The Treatment of Low Retrosternal Tracheal Stenosis in the Neonate and Small Children

Abstract

In the years 1979 to 1983, 8 infants or small children under 2 years of age were treated for severe low retrosternal (carinal) tracheal stenosis. The etiology was iatrogenic (postintubation) in 7 cases and congenital in one. Low tracheal stenosis was seen in 0.4% of all intubated (1607 patients) neonates during the same time period. In 6 cases of acute obstruction, diagnostic bronchoscopy was used to relieve the stenosis by forcefully dilating the trachea. One patient died and all had severe complications, but 3 children are living and doing well without further treatment. Only short granular retrosternal stenoses appeared to be suitable for violent dilatation, which is indicated if the patient is otherwise facing death due to suffocation. All other operative facilities must be at hand. Resection of low retrosternal trachea under cardiopulmonary bypass was performed in 4 patients - 2 of them had had earlier unsuccessful dilatations. One patient, aged 1.5 months, died. In this case the obstruction extended into both bronchi. Another patient was re-resected with success. The follow-up time of the 3 living patients with resection is already 2.4, 4.5 and 4.7 years respectively. The patients are living a normal life and the anastomoses are growing normally.

Vascular Tracheobronchial Compression Syndromes - Experience in Surgical Treatment and Literature Review1 -

“…The crucial importance of intraoperative endoscopic monitoring of airway decompression and its effectiveness has been emphasized in several reports [1,2,14,24,26]. It has been applied in all cases of this report (using either rigid or flexible instruments) and was certainly facilitated in the cases under ECC conditions: It permitted, after pulling back the tube for the necessary time, inspection of all accessible airway portions during the different surgical manoeuvres.…”

“…In the context of the known immaturity of the tissue of an infant-type airway wall, compression-induced cartilage destruction and malacia have been observed to appear even within weeks [16]. Early correction is also reported to allow for normal tracheobronchial growth especially in situations of tube or tracheostomy dependency [3,14,16,24,26].…”

“…Several authors have reported on their experience with concomitant repair of cardiac defects and vascular tracheobronchial compression syndromes which, in combination, carry a higher risk of morbidity and mortality concerning natural and surgical history [1 ± 3,14, 31, 42]. Structural and functional immaturity of the cardiovascular, pulmonary, and airway systems, with their respective interdependecy, may explain that pathologic hemodynamics on top of obstruction of a small-dimension airway with its known particular mucosal reactivity leave very low margins for compensatory mechanisms, especially in respiratory tract infections [1,26,36,37]. In this context, the extreme friability and mucosal reactivity of the neonatal airways which have been reported by several authors [1,15,26,28,34,36,37], were also observed in one of our patients (case 9) with low tracheal compression in pulmonary sling who died of intractable tracheal mucosal edema shortly after successful airway decompression.…”

Vascular airway compression management in a case of aortic arch and descending thoracic aortic aneurysm

“…The crucial importance of intraoperative bronchoscopic monitoring of airway decompression and its effectiveness has been emphasized in several reports. [ 11 12 13 ] Flexible bronchoscope facilitated inspection of all the accessible airway portions, assessment of endoluminal tissue properties of the airway wall, and effective direct clearing of retained secretions after decompression.…”