Aaron's Tracheal Reconstruction Surgery
Subglottic stenosis is a narrowing in the subglottic area of the trachea resulting in varying degrees of upper airway obstruction. Subglottic stenosis is a condition that can be either congenital or acquired. Acquired subglottic stenosis from endotracheal intubation--trauma to the subglottic structures secondary to endotracheal intubation--is the most common cause of subglottic stenosis in children. Symptoms of subglottic stenosis include respiratory distress, stridor or croup-like symptoms. Diagnosis is made by visualizing the trachea via a bronchoscopy.
- Subglottic stenosis is graded by % of occlusion
- Grade 1 obstruction in less than 70% occluded
- Grade 2 is 70 - 90% occluded
- Grade 3 is greater that 90% occluded
- Grade 4 is a complete occlusion
Using this grading system, Aaron's subglottic stenosis was a Grade 2. In some mild cases of subglottic stenosis, the child may not need any surgical intervention. This was not the case for Aaron.
- Some of the treatments for Subglottic Stenosis include:
- Serial dilations
- Endoscopic excision
- Anterior Cricoid Split (ACS)
- Laryngotracheoplasty (LTP)
Aaron had his tracheal reconstructive surgery (Laryngotracheoplasty) on Wednesday, June 11th, 1997 at Children's Hospital in Boston, MA by Gerald B. Healy, MD, FACS. First, a bronchoscopy was done to reassess Aaron's airway and make a final decision on grafting. Dr. Healy decided to use an anterior cartilage graft for Aaron. The general surgeon Dr. Wilson then harvested the appropriate size section of rib cartilage from Aaron's chest, which Dr. Healy then used to rebuild Aaron's airway. The entire surgery lasted approximately 5 1/2 hours.
- Reconstruction procedure This diagram shows the procedure for a single stage laryngotracheoplasty for subglottic stenosis using a costal cartilage graft.
- Subglottic stenosis before and after surgery Aaron's airway was approximately 75% occluded before surgery.
- Tracheotomy site and granuloma before and after surgery The granuloma is a growth of abnormal tissue which was caused by the irritation of the tracheostomy tube in Aaron's airway.
Following surgery, Aaron was intubated and the endotracheal tube acted as a stint as his trachea healed. Aaron was intubated for 7 days in the intensive care unit (ICU). He muscles were paralyzed with cisatracurium and he received Morphine and Ativan for comfort. He was also on anti-reflux medications to prevent stomach acids from damaging the graft and antibiotic to prevent infection.
On the following Tuesday, June 17th, Aaron was taken back to the O.R., where he was extubated and reassessed via a bronchoscopy. Dr. Healy was happy with Aaron's new airway and he returned to the ICU breathing on his own without any tubes for the first time in his life! Aaron remained in the ICU for 24 hours where his was monitored closely for any signs of airway problems. He was kept in a mist tent after extubation. Humidity is essential, according to Dr. Healy, because the normal trachea has cilia (tiny hairs) that help to moisten and remove secretions for the airway. Because the rib cartilage graft lacks cilia, it must be kept moist so that it doesn't dry out. We where interested to learn that the graft will eventually grow it's own cilia. Aaron will continue to sleep in a mist tent at home and will have a room humidifier while awake for several months. Aaron was moved to a regular pediatric floor on June 19th and discharged home on June 20th.
Aaron received short-term physical therapy and long-term speech therapy following his surgery. He was weak and had lost some weight during his hospital stay. It took about a month before Aaron is back to where he was before the surgery. He didn't quite understand all that has happened to him, and hopefully he will not remember most of his hospitalization. However, he is quite proud to show off his scar and declares, "Doctor Hehe [Healy] fixed the trach," "Trachs all gone."Update - August, 1997
By the end of July, Aaron began having increased respiratory distress. He returned to Children's Hospital on July 29, 1997 for an exploratory bronchoscopy/laryngoscopy. It was discovered that Aaron developed a subglottic "web" just below his vocal cords that encompassed his entire airway with the exception of a tiny pin hole, which he was breathing through! The doctors were surprised to find this and amazed that Aaron had compensated for as long as he had with this membrane-like tissue covering his trachea.
Dr. Healy removed the web during the bronchoscopy procedure, so Aaron's neck did not have to be re-opened. Dr. Healy said that the web could grow back, so we are watching him very closely. The web developed along the upper end of the suture line of the graft. Otherwise, the reconstruction area (rib graft) is healed and looks great (see subglottic stenosis before and after surgery for the new picture of his graft 7 weeks post-op).
- Subglottic Web before and after surgery Subglottic web is membrane-like tissue that grows across the trachea.
Aaron recovered quickly and was discharged for the hospital on July 31, 1997.
Update - May 2000
Almost 3 years post-op, Aaron's breathing began to sound louder and he was experiencing shortness of breath upon exertion. A soft tissue x-ray reveled a suspicious gray line that appeared to be a web in his airway. On May 3,2000 Aaron had an exploratory bronchoscopy/laryngoscopy which revealed a new web of tissue just below his vocal cords and obstructing approximately 30% of his airway. Webbing is a form of scar tissue formation which is fairly common in kids with airways that have been traumatized in any way (this includes intubation and all types of surgery). Aaron will also be re-evaluated for reflux, which can also contribute to the formation of webs in the airway. Aaron will need laser surgery in order to remove this web. We are waiting for this procedure to be scheduled.
Aaron is now almost 7 years old and trying to be so brave. These procedures sure where easier for all concerned when Aaron was too young to understand.
Update - June 2000
Aaron had laser surgery on May 31, 2000. The procedure involved several cuts into the scar tissue and then dilation on the web. They do not simple remove the scar tissue, since it will just grow back again. There is a good chance that the web will grow back anyway, but we did try a new experimental treatment that may help to reduce the formation of scar tissue. After the laser procedure, Mitomycin C was applied topically to the surgical site.
The pH probe and esophageal biopsies (test for reflux) were normal.
Update - September 2002
I've received many emails asking how Aaron is doing now, 5 years after his LTP (thanks for asking!). Here's a short update:
Aaron is doing well at this time. He has not had a bronchoscopy since May 2000. His breathing continues to sound noisy especially upon exertion, but we believe this is due to a "tabulate airway." Aaron's trachea is abnormally shaped so that air moving though it sounds louder than normal. This does not cause him any distress. As far as scar tissue, it is very difficult to evaluate Aaron. I would guess that he probably does have some scar tissue, but not enough to interfere with his activities of daily living. We are hoping that as Aaron grows and his airway gets larger, that whatever scar tissue or webbing he might have will not be a problem for him. We continue to monitor him closely and will do a bronchoscope if needed.
Some parents have also asked about scarring on the skin surface after surgery. All kids are different; kids like Aaron with light skin, blond hair and blue eyes tenders to scar easier. However, Aaron has very little noticeable scarring at this time. We feel that this is due in part to the application of Vitamin E Oil for a couple of months after surgery.
- Aaron's scars at age 9, 5 years after LTP
- More about Vitamin E Oil
- More about Aaron
- Bissell Home Page, Family Home Page
Update - August 2007
Over the past several years, Aaron's breathing had gradually become louder and more labored indicating that more scar tissue in his airway. He was seen by Dr. Nuss at Boston Children's because Dr. Healy is now semi-retired.
Aaron went to the OR on July 24, 2007 for evaluation of his airway. Bronchoscopy revealed a significant scar band posteriorly and in the left posterolateral region.
Several laser incisions were made into the scar band at 6 o'clock and 8 o'clock
Laser incisions into scar band
After dilation and application of mitomycin C
Aaron tolerated the surgery well and is doing very well at this time.
More on Subglottic Stenosis
- Subglottic Stenosis The Virtual Hospital
- Subglottic Stenosis Multimedia - The Virtual Hospital
- Table of Characteristics of Subglottic Stenosis The Virtual Hospital