Tracheal ring-graft reinforcement in lieu of tracheostomy for tracheomalacia

Abstract

Three children with tracheomalacia had tracheal reinforcement with free three-quarter circumference ring grafts of autologous cartilage taken from the costal margin. A low cervical manubrium-splitting approach gave excellent access to the anterior mediastinum and the intrathoracic trachea in two children. The first child, a neonate with oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF), had 11 grafts to support the whole of the trachea from the cricoid to the carina and never required a tracheostomy. For the first 5 years she had frequent pneumonic episodes and on one occasion bilateral pneumothoraces. These episodes and radiographic lung hyperinflation, attributed to distal bronchomalacia, have reduced spontaneously in frequency and severity. At 9 years of age she has a well-supported trachea with palpable cartilage rings in the cervical segment. The trachea has grown to approximately 75% of expected normal size for her age. Another child with tracheomalacia related to innominate-artery compression and who presented with 'dying episodes' was completely relieved and resumed a normal life without a tracheostomy following insertion of four grafts to the intrathoracic trachea. He remains well and symptom-free 8 months postoperatively. A third child had cartilage-graft reinforcement of the lower cervical trachea, including the tracheostomy site, to achieve tracheostomy closure at 16 months of age. Five years later he continues to have a well-supported trachea showing acceptable growth. However, he has ongoing evidence of tracheo-bronchomalacia presenting as expiratory wheezing, lung hyperinflation, and pneumonic episodes that are diminishing spontaneously with growth. Our experience, limited to three children, recommends primary tracheal reinforcement with autologous free costal-cartilage grafts for tracheomalacia in the neonate and young infant. This procedure and the anterior mediastinal approach are well-tolerated, providing instant tracheal support, removing the need for a tracheostomy, and allowing the child's rapid return to the family. Long-term follow-up, presently 9 and 5 years in two children originally presenting with OA and TOF, indicates adequate tracheal growth and an aesthetically acceptable appearance. It is relevant to prognosis that relief of the life-threatening tracheal component exposed the full extent of the bronchial cartilaginous weakness, which has significantly detracted from the quality of life for these two children with OA and TOF-related tracheomalacia.

A new technique for treatment of tracheal compression by the innominate artery: external reinforcement with autologous cartilage graft and muscle flap suspension

“…c The innominate artery was brought down by retracting it with a muscle sling. d The patient reqired Tracheostoma Retainer device to ensure patency of the stoma costal cartilage may promote growth and prevent fibrosis [4,5]. In our first case, we performed splinting (reinforcing) the posterior membranous wall of the trachea with cartilage ring graft to prevent its obstructive infolding by the protruding spine, but we recognized that if the cartilage graft is placed posteriorly to the trachea, there would obviously be some fibrosis and with time the trachea will not be able to widen as it normally would with growth and that if the trachea is elevated off the spine by both tracheopexy to the manubrium and removal of the manubrium to allow more space, the back of the trachea would not need to be supported further.…”

“…In our cases, the compressed segment of trachea by the innominate artery has been malacic and fragile, necessitating to be reinforced. In this instance, we performed external reinforcement with autologous cartilage graft [4] and muscle flap suspension of the innominate artery to relieve compression of the trachea.…”

Defect classification and reconstruction algorithm for patients with tracheostomy using the tunneled supraclavicular artery island flap

“…Stability of the anterior part of the trachea is crucial for functional reconstruction [2]. For type II patients, the fascial part of the fasciocutaneous flap reinforces of the anterior tracheal wall and avoids secondary strictures since the tracheal lining is not harmed.…”

“…For closure or, in patients with permanent tracheostomy, diameter reduction, simple procedures like local advancement flaps are inadequate because of the poor quality of the surrounding tissue and the multilayer structure of the defect [5]. In case of tracheal instability, the missing anterior wall of the trachea should be reconstructed with rigid tissue [2]. Also, the final aesthetic result is of great importance because of the visibility of the suprasternal notch.…”

“…Also, the final aesthetic result is of great importance because of the visibility of the suprasternal notch. Several procedures have been advocated for closure, including multilayered advancement flaps [7,13], sternocleidomastoid muscle flaps [9], free cartilage transfer [17,2], and free flap surgery [8,3].…”