Laryngotracheal reconstruction in the pediatric burn patient: surgical techniques and decision-making.

The management of laryngotracheal stenosis (LTS) in the pediatric burn patient is complex and requires a multi-disciplinary approach. The mainstay of treatment for LTS is laryngotracheal reconstruction (LTR), however, limited reports of burn-specific laryngotracheal reconstruction techniques exist. Here, we provide insight into the initial airway evaluation, surgical decision-making, anesthetic challenges, and incision modifications based on our experience in treating patients with this pathology. The initial airway evaluation can be complicated by microstomia, trismus and neck contractures - the authors recommend treatment of these complications prior to initial airway evaluation to optimize safety. The surgical decision-making regarding pursuing single-stage LTR, double-stage LTR, and 1.5 stage LTR can be challenging - the authors recommend 1.5 stage LTR when possible due to the extra safety of rescue tracheostomy and the decreased risk of granuloma, which is especially important in pro-inflammatory burn physiology. Anesthetic challenges include: obtaining intravenous access, securing the airway, and intravenous induction - the authors recommend peripherally inserted central catheter (PICC) when appropriate, utilizing information from the initial airway evaluation to secure the airway, and avoidance of succinylcholine upon induction. Neck and chest incisions are often within the total body surface (TBSA) covered by the burn injury - the authors recommend modifying typical incisions to cover unaffected skin whenever possible in order to limit infection and prevent wound healing complications. Pediatric laryngotracheal reconstruction in the burn patient is challenging, but can be safe when the surgeon is thoughtful in their decision-making.