Laryngotracheoplasty (LTP)

LTP

Source:  The Care of Children with Long-Term Tracheostomies, Edited by Ken M. Bleile, Singular Publishing Group, Inc.



More on Laryngotracheal Reconstruction

Surgical repair of subglottic stenosis is termed laryngotracheoplasty. The narrowed diameter of the windpipe (trachea) is enlarged by inserting an elliptical piece of cartilage and thereby increases the cross sectional area of the trachea. The cartilage is taken from the patients rib or ear depending on the size of cartilage needed.

Under general anesthesia, a horizontal neck incision is made at the level of the tracheostomy site. Retracting or pulling back the overlying muscles exposes the voice box and windpipe.A vertical midline incision is made along the entire length of the narrowed trachea exposing the inside lumen.

The size of cartilage needed is determined by measurement and harvested. The cartilage graft is then sculpted into the correct size and length for the narrowed trachea.

An endotracheal or breathing tube is placed through the patients nose and passed into the voicebox and windpipe with the surgeon observing to ensure proper positioning. The cartilage graft is then positioned in the tracheal defect and securely sutured. Attempt is made to increase the inner tracheal diameter by at least one endotracheal tube(ETT) size. Once again care is taken to ensure that the endotracheal tube is in proper position. Its position is securely marked and taped. Laryngotracheoplasty usually requires four to six hours of operative time.

The patient is taken to the Intensive Care Unit after surgery for vigilant monitoring. The endotracheal tube acts to stabilize and support the graft position until healing is complete. In order to protect against accidental dislodgment of the tube, the patient is pharmacologically paralyzed. Medications are given to prevent muscle movement while the patient is sedated and comfortable. The patient is fed intravenously and breathing is maintained by mechanical ventilation during this time. After usually 6 to 10 days, medications are stopped to allow the patient to breathe on their own and "wake up". When determined safe, the breathing tube is removed.

A common complication after removal of the endotracheal tube is airway swelling causing difficult breathing and possible replacement of the ETT. Intravenous steroids are given just before and just after extubation to prevent such a complication.

After the breathing tube is removed, the patient continues under close observation in the Intensive Care Unit. Eating and drinking are gradually reinstituted.

Laryngotracheoplasty can also be performed with a tracheostomy tube in place. The tracheostomy tube can be removed at a later date after the patient recovers from the initial surgical repair.

The outcome of laryngotracheal reconstruction is excellent. The majority of the patients are able to breathe on their own and resume normal activities. The cartilage graft will become a permanent "part" of the windpipe and grow as the child grows.

Source:  Atlanta Ear Nose & Throat, Associates, PC, ENT Kid's Center.

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