Airway Disorders and Reconstruction Surgeries for Children

Dr. Ian Jacobs and Dr. Karen Zur describe three types of surgeries used to reconstructing the pediatric airway: laryngotracheal reconstruction (LTR), cricotracheal resection (CTR), and slide tracheoplasty.


Introduction to Airway Disorders and Our Pediatric Airway Center

Mary Kelly, Mother: At 26 weeks gestation, Addison had fetal surgery to remove what was called a "mediastinal teratoma," which was a large benign mass in her chest.

Jed Kelly, Father: Five days later, Mary started to have some contractions. One thing led to another, and they weren't able to stop the contractions, and they had to deliver the baby, both for the health of Mary and for the baby.

Mary Kelly, Mother: And she was resuscitated right away at birth and put on life support and transferred to the NICU immediately.

Jed Kelly, Father: At that point they told us that they did not expect Addison to make it, and that we should be prepared for that. And we prepared ourselves for that, but we still prayed and hoped that she would. And the nurses and the doctors in the NICU did an unbelievable job with Addison, and we would look forward to each new hurdle that she would get over. And one of the biggest hurdles that was on the horizon was to get her extubated.

Mary Kelly, Mother: They removed the breathing tube, and right away they could tell Addison was in distress and was not ready. So they immediately had to reintubate her. They said to us, "She needs the ventilator for the foreseeable future, and in order to help her grow and develop, a tracheostomy is the best way to give her the support of the ventilator."

Jed Kelly, Father: When Addison got to tracheostomy tube, it changed our perspective immediately on what that really means. Your airway is essential to your survival, and you take it for granted until it's a situation where you can't take it for granted.

Ian N. Jacobs, MD: There's a saying in medicine that the airway comes first-- airway, breathing, and circulation. And that's so important because, if you can't breathe and respire, you really can't take care of the other systems in the body.

Karen B. Zur, MD: The airway seems to be a very simple structure. It's actually multiple components that we take for granted because we don't think about breathing.

Joanne Stow, MSN: When a child struggles to breathe, it's a very frightening experience for them and for their families to watch it happen.

Karen B. Zur, MD: Aside from their underlying medical problem, there are so many other issues that again we take for granted that we do. We speak. We babble. We breathe. We communicate. We feed by mouth. We eat normally. These children don't.

Joanne Stow, MSN: It is amazing the depth of courage that these families have in dealing with all these issues.

Ralph F. Wetmore, MD: I think the ultimate goal for many of these families is to resume some sort of a normal family life, something that they haven't had for years.

Children's Hospital of Philadelphia has several areas of excellence or centers that are nationally renowned for the care that they give. And the Pediatric Airway Program here at Children's is one of those centers.

Ian N. Jacobs, MD: We created the Center for Pediatric Airway Disorders to serve children with complicated airway disorders, and that includes children that have tracheotomies, that have narrowing of the airway, or have congenital problems that they're born with, which affect their air passages and block and obstruct the airway and are very complicated to take care of.

Karen B. Zur, MD: We think of the airway as just our breathing, but the airway is actually a pretty complex anatomical pathway from the nose into our trachea.

an N. Jacobs, MD: And that includes the larynx or so-called voice box, the trachea, or more commonly called "windpipe," and the two branches of the windpipe, or the bronchi, which go to the left and right lung respectively. And we focus on problems throughout the airway.

Karen B. Zur, MD: Airway disorders in broad terms can comprise of issues such as floppiness of the airway. You can have paralysis where the issue could be related to a nerve not working well. Or you can have a stenosis. And stenosis means a narrowing, which can be either congenital, something you're born with, or a stenosis that is acquired.

Ian N. Jacobs, MD: Acquired stenosis is most commonly caused from premature infants who are on a breathing machine or on a ventilator for long periods of time. They have a foreign body, or an endotracheal tube, in place in the airway.

Karen B. Zur, MD: The endotracheal tube can put some pressure on the cartilage of the subglottis, and the lining of the subglottis then gets irritated, and the cricoid cartilage loses its blood supply. And over time that inflammation can stimulate a reaction that can lead to a scarring.

Ian N. Jacobs, MD: The third less common category of stenosis would be trauma. Trauma from automobile accidents, sports injuries--

Karen B. Zur, MD: Or it could be a penetrating injury, such as a dog bite or stab wounds. Anything that enters into the cartilage of the airway can stimulate a reaction that can lead to scarring and narrowing.

Eric Nicolai, Father: When Alec turned 14, he tried out for his first travel hockey team.

Alec Nicolai: It's like normal practice. Went out on the ice, and we were warming up.

Eric Nicolai, Father: And I maybe was gone 10 minutes from dropping him off, and I got a phone call. And a woman on the phone said that Alec was struck by a puck.

Alec Nicolai: I was skating by the net and one of my teammates took a slap shot, and just it went wide and just hit me in the throat.

Eric Nicolai, Father: We met Dr. Jacobs. And when he came in, he explained to us what was wrong and what his plan was, and he felt very confident. He really put us at ease that they were going to be able to take care of him, to take care of the problem.

Ralph F. Wetmore, MD: There's a wide range of children that we care for in the airway -- in the Pediatric Airway Program. And this ranges from babies who were just born to teenagers who may be 17 or 18.

Joanne Stow, MSN: One of the beauties of our program is that we don't stop at a certain age. We can still follow with a lot of these kids, and we're comfortable with all of them.

What to Expect: Steps Before Surgery

Joanne Stow, MSN: When a family is first referred to the Center for Pediatric Airway Disorders, it's frequently a very traumatic event for them. They've learned that their child has an issue that's life threatening, life changing, and sometimes very devastating.

Ian N. Jacobs, MD: And many times they become immediately relieved that there are people, there are specialists, that have an interest and a special expertise in the disorder that their child has.

Joanne Stow, MSN: Their first contact with some of us is either with the Airway Program Coordinator when they call to make an appointment, or with one of the nurse practitioners to find out how we're going to help care for their child.

Ian N. Jacobs, MD: Our airway nurse practitioners play a vital role in the management and the care of the children with airway disorders.

Karen B. Zur, MD: She's there to, pretty much, be their hand holder along this process. They know her by name. They have her telephone number.

Ian N. Jacobs, MD: They'll do the intake process, and they'll gather all the information and start the relationship that we have with families that will go on for years and years.

Mary Kelly, Mother: If I had questions from home, I would call them, and they were so great at getting back to me.

Jed Kelly, Father: There's no such thing as a dumb question. They made you feel comfortable and explained every step of the way.

Karen B. Zur, MD: The management of patients with pediatric airway disorders is obviously very complex, and we have a large team of clinicians who are involved with their care.

Joanne Stow, MSN: That we have such a variety of specialties that are all a part of caring for that child in that family.

Asim Maqbool, MD: You have physicians. Certainly, you have surgeons. You have occupational therapists. You have speech and language pathologists. You have social workers. You have Child Life.

Ralph F. Wetmore, MD: And, from the time the patient comes into our program, that team is geared up to care for them and to give them the best care that we can.

Joanne Stow, MSN: When a child's airway needs to be evaluated, many different things need to happen all at once. It requires a lot of coordination and communication between all the team members.

Ian N. Jacobs, MD: We want to make it a one-stop shop. So we want to find out exactly what tests have been done in the past, and what operative procedures have been performed. And then we want to determine what tests need to be performed when they get here.

Karen B. Zur, MD: So, depending on the type of airway problem that the child presents with, we may order a variety of studies.

Ian N. Jacobs, MD: We'll work closely in the Airway Center with speech and swallowing therapists who evaluate every child. We'll evaluate their voice. We will want to evaluate their aerodigestive tract, which means their swallowing passage, prior to going to the operating room. So, many times, they'll have an upper GI series or barium swallow to look at the swallowing passage. Then we'll often get a chest x-ray, various labs, and then they'll see our Anesthesia Resource Center, which does the preoperative evaluation for children undergoing anesthesia at our hospital.

John E. Fiadjoe, MD: We get involved very early in the process during the diagnosis and evaluation phase, and we interact very closely with the subspecialist to craft an optimal plan for these patients around the time of surgery.

Karen B. Zur, MD: So the plan of what type of anesthetic to give, is the child going to be fully sedated, meaning paralyzed? Or are they going to be spontaneously breathing on their own for the procedure?

John E. Fiadjoe, MD: Because the surgery is happening on the airway, we often will not use the gas to maintain anesthesia and keep the patient anesthetized. Often what we will do is use an intravenous drug to maintain our anesthetic.

Ian N. Jacobs, MD: After we evaluate them in the office, the patients will be scheduled for an operative procedure which includes a full diagnostic airway and GI evaluation in the operating room.

Karen B. Zur, MD: And the bronchoscopy is our gold standard diagnostic tool for evaluating the airway.

Ralph F. Wetmore, MD: We examine the airway with a telescope. We look down. We look at all the problems that start from the area above the voice box, down through the voice box all the way down the trachea, or windpipe, to where the trachea spreads off into the right and left mainstem bronchus.

Ian N. Jacobs, MD: So we perform a microlaryngoscopy, bronchoscopy, and our gastroenterology service will perform an upper GI endoscopy.

Asim Maqbool, MD: Looking at the esophagus, stomach, and the small intestine with a video camera through which we're able to get biopsies and specimens as well. The other test that we do commonly is either a PH probe or an impedance probe, which is a long thin spaghetti-like tube that goes in through the nose and sits typically where the esophagus and the stomach meet, and it sits there for about 24 hours, and it gives us information about reflux. Reflux is the effortless spit up of previously ingested food. So, for example, when you see a baby who's just had a bottle feed and you put them over your shoulder or you pick them up you see some milk dribble out onto your clothes, that's reflux.

Karen B. Zur, MD: So the reason we're concerned about reflux, both acid and nonacid reflux, is it can cause irritation. And, if we're planning a large surgical intervention to reconstruct the child's airway and you make an incision into their airway, the healing process can be affected by reflux.

Asim Maqbool, MD: And for that reason one of the things that our otolaryngology colleagues like us to do is to say, "Does the child have reflux?" And if reflux is there, "How well can we control it?" to give the repair every chance of success. We try to combine these procedures with any other procedures that our airway colleagues may be performing in the operating room, such as bronchoscopies or laryngoscopies so that within a 24-hour period of time we do gather a lot of information.

John E. Fiadjoe, MD: This avoids multiple anesthetics, multiple procedures, and the interaction between the different teams works very well at CHOP.

Ian N. Jacobs, MD: After we perform the microlaryngoscopy, bronchoscopy, and the GI endoscopy, we will meet as a team with the family in the postoperative parent waiting area.

Karen B. Zur, MD: We review what the images of the airway look like and come up with a plan.

Ian N. Jacobs, MD: Now, that plan might include immediate airway surgery, or it might not. If there are still issues to deal with, we'll discuss those. We'll make a plan for dealing with those issues. If the child is ready for surgery or requires a number of tests to be checked, we'll make a plan to contact the family as soon as those tests are completed.

Jed Kelly, Father: We got Addison home, she'd been home for some time, and we started to sprint her. So we would take her off the machine for short periods of time, and the goal with that was to see if she could handle breathing on her own.

Mary Kelly, Mother: We got to the point where we were talking about decannulation and one of the steps that had to happen before decannulation was a bronchoscopy.

Jed Kelly, Father: We did not expect there to be anything that would happen, and we expected him to just say "Yep, great, let's go forward," when she was off the ventilator just breathing fine.

Mary Kelly, Mother: But sure enough, she actually developed a narrowing in her airway that we were told was just a result of having a tracheostomy long term.

Jed Kelly, Father: And that meant that she would need to have another procedure to fix that. It was disappointing. Because you work and strive for a goal and you think you can reach a goal, and all of a sudden you have to have more conditions put on that goal, and it was a challenge to prepare ourselves for what we had go through for the surgery.

Mary Kelly, Mother: But we also were still hopeful, like, you know, getting the trach out. We did not anticipate that Addison would be a candidate to get her trach out this soon. So we were just thrilled. We knew this was just one more hurdle. One more piece of the process to get there. You know, even though it was a little frustrating we felt like we were just getting so close, and it was almost there.

Reconstruction: Airway Surgeries

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.

A New Voice: After The Surgery

Joanne Stow, MSN: The postoperative period is also a very stressful one for the families. Will the reconstruction work? How effective will it be? How is this going to change my child's voice? How are they going to cope with this hospital stay? The way that they handle the postoperative period sometimes depends upon the surgical procedure that they've had.

Ian N. Jacobs, MD: Regardless of whether we're doing a CTR, an LTR, or a slide tracheoplasty, there are two ways to approach that and that's single-staged or double-staged. And there are specific reasons and indications to perform single-staged or double-staged procedures.

Jed Kelly, Father: I had approached the subject of doing a two stage because we weren't sure she was going to be able to do the whole procedure.

Mary Kelly, Mother: He explained to us that he had to do a single staged because of the location of her narrowing. He could not do the repair and then put her trach back in.

Karen B. Zur, MD: So the decision to perform a single-versus a double-staged reconstruction depends on multiple factors: the extent of the narrowing of the airway, the location of the tracheostomy tube in relation to the stenosis, the health of the child's lungs, and overall medical condition. So it really is individualized to each patient.

A single-staged reconstruction means that at the conclusion of the procedure there's no tracheostomy tube in place, and the child will wake up with an endotracheal tube that's actually placed through the nose, it makes it more comfortable for them during recovery and that nasotracheal tube is used as a stent. And a stent is a hollow tubing that helps support the area of the reconstruction.

Joanne Stow, MSN: So if a child is having a single-staged procedure, they're going to require a longer ICU stay. They may be in the intensive care unit for anywhere from two to four weeks.

Ian N. Jacobs, MD: We will perform a repeat endoscopy and remove the breathing tube, and then if everything looks like it's healing well and is in good position, then we'll get the child ready to take the breathing tube out usually the next day.

Eric Nicolai, Father: So we were all anticipating when they pulled the tube out what Alec's voice was going to be like.

Alec Nicolai: I think my voice was deep before it happened, but then after it just seemed like more raspier. It made it a little bit deeper.

Eric Nicolai, Father: So when he finally took the tube out and he got to speak a little bit, he had a voice, and that was a big relief.

Karen B. Zur, MD: That's a single-staged procedure. A double-staged procedure means that at the conclusion of the surgical reconstruction the child will wake up with a tracheostomy tube in place, and there will be a stent that is sitting above the tracheostomy tube through the area of reconstruction, but that stent is sutured into the trachea.

Joanne Stow, MSN: They wake up a lot faster from the surgical procedure. They may actually go home after a few days, or they may stay in the hospital for the entire week to ten days while the stent is in place.

Karen B. Zur, MD: That stent will need to be removed usually about two weeks after the reconstruction to make sure that there's no excess inflammation from the stent.

Ian N. Jacobs, MD: So the double-staged patients will be brought back to the operating room on an outpatient basis, often a week or two weeks later, after we remove the stent. And that's important because we make sure they're not collapsing down their airway, because if that's the case, I will employ a balloon to stretch the airway and then they will often have a repeat endoscopy several weeks or several months after that to check on the healing process. If it's healing well and the airway reconstruction has really been successful and they have an adequate airway, then we want to start to downsize the trach tube to a smaller size and start capping the child.

Karen B. Zur, MD: Capping means that you put a full piece of plastic cap on the tracheostomy tube, which forces the child for the first time, probably, to breathe through their mouth and their nose.

Joanne Stow, MSN: We will frequently send them home with a tracheostomy cap once we know that they're safe and are able to move some air now above the area that has been reconstructed and enlarged.

Karen B. Zur, MD: That can be traumatic for the kid who's never breathed from their nose or their mouth before. So we give them a period of time to get adjusted to this new type of breathing.

Once the capping process is successful, the child will be brought back to the hospital. We will do the capping trials overnight while they're sleeping now to make sure that they're able to sleep and not have any apneas or pauses or any difficulty breathing while asleep when you're less likely to be able to support your airway voluntarily. And then once that capping overnight is successful, then we talk about the decannulation. And the decannulation is very simple. It just involves pulling the tracheostomy tube out, putting a piece of gauze and tape on the stoma site, and that stoma heals over time.

Ian N. Jacobs, MD: Some of the kids we see have vocal cord paralysis. This can be either one sided, or unilateral, or bilateral.

Karen B. Zur, MD: Unilateral vocal cord paralysis is where one vocal cord is not moving well. And that leads to a gap between the two vocal cords while we're speaking. And when that happens, air can escape between the vocal cords and the child will most likely end up with some hoarseness. The vocal cord is a muscle, so if it loses its nerve supply over time, the muscle can shrivel, as well. And that creates even a bigger gap between the right and the left vocal cord.

Ian N. Jacobs, MD: We have a Pediatric Voice Center, which deals with patients with vocal cord paralysis, commonly unilateral paralysis. And there are procedures that can be done to alleviate this problem, such as reinnervation of the larynx using nerves in the neck.

Karen B. Zur, MD: So the reinnervation procedure involves cutting the recurrent laryngeal nerve in the neck and then another nerve called the "ansa cervicalis" and then under a microscopic visualization I reconnect both ends of the nerve with a couple of sutures. The recurrent laryngeal nerve reinnervation helps maintain tone in the vocal cord, and it helps force a better closure in the back of the vocal cords so there's a better contact there and less air escaping and an improved voice quality.

an N. Jacobs, MD: Along the healing process many of these children will be seen by our speech therapist and our feeding therapist who work very closely with them.

Karen B. Zur, MD: Children who've had a tracheostomy tube for a very long time may not have been able to phonate, or to create sounds. So now they need to learn that. And that's where our speech pathologists are usually involved with those patients through the Airway Clinic to make sure that they're getting the right services to develop their language skills.

Patient: Oh my.

Speech Pathologist: Good job, want to stand up? Oh my.

Patient: Oh my.

Mary Kelly, Mother: Well, since Addison first came home two and a half years ago, she's been receiving speech therapy.

Jed Kelly, Father: She had to relearn how to swallow. And it didn't take very long. But she had to learn how to drink water again and it was, the structure of her throat has changed, and she needed to get comfortable with that.

Asim Maqbool, MD: If a child has a swallowing dysfunction, we have to work with where their skills are at that particular point in time and advance those skills for them as well as to advance the skills of the parents to feed children, particularly those children who may have specific feeding issues.

Mary Kelly, Mother: We had to be careful the first couple weeks because they did not want to take the risk that Addison might aspirate. They didn't want anything going down past that graft, wanted to keep her healthy.

Jed Kelly, Father: She wasn't really eating much the first week. Now she's back to eating and exploring and everything goes into her mouth.

Mary Kelly, Mother: She's doing fine with her thin liquids again. She's eating chips, which she loves to eat. She likes to lick salt. She's doing great with soft foods.

Jed Kelly, Father: It's a great change. And it wasn't something that I really was prepared for. I didn't expect it to be so dramatic. But as soon as we got home she started doing things that she had never really wanted to do before.

Karen B. Zur, MD: Being in a premier institution such as The Children's Hospital of Philadelphia, where you have wonderful teams of nurses and nurse practitioners, intensivists and physicians, who can care for those kids in case of emergencies and to care for them to the immediate recovery period, it provides a tremendous service and benefit to these children.

Team for the Future: Research and Hope

Joanne Stow, MSN: It's important to come to a center like Children's Hospital of Philadelphia because of the strength and the depth of the talent that we bring to these children.

Asim Maqbool, MD: They say, "It takes a village to raise a child," but it takes a very dedicated team to take care of these complex medical conditions.

John E. Fiadjoe, MD: We all work very closely together. We deal with a lot of challenging patients, and we have the experience necessary to take care of these cases.

Joanne Stow, MSN: We feel very comfortable when we tell a family that we can handle their child's most difficult problems.

Karen B. Zur, MD: Twice a month we meet as a team to discuss our findings in the operating room.

Asim Maqbool, MD: We address every concern of the child and of the parents and approach them from every perspective possible to ensure every chance of success.

Ralph F. Wetmore, MD: When one has a team as large as the Pediatric Airway Program encompassing multiple specialties, nurses, support staff, communication is the key.

Ian N. Jacobs, MD: And we challenge each other. We're constantly collaborating with each other on surgical approaches.

Mary Kelly, Mother: They were there guiding us, letting us know what to expect during surgery, letting us know what to expect during recovery in the ICU.

Jed Kelly, Father: And they made us feel part of the process. And that was very important to us.

Ralph F. Wetmore, MD: We really couldn't do all this without having the family as an integral part.

Ian N. Jacobs, MD: The family is always part of the team. They really know the inside track on what's going on with the child, how their voice is, whether they're feeding well.

Ralph F. Wetmore, MD: They'll spend countless hours helping their child through a lot of difficult procedures, a lot of social support, a lot of physical support, and all of that's absolutely necessary of the a successful outcome.

Joanne Stow, MSN: It's phenomenal the things that we can do now that we weren't able to do even 10, 15 years ago.

Ian N. Jacobs, MD: We've had a number of advances in recent years that are continuing to build

John E. Fiadjoe, MD: And as we get more information, we integrate that into our practice.

Ralph F. Wetmore, MD: We want to attack all aspects of this problem, not only from a clinical end, but from a research end, from an education end.

Karen B. Zur, MD: Currently, we have great procedures that we can do in order to reconstruct the airway. But, ideally, we would like to prevent scarring from happening. And we would like to provide other types of reconstruction that do not necessarily include harvesting grafts from their rib site.

Joanne Stow, MSN: There's tissue engineering that is being looked at very closely.

Ian N. Jacobs, MD: Recreating new tissues and new organs using cells taken from specific sites in the body.

Ralph F. Wetmore, MD: There's a lot that's going to happen in the future that's going to make our care a lot better--more successful results, better outcomes in the future.

Ian N. Jacobs, MD: It's great to see families with such challenging situations rise up to that challenge and deal with the problems. It's also great to see the successful outcomes.

Eric Nicolai, Father: Alec got hurt in June, and he just made this travel team. And the big deal was in August or early September they were going to Boston to play in the tournament.

Alec Nicolai: My dad tells me that after surgery the first thing I asked was, "Can I play?"

Eric Nicolai, Father: When he got the news that he could play the week prior to the tournament, that was like the greatest news he ever got, and he got back out on the ice like nothing ever happened.

Joanne Stow, MSN: I love it when we put a cap on a child's trach in the office, and they make a sound for a first time. And they look at their parents in such surprise "Was that me?" And they repeat it over and over.

Ralph F. Wetmore, MD: Seeing a child, you know, use their voice for a first time after having a tracheostomy is always an exciting thing. The other is when you see a kid come in with a trach and leave without a trach, that's a great day.

Karen B. Zur, MD: The most rewarding part of my job as an airway surgeon is to see the little ones running in our clinic, singing Happy Birthday, not have a trach tube.

Ian N. Jacobs, MD: Once they get it out they seem to get much more active. They do a lot more activities. They go swimming for the first time.

Mary Kelly, Mother: Bringing Addison home without her trach has opened up a whole new world for all of us.

Jed Kelly, Father: Swimming. Taking a shower. Her sensation of water on her face. She had never had that before.

Mary Kelly, Mother: And it was just awesome not worrying about the water going into her trach.

Jed Kelly, Father: Watching her do that for the first time, she was a little scared and tentative and then she's smiling after a few moments.

Mary Kelly, Mother: And we're just having all these new experiences with her that are phenomenal.

Jed Kelly, Father: After having gone through so much with her to get to this point, you just are so thankful that it's happened.

Mary Kelly, Mother: And we'll joke with her. We'll say, "Oh, Addi, come on we got to do your trach care," and she'll show us her neck and she'll go like this, "No trach, no trach."

Asim Maqbool, MD: Seeing these children when all is said and done walking, running, skipping, normally with virtually no scar other than the old tracheostomy stoma that's been closed over.

John E. Fiadjoe, MD: The joy of seeing a patient coming back to follow up who we met as an infant and now is a teenager and is active and achieving all of his goals is really the reward that you get from taking care of these patients.

Joanne Stow, MSN: We have a real special place in our hearts for those kids and those families. We watch those children grow. We help them through a lot of different interventions that are required to try and help make their lives as happy and as normal as possible.

Related Centers and Programs: Center for Pediatric Airway Disorders, Pediatric Voice Program