Endoscopic Preoperative Assessment, Classification of Stenosis, Decision-Making

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.

Outcome of Post-intubation Tracheal Stenosis (PITS) with Primary Resection and Anastomosis

“…The ultimate objective of treating tracheal stenosis is to ensure luminal restoration, while preserving phonation and lower respiratory passage protection against aspiration. 14 To achieve these goals, many patients have to undergo more than one treatment modalities. The myriad of treatment modalities range from LASER ablation, possibly combined with dilatation and intraluminal placement of stent.…”

Unanticipated Difficult Airway During Elective Surgery: A Case Report and Review of Literature

“…LTR and CTR correct the stenosis by achieving decannulation, which is tracheostomy tube removal [5]. Studies have shown that 96% of children with subglottic stenosis achieve decannulation when undergoing a posterior graft LTR, which proves to be a very successful treatment and management of subglottic stenosis [9].…”

“…8 Includes postponing the case or postponing the intubation and returning with appropriate resources. 9 Other options include, but are not limited to, proceeding with the procedure utilizing a face mask or supraglottic airway ventilation. Pursuit of these options usually implies that ventilation will not be problematic.…”

Established and innovative surgical techniques for the treatment of benign subglottic stenosis

“…The proximity of the scar tissue to the vocal fold is determined and an involvement of the vocal chords or the arytenoid cartilages by the scar tissue is documented. The length of the stenosis and the entire trachea is also measured ( 4 ).…”

“…Figure4 Subglottic stenosis with significant lateral submucosal scar formations is shown in (A). A lateral cricoplasty using a scalpel is performed (B).…”