Posterior Costal Cartilage Graft Research Articles

A Single Center Description of Adult and Pediatric Endoscopic Posterior Costal Cartilage Grafting.

Posterior glottis impairment alters breathing, voicing, and swallowing. Bilateral vocal fold movement impairment (BVFMI) occurs when the vocal cords are fixed/remain midline. Studies inadequately assessed endoscopic posterior costal cartilage grafting (enPCCG) for BVFMI across broad ages. We aim to assess decannulation and prosthesis free airway in children and adults who have undergone enPCCG. Retrospective cohort. Referral center. This study included adults and children who received enPCCG for BVFMI (2010-2018) and were followed for 35 months on average. The main outcome was successful decannulation of patients, or airway improvement in those without tracheostomy. Data on comorbidities, surgical complications, and interventions following surgery were collected. Ten children and 11 adults underwent enPCCG for BVFMI. Eighty-one percentof patients had a tracheostomy at surgery; adults were more likely to have a tracheostomy at surgery (P = 0.035), and to undergo double-staged procedure (P = 0.035) and stent (P = 0.008). Average stent duration was 29.7 days. Overall decannulation rate was 76% (90% for children; 70% for adults). Children were more likely to receive postoperative intensivecareunit care (P = 0.004). Adults had mean 4.4 post-enPCCG interventions per patient compared to children's mean 3.91 interventions. The most common interventions were steroid injection (17.6%) and balloon dilation (16%). Preliminary analysis suggests postoperative dysphonia was reported in 66.7% of patients; postoperative dysphagia was rare. EnPCCG was more successful at achieving decannulation in children. Adults required additional interventions. A double-staged operation with prolonged stenting is recommended for adult patients. A majority of patients were decannulated at last follow-up.

Revision Endoscopic Posterior Costal Cartilage Grafting: Is It Feasible?

The objective of this work is to examine the feasibility of revision endoscopic posterior costal cartilage graft (EPCCG) placement for posterior glottic stenosis (PGS) and bilateral vocal fold immobility (BVFI). Revision and primary cases were compared with respect to decannulation rates, and it was hypothesized that there would be no difference in outcomes. Twenty-one patients met inclusion criteria (14 primary, 7 revision). Thirteen (62%) had a primary indication of PGS, and 8 (42%) were for BVFI. There were no differences between revision and primary groups with respect to age, gender, or comorbidities (p > .05). There was no difference between groups with respect to decannulation rate (85% primary vs100% revision, p = .32). Thus, revision EPCCG appears to have comparable results to primary EPCCG with respect to decannulation rate and time to decannulation. EPCCG may be a feasible alternative to open airway reconstruction for PGS and BVFI in selected patients.

Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction.

Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction. A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019. A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy (P = .86), age at decannulation (P = .97), duration of tracheostomy (P = .43), or gestational age (P = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm, P = .03). Tracheostomy tube diameter (P = .02) and stent size (P < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up. Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.

Paediatric Bilateral Vocal Cord Paralysis: Our Experience

Bilateral vocal cord paralysis (BVCP) is the second most common cause of neonatal stridor. The aim of this study was to describe the demographic features, aetiology, comorbidities, and management of our patients with BVCP. Material and methodsWe conducted a retrospective review of the clinical charts of all patients diagnosed with BVCP seen at the Department of Respiratory Endoscopy between 2011 and 2015. Results47 patients were included. Mean age at diagnosis was 1 month and male sex predominated (63%). The aetiology was congenital in 59% and acquired in 41% of the infants. The cause was most frequently idiopathic in the former group and secondary to postoperative injury in the latter. Overall, 42 patients (89%) required tracheostomy, without statistically significant differences between the causes. Of all the patients, 39% regained vocal-cord mobility; 44% of those with congenital BVCP, 31% of those with acquired BVCP and 62.5% with idiopathic BVCP. In five patients a laryngotracheoplasty was performed with a posterior costal cartilage graft and one underwent posterior cordectomy. All were decannulated. In one patient vocal-cord lateralisation was performed, avoiding tracheostomy. ConclusionBVCP was most commonly of congenital cause and was mainly idiopathic within this group of patients, with a slight male preponderance. A high percentage of patients required tracheostomy. A higher recovery rate of vocal-cord mobility was observed in idiopathic BVCP, which allowed for successful decannulation. In this series, decannulation was possible in all patients that underwent surgery; however, further studies with comparison of techniques and objective assessment of swallowing and phonation are necessary.

Parálisis bilateral de cuerdas vocales en pediatría: nuestra experiencia

Bilateral vocal cord paralysis (BVCP) is the second most common cause of neonatal stridor. The aim of this study was to describe the demographic features, aetiology, comorbidities, and management of our patients with BVCP. Material and methodsWe conducted a retrospective review of the clinical charts of all patients diagnosed with BVCP seen at the Department of Respiratory Endoscopy between 2011 and 2015. Results47 patients were included. Mean age at diagnosis was 1 month and male sex predominated (63%). The aetiology was congenital in 59% and acquired in 41% of the infants. The cause was most frequently idiopathic in the former group and secondary to postoperative injury in the latter. Overall, 42 patients (89%) required tracheostomy, without statistically significant differences between the causes. Of all the patients, 39% regained vocal-cord mobility; 44% of those with congenital BVCP, 31% of those with acquired BVCP and 62.5% with idiopathic BVCP. In five patients a laryngotracheoplasty was performed with a posterior costal cartilage graft and one underwent posterior cordectomy. All were decannulated. In one patient vocal-cord lateralization was performed, avoiding tracheostomy. ConclusionBVCP was most commonly of congenital cause and was mainly idiopathic within this group of patients, with a slight male preponderance. A high percentage of patients required tracheostomy. A higher recovery rate of vocal-cord mobility was observed in idiopathic BVCP, which allowed for successful decannulation. In this series, decannulation was possible in all patients that underwent surgery; however, further studies with comparison of techniques and objective assessment of swallowing and phonation are necessary.

Direct tracheobronchopexy via left lateral thoracotomy for severe tracheobronchomalacia

An infant with pulmonary atresia/ventricular septal defect/major aortopulmonary collateral arteries underwent unifocalization, ventriculoseptal defect closure and placement of a right ventricle to pulmonary artery conduit via median sternotomy. Aortopexy and pulmonary arteriopexy via redo sternotomy were insufficient to allow weaning of continuous positive airway pressure and he required direct tracheobronchopexy via left lateral thoracotomy to alleviate posterior trachealis intrusion along the length of the trachea and left main bronchus. He also underwent laryngotracheoplasty with placement of a posterior costal cartilage graft for bilateral vocal cord paralysis. The patient was weaned from positive pressure and discharged in stable condition.

Repair of short type IV laryngotracheoesophageal cleft using long, tapered, engaging graft without need for tracheotomy

An infant with a type IV laryngotracheoesophageal cleft underwent transcervical repair using a long tapered cartilage graft. A laryngofissure was carried down to the innominate artery to expose the cleft that extended 5 mm inferior to the vessel. The edges of the cleft were excised, the trachealis was separated from the esophagus that was reapproximated, and clavicular periosteum was placed. A long posterior costal cartilage graft that tapered inferiorly in anteroposterior dimension and engaged behind the cricoid plate was inserted. This added rigidity to the repair and obviated the need for a tracheotomy while providing a four-layer closure. NA.

Management of complex glottic stenosis in children with recurrent respiratory papillomatosis

ObjectivesTo describe our management of complex glottic stenosis in tracheotomy dependent children with severe recurrent respiratory papillomatosis. MethodsRetrospective chart review at a tertiary care children's hospital. ResultsThree children with complex glottic stenosis secondary to severe recurrent respiratory papillomatosis were treated at our institution since 2011. Two patients had complete stenosis, and the third had near-complete stenosis. Two patients were managed using balloon dilation alone, and the third also underwent laryngotracheal reconstruction with posterior costal cartilage grafting. Two patients have been successfully decannulated and the third has been tolerating continuous tracheotomy capping for greater than twelve months. All three patients underwent aggressive debridement of papillomatosis and balloon dilation every 4–6 weeks until their burden of disease was controlled. In two patients, the glottic airway was patent, and the third continued to have complete restenosis between procedures and required laryngotracheoplasty with multiple post-operative dilation procedures to establish an adequate glottic airway. ConclusionsSevere laryngeal stenosis is a well-described complication of recurrent respiratory papillomatosis, but its management is not well-defined. Aggressive management of papillomatosis with frequent debridement is critical in successfully managing laryngeal stenosis. Balloon dilation alone may be surprisingly effective in these patients, and laryngotracheoplasty can be used as an adjunct procedure in those patients who fail balloon dilation. Given the quality of life issues and concerns regarding distal spread of disease with tracheotomies in these patients, we feel that aggressive management and early decannulation is in the patient's best interest.

Sutureless vs Sutured Posterior Costal Cartilage Grafting in Laryngotracheal Reconstruction in Children

To compare the postoperative course, complication rate, and decannulation rate in children who underwent either sutureless or sutured posterior costal cartilage grafting during laryngotracheal reconstruction (LTR). Retrospective chart review. Tertiary care children's medical center. The study included children who required posterior costal cartilage grafting when undergoing LTR for subglottic stenosis between the years of 2000 and 2009 by the senior author (J.E.M.) and who had adequate records for review. Postoperative complications, including the incidence of graft prolapse, restenosis or reobstruction requiring surgical intervention, and decannulation rate. Forty-nine children who underwent 52 procedures met the inclusion criteria for this study. All patients had grade III acquired subglottic stenosis and underwent double-staged LTR. Twenty procedures were performed with a sutureless posterior graft, and 32 were performed with suture placement. None of the 20 procedures that were performed with a sutureless graft had prolapse of the graft into the airway compared with 2 of 32 prolapsed posterior grafts (6%) that were sutured (P=.52). Eleven of 20 children (55%) with sutureless posterior grafts compared with 24 of 32 children (75%) who underwent sutured posterior grafts required endoscopic surgical intervention for restenosis or reobstruction (P=.22). Decannulation was achieved in 19 of 20 sutureless cases (95%) and in 28 of 30 cases (93%) in which sutures were placed (P=.56) after a single LTR and necessary endoscopic interventions occurring at 6.3 months and 4.9 months, respectfully (P=.42). Sutureless posterior costal cartilage grafting in children with acquired grade III subglottic stenosis is an equally effective and secure technique compared with sutured posterior grafting during double-staged LTR.

Partial cricotracheal resection with tracheal intussusception and cricoarytenoid joint mobilization: Early experience in a new technical variant

Partial cricotracheal resection with tracheal intussusception and cricoarytenoid joint mobilization: Early experience in a new technical variant

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 laryngology committee: Controversies in the diagnosis and management of pediatric vocal cord paralysis

Pediatric vocal cord paralysis represents a relatively common cause of airway obstruction presenting to the pediatric otolaryngologist. Depending on whether the paralysis is unilateral or bilateral, the child may present with symptoms of stridor, vocal dysphonia or aphonia, and/or aspiration. A thorough search for a possible underlying disorder is critical. Exact timing of intervention and the method of intervention vary according to symptoms and remain controversial. This seminar will consist of talks from established pediatric otolaryngologists with a wide scope of experience with these disorders. Diagnostic evaluation including flexible fiberoptic evaluation of swallowing (FEES) as well as flexible digital stroboscopy will be discussed. Surgical treatment options including vocal fold injection, thyroplasty, laser cordotomy/arytenoidectomy, vocal fold pexy, posterior costal cartilage graft, and nerve reinervation procedures will be discussed as treatment options. Digital video will be used to demonstrate the various procedures. Timing of such interventions will be discussed as well as this remains a key controversy.

Acquired total (grade 4) subglottic stenosis in children.

Pediatric acquired total subglottic stenosis (SGS) is a challenging problem. The management of these patients has evolved at our institution over the past 25 years. We conducted a retrospective study to evaluate the surgical management and outcomes of children with grade 4 SGS. Fifty-six patients have presented with acquired grade 4 SGS since 1981. The causes included previous surgery (34), prolonged intubation (15), bums (1), and unknown causes (6). Of the 56 patients, 44 (79%) were decannulated; 120 total procedures were performed, and 39 patients (70%) required more than 1 procedure for decannulation. The decannulation rate has risen from 67% in the 1980s to 86% in the 1990s. Patients who underwent cricotracheal resection (CTR) had a higher decannulation rate than patients who underwent laryngotracheal reconstruction (LTR) with anterior and posterior costal cartilage grafting (CCG) (92% versus 81%), and were less likely to need additional open procedures to achieve decannulation (18% versus 46%). The decannulation rate for children with grade 4 SGS has improved because of advances in surgical technique. Currently, the principal operations used at our institution are 1) CTR and 2) LTR with anterior and posterior CCG. There was a trend toward a higher decannulation rate in patients who underwent CTR, and they were less likely to require further reconstructive surgery before decannulation.

Single-stage laryngotracheal reconstruction in children: A review of 200 cases

Objective: We reviewed our experience with pediatric single-stage laryngotracheal reconstruction (SSLTR) to identify factors that affect postoperative outcomes, including the need for reintubation and tracheostomy. Study Design: Retrospective chart review was done. Results: In total, 190 children underwent 200 SSLTRs; 29% were reintubated, and 15% required postoperative tracheostomy. Currently, 96% are decannulated. The use of anterior and posterior costal cartilage grafting, age less than 4 years, sedation for more than 48 hours, a leak pressure around the endotracheal tube at greater than 20 cm H 2O, and moderate/severe tracheomalacia significantly increased the rate of reintubation. The duration of stenting did not affect outcomes. Children with anterior and posterior grafts and those with moderate or severe tracheomalacia were more likely to need a postoperative tracheostomy. Conclusion: SSLTR can be effective for the treatment of pediatric laryngotracheal stenosis. Diligent preoperative assessment of the patient and the patient's airway and close postoperative care are important to the success of this operation. (Otolaryngol Head Neck Surg 2000;123:430-4.)

Laryngotracheal reconstruction for subglottic stenosis in children.

The experience with laryngotracheal reconstruction in 20 children in Chicago is reviewed. Nine of the 20 children (45%) operated upon had congenital subglottic stenosis. Ten (50%) had acquired stenosis. One child was classified as having combined types. All patients underwent laryngotracheal reconstruction with autogenous costal cartilage grafts. Eight patients had both anterior and posterior costal cartilage grafts with stent insertion. One had a posterior costal cartilage graft only. Sixteen of the 20 children (80%) have been decannulated. Midtracheal or lower tracheal disease concomitant with laryngotracheal stenosis is an indication that endoscopic management of severe subglottic stenosis is likely to fail. Early laryngotracheal reconstruction is indicated for patients with a high likelihood of failure of endoscopic management and for those with severe cricoid cartilage deformities. Our results support the use of laryngotracheal reconstruction as an alternative to conservative (endoscopic) management of severe subglottic stenosis in carefully selected patients.