Endoscopic airway management in children Michael J. Rutter a,b, Aliza P. Cohen b and Alessandro de Alarcon a,b

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1 Endoscopic airway management in children Michael J. Rutter a,b, Aliza P. Cohen b and Alessandro de Alarcon a,b a Division of Pediatric Otolaryngology Head and Neck Surgery, Aerodigestive and Sleep Center, Cincinnati Children s Hospital Medical Center and b Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Correspondence to Dr Michael J. Rutter, BHB, MBChB, FRACS, Division of Pediatric Otolaryngology Head and Neck Surgery, Aerodigestive and Sleep Center, Cincinnati Children s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH , USA Tel: ; fax: ; Mike.Rutter@cchmc.org Current Opinion in Otolaryngology & Head and Neck Surgery 2008, 16: Purpose of review To discuss the current status of endoscopic airway surgery in children. Recent findings More refined endoscopic instruments have been introduced, including balloon dilators, powered debriders, lasers with more exact modes of delivery, and innovative suspension laryngoscopes. The use of balloon dilatation for primary management of acquired subglottic stenosis is promising. Microdebriders are now considered a viable option to the CO 2 laser for the management of a number of airway diseases. Knowledge regarding supraglottoplasty continues to evolve. Endoscopic vocal cord lateralization is being successfully used at some centers for the management of bilateral vocal cord paralysis. The da Vinci Surgical Robot (Intuitive Surgical, Inc., Sunnyvale, California, USA) has been introduced to facilitate endoscopic laryngeal cleft repair. Summary Endoscopic airway surgery is presently regaining its early (1960s) popularity. This trend can be attributed to the availability of new and more sophisticated endoscopic instrumentation, the adjunctive use of new pharmaceuticals, and the realization that open and endoscopic techniques can often be used in a complementary fashion. Keywords airway lasers, airway stents, balloon dilatation, endoscopy, graft placement, laryngotracheal esophageal cleft repair, pediatric airway surgery, supraglottoplasty, vocal cord lateralization Curr Opin Otolaryngol Head Neck Surg 16: ß 2008 Wolters Kluwer Health Lippincott Williams & Wilkins Introduction Over the past five decades, pediatric airway management has shifted from a predominant reliance on endoscopic techniques (1960s) to open airway reconstruction with expansion grafting or resection (1980s) and, more recently, to the complementary use of both open and endoscopic techniques. The resurgence of endoscopy as a viable component of airway care is at least in part due to the development of new endoscopic instrumentation, which is sometimes combined with new pharmacologic approaches. In our discussion, we present an overview of the current status of endoscopic airway management in children, with particular reference to articles published over the past 18 months. Endoscopic tools Endoscopic surgery has historically relied on suspension laryngoscopy, with the use of microlaryngeal instruments and bougienage dilatation. Over the last several years, new instruments have been introduced, including balloon dilators, powered debriders, a wider range of lasers with more precise modes of delivery, and innovative suspension laryngoscopes. Balloon dilatation Traditional methods of airway dilatation have involved bougienage techniques, including cattail dilators and endotracheal tubes. Although these techniques are effective and still used by many surgeons, significant sheer forces are generated across the area of stenosis, and ongoing serial dilatations are often required [1]. A more recent development is the use of balloon dilatation in the airway. Balloons exert radial pressure at the site of stenosis, and the desired balloon diameter is selected based upon the anticipated normal age-related size of the airway; they can be inflated up to 20 atmospheres of pressure. Published studies using balloon dilatation for primary management are scant, though promising. Durden and Sobol [2 ] report that endoscopic balloon dilatation was an effective procedure in seven out of 10 infants with acquired subglottic stenosis, obviating the need for performing a tracheotomy or cricoid split. Similarly, Lee and Rutter [3] report excellent immediate outcomes in a small series with adult patients diagnosed with idiopathic subglottic stenosis. They conclude that balloon dilatation is generally effective for stabilizing a patient s airway until a definitive open procedure can be performed, and further suggest that, in select cases, it also may offer an alternative to cricotracheal resection ß 2008 Wolters Kluwer Health Lippincott Williams & Wilkins DOI: /MOO.0b013e

2 526 Pediatric otolaryngology Microdebrider Microdebriders were originally developed for arthroscopic applications. In the 1990s, however, they gained more widespread use in sinus surgery. Over the last decade, microdebriders have been designed for laryngeal applications, primarily for the management of laryngeal papillomatosis, using skimmer blades. A small series by Ulualp et al. [4] describes the modified use of the microdebrider in two children to remove tracheal papillomas through the tracheostomy site when translaryngeal access to tracheal papillomas cannot be achieved. Microdebriders are now considered an appropriate alternative to the CO 2 laser for the management of a variety of airway diseases [5]. A number of more aggressive cutting blades have also been designed. These blades are used for the management of laryngeal and tracheal stenosis as well as for granulation tissue [6]. Lasers CO 2 lasers have been a mainstay of airway management for more than three decades, with their initial application being for respiratory papillomatosis. These lasers were subsequently used for partial arytenoidectomy, posterior cordotomy, lysis of scar tissue, and removal of cysts, granulation, and airway tumors [7,8]. Recent advances in CO 2 laser technology have included new delivery algorithms, more focused and precise delivery of laser energy, and the introduction of fiber-optic-aiming devices. Although the CO 2 andpotassium-titanyl-phosphate (KTP) lasers were the most commonly used lasers in the airway, other lasers have more recently been advocated, including the thulium laser, a useful alternative to the CO 2 laser [9 ], the pulse dye laser for papilloma removal [10], and the Nd:YAG laser for subglottic hemangioma ablation [11]. The thulium laser has many of the characteristics of the CO 2 laser and has the distinct advantage of fiber-optic delivery, whereas the pulse dye laser may improve voice outcomes; and the Nd:YAG laser s selective absorption by hemoglobin is useful in the treatment of vascular lesions. However, all these lasers have the potential limitations of cost and access, and, specifically, the Nd:YAG laser has the risk of deep tissue penetration. Also noteworthy, however, is that many pediatric airway centers are presently using laser less frequently, as other alternatives, such as balloon dilatation, microdebriders, and sharp division of airway scar tissue, are preferred. Laser alternatives not only offer lower cost and less set-uptime, butalsofundamentally theriskofa laserfire(the worstcomplicationoflaseruse) iseliminatedif a laser is not used. Current indications for endoscopic management Indications for endoscopic management have broadened as a consequence of a number of factors, including the following. (1) The introduction of new surgical tools, as discussed earlier. (2) The use of complementary pharmaceuticals, such as mitomycin C, directed steroid injections, and topical steroid/antibiotic application [Ciprodex (ciprofloxacin and dexamethasone; Alcon Laboratories, Inc., Fort Worth, Texas, USA); unpublished observation of senior author, M.J.R.)]. (4) The increased use of combined approaches. For example, in a child with tracheal stenosis, the surgeon may use microlaryngeal instruments to divide scar tissue through suspension laryngoscopy. This procedure may be followed by balloon dilatation, injection of Kenalog (triamcinolone; Bristol-Myers-Squibb, New York, USA), and placement of a temporary stent across the stenosis while it heals. (5) The growing consensus that, although endoscopic management alone may be appropriate and effective, endoscopic approaches also may be used preoperatively, perioperatively, or postoperatively to complement open airway reconstruction. As an example, balloon dilatation may be used preoperatively to stabilize an airway prior to open reconstruction [3], and, if following airway reconstruction granulation tissue develops, the surgeon may shave out the granulation tissue with a microdebrider, balloon dilate the airway, and use Ciprodex topically until healing stabilizes the repair. Ciprodex ear drops are a potent topical dexamethasone and quinolone antibiotic combination solution, which is very effective in controlling granulation tissue and decreasing edema while permitting remucosalization of the airway. In a child with a tracheotomy, Ciprodex may be used as drops instilled through the tracheotomy tube, typically three drops three times daily (t.i.d.) for 5 7 days, with use of a speaking valve encouraging distribution of the medication into the subglottis. If a tracheotomy is not present, Ciprodex may be nebulized, usually 1 ml of Ciprodex diluted with 1 ml of physiological saline, and nebulized two or three times a day for 5 7 days. Common indications are following stent removal, following endoscopic surgery that breaches the mucosa, or for any condition in which tracheal granulation is a problem. Supraglottoplasty Although supraglottoplasty has been the most common interventional endoscopic airway operation performed over the past 30 years, our knowledge base regarding this procedure continues to evolve. In a large study of infants with severe laryngomalacia, Lee et al. [12] report that CO 2 laser supraglottoplasty is an effective treatment option. Supraglottoplasty can also be successfully performed with microlaryngeal instrumentation, as described by O Donnell et al. [13]. In view of the high incidence of aspiration associated with CO 2 laser supraglottoplasty reported by Schroeder et al. [14 ], the outcome may, however, be superior with microlaryngeal instrumentation. The senior author s preferred technique is to use microlaryngeal instruments to divide both aryepiglottic folds, and, if arytenoid prolapse is significant, to excise one or

3 Endoscopic airway management in children Rutter et al. 527 both cuneiform cartilages. Rarely, if the epiglottis is very tightly curled, a small wedge may be excised from one lateral aspect of the epiglottis to break the vacuum effect caused by inspiration. Our preference is to perform supraglottoplasty with the infant transnasally intubated with a small endotracheal tube, which still permits excellent operative exposure without any anesthetic inconvenience. Although supraglottoplasty is classically indicated in infants with failure to thrive or severe stridor associated with apnea or cyanosis, two recent articles describe broader applications of this technique. Zafereo et al. [15] describe the effectiveness of supraglottoplasty in treating 10 infants with laryngomalacia and obstructive sleep apnea (OSA), all of whom had a marked improvement in their obstructive apnea/hypopnea index and required no other surgical intervention. In older children presenting with laryngomalacia and failure to thrive, OSA, or exercise-induced stridor, Richter et al. [16 ] also report positive outcomes with supraglottoplasty. In this series, seven children with a mean age of 3.3 years presented with failure to thrive, which resolved after supraglottoplasty, with an improvement of weight from the 5th percentile to the 40th percentile. A further seven children, with a mean age 6.3 years and with a history of past adenotonsillectomy in five, had sleep study proven OSA, and all had clinical resolution following supraglottoplasty. A final three children, mean age 15 years, had exercise-induced laryngomalacia that completely resolved following supraglottoplasty. Stents Although experience in the use of intratracheal stents in adults is considerable, their use in children is more recent and more limited. Stents fall into two main categories: hollow silicone and expandable metal. Stents may be placed to combat malacia, compression, or stenosis of either the trachea or bronchi. A recent comprehensive review undertaken by Nicolai [17 ] provides excellent commentary on the use of intratracheal stents, concluding that both metal and silicone stents should only be considered after other options are exhausted, complications must be anticipated, and ideally stents should be removed as soon as their therapeutic benefit is no longer being achieved. A recent publication by Antón- Pacheco et al. [18] presents a good overview of the indication for stent placement, common types of stents, and some of the problems associated with their use. Interestingly, a similar article by several of the same authors at the same institution over a similar period presents similar results in presumably the same patients [19]. While intratracheal stents are superficially quite alluring, they are fraught with potential problems and should thus be placed with the utmost circumspection. Expandable metal wire stents may permit mucociliary clearance through the stent but have problems associated with stenosis at either end of the stent and granulation tissue formation within the stent; these complications are described by Mostafa and Dessouky [20]. Additionally, these stents have a strong tendency to become integrated, especially if overexpanded or left for a long period. A case series by Rampey et al. [21] discusses this complication and presents the authors experience with removal of expandable metallic tracheal stents. Silicone stents are associated with an entirely different set of problems primarily stent migration, and secondarily biofilm formation within the stent; the latter may cause partial or even complete stent occlusion. In the senior author s view, although intratracheal stents have a distinct benefit, it is generally best to consider them as a temporizing measure rather than a permanent solution. Ideally, they should be removed as soon as possible [22]. Endoscopic vocal cord lateralization The management of bilateral vocal cord paralysis remains controversial, with several procedures currently used. Endoscopic vocal fold lateralization in adults was initially advocated by Lichtenberger [23] in 1983, and was subsequently applied to children. The Lichtenberger needle driver greatly facilitates endoscopic placement of sutures to lateralize the vocal process without risk to the anterior commissure, as may occur with open approach vocal cord lateralization. An update of Lichtenberger s experience with adults was recently published by Sapundzhiev et al. [24]. Although no recent pediatric reports appear in the literature, several pediatric centers have begun to use endoscopic vocal cord lateralization in the management of bilateral vocal cord paralysis in children. We have used this technique in several patients at Cincinnati Children s Hospital Medical Center and are optimistic about its potential. It is a short operative procedure associated with only minimal morbidity. An additional advantage is that it is theoretically reversible. Nevertheless, longterm outcomes in a cohort are required to further determine the utility of this new approach. Endoscopic vocal cord lateralization combined with a posterior cordotomy may be used in selected cases of posterior glottic stenosis. Endoscopic graft placement Moderate to severe subglottic stenosis is best managed with open laryngotracheal reconstruction, often with costal cartilage grafts; however, as elegantly described by Inglis et al. [25] in 2003, it is possible to perform an endoscopic cricoid split and placement of a posterior costal cartilage graft. In a recent publication, Thakkar and Gerber [26] report their experience using this procedure to manage children with vocal cord paralysis. This technique relies on the availability of new endoscopic instrumentation (e.g. vocal cord spreaders) to achieve adequate exposure. This is, perhaps, the best example of the evolution of endoscopic surgery, to the point where it is a viable alternative to open airway surgery in selected

4 528 Pediatric otolaryngology cases. A similar though as yet unpublished technique of endoscopic anterior cricoid split with balloon dilation has been developed by David Albert at Great Ormond St Hospital, London (personal communication). Laryngotracheal esophageal cleft repair In recent years, several publications have described endoscopic repair of posterior laryngeal cleft, usually for type I or type II clefts (Benjamin and Inglis classification). Opinions have differed as to whether demucosalization of the cleft is best performed with sharp dissection or CO 2 laser ablation, and whether the subsequent repair is best performed as a single-layer or two-layer closure. There is general agreement that a successful endoscopic repair is preferable to a successful open repair, primarily because the former preserves the anterior commissure and thus results in better voice outcomes. Nonetheless, in our experience, the outcomes of endoscopic repair are somewhat less successful than the outcomes of open repair. A fascinating and enlightening article by Rahbar et al. [27 ] describes the novel use of the da Vinci Surgical Robot to facilitate endoscopic laryngeal cleft repair. Authors report their experience in five patients, three with a type I cleft and two with a type II cleft. Successful outcomes were achieved in two patients; however, owing to the inability to adequately expose the larynx for robotic instrumentation, the procedure had to be abandoned in three patients. This article also provides an excellent overview of robotic technology and briefly discusses the advantages of robot-assisted surgery over conventional endoscopic surgery. Whether more refined robotic tools will eventually herald a new era of endoscopic interventions (as occurred with the CO 2 laser) remains to be seen. Indeed, this is an exciting new area that should be followed with interest and an open mind. Tracheoesophageal fistula repair Although various open surgical approaches to the repair of recurrent tracheoesophageal fistula (TEF) have historically been used, these techniques are associated with both unacceptably high recurrence rates and significant morbidity and mortality. In view of these outcomes, several endoscopic techniques have gradually gained favor. A comprehensive review of the endoscopic literature undertaken by Richter et al. [28 ] identifies three endoscopic approaches used to date in 15 small reported series with a combined total of 37 cases. Authors categorize these approaches as deepithelialization of the fistula, application of tissue adhesives, or a combination of both. When viewed collectively, these series indicate that the greatest likelihood for success, both at the first attempt and overall, is achieved when a combined approach is used. In the same publication, Richter and colleagues describe their experience in four patients with recurrent fistulae, with closure achieved in three patients after a single attempt and in the fourth patient after a second attempt. This article presents practical guidelines for patient selection and both perioperative and postoperative recommendations. Their technique is to deepithelialize the fistula tract with bugbee electrocautery, to seal the tract with fibrin glue, and to place a cuffed endotracheal or tracheotomy tube past the fistula for 48 h to prevent ventilation pressure reopening the tract. Patient selection is also emphasized, with the ideal candidate having a long narrow fistula tract at least 1.5 cm proximal to the carina. Tracheal pouch repair An acquired tracheal pouch is typically a sequela of TEF repair. Shallow, wide-mouthed pouches in the region of the carina are common, usually asymptomatic, and do not require surgical repair. In contrast, pouches that occur more proximally are likely to be large, generally symptomatic, and require surgical intervention to alleviate associated respiratory symptoms, or the risk of inadvertent intubation of the pouch with endotracheal or tracheotomy tubes, with a resultant inability to ventilate. The repair is generally based on division of the shared diverticular and tracheal wall. Various techniques for repair have been described (i.e. electrocautery, Nd:YAG laser, and surgical resection through transcervical, transthoracic, or endoscopic approaches) and optimal management strategy remains a subject of debate. In the largest pediatric series to date (n ¼ 11), Johnson et al. [29] describe the evolution of their management of patients with symptomatic tracheal pouches resulting from TEF repair. These authors conclude that endoscopic pouch division with Clickline biopsy forceps, a true-cut laparoscopic instrument with incorporated suction and cautery, is the most optimal technique that has been used at their institution. In five children, this technique was simple, rapid, and safe, with complete resolution of pouch-related symptoms in all cases. Conclusion Endoscopic airway surgery is presently undergoing resurgence. This trend can be attributed to the availability of new and more sophisticated endoscopic instrumentation, the adjunctive use of new pharmaceuticals, and the growing consensus that open and endoscopic techniques can often be used in a complementary fashion. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 570). 1 Maksoud-Filho JG, Gonçalves ME, Cardoso SR, Tannuri U. Early diagnostic and endoscopic dilatation for the treatment of acquired upper airway stenosis after intubation in children. J Pediatr Surg 2008; 43:

5 Endoscopic airway management in children Rutter et al Durden F, Sobol SE. Balloon laryngoplasty as a primary treatment for subglottic stenosis. Arch Otolaryngol Head Neck Surg 2007; 133: This is the first study describing balloon laryngoplasty in a pediatric population. 3 Lee KH, Rutter MJ. Role of balloon dilation in the management of adult idiopathic subglottic stenosis. Ann Otol Rhinol Laryngol 2008; 117: Ulualp SO, Ryan MW, Wright ST. Microdebrider removal of tracheal papilloma via tracheostomy in the child with an obliterated larynx. J Laryngol Otol 2007; 121: Pasquale K, Wiatrak B, Woolley A, Lewis L. Microdebrider versus CO 2 laser removal of recurrent respiratory papillomas: a prospective analysis. Laryngoscope 2003; 113: Rees CJ, Tridico TI, Kirse DJ. Expanding applications for the microdebrider in pediatric endoscopic airway surgery. Otolaryngol Head Neck Surg 2005; 133: Roy S, Zito J. Bilateral subglottic cysts in an infant treated with CO 2 laser marsupialization. Ear Nose Throat J 2007; 86:212; Worley G, Bajaj Y, Cavalli L, Hartley B. Laser arytenoidectomy in children with bilateral vocal fold immobility. J Laryngol Otol 2007; 121: Ayari-Khalfallah S, Fuchsmann C, Froehlich P. Thulium laser in airway diseases in children. Curr Opin Otolaryngol Head Neck Surg 2008; 16: A study that nicely summarizes the advantages and disadvantages of differing lasers in airway surgery and introduces the thulium laser as a new alternative laser for endoscopic pediatric airway surgery. 10 Hartnick CJ, Boseley ME, Franco RA Jr, et al. Efficacy of treating children with anterior commissure and true vocal fold respiratory papilloma with the 585-nm pulsed-dye laser. Arch Otolaryngol Head Neck Surg 2007; 133: Fu CH, Lee LA, Fang TJ, et al. Endoscopic Nd:YAG laser therapy of infantile subglottic hemangioma. Pediatr Pulmonol 2007; 42: Lee K, Chen B, Yang C, Chen Y. CO 2 laser supraglottoplasty for severe laryngomalacia: a study of symptomatic improvement. Int J Pediatr Otorhinolaryngol 2007; 71: O Donnell S, Murphy J, Bew S, Knight LC. Aryepiglottoplasty for laryngomalacia: results and recommendations following a case series of 84. Int J Pediatr Otorhinolaryngol 2007; 71: Schroeder JW Jr, Thakkar KH, Poznanovic SA, Holinger LD. Aspiration following CO 2 laser-assisted supraglottoplasty. Int J Pediatr Otorhinolaryngol 2008; 72: The first study to raise the possibility that CO 2 laser supraglottoplasty may adversely affect aspiration risk. 15 Zafereo ME, Taylor RJ, Pereira KD. Supraglottoplasty for laryngomalacia with obstructive sleep apnea. Laryngoscope 2008 [Epub ahead of print]. 16 Richter GT, Rutter MJ, dealarcon A, et al. Late-onset laryngomalacia. Arch Otolaryngol Head Neck Surg 2008; 134: A good description of the effectiveness of supraglottoplasty for atypical (lateonset) laryngomalacia. 17 Nicolai T. Airway stents in children. Pediatr Pulmonol 2008; 43: An excellent review study on the risks and benefits of tracheal stents in children. 18 Antón-Pacheco JL, Cabezalí D, Tejedor R, et al. The role of airway stenting in pediatric tracheobronchial obstruction. Eur J Cardiothorac Surg 2008; 33: Cabezalí BD, Pacheco Sánchez JA, López Díaz M, et al. The role of tracheobronchial stenting in the management of pediatric airway obstruction. Cir Pediatr 2007; 20: Mostafa BE, Dessouky O. The role of endoluminal self-expanding stents in the management of pediatric tracheal stenosis. Int J Pediatr Otorhinolaryngol 2008; 72: Rampey AM, Silvestri MD, Gillespie MB. Combined endoscopic and open approach to the removal of expandable metallic tracheal stents. Arch Otolaryngol Head Neck Surg 2007; 133: Lim LH, Cotton RT, Azizkhan RG, et al. Complications of metallic stents in the pediatric airway. Otolaryngol Head Neck Surg 2004; 131: Lichtenberger G. Endo-extralaryngeal needle carrier instrument. Laryngoscope 1983; 93: Sapundzhiev N, Lichtenberger G, Eckel HE, et al. Surgery of adult bilateral vocal fold paralysis in adduction: history and trends. Eur Arch Otorhinolaryngol 2008 [Epub ahead of print]. 25 Inglis AF Jr, Perkins JA, Manning SC, Mouzakes J. Endoscopic posterior cricoid split and rib grafting in 10 children. Laryngoscope 2003; 113: Thakkar K, Gerber ME. Endoscopic posterior costal cartilage graft placement for acute management of pediatric bilateral vocal fold paralysis without tracheostomy. Int J Pediatr Otorhinolaryngol 2008; 72: Rahbar R, Ferrari LR, Borer JG, Peters CA. Robotic surgery in the pediatric airway. Arch Otolaryngol Head Neck Surg 2007; 133: It is hard to know just what impact robotic surgery may have on endoscopic airway surgery. Nevertheless, this is an excellent, well written, and thought-provoking article. 28 Richter GT, Ryckman F, Brown RL, Rutter MJ. Endoscopic management of recurrent tracheoesophageal fistula. J Pediatr Surg 2008; 43: A useful guide to the endoscopic management of recurrent TEF. 29 Johnson LB, Cotton RT, Rutter MJ. Management of symptomatic tracheal pouches. Int J Pediatr Otorhinolaryngol 2007; 71: