By JOHN A. BICLEB, M.D., PAui H. HOLINGEJI, M.D., KENNETH C. JOHNSTON, M.D.,
AND FILMom ScHILLER, M.D.
Chicago
476
A
LTHOUGH the indications for tracheot-J- omy have not changed, there is nowan acceptance of tracheotomy as an adjunct to other therapy rather than a last minute desperate emergency procedure.’ Anoxia
due to respiratory obstruction by secretions
or tissue masses plays an important role in
morbidity and mortality. Prompt
recogni-tion of the indications for tracheotomy will reduce infant mortality.
The indications for tracheotomy in young
infants are the same as for older children. Infants present the same symptoms and physical findings with respiratory obstruc-tion that are present in older children. These progress from restlessness associated
with air hunger, to inspiratory and
expira-tory stridor with or without hoarseness, suprasternal, sternal, intercostal and
sub-sternal retractions, poor respiratory cx-change in spite of increased respiratory ef-fort, huskiness and cyanosis. In addition, infants are more apt to have choking and
gagging episodes when fed, as well as sud-den cyanotic attacks during feedings. Furthermore, itt infants there is a signifi-cantly smaller margin of safety during an observation period before tracheotomy than
in older children. Finally, this study has
demonstrated that there are important
etiologic differences between respiratory obstruction in infants and older children; these lie in the underlying pathology, the small size of the infant airway, the great importance of the proper size of the trache-otomy tube and in the aftercare. It is dur-ing the period after tracheotomy that false
judgment, minor acts of carelessness or
in-From the Children’s Memorial Hospital and the Otho S. A. Sprague Memorial Institute Labora-tories, Chicago.
Presented at the Annual Meeting of the Anieri-can Academy of Pediatrics, Miami, Oct. 7, 1953.
(Received for publication Dec. 3, 1953.)
adequate care may suddenly mean the
dif-ference between life and death.
In the past 17 years the authors have ob-served 62 infants under one year of age at the Children’s Memorial Hospital in whom tracheotomy was necessary (table 1). The
youngest in this group was a newborn
in-fant five minutes old.
As can be seen from table 2, the basic
pathology necessitating tracheotomy in in-fants has been changing. More infants with congenital anomalies are being tracheoto-mized because of improved medical knowl-edge and the development of facilities for tracheotomy care in laryngoscopy and
bronchoscopy departments. The incidence of tracheotomy for inflammatory lesions of the larynx and trachea is decreasing
be-cause of the antibiotics and immunizations. The incidence of tracheotomy for
nonin-flammatory lesions is increasing because of
the associated respiratory symptoms that
may occur in the attempted correction of
other diseases.
The underlying pathology necessitating
a tracheotomy varied from congenital mal-formations and neoplasms to inflammatory
disease and trauma. In 51.6% of the cases, there was a congenital anomaly or a neo-plasm involving the larynx or trachea, which was present at birth. This is in
con-trast to older children where inflammatory
disease is responsible for about 90% of the tracheotomies. The pediatric textbooks
barely mention the role of congenital mal-formations in relation to tracheotomy.
The 62 cases here reported can be divided
into those in which the underlying
pathol-ogy was congenital and those in which it
was acquired. There appears to be a definite
difference in the sex ratio in these two
groups (table 3). In the congenital group,
there are 17 females and 15 males. In the
TABLE I
TRACHEOTOMY IN INFANTS UNDER ONE YEAR OF AGE
.
Basic Pathology Total Age First
ymptoms
Age
i
racneotomy,
Days Fube in Deaths
A. Congenital Lesions
1. Laryngeal Stenosis a. Laryngeal Web 3
82
Birth 3 12 days 1
22-34 days 2
Out 770 days 1 Still in 487 days 1
1 after 50 days
b. Laryngeal Stenosis S Birth 3 5
mm.
119-21 days 2
Out 984 days 1
Still in 1563 days 1
1 in 24 hr.
C. Subglottic Stenosis 1 1 Birth-7 days 7 3-7 wk. 4
1-4 wk. S
1-2 mo. 4
2-4 mo. 2
6 mo.-1 yr. 2
Out 85-1025 days 8 Still in 487-1 1 1 days 2
1 in 24 hr.
2. Vocal Cord Paralysis 6 Birth 4 4-6 days 2
1-2 days 2
6-8 wk. 2 8-6mo. 2
Out 525-640 days 2 Still in 185-485 days 4 0
3. Tracheal Malacia 1 Birth 1 8 wk. 1 Out 365 days 0
4. Neoplasms 8 a. Lymphangionias 2
b. Hemangiomas 2
C. Cysts 2
d. Tumors 2
Birth 3
1-3 mo. 5
17 hr. I
1-3 mo. 3
3-7 mO. 4
Out 7-36 days 2
161-768 days 4
1 after
5 mo. 1 after
3 yr.
B. Acquired Lesions 1. Inflammatory 18
30
III 1-5 days before tracheotomy
4-6 mo. 7
6-8 mo. 3
8-12 mo. 8
Out 10-26 days 9
83-83 days 4
455 days 1
4
2. Foreign Body 1 III 6 wk. 94 mo. 10 days 0
3. Miscellaneous I 1 Postoperative edema,
traunia, etc.
Birth and zieo-natal 9 3-4 mo.
1-4 days 6
3 wk. I
1-4 mo. 4
Out 165-180 days 2
Still in 1-488 days 8
TABLE 2
YEARLY INCIDENCE OF TRACHEOTOMY IN INFANCY
Basic Pathology 1936!1939k9401941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 Total
Congenital 2 1 1 2 1 1 I 2 3 4 8 3 3 32
Inflammatory 2 1 1 3 3 1 4 1 2 1 19
. TABLE 3
SEX INCIDENCE OF TRACHEOTOMY IN INFANCY
Congenital Acquired
Laryn- -
-
- -__________Sex geal Laryn- Vocal I Total . i’othl
Steiiosis geal Cord Tracheal Neo- I,iflain. Foreigii Iis.
Web Paralysis Malacia plasms Body
Male 7 1 3 1_ 3 i 5 21
F’einale 7 2 ‘3
__L5
17 3 69females who had laryngeal infections
pro-ducing obstruction. In the miscellaneous subgroup of 11 having nonlaryngeal con-genital malformations, the sex incidence is again about equal.
CONGENITAL MALFORMATIONS
There were 32 cases considered to have congenital defects of the larynx or trachea.
Congenital Laryngeal Stenosis : In this
group there were 17 cases, 9 females and 8
males. A laryngeal web was present in 3 cases, laryngeal stenosis in 3 and subglottic stenosis in 11. Respiratory symptoms oc-curred from birth to 7 days of age in 13 cases and at 3 to 7 weeks in 4 cases.
In one case the respiratory difficulty was sufficient at birth to necessitate immediate tracheotomy. In this infant a tracheotomy was done within five minutes after birth because of the failure of pulmonary air exchange in spite of good respiratory
move-ments. There was a complete weblike
atresia of the larynx at the level of the vocal cords. This infant still has his tube in place
after 1563 days and is doing well. He will
require external surgical procedures to establish an adequate airway.2 Another
in-fant required a tracheotomy at 7 days of age.
In the other 15 cases the symptoms were not as severe and medical management could be given a longer trial, although periods of oxygen therapy and high humidity were necessary. However, obstruction to breath-ing increased so that tracheotomy became necessary at 12 to 22 days in 4, at 1 to 3 months in 8, and at 4 months, 6 months and 12 months in one each.
A second tracheotomy was necessary in two infants, one after 12 days and one after
25 days. Although the basic pathology in
this group was an apparent congenital anomaly, it seemed that in five cases an infection of the respiratory tract precipi-tated the need for the tracheotomy. These five cases were in the laryngeal and sub-glottic stenosis group. These are the cases
in which tracheotomy had to be done from the second to the twelfth month. In eight of these infants the tracheotomy was done at the local hospital.
There were three deaths in this group.
One infant with respiratory embarrassment since birth was admitted at 37 days of age. Its condition was critical and death oc-curred while the tracheotomy was being
done. The second infant also had symptoms of respiratory difficulty from birth and was admitted at the age of 20 days. Tracheotomy became necessary within 24 hours. Death occurred within 24 hours due to a thick
mucus plug in the tracheotomy tube. In
both of these infants at autopsy, the cricoid
cartilage was found to have an anomalous configuration and position. The anterior
portion of the cricoid cartilage was
defec-tive in that its greatest length instead of lying in the cephalad-caudad position, was in the anterior-posterior position making a narrow opening in the cartilage between the anterior and posterior portions of the
cricoid. This produced a narrowing of the
Age
Congenital Group
Laryngeal Laryngeal Stenosis Web
Vocal
Cord
Paralysis
Tracheal
Malacia
Birth --10 days
10 (lays-I mo
10
Acquired Group
Total
Neo-plasms
Inflam.
3
3-4 mo.
l-2mo. 3 1 1 5
-3mo.
Foreign Misc.
Body
9
18
Days symp. Present
iday 3
days .5
Sdays 1
4days S
5 days S 14 days 1
Total
9
S
1
4-Omo.
6-8mo.
S
I 3
8through H mo. 10 10
Aec TRACHEOTOMY
Birth 1
Birth-l0days 1
I
6 6
1 4
10-30 days 4
1-mo.
I 7 2
1 I 6
-3 mo. 3
;-:---4-6 mo. 1
1
----
----p--;--6
-;--1
---t-
L-_-;-5
1
__3_
.5
1 4
6-8mo. 1 1
Sthrough H mo. 1
L______
10 i iiTABLE 4
AGE ONSET SYMPTOMS
revealed a laryngeal web above the vocal cords. The web was made up of dense tissue with only a small airway through it into the larynx. When this web was incised and removed piecemeal, it was found that the false cords had been pulled together and the supraglottic stenosis was present at the
epiglottic base. This had drawn the
epiglot-tis over the supraglottic area. Dilatations of the stenosis were done but tracheotomy became necessary on the thirty-fourth day.
This afforded adequate relief. She had been discharged from the hospital and was
re-turning for dilatations. On her last admis-sion at the age of 83 days, a severe broncho-pneumonia followed an apparently
uncom-plicated routine dilatation and death
oc-curred four days later in spite of antibiotic
therapy. At necropsy the supraglottic larynx was adequately open but the epiglottis was
abnormally mobile close to its base and was
bent to lie partially over the airway between the true cords. The opening between the cords was patent, oval in shape and meas-ured 0.6 cm. in diameter. The trachea was
normal. On microscopic examination the
mucosa of the epiglottis and cords was thin in focal areas and there was infiltration with small round cells. No anatomic narrowing
of the glottis itself was found. There was a
diffuse bronchopneumonia.
laryngeal stenosis has tissue from the larynx
been examined. This was from a biopsy
specimen in an infant with subglottic ste-nosis. There was no inflammatory reaction,
only normal muscle, connective tissue and
mucus membranes.
In congenital laryngeal stenosis, the
pa-thology is variable. In one case there was
a supraglottic fusion of the anterior portion
of the false cords and aryepiglottic folds.
In three cases a true laryngeal (glottic) web across the true cords was present.
Trache-otomy is not required in the majority of
cases of laryngeal web.4 In the remaining
cases the glottic and subglottic structures were thickened with, occasionally, even a
fusion of a portion of the anterior com-missure. The point of greatest obstruction
was 2 to 3 mm. below the true cords. In the two infants that came to necropsy, a deformity of the cricoid cartilage was found
as described above. This suggests that cartilaginous deformities may play a
con-siderable role in laryngeal stenosis.
A long program of treatment is usually
necessary when a congenital anomaly of the larynx is present. Of the 14 infants
living, 4 still have their tracheotomy tubes in place after 487 to 1563 days. In the other 10 cases the tubes were removed as early as 85 days in one patient but from 280 to
1025 days in the other nine. Total days hos-pital care for each patient varied widely from a minimum of 66 days to a maximum
of 1208.
Four infants had roentgenographic treat-ment over the thymus area at their local hospitals after the onset of symptoms be-cause of a wide mediastinal shadow.
Two infants had other congenital anoma-lies-one a double cleft lip and palate and one an Ehlers-Danlos syndrome.
The correct diagnosis of laryngeal ste-nosis is not always easy as illustrated by the following case. Stridor was present since
birth. At about monthly intervals, from the age of 3 months, the stridor and respiratory
symptoms would become exacerbated.
These episodes were diagnosed as croup
by the local physician. At the age of one
year, the laryngeal stridor became so severe
that tracheotomy became necessary at the local hospital. It was said that a pneumonia was also present. When examined by the
authors two months later, there was bi-lateral limitation of vocal cord motility and
a moderate subglottic stenosis. With
laryn-geal dilatation and improvement, the
tracheotomy tube could be removed after
85 days. About five months later vocal cord
movement was still moderately limited and
the subglottic area moderately narrow. The child now gets along well except during periods of throat infections when the stridor recurs. If the subglottic stenosis had been recognized early and dilated, tracheotomy
may not have been necessary. The
precipi-tating factor for the tracheotomy was
in-fection.
Vocal Cord Paralysis: This was the
un-derlying pathology in six cases. Respiratory
difficulty began in 4 at birth and in one each at 4 days and 6 weeks. Tracheotomy was necessary at the age of one day in one,
at the age of 2 days in one, 6 to 8 weeks in 2 and 3 to 6 months in 2. Bilateral cord in-volvement was present in 4 and unilateral
in 2. The tubes are still in place after 185 to 435 days in 4 cases. They were removed
after 525 and 640 days in 2 cases. Trache-otomy was done twice on one infant at the
age of 6 months and 13 months.
The cause of vocal cord paralysis has been
given as central in origin or as a peripheral paralysis occurring at birth. Two of the
infants with bilateral cord paralysis also had cervical myelomeningoceles, one of which has been removed surgically. They both have signs of other cranial nerve in-volvement. One other had an associated Erb’s palsy.
Tracheal Malacia: Tracheal malacia re-quiring tracheotomy has only been observed once. This infant had spent most of his life
then have shown a normal larynx but a
trachea that collapses as the instrument is
withdrawn. It was possible to extubatc this infant one year after the tracheotomy. There appears to be less rigidity of the tracheal cartilage than normal. The authors have had no postmortem observation on this type of
case.
Ncoplasms: In this group there were 2
laryngeal cysts, 2 hemangiomas, 2
lymph-angiomas and one each of a fibrosarcoma and neurofibroma. These are included with the congenital lesions because they were all apparently present at birth or shortly thereafter. Three had actual symptoms from
birth while in the others there were similar
lesions visible on other parts of the body
or in the pharynx at birth.
There were 8 patients in this group, 3
males and 5 females. Symptoms of
respira-tory difficulty appeared at birth in 3, at one
month of age in 2 and at 3 months in the
other three. Tracheotomy became necessary at 17 hours of age in one, at one to 3
months in 4, at 5 months in 2 and at 7
months in one.
Two infants with severe respiratory
symp-toms, cyanosis and hoarseness since birth
were found to have a cyst of the larynx.5
Tracheotomy was done at 17 hours of age in one and at 81 days in the other. The
cysts were in the ventricle between the true and false cords. They were aspirated,
in-cised and removed. On microscopic
exami-nation the walls were made up of
pseudo-stratified columnar epithelium and
connec-tive tissue. The tube was removed in 6 days
in one and in 161 days in the other. The
in-fants have done well since. One other infant with a similar cyst of the ventricle has been
observed; it was possible to remove the cyst
endoscopically without need of a
trache-otomy.
Two infants had a lymphangioma, one a
hemangioma and one a
hemangioendotheli-oma. In three infants the lesion involved the larynx itself. In one there were multiple hemangiomas involving the right side of the
face and ear, the submental area and the
pharynx. The diagnosis was confirmed by
biopsy of the larynx in each case. Treat-ment was by x-ray and the removal of
pieces of tissue at the time of the
laryn-goscopies. Tracheotomy tubes were in 7
days in one, 318 and 768 in the other 2
cases.
In the fourth case there was a hemangio-endothelioma in the deep tissues of the neck causing a pressure obstruction of the
larynx. On lateral view RGs of the neck,
there was retropharyngeal and tracheal
bulging pushing the trachea forward and causing marked narrowing of the trachea.
Roentgenographic treatment had no effect on the mass. The tumor was removed
surgi-cally by Dr. Danley Slaughter.6 This was
followed by roentgen therapy. The trache-otomy tube was in place for 356 days. The patient is in good health nine years later.
A fibrosarcoma of the larynx was present in one case with respiratory difficulty from
birth. A tracheotomy was necessary at the age of 30 days. Death occurred 152 days later. At necropsy a tumor 1.5 X 2 X 3 cm.
involving the muscles of the larynx and cx-tending into the vestibule of the larynx was
found. Attached to the tumor was a mass of hard lymph nodes measuring 1.3 by 7 cm.
The microscopic report was a nonencapsu-lated fibrosarcoma of the laryngeal muscles. The infant died an obstructive death even with the tracheotomy tube in place. There was also cardiac hypertrophy with
inter-stitial edema.7
A neurofibroma of the larynx was present in one infant. Respiratory distress began before 3 months of age and a tracheotomy became necessary at 3% months of age at the
local hospital. The tube was removed at
4% months of age although severe noisy, wheezy stridor was still present. A second
tracheotomy was done at 9 months of age. Three months later a tumor of the larynx
was diagnosed and transfer was made to
this hospital. The laryngeal lumen was small
after tracheotomy. At autopsy
neurofibro-matosis of the larynx, heart, the right pan-etal pleura and of the neck was found. The neurofibroma occluded the lumen of the larynx and of the trachea. There was also
a hydropenicandium and a left hydrothonax and marked atelectasis of the left lung.
ACQUIRED LESIONS
Inflammatory : In this group were 18
in-fants, 15 males and only 3 females. Thirteen cases occurred during the winter months of October through March and only 5 cases during April, May and July. One four month old infant had laryngotracheal diph-thenia requiring immediate tracheotomy.
One 11 month old infant had ulcerations of the pharynx, glottis and larynx. He ran a febnile course but smears and cultures
were all negative. There was no history of
caustic burns. There was an associated
cystic fibrosis of the pancreas. The other 16 cases were typical of laryngotracheo-bronchitis and occurred between the ages
of 4 and 12 months with fairly even age distributions.
Symptoms were present from one to 5 days before admission. They were all emer-gency admissions and tracheotomy was
necessary within a few hours in 8 cases and
within 48 hours in the others. There were
4 deaths. The infant with diphtheria died
on the second day and 3 infants with
laryn-gotracheobronchitis died on the day of the tracheotomy. Two deaths occurred in 1943 with only one of them having had a sul-fonamide. The other death occurred in 1945 in a mongolian idiot who had received a sulfonamide and penicillin. Fifteen of the tracheotomies were done before 1948, 2 in
1950 and one in 1952. Undoubtedly, the
newer antibiotics have had some influence on this decrease. The severity of the infec-tion plays some part because tracheotomies were also required more frequently in older children during these same years.
Throat cultures or cultures from direct
laryngoscopy were done on 16 patients.
The diphtheria bacillus was found in one
case. In the other cases Staphylococcus
aureus alone or in combination with other organisms was the most common infecting agent. Other organisms were the N. ca-tarrhalis, Streptococcus hemolyticus and E. coli. The influenza bacillus was not found
III any case.
The tracheotomy tubes were removed in 10 to 26 days III 9 and 33 to 83 days in 4
cases. In one patient tracheotomized
else-where and referred for extubation, the tube could not be removed for 455 days because
of laryngeal narrowing due to the infection.
Foreign Body: One 9 month old infant
was admitted with a history of an episode
of choking and gagging 6 weeks previously. There had been hoarseness since then and increasing respiratory difficulty of two days’
duration. Roentgenograms and bronchos-copy revealed a safety pin in the upper
trachea. Because of edema and thick secre-tions, it could not be removed and
trache-otomy was necessary. The pin was removed after 2 days and the tracheotomy closed after 10 days. In 201 other cases, foreign bodies have been removed from air or food passages in infants under one year of age. This is the only one requiring trache-otomy.
Miscellaneous Group : Eleven infants, 6 females and 5 males, are classified in this
heterogenous group. The reasons for tra-cheotomy were not always clear and were
often related to other serious primary con-rectable congenital conditions. Respiratory symptoms were present from birth or from
the neonatal period in 8 infants and de-veloped at 3 to 4 months in 2.
Three infants had esophageal atresia with tracheo-esophageal fistula. A tracheotomy
was done at the age of 12 hours at the local hospital on one infant because of choking
and periods of cyanosis. The infant was transferred to the Children’s Memorial Hos-pital where a diagnosis of
trachco-esopha-geal fistula was made and the infant was successfully operated on. Unfortunately, there was great difficulty with the
trachc-otomy which had to be revised. Difficulty
was also encountered with adjustment of
483
At postmortem two tracheal ulcers were
found above the carina caused by pressure
of the tube. There was also a mucous
mem-brane fold in the lower trachea producing a small pocket but it was thought that this did not contribute to respiratory obstruc-tion or death. A tracheotomy in another
infant was done at the time of the
esopha-gcal repair because of respiratory difficulty.
In the third infant it was done several hours
after the completion of the operation
be-cause of increasing respiratory
embarrass-ment due to laryngeal edema, possibly from
the intratracheal tube or preoperative
laryn-geal aspirations. Both died within 24 hours
and at necropsy pneumonia and atelectasis were present in addition to the laryngeal induration.
Respiratory difficulty and periods of
cya-nosis were present since birth in two infants with vascular rings. In one there was surgi-cal correction at the age of 20 days. Eight-een hours later tricheotomy was necessary because of laryngeal and tracheal edema. There was continuous trouble with the
tra-cheotomy tube because of length and size although various tubes were tried. Death occurred suddenly 41 days after operation. At necropsy there was ulceration and granu-lation tissue of the trachea just above the
bifurcation from the tip of the tube. It was apparent that a short tube would not traverse the obstruction while a tube long
enough to go beyond the obstruction rested
on the carina. This undoubtedly caused
sufficient tracheal spasm and obstruction to
cause death. There was also slight constric-tion of the trachea and esophagus at the site of the vascular ring. The other infant had
surgical correction of a vascular ring
else-where at 3 months of age. Nine hours later a
tracheotomy became necessary because of
severe respiratory difficulty. There was
laryngeal edema and tracheal collapse with
inspiration and expiration. Later RG re-vealed a paralysis of the left diaphragm.
Whether this was due to phrenic nerve
in-jury at the time of operation could not be established so it is not known what influ-ence this may have had on the necessity
for the tracheotomy. The tube was removed after 180 days.
One infant with frequent daily episodes of cyanosis and respiratory difficulty since
birth had had a tracheotomy at the age
of one month. The tube was removed after
3 weeks but a second tracheotomy was done 12 days later. Both were done at a local
hospital. Upon examination here 6 months
later, the larynx and trachea were found normal and the tube was removed after
having been in for 165 days. The infant was
retarded and had many lightning and gen-eralized major convulsions. The diagnosis was cerebral agenesis. With appropriate an-ticonvulsant drugs there has been fair con-trol with disappearance of the episodes of cyanosis and respiratory difficulty. It would appear that the tracheotomy had been
per-formed because of the cyanosis associated with the convulsions rather than organic
respiratory tract obstruction.
Tracheotomy was necessary in one infant
at the age of 4 months because of tracheal compression from an enlarging heart due to a congenital cardiac malformation. Death
occurred 3 days later. At necropsy a large
heart with an Eisenmenger complex was found. There was also obstructive emphy-sema and tracheal obstruction due to thick tenacious secretions.
Severe micrognathia and a double cleft palate were present in an infant with signs
Of respiratory obstruction. Tracheotomy was
done on the second day of life and death followed in 24 hours. The larynx and trachea were normal. It seemed that the
hypoplasia of the mandible and the low position of the tongue caused obstruction and did not allow for the proper position of the tube.
Laryngeal edema was present in two in-fants. One was admitted at the age of one day. Tracheotomy was necessary on the third day. There was also a duodenal atresia, a congenital heart malformation
(
in-traventnicular septal defect), an imperforatelaryngeal edema was thought to be due to
too vigorous pharyngeal aspiration. At necropsy the larynx and trachea were
nor-mal. Besides the anomalies already listed
there was bilateral hydronephrosis, poste-nor urethral valves and a unilateral cystic
kidney.
Congenital bilateral complete choanal atresia and other congenital malformations were present in one infant. He was admitted
at the age of 3 weeks with cyanosis, marked respiratory embarrassment and poor
pul-monary aeration. Tracheotomy was done 6
hours later with relief of his respiratory difficulty but death occurred 2 days later. The larynx and trachea were normal. There was bilateral complete obstruction of the
posterior nares, an interrupted aorta with a solitary pulmonary artery, hypoplasia of the ileum, pneumonia and atelectasis.
MORTALITY
Of the 62 cases there were 17 deaths, an over-all mortality of 27.4%, but the mortality varied widely with the underlying defects. In the 17 cases in which it was apparent
that an anomaly of the larynx or trachea was present, there were only 3 deaths, or a mortality of 17.7%. For the total 32 cases in the congenital group, the mortality was
15.6%. In the group in which there was acquired pathology, the mortality was 40%.
However, 8 deaths occurred in the miscel-laneous group of 11 cases in which the reasons for the tracheotomy were secondary to other serious pathology and generally
associated with the attempted surgical con-rection of nonrelated gross congenital
de-fects.
As mentioned before, aftercare in infants
with tracheotomy is of extreme importance. Problems arising in postoperative
manage-ment possibly contributed to the death of
4 cases. In one the tube became plugged with secretions leading to asphyxia. In 2 others ulceration from improperly fitting tubes occurred when the obstruction was near the level of the canina. In one the proper position of the tube was not
main-tamed because of the hypoplasia of the
mandible and the backward position of the
tongue.
DiscussioN
Tracheotomy was performed in 11 infants
(
17.7%) during the first week of life and in21 (33.8%) during the first month. The tech-nic followed was the standard midline
dis-section with a bronchoscope or intratracheal tube in place. This procedure is of inesti-mable value in infants with one exception; that of the cricoid cartilage deformity or the complete laryngeal atresia where an airway cannot be rapidly established through the larynx. The delay occurring during the
at-tempt to establish the oral airway with the bronchoscope in one of the infants was in part responsible for its death.
Infants with symptoms of respiratory
ob-struction must be watched closely. The
infant is particularly defenseless with such a lesion. He lacks a good cough reflex, is prone to vomiting, regurgitation and
aspira-tion. He cannot vocally express his symp-toms. These must be gauged entirely by
ob-servation and physical findings. During this
observation period high humidity and oxy-gen are employed. Frequent observation by the nursing and attending staff is necessary. If feeding is difficult, gavage is used with
a plexitron tube. Hydration, hemoglobin levels and weight gain are watched also. A
laryngologist is always on call. It is
pref-erable to do a tracheotomy early rather than late.
The most critical time for infants is after tracheotomy. It is during this period that constant observation, care and judgment are necessary. All infants are put in high
humidity and oxygen and 24 hour special nursing care with an experienced nurse is required in this hospital. Extreme care is
exercised during and immediately after feedings, including frequent suction with or without saline irrigation of the trachea,
485
The tracheotomy tube can be removed
early in most inflammatory cases and in a few of those with other lesions. In most
cases, however, the tube cannot be removed
for months or years. It is the authors’ prac-tice to keep these latter infants in the hos-pital for several months to be absolutely
sure that the infant is progressing safely. Before discharge, the mother comes in daily for training on aspiration, care of the
tra-cheotomy and feeding. An electric suction
machine is sent home with the infant. The authors have been fortunate in having no
death occur in the home during this period. Frequent return visits are made to the bronchoscopy department. Stricture at the
site of tracheotomy has not occurred al-though granulations must be removed.
SUMMARY
The incidence of tracheotomy in infants
under one year of age is increasing due to a
broadening of indications, greater
accept-ance of tracheotomy as an adjunct to other
therapy and a lower mortality through
im-provements in surgical technic and in the
postoperative care of tracheotomized
in-fants.
Tracheotomy for inflammatory lesions is
decreasing, but the incidence of trache-otomy for congenital and miscellaneous
lesions is increasing.
Of 62 infants under one year of age who
required tracheotomy, congenital lesions
were considered the cause of the respiratory obstruction in 32 cases
(
15 males and 17females) and acquired lesions in 30 (21
males and 9 females). In 8 of the 30 infants
in the “acquired” group congenital anoma-lies were indirectly responsible for the
tra-cheotomy, since it was necessitated
follow-ing extensive surgical procedures performed in an attempt to correct gross anomalies of
organs other than those of the respiratory
system.
There were 17 deaths in the series of 62
cases. Eight occurred in the miscellaneous
group, principally those operated on for gross anomalies of other organs, 3 in the group of 17 congenital laryngeal anomalies,
4 in the group of 18 inflammatory lesions
and 2 in the group of 8 neoplasms.
Tracheotomy is generally looked upon as
an emergency life-saving procedure.
How-ever, in most cases it can be a planned, care-ful operation, preceded by the establishment of an airway to avoid cerebral and surgical trauma. The post-tracheotomy period is the critical period during infancy.
ADDENDUM
Since completing this manuscript, the authors have had four more infants in which tracheotomy was necessary under one year of age.
1. R.D., symptoms since birth. Diagnosis: laryngeal web. Tracheotomy at age 8 weeks.
2. M.R., symptoms since birth. Diagnosis:
subglottic stenosis. Tracheotomy at age 4
weeks.
3. R.K., symptoms since birth. Diagnosis: laryngeal malacia. Tracheotomy at age 5
months.
4. D.P., symptoms since birth. Diagnosis:
bilateral vocal cord paralysis. Tracheotomy at age 10 days.
These cases would be added to the cases
recorded in 1953.
REFERENCES
1. Holinger, P. H., and Johnston, K. C., in Progress in Ophthalmology and
Otolaryngology, edited by Wiener et al., New York, Grune & Stratton, 1952, p.
590.
2. McNaught, R. C., Surgical correction of
anterior web of larynx, Laryngoscope 60: 264, 1950.
3. Clerf, L. H., Congenital stenosis of larynx,
Ann. Otol., Rhin. & Laryng. 40:770, 1931.
4. McHugh, H. E., and Loch, W. E., Congeni-tal webs of larynx, Laryngoscope 52:43,
1942.
5. Holinger, P. H., and Stcinmann, E. P.,
Con-genital cysts of larynx, Pract.
oto-rhino-laryng. 9:129, 1947.
6. Holinger, P. H., and Slaughter, D. P., Un-usual tumors obstructing lower
respira-tory tract of infants and children, Tr. Am. Acad. Ophth., 1950( Jan.-Feb., p. 223.
7. Holinger, P. H., and Rigby, R. G.,
707 Fullerton Avenue SPANISH ABSTRACT
TraqueotomIa en los Lactantes
Las indicaciones para la traqueotomIa no
han variado pero el concepto de su aplicaciOn 51, pues se acepta ya no como un procedimiento
de emergencia final sino como una ayuda al problema terap#{233}utico general. Son las mismas
para los lactantes que para los ni#{241}osmayores;
sin embargo, en los lactantes con frecuencia sobrevienen episodios de asfixia, ahogo y
cianosis durante la alimentaciOn, se reconoce
un margen m#{225}spequeflo de seguridad durante
el perIodo de observaciOn prcvio a la
traqueo-tomIa y por iiltimo presentan diferencias
etiolOgicas de importancia en Ia obstrucciOn respiratoria. Este trabajo se refiere a la
traqueo-tomIa en los lactantes. La patologIa b#{225}sica que Ia requiere se ha ido modificando poco a poco : los cuadros inflamatorios de laringe y tr#{225}quea han perdido terreno con los antibiO-ticos y las inmunizaciones, a medida que van aumentando como factor de traqueotomIa las
anomalIas cong#{233}nitas; esto contrasta con los
ni#{241}osmayores, en los que los padecimientos
inflamatorios son responsables de cerca dcl
90% de las traqueotomIas.
Sc presentan 62 casos dc niflos menores de
un a#{241}otraqucotomizados por causas diversas,
quc en general se dividieron en cong#{233}nitas y
adquiridas. Las malformaciones cong#{233}nitas sc
observaron en 32 ni#{241}osy consistieron en
esten-osis larIngea, par#{225}lisis de las cuerdas vocales, traqueomalacia y neoplasias diversas; las ad-quiridas se vieron en 30 ni#{241}osy se clasificaron en tres grandes grupos: inflamatorios, cuerpos
extra#{241}os y misccl#{225}neos ( fIstula
traqueoeso-f#{225}gica, anillos vasculares, agenesia cerebral,
paladar hendido, cardiopatIa cong#{233}nita, edema larIngeo, atresia cong#{233}nita bilateral de las
coa-nas, es deck, condiciones cong#{233}nitas ajenas a
defecto larIngeo traqucal primario) . De los 62
casos fallecieron 17, obteni#{233}ndose una
mortali-dad total de 27.4%; Ia mortalidad variO
franca-mente segIn los subyacentes: dcl 15.6% para los defectos cong#{233}nitos a 40% para los cuadros
ad-quiridos (dentro de estos iiltimos 8 casos fa-liecicron de los 1 1 correspondientes al grupo misccl#{225}neo). Once de los casos observados
su-frieron traqueotomIa durante la primera semana
de Ia vida y 21 durante ci primer mes; se rcalizO en Ia lInea media con colocaciOn previa
dcl broncoscopio o dcl tubo intratraqucal. Los ni#{241}oscon sIntomas de obstrucciOn respiratoria deben observarse cuidadosamente en un am-biente altamente himcdo, con oxIgcno y con
cuidados y manejos por personal bien
entre-nado.
Los autores insisten en Ia importancia
defini-tiva del cuidado postoperatorio de los ni#{241}os
traqucotomizados; Ia observacidn debe ser
cons-tante, en ambiente hitmedo y oxIgcno, con
vigilancia extrema durante Ia alimentaciOn,
cambios de posiciOn, etc. Su salida dcl hospital se autorizar#{225} sOlo cuando el manejo dcl ni#{241}o
no requiera atenciOn especializada.
Los autores concluyen que aunquc la
tra-(jueotomIa es un procedimiento de ernergencia para salvar una vida, en la mayorIa de los casos puede ser una operaciOn cuidadosa, bicn
pla-neada y precedida por el establecimiento de un
pasaje a#{233}reo que evite traumatismos cerebrales
