Management of A‐Frame Tracheal Deformity in Children With Endoscopic Resection Tracheoplasty

Abstract

Objectives Tracheal A‐frame deformity is a known consequence of tracheostomy that may lead to obstruction after decannulation. The goal of this study is to demonstrate the feasibility and success of endoscopic carbon dioxide (CO2) laser‐assisted tracheoplasty of tracheal A‐frame deformity in children. Methods Retrospective case series of symptomatic children with tracheal A‐frame deformity with no other site of airway obstruction (2016–2018). All patients underwent CO2‐laser assisted endoscopic resection tracheoplasty. Results Eight patients (six male) were included with a median age of 15.4 (IQR 12.3–17.9) years. Patients had a median of two previous open airway surgeries (IQR 1–2.5) and all patients had a history of tracheostomy with successful decannulation. Tracheal A‐frame deformity presented as dyspnea on exertion for all patients (n = 8, 100%). Obstructive sleep apnea was confirmed for all patients who underwent polysomnography (4/4, 100%). Median interval from decannulation to development of symptoms was 8.7 years (IQR 5.8–9.3). All patients sized with an age‐appropriate endotracheal tube despite the deformity. Endoscopic A‐frame tracheoplasty was successful for 7/8 (87.5%) patients and was performed with overnight observation for these patients (8/8, 100%). Unilateral A‐frame tracheoplasty was performed successfully for five patients (62.5%), bilateral A‐frame tracheoplasty was performed successfully for two patients (25.0%), and one patient (12.5%) did not have complete resolution of symptoms after bilateral A‐frame tracheoplasty due to multi‐level airway obstruction. Conclusions CO2 laser‐assisted tracheoplasty is an innovative endoscopic technique to relieve symptoms of airway obstruction for selected patients with tracheal A‐frame deformity although avoiding the morbidity and hospital stay duration associated with tracheal resection. Level of Evidence 4 Laryngoscope, 131:E719–E723, 2021

Association between surgical tracheostomy and chronic tracheal stenosis: A retrospective, single-center study

“…In the localization of tracheal stenosis, the minimum tracheal area was seen at the proximal and distal locations at BL, where there might be difficulty with intubation, even in patients without stenosis. After tracheostomy, the minimum tracheal area was predominantly observed above the tracheostomy site, consistent with prior reports examining symptomatic tracheal stenosis or deformity by endoscopy ( 6 , 12 ). On the other hand, the maximum area was broadly distributed across the trachea at BL.…”

“…In most reports regarding tracheostomy, bronchoscopy has been used to assess for tracheal stenosis ( 12 ). However, detailed changes in tracheal diameter by numerical value cannot be measured by bronchoscopy, and it is relatively invasive compared to CT ( 13 – 16 ).…”

Tracheal A‐Frame Deformities Following Airway Reconstruction

“…In the patients who require revision surgery, A-frames are less amenable to treatments such as balloon dilation and stent placement and frequently require aggressive laser-based endoscopic interventions, resection with end-to-end anastomosis, anterior graft LTR, or slide tracheoplasty. 9,15,16 In this study, the most important factor related to development of an A-frame deformity was the history of tracheostomy. From the population of children who developed this deformity, only one did not have a tracheostomy.…”

Assessing National Trends and Perceived Safety of Off‐Label Ciprofloxacin‐Dexamethasone Use by Pediatric Otolaryngologists

“…5 Anecdotal success of nebulized CPD has been reported for airway foreign body retrieval 13 , laryngeal trauma management 14 , tracheoplasty and tracheal resection 8 , and endoscopic airway management in children. 4,16 Notably, in our survey, a significantly greater percentage of respondents practicing for <10 years use nebulized CPD compared to those practicing for >10 years. This trend may be explained by greater exposure to offlabel CPD use for pediatric otolaryngologists who completed training more recently.…”

“…4 Studies have reported dosing nebulized CPD at 1 mL (20 drops) and 0.5 mL (10 drops) in 1 mL normal saline 2-3 times daily for 7 days after tracheal surgery for patients ≥2 years-old and <2 years-old, respectively. 4,8,12,16 Each mL of CPD contains 3 mg ciprofloxacin and 1 mg dexamethasone; one drop contains 0.04 mg ciprofloxacin and 0.11 mg dexamethasone. 5 Anecdotal success of nebulized CPD has been reported for airway foreign body retrieval 13 , laryngeal trauma management 14 , tracheoplasty and tracheal resection 8 , and endoscopic airway management in children.…”