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Background: Oesophageal atresia (OA) is often accompanied by tracheomalacia (TM). The aim of this study was to evaluate its presence in OA patients during routine rigid tracheobronchoscopy (TBS) before primary correction and compare this to postoperative TBS and clinical signs of TM., Methods: This retrospective cohort study included patients born with OA between June 2013 and December 2022 who had received a TBS before OA correction and had been followed for at least twelve months. Definite TM was postoperatively diagnosed through TBS, and probable TM was defined as having symptoms of TM., Results: We analysed data from 79 patients, of whom 87% with OA type C. Preoperatively, TM was observed in 33 patients (42% of all patients), seven of whom had severe TM. Definite TM was observed in 21 patients (27%), of whom 15 had severe TM. Forty-one patients (52% of all patients) had developed symptoms of TM within twelve months, including harsh barking cough (n = 15), stridor and/or wheezing (n = 20), recurrent respiratory insufficiency (n = 11), or needing airway surgery (n = 7). The sensitivity of preoperative TBS for the presence of postoperative (definite and probable combined) TM is 50.0%, 95% CI [35.2-64.8], and the specificity 67.6%, 95% CI [51.7-81.1]. Clinical characteristics did not differ between the patients with or without postoperative TM., Conclusions: More than half of the studied patients with OA experienced symptoms of TM. While preoperative TBS is routinely performed prior to surgical OA correction, its predictive value for the presence of postoperative TM remains limited., Level of Evidence: Level II., Type of Study: Study of Diagnostics Test., Competing Interests: Conflicts of interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Vascular Rings (VRs) are congenital malformations of the aortic arch that can compress the trachea and esophagus producing symptoms. Approximately, 5%-10% of patients experience persistent symptoms postrepair and 9% require reintervention. There are various approaches to repair-simple ligation and division of the ring or more complex procedures. Our objective was to describe outcomes for VR repair using a "simple" surgical approach., Methods: We identified patients who underwent VR repair from 2012 to 2022 at our institution. Clinical and surgical data, demographics, intraoperative, and postoperative outcomes were extracted from their electronic medical records. Outcomes were analyzed and regression analysis was used to identify risk factors for residual symptoms after repair., Results: Ninety three patients with VR repair were included. Prevalence of symptoms were reduced following surgery (80% preoperative versus 13% postoperative, P 0.03). Tracheomalacia also decreased from 16% to 7% postrepair. No deaths were reported in our cohort and 2% of our patients required reintervention. Multivariable regression analysis showed that preoperative tracheomalacia was associated with having persistent symptoms after VR repair (odds ratio 6.2, 95% CI 1.02-37.6)., Conclusions: Our institutional experience using a simple surgical approach showed a significant decrease in symptoms, a very low reintervention rate and no mortality. Preoperative tracheomalacia can be a risk factor for persistent symptoms postrepair. We believe a simple surgical approach for children with complete VR repair can be effective in relieving symptoms., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction:  Posterior tracheopexy (PT) directly addresses the posterior trachealis membrane intrusion in severe tracheomalacia. During PT, the esophagus is mobilized and membranous trachea is sutured to the prevertebral fascia. Although dysphagia has been reported as a possible complication of PT, in the literature there are no data investigating postoperative esophageal anatomy and digestive symptoms. Our aim was to study clinical and radiological consequences of PT on esophagus., Methods:  Patients with symptomatic tracheobronchomalacia scheduled for PT between May 2019 and November 2022 underwent pre- and postoperative esophagogram. For each patient, we analyzed radiological images and measured esophageal deviation providing new radiological parameters., Results:  All 12 patients underwent thoracoscopic PT ( n  = 3) or robot-assisted thoracoscopic PT ( n  = 9). For all patients, the postoperative esophagogram showed a right dislocation of the thoracic esophagus (median postoperative deviation = 27.5 mm). We report an esophageal perforation at postoperative day 7 in a patient affected by esophageal atresia, who underwent several surgical procedures before. A stent was placed and esophagus healed. Another patient with severe right dislocation referred transient dysphagia to solids, which resolved gradually in the first postoperative year. All the other patients did not present any esophageal symptoms., Conclusion:  For the first time, we demonstrate the right dislocation of the esophagus after PT and we propose an objective method to measure it. In most patients, PT is a procedure not affecting esophageal function, but dysphagia can occur if dislocation is important. Esophagus mobilization during PT should be cautious, especially in patients who underwent previous thoracic procedures., Competing Interests: None declared., (Thieme. All rights reserved.)

A tracheostomy is usually necessary for long-term mechanical ventilation or complicated weaning. Other indications include swallowing disorders with recurrent aspiration in neuromuscular disease and high-grade subglottic stenosis. The tracheostomy can be performed as a percutaneous dilatational tracheostomy or as a surgical tracheostomy. The complication rate is low, and intraoperative complications are differentiated from early and late postoperative complications. This article aims to present the indications, the techniques and complications of percutaneous dilatational and surgical tracheostomy, and highlights the long-term complications of tracheal stenosis and tracheomalacia., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

It was a descriptive cross-sectional study to determine the frequency and risk factors of tracheomalacia in patients undergoing thyroidectomy. One hundred and forty-nine patients underwent thyroidectomy at MTI-Khyber Teaching Hospital Peshawar between 1st January 2021 and 1st March 2022. The frequency of post-thyroidectomy tracheomalacia and possible associated factors were determined. The inclusion criteria were patients of either gender, between 18 to 70 years fulfilling criteria of clinically diagnosed cases of thyroid disorders who underwent subtotal, hemi, near or total thyroidectomy for their respective thyroid diseases. Post-thyroidectomy tracheomalacia was recorded in 18 patients (12.1%): Seventeen patients were aged less than 30 (p-value 0.038) and 14 (77.8%) patients had a duration of surgery > three hours (p-value <0.001). Young female patients with multinodular goitre who had a longer duration of surgery developed post-thyroidectomy tracheomalacia more frequently. Hence, the incidence of post-thyroidectomy tracheomalacia can be markedly reduced with proper preoperative assessment and postoperative measures. Key Words: Thyroid gland, Thyroid disorders, Tracheomalacia, Thyroidectomy.

Background: Fetoscopic endoluminal tracheal occlusion (FETO) has been shown to improve survival of infants with congenital diaphragmatic hernia (CDH). However, there are concerns that FETO may lead to tracheomegaly, tracheomalacia and related complications., Methods: A systematic review was conducted to estimate the prevalence of symptomatic tracheal complications in infants who underwent FETO for CDH. Presence of one or more of the following was considered as tracheal complication: tracheomalacia, stenosis, laceration or tracheomegaly with symptoms such as stridor, effort-induced barking cough, recurrent chest infections or the need for tracheostomy, tracheal suturing, or stenting. Isolated tracheomegaly on imaging or routine bronchoscopy without clinical symptoms was not considered as tracheal morbidity. Statistical analysis was performed using the metaprop command on Stata V.16.0., Results: A total of 10 studies (449 infants) were included (6 retrospective cohort, 2 prospective cohort and 2 randomised controlled trials). There were 228 infants who survived to discharge. Prevalence rates of tracheal complications in infants born alive were 6% (95% CI 2% to 12%) and 12% (95% CI 4% to 22%) in those who survived to discharge. The spectrum of severity ranged from relatively mild symptoms such as effort-induced barking cough to the need for tracheostomy/tracheal stenting., Conclusion: A significant proportion of FETO survivors have symptomatic tracheal morbidities of varying severity. Units that are planning to adopt FETO for managing CDH should consider ongoing surveillance of survivors to enable early identification of upper airway issues. Inventing FETO devices that minimise tracheal injury is needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Operating on a huge and long-standing goiter is challenging to the surgeon and anesthetist because of the possibility of tracheomalacia and collapse of the tracheal rings after extubation. We report our innovation of tenting the trachea to the skin using sutures (passed through the strap and sternocleidomastoid muscles) to prevent post-thyroidectomy tracheomalacia., Competing Interests: None

Tracheostomy for prolonged ventilation of patients with COVID-19 was often delayed due to high viral loads and persistent high ventilatory requirements. With prolonged intubation and significant dose corticosteroid use, patients with COVID-19 are at risk for tracheomalacia, and urgent tube exchange may be required to address persistent cuff leak and to maintain adequate mechanical ventilation. We sought to describe our single center experience with COVID-19 patients requiring tracheostomy and the tracheal complications that followed. We performed a review of patients with COVID-19 who underwent tracheostomy from June 2020 to October 2021. 45 patients were identified; 82.2% survived their index hospitalization. Tracheostomy was performed after 16.4 days of mechanical ventilation. 22.2% required urgent exchange to an extended length tracheostomy tube after 7.2 days from initial tracheostomy. Placement of an extended length tracheostomy tube can reduce cuff leak in ventilated COVID-19 patients and may be considered during initial tracheostomy placement.

Tracheal stenosis and tracheomalacia in patients with congenital scoliosis are serious and rare conditions caused by congenital dysplasia, postintubation injury, trauma, and tracheal tumor. Anesthesia of a child with tracheal stenosis is challenging for anesthesiologists. We describe an 8-year-old female patient developed severe tracheal stenosis and tracheomalacia after growing rod implantation for congenital scoliosis. Comprehensive assessment of preoperative pulmonary function and airway morphology, which can be neglected clinically, should be performed in congenital scoliosis patients., (© 2022 John Wiley & Sons Ltd.)

Introduction: Tracheomalacia after thyroidectomy is not well understood. Reports on tracheomalacia are conflicting, with some suggesting a high rate and other large cohorts in which no tracheomalacia is reported. The aim of our study was to assess the incidence and factors associated with tracheomalacia after thyroidectomy in patients with retrosternal goitres requiring sternotomy at a high-volume tertiary care referral centre., Methods: A longitudinal cohort study was conducted from January 2011 to December 2019. All adult patients who underwent thyroidectomy with sternotomy were included. Tracheomalacia was considered when tracheal rings were soft compared with other parts (proximal or distal) of the trachea and required either tracheostomy or resection with anastomosis. The decision to perform a tracheostomy or to administer continuous or bilevel positive airway pressure postoperatively was made depending on the degree of tracheomalacia. Logistic regression analysis was used to assess factors associated with tracheomalacia., Results: We evaluated 40 patients who underwent thyroidectomy with sternotomy. The mean age of our cohort was 48.7 ± 11.3 years and the population was predominantly female (67.5%). One patient required tracheal resection with anastomosis, and two patients required tracheostomy. Multivariable logistic regression analysis did not reveal any patient- or thyroid-related factor significantly associated with the development of tracheomalacia in our cohort., Conclusions: The incidence of tracheomalacia after thyroidectomy with sternotomy appears to be very low. However, the occurrence of tracheomalacia after thyroidectomy in cases of large goitre is possible and hence worrisome.

Tracheomalacia in straight back syndrome results from chronic compression of the trachea and the mainstem bronchi mainly because of decreased mediastinal diameter. The mainstay of correction is the increase of mediastinal space and the restoration of the tracheal lumen and stability. Owing to the great variability of the manifestation of this disease, individualized approaches are required. We describe our approach in a 36-year-old woman with straight back syndrome associated severe tracheobronchomalacia with reconstruction of the proximal aorta, brachiocephalic artery, sternoplasty, and anterior tracheopexy, which resulted in successful treatment of the condition., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Airway clearance is an essential part of airway maintenance to ensure the airway lumen is protected against particulate and infectious insults. The mechanisms involved in airway clearance include intrinsic structural and cellular components that can be impaired or inhibited through developmental defects and surgical interventions. Tracheomalacia is a developmental defect of the airway that can contribute to the mechanical failure to clear the airway. This chapter will review the mechanisms of airway clearance and the processes that can impair this vital process., (Copyright © 2021. Published by Elsevier Inc.)

Hunter Syndrome is a genetic disease characterized by deficiency of Iduronate-2-Sulfatase enzyme activity, resulting in accumulation of glycoaminoglycans in various organs including the central airways. We report a case of severe tracheomalacia and airway stenosis at Hospital Sultanah Aminah, Johor Bahru, Malaysia requiring mechanical ventilation in a middle aged gentleman who was previously undiagnosed of mucopolysaccharidosis. The patient underwent emergency tracheostomy for failed intubation, when he presented with shortness of breath and acute respiratory failure. A contrast-enhanced computed tomography of the neck and thorax revealed that the trachea distal to the tracheostomy tube had collapsed with narrowed right and left main bronchus. These findings were confirmed via direct visualization of the airway through a flexible bronchoscopy. Eventually, a tracheal stenting were performed to maintain the airway patency and assist in weaning off from mechanical ventilation. Further investigations to identify the aetiology of the central airway stenosis revealed elevated urinary glycoaminoglycans and the absence of iduronate-2-Sulfatase activity tested on dried blood spots, thus confirming the diagnosis of Hunter Syndrome. Managing mucopolysacharidosis with central airway obstruction requires multidisciplinary team effort in handling the difficult airway, anaesthesiology risk, potential comorbidities and providing genetic counselling.

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed., (© 2020 Wiley Periodicals LLC.)

Importance: Peristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved., Objective: We evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies., Methods: The medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed., Results: In total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p = .03) and tracheal stenosis (p = .02) were significantly associated with decannulation failure., Conclusion: Combined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Tracheomalacia may be caused by long-standing compression of retrosternal goitre because of destruction of support of tracheal cartilages. Life-threatening airway collapses may occur after surgical removal of goitre. However, available literature on management methods of tracheomalacia is sparse. Our study highlights prolonged endotracheal intubation as a feasible treatment method., Methods: This retrospective study analysed 106 thyroidectomies for retrosternal goitre performed between 1994 and 2019. We recorded each patient's clinical profile. Severe tracheomalacia was confirmed through the following: soft and floppy trachea on intra-operative palpation and the collapse of cross-sectional tracheal area measured in computed tomography (CT) images by >80%. We assessed the extent of airway stenosis of these cases. All severe cases were treated by prolonged endotracheal intubation., Results: Surgical treatment was successfully performed in all 106 retrosternal goitre patients with no mortality. Seventeen severe tracheomalacia cases were confirmed. The extent of airway stenosis was assessed: the minimal tracheal diameter of compressed trachea was 0.2-0.4 [mean 0.31, standard deviation (SD) 0.06] cm, and the narrow tracheal length was 4-6.7 (mean 5.1, SD 0.6) cm. These patients underwent endotracheal intubation for 17-47 h after surgery. All patients were transferred to the general ward after extubation and successfully discharged. There were no cases of tracheal stenosis on follow-up., Conclusions: Tracheomalacia is a rare but serious complication of retrosternal goitre surgery. Based on our experience, prolonged endotracheal intubation is a feasible treatment for tracheomalacia after retrosternal goitre surgery.

We report one-stage radical surgical treatment of a 54-year-old patient with extensive cicatricial posttracheostomy tracheal stenosis complicated by tracheomalacia of anterior tracheal wall and previous numerous unsuccessful endoscopic attempts of tracheal recanalization. A new method of prevention of tracheal anastomosis failure was applied.

Background: Esophageal injury is a severe surgical complication of a transsternal approach to high thoracic vertebral metastasis, which can result in mediastinitis and life-threatening consequences. A covered stent can be placed in the esophagus to prevent mediastinal leakage. However, tracheomalacia is a rare complication following esophageal stenting., Case Description: A 56-year-old man had a pathologic fracture of the T3 vertebral body with spinal cord compression, myelopathy, and neurogenic bladder. An esophageal injury was noticed during the transsternal approach. Immediate suture repair, drainage tube placement, and subsequent esophageal stenting were carried out. One month after discharge, the endoscopic examination revealed nonhealing of the esophagus, and a new covered stent was replaced. Episodes of severe stridor and dyspnea led to the patient being sent to the emergency department. Computed tomography scan of the chest revealed a focal collapse of the trachea at the thoracic inlet, and tracheomalacia was suspected. The covered stent was removed, despite nonhealing of the esophagus. His stridor, dyspnea, and constant coughing subsided afterwards. The endoscopic examination at 3 months after stent removal showed complete healing of the esophagus., Conclusions: Esophageal stenting can be used to prevent mediastinal leakage due to esophageal injury in the transsternal approach for high thoracic vertebral metastasis, but the stent might be a cause of tracheomalacia. Stent removal should be considered if upper airway obstruction occurs. Awareness of the radial force of the stent, esophageal composition (e.g., status post suture repair), and esophageal diameter must be considered for optimal stent tolerance to avoid complications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Intrathoracic goitres (ITG) often present with compressive symptoms and require specialised care by experienced surgical teams. Most ITG can be accessed by a transcervical approach (TCA) and only between 1 and 15% will require an extracervical approach (ECA). Many controversies exist regarding the clinical presentation, evaluation, selection of cases for ECA, surgical technique and outcomes. This paper reviews the recent literature on the management, outcomes and evidence-based treatment strategies of ITG., Methods: We conducted a review of the literature on the evaluation, management and outcomes of surgery for ITGs., Results: The incidence of cancer in the ITGs ranges between 4 and 20%. Multiplanar CT scanning offers the best preoperative evaluation and aids to determine the approach. Most ITG can be accessed by TCA and ECA are only needed in maximum 15% of cases. In experienced hands, the outcome of these surgeries is comparable to thyroid surgery for non-ITG., Conclusions: Surgery for ITG is challenging. The experienced surgeon however, with few exceptions can address ITG via TCA, with outcomes comparable to those of uncomplicated thyroid surgery.

Rationale: Tracheobronchomalacia (TBM) refers to the weakening trachea or the trachea loss of structural integrity of airway cartilaginous structures. It causes tracheal stenosis, resulting in significantly high rates of mortality. Bronchoplasty by high-pressure balloon dilation under general anesthesia is a simple but effective and safe method to treat tracheobronchial stenosis. However, recurrent postoperative dyspnea after extubation due to tracheal collapse is still a challenge for anesthetists., Patient Concerns: A 52-year-old man weighing 72 kg was scheduled for balloon dilatation surgery under general anesthesia because of breathing difficulties caused by tracheal stenosis. His previous medical history included rheumatoid arthritis, obstructive sleep apnea syndrome (OSAS), chronic bronchitis and a history of tracheal intubation. Laryngeal computerized tomography confirmed the stenosis at the level of thyroid gland., Diagnosis: The tracheal collapse after balloon dilatation for tracheal stenosis therapy., Interventions: Postoperatively, the patient presented with more serious and repetitive symptoms of dyspnea after extubation when compared to that before treatment. So, we had to re-insert the laryngeal mask airway (LMA), and exclude some anesthesia-associated factors, such as laryngospasm, bronchospasm and so on. After a series of treatments, we ultimately found the cause in time (the airway collapsed), and succeeded in tracheal extubation after the stent was inserted., Outcomes: The patient recovered well and reported high satisfaction with anesthesia management., Lessons: In such an emergency even, the anesthesiologist should take valuable treatments to ensure the patient's effective ventilation. If the anesthesia-related factors can be eliminated, tracheomalacia or airway collapse should be considered whenever dyspnea occurs in the patients who unexpectedly fail to be extubated.

Aim: Oesophagealatresia/tracheo-oesophageal fistula (OA-TOF) is associated with tracheomalacia (TM). In our institution it is routine for OA-TOF patients to undergo dynamic flexible bronchoscopy (DFB) assessing both the site of the fistula and the presence or absence of TM. We aimed to determine the value of this investigation as a screening tool to predict subsequent symptomatic tracheomalacia in these patients., Methods: All patients with OA-TOF who underwent DFB at the time of initial repair between June 2014 and November 2016 were included prospectively. The findings at DFB were recorded. Patients were grouped according to the presence or absence of TM and followed to determine which of them developed symptomatic airway problems. The sensitivity and specificity of TM at initial bronchoscopy as a screening tool for subsequent symptomatic TM were calculated. The study was given ethical approval by our institution., Main Results: Twenty-three patients were included in the study. Median follow-up was for 7 (1-27) months. Fifteen (65%) were found to have TM at their first DFB; 13 (57%) subsequently developed airway symptoms, and of these 11 had TM at initial DFB. One patient with severe TM (>90% tracheal collapse) at initial DFB was completely asymptomatic following OA-TOF repair. The sensitivity was 85%, and specificity was 60%. The positive and negative predictive values were 73% and 75%, respectively., Conclusions: DFB is a useful tool in many aspects of the management of OA/TOF. However, it is not a good screening tool to predict symptomatic tracheomalacia with moderate sensitivity and a low specificity., Level of Evidence: Level IIb, Retrospective cohort study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Stereoscopic bronchoscopy is a new diagnostic tool to measure the diameter and cross-sectional area of the airway. The stereoscopic bronchoscope, which operates the same as a standard bronchoscope, utilizes 2 lenses to measure the airway using the principles of triangulation. Furthermore, the stereoscopic bronchoscope has the capability to measure the size of the airway during intervention in real-time, including variable stenosis., Materials and Methods: To prospectively compare preoperative stereoscopic and multidetector computed tomography (MD-CT) images to select the appropriate stent size for airway stenosis. Stereoscopic and MD-CT images were then measured to confirm the correct placement of the stent., Results: Airway stenting was performed on 21 consecutive patients of whom, 15 were diagnosed with malignant and 6 with benign diseases. In total, 165 measurements were taken (134 healthy; 31 affected). For the diameter, Bland-Altman plots were used to measure data from 165 matched stereoscopic and MD-CT measurement sites (bias, 0.40±2.86 mm SD; percentage error, 33%), 134 healthy sites (bias, 0.554±2.83 mm SD; percentage error, 34%), and 31 affected sites (bias, 1.20±2.67 mm SD; percentage error, 52%). For the cross-sectional area, matched stereoscopic and MD-CT measurements were analyzed for 65 sites (bias, -10.53±92.85 mm SD; percentage error, 89%), 49 healthy sites (bias, -9.88±39.00 mm SD; percentage error, 32%), and 16 affected sites (bias, -13.12±48.81 mm SD; percentage error, 92%)., Conclusion: Stereoscopic bronchoscopy was able to accurately measure the size of the airway during intervention, to assist in selecting the appropriate size of the stent.

We report a case of severe respiratory distress in a neonate who was not endotracheally intubated soon after esophageal atresia/tracheoesophageal fistula (EA/TEF) repair. In this serious situation, any form of emergency respiratory support or definitive airway management may compromise the esophageal anastomosis and fistula repair. The cause of respiratory distress in the early postoperative period after EA/TEF is multifactorial, and in this case, included symptomatic tracheomalacia, which is commonly associated with EA/TEF.

We describe the implantation of an absorbable, custom-made stent of polydioxanone to treat tracheomalacia in a 5-month-old patient with extrinsic compression by a double aortic arch. The use of an absorbable, oversized stent treated the tracheal collapse caused by vascular compression, avoided removal procedures, and allowed the infant's growth. The use of an oversized stent prevented stent migration and gave minimal problems of granulation.

Tracheomalacia (TM) is defined as an increased collapsibility of the trachea due to structural anomalies of the tracheal cartilage and/or posterior membrane. Tracheomalacia has a wide range of etiologies but is most commonly present in children born with esophageal atresia and tracheal esophageal fistula. Clinical symptoms can range from minor expiratory stridor with typical barking cough to severe respiratory distress episodes to acute life-threatening events (ALTE). Although the majority of children have mild-to-moderate symptoms and will not need surgical intervention, some will need life-changing surgical treatment. This article examines the published pediatric literature on TM, discusses the details of clinical presentation, evaluation, diagnosis, and a variety of treatments., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: There is no consensus on the evaluation of pediatric patients with aspiration., Objectives: To determine the yield of direct laryngoscopy and bronchoscopy (DLB) using general anesthesia in pediatric patients who aspirate and to identify clinical predictors of aspiration-related airway lesions., Design, Setting, and Participants: Retrospective review at a tertiary referral children's hospital. A medical record review was performed on all patients with a documented diagnosis of pulmonary aspiration who underwent DLB using general anesthesia during a 5-year period (January 2010 to December 2014)., Intervention: Direct laryngoscopy and bronchoscopy using general anesthesia., Main Outcomes and Measures: Data were collected and analyzed, including age, sex, history of intubation, flexible laryngoscopy results, DLB findings, recurrent pneumonia, and associated diagnoses., Results: Five hundred thirty-two patients met the inclusion criteria. Their mean (SD) age was 2.2 (3.6) years (age range, 0.1-25.0 years), with more than half younger than 1 year. Sixty-two percent (328 of 532) of the participants were male. Flexible laryngoscopy examination alone identified 93 patients with an airway lesion. Direct laryngoscopy and bronchoscopy identified 173 additional diagnoses and had a greater diagnostic yield for airway lesions (45.1% [240 of 532]) than flexible laryngoscopy examination alone (P < .001). Patients with an aspiration-related airway lesion were older (mean [SD] age, 2.7 [3.8] vs 2.2 [3.8] years; P = .02) and more likely to have another aerodigestive disorder than were patients without an airway lesion (21.7% vs 11.6%; P = .004). Older age (adjusted risk ratio [95% CI], 1.37 [1.08-1.73]; P = .01), recurrent pneumonia (1.40 [1.11-1.76]; P = .004), and history of intubation (1.35 [1.07-1.70]; P = .01) were significantly associated with the presence of an aspiration-related airway lesion in the multivariable model. Patients with an aspiration-related airway lesion were less likely to have neurologic disease than were patients without an airway lesion (0.50 [0.34-0.73]; P < .001). In all, 66.3% of patients (110 of 166) eventually underwent surgical repair of an identified aspiration-related airway lesion., Conclusions and Relevance: In children with chronic aspiration who warrant further evaluation, flexible laryngoscopy alone is not sufficient. There is a high incidence of aspiration-related airway lesions identified on DLB and not seen on flexible laryngoscopy, with 66.3% (110 of 166) of those lesions eventually requiring surgical intervention. Patients 1 year or older with a history of recurrent pneumonia or intubation are more likely to have an aspiration-related airway lesion.

Background: In children with aberrant innominate artery (AIA) one of the most prevalent respiratory symptom is dry cough. How frequently this mediastinal vessels anomaly, that can induce tracheal compression (TC) of different degree, may be detected in children with chronic dry cough is not known., Methods: In a 3-year retrospective study, the occurrence of mediastinal vessels abnormalities and the presence and degree of TC was evaluated in children with recurrent/chronic dry cough., Results: Vascular anomalies were detected in 68 out of the 209 children evaluated. A significant TC was detected in 54 children with AIA, in eight with right aortic arch, in four with double aortic arch but not in two with aberrant right subclavian artery. In AIA patients, TC evaluated on computed tomography scans, was mild in 47, moderate in six and severe in one. During bronchoscopy TC increased in expiration or during cough, but this finding was more pronounced in children with right aortic arch and double aortic arch in which a concomitant tracheomalacia was more evident. Comorbidities were detected in 21 AIA patients, including atopy, reversible bronchial obstruction and gastroesophageal reflux. Aortopexy was performed in eight AIA patients, while the remaining AIA patients were managed medically and showed progressive improvement with time., Conclusion: Mild TC induced by AIA can be detected in a sizeable proportion of children with recurrent/chronic dry cough. The identification of this anomaly, that may at least partially explain the origin of their symptom, may avoid further unnecessary diagnostic examinations and ineffective chronic treatments., (© 2015 Wiley Periodicals, Inc.)

Aim: To analyze the role of ray functional computerized diagnostic technologies in assessment of the state of tracheal wall in cicatricial stenosis., Material and Methods: We examined 45 patients with cicatricial tracheal stenosis during August 2013 -- March 2015. Fibrobronchoscopy, multislice computerized tomography, magnetic resonance imaging and lungs function examination were performed. For the first time dynamic (functional) CT and MRI were included in research algorithm. These techniques have not been used for cicatricial stenosis and tracheomalacia in our country until this moment. Circular resection with anastomosis was made in 38 patients and stage reconstructions were preferred in 7 cases. Last ones had advanced tracheomalacia on the background of cicatrical stenosis that forced to abandon from tracheal resection. So time to treatment and incidence of complications and recurrences were reduced and the results were improved., Conclusion: Endoscopy remains the main method of diagnosis of tracheal stenosis despite its invasiveness. Data of cicatrical transformation of tracheal wall per se can be obtained non-invasively using dynamic CT and MRI. These techniques help to identify or exclude tracheomalacia. They potentially complement fibrobronchoscopy and may be preferable to assess perioperative intramural pathological changes of the trachea.

VACTERL association includes vertebral anomalies, anal atresia, cardiac defects, tracheao-esophageal fistula, renal anomalies, and limb abnormalities. It is defined by the presence of at least three of these congenital malformations. The incidence has been estimated to be 1/10.000-1/40.000 live births. We report on a preterm infant with VACTERL presentin with respiratory complicatons due to the presence of severe tracheomalacia and bronchomalacia. He also had an annular pancreas.

Tracheostomy tube placement is a therapeutic procedure that has gained increased favor over the past decade. Upper airway obstructions, failure to liberate from the ventilator, and debilitating neurological conditions are only a few indications for tracheostomy tube placement. Tracheostomy tubes can be placed either surgically or percutaneously. A percutaneous approach offers fewer surgical site infections and postsurgical bleeding than a surgical approach. A surgical placement posses a lower risk of injury to the posterior tracheal wall and spontaneous decannulation is less common. Late complications of both approaches include stenosis, malacia, along with tracheoesophageal, tracheoinnominate, and tracheocutaneous fistulas. This review describes the indications and methods of placement of tracheostomy tubes along with early and late complications that may occur following placement.

Tracheomalacia is a disorder of the large airways that is often caused by a large anterior mediastinal mass. This study describes 7 patients who underwent controlled trachea suspension as a surgical intervention to prevent severe tracheomalacia and provide potent relief of airway symptoms. All patients recovered well. The results demonstrate this procedure may be safe and effective for resection of a large mediastinal mass compressing the trachea with collapsed segments., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Complications associated with long-term tracheotomy are obstruction of the distal end of the tube by granulation tissue and tracheomalacia. These complications have traditionally been surgically treated., Methods: Prospective study in a chronic ventilator-dependent division, including 234 consecutive patients with tracheotomy and mechanical ventilation. Endoscopic evaluation was performed in patients in whom there was respiratory distress with difficulty in passing a suction catheter through the tube, and/or increased inspiratory resistance and increased peak inspiratory pressure., Results: Nineteen patients were diagnosed with granulation or tracheomalacia. Two patients were treated by surgical removal of the obstructing tissue. Nonsurgical patients were conservatively managed with symptoms' resolution by bypassing the pathology with a longer tube than the previous one or by an adjustable flange tube under endoscopic visualization, with a median symptom-free period of 433 days (range, 55-1230 days)., Conclusion: In nonsurgical candidates, insertion of a longer tube is a conservative and feasible long-term treatment., (© 2014 Wiley Periodicals, Inc.)

Severe tracheomalacia (TM) is a difficult problem in esophageal atresia (EA) patients. We reviewed our experience with aortopexy and other interventions for severe TM in this population. With review ethics board approval, a retrospective review of TM in postoperative EA patients was conducted (1989-2010). Demographics, perinatal, and surgical information regarding EA repair was collected. TM infants were analyzed for symptomatology, clinical severity, investigations, interventions, and outcomes. Data are presented as proportions or median(range). One hundred and thirty-two EA patients were reviewed. Most had type C atresia (87.3%), and 18 patients (13.6%) died. Twenty-five patients (18.9%) had TM of whom five (20%) died. Median symptom onset was 18 days (0-729) after EA repair, with stridor (64%) or retractions/distress (44%) being most frequent. Four and two patients had airway obstruction or cardiorespiratory arrest, respectively. Median time from symptom onset to investigations was 11 days; these were most commonly rigid bronchoscopy (56%) and fluoroscopy (36%). Ten patients (40%) had severe TM on bronchoscopy. Six underwent aortopexy, one fundoplication, and three were treated medically. Length of hospital stay (LOS) post-aortopexy was 13 days (5-60), and ventilation time was 2 days (0-9). LOS was 60.5 (1-69) days postdiagnosis in non-aortopexy patients. Readmission rates for respiratory issues were significantly less in the aortopexy (median 0 vs. 5; P = 0.048) group over 2-year follow up after discharge. Complications of aortopexy included transfusion (1) and temporary diaphragmatic paresis (1), and one mortality secondary to severe congenital cardiac anomalies. Our experience suggests that aortopexy is safe and effective for the treatment of severe TM. It is associated with reduced LOS compared with other treatment strategies and few complications or long-term sequelae., (© 2014 International Society for Diseases of the Esophagus.)

A 77-year-old man underwent thoracic surgery. He had a history of two previous operations: parapharyngeal tumor removal with temporal tracheotomy 14 years ago and, two years later, a sinus surgery when, according to our anesthesia registry, intubation was extremely difficult due to stricture of the trachea underneath the tracheotomy scar. Pathology was not fully elucidated. Preoperative examinations including chest x-ray, spirogram and CT were not remarkable. The scar above the suprasternal notch was visibly sunken and retracted with respiration. Stridor was auscultated but breathing was not labored. The patient was anesthetized with propofol and intubation was smooth. During surgery anesthesia was maintained with sevoflurane, remifentanil and rocuronium. However, extubation was followed by desperate gasping and severe respiratory distress. The tracheotomy scar caved in and the airway collapsed. Continuous airway pressure via a facemask restored airway patency and improved breathing. After overnight respiratory support with non-invasive positive pressure ventilation (NPPV), patient was weaned from ventilator. Airway collapse and the two episodes of respiratory failures while under general anesthesia were attributed to post-tracheotomy tracheomalacia.

Tracheomalacia is excessive collapsibility of the trachea, typically during expiration. Congenital forms are associated with severe symptoms. Milder forms often present after the neonatal period. Adult malacia is mostly associated with chronic obstructive pulmonary disease. Functional bronchoscopy is still not standardized. Dynamic airway CT is a promising tool for noninvasive diagnosis. Bronchoscopy and stent insertion lead to significant improvement, but with a high complication rate. Surgical lateropexia, tracheal resection, and surgical external stabilization are options. Tracheoplasty seems to be the best choice for selected cases of adult malacia. The most commonly performed surgery in children is aortopexy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Importance: Pediatric imaging carries the risk of radiation exposure. Children frequently undergo computed tomography with angiography (CTA) for findings on bronchoscopy with limited knowledge regarding the necessity of such imaging., Objective: To report our experience with all pediatric patients at our institution over an 8-year period with airway symptoms warranting bronchoscopy followed by CTA for potential vascular anomaly. Goals were to report the percentage of positive findings seen on CTA leading to surgery; discuss relative radiation exposure risk and sedation risk for additional radiologic studies; and propose a functional diagnostic algorithm., Design, Setting, and Participants: Retrospective chart review of 42 children aged 2 months to 11 years with tracheomalacia who underwent CTA between 2004 and 2012 in our tertiary aerodigestive center., Interventions: Bronchoscopy and CTA., Main Outcomes and Measures: Presence of vascular anomaly and need for thoracic surgery., Results: Of these 42 children, 21 (50%) had a vascular anomaly identified on CTA. Of these 21, 17 (81%) had innominate artery compression; 1 (5%) had double aortic arch; 1 (5%) had right aortic arch; 3 (14%) had bronchial compression by pulmonary artery; and 1 (5%) had dextrocardia with duplicated vena cava. Six (29%) of these 21 had clinical symptoms and CTA findings requiring thoracic surgery. The most common symptoms in children requiring thoracic surgery were cough, cyanosis, and stridor., Conclusions and Relevance: Deciding when to obtain imaging for bronchoscopic findings suggestive of vascular compression remains challenging. A diagnostic algorithm is proposed as a means to provide the best clinical care while weighing risks of additional radiation exposure vs sedation and exposure to general anesthesia.

Objective: To reflect on lessons learned placing endotracheal nitinol stents in children., Study Design: Case series with chart review., Setting: Tertiary care children's hospital., Subjects and Methods: All children who underwent nitinol cervical tracheal stenting were included. Records were carefully reviewed for intraoperative and postoperative complications, management choices, outcomes, and factors that influenced results., Results: Between 1999 and 2011, 7 children underwent 13 stent placements. Median follow-up was 5 years (range, 1-12 years). Six patients underwent stenting as a salvage procedure following open attempts at airway reconstruction. Four patients remain decannulated with their stent in place (median follow-up 7 years). The fifth patient had his stent removed endoscopically after 50 days because it became apparent that his obstruction was primarily laryngeal. The sixth child had his stent removed via a tracheal fissure after 14 months because of recalcitrant subglottic inflammation at the superior stent border. The seventh patient was decannulated for over 2 years but ultimately required tracheotomy replacement because of stenosis with the stent lumen. Complications included stent migration (23%), restenosis (29%), edema (29%), and granulation (57%)., Conclusion: Endotracheal nitinol stents provide a realistic opportunity for decannulation in children for whom other options have failed but should be reserved only as a salvage procedure in severely complicated airways. Our experience has taught valuable lessons about stent indications, sizing, characteristics, and deployment, as well as means to avoid and manage their complications.

Tracheobronchomalacia (TBM) and hyperdynamic airway collapse (HDAC) can be debilitating diseases associated with decreased functional capacity and poor quality of life, although there is no standard definition of this complex condition, and there are numerous terms used to describe it. The diverse etiology associated with TBM and HDAC can obscure and delay an accurate diagnosis for years. A thorough medical history is important in understanding possible causes and in guiding diagnostic testing. Medical history may also suggest what treatments may be most beneficial., (Copyright © 2013 Elsevier Inc. All rights reserved.)

We report obstructive sleep apnea in a 3-year-old boy with tracheomalacia secondary to tracheotomy that resolved after placement of a metallic stent in the region of tracheomalacia. The tracheal location of obstruction during sleep in this case contrasts with the usual location in the pharynx or, less often, the larynx. This case also demonstrates the utility of polysomnography in managing decannulation of tracheostomies.