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Original Investigation |

Laryngotracheal Reconstruction Outcomes in Hypotonic Children

Jordan M. Virbalas, MD1; John P. Bent, MD2; Hillel W. Cohen, DrPH, MPH3; Sanjay R. Parikh, MD3
[+] Author Affiliations
1Department of Otorhinolaryngology–Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, New York
2Department of Otorhinolaryngology–Head and Neck Surgery, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
3Department of Otorhinolaryngology–Head and Neck Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle
JAMA Otolaryngol Head Neck Surg. 2013;139(12):1296-1300. doi:10.1001/jamaoto.2013.5546.
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Importance  Children with poor muscle tone may demonstrate upper airway obstruction due to several mechanisms including obstructive sleep apnea, laryngopharyngeal reflux, and laryngomalacia. Though hypotonia has been shown to compromise the pediatric airway, and some authors suggest that neurologic deficits can compromise the success of laryngotracheal reconstruction (LTR), to our knowledge no studies have evaluated the effect of neurologic diagnoses or hypotonia on outcomes in LTR.

Objective  To determine whether hypotonic children with subglottic stenosis have lower rates of successful decannulation after LTR compared with children without neurologic deficit.

Design, Setting, and Participants  A retrospective medical chart review was conducted for 27 children aged 0 to 6 years, who underwent LTR for subglottic stenosis between December 2007 and December 2012 at a tertiary care children’s hospital. Children were classified based on documented neurologic findings. Group 1 comprised those children without neurologic impairment (n = 16). Group 2 included those children with a documented neurocognitive or neuromuscular diagnosis but without evidence of hypotonia (n = 7). Group 3 comprised hypotonic children (n = 4).

Interventions  Laryngotracheal reconstruction.

Main Outcomes and Measures  The number of procedures performed after LTR to optimize the airway and whether the child was successfully decannulated.

Results  All 16 of the neurologically intact patients (100%) were decannulated. Among children with a neurologic deficit, 5 of 7 (71%) were ultimately decannulated. No hypotonic children 0 of 4 were decannulated. The difference in rates of decannulation between unaffected and normotonic children with a neurologic deficit was not statistically significant (P = .08). However, the difference in outcomes between hypotonic children and neurologically intact patients was statistically significant (P < .001).

Conclusions and Relevance  Findings from this study suggest that hypotonic children may experience poorer rates of post-LTR decannulation compared with children without neurologic deficit. Dynamic upper airway obstruction may be unappreciated in hypotonic children. Future research may be directed at the appropriate evaluation and treatment of children with poor muscle tone and subglottic stenosis.

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Figure.
Percentage of Children Decannulated After Laryngotracheal Reconstruction (LTR)

Number of patients decannulated after LTR. A significant difference was noted in the rates of decannulation between group 1 and group 3 (all LTRs, P < .001; double-stage LTR only, P = .008). Decannulation rates between group 1 and group 2 were not significant (all LTRs, P = .08; double-stage LTR only, P = .44).

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