I enjoy open airway surgery In 2010: LTRs 28 CTRs 6 Clefts 4 Slides 20

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1 Michael J. Rutter, FRACS Department of Pediatric Otolaryngology- Head & Neck Surgery Aerodigestive and Esophageal Center Cincinnati Children s Hospital Medical Center Cincinnati, Ohio IPSA Denver, CO June 2 nd 2016 Disclosure 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! Setting 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 21 st century a resurgence of interest in endoscopic surgery Often complimenting open surgery Context I enjoy open airway surgery In 2010: LTRs 28 CTRs 6 Clefts 4 Slides 20 Context I am also an endoscopic airway surgeon Since 2001 Balloon dilations > 2700 Cleft > 25 TEF > 18 Glottic web > 8 Posterior grafts > Trends Evolution, both of operative techniques, and the patients themselves Collaboration Pre-operative evaluation and optimization New tools Endoscopic techniques compliment open reconstructive techniques

2 Optimization 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 STATE OF THE ART Evaluation, Collaboration, Optimization Team Approach ADEC evaluation Triple scope Pulmonary ORL GI Reflux Eosinophilic Esophagitis AERODIGESTIVE AND ESOPHAGEAL CENTER Reconstruction Options Endoscopic techniques Expansion Anterior cricoid split Anterior cartilage graft Posterior cartilage graft Anterior / posterior cartilage grafts Resection Cricotracheal resection TEAM APPROACH Costal Cartilage The workhorse Thyroid alar cartilage Auricular cartilage Other Nasal septum Hyoid Clavicular periosteum Buccal Graft Materials Stenting Options Nil Single stage - extubate on table Single stage - endotracheal tube T-Tube Suprastomal stent (Wired in full length stent)

3 What We have Learned Risk factors for failure: MRSA The Active larynx Causes of an active larynx Reflux Eosinophilic esophagitis Unknown Zithromax trial? 2 Year Old Boy 8.5kg, tracheotomy dependent, ex-25 weeker LTP declined due to weight Mother (a urologist) seeking a second opinion MLB Active Larynx Other Investigations? Impedance probe NEGATIVE Esophagoscopy + biopsies NEGATIVE No reflux, no eosinophilic esophagitis What next? WAIT 2 Months Zithromax 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

4 LTP Stent Removal 6 Weeks 6 Months Later Endoscopic 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 Endoscopic Surgery Balloon 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 Balloon 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

5 Airway Balloon Dilation This is not new Resurgence of interest High pressure balloon dilation Primary intervention Complimentary procedure Adjunctive procedure Current 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 The 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 Advantages / Disadvantages Advantages Radial dilation - no shear forces Precise high pressure dilation Low risk Disadvantages Cost Balloon slips easily Single use device Formula: Take the outer diameter of an age appropriate endotracheal tube Add 1mm for laryngeal dilation Add 2mm for tracheal dilation Guidelines 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 Technique 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

6 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 6 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! 6 Year Old Girl Tools Blitzer Knife 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 Oral Tracheal Injector 6 Year Old Girl Returns 2 weeks later Now 4.5 ETT airway Asymptomatic Re-dilation 10mm balloon Age appropriate airway at 1 year

7 Open Airway Surgery There are only 3 open airway operations for laryngotracheal stenosis: Augmentation grafting Resection Slide Open Airway Surgery 21 st 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) Augmentation Grafting Augmentation 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 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 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

8 Posterior 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 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: epinephrine and lidocaine The posterior cricoid is split and pockets created

9 Advantages 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 Graft Gd III and IV subglottic stenosis Especially if lateral shelves Especially if close to the cords

10 Rutter, Michael, MD LTP 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) Cricotracheal Resection Best Candidates for CTR CONCEPT: Remove the Diseased or damaged segment of the laryngotracheal airway Connect the Healthy superior and inferior airway segments Achieve decannulation Grade IV or Severe Grade III Subglottic Stenosis with a Clear Margin (> 3 mm) Between the Stenosis and the Vocal Folds

11 The 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 Subglottic 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 Tracheal Stenosis - Slide Tracheoplasty The 3 rd 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 - Evolution Acquired tracheal stenosis Initially long segment Increasingly as a replacement for tracheal resection even for short segment Salvage

12 Mike Rutter Catherine Hart Robin Cotton Alessandro dealarcon