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Cricoid split for acute subglottic injury in the older child
International Journal of Pediatric Otorhinolaryngology 76 (2012) 1017–1019
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Cricoid split for acute subglottic injury in the older child M.M.C. Yaneza *, H. Kubba, D.M. Wynne, W.A. Clement Department of Paediatric Otolaryngology, The Royal Hospital for Sick Children, Dalnair Street, Yorkhill, Glasgow G3 8SJ, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 January 2012 Received in revised form 21 March 2012 Accepted 24 March 2012 Available online 24 April 2012
Objectives: To describe our experience of cricoid split in the older child for acquired subglottic stenosis secondary to chemical or thermal burns. Methods: A retrospective case series. Results: We describe two patients, both two years old, who benefitted from the procedure and had a return to a normal-sized airway. Neither child required a tracheostomy or further airway intervention after the cricoid split. Conclusions: Laryngotracheal reconstruction (LTR) is the standard treatment for subglottic injuries with associated subglottic stenosis in children, infants and (where possible) neonates. We have found the cricoid split a useful technique in carefully selected older children with acute subglottic injury and associated early subglottic stenosis, where LTR or ballooning is not feasible, where there is limited experience of ballooning, and/or ballooning has failed in the early stages of treatment. Cricoid split is a technique that is part of the airway surgeon’s open operative repertoire and therefore should be remembered as a management option. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Airway obstruction Burns Cricoid cartilage Child Preschool Laryngostenosis
1. Introduction Laryngotracheal reconstruction (LTR) is the standard treatment for subglottic injuries with associated subglottic stenosis in children, infants and (where possible) neonates [1]. We have found the cricoid split a useful technique in carefully selected older children with acute subglottic injury and associated early subglottic stenosis, where LTR is not feasible. The feasibility of LTR is limited when graft material is not available due to torso injuries, or there is the potential for grafting on to necrotic cartilage due to the mechanism of injury (i.e. acute airway, thermal or chemical, burns). The cricoid split procedure was classically described for neonates, particularly those born preterm, with acquired subglottic stenosis due to endotracheal intubation. The cricoid split is performed via an external approach, opening the lower half of the thyroid cartilage, the cricoid and the first one or two tracheal rings anteriorly in the midline to relieve pressure on the mucosa from the endotracheal tube, thus allowing oedema and ulceration to heal. The posterior cricoid ring may also be split. The infant is usually kept intubated for a further week after the procedure. The procedure has a good success rate, with 27–84% of neonates being successfully extubated and avoiding further intervention such as tracheostomy [2–6]. We describe two patients, both two years old,
* Corresponding author. E-mail address: [email protected] (M.M.C. Yaneza). 0165-5876/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2012.03.022
who benefitted from the procedure and had a return to a normalsized airway. Neither child required a tracheostomy or further airway intervention after the cricoid split.
2. Patients 2.1. Case 1 A two year old girl suffered a scald injury to 33% of her total body surface area. She was intubated on the day of injury with a size 4.0 endotracheal tube, but then extubated 24 h later because there were no concerns regarding her airway and no oedema was noted on laryngoscopy. The burns covered her neck, right arm, chest and abdomen. She developed stridor 8 days after the injury, and 2 days after that (10 days after the scald injury) she underwent a microlaryngoscopy and bronchoscopy. This revealed 50% circumferential subglottic stenosis (Fig. 1), more severe posteriorly than anteriorly. The operating surgeon felt that a laryngeal reconstruction with costal cartilage grafts might have been the optimal management in other circumstances, but the burns to the chest wall precluded graft harvest. The decision was therefore taken to proceed immediately to an external approach anterior and posterior cricoid split as a means of potentially avoiding tracheostomy. She remained intubated for one week and had a successful trial of extubation on day 17 after the initial scald injury. A follow-up microlaryngoscopy and bronchoscopy one week after her cricoid split revealed no stenosis. She was successfully
1018
M.M.C. Yaneza et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1017–1019
Fig. 1. First microlaryngoscopy and bronchoscopy of a child with a scald injury. 50% circumferential subglottic stenosis is noted, more severe posteriorly than anteriorly. Fig. 3. Return of pinhole lumen after balloon dilatation of soft stenotic areas in a child who inhaled a ‘‘liquitab.’’.
discharged one month after the initial injury with no further ENT problems. 2.2. Case 2 A two year old boy ingested and inhaled a caustic laundry detergent ‘‘liquitab’’. On arrival to the accident and emergency department he had stridor and increased work of breathing and was intubated. He was noted to have an erythematous epiglottis with mild oedema and a flexible endoscope was passed through the endotracheal tube to reveal a normal trachea. One week after the chemical injury the boy underwent a microlaryngoscopy and bronchoscopy. This revealed a normal supraglottis, oedema at the anterior commissure occluding 50% of the airway, and oedema and ulceration of the subglottis with exposed cartilage (Fig. 2). A soft stenosis was present at two levels in the subglottis, each narrowing to a pinhole. The trachea and bronchi were normal. Balloon dilatation of the soft stenotic areas was performed twice but the stenosis recurred within one minute of deflating the balloon each
time (Fig. 3). The patient was re-intubated with a size 4.0 endotracheal tube. 11 days after the chemical airway burn the boy underwent a microlaryngoscopy and external approach anterior cricoid spilt. Vocal cord granulations were also removed from the vocal cords using a microdebrider. The patient was re-intubated with a follow-up microlaryngoscopy and bronchoscopy planned for one week after the procedure. He developed a leak around the endotracheal tube two days before the planned microlaryngoscopy. One week after the cricoid split, the microlaryngoscopy revealed a normal diameter airway (Fig. 4) and he was successfully extubated. He underwent a further microlaryngoscopy two weeks after the cricoid split due to increased work of breathing and oxygen desaturation. There was mild posterior glottic stenosis, a good subglottic airway and copious secretions in the trachea. The respiratory symptoms were therefore attributed to infection, which was successfully managed with antibiotics. He was discharged home 26 days after the initial chemical injury with no further ENT symptoms. 3. Summary of post-operative course Both patients underwent a period of airway rest and medical therapy (steroids) before the cricoid split. Both patients had the
Fig. 2. First microlaryngoscopy and bronchoscopy of a child who inhaled a ‘‘liquitab’’. Oedema of the anterior commissure occluding 50% of the airway, and oedema and ulceration of the subglottis with exposed cartilage is present.
Fig. 4. Subglottis of a child who had inhaled a ‘‘liquitab,’’ one week after an anterior cricoid split. The airway has returned to a normal diameter.
M.M.C. Yaneza et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1017–1019
operation between 10 and 11 days after the initial injury and were intubated for a further week after the procedure before a trial of extubation occurred. Both trials of extubation were successful and neither child required a tracheostomy or further interventional procedures. Surveillance microlaryngoscopy procedures were performed one week after the cricoid split and revealed no significant mucosal oedema or scarring restricting the airway. 4. Discussion The cricoid split is an operation that has been well-described for acquired subglottic stenosis in neonates. We have found the operation to also be useful in the older child with an acquired airway injury. Cricoid spit is classically performed in early oedematous subglottic stenosis (usually secondary to prolonged or repeated intubation) [2–6]. Indeed, Cotton et al. [4] declared that ‘‘specifically this operation should be restricted to neonates or young infants whose pathology is limited to the glottis and subglottis or both, and in whom there is adequate pulmonary reserve’’ and ‘‘the anterior cricoid split procedure was viewed as an alternative to tracheostomy in the neonate in whom extubation was not possible because of non-fibrotic subglottic pathology.’’ In our two cases we describe the operation’s use in the older child and in the acute, oedematous phase of subglottic stenosis. Cotton and Seid [7] and Hawkins [8] described the pathogenesis of subglottic stenosis in the intubated neonate. In the early phase there is oedema and mucosal haemorrhage. This is followed by mucosal ulceration and then cartilage exposure. Granulation tissue may form in the ulcers and then be replaced by collagen tissue which may epithelialize. Perichondritis may result in submucosal fibrosis and cartilage thickening. Burns (including chemical and thermal) also cause oedema as a coagulative necrosis occurs. This results in interstitial oedema as the capillary beds are disrupted and causes plasma to leak into the interstitium. The cricoid split may relieve subglottic stenosis via a number of mechanisms; (1) relieving pressure on the endotracheal tube which allows circulation to return to the mucosa and thus resorption of oedema [5], (2) draining of submucosal cysts and herniation of oedematous tissue within the loose areolar tissue when the tissue is incised [4], or by (3) the elastic properties of immature cartilage cause the incomplete cricoid to spring open [5]. Successful cricoid splits have been described in the older child previously [5,6] in only three patients; two 2-year olds and a
1019
5.5 year old. The reported indications for cricoid split in these three cases were to facilitate decannulation of a tracheostomy, for a severe episode of croup and for subglottic stenosis secondary to repeated intubations. The two cases we describe are the first described for these individual indications in the literature. Repeated endoscopic ballooning is a new technique for the treatment of both soft and firm subglottic stenosis [9,10] and has been used in neonates and infants who have not had an acute airway injury [9,10] but was unsuccessful in one of our patients. Optimal balloon pressures and sizes are yet to be determined in this new technique, and the grade of stenosis, as well as the age and size of the patient may affect the results. 5. Conclusion Cricoid split is a technique that has proved reliable in our hands. It is a technique that is part of the airway surgeon’s open operative repertoire and therefore should be remembered as a management option where LTR or ballooning is not feasible, where there is limited experience of ballooning, and/or ballooning has failed in the early stages of treatment. Conflict of interest None to declare. References [1] D.R. White, M. Bravo, S. Vijayasekaran, M.J. Rutter, R.T. Cotton, R.G. Elluru, Laryngotracheoplasty as an alternative to tracheotomy in infants younger than 6 months, Arch. Otolaryngol. Head Neck Surg. 135 (2009) 445–447. [2] J.A. Matute, M.A. Villafruela, M.D. Delgado, F.J. Berchi, J. Vazquez, Surgery of subglottic stenosis in neonates and children, Eur. J. Pediatr. Surg. 10 (2000) 286–290. [3] C.E. Bagwell, M.B. Marchildon, L.L. Pratt, Anterior cricoid split for subglottic stenosis, J. Pediatr. Surg. 22 (1987) 740–742. [4] R.T. Cotton, C.M. Myer 3rd, G.O. Bratcher, C.M. Fitton, Anterior cricoid split, 1977– 1987. Evolution of a technique, Arch. Otolaryngol. Head Neck Surg. 114 (1988) 1300–1302. [5] L.D. Holinger, J.A. Stankiewicz, G.L. Livingston, Anterior cricoid split: the Chicago experience with an alternative to tracheotomy, Laryngoscope 97 (1987) 19–24. [6] S. Palasti, D.S. Respler, R.J. Fieldman, J. Levitt, Anterior cricoid split for subglottic stenosis: experience at the Children’s Hospital of New Jersey, Laryngoscope 102 (1992) 997–1000. [7] R.T. Cotton, A.B. Seid, Management of the extubation problem in the premature child. Anterior cricoid split as an alternative to tracheostomy, Ann. Otol. Rhinol. Laryngol. 89 (1980) 508–511. [8] D.B. Hawkins, Hyaline membrane disease of the neonate prolonged intubation in the management: effects on the larynx, Laryngoscope 88 (1978) 201–224. [9] F. Durden, S.E. Sobol, Balloon laryngoplasty as a primary treatment for subglottic stenosis, Arch. Otolaryngol. Head Neck Surg. 133 (2007) 772–775. [10] N.E. Edmondson, J. Bent III, Serial intralesional steroid injection combined with balloon dilation as an alternative to open repair of subglottic stenosis, Int. J. Pediatr. Otorhinolaryngol. 74 (2010) 1078–1081.
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Cricoid split for acute subglottic injury in the older child M.M.C. Yaneza *, H. Kubba, D.M. Wynne, W.A. Clement Department of Paediatric Otolaryngology, The Royal Hospital for Sick Children, Dalnair Street, Yorkhill, Glasgow G3 8SJ, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 January 2012 Received in revised form 21 March 2012 Accepted 24 March 2012 Available online 24 April 2012
Objectives: To describe our experience of cricoid split in the older child for acquired subglottic stenosis secondary to chemical or thermal burns. Methods: A retrospective case series. Results: We describe two patients, both two years old, who benefitted from the procedure and had a return to a normal-sized airway. Neither child required a tracheostomy or further airway intervention after the cricoid split. Conclusions: Laryngotracheal reconstruction (LTR) is the standard treatment for subglottic injuries with associated subglottic stenosis in children, infants and (where possible) neonates. We have found the cricoid split a useful technique in carefully selected older children with acute subglottic injury and associated early subglottic stenosis, where LTR or ballooning is not feasible, where there is limited experience of ballooning, and/or ballooning has failed in the early stages of treatment. Cricoid split is a technique that is part of the airway surgeon’s open operative repertoire and therefore should be remembered as a management option. ß 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Airway obstruction Burns Cricoid cartilage Child Preschool Laryngostenosis
1. Introduction Laryngotracheal reconstruction (LTR) is the standard treatment for subglottic injuries with associated subglottic stenosis in children, infants and (where possible) neonates [1]. We have found the cricoid split a useful technique in carefully selected older children with acute subglottic injury and associated early subglottic stenosis, where LTR is not feasible. The feasibility of LTR is limited when graft material is not available due to torso injuries, or there is the potential for grafting on to necrotic cartilage due to the mechanism of injury (i.e. acute airway, thermal or chemical, burns). The cricoid split procedure was classically described for neonates, particularly those born preterm, with acquired subglottic stenosis due to endotracheal intubation. The cricoid split is performed via an external approach, opening the lower half of the thyroid cartilage, the cricoid and the first one or two tracheal rings anteriorly in the midline to relieve pressure on the mucosa from the endotracheal tube, thus allowing oedema and ulceration to heal. The posterior cricoid ring may also be split. The infant is usually kept intubated for a further week after the procedure. The procedure has a good success rate, with 27–84% of neonates being successfully extubated and avoiding further intervention such as tracheostomy [2–6]. We describe two patients, both two years old,
* Corresponding author. E-mail address: [email protected] (M.M.C. Yaneza). 0165-5876/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2012.03.022
who benefitted from the procedure and had a return to a normalsized airway. Neither child required a tracheostomy or further airway intervention after the cricoid split.
2. Patients 2.1. Case 1 A two year old girl suffered a scald injury to 33% of her total body surface area. She was intubated on the day of injury with a size 4.0 endotracheal tube, but then extubated 24 h later because there were no concerns regarding her airway and no oedema was noted on laryngoscopy. The burns covered her neck, right arm, chest and abdomen. She developed stridor 8 days after the injury, and 2 days after that (10 days after the scald injury) she underwent a microlaryngoscopy and bronchoscopy. This revealed 50% circumferential subglottic stenosis (Fig. 1), more severe posteriorly than anteriorly. The operating surgeon felt that a laryngeal reconstruction with costal cartilage grafts might have been the optimal management in other circumstances, but the burns to the chest wall precluded graft harvest. The decision was therefore taken to proceed immediately to an external approach anterior and posterior cricoid split as a means of potentially avoiding tracheostomy. She remained intubated for one week and had a successful trial of extubation on day 17 after the initial scald injury. A follow-up microlaryngoscopy and bronchoscopy one week after her cricoid split revealed no stenosis. She was successfully
1018
M.M.C. Yaneza et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1017–1019
Fig. 1. First microlaryngoscopy and bronchoscopy of a child with a scald injury. 50% circumferential subglottic stenosis is noted, more severe posteriorly than anteriorly. Fig. 3. Return of pinhole lumen after balloon dilatation of soft stenotic areas in a child who inhaled a ‘‘liquitab.’’.
discharged one month after the initial injury with no further ENT problems. 2.2. Case 2 A two year old boy ingested and inhaled a caustic laundry detergent ‘‘liquitab’’. On arrival to the accident and emergency department he had stridor and increased work of breathing and was intubated. He was noted to have an erythematous epiglottis with mild oedema and a flexible endoscope was passed through the endotracheal tube to reveal a normal trachea. One week after the chemical injury the boy underwent a microlaryngoscopy and bronchoscopy. This revealed a normal supraglottis, oedema at the anterior commissure occluding 50% of the airway, and oedema and ulceration of the subglottis with exposed cartilage (Fig. 2). A soft stenosis was present at two levels in the subglottis, each narrowing to a pinhole. The trachea and bronchi were normal. Balloon dilatation of the soft stenotic areas was performed twice but the stenosis recurred within one minute of deflating the balloon each
time (Fig. 3). The patient was re-intubated with a size 4.0 endotracheal tube. 11 days after the chemical airway burn the boy underwent a microlaryngoscopy and external approach anterior cricoid spilt. Vocal cord granulations were also removed from the vocal cords using a microdebrider. The patient was re-intubated with a follow-up microlaryngoscopy and bronchoscopy planned for one week after the procedure. He developed a leak around the endotracheal tube two days before the planned microlaryngoscopy. One week after the cricoid split, the microlaryngoscopy revealed a normal diameter airway (Fig. 4) and he was successfully extubated. He underwent a further microlaryngoscopy two weeks after the cricoid split due to increased work of breathing and oxygen desaturation. There was mild posterior glottic stenosis, a good subglottic airway and copious secretions in the trachea. The respiratory symptoms were therefore attributed to infection, which was successfully managed with antibiotics. He was discharged home 26 days after the initial chemical injury with no further ENT symptoms. 3. Summary of post-operative course Both patients underwent a period of airway rest and medical therapy (steroids) before the cricoid split. Both patients had the
Fig. 2. First microlaryngoscopy and bronchoscopy of a child who inhaled a ‘‘liquitab’’. Oedema of the anterior commissure occluding 50% of the airway, and oedema and ulceration of the subglottis with exposed cartilage is present.
Fig. 4. Subglottis of a child who had inhaled a ‘‘liquitab,’’ one week after an anterior cricoid split. The airway has returned to a normal diameter.
M.M.C. Yaneza et al. / International Journal of Pediatric Otorhinolaryngology 76 (2012) 1017–1019
operation between 10 and 11 days after the initial injury and were intubated for a further week after the procedure before a trial of extubation occurred. Both trials of extubation were successful and neither child required a tracheostomy or further interventional procedures. Surveillance microlaryngoscopy procedures were performed one week after the cricoid split and revealed no significant mucosal oedema or scarring restricting the airway. 4. Discussion The cricoid split is an operation that has been well-described for acquired subglottic stenosis in neonates. We have found the operation to also be useful in the older child with an acquired airway injury. Cricoid spit is classically performed in early oedematous subglottic stenosis (usually secondary to prolonged or repeated intubation) [2–6]. Indeed, Cotton et al. [4] declared that ‘‘specifically this operation should be restricted to neonates or young infants whose pathology is limited to the glottis and subglottis or both, and in whom there is adequate pulmonary reserve’’ and ‘‘the anterior cricoid split procedure was viewed as an alternative to tracheostomy in the neonate in whom extubation was not possible because of non-fibrotic subglottic pathology.’’ In our two cases we describe the operation’s use in the older child and in the acute, oedematous phase of subglottic stenosis. Cotton and Seid [7] and Hawkins [8] described the pathogenesis of subglottic stenosis in the intubated neonate. In the early phase there is oedema and mucosal haemorrhage. This is followed by mucosal ulceration and then cartilage exposure. Granulation tissue may form in the ulcers and then be replaced by collagen tissue which may epithelialize. Perichondritis may result in submucosal fibrosis and cartilage thickening. Burns (including chemical and thermal) also cause oedema as a coagulative necrosis occurs. This results in interstitial oedema as the capillary beds are disrupted and causes plasma to leak into the interstitium. The cricoid split may relieve subglottic stenosis via a number of mechanisms; (1) relieving pressure on the endotracheal tube which allows circulation to return to the mucosa and thus resorption of oedema [5], (2) draining of submucosal cysts and herniation of oedematous tissue within the loose areolar tissue when the tissue is incised [4], or by (3) the elastic properties of immature cartilage cause the incomplete cricoid to spring open [5]. Successful cricoid splits have been described in the older child previously [5,6] in only three patients; two 2-year olds and a
1019
5.5 year old. The reported indications for cricoid split in these three cases were to facilitate decannulation of a tracheostomy, for a severe episode of croup and for subglottic stenosis secondary to repeated intubations. The two cases we describe are the first described for these individual indications in the literature. Repeated endoscopic ballooning is a new technique for the treatment of both soft and firm subglottic stenosis [9,10] and has been used in neonates and infants who have not had an acute airway injury [9,10] but was unsuccessful in one of our patients. Optimal balloon pressures and sizes are yet to be determined in this new technique, and the grade of stenosis, as well as the age and size of the patient may affect the results. 5. Conclusion Cricoid split is a technique that has proved reliable in our hands. It is a technique that is part of the airway surgeon’s open operative repertoire and therefore should be remembered as a management option where LTR or ballooning is not feasible, where there is limited experience of ballooning, and/or ballooning has failed in the early stages of treatment. Conflict of interest None to declare. References [1] D.R. White, M. Bravo, S. Vijayasekaran, M.J. Rutter, R.T. Cotton, R.G. Elluru, Laryngotracheoplasty as an alternative to tracheotomy in infants younger than 6 months, Arch. Otolaryngol. Head Neck Surg. 135 (2009) 445–447. [2] J.A. Matute, M.A. Villafruela, M.D. Delgado, F.J. Berchi, J. Vazquez, Surgery of subglottic stenosis in neonates and children, Eur. J. Pediatr. Surg. 10 (2000) 286–290. [3] C.E. Bagwell, M.B. Marchildon, L.L. Pratt, Anterior cricoid split for subglottic stenosis, J. Pediatr. Surg. 22 (1987) 740–742. [4] R.T. Cotton, C.M. Myer 3rd, G.O. Bratcher, C.M. Fitton, Anterior cricoid split, 1977– 1987. Evolution of a technique, Arch. Otolaryngol. Head Neck Surg. 114 (1988) 1300–1302. [5] L.D. Holinger, J.A. Stankiewicz, G.L. Livingston, Anterior cricoid split: the Chicago experience with an alternative to tracheotomy, Laryngoscope 97 (1987) 19–24. [6] S. Palasti, D.S. Respler, R.J. Fieldman, J. Levitt, Anterior cricoid split for subglottic stenosis: experience at the Children’s Hospital of New Jersey, Laryngoscope 102 (1992) 997–1000. [7] R.T. Cotton, A.B. Seid, Management of the extubation problem in the premature child. Anterior cricoid split as an alternative to tracheostomy, Ann. Otol. Rhinol. Laryngol. 89 (1980) 508–511. [8] D.B. Hawkins, Hyaline membrane disease of the neonate prolonged intubation in the management: effects on the larynx, Laryngoscope 88 (1978) 201–224. [9] F. Durden, S.E. Sobol, Balloon laryngoplasty as a primary treatment for subglottic stenosis, Arch. Otolaryngol. Head Neck Surg. 133 (2007) 772–775. [10] N.E. Edmondson, J. Bent III, Serial intralesional steroid injection combined with balloon dilation as an alternative to open repair of subglottic stenosis, Int. J. Pediatr. Otorhinolaryngol. 74 (2010) 1078–1081.