Optimum Treatment Found for Tracheotomy Tube Removal in Infants

An outcome identifies the surgical procedure that is effective and safe for children with vocal cord paralysis.

 

Boca Raton, FL -- Vocal cord paralysis (VCP) is the second most common cause of neonatal stridor, a high-pitched, noisy respiration like the blowing of the wind, that is a sign of respiratory obstruction, especially in the trachea or larynx. VCP accounts for one in ten of all congenital laryngeal lesions and is an anomaly usually found as part of a multisystem process. Causes for this condition include central nervous system lesions and cardiovascular/pulmonary malformations. Other causes for neonatal stridor are trauma (both iatrogenic [ intubation related] and non iatrogenic [i.e. following events such as motor vehicle accidents]), inflammatory, and metabolic derangements. VCP has no known gender predilection and generally is found in infants before age two. More infants are being diagnosed with vocal cord paralysis due to the widespread availability of flexible laryngoscopy or the increasing successful recovery of affected infants.

Treating VCP remains controversial. In particular, the proper management of children with bilateral cord palsy (which has been reported to involve 30-62 percent of affected children) continues to be debated. Although it is generally accepted that airway intervention such as tracheotomy is required in over 50 percent of affected patients, there exists a number of recommendations with regards to when and which surgical procedures are warranted to attempt to remove the tracheotomy tube and to allow the child to breathe more freely. Many specialty care centers believe that after one year of close observation, surgical alternatives should be offered to achieve removal of the tube in these children.  It is the authors’ experience that unilateral vocal cord paralysis has an increased incidence of spontaneous recovery as opposed to bilateral vocal cord paralysis, but that, after one year, the chances of spontaneous recovery are low. It is important to realize that no one surgical technique has evolved as the generally accepted first line treatment for removal of the tracheotomy tube (decannulation). Limitations are inherent with each, and the physician must balance the aim of decannulation on the one hand and vocal damage and aspiration on the other hand.

A team of surgeons has performed various procedures for bilateral VCP. The goal of these procedures was the decannulation of tracheotomy dependent children while maintaining a safe airway, preserving the ability to phonate, and avoiding post-operative aspiration. They have now reviewed 18 years of experience and assessed outcomes to determine the preferred procedure.

The authors of “Surgery for Pediatric Vocal Cord Paralysis: a Retrospective Review,” are Christopher J. Hartnick MD, from the Harvard Medical School and Massachusetts Eye and Ear Infirmary; Mathew T. Brigger MD, from the National Naval Medical Center, Bethesda, MD; and J. Paul Willging MD, Robin T. Cotton MD, and Charles M Myer III MD, all from the Children’s Hospital Medical Center, Cincinnati, OH. Their findings were presented May 11, 2002, at the Annual Meeting of the American Broncho-Esophagological Association, at the Boca Raton Resort & Club, Boca Raton, FL.

Methodology:  An 18-year retrospective review was completed of children undergoing surgical management of bilateral VCP at the Children’s Hospital Medical Center at Cincinnati between 1983 and 2001. Surgical procedures performed for all tracheotomy dependent children diagnosed with bilateral VCP were vocal cord lateralization and arytenoidectomy/ pexy procedures, CO2 laser procedures, and posterior costal cartilage graft procedures in combination with a diagnosis of vocal cord paralysis.

Children included were diagnosed with isolated bilateral VCP, were tracheotomy dependent, and underwent a surgical procedure with a goal of decannulation. Children were excluded from the study if the pathologic lesion included either the subglottic or supraglottic regions, or if the lesion consisted of non-paralytic glottic stenosis. The review found 52 patients who met inclusion criteria. The mean age at the time of the first surgical intervention (after tracheotomy) for these subjects is 6.2 years (range of 0.5 to 19 years).

Results: The chief outcome measure was the primary operation specific decannulation rate.This measure describes the efficacy of each procedure as a primary intervention toward a goal of decannulation in a child with bilateral VCP.

The data revealed that of patients who underwent vocal cord lateralization with partial arytenoidectomy (removal of the anterior arytenoid at the region of the vocal process), 17/24 (71 percent) achieved primary decannulation, and 21/24 (88 percent) were ultimately decannulated. Two children underwent arytenoidectomy without suture lateralization initially; neither achieved primary decannulation.One was decannulated after revision procedures; four children underwent primary arytenoidopexy; one was child was decannulated primarily and three overall.For CO2 procedures, five of 17 children were primarily decannulated and 14 of 17 children were ultimately decannulated. Five patients underwent posterior cartilage graft procedures, and three were decannulated after only one procedure while all were eventually decannulated.

Statistical analysis of the operation specific decannulation rate was achieved using chi-squared methods to test for significance between surgical procedures. Statistically significant results were demonstrated between vocal cord lateralization with arytenoidectomy procedures and isolated arytenoidopexies, CO2 procedures, and posterior cartilage grafting procedures.

The overall decannulation rate was based on the final procedure undertaken in each child.When VC lateralization procedures with arytenoidectomy were the final procedure undertaken, 19 of 21 (90 percent) were decannulated.One child underwent an arytenoidectomy without suture lateralization and was not decannulated.Three of four children underwent pure arytenoidopexies for decannulation. CO2 procedures allowed 14 of 18 patients to be decannulated. For the eight children who underwent a posterior cartilage grafting procedure last, all were decannulated.

Conclusions: The review revealed that the highest level of success has been with open VC lateralizations involving a partial arytenoidectomy.  When used as a primary definitive procedure, 17 of 24 patients have been decannulated. When compared to other procedures used as a primary intervention, these vocal cord lateralizations and partial arytenoidectomies are shown to be statistically superior. There exists a low complication rate and a high degree of patient satisfaction with this procedure. CO2 laser procedures, while having limited success as a primary procedure, are effective for revision procedures. After waiting for at least one year to allow for possible return of vocal cord function, early surgical intervention is a feasible option to achieve decannulation in these children.

Source:  American Academy of Otolaryngology−Head and Neck Surgery

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