Decreasing morbidity following laryngotracheal reconstruction in children.

Our objectives are to report (1) methods for decreasing infectious complications and excessive weakness associated with the period of sedation and neuromuscular blockade (NMB) following single-stage laryngotracheal reconstruction (SSLTR); (2) an association between gastroesophageal reflux (GER) and subglottic stenosis (SGS); (3) results of 21 SSLTRs and 15 two-stage LTRs (TSLTRs). A retrospective chart review was performed for the period January, 1990-August, 1995, including 36 patients who had 38 LTRs for SGS and/or posterior glottic stenosis at a tertiary care center. Our most recent post-SSLTR protocol included: (1) prophylactic antimicrobials (clindamycin plus antipseudomonal agents = C + A); (2) GER treatment; (3) titrated infusion NMB with daily recovery of neuromuscular function; (4) avoidance of prolonged simultaneous administration of NMB and corticosteroids. Patients who had prophylactic antimicrobials (C + A) during intubation following SSLTR had fewer (1/13, 8%) postoperative infectious complications than patients who received other/no antibiotics (4/8, 50%) (P < 0.05). Avoidance of prolonged simultaneous administration of NMB and corticosteroids and use of titrated infusion of NMB with daily recovery of neuromuscular function was associated with less weakness following extubation (0/11, 0% vs. 4/6, 66%) (P < 0.002). Of 26 patients tested for GER, 21 (81%) had at least one positive test, suggesting a significant association between GER and SGS (P < 0.05). The overall success rate for LTR was 33/36 or 92%. SSLTR had a 95% success rate while two-stage LTR had an 87% success rate, although two revisions were required. Prophylactic antimicrobials, improved postoperative management and GER treatment allowed successful LTRs with decreased infectious complications and less weakness.