Single stage laryngotracheal reconstruction with anterior rib cartilage graft

For pediatric patients with intermediate grade subglottic stenosis (typically grade 2 or 3) who either have a pre-existing tracheotomy or who have undergone prior interventions such as balloon dilation with persistent area of stenosis. This procedure is ideal for patients with an uncomplicated clinical history and without any significant medical co-morbidities

Other significant co-existing airway obstruction, reactive or edematous larynx, uncontrolled GERD or laryngopharyngeal reflux, presence of eosinophilic esophagitis

The rib and neck are prepped and draped as two separate surgical fields. The rib harvest must be done under sterile conditions whereas the neck is considered a clean-contaminated field. A separate direct laryngoscopy setup with telescope and camera is situated at the head of the bed for use throughout the case.

The patient's history must be reviewed and if a tracheotomy is already present the indication for that trach being placed should be examined. The presence of other pulmonary co-morbidities, usage of supplemental oxygen at baseline, and adequate pulmonary clearance with a good cough are vital pre-requisites to a successful operation. Other considerations include feeding tube dependency, oral aversion, neurological dis-coordination, preoperative vocal quality and presence of other anatomical defects.

It is important to understand the length of the area of stenosis on direct laryngoscopy and bronchoscopy and (if present) its relation to the tracheostomy site. This will determine the length of the cartilage graft necessary to open up the airway.

By performing a single stage procedure the patient is able to avoid having a tracheotomy at the end of the case. The airway is typically stented with an endotracheal tube in the immediate postoperative period and the patient is then extubated in the OR within the first week following the initial procedure. This is in contrast to a double stage reconstruction where the patient has a tracheotomy following reconstruction and airway stenting is done with a stand alone laryngeal stent for 3-4 weeks.

In the immediate postoperative period the patient requires expert ICU level care and adequate sedation in order to allow for appropriate airway healing. Also, as there is no tracheostomy present there is potential for a tenuous airway following extubation.

In the immediate postoperative period the patient requires expert ICU level care and adequate sedation in order to allow for appropriate airway healing. Also, as there is no tracheostomy present there is potential for a tenuous airway following extubation.