Operation-specific Decannulation Rates Research Articles

Revision surgery for laryngotracheal stenosis in children: A single center's 44 years experience.

Outcome measures of revision open airway surgery in pediatric laryngotracheal stenosis (LTS) are reported. Data on 46 pediatric LTS patients undergoing revision open airway surgery were collected retrospectively. The measured outcomes were decannulation rate, time to decannulation, postoperative complications, additional surgery to achieve decannulation, and functional results. The most common revision surgery was partial cricotracheal resection (PCTR) in 21/46, followed by extended PCTR (ePCTR) in 20/46, and laryngotracheal reconstruction (LTR) in 5/46 patients. A 90.7% overall decannulation rate (ODR) and a 74.4% operation-specific decannulation rate (OSDR) were achieved. Delayed decannulation was identified in children aged 5 years or less (p= 0.038) and in patients with previous primary open airway surgery (p= 0.039). Complications were observed in 52.2% of patients. To achieve optimal airway patency, additional open or endoscopic airway surgeries were necessary in 30.4% and 47.7% of patients, respectively. Age 5 years or less (p= 0.034), multiple comorbidities (p= 0.044), revision ePCTR (p= 0.023), and laryngeal stenting (p= 0.018) were risk factors requiring additional open surgery to achieve age-appropriate airway. Failed primary open airway surgery (p= 0.034) and comorbidities (p= 0.044) were risk factors for a higher rate of additional endoscopic surgeries. Postoperatively 63.0% of patients achieved normal breathing, 82.2% were dysphonic and 91.1% were orally fed. In this report, the patient's age under 5 years, previous primary open airway surgery, medical comorbidities, and laryngeal stenting had a significant negative impact on revision open airway surgery outcomes. Level 4 Laryngoscope, 133:3200-3207, 2023.

Immediate extubation after single-stage laryngotracheal reconstruction for subglottic stenosis in children

PurposeTo evaluate the feasibility and clarify the appropriate indications for extubation immediately after single-stage laryngotracheal reconstruction (SS-LTR) in pediatric subglottic stenosis (SGS).MethodsA retrospective study was performed from July 2017 to July 2022. All patients underwent SS-LTR with anterior costal cartilage graft. Information such as demographics, comorbidities, history of intubation or tracheostomy, Classification and grading of airway stenosis, the operation-specific decannulation rate and overall decannulation rate were analyzed.ResultsTwenty-two patients with simple SGS were identified. The median age at SS-LTR was 19 months (IQR = 18.5 months). Fourteen patients (63.6%) were intubated prior to the presentation of symptoms. Fourteen patients (63.6%) required preoperative tracheostomy to maintain a secure airway. Eight patients (36.4%) had congenital SGS, 10 patients (45.5%) had acquired SGS, and 4 patients (18.2%) had mixed SGS. Three patients had Grade II stenosis. Nineteen patients had Grade III stenosis. Comorbidities were found in 10 patients (45.5%). Major comorbidities were pneumonia. Congenital airway anomalies were found in 6 patients (27.3%). After anesthesia, all 22 patients were successfully extubated and returned to the general ward. Twenty patients had a satisfactory airway after SS-LTR. Two patients required reintubation or tracheostomy after operation. Operation-specific decannulation rate was 90.9%. The overall decannulation rate is 100%.ConclusionSS-LTR with anterior costal cartilage graft is an effective method to treat simple SGS ranging from Grades I to III in children. Extubation immediately after surgery is safe and feasible.

Hybrid laryngotracheal reconstruction vs single and double stage: Indications and outcomes

ObjectivesTo describe outcomes from laryngotracheal reconstruction and decannulation rates for patients undergoing single stage, double stage and hybrid staged procedures at a single tertiary care institution and evaluate if the 1.5LTR is a viable reconstructive option for patients with subglottic stenosis. Study designRetrospective chart review. SettingTertiary care otolaryngology specialty hospital and internationally. SubjectsAll patients who underwent LTR by a single pediatric otolaryngology surgeon from 2008 to 2018. MethodsCharts were assessed for age, gender, etiology, type of reconstruction, comorbidities, length of stay, tracheostomy status and socioeconomic status. Analysis was performed using Microsoft Excel and multivariate logistic regression models. Results96 patients underwent laryngotracheal reconstruction at MEEI. Internationally, 36 patients underwent laryngotracheal reconstruction with the primary surgeon. Overall decannulation rates for ssLTR, dsLTR, and 1.5LTR were 95.6%, 77.8%, and 91.2% respectively. Our Operation Specific Decannulation Rates (one open airway procedure only) for ssLTR, dsLTR, and 1.5LTR were 87.5%, 33%, and 88% respectively. Adjusted odds of decannulation were not significantly different between males and females, white and non-white patients, or socioeconomic status. Neurological comorbidity was statistically significant for a decreased rate of decannulation (p = 0.0216). ConclusionThe 1.5LTR is a viable option for airway reconstruction with strengths derived from both the ssLTR and dsLTR. At our institution we have seen decannulation rates and operation specific decannulation rates with the 1.5LTR approaching our ssLTR. It has replaced the bulk of our dsLTRs, which we reserve for patients that have significant neurological deficits and cannot tolerate extended sedation. Level of evidence4

Balloon-Assisted Rib Graft Placement in Endoscopic Posterior Cricoid Split Procedure.

View Video S1 Laryngoscope, 132:212–214, 2022

Systematic review/meta-analysis comparing successful outcomes after single vs. double-stage laryngotracheal reconstruction

ObjectiveTo compare operation-specific decannulation rates between single-stage (SSLTR) and double-stage laryngotracheal reconstruction (DSLTR) when controlling for grade of airway stenosis. MethodsA systematic review and meta-analysis were performed using PubMed, EMBASE and Cochrane databases from 1970 to 2015 to examine primary SSLTR and DSLTR for subglottic stenosis in patients 18 years or younger. Primary outcome was decannulation or extubation after LTR. Failures included patients not decannulated or requiring additional open airway procedures prior to decannulation. Only studies providing outcomes delineated by airway stenosis grade were included. Non-English language studies and case reports were excluded. ResultsThere were 712 abstracts reviewed and 16 studies with 663 pooled patients included in the systematic review analysis. The metaanalysis included 5 studies. Overall, the operation-specific decannulation success was statistically significantly different between SSLTR [93.2% (N = 221)] and DSLTR [83.7% (N = 442)] (P<0.001). When controlling for stenosis severity, however, no difference was found in decannulation success between SS- or DSLTR except in the grade 3 group: Grade 1–100% (N = 6) vs. 100% (N = 6), (P = 1); Grade 2 - 84.9% (N = 106) vs. 83.3% (N = 138), (P = 0.72); Grade 3–80.2% (N = 101) vs. 69.7% (N = 238), (P = 0.03); Grade 4–33.3% (N = 6) vs. 50% (N = 58), (P = 0.67). ConclusionNo difference in decannulation rates was seen between SSLTR and DSLTR when comparing similar grades of stenosis except in grade 3 stenosis. With worsening stenosis, the success rate declines with both methods. Prospective studies with standardized enrollment criteria and reported outcomes are needed to better understand the advantages and disadvantages of each approach.

Endoscopic posterior cricoid split with costal cartilage graft: A fifteen-year experience.

To evaluate outcomes of the endoscopic posterior cricoid split with rib graft (EPCS/RG) procedure in the treatment of subglottic stenosis (SGS), posterior glottic stenosis (PGS), and bilateral vocal fold immobility (BVFI). Retrospective chart review. Chart review of all patients who underwent EPCS/RG at a single tertiary-care facility between 1999 and 2014. Patients were grouped based on the primary indication for the procedure. Decannulation was the primary endpoint. Secondary endpoints were the number of subsequent airway procedures and length of hospitalization. Thirty-three patients were identified; 32 had tracheotomy. Overall decannulation rate was 65.6%. Subgroup analysis demonstrated the following decannulation rates: 53.8% for SGS, 100% for PGS, and 28.6% for BVFI. Fisher exact test found a significant difference in overall decannulation rates between groups (P = 0.002). Operation-specific decannulation rates for patients who never required an open procedure were 23% for SGS, 91.6% for PGS, and 28.6% for BVFI. This difference was also statistically significant (P = 0.001). Multivariate logistic regression analysis found prematurity had a positive correlation with decannulation that approached statistical significance (P < 0.051; odds ratio 6.1; 95% confidence interval 0.99, 37.6). The percentage of patients who underwent repeat airway procedures for the groups was 61.5% for SGS, 16.6 % for PGS, and 14.3% for BVFI. The median length of hospitalization after EPCS/RG was 3 days. This represents the largest series of patients who have undergone EPCS/RG and demonstrates that the majority of patients can be decannulated after this procedure. Patients with PGS had the highest operation-specific decannulation rates. 4. Laryngoscope, 127:252-257, 2017.

Severe acquired subglottic stenosis in children: analysis of clinical features and surgical outcomes based on the range of stenosis.

The present study analyzed the clinical features and surgical outcomes of laryngotracheal reconstruction (LTR) in pediatric patients with severe acquired subglottic stenosis (SGS) based on the range of stenosis. The aim was to clarify the indications for LTR in severe acquired SGS. The medical records of 33 pediatric patients with severe acquired SGS (Myer-Cotton grade III or IV) at our institution between January 1994 and December 2013 were retrospectively reviewed. Nine patients had stenosis localized at the subglottis (localized SGS), and twenty-four patients had stenosis extending to the glottis or supraglottis from the subglottis (extended SGS). 66.7 % (6/9) of localized SGS patients were intubated after infancy, and 95.8 % (22/23) of extended SGS patients were intubated in the neonatal period. The duration of intubation was significantly shorter with localized than with extended SGS. Sixteen patients underwent LTR. The operation-specific decannulation rate was 80.0 % (4/5) in the localized SGS group and 14.3 % (1/7) in the extended SGS group. The range of stenosis was affected by the period and duration of endotracheal intubation. Surgical outcomes of LTR tended to differ between localized SGS and extended SGS. LTR can be effective for localized SGS.

Comparison of Hybrid Laryngotracheal Reconstruction to Traditional Single and Double‐Stage Laryngotracheal Reconstruction

Objectives: (1) Describe outcomes from and modifications to the hybrid, also known as the one-and-a-half stage, laryngotracheal reconstruction (LTR) technique. (2) Compare this technique to traditional single and double-stage LTR (ssLTR/dsLTR). Methods: Retrospective review of patients under 18 years of age who underwent LTR by a single surgeon at a tertiary care otolaryngology specialty hospital from July 1, 2009, to December 31, 2013, was performed. Charts were assessed for age, sex, etiology of stenosis, type of reconstruction, comorbidities, length of stay, complications, and tracheostomy status. Results: Forty-four patients were identified, with 13 one-and-a-half stage LTRs, 27 ssLTRs, and 4 dsLTRs. Of the one-and-a-half stage LTRs, an operation-specific decannulation rate of 77% was noted, comparable with those for ssLTR and dsLTR. The one-and-a-half stage LTR technique offered a significantly shorter period of narcotic use when compared with ssLTR (16 vs 23 days, P &lt; .01). Average length of stay for ssLTRs and hybrid LTRs was identical at 16 days; difference in length of stay between hybrid and dsLTRs was not statistically significant (16 vs 12.5 days, P = .16). Conclusions: The hybrid LTR technique is well-tolerated and useful in patients of all ages. Narcotics are able to be weaned more quickly because of the presence of a secure airway at all times via the existing tracheostomy. Use of a long stent prevents formation of granulation tissue that may be seen with a suprastomal stent. This technique should be considered in patients with high-grade stenosis with a pre-existing tracheostomy.

Partial cricotracheal resection for paediatric subglottic stenosis: update of the Lausanne experience with 129 cases.

Partial cricotracheal resection (PCTR) is widely accepted for treating severe paediatric laryngotracheal stenosis (LTS). However, it remains limited to a few experienced centres. Here we report an update of the Lausanne experience in paediatric PCTR performed or supervised by a senior surgeon (Philippe Monnier). An ongoing database of 129 paediatric patients who underwent PCTR for benign LTS between March 1978 and July 2012 at our hospital was retrospectively reviewed. Demographic characteristics and information on preoperative status, stenosis and surgery were collected. Primary outcomes were measured as overall and operation-specific decannulation rates (ODR and OSDR, respectively), and secondary outcomes as morbidity, mortality and postoperative functional results. A total of 129 paediatric patients [79 males and 50 females; mean age, 4.1 years (1 month-16 years, median age of 2 years old)] underwent PCTR during the study period. ODR and OSDR were 90 and 81%, respectively. The decannulation rates were significantly superior for single-stage PCTR compared with double-stage PCTR in both ODR and OSDR. Eight patients died postoperatively for reasons unrelated to surgery. Partial anastomotic dehiscence was seen in 13 patients, 9 of whom were successfully treated by revision surgery. Respiratory, voice and swallowing functions were near normal or only minimally impaired in 86, 65 and 81% of patients, respectively. PCTR is effective and feasible with good ODR and OSDR for highgrade / severe LTS. Glottic involvement and the presence of comorbidities were negative predictive factors of decannulation. Early detection and reintervention of postoperative incipient dehiscence contribute to avoiding the progress to late restenosis; however, voice improvement remains a challenge.

Laryngotracheal reconstruction for pediatric glotto-subglottic stenosis

BackgroundThe management of pediatric laryngotracheal stenosis (LTS) can be challenging, and laryngotracheal reconstruction (LTR) with cartilage interposition grafting remains the mainstay of surgical treatment for pediatric LTS in most experienced centers. The purpose of this study was to report the results of this procedure in a center where primary cricotracheal resection is frequently performed. MethodsA retrospective chart review was performed on 45 patients who underwent LTR in our hospital between October 1997 and July 2012. Demographic characteristics and information on the preoperative status, stenosis, and operation were collected. Primary outcomes were measured as overall (ODR) and operation-specific (OSDR) decannulation rates and secondary outcomes as morbidity, mortality, and postoperative functional results. ResultsODR and OSDR were 86.7% (39/45) and 66.7% (30/45), respectively. Re-stenosis was observed in 11/45 (24%) patients, all of whom were endoscopically or surgically treated. Revision surgery was performed in 10 patients, 6 for re-stenosis and 2 for peristomial tracheomalacia. Two children died of mucous obstruction of tracheostomy tube at 3 and 6 months postoperatively (4.4%). Respiratory, voice, and swallowing functions were excellent or good in 86, 75, and 84% of patients, respectively. ConclusionsLTR for pediatric LTS has high decannulation rates with acceptable morbidity and mortality in selected patients. Most LTR procedures were double-stage for lower grade subglottic stenoses associated with glottic involvement that required stenting. Careful preoperative evaluation and adequate surgical indications are extremely important to achieve high decannulation rates.

A randomized study of suprastomal stents in laryngotracheoplasty surgery for grade III subglottic stenosis in children

Studies comparing the relative effectiveness of suprastomal stents in laryngotracheoplasty surgery are lacking in the literature. The goal of this study was to compare the performance of two widely used short-term suprastomal stents in open airway surgery. Prospective, randomized study of a single surgeon's outcomes for grade III subglottic stenosis (SGS) in children. The open Aboulker Teflon stent versus the cut, closed, soft Silastic Montgomery T-tube stent for short-term stenting in double-stage laryngotracheoplasty (dsLTP) were compared. Twenty-four patients were recruited into the study; 12 received an Aboulker (A) stent and 12 a cut, soft, Silastic (S) stent. There was no statistically significant difference in the operation specific decannulation rate between the two stent groups. Patients who received S stents were found to tolerate postoperative feeding better than those with A stents. The median time to decannulate, however, was longer for those receiving S stents (5.5 vs. 3.5 months, P = .02). Furthermore, those receiving S stents had increased need for airway dilation after stent removal (1.75 vs. 0.17 dilations per patient, P = .02) and increased presence of granulation tissue in the airway at the time of stent removal. Multivariate analysis showed the type of stent used independently correlated to time to decannulate (P = .022). Compared to the Teflon Aboulker stents, closed, soft, Silastic stents are associated with improved feeding in the postoperative period. Their use, however, also correlates with worsened granulation tissue formation and longer time to decannulation in patients undergoing dsLTP for grade III SGS.

Pediatric Tracheal Reconstruction Using Cadaveric Homograft

To examine the indications, risks, and surgical outcomes after tracheal reconstruction using cadaveric homograft in children. Retrospective medical record review. Tertiary referral center. Ten children (4 boys and 6 girls). Tracheal reconstruction using cadaveric homograft. Cause of stenosis, number and type of procedures before homograft reconstruction, severity of preoperative stenosis, surgical approach, homograft length, duration of stenting, number and type of procedures after reconstruction, and rates of decannulation and survival. Ten children (mean [SD] age, 8.4 [5.5] years) underwent 14 tracheal reconstructions using cadaveric homograft. Patients had an average of 7.0 (range, 1-16) procedures before homograft reconstruction, including an average of 2.8 (range, 0-6) major open airway reconstructions. Mean (SD) pretracheoplasty Myer-Cotton grade of stenosis was 3.80 (0.42) (range, 3-4), and all patients were tracheotomy dependent. A cervical approach was used in 12 reconstructions (86%), and 2 (14%) required median sternotomy. Mean (SD) homograft length was 3.9 (1.7) cm (range, 2-8 cm), which was approximately 0.60 times the length of the total recipient trachea. Mean (SD) duration of stenting for all homografts was 0.67 (0.46) years (range, 0.24-1.98 years). The survival rate was 90% after a mean follow-up of 5.47 (1.52) years (range, 3.32-7.55 years). Surviving patients required an average of 7.38 (5.52) procedures (range, 1-19) after homograft transplant, including an average of 1 major open airway reconstruction (range, 0-4). The mean (SD) grade of stenosis after the final homograft placement was 1.89 (1.27) (range, 1-4). Although the operation-specific decannulation rate was only 7% (1 of 14), the overall decannulation rate eventually reached 60%. Statistical bootstrapping methods and a multivariate regression model determined that increasing patient age (odds ratio, 1.21; 95% confidence interval, 1.07-1.36), increasing number of prior procedures (1.26; 1.02-1.57), and increasing homograft length (2.42; 1.60-3.40 [P < .001]) were associated with an increased risk of no decannulation after tracheal homograft reconstruction. Tracheal reconstruction using cadaveric homograft is an option in children who have undergone multiple airway surgical procedures and present with long-segment stenoses that cannot be bridged using conventional methods. These patients must receive close postoperative follow-up. Subsequent procedures are almost always required before decannulation, and eventual decannulation rates are only 60%. Decannulation rates are lower in older patients who have previously undergone many procedures and require a long tracheal homograft.

Single- vs Double-Stage Laryngotracheal Reconstruction

To compare single-stage laryngotracheal reconstruction (ssLTR) and double-stage LTR (dsLTR). Retrospective medical record review. Tertiary care children's hospital. Seventy-one patients underwent 84 procedures (22 ssLTRs and 62 dsLTRs). Review of preoperative disease severity and surgical outcomes for patients who underwent ssLTR vs dsLTR. Operation-specific and overall decannulation rates. Regarding ssLTRs, the mean grade of subglottic stenosis was 2.1 and the overall and operation-specific decannulation rates were 100% and 91%, respectively. The mean grade of subglottic stenosis for double-stage procedures was 2.9, and the overall and operation-specific decannulation rates were 93% and 68%, respectively. Patients who underwent ssLTR and dsLTR were further divided into early and late groups based on whether the posterior graft was sutured in place (early) or not (late). Overall and operation-specific decannulation rates were 100% and 89%, respectively, for the early single-stage group and 100% and 92% for the late group. Regarding the dsLTR group, overall and operation-specific decannulation rates were 88% and 42%, respectively, for the early group and 95% and 79% for the late group. Among all groups, there was no significant difference in overall decannulation rates (P > .05). Single-stage LTR offered an increased rate of operation-specific decannulation over dsLTR (P < .05). However, that difference was not significant between the late ssLTR and the late dsLTR groups (P > .05). Careful assessment of preoperative disease severity and overall medical status will help surgeons choose between ssLTR and dsLTR, maximizing patient outcomes for both modalities.

Management of severe pediatric subglottic stenosis with glottic involvement

We sought to describe our experience in the management of complex glotto-subglottic stenosis in the pediatric age group. Between 1978 and 2008, 33 children with glotto-subglottic stenosis underwent partial cricotracheal resection, and they form the focus of this study. They were compared with 67 children with isolated subglottic stenosis (no glottic involvement). The outcomes measured were need for revision open surgical intervention, delayed decannulation (>6 months), and operation-specific and overall decannulation rates. Fisher's exact test was used for comparison of outcomes. Results of preoperative evaluation showed Myer-Cotton grade III or IV stenosis in 32 (97%) patients and grade II stenosis in 1 patient. All patients with glotto-subglottic stenosis were treated with partial cricotracheal resection and simultaneous repair of the glottic pathology. Bilateral fixed vocal cords were seen in 19 (58%) of 33 patients, bilateral restricted abduction was seen in 7 (21%) of 33 patients, and unilateral fixed vocal cord was seen in 7 (21%) of 33 patients. Ten patients underwent single-stage partial cricotracheal resection with excision of interarytenoid scar tissue. The endotracheal tube was kept for a mean period of 7 days as a stent. Twenty-three patients underwent extended partial cricotracheal resection with LT-Mold (Bredam S.A., St. Sulpice, Switzerland) or T-tube stenting. The overall decannulation rate included 26 (79%) patients, and the operation-specific decannulation rate included 20 (61%) patients. Glotto-subglottic stenosis is a complex laryngeal injury associated with delayed decannulation and decreased overall and operation-specific decannulation rates when compared with those after subglottic stenosis without glottic involvement after partial cricotracheal resection.

Partial cricotracheal resection for congenital subglottic stenosis in children: The effect of concomitant anomalies

Objective To review the surgical outcomes of partial cricotracheal resection in children with severe congenital subglottic stenosis and define the effect of concomitant anomalies or syndromes affecting outcome. Methods Forty-one children with subglottic stenosis of congenital and mixed (acquired on congenital) etiologies who underwent partial cricotracheal resection were identified from a prospectively collected database. Children with congenital subglottic stenosis and concomitant anomalies/syndromes were compared to children with congenital subglottic stenosis with no syndromes or concomitant anomalies. Operation-specific decannulation rates and complication rates were the primary outcome measures. We performed a two-sample test of proportion using the STATA-10 software for categorical variables to detect differences in proportions. Significance was set at p value < 0.05. Results Twenty-seven (66%) of 41 children had concomitant anomalies/syndromes and 14 (34%) had congenital subglottic stenosis without concomitant anomalies/syndromes. Four patients needed revision surgery in the concomitant anomaly group and two patients needed revision surgery in the non concomitant anomaly group before achieving decannulation. The operation-specific decannulation rate in the concomitant anomaly group was 85% and 86% in the non anomaly group. When compared to children without concomitant anomaly, children with concomitant anomalies were more likely to have delayed decannulation following partial cricotracheal resection. However, this difference was not found to be statistically significant. The complication and operation-specific decannulation rates after partial cricotracheal resection were comparable to children without concomitant anomalies. Mortality rate was 11% (three of 27 patients) in the group with associated congenital anomalies or syndromes. Two patients succumbed to the primary pathology and one patient died due to tracheostomy-tube obstruction. There was no post-operative death in the non anomaly group. Conclusion Partial cricotracheal resection can be done safely and effectively in children with concomitant anomalies/syndromes to achieve decannulation. The post-operative course may be prolonged but the decannulation and the complication rates are comparable to those children with congenital subglottic stenosis without concomitant anomalies.

Laryngotracheal reconstruction with posterior costal cartilage grafts: Outcomes at a single institution

To describe our outcomes after laryngotracheal reconstruction that required posterior costal cartilage grafting focused on decannulation rates and complications. Case series with chart review. Charts were reviewed on 58 patients. Operation specific and overall decannulation rates were determined. Complications were reviewed and correlated with technique of graft placement. Available voice outcomes were reviewed. Forty-eight patients were included. There was no statistically significant correlation between degree of stenosis and rate of decannulation. The overall decannulation rate, regardless of number of surgeries performed, was 96 percent. The relative risk for complications was higher among children who had a sutured versus a sutureless flanged posterior graft (RR = 2.5, P < 0.01). The most common voice anomaly was supraglottic compression. Operation-specific decannulation rates are not significantly different with increasing disease severity, although the power to detect small differences in this study is low. Sutureless graft placement is associated with a lower complication rate. Supraglottic compression is a common postoperative compensatory vocal behavior and may correlate with disease severity.

Outcomes of Pediatric Posterior Graft Laryngotracheoplasty

Objective 1) Determine the operation specific decannulation rate of patients who required posterior costal cartilage grafting (PCCG) in the management of laryngeal stenosis. 2) Describe the complications associated with PCCG laryngotracheoplasty. 3) Describe voice outcomes for selected patients. Methods A retrospective review was performed on all cases of posterior graft laryngotracheoplasty (LTP) performed by the 2 senior authors over a 9-year period at a tertiary care children's hospital. Results There were 42 total patients. The operation specific decannulation rates were 100% (3/3) for Myer-Cotton grade II SGS, 75% (20/26) for grade III, and 60% (3/5) for grade IV. For posterior glottic stenosis (PGS), it was 57% (4/7) and for PGS with grade II SGS, it was 60% (6/10). There was no significant difference (p=0.727) among these groups. The overall decannulation rates were 100% (3/3), 96% (25/26), and 100% (5/5) for Myer-Cotton grades II, III and IV. For PGS, it was 83% (5/6), and for PGS with grade II SGS, it was 100% (8/8). There was no significant difference (p=0.527) among these groups. The relative risk for complications was higher among children who had a sutured vs. a sutureless posterior graft (RR= 2.7, p&lt;.01). The most commonly seen compensatory vocal behavior was supraglottic dysphonia. Conclusions Operation-specific decannulation rates are not significantly different with increasing disease severity, although the power to detect small differences in this study is low. PCCG via a sutureless technique is associated with a lower complication rate. Supraglottic dysphonia is a common compensatory vocal behavior after PCCG LTP.

Pediatric Cricotracheal Resection

To identify risk factors for operation-specific outcomes of pediatric cricotracheal resection (CTR). We identified the first 100 consecutive children undergoing CTR at our institution from January 1, 1993, to December 31, 2004. Retrospective review of medical records provided data on demographics, operation dates, decannulation dates, and proposed risk factors, including age, stenosis grade, vocal cord function, Down syndrome, history of distal tracheal surgery, history of open laryngotracheal surgery, presence of tracheotomy at the time of operation, use of suprahyoid release, extended CTR, and use of chin-to-chest sutures. Complete data sets were available for 93 patients. We performed multivariable logistic regression analysis to identify significant independent risk factors. A tertiary care children's hospital. All patients younger than 18 years who underwent CTR at our institution. Operation-specific and overall decannulation rates. Results of the preoperative evaluation showed grade III or IV stenosis in 89 patients (96%). The overall decannulation rate included 87 patients (94%); the operation-specific decannulation rate, 66 patients (71%). The only significant risk factor for failure to decannulate after 1 operation was the presence of unilateral or bilateral vocal cord paralysis (P = .007). Cricotraceal resection may be safely performed in patients with multiple airway lesions. Patients with a history of vocal cord paralysis who undergo CTR often require more than 1 open airway procedure for decannulation and should be counseled appropriately. This study represents the largest reported series of pediatric CTR.

Surgery for Pediatric Subglottic Stenosis: Disease-Specific Outcomes

To set the foundation to develop a disease-based, operation-specific model to predict the outcome of pediatric airway reconstruction surgery, we performed a retrospective database review of children operated on at a single, tertiary-care children's hospital. Over the 12-year period 1988 to 2000, a total of 1,296 airway reconstruction procedures were performed. Out of these, charts were identified for 199 children who underwent laryngotracheal reconstruction for a sole diagnosis of subglottic stenosis. Children were excluded from the study if their disorder included supraglottic, glottic, or upper tracheal disease. The main outcome measures were Myer-Cotton grade-specific decannulation and extubation rates, including both operation-specific and overall results. There were 101 children who underwent double-stage laryngotracheal reconstruction. The operation-specific decannulation rates for Myer-Cotton grades 2, 3, and 4 were 85% (18/21), 37% (23/61), and 50% (7/14) (chi2 analysis, p = .0007). The overall decannulation rates were 95% (20/21), 74% (45/61), and 86% (12/14) (chi2 analysis, p = .04). There were 98 children who underwent single-stage laryngotracheal reconstruction. The operation-specific extubation rates for Myer-Cotton grades 2, 3, and 4 were 82% (37/45), 79% (34/43), and 67% (2/3) (chi2 analysis, p = .63). The overall extubation rates were 100% (45/45), 86% (37/43), and 100% (3/3) (chi2 analysis, p = .03). Logistic regression analysis showed no effect of age (less than or greater than 2 years of age) on operation-specific or overall outcome parameters. We conclude that laryngotracheal reconstruction for pediatric subglottic stenosis remains a challenging set of procedures in which multiple operations may be required to achieve eventual extubation or decannulation. Children with Myer-Cotton grade 3 or 4 disease continue to represent a significant challenge, and refinements of techniques are being examined to address this subset of children. Disease-based, operation-specific outcome statistics are the first step in the development of a meaningful predictive model.