Chapter 42: Airway Reconstruction

INTRODUCTION

OVERVIEW OF AIRWAY RECONSTRUCTION

Open airway reconstruction refers to a number of airway expansion surgeries that may be utilized in the setting of a critical narrowing of the laryngeal, subglottic, or tracheal airway. Less severe lesions or those that produce mild or well-tolerated symptoms, may be managed expectantly or with endoscopic intervention. The most common indication for airway reconstruction in children is acquired subglottic stenosis resulting from prolonged or traumatic intubation, though open airway reconstruction can be useful in patients with other types of fixed airway narrowing such as supraglottic, glottis, or tracheal stenosis; complete tracheal rings; VC paralysis; and A-frame suprastomal deformities.

Improvements in neonatal care have reduced the incidence of subglottic stenosis. Historically, subglottic stenosis developed in up to 8% of children who were intubated in the neonatal period, but newer intubation techniques and improved endotracheal tube technology including low-pressure cuffs have decreased the incidence to below 1%. Though rates of subglottic stenosis have declined, advances in the care of premature infants have increased the number of children who survived a prolonged intubation in infancy.

New technologies for the endoscopic management of airway stenosis, specifically endoscopic balloon dilation, have enhanced our ability to manage airway stenosis without open surgery. These balloon dilators apply controlled radial pressure to discrete areas of stenosis, often leading to a sustained expansion of the caliber of the airway. Variable sizes of balloons may be used to match airway size, and pressure can be applied up to 20 atmospheres. Reports have shown effectiveness of balloon laryngoplasty in both the primary treatment of subglottic stenosis as well as with dilation of restenosis after primary airway reconstruction surgery. Balloon laryngoplasty may serve to stabilize airway stenosis prior to definitive surgical intervention or obviate the need for open airway reconstruction altogether.

Many techniques are available to evaluate the location, severity, and impact of airway obstruction in children. The results of these tests can inform a surgeon’s choice of many established and evolving techniques to reconstruct the airway and relieve obstruction in a child.