setting the stage contextcontext - denver, colorado · first slide tracheoplasty on a baby with...

Acquired Subglottic StenosisAcquired Subglottic Stenosis

Michael J. Rutter, FRACSDepartment of Pediatric Otolaryngology-

Head & Neck SurgeryAerodigestive and Esophageal Center

Cincinnati Children’s Hospital Medical CenterCincinnati, Ohio

Michael J. Rutter, FRACSDepartment of Pediatric Otolaryngology-

Head & Neck SurgeryAerodigestive and Esophageal Center

Cincinnati Children’s Hospital Medical CenterCincinnati, Ohio

IPSADenver, CO

June 2nd 2016

Disclosure InformationDisclosure Information• Formerly scientific advisory board:

• Acclarent Medical• Airway balloon dilator

• Consultant / Patent holder• Bryan Medical – Aeris balloon dilator

• Consultant (no financial relationship)• Boston Medical Products

• Suprastomal stent

• And I also use many products off-label!

• Formerly scientific advisory board:• Acclarent Medical

• Airway balloon dilator

• Consultant / Patent holder• Bryan Medical – Aeris balloon dilator

• Consultant (no financial relationship)• Boston Medical Products


• And I also use many products off-label!

Setting the StageSetting the Stage

• Before the 1970s endoscopic surgery was the mainstay of airway surgery • Mainly bouginage dilation

• 1970s – 2000 open airway surgery predominated• Expansion grafting and resection

• 21st century a resurgence of interest in endoscopic surgery• Often complimenting open surgery

• Before the 1970s endoscopic surgery was the mainstay of airway surgery • Mainly bouginage dilation

• 1970s – 2000 open airway surgery predominated• Expansion grafting and resection

• 21st century a resurgence of interest in endoscopic surgery• Often complimenting open surgery

ContextContext

• I enjoy open airway surgery• In 2010:

• LTRs 28• CTRs 6• Clefts 4• Slides 20

• I enjoy open airway surgery• In 2010:

• LTRs 28• CTRs 6• Clefts 4• Slides 20

ContextContext

• I am also an endoscopic airway surgeon• Since 2001

• Balloon dilations > 2700

• Cleft > 25

• TEF > 18

• Glottic web > 8

• Posterior grafts > 10

• I am also an endoscopic airway surgeon• Since 2001

• Balloon dilations > 2700

• Cleft > 25

• TEF > 18

• Glottic web > 8

• Posterior grafts > 10

2016 - Trends2016 - Trends

• Evolution, both of operative techniques, and the patients themselves

• Collaboration

• Pre-operative evaluation and optimization

• New tools

• Endoscopic techniques compliment open reconstructive techniques

• Evolution, both of operative techniques, and the patients themselves

• Collaboration

• Pre-operative evaluation and optimization

• New tools

• Endoscopic techniques compliment open reconstructive techniques

Rutter, Michael, MD Acquired Subglottic Stenosis

Optimization and EvaluationOptimization and Evaluation

• Airway surgery may be challenging and risky• Revision surgery especially

• Pre-operative evaluation, patient optimization, and team collaboration improves outcomes• Not just airway, but voice,

aspiration, etc

• Airway surgery may be challenging and risky• Revision surgery especially

• Pre-operative evaluation, patient optimization, and team collaboration improves outcomes• Not just airway, but voice,

aspiration, etc

STATE OF THE ARTEvaluation, Collaboration, Optimization

STATE OF THE ARTEvaluation, Collaboration, Optimization

• Team Approach

• ADEC evaluation

• Triple scope• Pulmonary

• ORL

• GI• Reflux

• Eosinophilic Esophagitis

• Team Approach

• ADEC evaluation

• Triple scope• Pulmonary

• ORL

• GI• Reflux

• Eosinophilic Esophagitis

AERODIGESTIVE AND ESOPHAGEAL CENTERAERODIGESTIVE AND

ESOPHAGEAL CENTER

TEAM APPROACH

Reconstruction OptionsReconstruction Options

• Endoscopic techniques

• Expansion• Anterior cricoid split

• Anterior cartilage graft

• Posterior cartilage graft

• Anterior / posterior cartilage grafts

• Resection• Cricotracheal resection

• Endoscopic techniques

• Expansion• Anterior cricoid split

• Anterior cartilage graft

• Posterior cartilage graft

• Anterior / posterior cartilage grafts

• Resection• Cricotracheal resection

Graft MaterialsGraft Materials

• Costal Cartilage • The workhorse

• Thyroid alar cartilage• Auricular cartilage• Other

• Nasal septum• Hyoid• Clavicular periosteum• Buccal

• Costal Cartilage • The workhorse

• Thyroid alar cartilage• Auricular cartilage• Other

• Nasal septum• Hyoid• Clavicular periosteum• Buccal

Stenting OptionsStenting Options

• Nil

• Single stage - extubate on table

• Single stage - endotracheal tube

• T-Tube


• (Wired in full length stent)

• Nil

• Single stage - extubate on table

• Single stage - endotracheal tube

• T-Tube


• (Wired in full length stent)


What We have LearnedWhat We have Learned

• Risk factors for failure:• MRSA

• The “Active” larynx

• Causes of an active larynx• Reflux

• Eosinophilic esophagitis

• Unknown• Zithromax trial?

• Risk factors for failure:• MRSA

• The “Active” larynx

• Causes of an active larynx• Reflux

• Eosinophilic esophagitis

• Unknown• Zithromax trial?

2 Year Old Boy2 Year Old Boy

• 8.5kg, tracheotomy dependent, ex-25 weeker

• LTP declined due to weight

• Mother (a urologist) seeking a second opinion

• 8.5kg, tracheotomy dependent, ex-25 weeker

• LTP declined due to weight

• Mother (a urologist) seeking a second opinion

MLB – Active LarynxMLB – Active Larynx Other Investigations?Other Investigations?

• Impedance probe – NEGATIVE

• Esophagoscopy + biopsies – NEGATIVE

• No reflux, no eosinophilic esophagitis

• What next?

• Impedance probe – NEGATIVE

• Esophagoscopy + biopsies – NEGATIVE

• No reflux, no eosinophilic esophagitis

• What next?

WAITWAIT

• Didn’t work

• Zithromax• Azithromycin, macrolide antibiotic

• Suggested by pulmonology

• Used as an anti-inflammatory drug in cystic fibrosis

• 5 mls (200mg) Monday, Wednesday, Friday

• Didn’t work

• Zithromax• Azithromycin, macrolide antibiotic

• Suggested by pulmonology

• Used as an anti-inflammatory drug in cystic fibrosis

• 5 mls (200mg) Monday, Wednesday, Friday

2 Months Zithromax2 Months Zithromax


LTPLTP Stent Removal 6 WeeksStent Removal 6 Weeks

6 Months Later6 Months LaterEndoscopic vs Open for Stenosis

Framework ConceptEndoscopic vs Open for Stenosis

Framework Concept

• Intact framework• Cartilaginous framework is intact

• Intraluminal component is the main obstructive component

• Both options are viable

• Poor framework• Absence of cartilage

• Weak or degraded framework

• Open surgery to recreate framework

• Intact framework• Cartilaginous framework is intact

• Intraluminal component is the main obstructive component

• Both options are viable

• Poor framework• Absence of cartilage

• Weak or degraded framework

• Open surgery to recreate framework

Endoscopic SurgeryBalloon Dilation

Endoscopic SurgeryBalloon Dilation

• A powerful tool

• Results are all over the map

• Temptation is to lump together differing procedures done with differing techniques for differing problems

• We are lacking guidelines, both regarding technique and patient selection• We are still in expert opinion mode

• A powerful tool

• Results are all over the map

• Temptation is to lump together differing procedures done with differing techniques for differing problems

• We are lacking guidelines, both regarding technique and patient selection• We are still in expert opinion mode

Balloon DilationBalloon Dilation

• What we don’t know:• What size balloon to select

• How much pressure is appropriate

• How long to leave it inflated

• When to repeat

• How often to repeat

• Who should not be dilated

• When additional procedures should be done

• What we don’t know:• What size balloon to select

• How much pressure is appropriate

• How long to leave it inflated

• When to repeat

• How often to repeat

• Who should not be dilated

• When additional procedures should be done


Airway Balloon DilationAirway Balloon Dilation

• This is not new• Resurgence of

interest

• High pressure balloon dilation• Primary

intervention

• Complimentary procedure

• Adjunctive procedure

• This is not new• Resurgence of

interest

• High pressure balloon dilation• Primary

intervention

• Complimentary procedure

• Adjunctive procedure

Current ExperienceCurrent Experience

• Since 2001, over 2700 balloon dilations performed• 1 complication

• Even my more cynical colleagues are converting!

• As with standard dilation techniques, not effective for everything

• Since 2001, over 2700 balloon dilations performed• 1 complication

• Even my more cynical colleagues are converting!

• As with standard dilation techniques, not effective for everything

The Index CaseThe Index Case

• In February 2001, Peter Manning and I performed our first slide tracheoplasty on a baby with complete tracheal rings and a Grade 1 subglottic stenosis

• Post operatively she developed a “Figure 8” trachea

• Wished to dilate, but was limited by the subglottic stenosis

• An angioplasty balloon dilator was the solution

• In February 2001, Peter Manning and I performed our first slide tracheoplasty on a baby with complete tracheal rings and a Grade 1 subglottic stenosis

• Post operatively she developed a “Figure 8” trachea

• Wished to dilate, but was limited by the subglottic stenosis

• An angioplasty balloon dilator was the solution

Advantages / DisadvantagesAdvantages / Disadvantages

• Advantages• Radial dilation - no

shear forces

• Precise high pressure dilation

• Low risk

• Disadvantages• Cost

• Balloon “slips” easily

• Single use device

• Advantages• Radial dilation - no

shear forces

• Precise high pressure dilation

• Low risk

• Disadvantages• Cost

• Balloon “slips” easily

• Single use device

GuidelinesGuidelines

• Formula:• Take the outer diameter

of an age appropriate endotracheal tube

• Add 1mm for laryngeal dilation

• Add 2mm for tracheal dilation

• Formula:• Take the outer diameter

of an age appropriate endotracheal tube

• Add 1mm for laryngeal dilation

• Add 2mm for tracheal dilation

Example: A 4 year old child should take a 5.0 ETT, with an outer diameter of 6.8mm, therefore I would choose a 8mm balloon to dilate the larynx, and a

9mm balloon to dilate the trachea

TechniqueTechnique• Endoscopically guided balloon

placement• Usually direct placement into the

trachea• Occasionally through the suction port

of a ventilating bronchoscope or tracheoscope

• Patient is pre-oxygenated, then Propofol bolus

• Balloon is inflated to rated burst pressure• Pressure is maintained for either 2

minutes, or until the oxygen saturation drops to 90%

• Balloon is then deflated and removed

• Endoscopically guided balloon placement• Usually direct placement into the

trachea• Occasionally through the suction port

of a ventilating bronchoscope or tracheoscope

• Patient is pre-oxygenated, then Propofol bolus

• Balloon is inflated to rated burst pressure• Pressure is maintained for either 2

minutes, or until the oxygen saturation drops to 90%

• Balloon is then deflated and removed


Complimentary Procedure 6 Week Old Girl

Complimentary Procedure 6 Week Old Girl

• Transferred with stridor

• Term delivery

• Apnea at home at 2 weeks – intubated by the ambulance crew, transferred to local hospital. 4.5ETT

• Extubated 3 days later

• Home day 7

• Increasing stridor

• Transferred with stridor

• Term delivery

• Apnea at home at 2 weeks – intubated by the ambulance crew, transferred to local hospital. 4.5ETT

• Extubated 3 days later

• Home day 7

• Increasing stridor

6 Week Old Girl6 Week Old Girl

• Balloon dilation with a 5mm balloon at 20 atmospheres for 30 seconds

• Now leaking around a 3.0 ETT

• 5 days later “elective” LTR

• Today I would have tried to avoid the LTR!

• Balloon dilation with a 5mm balloon at 20 atmospheres for 30 seconds

• Now leaking around a 3.0 ETT

• 5 days later “elective” LTR

• Today I would have tried to avoid the LTR!

6 Year Old Girl6 Year Old Girl

• Ex-premmie, prolonged intubation, past cricoid split

• Past “bouginage” dilation

• Stridor at rest, exercise intolerance, 3.0 ETT airway

• Sickle knife division, kenalog injection, dilation

• Ex-premmie, prolonged intubation, past cricoid split

• Past “bouginage” dilation

• Stridor at rest, exercise intolerance, 3.0 ETT airway

• Sickle knife division, kenalog injection, dilation

Tools – Blitzer KnifeTools – Blitzer Knife

Tools – Oral Tracheal InjectorTools – Oral Tracheal Injector 6 Year Old Girl6 Year Old Girl

• Returns 2 weeks later

• Now 4.5 ETT airway

• Asymptomatic

• Re-dilation 10mm balloon

• Age appropriate airway at 1 year

• Returns 2 weeks later

• Now 4.5 ETT airway

• Asymptomatic

• Re-dilation 10mm balloon

• Age appropriate airway at 1 year


Open Airway SurgeryOpen Airway Surgery

• There are only 3 open airway operations for laryngotracheal stenosis:• Augmentation grafting

• Resection

• Slide

• There are only 3 open airway operations for laryngotracheal stenosis:• Augmentation grafting

• Resection

• Slide

Open Airway Surgery21st Century

Open Airway Surgery21st Century

• LTR• Anterior vs posterior vs anterior and posterior• Posterior grafting without sutures• Infant LTR

• CTR• With combined posterior grafting

• Slide tracheoplasty• Congenital tracheal stenosis (transthoracic)• Acquired tracheal stenosis (transcervical)

• LTR• Anterior vs posterior vs anterior and posterior• Posterior grafting without sutures• Infant LTR

• CTR• With combined posterior grafting

• Slide tracheoplasty• Congenital tracheal stenosis (transthoracic)• Acquired tracheal stenosis (transcervical)

Augmentation GraftingAugmentation Grafting

• Aim is to expand the laryngotracheal exoskeleton

• Grafts may include costal cartilage, thyroid cartilage, pericardium, even homograft

• Operations include anterior graft LTP, posterior graft LTP, A/P grafts, pericardial patches etc

• Aim is to expand the laryngotracheal exoskeleton

• Grafts may include costal cartilage, thyroid cartilage, pericardium, even homograft

• Operations include anterior graft LTP, posterior graft LTP, A/P grafts, pericardial patches etc

Augmentation GraftingAugmentation Grafting

• A 2 dimensional operation• Less surgeon specific

• Outcomes relate to Grade of stenosis

• Negative predictors of success include• Active larynx

• GER, EoE

• MRSA colonization

• Revision surgery

• 50 - 90% success

• A 2 dimensional operation• Less surgeon specific

• Outcomes relate to Grade of stenosis

• Negative predictors of success include• Active larynx

• GER, EoE

• MRSA colonization

• Revision surgery

• 50 - 90% success

LTR in the InfantLTR in the Infant

• This is an alternative to tracheotomy in small children who have left hospital, but returned with SGS and stridor• Often post RSV, or ex-premmies

• Anterior thyroid alar graft, posterior cricoid split• A posterior split is ideal for the young child (< 1

year)• Posterior split stabilizes rapidly in infants• Complete laryngofissure not required

• May be single staged• Appropriate for children as small as 2.5kgs

• This is an alternative to tracheotomy in small children who have left hospital, but returned with SGS and stridor• Often post RSV, or ex-premmies

• Anterior thyroid alar graft, posterior cricoid split• A posterior split is ideal for the young child (< 1

year)• Posterior split stabilizes rapidly in infants• Complete laryngofissure not required

• May be single staged• Appropriate for children as small as 2.5kgs


Posterior Cricoid GraftingPosterior Cricoid Grafting

• Technique evolution• Non-sutured posterior

costal cartilage grafts

• Shorter stenting periods

• Attempting to preserve the anterior commissure

• LTR number 1000!• 1998

• Our first sutureless posterior graft

• Technique evolution• Non-sutured posterior

costal cartilage grafts

• Shorter stenting periods

• Attempting to preserve the anterior commissure

• LTR number 1000!• 1998

• Our first sutureless posterior graft

The cricoid, cricothyroid membrane and lower 1/3rd of the thyroid cartilage are incised in the midline, preserving the anterior commissure, and the integrity of the thyroid cartilage

The cricoid, cricothyroid membrane and lower 1/3rd of the thyroid cartilage are incised in the midline, preserving the anterior commissure, and the integrity of the thyroid cartilage

The posterior cricoid is infiltrated with 1:100 000 epinephrine and lidocaineThe posterior cricoid is infiltrated with 1:100 000 epinephrine and lidocaine

The posterior cricoid is split and pockets createdThe posterior cricoid is split and pockets created


AdvantagesAdvantages

• Avoiding a complete laryngofissure stabilizes the larynx

• LA infiltration posterior to the cricoid provides hemostasis and protects the esophagus

• Keeping the anterior commissure intact is desirable• Voice• Laryngeal cartilage stability

• The flanged graft is rapidly carved

• The technique is faster

• Avoiding a complete laryngofissure stabilizes the larynx

• LA infiltration posterior to the cricoid provides hemostasis and protects the esophagus

• Keeping the anterior commissure intact is desirable• Voice• Laryngeal cartilage stability

• The flanged graft is rapidly carved

• The technique is faster

Anterior / Posterior GraftAnterior / Posterior Graft

• Gd III and IV subglottic stenosis

• Especially if lateral shelves

• Especially if close to the cords

• Gd III and IV subglottic stenosis

• Especially if lateral shelves

• Especially if close to the cords


LTP OutcomesLTP Outcomes

• LTR has been established as a mainstay for treatment of laryngotracheostenosis

• Success is highly correlated with the degree of stenosis• (increasing stenosis and decreasing success

rate)

• LTR has been established as a mainstay for treatment of laryngotracheostenosis

• Success is highly correlated with the degree of stenosis• (increasing stenosis and decreasing success

rate)

Cricotracheal ResectionCricotracheal Resection

• CONCEPT:• Remove the

“Diseased” or damaged segment of the laryngotracheal airway

• Connect the “Healthy” superior and inferior airway segments

• Achieve decannulation

• CONCEPT:• Remove the

“Diseased” or damaged segment of the laryngotracheal airway

• Connect the “Healthy” superior and inferior airway segments

• Achieve decannulation

Best Candidates for CTRBest Candidates for CTR

• Grade IV or Severe Grade III Subglottic Stenosis with a Clear Margin (> 3 mm) Between the Stenosis and the Vocal Folds

• Grade IV or Severe Grade III Subglottic Stenosis with a Clear Margin (> 3 mm) Between the Stenosis and the Vocal Folds


The Future Role of CTRThe Future Role of CTR

• Ideal for severe SGS and salvage SGS

• Complementary to LTR• Very useful to have both

tools available

• CTR is a technically challenging operation in children (compared to LTR)

• There is a significant learning curve

• When it goes wrong, it can really go wrong

• Ideal for severe SGS and salvage SGS

• Complementary to LTR• Very useful to have both

tools available

• CTR is a technically challenging operation in children (compared to LTR)

• There is a significant learning curve

• When it goes wrong, it can really go wrong

Subglottic Stenosis - CTRSubglottic Stenosis - CTR

• This is a difficult operation• Demands 3 dimensional thinking

• A distinct learning curve

• Certain operative risks• Is CTR the right procedure?

• Hug the tracheal perichondrium to avoid recurrent laryngeal nerves

• Very vunerable close to the cricothyroid joints

• This is a difficult operation• Demands 3 dimensional thinking

• A distinct learning curve

• Certain operative risks• Is CTR the right procedure?

• Hug the tracheal perichondrium to avoid recurrent laryngeal nerves

• Very vunerable close to the cricothyroid joints

Tracheal Stenosis -Slide TracheoplastyTracheal Stenosis -Slide Tracheoplasty

• The 3rd alternative

• Introduced by Tsang and Goldstraw in 1989

• Popularized by Grillo in the 1990s

• Introduced at Cincinnati Children’s in 2001

• Conceived as an intrathoracic technique for managing complete tracheal rings

• The 3rd alternative

• Introduced by Tsang and Goldstraw in 1989

• Popularized by Grillo in the 1990s

• Introduced at Cincinnati Children’s in 2001

• Conceived as an intrathoracic technique for managing complete tracheal rings

Cervical Slide - EvolutionCervical Slide - Evolution

• Acquired tracheal stenosis • Initially long segment

• Increasingly as a replacement for tracheal resection even for short segment

• Salvage

• Acquired tracheal stenosis • Initially long segment

• Increasingly as a replacement for tracheal resection even for short segment

• Salvage


Mike Rutter

Catherine Hart

Robin Cotton

Alessandro deAlarcon


setting the stage contextcontext - denver, colorado · first slide tracheoplasty on a baby with...

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