Airway Splint Research Articles

“Double‐Doyle” Intranasal Airway Splint Technique

Objective: Present a novel technique utilized by the senior author for support of unstable, comminuted nasal bone fractures and its adaptation to rhinoplasty and septal surgery to provide greater stabilization of the nasal septum and bones. Illustrate safe and adequate results with this technique.Method: Retrospective chart review of the senior author’s past surgical procedures since 2001 utilizing this Double-Doyle intranasal airway splint technique. Patient demographics, diagnoses, surgical procedure, stenting duration, and complications were identified. This technique involves 2 modified Doyle II intranasal airway splints (Medtronic) to provide greater intranasal support.Results: Eighty-seven cases involving the Double-Doyle intranasal airway splint technique performed for closed nasal reduction, selected cases of open rhinoplasty, and septal procedures revealed overall that this intranasal splint modification was safe, tolerated well by patients, and presented minimal morbidity. All but one patient ex...

Double‐Doyle Intranasal Airway Splint Technique

Objective: Present a novel technique utilized by the senior author for support of unstable, comminuted nasal bone fractures and its adaptation to rhinoplasty and septal surgery to provide greater stabilization of the nasal septum and bones. Illustrate safe and adequate results with this technique. Method: Retrospective chart review of the senior author’s past surgical procedures since 2001 utilizing this Double-Doyle intranasal airway splint technique. Patient demographics, diagnoses, surgical procedure, stenting duration, and complications were identified. This technique involves 2 modified Doyle II intranasal airway splints (Medtronic) to provide greater intranasal support. Results: Eighty-seven cases involving the Double-Doyle intranasal airway splint technique performed for closed nasal reduction, selected cases of open rhinoplasty, and septal procedures revealed overall that this intranasal splint modification was safe, tolerated well by patients, and presented minimal morbidity. All but one patient experienced a successful cosmetic and functional outcome as described by the senior author. Six overall possible complications were noted; 3c cases of minor nasal mucosa damage and 3c cases of possible infection that resolved after removal of the splint and treatment with antibiotics. Conclusion: We present a safe technique that provides prolonged nasal dorsal support in severely comminuted nasal bone fractures without the need for external suspension devices or additional incisions. Additionally, this technique may be applied to rhinoplasty and septal procedures involving significant septal correction to allow greater stabilization of the septum postoperatively.

S56 Flat Trachea Syndrome: an under-diagnosed and under-treated condition?

ObjectivesFlat Trachea Syndrome (Tracheobronchomalacia) is a central airway disease characterised by weakness of the wall and dynamic decrease in the tracheal lumen and the large bronchi, particularly while exhaling. It...

Treatment of Adult Tracheobronchomalacia and Excessive Dynamic Airway Collapse

Tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) are both dynamic forms of central airway obstruction characterized by a decrease of >/=50% in the cross-sectional area of the tracheobronchial lumen. The differences between these two entities, however, are not uniformly accepted in the medical community. While TBM is characterized by a weakness of the tracheobronchial cartilaginous structures, EDAC is marked by excessive bulging of the posterior membrane into the airway lumen during exhalation. These disease entities are probably underdiagnosed because they present with a variety of nonspecific symptoms similar to patients with other obstructive ventilatory disorders such as asthma and COPD. Diagnosis is confirmed by dynamic radiologic imaging studies or bronchoscopy. Current therapeutic management depends on the extent, type, and severity of airway abnormalities noted and the clinical presentation. Proposed management alternatives include conservative medical therapy, and minimally invasive and open surgical interventions. Inhaled bronchodilators should be used only if symptoms and ventilatory function improve after use. Continuous positive airway pressure acts as a pneumatic stent and should be considered as an alternative or additional therapeutic modality. Endoluminal stent insertion can improve symptoms and pulmonary function in patients with central airway obstruction and should be considered for patients with symptoms refractory to conservative therapy. Several open surgical procedures have also been performed over the years, including tracheostomy, airway splinting, tracheal resection and, more recently, external tracheal stents. Endobronchial laser therapy, resorbable stents, application of grafting materials used to support the collapsed airway as well as the use of cartilage regeneration techniques are experimental, and their efficacy in humans remains to be determined. Future studies should compare therapeutic interventions and outcomes such as functional status, ventilatory function, and bronchoscopic and radiologic appearances in order to define the costs and benefits of individual and combined treatment modalities.

A new intratracheal stent made from nitinol, an alloy with “shape memory effect”

Temporary or permanent tracheal splinting in pediatric patients may be indicated in tracheomalacia or bronchomalacia, repair of congenital tracheal stenosis, and after tracheal resection. This study presents the results of the development of a new intraluminal airway stent made from titanium alloy, a metal with "shape memory effect". At low temperatures (martensitic state) the titanium alloy stent can be fashioned into a specific shape; then when heated to a higher temperature (austenitic state) the stent alters its shape, only to regain its original shape when recooled to the lower temperature. The stent, connected to a small electric power supply, was introduced into 20 young rabbits with the use of a 2.5 cm rigid bronchoscope. After implantation in the martensitic state the stent was warmed to 40 degrees C, the austenitic state, by an electric current of 1.5 to 3 ampere for 1 to 2 seconds. After a period of 8 to 10 weeks the stent was removed (in its martensitic state) through the same-sized bronchoscope after being cooled with 3 to 4 ml of 80% alcohol solution at 6 degrees C. No signs of airway obstruction developed in any of the animals after implantation or extraction of the stent. The biomechanical properties of the trachea, as shown by strain measurements with the use of incremental forces, showed significant differences between the stented and unstented segments (p < 0.005). The titanium alloy intratracheal stent adequately fulfilled the requirements of a temporary intraluminal airway splint, and because of its unique feature of shape memory effect the stent could be inserted, fixed, and removed easily, even in very small airways.

Severe tracheomalacia associated with esophageal atresia: Results of surgical treatment

This study reviews our experience from 1977 to 1991 with 32 children born with esophageal atresia and tracheoesophageal fistula (EA-TEF) who later underwent surgery for severe tracheomalacia. Indications for surgery included dying spells (21), inability to extubate the airway (nasotracheal tube 5, tracheotomy 3), and recurrent pneumonia (3). Diagnosis was confirmed by chest x-ray, esophagogram, and bronchoscopy. Aortopexy was performed in 31 of 32 children; a splint without aortopexy was used in one older girl. Splinting was also necessary in two of the 31 at the initial operation, when aortopexy failed to prevent tracheal collapse. There were four initial failures. Currently, 29 children are well (median follow-up, 6.6 years). Two have a tracheostomy in place, and one, who had a vascular ring divided after aortopexy, died at home of unknown cause 1 month later. These findings indicate that aortopexy provides long-term relief of severe symptoms of tracheomalacia associated with EA-TEF in almost all affected children. When aortopexy fails, the insertion of an airway splint may succeed; otherwise, tracheostomy is necessary.

Long-term functional results of prosthetic airway splinting in tracheomalacia and bronchomalacia

The long-term functional results of splinting a collapsing major airway with a silastic Marlex mesh prosthesis were assessed. Six patients in whom follow-up has been longer than 4 years (mean 5.3 years) were studied. The prosthetic semirigid splints had been implanted in five children with tracheomalacia and one with bronchomalacia. Mean age at the time of airway splinting was 4 years (range 6 months to 8 years). At their last clinical evaluation, all six children were leading normal active lives. Three had mild respiratory symptoms not related to the splinting. The only long-term complication was a serous effusion that developed around the splint and compressed the trachea in one child 2 years postoperatively. Tracheal fluoroscopy, barium swallow, and computed tomography scans of the trachea in five patients demonstrated satisfactory tracheal caliber without airway collapse during expiration and coughing. Pulmonary function testing showed a mild increase in airway resistance in one child who had had a tracheostomy. These results demonstrate that the application of composite synthetic graft to a segment of a malacic airway in young patients can provide long-term relief from airway collapse without compromising airway growth.

Treatment of tracheomalacia: Eight years' experience

Between 1978 and 1985, 21 patients were treated for tracheomalacia, (group I) and 4 for tracheobronchomalacia (group II). The median age at treatment was 7 months (range 1 to 96 months). Indications for surgery in group I were, "dying spells" (n = 12), recurrent pneumonia (n = 4), intermittent respiratory obstruction (n = 3) and inability to extubate airway (n = 2). 18 had esophageal atresia repair. Treatment in group I was aortopexy (n = 19), three of whom also required an external airway splint; two had an airway splint only. Airway obstruction was relieved in all. Group II patients required surgery because they could not be extubated; none had esophageal atresia. Aortopexy in all and splinting in one failed in 3 of 4 patients. Aortopexy is the primary treatment of tracheomalacia. External airway splinting may be used where aortopexy is inadequate. A satisfactory treatment for tracheobronchomalacia has not yet been devised.

Effect of prosthetic airway splint on the growing trachea

Airway splints are now used clinically to treat tracheomalacia and may also have a place in the management of tracheal stenosis. These studies in 5 to 7 Kg piglets were designed to assess the effects of prosthetic airway splints on airway growth and to establish their usefulness in the reconstruction of tracheal defects. Three experimental groups were studied: group I (n = 8). Silastic reinforced Marlex mesh or Vicryl mesh prostheses were placed around 75% of the circumference of a 3 cm segment of trachea. Pigs were sacrificed at 4 months (average weight = 78.9 +/- 9.0 Kg) and the cross-sectional area of trachea was measured. Group II (n = 5). The same prostheses were used to replace the tracheal defect created by excising three rings (50% of tracheal circumference). Tracheas were examined grossly and histologically at sacrifice. Group III (n = 5). Same as Group II except tracheal defect covered by strap muscles. Prostheses placed external to them to prevent airway collapse. Group I had 4% to 14% (mean 8%) decrease from normal cross-sectional area of trachea at site of splint. No airway obstruction and no infection was encountered. Group II, severe airway obstruction, granulation tissue, and infection at site of defect was noted. Group III showed no signs of airway obstruction, no infection, and minimal airway narrowing. Re-epithelialization of the muscle surface in contact with airway occurred in all these animals. Silastic reinforced Marlex or Vicryl splints placed around the intact rapidly growing trachea do not significantly limit its growth. In addition, these synthetic materials appear to be well-tolerated when used to reconstruct tracheal defects if placed over well-vascularized tissue such as muscle.

Treatment of segmental tracheomalacia and bronchomalacia by implantation of an airway splint

A silastic reinforced marlex mesh splint was inserted surgically to support a collapsing airway in 3 children with tracheomalacia and 1 with bronchomalacia. The operation was well tolerated and no complications occurred. The splint successfully eliminated symptoms of airway collapse in all children. Its effect on airway growth is not yet certain. This method is applicable to patients with tracheomalacia in whom vascular suspension does not eliminate collapse and for those with bronchomalacia in whom pulmonary resection might otherwise be necessary.