Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston.
Department of Otolaryngology-Head and Neck Surgery, McGill University Health Center, Montréal, Canada.
J Burn Care Res. 2020 Jul 3;41(4):882-886. doi: 10.1093/jbcr/iraa032.
The management of laryngotracheal stenosis (LTS) in the pediatric burn patient is complex and requires a multidisciplinary approach. The mainstay of treatment for LTS is laryngotracheal reconstruction (LTR), however, limited reports of burn-specific LTR techniques exist. Here, we provide insight into the initial airway evaluation, surgical decision making, anesthetic challenges, and incision modifications based on our experience in treating patients with this pathology. The initial airway evaluation can be complicated by microstomia, trismus, and neck contractures-the authors recommend treatment of these complications prior to initial airway evaluation to optimize safety. The surgical decision making regarding pursuing single-stage LTR, double-stage LTR, and 1.5-stage LTR can be challenging-the authors recommend 1.5-stage LTR when possible due to the extra safety of rescue tracheostomy and the decreased risk of granuloma, which is especially important in pro-inflammatory burn physiology. Anesthetic challenges include obtaining intravenous access, securing the airway, and intravenous induction-the authors recommend peripherally inserted central catheter when appropriate, utilizing information from the initial airway evaluation to secure the airway, and avoidance of succinylcholine upon induction. Neck and chest incisions are often within the TBSA covered by the burn injury-the authors recommend modifying typical incisions to cover unaffected skin whenever possible in order to limit infection and prevent wound healing complications. Pediatric LTR in the burn patient is challenging, but can be safe when the surgeon is thoughtful in their decision making.
儿童烧伤患者的喉气管狭窄（LTS）的管理是复杂的，需要多学科的方法。LTS 的主要治疗方法是喉气管重建（LTR），然而，烧伤特异性 LTR 技术的报道有限。在这里，我们根据我们在治疗这种病理患者的经验，提供了关于初始气道评估、手术决策、麻醉挑战和切口修改的见解。初始气道评估可能因小口畸形、牙关紧闭和颈部挛缩而变得复杂-作者建议在进行初始气道评估之前治疗这些并发症，以优化安全性。关于追求单阶段 LTR、双阶段 LTR 和 1.5 阶段 LTR 的手术决策可能具有挑战性-作者建议尽可能采用 1.5 阶段 LTR，因为挽救性气管切开术的额外安全性和肉芽肿的风险降低，这在促炎烧伤生理学中尤为重要。麻醉挑战包括获得静脉通路、确保气道通畅和静脉诱导-作者建议在适当的情况下使用外周插入中心导管，利用初始气道评估的信息来确保气道通畅，并避免在诱导时使用琥珀胆碱。颈部和胸部切口通常位于烧伤损伤所覆盖的 TBSA 内-作者建议尽可能修改典型切口以覆盖未受影响的皮肤，以限制感染并预防伤口愈合并发症。儿童烧伤患者的 LTR 具有挑战性，但如果外科医生在决策时深思熟虑，就可以安全进行。
