Practice Patterns After Tracheotomy in Infants Younger Than 2 Years

Abstract

To report survey results of members of the American Society of Pediatric Otolaryngology (ASPO) on the practice patterns of surveillance endoscopy and management of suprastomal granuloma (SSG) in children younger than 2 years with indwelling tracheostomy tubes and to review our internal practice patterns. All patients younger than 2 years who underwent tracheotomy between 1996 and 2006 at a tertiary children's hospital. (1) Retrospective medical chart summary and (2) ASPO-approved and -administered online surveys to the membership of a 14-question survey on indications for infant tracheotomy, indications for bronchoscopy after tracheotomy, and treatment preferences for SSG in this population. Summary and findings of survey results and of data collected from medical chart review, including demographics, medical comorbidities, age at time of tracheotomy, indications for tracheotomy, frequency of bronchoscopy after tracheotomy, frequency of observed SSG, and interventions for SSG. Seventy-five ASPO members completed the online surveys. Practice patterns varied for frequency of bronchoscopy: only as needed, every 12 months, every 6 months, and every 3 months were reported by 38% (n = 26), 25% (n = 17), 24% (n = 17), and 9% (n = 6) of ASPO members, respectively. Most important indications for bronchoscopy were preparation for laryngotracheal reconstruction and decannulation (100% [n = 65] and 92% [n = 60], respectively), bleeding (76% [n = 59]), and difficult tracheostomy tube changes (70% [n = 57]). Lumen obstruction of 25% to 50% and 50% to 75% by SSG would likely receive intervention (30% [n = 22] and 14% [n = 11], respectively) with skin hook eversion and removal being the most popular technique. We reviewed the medical records of a total of 201 infants who underwent tracheotomy at our institution (110 boys [54.7%]). Indications included ventilator dependence (32.2%), craniofacial anomaly (15.0%), cardiopulmonary insufficiency(15.0%), neuromuscular indication (15.0%), and subglottic stenosis (6.7%). Thirty patients (14.9%) were premature (mean gestational age, 27 weeks). Median age at time of tracheotomy was 4 months for premature infants and 3 months for term infants. Practice patterns regarding endoscopy and SSG management varied widely within our own institution. A total of 205 bronchoscopies were performed on 109 patients during the study period. At the time of first bronchoscopy 43 of 109 patients were noted to have an SSG (39.4%). Elective removal of SSG occurred in 20 of 43 cases (46.5%), and 9 of 20 patients were noted to have recurrent SSG at subsequent endoscopy (45%). In addition, of the 23 children who did not have intervention for their SSG, 15 of 23 had spontaneous resolution and no appreciable SSG at the time of follow-up endoscopy (65.0%). There are currently various practice patterns for surveillance endoscopy and management of SSG in children younger than 2 years with indwelling tracheostomy tubes. Development of clinical practice guidelines on this topic may improve patient care and reduce unnecessary procedures.