Aaron's Tracheal Reconstruction Surgery
Laryngotracheoplasty (LTP)
Subglottic stenosis is a narrowing in the subglottic area of the trachea resulting in varying degrees of upper airway obstruction. Subglottic stenosis is a condition that can be either congenital or acquired. Acquired subglottic stenosis from endotracheal intubation--trauma to the subglottic structures secondary to endotracheal intubation--is the most common cause of subglottic stenosis in children. Symptoms of subglottic stenosis include respiratory distress, stridor or croup-like symptoms. Diagnosis is made by visualizing the trachea via a bronchoscopy.
Subglottic Stenosis
* Subglottic stenosis is graded by % of occlusion
o Grade 1 obstruction in less than 70% occluded
o Grade 2 is 70 - 90% occluded
o Grade 3 is greater that 90% occluded
o Grade 4 is a complete occlusion
Using this grading system, Aaron's subglottic stenosis was a Grade 2. In some mild cases of subglottic stenosis, the child may not need any surgical intervention. This was not the case for Aaron.
* Some of the treatments for Subglottic Stenosis include:
o Serial dilations
o Endoscopic excision
o Anterior Cricoid Split (ACS)
o Laryngotracheoplasty (LTP)
Aaron had his tracheal reconstructive surgery (Laryngotracheoplasty) on Wednesday, June 11th, 1997 at Children's Hospital in Boston, MA by Gerald B. Healy, MD, FACS. First, a bronchoscopy was done to reassess Aaron's airway and make a final decision on grafting. Dr. Healy decided to use an anterior cartilage graft for Aaron. The general surgeon Dr. Wilson then harvested the appropriate size section of rib cartilage from Aaron's chest, which Dr. Healy then used to rebuild Aaron's airway. The entire surgery lasted approximately 5 1/2 hours.
* Reconstruction procedure This diagram shows the procedure for a single stage laryngotracheoplasty for subglottic stenosis using a costal cartilage graft.
* Subglottic stenosis before and after surgery Aaron's airway was approximately 75% occluded before surgery.
* Tracheotomy site and granuloma before and after surgery The granuloma is a growth of abnormal tissue which was caused by the irritation of the tracheostomy tube in Aaron's airway.
Following surgery, Aaron was intubated and the endotracheal tube acted as a stint as his trachea healed. Aaron was intubated for 7 days in the intensive care unit (ICU). He muscles were paralyzed with cisatracurium and he received Morphine and Ativan for comfort. He was also on anti-reflux medications to prevent stomach acids from damaging the graft and antibiotic to prevent infection.
* Post-op pictures of Aaron
On the following Tuesday, June 17th, Aaron was taken back to the O.R., where he was extubated and reassessed via a bronchoscopy. Dr. Healy was happy with Aaron's new airway and he returned to the ICU breathing on his own without any tubes for the first time in his life! Aaron remained in the ICU for 24 hours where his was monitored closely for any signs of airway problems. He was kept in a mist tent after extubation. Humidity is essential, according to Dr. Healy, because the normal trachea has cilia (tiny hairs) that help to moisten and remove secretions for the airway. Because the rib cartilage graft lacks cilia, it must be kept moist so that it doesn't dry out. We where interested to learn that the graft will eventually grow it's own cilia. Aaron will continue to sleep in a mist tent at home and will have a room humidifier while awake for several months. Aaron was moved to a regular pediatric floor on June 19th and discharged home on June 20th.
* Aaron's post-extubation pictures
Aaron received short-term physical therapy and long-term speech therapy following his surgery. He was weak and had lost some weight during his hospital stay. It took about a month before Aaron is back to where he was before the surgery. He didn't quite understand all that has happened to him, and hopefully he will not remember most of his hospitalization. However, he is quite proud to show off his scar and declares, "Doctor Hehe [Healy] fixed the trach," "Trachs all gone."
Update - August, 1997
By the end of July, Aaron began having increased respiratory distress. He returned to Children's Hospital on July 29, 1997 for an exploratory bronchoscopy/laryngoscopy. It was discovered that Aaron developed a subglottic "web" just below his vocal cords that encompassed his entire airway with the exception of a tiny pin hole, which he was breathing through! The doctors were surprised to find this and amazed that Aaron had compensated for as long as he had with this membrane-like tissue covering his trachea.
Dr. Healy removed the web during the bronchoscopy procedure, so Aaron's neck did not have to be re-opened. Dr. Healy said that the web could grow back, so we are watching him very closely. The web developed along the upper end of the suture line of the graft. Otherwise, the reconstruction area (rib graft) is healed and looks great (see subglottic stenosis before and after surgery for the new picture of his graft 7 weeks post-op).
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blu-ray replication
Colin Lewin on Aaron Ramsey, “The surgery went very well and Aaron will make a full r
