QUAD #15: Managing A-Frame Deformities with Dr. Matt Smith

GlobalcastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi, I'm M. Gody from Cincinnati Children's Hospital Medical Center. 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 in this video, we are going to hear from Dr. Matt Smith, an ENT surgeon at Cincinnati Children's, on A-frame deformities and their management, a section from How to Manage Long-term Airway Reconstruction Patient Session. When it comes to tracheal A-frame deformity, it typically occurs at the site of a prior tracheostomy. It is where the tracheal cartilage is damaged or destabilized, and it occurs in about a third of those who have had some type of tracheostomy or airway reconstructive procedure in the past, if they had never had a trach. Traditionally, we will size an airway with an endotracheal tube to determine, okay, is there any subglottic stenosis or tracheal stenosis. But with A-frame deformities, that traditional endotracheal tube sizing is not reliable because of the oblong shape of that A-frame. You can put a large breathing tube in there, and they'll still leak around at the top because it's not that traditional circular size of the airway. Another important thing to know is that when you size a kid with an A-frame, it may not seem too problematic at first glance. However, the key factor to consider is that the A-frame can be either static or dynamic. That's especially helpful where, looking in conjunction with our pulmonary colleagues, is to be able to see what are the dynamics of the airway because, even though something might look relatively good, if there's no stability from the cartilage around there, it's going to have a dynamic collapse there. Another aspect to consider with A-frame deformities is that, if someone has recently been decannulated and is resuming their daily life, it will likely take about one to two years before the A-frame deformity begins to manifest symptoms. And it's usually a gradual exercise intolerance or a gradual dyspneal exertion, or especially with the retinoid prolapse, you can have increased snoring or apnea at night, and it might manifest as an obstructive sleep apnea. Here, Dr. Smith shows the two typical methods we use to address A-frame deformities, if intervention is necessary. One is through the traditional route of an open repair, so you could excise that area and do a slide tracheoplasty at the side of the A-frame deformity or potentially even put in an anterior graph. One of the approaches they have begun exploring for certain off-level static A-frame deformities is using a CO2 laser to potentially carve out some of the scar tissue and cartilage present in the area. Now, when we do that, we do not do it in a bilateral fashion. We will stage the procedure and only do one side because we don't want to create any type of circumferential scar. So, here's our first case. A 6-year-old female with a history of campomelic dysplasia. She previously had a double stage with an anterior graft in order to address her subglottic stenosis. But after successfully getting decannulated, you're seeing this A-frame right there, and you can see how dynamic that A-frame is. Part of that has to do with her underlying condition of having poor cartilage, but you're seeing that collapse of her airway right there. Symptom-wise, this patient was having increased dyspnea. So, Dr. Smith and his team ended up doing a cervical slide tracheoplasty in order to address the dynamic A-frame deformity. This is one year post. That dynamic point of her trachea right there is no longer dynamic, and it's nice and open. And that was a year after reconstruction, and her symptoms have resolved. This is another example. A 12-year-old female with a history of subglottic and tracheal stenosis, underwent multiple airway reconstructions to address this area, was decannulated, but she came in and was having increasing dyspnea and exertion. This is where it's slightly off level. You can see that right side is just slightly higher than the left side in regards to that A-frame deformity, and it's static. In this option, they ended up doing a stage endoscopic resection of that A-frame deformity. You might be able to see that there's a platform section that's placed behind that right side of the airway. We're basically lasering out some of that hardened cartilage and scar. We basically did that right-sided tracheal A-frame resection first. This is afterward. You're seeing what we resected there, but you can see that left side is untouched. She comes back. So, this is the pre-op. You can see on the left. This is before they addressed the left side. You can see that right side has stayed relatively open, it's better than it was before, and now we've addressed the left side, and you can see where we've cut out that area there. After doing these two relatively simple procedures that took about 30 minutes each, this patient has been symptom-free and without any airway issues for the past six years. In summary, tracheal A-frame deformities are relatively common after airway surgery, whether that's just be a tracheostomy or airway reconstruction. It is important to remember that traditional sizing technique is not a reliable guide of the airway size because of the different shape of that area. Treatment should be guided by symptomatology, and both open and endoscopic surgical options exist. 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. GlobalcastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.