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Cotton Grading System of Subglottic Stenosis
Cotton Grading System of Subglottic Stenosis
1.
Rethi  A An operation for cicatricial stenosis of the larynx. J Laryngol Otol. 1956;70283- 293Article
2.
McDonald  IHStocks  JG Prolonged nasotracheal intubation: a review of its development in a paediatric hospital. Br J Anaesth. 1965;37161- 172Article
3.
Holinger  PHKutnick  SLSchild  JAHolinger  LD Subglottic stenosis in infants and children. Ann Otol. 1976;85591- 599
4.
Fearon  BCotton  R Surgical correction of subglottic stenosis of the larynx in infants and children. Ann Otol Rhinol Laryngol. 1974;83428- 431
5.
Bailey  CM Surgical management of acquired subglottic stenosis. J Laryngol Otol. 1988;17(suppl)45- 48
6.
Cotton  RT Pediatric laryngotracheal stenosis. J Pediatr Surg. 1984;19699- 704Article
7.
Cotton  RTGray  SDMiller  RP Update of the Cincinnati experience in pediatric laryngotracheal reconstruction. Laryngoscope. 1989;991111- 1116Article
8.
Myer  CM  IIIO'Connor  DMCotton  RT Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol. 1994;103 ((4 pt 1)) 319- 323
9.
Cotton  R Management of subglottic stenosis in infancy and childhood: review of a consecutive series of cases managed by surgical reconstruction. Ann Otol. 1978;87649- 657
10.
Ochi  JWEvans  JNGBailey  CM Pediatric airway reconstruction at Great Ormond Street: a ten year review. Ann Otol Rhinol Laryngol. 1992;101465- 468
11.
Cotton  RTEvans  JNG Laryngotracheal reconstruction in children: five-year follow-up. Ann Otol. 1981;90516- 520
12.
Sell  DMacCurtain  F Speech and language development in children with acquired subglottic stenosis. J Laryngol Otol. 1988;17(suppl)35- 38
13.
Zalzal  GHLoomis  SRFischer  M Laryngeal reconstruction in children: assessment of vocal quality. Arch Otolaryngol Head Neck Surg. 1993;119504- 507Article
14.
Swift  ACRogers  JH The changing indications for tracheostomy in children. J Laryngol Otol. 1987;1011258- 1262Article
15.
Tucker  JASilberman  HD Tracheotomy in pediatrics. Ann Otol Rhinol Laryngol. 1972;81818- 824
16.
Rogers  JH Tracheostomy and decannulation. Kerr  AGAdams  DACinnamond  MJedsScott-Brown's Otolaryngology. Oxford, England Butterworth-Heinemann1997;6
17.
Donnelly  MJLacey  PDMaguire  AJ A twenty year (1971-1990) review of tracheostomies in a major paediatric hospital. Int J Pediatr Otorhinolaryngol. 1996;351- 9Article
18.
Wetmore  RF Tracheotomy. Bluestone  CDStool  DEKenna  MAedsPediatric Otolaryngology. Vol 23rd ed. Philadelphia, Pa WB Saunders Co1990;1425- 1440
19.
Granger  AP Pediatric tracheostomies: changing trends. J Otolaryngol. 1988;17121- 124
20.
Crysdale  WSFeldman  RINaito  K Tracheotomies: a 10-year experience in 319 children. Ann Otol Rhinol Laryngol. 1988;97439- 443
21.
Line  WSHawkins  DBKohlstrom  EJ  et al.  Tracheotomy in infants and young children: the changing perspective, 1970-1985. Laryngoscope. 1986;96510- 515Article
22.
Westmore  RFHandler  SDPotsic  WP Pediatric tracheostomy: experience during the past decade. Ann Otol Rhinol Laryngol. 1982;91628- 632
23.
Smith  MEMortelliti  AJCotton  RTMyer  CM Phonation and swallowing considerations in pediatric laryngotracheal reconstruction. Ann Otol Rhinol Laryngol. 1992;101731- 738
24.
Cotton  RTSeid  AB Management of the extubation problem in the premature child: anterior cricoid split as an alternative to tracheotomy. Ann Otol. 1980;89508- 511
25.
Silver  FMMyer  CMCotton  RT Anterior cricoid split: update 1991. Am J Otolaryngol. 1991;12343- 346Article
26.
Lusk  RPGray  SMuntz  HR Single-stage laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1991;117171- 173Article
27.
Seid  ABPransky  SMKearns  DB On-stage laryngotracheoplasty. Arch Otolaryngol Head Neck Surg. 1991;117408- 410Article
28.
Cotton  RTMyer  CMO'Connor  DM Innovations in pediatric laryngotracheal reconstruction. J Pediatr Surg. 1992;27196- 200Article
29.
Stenson  KBerkowitz  RMcDonald  TGruber  B Experience with one-stage laryngotracheal reconstruction. Int J Pediatr Otorhinolaryngol. 1993;2755- 64Article
30.
Seid  ABGodin  MSPransky  SMKearns  DBPeterson  BM The prognostic value of endotracheal tube air leak following tracheal surgery in children. Arch Otolaryngol Head Neck Surg. 1991;117880- 882Article
31.
Cotton  RTMyer  CMO'Connor  DMSmith  ME Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the single-stage approach. Laryngoscope. 1995;105818- 821Article
Original Article
March 1999

Single-Stage Laryngotracheal ReconstructionThe Great Ormond Street Experience and Guidelines for Patient Selection

Author Affiliations

From the Division of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill (Dr McQueen); Department of Pediatric Otolaryngology, University of California, Los Angeles (Dr Shapiro); Department of Pediatric Otolaryngology, Hospital for Sick Children, London, England (Drs Leighton and Albert); and Department of Statistical Analysis, University of North Carolina School of Public Health, Chapel Hill (Mr Guo).

Arch Otolaryngol Head Neck Surg. 1999;125(3):320-322. doi:10.1001/archotol.125.3.320
Abstract

Objectives  To review all patients undergoing single-stage laryngotracheal reconstruction and to determine guidelines to predict successful outcomes and prevent the necessity of tracheotomy following laryngotracheal reconstruction.

Design  Chart review.

Setting  Tertiary care children's hospital.

Patients  A retrospective chart review was performed at our institution involving all patients who underwent single-stage laryngotracheal reconstruction from 1993 through 1996. A total of 28 patients were reviewed.

Results  Based on this chart review, a statistically higher incidence of extubation complications (P=.045), ie, bleeding, reintubation, or subcutaneous emphysema, occurred in children who weighed less than 4 kg. Although not statistically significant (P>.99), the relative risks of failure, defined as tracheotomy dependent or significant airway compromise following single-stage laryngotracheal reconstruction, were 3.43 if the child's weight was less than 4 kg at the time of surgery and 2.31 if the gestational age was less than 30 weeks at the time of surgery. Length of time for intubation did not appear to have any effect on outcome.

Conclusions  Patients' gestational age and weight at the time of surgery appear to have the most impact on successful outcome. Children weighing more than 4 kg and those with gestational age of greater than 30 weeks appear to have a greater chance at successful extubation and eventual patent airway. Duration of intubation following single-stage laryngotracheal reconstruction does not appear to affect outcome.

THE SURGICAL management of subglottic stenosis (SGS) has been evolving since posterior cricoidotomy was first described by Rethi1 in 1956. In the late 1960s, following the reintroduction of long-term intubation in children as an alternative to tracheotomy for ventilatory support, the incidence of acquired SGS has increased.2 This was found to be more severe than congenital SGS, and was twice as likely to require tracheotomy. There was a higher rate of morbidity and mortality in patients with acquired SGS than in those with congenital SGS.3

In 1974, Fearon and Cotton4 reported surgical correction of SGS by laryngotracheal reconstruction (LTR) with an interposition of autogenous cartilage anteriorly between the edges of the longitudinally divided cricoid cartilage and upper tracheal rings. This was followed by stenting of the larynx with a prosthesis for a period of weeks or months until healing occurred. Until recently, standard management of children with acquired SGS has consisted of tracheotomy and serial endoscopy to assess the size of the subglottic airway. Subglottic stenosis usually requires reconstruction when the subglottis will only accept a rigid bronchoscope of 2 or more sizes below the normal for that child's age or weight.5 In up to 20% of children with grade I SGS (Table 1), growth of the airway results in decannulation without further intervention. In patients with higher grades of stenosis, LTR is required.9 In the series by Bailey5 (1988), 62% of patients needed anterior grafting (grades I and II), 30% required anterior and posterior grafting (grades III and IV), and 8% required only a posterior graft; the last group had primarily posterior stenosis and dense interarytenoid scarring. Ochi et al10 reported decannulation rates after reconstruction of 88% for patients with grades I and II SGS, 78% for grade III, and 50% for grade IV. Overall, with some children undergoing several procedures, a decannulation rate of more than 90% has been achieved.7 No adverse effects on laryngeal growth have been reported.11

The problems inherent in this management of SGS in children include the complications of a long-term tracheotomy. Adverse effects of tracheotomy on speech and language development have been documented, and the abnormal respiratory patterns and unduly effortful phonation of tracheotomy-dependent children have been shown to persist, even after successful LTR and subsequent decannulation.12,13 Rates of morbidity and mortality for tracheotomies in children are variable, with reports of morbidity up to 44% and mortality from 0.9% to 8.7%.1422 There is also a considerable risk of behavioral difficulties in these children; the strain on the family of a child with a long-term tracheotomy should not be underestimated.

Long-term stenting of the larynx in traditional LTR is another factor associated with a significant morbidity. Swallowing difficulties and aspiration during stenting, granulation tissue delaying decannulation, and trauma to the free edge of the vocal fold mucosa with subsequent fibrosis have all been documented.6,23

The anterior cricoid split procedure was reported by Cotton and Seid24 to reduce the need for tracheotomy in neonates in whom extubation is not possible because of SGS secondary to damage related to the endotracheal tube. Following the procedure, the endotracheal tube is left in place, acting as a stent, and then the child is subsequently extubated. The authors reported a success rate of 70% with this procedure. It has been emphasized that the pulmonary reserve in these neonates must be adequate to allow spontaneous respiration once the SGS is relieved so that reintubation is not required with its risk of further subglottic trauma.25

Single-stage LTR (SS-LTR) has been a logical development of the anterior cricoid split. It developed independently in a number of centers in the late 1980s.2628 The term has been used to describe both LTR as the primary surgery performed on a stridulous or intubated patient, avoiding tracheotomy, and LTR combined with surgical closure of a preexisting tracheotomy by a cartilage grafting technique.29 The 2 procedures resemble each other in that postoperatively, instead of prolonged endolaryngeal stenting, a nasotracheal tube is left in situ for a short period, usually 7 to 10 days, and the child is traditionally sedated, paralyzed, and ventilated in the pediatric intensive care unit. Although many practices paralyze and sedate their children, at the Hospital for Sick Children, Great Ormond Street, London, England (GOS), we traditionally limit sedation and rarely paralyze. Once subglottic edema has settled, signified by a low-pressure leak around the indwelling tube, the child is extubated.30

Cotton et al31 reported in 1995 the Cincinnati experience of SS-LTR. One hundred sixteen children underwent SS-LTR with endotracheal tube stenting. One hundred seven of these 116 children underwent reconstruction of the laryngotracheal complex; 77 of whom had tracheotomies preoperatively and 30 of whom had no tracheotomy preoperatively. Sixty-three percent of all patients had Cotton grade I or II SGS. Eighty-seven percent of these patients left the hospital with an adequate airway without a tracheotomy. Although observations were made regarding failures and successes, no definitive comments were made regarding patient selection except for guidelines for adequate pulmonary function prior to the SS-LTR. In an effort to define guidelines for successful SS-LTR, we reviewed all cases of SS-LTR performed at GOS.

PATIENTS AND METHODS

Twenty-eight children underwent SS-LTR at GOS since this procedure was begun at GOS in 1993. There were 9 females and 19 males. The mean and median gestational ages at birth were 32.8 and 31 weeks, respectively. The mean and median weights at the time of surgery were 7.6 and 6.25 kg, respectively. Twenty-two procedures were performed for acquired SGS, 5 for congenital SGS, and 1 for trauma of the subglottic airway. The grade of stenosis, based on the Cotton grading system of SGS, was as follows: 7 patients (25%), grade III; 12 patients (43%), grade II; 5 patients (18%), grade I; and 4 patients (14%), grade unknown.

All children had an SS-LTR as their first procedure for corrective airway surgery. The mean and median number of days after birth to the time of the first procedure were 421.75 and 255, respectively, with a range of 56 to 2460 days. Three (11%) of 28 patients had anterior and posterior grafts. The remaining 25 (89%) had anterior grafts only. Five (18%) of the 28 children had tracheotomies at the time of the first procedure. All procedures were performed by the consultant staff at GOS.

RESULTS

The mean and median duration of intubation following SS-LTR were both 6.5 days, with a range of 2 to 14 days. Complications following extubation were as follows: no complications, 16 patients (57%); stridor but not requiring reintubation, 5 patients (18%); and stridor requiring reintubation, 7 patients (25%).

Final outcomes of the first procedure for the 28 children were as follows. Fourteen (50%) had an excellent result with no resulting stridor, 8 (29%) had good results with mild stridor but no airway compromise, and 6 (21%) were tracheotomy dependent. Follow-up ranged from 14 to 1470 days.

Eleven (39%) of the 28 children required a second procedure: 1 (4%) required a revision SS-LTR for persistent stridor; 6 (21%) required tracheotomy; and 4 (14%) required laser excision of granulation tissue around the graft site.

Following the second procedure, the one child requiring a revision SS-LTR had an excellent airway with no residual stridor at 330 days' follow-up. Outcomes of the 6 who required tracheotomies were as follows: 2 succumbed to disease other than airway; 1 underwent revision SS-LTR, resulting in a good airway with mild stridor but no airway compromise (follow-up, 60 days postoperatively); 1 was tracheotomy dependent; 1 had revision SS-LTR with excellent results and no residual stridor at 180 days follow-up; and 1 underwent 2-staged LTR with excellent results.

Of the 4 second procedures that required laser excision of granulation tissue, 3 had excellent results and 1 required a tracheotomy and died of disease unrelated to airway.

Twenty-four (86%) of the 28 patients left the hospital without requiring a tracheotomy. Of the 4 remaining patients, 1 (4%) remained tracheotomy dependent and 3 (11%) died of diseases unrelated to airway.

Statistical analysis was undertaken to identify factors that may predict successful outcomes. For the purpose of statistical analysis, successes were reported as children who underwent surgery and were not tracheotomy dependent and had no significant airway compromise following surgery. For weight less than 4 kg at the time of surgery, the relative risk of failure was 3.43 (P=.14). If gestational age was less than 30 weeks, the relative risk of failure was 2.31 (P=.37). There was no relative risk to intubation less than 7 days after the procedure. However, for children who weighed less than 4 kg, there was a statistically higher incidence of extubation complications, ie, bleeding, reintubation, or subcutaneous emphysema (P=.045). The relative risk of extubation complications was 2.88 (P=.20) for children who had a gestational age less than 30 weeks. There was no significant relative risk to extubation complications in children who were intubated less than 7 days (P >.99). No statistical significance was identified with respect to the sex of the child and successful outcome.

COMMENT

Single-stage laryngotracheal reconstruction remains an excellent treatment modality for repair of the SGS in children. We have tried to define guidelines for selecting children for successful repair of SGS using the single-staged approach. Because our numbers are relatively small, statistical power was limited; however, based on relative risks, it appears that children weighing more than 4 kg and those with a gestational age greater than 30 weeks have a greater chance at successful extubation and eventual airway patency. It also appears that children weighing less than 4 kg have more complications surrounding extubation. This may be due to the other underlying disease states that are often present in these neonates or purely to their incredibly small size. Finally, although not statistically significant, duration of intubation following surgery had no bearing on extubation complications or on final outcome.

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Article Information

Accepted for publication March 18, 1998.

Corresponding author: Chapman T. McQueen, MD, Division of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, CB 7070, Burnett-Womack Building, Chapel Hill, NC 27599-7070 (e-mail: mcqueenc@unc.med.edu).

References
1.
Rethi  A An operation for cicatricial stenosis of the larynx. J Laryngol Otol. 1956;70283- 293Article
2.
McDonald  IHStocks  JG Prolonged nasotracheal intubation: a review of its development in a paediatric hospital. Br J Anaesth. 1965;37161- 172Article
3.
Holinger  PHKutnick  SLSchild  JAHolinger  LD Subglottic stenosis in infants and children. Ann Otol. 1976;85591- 599
4.
Fearon  BCotton  R Surgical correction of subglottic stenosis of the larynx in infants and children. Ann Otol Rhinol Laryngol. 1974;83428- 431
5.
Bailey  CM Surgical management of acquired subglottic stenosis. J Laryngol Otol. 1988;17(suppl)45- 48
6.
Cotton  RT Pediatric laryngotracheal stenosis. J Pediatr Surg. 1984;19699- 704Article
7.
Cotton  RTGray  SDMiller  RP Update of the Cincinnati experience in pediatric laryngotracheal reconstruction. Laryngoscope. 1989;991111- 1116Article
8.
Myer  CM  IIIO'Connor  DMCotton  RT Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol. 1994;103 ((4 pt 1)) 319- 323
9.
Cotton  R Management of subglottic stenosis in infancy and childhood: review of a consecutive series of cases managed by surgical reconstruction. Ann Otol. 1978;87649- 657
10.
Ochi  JWEvans  JNGBailey  CM Pediatric airway reconstruction at Great Ormond Street: a ten year review. Ann Otol Rhinol Laryngol. 1992;101465- 468
11.
Cotton  RTEvans  JNG Laryngotracheal reconstruction in children: five-year follow-up. Ann Otol. 1981;90516- 520
12.
Sell  DMacCurtain  F Speech and language development in children with acquired subglottic stenosis. J Laryngol Otol. 1988;17(suppl)35- 38
13.
Zalzal  GHLoomis  SRFischer  M Laryngeal reconstruction in children: assessment of vocal quality. Arch Otolaryngol Head Neck Surg. 1993;119504- 507Article
14.
Swift  ACRogers  JH The changing indications for tracheostomy in children. J Laryngol Otol. 1987;1011258- 1262Article
15.
Tucker  JASilberman  HD Tracheotomy in pediatrics. Ann Otol Rhinol Laryngol. 1972;81818- 824
16.
Rogers  JH Tracheostomy and decannulation. Kerr  AGAdams  DACinnamond  MJedsScott-Brown's Otolaryngology. Oxford, England Butterworth-Heinemann1997;6
17.
Donnelly  MJLacey  PDMaguire  AJ A twenty year (1971-1990) review of tracheostomies in a major paediatric hospital. Int J Pediatr Otorhinolaryngol. 1996;351- 9Article
18.
Wetmore  RF Tracheotomy. Bluestone  CDStool  DEKenna  MAedsPediatric Otolaryngology. Vol 23rd ed. Philadelphia, Pa WB Saunders Co1990;1425- 1440
19.
Granger  AP Pediatric tracheostomies: changing trends. J Otolaryngol. 1988;17121- 124
20.
Crysdale  WSFeldman  RINaito  K Tracheotomies: a 10-year experience in 319 children. Ann Otol Rhinol Laryngol. 1988;97439- 443
21.
Line  WSHawkins  DBKohlstrom  EJ  et al.  Tracheotomy in infants and young children: the changing perspective, 1970-1985. Laryngoscope. 1986;96510- 515Article
22.
Westmore  RFHandler  SDPotsic  WP Pediatric tracheostomy: experience during the past decade. Ann Otol Rhinol Laryngol. 1982;91628- 632
23.
Smith  MEMortelliti  AJCotton  RTMyer  CM Phonation and swallowing considerations in pediatric laryngotracheal reconstruction. Ann Otol Rhinol Laryngol. 1992;101731- 738
24.
Cotton  RTSeid  AB Management of the extubation problem in the premature child: anterior cricoid split as an alternative to tracheotomy. Ann Otol. 1980;89508- 511
25.
Silver  FMMyer  CMCotton  RT Anterior cricoid split: update 1991. Am J Otolaryngol. 1991;12343- 346Article
26.
Lusk  RPGray  SMuntz  HR Single-stage laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1991;117171- 173Article
27.
Seid  ABPransky  SMKearns  DB On-stage laryngotracheoplasty. Arch Otolaryngol Head Neck Surg. 1991;117408- 410Article
28.
Cotton  RTMyer  CMO'Connor  DM Innovations in pediatric laryngotracheal reconstruction. J Pediatr Surg. 1992;27196- 200Article
29.
Stenson  KBerkowitz  RMcDonald  TGruber  B Experience with one-stage laryngotracheal reconstruction. Int J Pediatr Otorhinolaryngol. 1993;2755- 64Article
30.
Seid  ABGodin  MSPransky  SMKearns  DBPeterson  BM The prognostic value of endotracheal tube air leak following tracheal surgery in children. Arch Otolaryngol Head Neck Surg. 1991;117880- 882Article
31.
Cotton  RTMyer  CMO'Connor  DMSmith  ME Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the single-stage approach. Laryngoscope. 1995;105818- 821Article
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