Laryngotracheal separation in pediatric patients: 13-year experience in a reference service

Abstract

Objective: To evaluate clinical stability of neurologically impaired children and adolescents with recurrent pneumonia submitted to laryngotracheal separation. Methods: Between October 2002 and June 2015, 92 neurologically impaired children from a reference service, with median age of 68.5 months were submitted to laryngotracheal separation. Data were evaluated and statistical analysis was made by Student's t test and Pearson's χ 2 test (significance level adopted of 95%). Results: Fifty-three children were male (57.6%). Forty-six children required admission to intensive care, and 42.4% needed mechanical ventilation. We observed that 90.2% of patients were exclusively fed by gastrostomy and 72.4% of the gastrostomies were performed before the tracheal surgery. Thirteen (14.1%) children had postoperative complications as follows: fistulae (5.4%), bleeding (4.3%), granuloma (2.2%) and stenosis (3.2%). A total of 24 patients had pneumonia in the postoperative period (26.1%), but there was a significant drop in occurrence of this condition after surgery (100% versus 26.1%; p<0.001). Twenty-three patients (25%) died. Postoperative complications were similar when comparing patients who died and those that presented good outcome (16.7% versus 13.2%; p=0.73). Conclusion: When well-indicated, the laryngotracheal separation reduces the incidence of postoperative pulmonary infections, thus improving quality of life and reducing admissions to hospital. Laryngotracheal separation should be indicated as a primary procedure in patients with cerebral palsy and recurrent aspiration pneumonia.

Surgical Management of Sialorrhea: A Systematic Review and Meta‐analysis

“…For refractory cases with intractable aspiration pneumonias, laryngotracheal separation is occasionally utilized as a last resort. 12,13…”

“…Current surgical approaches include submandibular gland excision (SMGE) alone, parotid duct rerouting or ligation (PDR or PDL), submandibular duct rerouting or ligation, sublingual gland excision, 4‐duct ligation, or any combination of these. For refractory cases with intractable aspiration pneumonias, laryngotracheal separation is occasionally utilized as a last resort 12 , 13 …”

“…For refractory cases with intractable aspiration pneumonias, laryngotracheal separation is occasionally utilized as a last resort. 12,13 Surgery involving the submandibular glands is effective due to the glands' role in salivary production while at rest, but there is limited evidence demonstrating the superiority of one technique over another. 14 Some practitioners determine the type of surgical intervention based on the exact location of excess saliva, with submandibular rerouting utilized for patients with anterior drooling only.…”

Challenge for management without tracheostomy tube after laryngo‐tracheal separation in children with neurological disorders

“…Tracheostomy is a simple procedure, although it requires frequent suction for neurologically impaired patients, and using a tracheostomy tube with an inflated cuff leads to laryngeal desensitization of the cough reflex. An LTS can reduce the need for tracheal suctioning and aspiration, decrease the number of hospitalizations for aspiration pneumonia, 13‐16 and improve respiratory status, sometimes without the need for tracheostomy tubes. In our study, an LTS facilitated the respiratory management for all the patients, which led to a decreased need for hospitalization due to pneumonia.…”

Quality of life of caregivers supporting neurologically impaired patients who underwent surgery

“…Several previous studies reported that surgical procedures reduce the symptoms related to the complications and consequently improve QOL in NI patients. More specifically, these procedures result in stabilization of breathing by securing a surgical airway via tracheostomy, 5 prevent aspiration pneumonia by laryngotracheal separation to interrupt the aspiration route, 6 improve GERD‐related symptoms by fundoplication, 7 and secure the route of enteral nutrition by gastrostomy 8 …”