricoid resection with primary thyrotracheal anastomosis should be considered an important treatment option for severe SGS in infants and children.

Slide thyrocricotracheoplasty for the treatment of high-grade subglottic stenosis in children

“…In the last patient (patient 5), the primary problem was not with the anastomosis but rather resulted from luminal bulging growth of granulation tissue growing from the closed site of the previous tracheostomy. Thus, although the number of patients in our series was small, the anastomosis was found to be intact in all patients with the exception of one (MRSA infection) and the overall decannulation rate was 100% after slide thyrocricotracheoplasty, which is actually higher than other series reporting postoperative decannulation rate in patients with high-grade SGS [9,[13][14][15][16][17]. This high success rate of overall decannulation in our study can be explained by several advantages specific to slide-type reconstruction.…”

Posterior cricoid split with costal cartilage augmentation for high subglottic stenosis

“…Most severe (Grade 3 and 4) stenosis of the trachea is associated with involvement of the cartilaginous framework, and for these, resection of the involved trachea with end-to-end anastomoses of the residual trachea is currently the standard of care [2,4]. The option of Resection-Anastomosis can also be extended to lower subglottic stenosis, wherein the lower cricoid lamina and the cricoid arch are included in the resection [3].…”

Single-stage tracheal resection for severe tracheal stenosis in older children

“…This feeling had stemmed from concern over possible injury to the recurrent laryngeal nerves, negative effects on laryngotracheal growth, and the overall complexity of the procedure. Recent series have disproven this notion, as CTR has been performed with success in the pediatric age group [8,9]. Indeed, CTR has become the preferred treatment method for children with severe type III and type IV stenosis [10,11] as long as the margin of resection is adequately below the free glottic edge [12].…”