Outcomes of balloon dilation for paediatric laryngeal stenosis

There is obviously balloon dilatation was used for treatment of children with subglottic laryngeal stenosis (SGS) who suffered from worsening of dyspnea with stridor and would otherwise be indicated for tracheotomy or other optional surgical treatments. Two patients had a tracheostomy cannula previously removed followed by a plastic surgery of the tracheostomy site. The other three children had never had a tracheostomy cannula [1].

Balloon dilatation of laryngeal stricture is a modification of a method used for esophageal strictures. Laryngeal strictures are shorter; therefore, shorter balloon can be used. The catheter is guided under laryngoscopic control. General anesthesia with deeper relaxation compared to esophageal dilatations is beneficial. Angiographic guide wire reinforces the catheter but is not used for the placement of balloon into the stricture. Ventilation during the procedure is usually possible through tracheostomy cannula which is applied to the majority of patients.

The dilatations were always performed with the patient under general anesthesia, spontaneous ventilation, and intermittent apnea during balloon inflation, as needed. Vascular balloons of three different brands were used, always with a length of 20–30 mm. The diameters of the balloons varied according to the child's age. Generally, the outside diameter of the most suitable endotracheal tube was considered for each child, adding approximately 2 mm to determine the diameter of the balloon. The time and number of inflations varied according to size of the airway, as well as the pulmonary reserve of the child and/or the perception of glottis edema secondary to dilatation. Generally, the maintenance time of the inflated balloon did not exceed 1.5 min, and the inflations were repeated three times. The inflation pressure of the balloons ranged from 3 to 15 mmHg with a progressive tendency for the use of higher pressures in the last year, after analyzing reports and personal communications from other colleagues with renowned experience in the subject, especially in the most extensive and chronic stenoses. The time elapsed between dilatation procedures ranged from 15 to 60 days, due to availability of surgical time and possible clinical complications, or the lack of favorable conditions for general anesthesia [2].

The use of balloon dilatation is becoming progressively widespread in several surgical fields and is considered a valid and minimally invasive alternative to major open surgical procedures. The morbidity associated with airway dilation is low if the procedure is cautiously performed and if the indications and contraindications are correctly respected.

In author’s opinion, balloon dilatation is mainly indicated for grade I-III stenosis (Cotton-Myer classification) and in rare cases of thin diaphragm-like grade IV stenosis. Conversely, long and thick stenoses, narrow congenital cricoid malformations, associated airway malacia, inflammation and multisite dense stenoses require open operations such as airway expansion or airway resection and anastomosis; balloon dilatation can be used as a complementary procedure to enhance open surgical results [5]. 

Most patients with correct selection criteria can undergo laryngeal balloon dilatation without needing tracheotomy. In author’s series, for example, only one of the 8 non-tracheotomised patients’ needs a tracheotomy on the day of his first dilation. 

The type of anesthesia adopted is of crucial importance for both diagnostic assessment and the endoscopic procedure, as spontaneous breathing under intravenous anesthesia provides an unobstructed surgical field and excellent evaluation of the dynamic airway function and the grades of obstruction. It is strongly advocated the use of noninvasive ventilation in the immediate postoperative period. The continuous airway pressure acts like a pneumatic stent and promotes satisfactory airway epithelisation.

Laryngeal stenosis can be associated with some syndromes, and its treatment may be challenging if comorbidities are severe [11]. 

In conclusion, balloon dilatation of a subglottic laryngeal stenosis can be safely performed in those patients where the worsening of dyspnea and stridor would lead to tracheostomy cannula insertion. Balloon dilatation of laryngeal stenosis in apneic pause allowed achieving sufficient diameter of laryngeal lumen in 80% of children with subglottic stenosis and avoiding threatening tracheostomy placement or alternative surgical method without any significant complication after the procedure. 

Mature, severe laryngeal and tracheal stenosis in pediatric patients can be successfully managed with balloon dilation. In the most severe cases with prior tracheotomy, stenting is necessary. In patients without prior tracheotomy, tracheotomy and stenting can often be safely avoided with appropriate postoperative management.

The efficacy of balloon dilatation as a minimally invasive technique and as the first therapeutic option in selected cases of chronic and multilevel laryngo stenosis with an intact laryngotracheal cartilaginous framework is confirmed. Failure of this first-line upfront endoscopic procedure does not compromise the chances of success of subsequent major reconstructive surgery.

This limited series also confirms the validity of dilation laryngoplasty as an adjuvant treatment to improve and stabilize the results of previous reconstructive surgeries.