Practical Tips for Surgical Management of Bilateral Choanal Atresia.

Choanal atresia refers to congenital blockage of posterior choana of nose by the presence of a bony or membranous soft tissue. It causes respiratory distress in newborn which requires emergency surgical intervention. Various surgical methods are available for correction of choanal atresia and endoscopic approach is the commonly used one. However there is risk of re-stenosis after surgery. This article focuses on surgical refinements to improve the surgical outcome. It is a retrospective study done on eight newborns with bilateral congenital choanalatresia. Data included gestational age, any ante-natal issues, breathing activity at birth, diagnostic tests for choanal atresia and Head to Foot examination findings. Initial diagnostic work up included CT scan of paranasal sinus and Echocardiography to rule out associated cardiac anomalies. All the newborns were treated initially in NICU with ventilator support and then taken up for endoscopic correction of atresia. After surgery, newborns were successfully weaned off from ventilator. Among the 8 newborns, there were 5 males and 3 females and their gestational age was full term. (except in one). Initial presentation included respiratory distress on day 1 of life with difficulty in inserting feeding tube through the nose. Imaging showed bilateral atresia in 7 newborns and unilateral atresia in one newborn. 5 of them underwent atresia surgery using endoscopic approach. One newborn required revision surgery. Remaining newborns remained symptom free during the follow up period. Currently endoscopic approach remains a safer method for correction of choanal atresia with very minimal chance of re-stenosis. Surgical refinements like adequate widening of neo-choana and usage of mucosal flaps to cover the raw area has been found to improve the surgical outcome.

Safety of Percutaneous vs Open Tracheostomy on Intubated Patients in ICU Setting: Which One is Better?

To study the safety of percutaneous vs open tracheostomy approaches on patients requiring long term ventilation in ICU setting. It is a prospective study done over a period of 2 years on 105 patients requiring long term ventilation in ICU set up in a tertiary care hospital. Patients were subjected to either open approach or percutaneous tracheostomy bedside in ICU itself. Then patients were followed during their hospital stay to look for any tracheostomy related complications. Data regarding age, gender, indications of long term ventilation and complications were compiled and analysis was done. It was found that most of the patients were of male gender (88.6%) in the age group of 50-59 years of age. The most common cause for tracheostomy was head injury secondary to road traffic accident, seen in 79 out of 105 cases. On comparing complications rate, there was no statistically significant difference in both the groups. However rate of peristomal infection is more with open approach group (P < 0.05). Percutaneous tracheostomy can be performed safely in ICU as a bedside procedure. There is significant reduction in peristomal infection with percutaneous tracheostomy and there is no significant difference in other complications between the two groups. Thus percutaneous tracheostomy is as safe as an open approach tracheostomy in properly selected cases.

Acquired subglottic stenosis: aetiological profile and treatment results.

OBJECTIVES: To analyse the aetiological profile and surgical results of patients with acquired chronic subglottic stenosis, and formulate a surgical scheme based on an audit of various surgical procedures. METHODS: Thirty patients were treated by 65 procedures (31 endoscopic and 34 external) between 2004 and 2009. RESULTS: Isolated subglottic stenosis was noted as unusual in the majority (27 cases), demonstrating contiguous tracheal or glottic involvement. The major aetiologies were intubation injury (n = 8) and external injury (n = 21) (i.e. blunt trauma, strangulation or penetrating injury). Vocal fold immobility and cartilage framework involvement were frequent with external injury and infrequent with intubation injury. Luminal restoration was achieved by endoscopic procedures in 2 cases, external procedures in 19 cases, and external plus adjuvant endoscopic procedures in 8 cases. The preferred surgical options were: endoscopic procedures, restricted to short, recent, grade I or II mucosal stenosis cases; and external procedures for all other stenosis situations, including isolated subglottic (anterior cricoid split plus cartilage graft), subglottic and glottic or high subglottic (anterior plus posterior cricoid split with cartilage graft), and subglottic and tracheal (cricotracheal resection with anastomosis). CONCLUSIONS: External injury stenosis has a worse profile than intubation injury stenosis. Anatomical categorisation of subglottic stenosis guides surgical procedure selection. Endoscopic procedures have limited indications as primary procedures but are useful adjunctive procedures.

Laryngotracheal stenosis: clinical profile, surgical management and outcome.

Despite the availability of various surgical options, management of laryngotracheal stenosis (LTS) still remains an enigma. Proper selection of surgical technique in each clinical setting is the key for successful outcome. The purpose of this article is to guide one in selection of appropriate surgical procedures depending upon various stenosis parameters. Aim To record the clinical profile of cases with LTS. To assess the outcome following various surgical interventions based on site, severity, cause of stenosis and to derive conclusions regarding treatment options in various stenosis. Materials and Methods It is a study of 60 cases with chronic LTS. It includes retrospective study of 30 cases treated from 2004 and prospective study of 30 cases from Jan 2007 to Dec 2009. A total of 60 cases with LTS were enrolled in the study. Patients were assessed clinically by eliciting detailed history and analyzing previous records. After assessment of extent of stenosis, they were subjected to surgical interventions (endoscopic/open approach). Outcome after surgical interventions was assessed. Results 60 patients were included in the study, in the age group of 2.5-50 years. There were 46 (77%) male patients and 14 (23%) female patients. Intrinsic trauma, secondary to prolonged intubation was the most common cause of LTS, seen in 23 (38%) cases followed by post traumatic stenosis (strangulation-18 (30%), blunt injury-15 (25%), penetrating neck injury-4 (7%)). Stenosis was divided into 6 types based on subsite involvement. Of which, cervical trachea was the commonest site of involvement (25/60 cases). Majority of cases had fixed vocal cords at presentation (55%), more commonly due to post traumatic injury. 60 cases had undergone a total of 110 surgical procedures (endoscopic-56,open approach-54). In the end, overall decannulation rate is 93.3%. In site wise tracheal stenosis, isolated subglottis, combined glottis and subglottic stenosis had decannulation rate of 100% each and with mobile vocal cords, the success rate is 96%. Conclusions Post traumatic stenosis with fixed vocal cords is more common in our practice. Categorizing stenosis into various subtypes helps in treatment planning and predicts surgical outcome. Tracheal or subglottic stenosis with mobile vocal cords has better success rate.