A New Voice: After The Surgery - Airway Disorders and Reconstruction in Children (4 of 5)

Author: The Children's Hospital of Philadelphia

The postoperative period is also a very stressful one for the families. Will the reconstruction work? how effective will it be? how is this going to change my child's voice? how are they going to cope with this hospital stay? the way that they handle the postoperative period sometimes depends upon the surgical procedure that they've had. regardless of whether we're doing a ctr, an ltr, or a slide tracheoplasty, there are two ways to approach that and that's single-staged or double-staged. And there are specific reasons and indications to perform single-staged or double-staged procedures. i had approached the subject of doing a two stage because we weren't sure she was going to be able to do the whole procedure. he explained to us that he had to do a single-staged because of the location of her narrowing. He could not do the repair and then put her trach back in. so the decision to perform a single-versus a double-staged reconstruction depends on multiple factors: the extent of the narrowing of the airway, the location of the tracheostomy tube in relation to the stenosis, the health of the child's lungs, and overall medical condition.

So it really is individualized to each patient. A single-staged reconstruction means that at the conclusion of the procedure there's no tracheostomy tube in place, and the child will wake up with an endotracheal tube that's actually placed through the nose, it makes it more comfortable for them during recovery and that nasotracheal tube is used as a stent. And a stent is a hollow tubing that helps support the area of the reconstruction. so if a child is having a single-staged procedure, they're going to require a longer icu stay.

They may be in the intensive care unit for anywhere from two to four weeks. we will perform a repeat endoscopy and remove the breathing tube, and then if everything looks like it's healing well and is in good position, then we'll get the child ready to take the breathing tube out usually the next day. so we were all anticipating when they pulled the tube out what alec's voice was going to be like. i think my voice was deep before it happened, but then after it just seemed like more raspier. It made it a little bit deeper. so when he finally took the tube out and he got to speak a little bit, he had a voice, and that was a big relief. that's a single-staged procedure. A double-staged procedure means that at the conclusion of the surgical reconstruction the child will wake up with a tracheostomy tube in place, and there will be a stent that is sitting above the tracheostomy tube through the area of reconstruction, but that stent is sutured into the trachea.

they wake up a lot faster from the surgical procedure. They may actually go home after a few days, or they may stay in the hospital for the entire week to ten days while the stent is in place. that stent will need to be removed usually about two weeks after the reconstruction to make sure that there's no excess inflammation from the stent. so the double-staged patients will be brought back to the operating room on an outpatient basis, often a week or two weeks later, after we remove the stent. And that's important because we make sure they're not collapsing down their airway, because if that's the case, i will employ a balloon to stretch the airway and then they will often have a repeat endoscopy several weeks or several months after that to check on the healing process. If it's healing well and the airway reconstruction has really been successful and they have an adequate airway, then we want to start to downsize the trach tube to a smaller size and start capping the child. capping means that you put a full piece of plastic cap on the tracheostomy tube, which forces the child for the first time, probably, to breathe through their mouth and their nose.

A New Voice: After The Surgery - Airway Disorders and Reconstruction in Children (4 of 5)

we will frequently send them home with a tracheostomy cap once we know that they're safe and are able to move some air now above the area that has been reconstructed and enlarged. that can be traumatic for the kid who's never breathed from their nose or their mouth before. So we give them a period of time to get adjusted to this new type of breathing. Once the capping process is successful, the child will be brought back to the hospital. We will do the capping trials overnight while they're sleeping now to make sure that they're able to sleep and not have any apneas or pauses or any difficulty breathing while asleep when you're less likely to be able to support your airway voluntarily.

And then once that capping overnight is successful, then we talk about the decannulation. And the decannulation is very simple. It just involves pulling the tracheostomy tube out, putting a piece of gauze and tape on the stoma site, and that stoma heals over time. some of the kids we see have vocal cord paralysis. This can be either one sided, or unilateral, or bilateral.

unilateral vocal cord paralysis is where one vocal cord is not moving well. And that leads to a gap between the two vocal cords while we're speaking. And when that happens, air can escape between the vocal cords and the child will most likely end up with some hoarseness. The vocal cord is a muscle, so if it loses its nerve supply over time, the muscle can shrivel, as well. And that creates even a bigger gap between the right and the left vocal cord. we have a pediatric voice center, which deals with patients with vocal cord paralysis, commonly unilateral paralysis.

And there are procedures that can be done to alleviate this problem, such as reinnervation of the larynx using nerves in the neck. so the reinnervation procedure involves cutting the recurrent laryngeal nerve in the neck and then another nerve called the "ansa cervicalis" and then under a microscopic visualization i reconnect both ends of the nerve with a couple of sutures. The recurrent laryngeal nerve reinnervation helps maintain tone in the vocal cord, and it helps force a better closure in the back of the vocal cords so there's a better contact there and less air escaping and an improved voice quality. along the healing process many of these children will be seen by our speech therapist and our feeding therapist who work very closely with them. children who've had a tracheostomy tube for a very long time may not have been able to phonate, or to create sounds. So now they need to learn that. And that's where our speech pathologists are usually involved with those patients through the airway clinic to make sure that they're getting the right services to develop their language skills.

oh my. good job, want to stand up? oh my. oh my. well, since addison first came home two and a half years ago, she's been receiving speech therapy. she had to relearn how to swallow. And it didn't take very long.

But she had to learn how to drink water again and it was, the structure of her throat has changed, and she needed to get comfortable with that. if a child has a swallowing dysfunction, we have to work with where their skills are at that particular point in time and advance those skills for them as well as to advance the skills of the parents to feed children, particularly those children who may have specific feeding issues. we had to be careful the first couple weeks because they did not want to take the risk that addison might aspirate. They didn't want anything going down past that graft, wanted to keep her healthy. she wasn't really eating much the first week.

Now she's back to eating and exploring and everything goes into her mouth. she's doing fine with her thin liquids again. She's eating chips, which she loves to eat. She likes to lick salt. She's doing great with soft foods.

it's a great change. And it wasn't something that i really was prepared for. I didn't expect it to be so dramatic. But as soon as we got home she started doing things that she had never really wanted to do before. being in a premier institution such as the children's hospital of philadelphia, where you have wonderful teams of nurses and nurse practitioners, intensivists and physicians, who can care for those kids in case of emergencies and to care for them to the immediate recovery period, it provides a tremendous service and benefit to these children.

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