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

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.