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International Physician Update
| OTOLARYNGOLOGY-HEAD & NECK SURGERY |
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| NOVEMBER 2002 |
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New Techniques for Treating Life-Threatening Narrowing of the Throat
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| Pediatric head and neck surgeon David Tunkel with three-year-old patient James Alban. |
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The patient, 31/2 year-old Jesse Kerns from West Virginia, had a tracheotomy tube placed in his throat when he was 8 months old because of subglottic stenosis, a life-threatening narrowing in his throat.
Like other children with tracheotomy tubes, he needed constant monitoring and nursing care at home to ensure that the tube did not clog. Eventually, the windpipe could be reconstructed and the tube removed, but the procedure wasn’t as simple as it sounded.
“It’s complicated surgery,” says pediatric otolaryngologist David Tunkel, M.D. “Making the decision is almost as complicated as the procedure itself.”
Tunkel explains that the placement of the tube, while allowing the child to breathe, can cause extensive scarring and damage to his larynx and the upper part of the trachea. To preserve the patient’s voice and ability to swallow–the larynx must be able to rise for proper swallowing–his larynx would have to be rebuilt. But when to operate and what type of surgery to perform are critical.
First, using an endoscope and a tiny camera, and relying on his vast experience in performing laryngeal reconstructions in children, Tunkel determined that the child was indeed a candidate for surgery. But, considering the boy’s throat anatomy, Tunkel decided on a plan involving several stages.
First, Tunkel rebuilt and enlarged the child’s larynx using cartilage grafts from the patient’s own ribs. Tunkel also placed a stent, or internal cast, to keep the windpipe open while it healed. He kept a trach tube in, but one that was smaller. Also, in this open procedure, Tunkel dissected scar tissue between the vocal cords. In some cases he is able to use a less-invasive endoscopic technique and a laser to vaporize scar tissue.
Five weeks later, Tunkel checked the larynx and the grafts and, finding them ok, removed the stenting tube. Over the next four weeks he checked the child’s airways, voice and swallowing function. Satisfied, he then removed the tube.
“His voice is normal and his swallowing better,” Tunkel says. “It’s just a matter of making the correct diagnosis and applying these newer laryngeal reconstruction techniques.”
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