CASE REPORT
Year : 2023 | Volume
: 17 | Issue : 1 | Page : 72--74
Anesthesia management of pediatric subglottic stenosis: A case report
Patricia B Viana1, Francisco A Sousa2, Ana I N. Pinto2, Teresa B Leal1,
1 Serviço de Anestesiologia, Centro Hospitalar e Universitário do Porto, Porto, Portugal
2 Serviço de Otorrinolaringologia, Centro Hospitalar e Universitário do Porto, Porto, Portugal
Correspondence Address:
Patricia B Viana
Largo Prof. Abel Salazar, 4099-001 Porto
Portugal
Abstract
Subglottic stenosis balloon dilation in selected patients may be an option for the treatment of acquired subglottic stenosis, reducing the need for open surgical approaches or tracheostomy. This treatment is a major challenge to otolaryngologists and anesthesiologists, with an interactive collaboration being critical throughout the procedure. When performed, it is fundamental that otolaryngologists and anesthesiologists communicate properly during the procedure to achieve acceptable results. The complex management of the airway and inherent delicacy and risks of the intervention may be challenging. A proper preparation of the procedure and familiarization with the step-by-step technique could optimize the results and prepare the team to deal with intervening complications. We report a case of management and treatment of an 8-month-old baby with subglottic stenosis proposed for endoscopic balloon dilation treatment from Porto, North of Portugal.
How to cite this article:
Viana PB, Sousa FA, Pinto AI, Leal TB. Anesthesia management of pediatric subglottic stenosis: A case report.Saudi J Anaesth 2023;17:72-74
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How to cite this URL:
Viana PB, Sousa FA, Pinto AI, Leal TB. Anesthesia management of pediatric subglottic stenosis: A case report. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 22 ];17:72-74
Available from: https://www.saudija.org/text.asp?2023/17/1/72/364846 |
Full Text
Introduction
Subglottic stenosis is one cause of airway obstruction in infancy, being an important cause of stridor in children. It is the most common laryngotracheal disease eliciting tracheostomy in children under 1 year of age.[1],[2] The incidence in children after prolonged intubation is 11.3%. Direct laryngotracheoscopy with a bare 0-degree telescope allows visualization of the airway with the advantage of reaching the subglottic and tracheal regions. After this diagnostic evaluation, the airway surgeon can plan the individualized treatment for each case. We report a case of subglottic stenosis proposed for endoscopic balloon dilation. Parents authorized the publication of this case and provided written informed consent.
Case History
We present the case of an 8-month-old baby of 8 kg with a history of multiple hospitalizations for exacerbation of recurrent wheezing, with one of them requiring invasive mechanical ventilation. According to her mother, the baby presented persistent stridor since extubation. Her parents were both smokers, and there was a family history of asthma. The patient was admitted to the hospital because of bronchiolitis obliterans associated with hypoxemia. Because of worsening of stridor, the patient was evaluated by an otolaryngologist, who performed nasopharyngolaryngoscopy; however, the cause of the stridor was not identified, so diagnostic laryngotracheoscopy was proposed. We discussed with the parents that if the stenosis was identified, we could proceed with the endoscopic balloon treatment at the same time.
Anesthetic inhalation induction was performed with sevoflurane 8% and O2 100%. Peripheral access was placed. After achieving an adequate anesthetic depth, conventional laryngoscopy, airway spraying with 10% lidocaine spray, and placement of a nasopharyngeal tube were performed, allowing for oxygenation by passive diffusion. Direct laryngotracheoscopy with a bare 0-degree telescope was performed, allowing the identification of grade II subglottic stenosis. After the diagnosis, it is decided to perform an endoscopic balloon treatment. Suspension laryngoscopy was performed with a Parson laryngoscope. We administered 1% lidocaine (insulin syringe) in the subglottic region, and oxygenation was maintained through the surgeon's laryngoscope.
Anesthesia was maintained with sevoflurane and propofol boluses, adjusting the anesthetic depth according to multi-modal monitoring with processed electro-encephalography and bispectral index. Analgesia was maintained with alfentanil, anticipating critical moments of surgical stimuli.
Subglottic radial incisions were undertaken using a sickle knife (4h, 8h, and 12h), followed by balloon dilation. Dilation was performed with a 5 mm diameter balloon, followed by further dilation with a 6 mm balloon without de-saturation throughout the procedure. At the end of the surgical procedure, the airway was calibrated with a 3.5 cm orotracheal tube. Local application of corticosteroids was performed through the dilated stenotic region. The surgical procedure was uneventful. In the post-operative period, she was monitored in an intensive care unit for 24 hours and treated with dexamethasone for 3 days.
Discussion
The majority of subglottic stenosis cases are acquired because of prolonged intubation, pharyngeal reflux, or airway infection with overt inflammation response.[1],[3]
A subglottic diameter ≤4 mm in term newborns or ≤3 mm in pre-term is consistent with the diagnosis of subglottic stenosis.[3],[4],[5] The Cotton–Myer classification is used to classify the degree of the stenosis.[6] Grades I and II are candidates for endoscopic treatments,[3],[5] and Grades III and IV are candidates for open surgical techniques.[2],[3]
Endoscopic balloon dilation has been suggested as an effective treatment of appropriately selected patients.[3] Balloon dilation is intended to mechanically interrupt the process of scar maturation. The radial force exerted by the balloon over the segment of stenosis constitutes a mechanistic advantage of dilation, thereby reducing the risk of mucosal injury or airway rupture.[3] In a series, endoscopic balloon dilation of the subglottic region has reduced the need for open airway re-construction by an estimated 80%.[7],[8]
Airway surgery is probably the paradigm of collaboration between otolaryngologists and anesthesiologists. The surgical success relies profoundly on the applied anesthetic technique. The stenosis may present as a challenge because of the potential difficulty of manual ventilation and orotracheal intubation. Maintenance of spontaneous ventilation may be advantageous. From the surgeon's perspective, the localization and extent of the stenosis may hinder the surgical approach to the airway.[3],[9]
In this case, anesthesia induction and maintenance were performed with inhalation agents because the objective was to maintain spontaneous ventilation during the surgical procedure. The main disadvantages of this technique are the impediment for end-tidal CO2 monitoring plus the environmental pollution because of high sevoflurane volumes. The main challenge of the technique is the assurance of an adequate anesthetic depth, keeping the balance between minimizing substantial pain stimuli and maintaining adequate oxygenation.[10]
In the pre-operative period, it is important to discuss the risks with the patient's family, including the potential need for tracheostomy. It is essential to establish a comprehensive anesthetic plan and discuss the case with the surgeon and coordinate and communicate the strategy with the operating room team. It is mandatory to have all potentially needed airway equipment prepared, including orotracheal tubes with superior and inferior sizes related to the patient's age/weight, facial mask, nasopharyngeal tubes, laryngeal masks, tracheostomy tubes, the laryngoscope, the videolaryngoscope, and the pediatric fiberscope. A tracheostomy table should be kept in the corner of the operating room.
During the intra-operative period, the objectives are effective communication with the otolaryngologist, alerting to the potential need to assist ventilation at any time; soft and slow sedation with minimal respiratory depression; control of airway reflexes; maintaining hemodynamic stability; minimizing secretion production; and attention to the moments of the greatest surgical stimuli (subglottic radial incisions and balloon dilation). The recommended dilation time is 2 minutes or until the SpO2 drops to 92%. In our case, two dilation cycles were performed.
In the post-operative period, there is a risk of airway compromise because of secretions or edema, and administering intravenous corticosteroids and topical adrenaline may prevent airway complications. The possible complications are tracheal rupture, pneumothorax, pneumomediastinum, and hemorrhage. When there is a risk for ventilation failure at the end of the procedure, the patient should be intubated and admitted in an intensive care unit. The size of the endotracheal tube should be selected in order to avoid edema or subsequent stenosis.
The present work aims to provide practical guidance and a pre-operative concise procedural checklist to be used by the surgical team in this setting.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient's consent forms. In the form, the patient's parents have given their consent for the child images and other clinical information to be reported in the journal. The parents understand that their names (including child name) and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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