Progress in Pediatric Surgery Volume 21 Executive Editors W.Ch.Hecker . J.Prevot . L.Spitz U.G.Stauffer' P.Wurnig SeniorEditor P.P.Rickham Editors A.H.Bill, Seattle/USA J.A.Haller, Baltimore J.Boix-Ochoa, Barcelona M.Kasai, Sendai C.C.Ferguson, Winnipeg O.Knutrud, Oslo R.K.Ghandi, Bombay J.Lister, Liverpool S.L.Gans, Los Angeles N.A.Myers, Melbourne Assistant Editor T.A.Angerpointner, Munich Trachea and Lung Surgery in Childhood Volume Editor P. Wurnig, Vienna With 75 Figures Springer-Verlag Berlin Heidelberg NewYork London Paris Tokyo PrimariusProfessorDr.PETERWURNIG ChirurgischeAbteilungdes MautnerMarkhof'schenKinderspitals derStadtWien Baumgasse75, A-1030Wien Volumes1-17ofthisserieswerepublishedbyUrban& Schwarzenberg, Baltimore-Munich ISBN-13: 978-3-642-71667-6 e-ISBN-13: 978-3-642-71665-2 001: 10.1007/978-3-642-71665-2 Library of Congress Cataloging-in-Publication Data. Trachea and lung surgery in childhood. (Progressinpediatricsurgery;v.21).Includesindex.1.Trachea- Stenosis- Surgery.2.Trachea - Surgery. 3. Lungs - Surgery. I. Wurnig, Peter. II. Series. [DNLM: 1. Lung - surgery. 2. Trachea- surgery.3.TrachealStenosis- ininfancy&childhood.WIPR677KAv.21/WF490 T7588] RD137.AIP7 vol.21 [RF516] 617'.98s 86-31420 ISBN0-387-17232-7(U.S.) [617.533059] Thisworkissubjecttocopyright.Allrightsarereserved,whetherthewholeorpartofthemate rialisconcerned,specificallythoseoftranslation,reprinting,re-useofiIlustrations,broadcasting, reproductionbyphotocopyingmachineorsimilarmeans, andstorageindatabanks. Under§54 oftheGennanCopyrightLawwherecopiesaremadeforotherthanprivateuse,afeeispayable to"VerwertungsgesellschaftWort",Munich. ©Springer-VerlagBerlinHeidelberg1987 Softcoverreprintofthehardcover1stedition 1987 Theuseofregisterednames,trademarks,etc.inthispublicationdoesnotimply,evenintheab senceofaspecificstatement,thatsuchnamesareexemptfromtherelevantprotectivelawsand regulationsandthereforefreeforgeneraluse. Product liability: The publishercangive noguaranteefor information about drugdosage and applicationthereofcontainedinthisbook.Ineveryindividualcasetherespectiveusermustcheck itsaccuracybyconsultingotherpharmaceuticalliterature. Typesettingandprinting:PeterscheDruckereiGmbH&Co.OffsetKG,RothenburgobderTauber Bookbinding:KonradTriltsch,GraphischerBetrieb,D-8700Wtirzburg 2123/3130-543210 Preface Withimprovementsinrespiratortherapyandintensivecare, congenital malformations and various acquired pathologic deformities of the trachea or bronchi are more often observed than used to be the case. For a while it seemed that tracheostomy would be unnecessary, but it has since become quite clear that severe disturbance of the trachea would be the outcome owing to primary or secondary pathologic changes that had not been given adequate consideration previous. These changes can lead to urgent life-threatening episodes or definite mutilation for the rest of the child's life. Tracheal surgery thus repre sents a new and special challenge for the pediatricsurgeon. A solution totheseseriousproblemsmustbefound andmeritsdiscussion. Further more, it seems worthwhile to review cases of surgical pulmonary dis eases,exceptforthealreadywidelydiscussedproblemsofempyemasor bronchiectasis. P.WURNIG, Vienna Contents Pathophysiology of Subglottic Tracheal Stenosis in Childhood. B.MINNIGERODEand H.G.RICHTER. With2Figures 1 Subglottic Stenosis in Newborns After Mechanical Ventilation. M.MARCOVICH, F.POLLAUF, and K.BURIAN. With3Figures ... 8 Treatment of Congenital Cricoid Stenosis. R.N.P.BERKOVITS, E.J.VANDERSCHANS, andJ.C.MOLENAAR. With7Figures . . .. 20 Surgical Correction of Laryngotracheal Stenoses in Children. E.HOF. With6Figures . . . . . . . . . . . . . . . . . . . . .. 29 Surgical Treatment of Congenital Laryngotracheo-oesophageal Cleft. R.N.P.BERKOVITS, N.M.A.BAX, and E.J.VANDERSCHANS. With4Figures 36 Free Periosteal Grafts in Tracheal Reconstruction: An Experi mentalStudy. S.E.HAUGEN,T.KUFAAS, andS.SVENNINGSEN. With 2Figures 47 Tumour-InducedIntraluminalStenosesoftheCervicalTrachea Tumour Excision and Tracheoplasty. R.DAUM, H.J.DENECKE, and H.ROTH. With6Figures . . . . . . . . . . . . . . . . . .. 50 CardiopulmonaryBypassinTrachealSurgeryinInfantsandSmall Children. I.LOUHIMOand M.LEIJALA. With 1Figure . . . . . .. 58 Resection ofan IntrathoracicTracheal Stenosis in a Child. T.A. ANGERPOINTNER, W.STELTER, K.MANTEL, and W.CH.HECKER. With 12Figures 64 TreatmentofTrachealStenosesbyResectioninInfancyandEarly Childhood. G.M.SALZER, H.HARTL, andP.WURNIG . . . . . .. 72 Long-DistanceResectionoftheTracheawithPrimaryAnastomo- sisin SmallChildren. H.HALSBAND. With3Figures 76 ClinicalSymptomsandTreatmentofLungSeparation.K.GDANIETZ, K.VORPAHL, G.PIEHL, and A.HOCK. With7Figures . . . . . ., 86 Extralobar Sequestration of the Lung in Children. M.LEIJALA andI.LOUHIMO. With 4Figures 98 VIII Contents Scimitar Syndrome and Associated Pulmonary Sequestration: Report of a Successfully Corrected Case. E. HORCHER and F.HELMER. With5Figures . . . . . . . . . . . . . . . . . .. 107 CongenitalCysticAdenomatoidMalformationofthe Lung. M.R.BECKER, F.SCHINDERA, and W.A.MAIER. With5Figures 112 Experience in Surgical Treatment of Pulmonary and Bronchial Tumours in Childhood. W.TiSCHER, H.REDDEMANN, P.HERZOG, K.GDANIETZ, J.WITT, P.WURNlG, and A.REINER. With 4 Figures 118 Endotrachealand EndobronchialTumoursinChildhood. N.AuGUSTIN, S.HOFMANN-V.KAP-HERR, and P.WURNIG. With 4 Figures . . . . . . . . . . . . . . . . . . . . . .. 136 SubjectIndex 145 List of Editors and Contributors Editors Angerpointner, T.A., Dr., Kinderchirurgische Klinik im Dr. von Haunerschen Kinderspital der UniversiHit Munchen, Lindwurm straBe4, D-8000Munchen2 Hecker, W.Ch., Prof. Dr., Kinderchirurgische Klinik im Dr. von Haunerschen Kinderspital der UniversiHit Munchen, Lindwurm straBe4, D-8000Munchen2 Rickham, P.P., Prof. Dr. M.D., M.S., F.R.C.S., F.R.C.S.I., F.R.A.C.S., D.C.H., F.A.A.P., UniversiHitskinderklinik, Chirur gische Abteilung, SteinwiesstraBe75, CH-8032Zurich Prevot, J., Prof., Clinique Chirurgical Pediatrique, H6pital d'Enfants de Nancy, F-54511 Vandrevre Cedex Spitz, L., Prof., PhD. FRCS, Nuffield Professor ofPediatric Surgery, Institute of Child Health, University of London, Hospital for Sick Children, Great Ormond Street, 30 Guilford Street, GB-London WCIN lEH Stauffer, U.G., Prof. Dr., Universitatskinderklinik, Kinderchirur gische Abteilung, SteinwiesstraBe75, CH-8032Zurich Wurnig, P., Prof. Dr., Kinderchirurgische Abteilung des Mautner MarkhofschenKinderspitals, Baumgasse75, A-I030Wien x ListofEditorsandContributors Contributors Youwillfindtheaddressesatthebeginningoftherespectivecontribution Angerpointner,T.A. 64 Louhimo,1. 58,98 Augustin, N. 136 Maier, W.A. 112 Bax, N.M.A. 36 Mantel, K. 64 Becker, M.R. 112 Marcovich, M. 8 Berkovits, R.N.P. 20,36 Minnigerode, B. 1 Burian, K. 8 Molenaar, J.C. 20 Daum, R. 50 Piehl, G. 86 Denecke, H.J. 50 Pollauf, F. 8 Gdanietz, K. 86, 118 Reddemann, H. 118 Halsband, H. 76 Reiner, A. 118 Hartl, H. 72 Richter, H.G. 1 Haugen, S.E. 47 Roth, H. 50 Hecker, W.Ch. 64 Salzer, G.M. 72 Helmer, F. 107 Schindera, F. 112 Herzog, P. 118 Stelter, W. 64 Hock, A. 86 Svenningsen, S. 47 Hof, E. 29 Tischer, W. 118 Hofmann-v.Kap-herr, S. 136 vanderSchans, E.V. 20,36 Horcher, E. 107 Vorpahl, K. 86 Kufaas, T. 47 Witt, J. 118 Leijala, M. 58, 98 Wumig, P. 72,118,136 Pathophysiology ofSubglottic Tracheal Stenosis in Childhood B.MINNIGERODE1and H.G.RICHTER1 Thesubglotticspaceisaregionoftheairwaythatisnotwelldefinedanatomically, extending inits widestdefinitionfrom the vocal cord down to thesmallestbronchi. Inthispaperthetermisusedtomeanonlyasthespatiumsubglotticum,thespace enclosed ventrally and laterallyby the elasticcone, which bearsthe cricoid plate in its posteriorwall and which thenwithout abreakbecomesthecervicaltrachea atthe caudalendofthe cricoidcartilage. There is avarietyofcausesofstenosesinthissegmentoftheairway,onlytwo particularlyproblematictypesofwhichwillbediscussed: (1)Disturbedembryonic development, typicallygiving rise to primarylesions, and (2) trauma, whichleads mainly tosecondarylesions. 1. Embryonicdevelopmentaldisturbancesinthis area resultinso-calledhardand soft stenoses of the subglottic space (Minnigerode and Richtering 1969; Min nigerode 1969, 1971). This means a narrowing ofthe normal shape ofthe infra glottic conus with a pad-like swelling of the mucosa, reducing the lumen to less than4mminmostinstances.Thebasisisprobablyametabolicdisturbanceduring the 9th embryonicweek, i.e., during the break-offofthe physiologicalepithelial occlusion (Kallius 1897; Minnigerode 1962), which involves all three sections of the larynx. During this developmental stage the epithelium is actually an inter mediate layer, a diathelium in the statically and dynamically defined metabolic field between liquid-rich connective tissue and embryonic amniotic fluid. A dis turbanceofthe normalcontinuousreorganizationwhich typicallyalsotakesplace in the development ofother hollow organs in the humanorganism (Singer 1933) results in uneven growth of the tissues making up this airway region, an over growth ofthe mesenchymal tissuecontrastingwith normalgrowthorhypotrophy ofthe epithelium. The epitheliumisthen damaged bythe pressureofthe mesen chymal pads, and the mesenchymal tissues of both sides may advance and even grow together in an interlockingpattern through the epithelial defects. The kind of stenosis resulting from this depends on whether the maximum of this growth disturbance is more ventrally or more dorsally located, i.e., within the region of the chondrification centre of the cricoid area (Heineken 1952; Walender 1955; Smith andBain 1965). Clinically,thiskindofstenosispresentsasaninspiratorystridorfrombirthon, initially without obvious impairment of respiration. Impairment of respiration, 1UniversityHospitalforOtorhinolaryngology,D-4300Essen,FRG. ProgressinPediatricSurgery,Vol.21 Ed.byP.Wumig ©Springer-VerlagBerlinHeidelberg1987