See also: Laryngotracheal Reconstruction with Costal Cartilage Grafting; The Evaluation of Stridor in Pediatric Patients

Click for VIDEO: https://www.youtube.com/watch?v=j38wdG1sZt0&feature=youtu.be

Indications

• For symptomatic grade 1, 2 and some grade 3 sublgottic stenosis
• Two or fewer laryngotracheal units involved
• Good pulse oximetry
• No recent oxygen or ventilator requirement

Contraindications

• Ventilator-dependence
• Poor pulmonary status
• Poor overall condition
• Anesthesia related contraindications
• Severe reflux (relative contraindication)

**No minimum age or weight requirements for laryngotracheal reconstruction

Preoperative Preparation

Evaluation

• Complete history and physical examination
• Flexible fiberoptic laryngoscopy
• Diagnostic laryngoscopy, bronchoscopy

Consent

• Description of procedure
• Explain possible complications
  • Bleeding
  • Complications related to general anesthesia
  • Graft dislodgment
  • Need for tracheotomy
  • Hypoxic injury
  • Pneumothorax/pneumomediastinum from graft harvest
  • Loss of airway / ventilation issues
  • Inadvertent separation of trachea with retraction of distal trachea into chest
  • ETT obstruction
  • Accidental extubation
  • Glottic edema
  • Wound dehiscence / infection
  • Airway obstruction post-extubation
  • Death

Medications

• 0.5% Lidocaine with 1:100,000 Epinephrine

Positioning

• Supine position with shoulder roll, donut jelly, and eye protection
• Turn table 90° for DL and B
• Turn bed back towards anesthesia side for ssLTR with anterior costal cartilage graft

Prep and Drape

• Insert foley catheter
• Prep from the lip to the naval
• Drape to separate the chest and neck incisions
• Please see video for details

Drains and Dressings

• Quarter inch Penrose drains x 2
• 4x4 gauze pack
• Medium size Tegaderm transparent dressing x 2
• Dermabond skin glue

Anesthesia Considerations

• Well communication and coordination with the anesthesia team
• General anesthesia for induction and bag mask ventilation to maintain spontaneous respiration
• Direct laryngoscopy and bronchoscopy to reassess the grade, location, and length of airway stenosis
• Size the airway using cuffless pediatric ETT to age appropriate expected ETT. Assess air leak. If leak present with <10cm H20, upsize tube. If between 10-25 cmH20, compare to expected ETT. If >25 cmH20, downsize tube.
• Balloon dilation according to grade of stenosis (e.g. 5, 7 dilators)
• Nasal endotracheal intubation

Procedure

Costal cartilage graft harvest

• A skin marker to plan a 4.5cm incision 1.5cm below the right nipple
• 0.5% Lidocaine mixed with 1:100,000 Epinephrine is injected to the incision site

• Aim to harvest the right 5th costal cartilage
• A 15 blade to make a 4.5 cm right chest incision through subcutaneous tissue
• Monopolar cautery to dissect through pectoralis major and serratus anterior and reveal the cartilaginous portion of the right rib
• Bipolar cautery to remove the attachments of the external intercostals inferior and superior to the cartilaginous portion of the rib
• A 15 blade to sharply dissect pericondrium superiorly and inferiorly
• A cottlle's elevator and freer elevator to dissect the plane between perichondrium and rib to connect the inferior and superior incisions, leaving the deep layer of pericondrium down
• Laterally, the blue line, separating cartilage from bone, is identified. A 22-gauge needle is used to identify the bony cartilaginous junction
• The flat portion of a Senn retractor is placed in the pocket beneath the rib to protect the pleura and a 15 blade is used to cut down through cartilage completely
• The rib is dissected free from the perichondrium underneath under direct visualization
• The flat portion of a Senn retractor is then placed deep to the rib medially and a 15 blade is used to complete the removal of the rib cartilage
• The rib cartilage is placed in saline
• Irrigation of the surgical bed to check for leak at 35 mmHg
• Deep muscle and fascia are approximated with running and interrupted 3-0 vicryl sutures
• A quarter inch penrose drain is placed deep to this and secured to skin using 2-0 Proline
• Skin closure using 4-0 monocryl is running subcuticular fashion
• The skin is sealed with dermabond
• Gauze covered in tegaderm is used to dress the wound

Single Stage Laryngotracheal Reconstruction

• A skin marker to plan a 5.5cm incision in the neck midway between the thyroid cartilage and suprasternal notch at midline
• 0.5% Lidocaine mixed with 1:100,000 Epinephrine is injected to the incision site
• A 15 blade to make the incision through skin and platysma
• Monopolar cautery to raise upper and lower subplatysmal flaps
• The midline raphe of the strap muscles is divided and retracted laterally
• Hyoid, thyroid and cricoid cartilage landmarks are palpated
• The thyroid gland is divided with bipolar cautery
• Kittners to remove fascia and soft tissue from the larynx
• 3-0 Proline sutures to be placed through the cricoid and trachea bilaterally as retraction suture. Care taken not to puncture the ETT cuff
• A straight beaver blade to make a ~1.5cm incision through the very caudal portion of thyroid cartilage down through the cricoid, down to the first and second tracheal rings
• A caliber to measure the dimensions required to expand the airway with the anterior right rib graft (length, distraction and thickness)
• The rib cartilage graft is crafted in a boat shape in a sterile setup
• The required dimension are crafted with flanges to fit easily and to prevent dislodgement
• Perichondrium is preserved to line the airway
• The anterior graft is then positioned to the anterior open defect such that perichondrium lines the expanded airway
• 3-0 PDS mattress sutures are placed in a stepwise fashion through the graft at a 90 degree angle of the graft and through the intercartilaginous trachea. 3 of these are placed on either side and the graft is parachuted in place
• An interrupted PDS suture is placed superior to the graft
• Tiseel is used to cover the graft
• Air leak is checked with valsalva
• The thyroid lobes are approximated using interrupted 3-0 Vicryl
• Strap musculature are re-approximated in a similar fashion and deep dermal Vicryl sutures are placed
• A quarter inch penrose is placed for drainage
• 4-0 Monocryl is used for running subcuticular closure
• This skin closure is coated with dermabond
• Gauze covered in tegaderm is used to dress the wound
• The ETT cuff is deflated and should remain deflated till extubation
• ETT is taped securely in place while taking care to avoid alar pressure that may cause necrosis. It is confirmed in position by flexible bronchoscopy and intraoperative CXR
• A size appropriate nasogastric tube is placed and secured. This is confirmed in place by direct visualization and CXR

Postoperative Care and Instructions

• Transfer to neonatal/pediatric intensive care unit
• Airway cart, bronchoscopy tower, flexible fiberoptic bronchoscope, similar and smaller size ETT at bedside in case of accidental extubation requiring emergent reintubation
• Prominent sign to call pediatric otolaryngology for any airway concerns
• Keep nasally intubated and sedated and provide NICU/PICU with sedation protocol
• Watch for nasal alar redness/necrosis
• Keep ETT cuff deflated till time of extubation
• Paralysis for 2 days then wean per protocol 
• Nutrition consults and NG feeds 
• Intravenous broad-spectrum antibiotic: Zosyn for 10 days
• Omeprazole for 3 months 
• Avoid steroids until planned extubation
• Neck and chest Penrose drains to be removed on POD1 
• Repeat DL and B in 4-5 days to examine the airway, downsize to an uncuffed ETT with planned extubation the following day

LTR sedation protocol

• All patients managed in the neonatal or pediatric ICU postoperatively
• State behavioral scale to monitor depth of sedation
• Morphine and Dexmedetomidine infusions through central venous lines to maintain SBS goal -2 (responsive to noxious stimuli) to -3 (unresponsive) as prescribed by the ICU team
• If needed, opioid boluses given q 2 to 4 hours as prescribed by the ICU team
• NM blockade initiated with vecuronium and titrated to maintain a train-of-four of one
• Train-of-four monitoring by trained nursing staff as per PICU standard of practice 
• Daily NM blockade  “holidays”  as decided by PICU and ENT teams
• Avoid Corticosteroids due to association with myopathy when used in conjunction with Aminosteroid paralytic agents and delays in healing
• Enteric nutrition (TP) initiated on postoperative day 1 to optimize nutrition
• Prior to extubation, Dexamethasone (0.25–0.5 mg/kg IV q6h 2–4 doses) empirically for all patients starting 8 hours prior to planned extubation. Patients should not otherwise receive steroids during their hospitalization
• Neuromuscular blockade discontinued 4 to 6 hours prior to extubation
• Propofol initiated and titrated to goal SBS -2 as paralysis is lifted
• Dexmedetomidine continued at its prior rate, unless bradycardia limited coadministration with Propofol
• Propofol is discontinued in all patients and washout is ensured prior to extubation. Patients frequently remain on Dexmedetomidine through extubation
• Opioid infusions discontinued entirely for the 1 to 2 hours immediately surrounding extubation and restarted at 25% to 50% of prior dose only if needed for withdrawal symptoms

Extubation criteria

• Awake
• Breathing tidal volumes >5 to 7 ml/kg on pressure support of 6-10 cm H2O
• Positive end-expiratory pressure of 5 cm H2O with FiO2 of 40% or lower, without tachypnea or respiratory distress

Post extubation

• Dexmedetomidine infusion maintained as Morphine stopped or tapered
• Opioid and Dexmedetomidine taper as per PICU pharmacy protocol
• Nebulized Ciprodex should be started 
• PO diet initiated and advanced as tolerated

References

Cable BB, Manaligod JM, Bauman NM, Smith RJ. Pediatric airway reconstruction: principles, decision-making, and outcomes at the University of Iowa hospitals and clinics. Ann Otol Rhinol Laryngol. 2004 Apr;113(4):289-93. doi: 10.1177/000348940411300406. PMID: 15112971.

Fauman KR, Durgham R, Duran CI, Vecchiotti MA, Scott AR. Sedation after airway reconstruction in children: A protocol to reduce withdrawal and length of stay. Laryngoscope. 2015 Sep;125(9):2216-9. doi: 10.1002/lary.25176. Epub 2015 Jul 7. PMID: 26152806.