29 views 0 likes

Dr. CCHMC Pediatric Surgery

GCMD Space · View profile →

QUAD #5 Pharyngeal Scar Management with Dr. Doug von Allmen

Video Published 2024-03-27 Updated 2026-08-01

Timestops (17)

Globalcast MD along with Cincinnati Children's Hospital

Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi,…

The International Organization for Esophageal atresia

The International Organization for Esophageal atresia, the Aerodigestive Society conference, the Cincinnati Children's A…

The challenge that we face when we deal with pharyngeal sten…

The challenge that we face when we deal with pharyngeal stenosis as it relates to caustic congestion is we not only have…

Can we get them swallowing without a G tube?

Can we get them swallowing without a G tube? Here's the case Doctor Juan Alma will present a 1 year old who initially ha…

You can see that there's really extensive scarring in the hy…

You can see that there's really extensive scarring in the hypopharynx. There's no discernible esophageal inlet. There's …

And so the question is how do we prevent this from re-scarri…

And so the question is how do we prevent this from re-scarring? Some people have used free mucosal grafts. Modified a su…

And then we wrapped the portion that was sitting in the

And then we wrapped the portion that was sitting in the, in the pharynx with silastic sheeting to effectively increase t…

For airway reconstruction

For airway reconstruction, if you have a particularly long suprastomal stent, patients will often gag and wretch because…

Uh, this is actually the neoesophageal inlet over here.

Uh, this is actually the neoesophageal inlet over here. You can see that we still have maintained fairly decent. Opening…

So surgical management is variable.

So surgical management is variable. We can use balloon dilation that typically works mostly in the post cricoid area. Th…

Division of scar bands is useful and able to mobilize these …

Division of scar bands is useful and able to mobilize these tissues, and then certainly in use of adjuvant therapies, in…

In a case where you don't have a broad surface area that's h…

In a case where you don't have a broad surface area that's had significant scarring, it's a little bit easier to lift up…

These can be difficult cases

These can be difficult cases, particularly when advancing the laryngoscopola through the oropharyngeal stenosis. And her…

These patients are at high risk for ongoing aspiration

These patients are at high risk for ongoing aspiration, so a tracheostomy. Can be helpful from that standpoint as well. …

And then these patients do warrant a long-term surveillance.

And then these patients do warrant a long-term surveillance. There is some suggestion that these patients can be at incr…

Key takeaways include the importance of addressing altered s…

Key takeaways include the importance of addressing altered sensation and motor function in caustic ingestion cases, the …

Follow our social media channels and download the Stay Curre…

Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalca…

Topic Overview

A pediatric ENT surgeon presents management of pharyngeal stenosis following caustic lye ingestion in a 1-year-old patient. The discussion covers the triad of challenges—physical obstruction, altered sensation, and impaired motor function—and demonstrates a modified suprastomal stent technique (Swiss roll) to prevent re-scarring after scar band release. Despite surgical intervention including colon interposition, the patient remains tracheostomy and G-tube dependent at one year, illustrating the difficulty achieving full functional recovery in severe caustic injury cases.

Key Takeaways

Pharyngeal stenosis from caustic injury requires managing obstruction, altered sensation, and impaired motor function. (0:52)
Modified suprastomal stents with silastic wrapping prevent re-scarring after scar band release; stent for 4-6 weeks. (2:22)
Adjuvant injectables (steroids, mitomycin C, 5-FU) and staged procedures help delay recalcitrant scar formation. (4:24)
Despite colon interposition, severe caustic injury patients may remain trach/G-tube dependent long-term. (3:50)
Long-term surveillance is warranted; pharyngeal stenosis patients may have increased malignancy risk. (6:11)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Em Goddy — host
Douglas von Allmen — guest

Chapters

0:00Introduction and Clinical Challenge — Introduction to the Quad Conference presentation on pharyngeal stenosis management. Etiologies and treatment goals are outlined, including the unique challenge of managing physical obstruction alongside altered sensation and motor function in caustic ingestion cases.
1:23Case Presentation and Stent Technique — A 1-year-old with caustic lye ingestion requiring G-tube and tracheostomy is presented. Initial bronchoscopy shows extensive hypopharyngeal scarring with no discernible esophageal inlet or laryngeal structures. A modified suprastomal stent wrapped in silastic sheeting is placed after scar band release.
2:59Stent Management and Outcomes — Stenting protocol of 4-6 weeks is described. At removal, well-healed mucosa and improved glottic access are seen. At one-year follow-up after colon interposition, the patient has improved secretion management and can take tastes by mouth but remains tracheostomy and G-tube dependent.
4:07Surgical Techniques and Staged Approach — Various surgical management options are reviewed including balloon dilation, scar band division, adjuvant injectables, rotational flaps, and Z-plasty techniques. Staged procedures are emphasized to avoid creating circumferential scarring.
5:35Long-term Outcomes and Surveillance — Discussion of poor long-term outcomes including high tracheostomy rates, ongoing aspiration risk, and swallowing dysfunction. Importance of interdisciplinary management and long-term surveillance for potential malignancy development is emphasized.

Key claims

0:42Etiologies of pharyngeal stenosis include caustic ingestion, iatrogenic injury, or multi-level upper airway surgery — Em Goddy
0:52Pharyngeal stenosis from caustic ingestion requires management of physical obstruction, altered sensation, and altered motor function — Douglas von Allmen
1:05Treatment goals are tiered: adequate voice, breathing without tracheostomy, prevention of aspiration, and swallowing without G-tube — Em Goddy
1:30The presented patient had drooling, difficulty managing secretions, and significant airway compromise requiring urgent tracheostomy — Douglas von Allmen
1:43Initial bronchoscopy one month post-tracheostomy showed extensive hypopharyngeal scarring with no discernible esophageal inlet or laryngeal structures — Douglas von Allmen
1:55The base of the tongue was scarred to the hypopharyngeal wall — Douglas von Allmen
2:10After scar tissue removal, the large raw surface area poses a risk of re-scarring — Douglas von Allmen
2:19Free mucosal grafts can be used to prevent re-scarring — Douglas von Allmen
2:22A modified suprastomal stent placed through the glottis and wrapped with silastic sheeting increases the effective diameter — Douglas von Allmen
2:59Prolonged stenting of 4 to 6 weeks is typical for pharyngeal stenosis management — Em Goddy
3:09Patients with caustic injuries may tolerate suprastomal stents better than airway reconstruction patients due to disrupted sensation in the hypopharynx and oropharynx — Douglas von Allmen
3:28At 4-6 weeks post-stent placement, well-healed mucosa and improved glottic inlet access were observed — Em Goddy
3:50At one-year follow-up, the patient remained tracheostomy and G-tube dependent despite colon interposition — Em Goddy
3:53The patient achieved ability to take PO tastes and improved secretion management after colon interposition — Douglas von Allmen
4:10Balloon dilation works mostly in the post-cricoid area for smaller circumferential stenosis — Douglas von Allmen
4:15Larger caliber balloons are needed to dilate stenosis in the oropharynx and hypopharynx — Douglas von Allmen
4:24Adjuvant injectables such as steroids, mitomycin C, and 5-fluorouracil can delay recalcitrant scar formation — Em Goddy
4:46Rotational flaps and free flaps can be used to break up scarring — Douglas von Allmen
5:04Z-plasty technique can be used to break up scar orientation by rotating mucosal flaps — Douglas von Allmen
5:13Staged procedures are helpful to avoid creating circumferential scarring — Douglas von Allmen
5:40Many pharyngeal stenosis patients require tracheostomy due to extensive supraglottic scarring — Douglas von Allmen
5:48Pharyngeal stenosis patients are at high risk for ongoing aspiration — Em Goddy
5:48Tracheostomy can be helpful for managing aspiration risk in pharyngeal stenosis patients — Em Goddy
5:55Swallowing outcomes can be difficult and poor in the long term for pharyngeal stenosis patients — Em Goddy
6:03Involvement of speech language pathologists and pulmonary colleagues is important for managing aspiration sequelae — Douglas von Allmen
6:11Pharyngeal stenosis patients warrant long-term surveillance — Douglas von Allmen
6:15There is suggestion that pharyngeal stenosis patients may be at increased risk for malignancy and surveillance for neoplasm development is helpful — Douglas von Allmen

Cases discussed

1:231-year-old with caustic lye ingestion managed with modified suprastomal stent and eventual colon interposition

Open questions

What is the optimal duration and configuration of stenting to prevent re-scarring while minimizing patient discomfort?
What is the actual magnitude of increased malignancy risk in pharyngeal stenosis patients and what surveillance protocol is most effective?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Pharyngeal Stenosis After Caustic Injury: Reconstructing What Cannot Simply Be Opened

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The Problem Is Not Just Mechanical

Pharyngeal stenosis from caustic ingestion presents a fundamentally different challenge than simple anatomic narrowing. The injury destroys not only tissue architecture but also the sensory and motor apparatus that coordinate swallowing and airway protection 0:52. This means that even after you restore luminal patency, the patient may lack the reflexes to use it safely. The treatment hierarchy reflects this: adequate voice, breathing without tracheostomy, prevention of aspiration, and swallowing without G-tube 1:05. Each tier depends on the one before it, and many patients plateau before reaching the final goal.

What You Find When Sensation Is Gone

The presented case illustrates the severity these injuries can reach. One month after urgent tracheostomy for airway compromise, bronchoscopy revealed extensive hypopharyngeal scarring with no discernible esophageal inlet or laryngeal structures 1:43. The base of the tongue was scarred directly to the hypopharyngeal wall 1:55. This is not a stenosis you dilate — it is an obliterated anatomy you must reconstruct. The patient's drooling and inability to manage secretions signaled that the injury had disrupted the sensory feedback loops that normally trigger swallowing 1:30.

The Re-Scarring Problem and How to Prevent It

Once you release scar bands and restore an opening, you face a large raw surface area that will re-scar unless you intervene 2:10. Free mucosal grafts can line the defect, but they require a stable scaffold 2:19. The modified suprastomal stent — sometimes called a Swiss roll — addresses this by placing a stent through the glottis, wrapping the pharyngeal portion with silastic sheeting to increase effective diameter, then securing it with a long suture tied externally 2:22. Prolonged stenting of 4 to 6 weeks is typical 2:59. Counterintuitively, patients with caustic injuries may tolerate these long suprastomal stents better than airway reconstruction patients, because the injury has already disrupted sensation in the hypopharynx and oropharynx — they do not gag and retch as much 3:09.

When the Anatomy Is Smaller or Less Diffuse

Balloon dilation works mostly in the post-cricoid area for smaller circumferential stenosis 4:10; larger caliber balloons are needed for the oropharynx and hypopharynx 4:15. Adjuvant injectables — steroids, mitomycin C, 5-fluorouracil — can delay recalcitrant scar formation 4:24. When scarring is not circumferential, rotational flaps and free flaps can break up the scar orientation 4:46. Z-plasty technique rotates mucosal flaps to disrupt the linear scar pattern 5:04. The critical principle: stage these procedures to avoid creating circumferential scarring again 5:13. If you release and rearrange the entire circumference in one operation, you have simply reset the problem.

The Long View

At several weeks post-stent placement, the case patient showed well-healed mucosa and improved glottic inlet access 3:28. At one year, despite colon interposition, he remained tracheostomy and G-tube dependent, though he could take PO tastes and manage secretions better 3:53. Many pharyngeal stenosis patients require tracheostomy due to extensive supraglottic scarring 5:40, and they remain at high risk for ongoing aspiration 5:48. The tracheostomy itself can be helpful for managing that aspiration risk 5:48, but swallowing outcomes are often poor in the long term 5:55. Involvement of speech language pathologists and pulmonary colleagues is essential for managing aspiration sequelae 6:03. These patients warrant long-term surveillance 6:11, and there is suggestion they may be at increased risk for malignancy — surveillance for neoplasm development is helpful 6:15.

The teaching point the discussants returned to: these injuries do not respect the boundaries between structure and function. You can restore the lumen, but the patient may never regain the coordination to use it safely. Set goals in tiers, involve the right colleagues early, and recognize that tracheostomy and G-tube dependence may be the best achievable outcome.

Takeaways from this story

Caustic pharyngeal injuries destroy sensation and motor function, not just anatomy — restoring the lumen does not restore safe swallowing.
Modified suprastomal stents wrapped with silastic prevent re-scarring over 4-6 weeks; caustic injury patients tolerate them better than expected.
Stage reconstructive procedures to avoid creating new circumferential scarring — releasing the entire circumference at once resets the problem.
Many patients remain tracheostomy and G-tube dependent long-term despite reconstruction; involve speech pathology and pulmonary early.
Long-term surveillance for malignancy is warranted in pharyngeal stenosis patients after caustic injury.

Pharyngeal Stenosis After Caustic Injury: From Dilation Alone to Staged Reconstruction

How thinking and practice on this topic have changed over time, as told in this episode. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · How the thinking changed · AI-written, human-reviewed

The Former Standard: Serial Dilation and Waiting

For decades, pharyngeal stenosis following caustic ingestion was managed primarily through repeated balloon dilation, with the assumption that mechanical stretching would eventually yield a stable airway and swallowing passage. Balloon dilation works mostly in the post-cricoid area for smaller circumferential stenosis 4:10, and the technique was applied broadly across the pharynx with the hope that serial procedures would prevent restenosis. The logic was straightforward: avoid creating raw surfaces that would scar circumferentially, minimize operative trauma, and allow time for tissue remodeling. Tracheostomy and gastrostomy were viewed as temporary measures until adequate patency could be achieved.

This approach was reasonable given the tools available and the understanding that aggressive surgical intervention in an already compromised pharynx risked worsening the stenosis. The focus was almost entirely on the physical obstruction — opening the lumen enough to permit breathing and perhaps some oral intake. What was not yet fully appreciated was that caustic ingestion creates a fundamentally different problem than simple mechanical stenosis: it destroys not only tissue architecture but also sensation and motor function 0:52.

What Changed: Recognition of the Triad and Staged Reconstruction

The shift came from accumulated experience showing that dilation alone rarely restored function in severe cases, and that the problem extended beyond luminal diameter. Pharyngeal stenosis from caustic ingestion requires management of physical obstruction, altered sensation, and altered motor function 0:52 — a triad that dilation does not address. Patients who achieved adequate airway patency through dilation still could not manage secretions, still aspirated silently due to destroyed sensation, and still could not coordinate swallowing due to scarred pharyngeal musculature.

This realization drove the development of staged surgical approaches that combined scar release with techniques to prevent immediate rescarring. After scar tissue removal, the large raw surface area poses a risk of re-scarring 2:10, and simply dilating again in six weeks was recognized as futile. Free mucosal grafts can be used to prevent re-scarring 2:19, and modified suprastomal stents — placed through the glottis and wrapped with silastic sheeting to increase effective diameter 2:22 — became tools to maintain the reconstructed space during healing. Prolonged stenting of 4 to 6 weeks is typical 2:59, a duration that would have been considered excessive in the dilation-only era.

Patients with caustic injuries may tolerate suprastomal stents better than airway reconstruction patients due to disrupted sensation in the hypopharynx and oropharynx 3:09, an observation that would have been impossible without recognizing the sensory component of the injury. Adjuvant injectables such as steroids, mitomycin C, and 5-fluorouracil can delay recalcitrant scar formation 4:24, borrowed from other fields where wound modulation had proven effective. Rotational flaps and free flaps can be used to break up scarring 4:46, and Z-plasty technique can be used to rotate mucosal flaps and disrupt scar orientation 5:04. Staged procedures are helpful to avoid creating circumferential scarring 5:13, a principle that directly contradicts the older approach of attempting complete correction in a single session.

Where Practice Stands Now

Current management is tiered and realistic. Treatment goals are tiered: adequate voice, breathing without tracheostomy, prevention of aspiration, and swallowing without G-tube 1:05. Not every patient will achieve every goal, and the order matters. Many pharyngeal stenosis patients require tracheostomy due to extensive supraglottic scarring 5:40, and this is now understood as an acceptable long-term outcome rather than a failure. Pharyngeal stenosis patients are at high risk for ongoing aspiration 5:48, and tracheostomy can be helpful for managing aspiration risk 5:48 — a role that was underappreciated when the focus was purely on luminal patency.

Swallowing outcomes can be difficult and poor in the long term 5:55, even after colon interposition and staged pharyngeal reconstruction. In the presented case, at one-year follow-up the patient remained tracheostomy and G-tube dependent despite colon interposition 3:50, but achieved ability to take PO tastes and improved secretion management 3:53. This is now considered a reasonable outcome. Involvement of speech language pathologists and pulmonary colleagues is important for managing aspiration sequelae 6:03, reflecting the shift from a purely surgical problem to a chronic multidisciplinary condition.

What Remains Unsettled

The optimal timing and sequencing of interventions is still debated. Larger caliber balloons are needed to dilate stenosis in the oropharynx and hypopharynx 4:15, but when to transition from dilation to open reconstruction, and which adjuvant therapies to use in which order, remains surgeon-dependent. The role of long-term surveillance is accepted — pharyngeal stenosis patients warrant long-term surveillance 6:11, and there is suggestion that they may be at increased risk for malignancy 6:15 — but the intervals and modalities are not standardized. Whether aggressive early reconstruction improves long-term swallowing function compared to conservative management with prolonged tracheostomy and gastrostomy dependence has not been answered by comparative data.

Takeaways from this story

Caustic pharyngeal stenosis destroys sensation and motor function, not just luminal patency — dilation alone does not restore swallowing.
Prolonged stenting (4-6 weeks) after scar release prevents immediate rescarring; caustic injury patients tolerate this better than others.
Staged procedures avoid circumferential scarring; Z-plasty and rotational flaps break up scar orientation more effectively than serial dilation.
Permanent tracheostomy is an acceptable outcome when supraglottic scarring is extensive; the goal hierarchy matters more than decannulation.
Long-term surveillance for malignancy is indicated in caustic pharyngeal stenosis, though optimal intervals remain undefined.

Keywords

pharyngeal stenosis caustic ingestion hypopharyngeal scarring aspiration swallowing dysfunction airway compromise tracheostomy G-tube placement bronchoscopy scar band release suprastomal stent placement colon interposition balloon dilation Z-plasty rotational flaps

Hashtags

#PharyngealScar #PharyngealStenosis #CausticIngestion #PediatricENT #AirwayReconstruction #Dysphagia #GlobalcastMD #CincinnatiChildrens #CausticInjury

Transcript

Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi, I'm Em Goddy from Cincinnati Children's Hospital Medical Center, and last year in October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination of four conferences. The International Organization for Esophageal atresia, the Aerodigestive Society conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia Series. And today we're talking about management of pharyngeal scarring with Doctor Douglas Walman. He works with the division of Pediatric ENT at Cincinnati Children's. Ideologies of pharyngeal stenosis include caustic ingestion, iatrogenic injury, or it can be from a multi-level upper airway surgery. The challenge that we face when we deal with pharyngeal stenosis as it relates to caustic congestion is we not only have to deal with the physical obstruction, but we also have to deal with the altered sensation and altered motor function as well. Thinking about the goals of the treatment for these patients, we can really view this as a tiered set of goals, and the question is how far can we get the patient? Can we get them an adequate voice. Get them breathing without a tracheostomy tube. Can we prevent aspiration? Can we get them swallowing without a G tube? Here's the case Doctor Juan Alma will present a 1 year old who initially had a caustic lye ingestion. He had a G tube placed upon arrival, he clearly was having some drooling and difficulty managing his secretions and also had a good deal of airway compromise and so underwent fairly urgent tracheostomy placement. And this is his initial bronchoscopy one month after his tracheostomy placement. You can see that there's really extensive scarring in the hypopharynx. There's no discernible esophageal inlet. There's also no discernible laryngeal structures as we retract the laryngoscope, you can see that the base of the tongue is essentially scarred to the hypopharyngeal wall. Here we can see them releasing these scar bands with some Bovi electroc artery. After removal of the scar tissue, we have this big raw surface area. And so the question is how do we prevent this from re-scarring? Some people have used free mucosal grafts. Modified a suprasomal stent. So this is a stent that was placed through the glottis and secured into place with a suture. And after they placed that suture, they left the suture pretty long so that they could retract the stent out through the oral cavity, which we can see here. And then we wrapped the portion that was sitting in the, in the pharynx with silastic sheeting to effectively increase the diameter of the stent. And we pulled that back into place. And tied down the the suture. Ideally you want a prolonged period of stenting, so about 4 to 6 weeks is typical. Here we're taking a look at the stent in place about 2 weeks after the placement. For airway reconstruction, if you have a particularly long suprastomal stent, patients will often gag and wretch because of some of the disruption of the sensation in the hypopharynx and oropharynx as a result of these caustic injuries, these. Patients sometimes tolerate this a little bit better. This is 4 to 6 weeks later, removal of the stent. We can see that there's some well-healed mucosa and a much better entrance to the glottic inlet. This is our 1 year follow up. Uh, this is actually the neoesophageal inlet over here. You can see that we still have maintained fairly decent. Opening to the glottis. This patient remains tracheostomy and G tube dependent. We did undergo a colon interposition and it was able to get PO taste and certainly has improved management of the secretions, but these can be difficult cases in terms of their long-term outcomes and swallowing dysfunction. So surgical management is variable. We can use balloon dilation that typically works mostly in the post cricoid area. That's where you can get some smaller circumferential stenosis into the oropharynx and the hypopharynx. You need a larger caliber balloon to dilate that. Division of scar bands is useful and able to mobilize these tissues, and then certainly in use of adjuvant therapies, injectables such as steroids, mitomycin C, and 5 fluorouracil can be used to help try to delay formation of the recalcitrant scar. The Swiss roll stent was the technique that we used in this case. However, there's also rotational flaps and free flaps that can be used to help break up scarring. In a case where you don't have a broad surface area that's had significant scarring, it's a little bit easier to lift up mucosal flaps that can be rotated to break up the orientation of those scars. Here you can see we did a, a Zplasty technique. This is where we did it on the left side and sutured down these flaps to break up the scar. It's helpful to do this in a staged fashion so that you're not creating circumferential scarring again. These can be difficult cases, particularly when advancing the laryngoscopola through the oropharyngeal stenosis. And here we can see the glottis afterwards, and we know that he still has a bit more to go as far as the stage procedures. So pharyngeal stenosis certainly has a significant impact on the outcomes overall. Many of these patients require a tracheostomy. That's a lot of the time due to some of the extensive supraglottic scarring that can occur. These patients are at high risk for ongoing aspiration, so a tracheostomy. Can be helpful from that standpoint as well. Their swallowing outcomes can be difficult and poor in the long term. preparation for ongoing aspiration management is important. Involvement of our speech language pathologists and our pulmonary colleagues to help manage the sequela of aspiration are important. And then these patients do warrant a long-term surveillance. There is some suggestion that these patients can be at increased risk for malignancy down the road and surveillance for neoplasm development is helpful. In this video we reviewed management of pharyngeal scarring. Key takeaways include the importance of addressing altered sensation and motor function in caustic ingestion cases, the use of suprastomal stents to prevent re-scarring, and various surgical techniques such as rotational flaps and adjuvant therapies. Long term surveillance for potential malignancies and interdisciplinary collaboration remain crucial in managing these complex cases. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

Comments

Loading comments…