QUAD #8 EA/TEF Repair– Thoracoscopic vs Thoracotomy, Role of ENT with Dr. Catherine Hart with Dr. Catherine Hart

Global cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello everyone. This is Kim Pribin and I'd like to welcome you back to the continuation of our quad series. 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 Disphagia Series. Today, we are going to talk about the role that ENT plays in managing the airway, primarily in esophageal atresia repair with Dr. Katherine Heart, a pediatric otolaryngologist specialist at Cincinnati Children's. I think about these kids in two different buckets. We've got the kids where we're involved in the initial repair and then the kids that we encounter a little bit later on in our Aerodigestive program. The child's diagnosis is typically known prior to going into the initial repair procedure. While the ENT provider may not have a role in initial diagnosis, their participation in the operating room is a crucial one. They are tasked with the localization of the fistula and the management of the airway, which are both challenging in children with this condition. The initial airway evaluation is always performed and this is a little guy with charge syndrome day of life one. You might ask, what is charge syndrome? Charge syndrome is a disorder that affects many areas of the body. Charge is an abbreviation for several of the features common in the disorder. Coloboma, heart defects, atresia coana, also known as coanal atresia, growth retardation, genital abnormalities and ear abnormalities. And you can see it's not the most straightforward intubation. He doesn't have a completely normal airway. He has a little bit of a difficult exposure. As he passed through, you can see where the endotracheal tube was rubbing. He's got a fair amount of Malaysia to begin with and also has a significant tracheoesophageal fistula, which was not hard to find. But in this baby, knowing what his airway was like impacted some of the decisions that was made in the perioperative or particularly a post-operative period in terms of safety for extubation and how to move forward there. As I had mentioned, ENT's have the important job of assisting with localization. So sometimes when these are subtle, they're not as easy to find, but the primary role we pay play in the little babies is placing a fody catheter through the TF to help our pediatric surgery colleagues localize it more easily. And here is an example of that fody being placed through a fistula. In a case like this, where you could easily see that the fistula was actually about at the distal third of the trachea and placing the endotracheal tube can be a little bit tricky. We did this over a telescope in order to make sure that the endotracheal tube is beyond the fistula and that our anesthesia colleagues were able to ventilate appropriately. As a member of the interdisciplinary team, ENT may oftentimes play a more significant role in the diagnosis and surgical management for the kids that have already had their initial repair and have to come back later in life. So this is a little guy, had a history of a TF that was repaired and was now eight or nine years old and presented actually to have his tonsils removed. But he was also having recurrent pneumonias. So we took him to the operating room and sure enough, he had either a pouch or a recurrent fistula, was a little hard to tell. They then intentionally intubated the esophagus. The cuff was inflated and they gave some big positive pressure breaths into the esophagus. And if you watch along the back wall of the trachea once we get back down here, you can see that there's some bubbles and you can see the jet of air streaming up the back wall. And that confirmed that there was in fact a fistula that was still present. This is one of the ways that you can diagnose or confirm the presence of a fistula. If you didn't look closely, you could have thought this was just a pouch. History of TF repair, having recurrent pneumonias. And when you put the scope in, at first glance, it looks fairly normal apart from all the secretions down in the distal airway. If you watch really carefully as the scope is withdrawn, you see a little area of furring, which is indicative of a reoccurring tracheoesophageal fistula. We typically do these as a triad with our GI colleagues and our pulmonary colleagues and given the nature of this fistula, the pulmonary scope actually couldn't pass into it. And so we were able to use a rigid suction to confirm that there was in fact still a hole there. Upon beginning an endoscopy, it was pretty obvious from the esophageal side where the hole was. This was a child who ended up having a combined repair to fix the hole. For these recurrent persistent or H-type TFs, a lot of times at our institution, ENT is primary in management, a team sport, particularly here in Cincinnati where every specialty has a role. And for the ENT standpoint, the role really varies depending on what phase of care the child is in, including that diagnosis and management of the airway and then the surgical management. To summarize, ENTs play critical roles in managing TF cases, including localization, diagnosis and surgical management. In initial repair cases, ENTs help identify airway issues and facilitate safe intubation. For reoccurring or persistent TFs, ENTs often take a primary role in management, working in collaboration with other specialties. Care for TF patients is highly multidisciplinary with each specialty contributing at different phases of care. This comprehensive approach ensures the best outcomes for these challenging cases. 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. Global cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.