Non Operative Treatment

Growth has also provided numerous instances where lesser acquired stenotic lesions or limited areas of malacia improved or became sufficiently corrected over time to obviate need for reconstruction. For this reason, and since anastomosis is more safely performed in larger airways, I have approached many pedi-atric patients conservatively, even accepting prolonged presence of a tracheostomy tube in the interim. Although a silicone T tube has many functional advantages over tracheostomy for prolonged interim treatment, the failure rate of T tubes in very small tracheae is much greater than in the adult, due to easy obstruction of the tube.74 A particularly favorable application of the T tube is in a child with obstruction from a residual depressed flap in the anterior tracheal wall due to the tracheostomy tube lying just below. A T tube splints the deformed wall flap forward, allowing cartilage to remodel in the corrected position. The tube is later removed and the stoma allowed to close. Permanent stents of small caliber or expandable

figure 6-23 Diagram of tracheal cross sections at anastomotic sites when fully grown, from puppies that were transected or resected, and in dogs resected as adults. Sagittal diameters are vertical (cm). Fully adequate airways resulted within the range of permissible resection. Reproduced with permission from Maeda M and Grillo HC.58

figure 6-23 Diagram of tracheal cross sections at anastomotic sites when fully grown, from puppies that were transected or resected, and in dogs resected as adults. Sagittal diameters are vertical (cm). Fully adequate airways resulted within the range of permissible resection. Reproduced with permission from Maeda M and Grillo HC.58

stents should be avoided, because of their failure to account for growth, their ease of occlusion, their potential to cause additional injury, and the difficulty of removal.

Dilation of acquired stenosis, just as in the adult, provides temporary relief at best in most patients, with or without use of the laser. An exception may be web-like congenital strictures (rarely seen as acquired lesions). Kim and Hendren noted satisfactory results in selected cases with electrocautery excision of subglottic webs.75 Congenital segmental stenosis should not be dilated since this can split the "O" rings, which are usually present.

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