Principles of surgical treatment of chronic post-intubation laryngotracheal stenosis in childhood

Abstract

Introduction: Post-intubation stenosis of the larynx and trachea in childhood increases annually. This is associated with an increasing number of children with severe pathology of the upper respiratory tract, as well as children requiring artificial ventilation for other reasons. Until now there have been debatable questions about surgical tactics in children with chronic cicatricial laryngeal stenosis. Aim: The aim of this article is to evaluate the effectiveness of different tactics of surgical treatment of children with chronic cicatricial post-intubation stenosis of the larynx, depending on the state of the cartilaginous frame of the larynx. Materials and Methods: We have treated 47 children with chronic cicatricial post-intubation stenosis of the larynx. Preoperative examination included endoscopy and computed tomography of the larynx and trachea. We assessed the cartilaginous framework of the larynx and trachea that influenced the choice of surgical approach. For 20 children with intact laryngeal cartilaginous frame the method of endolaryngeal microsurgery using a CO2 laser was applied. This method allowed to form a wound surface by minimum submucosal resection scar tissue, which made it possible to cover the wound with mucosal microflaps to prevent restenosis. In the surgical treatment of extended stenoses of the middle larynx, there are prerequisites for repeated replacement of the wound with excess scar tissue, which in our observations was avoided by using endoprostheses for a period of 21 days. Despite it, with a lesion of the subglottic part of the larynx, the risk of restenosis remained quite high (5 out of 12 patients), even in the absence of data for damage to the cartilaginous frame of the larynx. In 27 cases of chronic post-intubation cicatricial stenosis of the larynx, in identifying of laryngeal cartilage framework lesion before surgery, extralaryngeal laryngotracheoplasty was performed. Laryngofissure was performed in 18 children, followed by stenting from 6 to 18 months with a T-shaped silicone stent, in 9 cases—one-stage laryngotracheoplasty using auto-cartilage grafts. The applied techniques have shown high efficiency, while the use of autografts made it possible to reduce the stages and duration of surgical treatment. Conclusion: The use of a CO2 laser in combination with balloon laryngoplasty in microsurgical treatment of chronic post-intubation stenosis of the larynx in children significantly expands surgical capabilities due to high accuracy and low level of damage of surrounding tissues.