Titular professor, Department of Otorhinolaryngology, Universidad Nacional de Colombia, Bogotá, Colombia. Fundación hospital de la misericordia.
gemarrugop@unal.edu.co
JuanSebastián Parra Charris
Department of Otorhinolaryngology, Universidad Nacional de Colombia, Bogotá, Colombia
jusparrach@unal.edu.co
Tracheostomy on an infant
As a procedure, it was established in the 19th century in Europe because of diphtheria and polio epidemics.In children its frequency is growing, in USA it is calculated in 6.6 procedures/100.000 kids/ year. It is indicated in cases where there is an obstruction of the superior airway, prolonged intubations and in cases of chronic pulmonary aspiration.
Upper airway obstruction
Prolonged mechanical ventilation
Pulmonary toilet in cases of chronic pulmonary aspiration
Preferably always planned, not as an urgent procedure.
Distal tracheal stenosis.
Preferably always planned, not as an urgent procedure. During it, communication between the anesthetist and the surgeon is mandatory.
For a successful procedure, it is essential to evaluate the indication and the patient, knowing and performing and adequate surgical technique, and to be prepared and treat properly any complication.
Preoperative evaluation includes a full medical exam in which second obstruction sites must be discarded, external neck exam to predict the approach difficulty, cardiorespiratory status that can predict certain complications.
Infant neck extended, thyroid and cricoid cartilages.The larynx is higher in the neck
The cricoid cartilage is the most prominent structure, thyroid cartilage has a broader angle in infants and is partially shielded by the hyoid superiorly. The trachea is soft and has more lateral mobility.
Its necessary to understand the changes in size and orientation during dissection.
knowledge of the different types of tracheostomy tubes and the proper size for each patient is mandatory.
Complications can be immediate: emphysema, pneumothorax, bleeding, selective cannulation, obstruction or decannulation. Late complications are: tracheal stenosis, esophageal puncture, fistula, suprastomal collapse and tracheomalacia.
The authors have no funding or financial relationships or conflict of interest to disclose
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Lewis et al. Tracheotomy in pediatric patients: A national perspective. Archives of Otolaryngology Head and Neck Surgery, 2003; 129: 523 – 529.
Campisi, et al. Pediatric Tracheostomy. Seminars in Pediatric Surgery. 2016
Keinman et al. Part 14: Pediatric Advanced Life Support. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122 (suppl 3): S876 – S908.
Kremer et al. Indications, Complications ans Surgical Techniqes for Pediatric Tracheostomies – An Update. Journal of Pediatric Surgery. Nov, 2002; vol 37 (11). 1556 – 1562.
Greenberg, et al. The role of postoperative chest radiography in pediatric tracheotomy. International Journal of Pediatric Otorhinolaryngology. 2001; 60: 41 – 47.
Mitchell et al., Clinical consensus statement: tracheostomy care. Otolaryngology Head and Neck Surgery. 2013;148 (1): 6 – 20.
Lee, et al. The role of polysomnography in tracheostomy decannulation of the paediatric patient. International Journal of Pediatric Otorhinolaryngology. 2016; 83: 132 – 136.
Lippert et al. Care of pediatric tracheostomy in the immediate postoperative period and timing of first tube change. International Journal of Pediatric Otorhinolaryngology. 2014; 78: 2281 – 2285.
Van Buren, et al. Pediatric Tracheostomy: Timinf of the First Tube Change. Annals of Otology, Rhinology & Laryngology. 2015; Vol 124 (5): 374 – 377.
McCormick, et al. Life after Tracheostomy: Patient and Family Perspectives on Teaching, Transitions, and Multidisciplinary Teams. Otolaryngology Head and Neck Surgery. 2015; Vol 153 (6): 914 – 920.
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Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
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