1 00:00:00,000 --> 00:00:08,000 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. 2 00:00:08,000 --> 00:00:13,000 Hi, I'm Em Gootee from Cincinnati Children's Hospital Medical Center. 3 00:00:13,000 --> 00:00:21,000 In October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination of four conferences. 4 00:00:21,000 --> 00:00:33,000 The International Organization for Isophagia Laetrisia, the Aerodigestive Society Conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphasia Series. 5 00:00:33,000 --> 00:00:46,000 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 Patients Session. 6 00:00:46,000 --> 00:00:53,000 When it comes to tracheal A-Frame deformities, it typically occurs at the site of a prior tracheostomy. 7 00:00:53,000 --> 00:01:06,000 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 aerobatic reconstructive procedure in the past, if they had never had a trach. 8 00:01:06,000 --> 00:01:15,000 Traditionally, we will size an airway with an endotracheal tube to determine, okay, is there any subglottic stenosis or tracheal stenosis? 9 00:01:15,000 --> 00:01:24,000 But with A-Frame deformities, that traditional endotracheal tube sizing is not reliable because of the oblong shape of that A-Frame. 10 00:01:24,000 --> 00:01:33,000 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. 11 00:01:33,000 --> 00:01:41,000 Another important thing to know is that when you size a kit with an A-Frame, it may not seem too problematic at first glance. 12 00:01:41,000 --> 00:01:47,000 However, the key factor to consider is that the A-Frame can be either static or dynamic. 13 00:01:47,000 --> 00:02:05,000 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. 14 00:02:05,000 --> 00:02:19,000 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. 15 00:02:19,000 --> 00:02:33,000 And it's usually a gradual exercise intolerance or a gradual dyspnea on exertion or especially with the retinoid prolapse, you can have increased snoring or apneas at night and it might manifest as an obstructive sleep apnea. 16 00:02:33,000 --> 00:02:40,000 Here, Dr. Smith shows the two typical methods we use to address A-Frame deformities if intervention is necessary. 17 00:02:40,000 --> 00:02:52,000 One is through the traditional route of an open repair. So you could excise that area into a slight tracheoplasty at the site of the A-Frame deformity or potentially even put in an anterior graft. 18 00:02:52,000 --> 00:03:05,000 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. 19 00:03:05,000 --> 00:03:15,000 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. 20 00:03:15,000 --> 00:03:26,000 So here's our first case. A six-year-old female with a history of chempomelic dysplasia. She previously had a double stage with an anterior graft in order to address her subglottic stenosis. 21 00:03:26,000 --> 00:03:34,000 But after successfully getting decannulated, you're seeing this A-Frame right there and you can see how dynamic that A-Frame is. 22 00:03:34,000 --> 00:03:41,000 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. 23 00:03:41,000 --> 00:03:51,000 Symptom-wise, this patient was having increased dyspnea. So Dr. Smith and his team ended up doing a cervical slight tracheoplasty in order to address the dynamic A-Frame deformity. 24 00:03:51,000 --> 00:04:02,000 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 had resolved. 25 00:04:02,000 --> 00:04:12,000 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. 26 00:04:12,000 --> 00:04:17,000 Was decannulated, but she came in and was having increasing dyspnea and exertion. 27 00:04:17,000 --> 00:04:26,000 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. 28 00:04:26,000 --> 00:04:37,000 In this option, they ended up doing a stage endoscopic resection of that A-Frame deformity. You might be able to see that there is a platform section that's placed behind that right side of the airway. 29 00:04:37,000 --> 00:04:46,000 We're basically lasering out some of that hardened cartilage and scar. We basically did that right-sided tracheal A-Frame resection first. 30 00:04:46,000 --> 00:04:53,000 This is afterwards. You're seeing what we resected there, but you can see that left side is untouched. She comes back. 31 00:04:53,000 --> 00:04:59,000 So this is the pre-op. You can see on the left. This is before they addressed the left side. 32 00:04:59,000 --> 00:05:04,000 You can see that right side has stayed relatively open. It's better than it was before. 33 00:05:04,000 --> 00:05:09,000 And now we've addressed the left side and you can see where we've cut out that area there. 34 00:05:09,000 --> 00:05:14,000 After doing these two relatively simple procedures that took about 30 minutes each. 35 00:05:14,000 --> 00:05:20,000 This patient has been symptom-free and without any airway issues for the past six years. 36 00:05:20,000 --> 00:05:29,000 In summary, tracheal A-Frame deformities are relatively common after airway surgery, whether that's just be a tracheostomy or airway reconstruction. 37 00:05:29,000 --> 00:05:38,000 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. 38 00:05:38,000 --> 00:05:44,000 Treatment should be guided by symptomatology and both open and endoscopic surgical options exist. 39 00:05:44,000 --> 00:05:46,000 Thank you for watching this video. 40 00:05:46,000 --> 00:05:50,000 Don't forget to subscribe to the Stay Current MD YouTube channel. 41 00:05:50,000 --> 00:05:56,000 Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. 42 00:05:56,000 --> 00:06:17,000 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.