The history of pediatric airway reconstruction.

OBJECTIVES/HYPOTHESIS: To review the history of pediatric laryngotracheal reconstruction and to highlight those who made major contributions in the field. STUDY DESIGN: Retrospective literature review. METHODS: A literature search using the PubMed database from 1950 to the present. Earlier references were obtained from the Adams Center, the National Library of Medicine, and Virginia Commonwealth University Library. RESULTS: A total of 20 articles were identified. The articles reported 274 airway reconstructions of which 79% were in children. Pre-1935 infection was the leading cause of laryngotracheal stenosis. Laryngostomy, pioneered by Chevalier Jackson, was the most common method of reconstruction. Between 1935 and 1970, trauma was the predominant cause of laryngotracheal stenosis. The most common procedure was the anterior/posterior cricoid split or Rethi procedure. It marked the introduction of bony grafts in laryngotracheal surgery as pioneered by Looper. Post-1970, prolonged intubation in neonates was the most common cause of subglottic stenosis. The field was revolutionized by the work of Evans and Cotton, with widespread use of costal cartilage grafts and laryngotracheoplasty leading to a decannulation rate of over 90%. Advances included decreased morbidity, tolerability, shorter recovery time, and fewer stages of reconstruction. CONCLUSIONS: The pioneering work of many leaders in the field of airway reconstruction over the last 100 years has resulted in a number of effective airway reconstructive procedures that have led to the majority of children being successfully decannulated. In the future, more extensive surgeries, such as tracheal transplantation, may address the small number of children who presently cannot be decannulated.

History of pediatric laryngotracheal reconstruction.

In the early twentieth century, John Winslow wrote that there was no more difficulty in laryngology than treating chronic stenosis of the larynx and trachea. Winslow described cases as "excessively rebellious to treatment" and treatment requiring "patience, persistence, self-sacrifice and skill on the part of the surgeon" and "discomfort or even suffering by the patient." Three decades later, Chevalier Jackson wrote that curing patients required perseverance over a period of time rarely as short as 3 months and as long as 7 years. Significant strides in surgical technique have been made; this article chronicles the development of laryngotracheal reconstruction in children.

[Treatment of acute and chronic laryngeal and tracheal stenoses in the 19th and beginning of the 20th century by tracheotomy, coniotomy, intubation and dilatation. Pictures from the history of otorhinolaryngology illustrated by instruments from the collection of the Ingolstadt Medical History Museum]. / Die Behandlung akuter und chronischer Larynx- und Trachealstenosen im 19. und Anfang des 20. Jahrhunderts durch Tracheotomie, Koniotomie, Intubation und Dilatation. Bilder aus der Geschichte der Hals-Nasen-Ohren-Heilkunde, dargestellt an Instrumenten aus der Sammlung im Deutschen Medizinhistorischen in Ingolstadt.

Although tracheotomy had been described in the Middle Ages and especially in the 17th century in writings (Fabricius d'Aquapendente 1620) and illustrations (Scultetus 1645), there was hardly any possibility of actually performing this operation as a life-saving intervention until the middle of the 19th century. It was only after suitable cannulae had been introduced by Trousseau in 1851 (double cannula with removeable insert) that tracheotomy became a routine procedure, and it was immediately carried out in a great many cases of diphtheria, croup, typhus, and lues, which often caused critical dispnea. Within the following 25 years, all technical modifications of cannulae were devised that are in use up to this day: the flap valve for the artificial larynx (1861), inflatable cuff (1871), and extra long flexible cannula. Beginning in 1885, O'Dwyer's method of intubation became established as an alternative to tracheotomy. Both procedures, like the underlying disease itself, frequently resulted in a permanent stenosis of the larynx or the trachea rendering decannulation impossible. Since about 1870 the treatment of these stenoses, primarily by bougienage, became an important issue in laryngology, which had just been established as a discipline in its own right. The history of this evolution and the therapeutic approaches by Schrötter in Vienna and Thost in Hamburg are described in detail, including their specially devised equipment. Apart from that, other medical aspects of historical interest around the turn of the century are mentioned, such as artificial nutrition by subcutaneous injections and tracheotomy in horses.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic stenosis of the larynx with special consideration of skin grafting. 1940.

1. Treatment for chronic stenosis of the larynx should be delayed until the patient is in the best possible general condition and until any local inflammatory reaction has entirely cleared. 2. The type of treatment indicated in a given instance depends largely on the character and extent of the stenosis rather than on its cause. 3. Bouginage, the most commonly employed procedure in the treatment of stenosis of the larynx, has in our experience at The Mayo Clinic been one of the least effective procedures. 4. Elastic pressure applied by means of soft rubber dilators is one of the most satisfactory methods of treating chronic stenosis. 5. Laryngofissure with excision of the scarring and any thickened or distorted cartilage, followed by skin grafting, is the most effective method of dealing with chronic cicatricial stenosis and often will restore a satisfactory laryngeal lumen after other methods of treatment have failed.

A historical overview of the aetiology and treatment of laryngeal stenosis.

A review of over a century of publication on laryngeal stenosis reveals much about the aetiology and treatment. The earlier aetiologies of infection and in particular diphtheria of the early part of the twentieth century have given way to more complex and insidious causes. Trauma, particularly from intubation by endotracheal, tracheal or nasogastric tubes, is now the primary cause of simple and complex laryngeal stenosis. The treatments over the past century have been varied and ingenious, ranging from simple dilatation and intubation of the 1800s to galvanocautery, endoscopic scar incision and heated bougienage of the early twentieth century. By the 1930s and 1940s the concept of laryngofissure, scar excision, stenting and skin grafting was the accepted approach to laryngeal stenosis. More recently endoscopic approaches, local flap placement and laser surgery have been advocated. The open approach, however, has stood the test of time. This review presents a comprehensive bibliography and from the reading of these texts a method of classification is presented. This classification is coupled to available modern treatments as described in the literature and so gives the surgeon the available options for the stenosis encountered. The choice remains with the surgeon; however, as in most complex clinical problems there is usually a safe, reliable, dependable procedure, and it is the author's opinion, from this literature review, that the open laryngofissure procedure fulfils these criteria.