Abstract
Pediatric Laryngo-Tracheal Stenosis (LTS) comprises different conditions that require precise preoperative assessment and classification. According to the guidelines, the optimal diagnostic work-up of LTS patients relies both on a comprehensive anamnesis and on endoscopic and radiological assessments. All the causes of LTS result in an impairment in airflow, mucociliary clearance, phonation, and sometimes in swallowing disorders. The main goals of treatment are to maintain an adequate respiratory space and restore the Upper Aero-Digestive Tract (UADT) physiology. The first step when dealing with LTS patients is to properly assess their medical history. The main causes of pediatric LTS can be divided into two groups, i.e., congenital and acquired. The most common causes of congenital LTS are: laryngomalacia (60%), vocal fold paralysis (15–20%), subglottic stenosis (SGS) (10–15%), laryngeal webs and atresia (5%), subglottic hemangioma (1.5–3%), and others. On the other hand, 90% of acquired pediatric LTS cases are subsequent to post-intubation injuries. Other less frequent causes are: iatrogenic complications from endoscopic laryngeal interventions, benign tumors, caustic or thermal injuries, external blunt force injury or trauma, chronic inflammatory disorders, or idiopathic causes. Diagnostic work-up consists in a step-by-step investigation: awake and asleep transnasal fiberoptic laryngoscopy (TNFL), direct laryngoscopy with 0° and angled telescopes to investigate the type of stenosis (arytenoid mobility, craniocaudal extension, involved anatomical sites, and active or mature scar tissue), and broncho-esophagoscopy to rule out associated mediastinal malformations. To date there are several available classifications for each of the involved sites: Cohen's classification for anterior glottic stenosis, Bogdasarian's for posterior glottic stenosis (PGS) and Myer-Cotton's for subglottic stenosis, even though others are used in daily practice (Lano-Netterville, FLECS, etc.). The European Laryngological Society recently proposed a new classification which is applicable in all LTS cases. In this chapter we deal with preoperative assessment and staging, reviewing the most relevant classifications applicable in patients affected by LTS, conditio sine qua non in order to tailor the best treatment modality to each subject. We'll also detail the comprehensive radiological, endoscopic and functional assessment for the correct use of each staging classification.
Highlights
Pediatric laryngotracheal stenosis (LTS) comprises a wide number of conditions that require precise pre- and intraoperative assessment.The main causes of pediatric LTS can be divided into two groups, i.e., congenital and acquired
The main advantage of European Laryngological Society (ELS) classification is its comprehensive value and its aid guiding the whole work-up for a patient affected by laryngotracheal stenosis; regarding the scoring system it introduces the three-dimensional view, taking into account together the cranio-caudal shape of the stenosis and its smaller area on the axial plane; relevant comorbidities of the patient are included, as they are crucial for the correct decision-making process
Beyond all these favorable features of the ELS classification, it has some limits as it lacks specificity for some subsites of the airway, such as the different compartments of the glottis, for which the older Cohen’s and Bogdasarian’s classification still play a relevant role for the staging of anterior and posterior glottic stenosis, respectively. The functional investigation, such as spirometry, is included in the suggested work-up but its specific parameters are not taken into consideration in detail; beneath this kind of test is mostly applicable in adults population, the results by the recent literature about the usefulness of such exam are rising the value of spirometry for an objective evaluation of patients both for the pre-treatment staging and for follow-up period [19, 20]
Summary
Pediatric laryngotracheal stenosis (LTS) comprises a wide number of conditions that require precise pre- and intraoperative assessment.The main causes of pediatric LTS can be divided into two groups, i.e., congenital and acquired. The authors attempted to standardize the pre- and intraoperative assessment techniques in order to fully investigate the lesion in all its aspects (type of stenosis, involved subsites, extension, laryngeal motility, and airway lumen).
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