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Dr. Ian Jacobs and Dr. Karen Zur describe three types of surgeries for reconstructing the pediatric airway - laryngotracheal reconstruction (LTR), cricotracheal resection (CTR), and slide tracheoplasty.
"Airway comes first." The Center for Pediatric Airway Disorders at The Children's Hospital of Philadelphia is nationally renowned for expert repair and comprehensive care for children with complex airway disorders.
Joanne Stow, MSN: So the day of surgery is very stressful for these families. Some of them have waited a year, year and a half, maybe two or three years, to get to this point of surgical reconstruction. It's a very big day in their lives.
John E. Fiadjoe, MD: And everyone's goal is to make sure we have a calm patient and a calm family.
Joanne Stow, MSN: Children frequently get a medication to help them if they're feeling anxious. So that they're very relaxed. In fact, a lot of the kids leave their parents giggling, which is very reassuring for family to see. The family gets to stay with the child in the preoperative area right up until the moment of surgery.
John E. Fiadjoe, MD: We have a Child Life team that engages the child to make the process of coming to the operating room a very comfortable and relaxing process for our patients and for our parents. As anesthesiologists we consider ourselves the primary managers of the airway. During many of these airway reconstruction cases, we have to share the airway with the surgeon.
Ian N. Jacobs, MD: So there's a tremendous choreography that goes into designing an operation and planning it out.
Ralph F. Wetmore, MD: We have several anesthesiologists who work with the Airway Program.
John E. Fiadjoe, MD: And I think one of the strengths of our staff is that we have developed a very outstanding working relationship with the surgeons and are able to share the airway effectively by communicating throughout the procedure to avoid many problems that can occur when you're sharing the airway.
Ian N. Jacobs, MD: There really are two basic approaches to reconstructing the pediatric airway. One is known as "laryngotracheal reconstruction, or LTR." The other is known as "cricotracheal resection, or CTR."
Karen B. Zur, MD: The choice between laryngotracheal reconstruction and cricotracheal resection depends on the degree of stenosis, or how severe is the narrowing, and how far away from the vocal cords the narrowing is. Subglottic stenosis is a little more common in children because the cricoid cartilage, which is the narrowest portion of our airway, is a signet-shaped ring that sits right below the vocal cords, and that area is vulnerable to intubation trauma. So there are many premature babies who are born who have to have a breathing tube in place for an extended period of time that can cause some narrowing in that area. So acquired subglottic stenosis is a very common reason why we end up performing laryngotracheal reconstruction.
Ian N. Jacobs, MD: Laryngotracheal reconstruction, or LTR, involves reconstruction using cartilage grafts to expand or enlarge the airway. These cartilage grafts are borrowed from the rib, so cartilage can be easily transplanted from one portion of the body to the other and will survive in a remarkable fashion. And what it's used as is a spacer, in other words, it enlarges the size of the airway.
Karen B. Zur, MD: We're going to be splitting up the cricoid cartilage and the trachea in the midline and then importing a piece of rib cartilage, or it could be another type of cartilage, but most commonly a rib cartilage. The piece of graft is shaped to fit that defect and then it gets snapped into the area between those split ends of the cricoid.
Ian N. Jacobs, MD: We take a very narrowed airway, and we'll transect that airway in one or two positions and place one of these spacers in there to dramatically enlarge the size of the airway.
Mary Kelly, Mother: The cartilage, actually, he said just went beautifully into her airway.
Jed Kelly, Father: And where they had done the graft you could see the new tissue was growing around the graft.
Mary Kelly, Mother: And the cartilage is now just going to become part of her airway, and eventually, when you go down there with another scope, you won't even see it.
Ian N. Jacobs, MD: Now, the other potential surgery we may do for the more advanced cases of stenosis is known as "cricotracheal resection," or CTR.
Karen B. Zur, MD: The cricotracheal resection is when you're actually removing a diseased portion of the airway and then reconnecting two healthy portions.
Ian N. Jacobs, MD: That involves cutting out the scarred portion of the airway or the larynx and moving up normal trachea to replace it.
Karen B. Zur, MD: So we have to make sure before committing to performing a cricotracheal resection that we have enough space below the vocal cords to accommodate that suturing of the trachea to the voice box.
Ian N. Jacobs, MD: It's a more involved operation, which is not done as commonly as LTR, but it can treat the most severe cases of subglottic stenosis and tracheal stenosis with outstanding results.
Karen B. Zur, MD: The other type of reconstruction for a tracheal stenosis that's further down in our airway is something called a "slide tracheoplasty," where you don't remove the area of narrowing, but you just cut into it and then you slide the trachea side by side and connect it. So you make it shorter, but it's wider.
Ian N. Jacobs, MD: An incision is made in the back portion of the upper end of the trachea and the front portion of the bottom end, and the two ends are slid together to double the diameter of the airway but to shorten the length. And that effect gives you a much wider airway and is a different way to deal with the same types of problems. It's better and improved, in a way, because it involves less resection, and it can expand the airway very effectively.