Podcast Transcript: Airway Surgery: What's in Your Toolbox?

[Romaine Johnson MD]
It is interesting that you mentioned the Triological Society. I think, all three of us are members. And of course, Dr. Shah was just nominated this year. She's got to write her thesis. I think Triological Society has been a great organization to find mentoring. Obviously, Dr. Cotton and Dr. Willging and Dr. Schott and everyone you could think of along the pediatric side and as well as on the adult laryngology side belongs to that society. So, I'm just gonna give a shout out to the Triol Society for anyone listening. You can do it, you can write your thesis, you can become a member, start working on it today, it'll pay off dividends in ways I can't even tell you. Anyway, let's get back to talking about surgery. Let's talk about the open airway. When do you do it? I know you have choices. You can do endoscopic, you can do open. Open is still sort of the game, if you will. It's how you define yourself as a surgeon I think, but obviously, it has more risks. And so I'm curious, what are some of the pearls in your decision-making seeing a patient, saying this is a good open reconstructive case, this is not a good open reconstructive case?

[Mark Gerber MD]
I think for me, it's always easier if there's a trach. I can be patient and wait and bide my time. When you have a child who doesn't have a trach, and who has undergone attempts of endoscopic management that fail, how do you define failure? Is it two or three? I've seen kids who show up having had a dozen endoscopic attempts, and that's too much. Where is that dividing line? And again, there is a Gestalt there, right? Because sometimes, it may be better that you put a trach in and wait and do that later, and other times, you turn away right there and set up for your open reconstruction. But I like to be able to study my kids. So, for the pediatric population, I want to be able to do a flex scope to see what's happening with the supraglottic and glottic dynamics, what's their feeding history. I want to make sure I study that so I'm not presuming anything. So, either a FEES or a videofluoroscopic study, I want to be able to do my endoscopic assessment with the kids asleep and include a BAL so I'm getting cultures. And then, this is the one time that I'm also pretty anal about managing reflux. And it's not reflux disease, I'm managing reflux and how it can affect the outcome of airway reconstruction for a child. So, I want all of those kids to have an EGD with biopsy. I want to make sure I'm not dealing with EoE. And for the kids that I'm able to, I want to do a voice analysis. So, all of those things are my perfect setup, and if all the stars line up, then I'm ready. Sometimes, I can't wait for the stars to line up and you're forced, right? If I start an endoscopy, and when I'm done with an endoscopy, I'm pretty much hands off. I'm not using a sheath bronchoscope when I'm looking at an airway, so I'm just putting in telescopes most of the time. And if I come out with a telescope and I already see effacement of the ventricular space, that's not really an airway I want to manipulate yet, right? So, all those things play a role. And then, the severity, the stenosis, one if the... Obviously, grade three stenosis or worse, if you're talking about subglottis or tracheal, right? If you have a significant effacement and symptomatic in a child that doesn't have a trach, then I think those are the ones you have to go after and choosing to do it open versus putting in a temporary trach. Now, since I've been in Arizona, and I've seen the population which I know, Romaine, you came into in getting to Texas is the decision-making on putting in a trach for these families. I've been pushed many times already to do that reconstruction because I have a family that just can't handle a tracheotomy, and so I'm taking added risk to avoid. And sometimes I win, and sometimes I lose, but I've done my best. That also plays a role in the decision-making process.

[Laura Matrka MD]
So, I'm trying to think of concepts that will span across pediatric and adult airway, both, and I think this maybe is one, but one problem that I've had in my own practice, and maybe I'm going to raise more questions and answer, but we see a lot of idiopathic subglottic stenosis patients. And I find that considering open approaches for them is the very hardest decision I have to make because at least in my mind, they have so much more to lose. And so I think that if you have a patient who's otherwise pretty healthy and functional and you can temporize with endoscopic approaches, and I mean in our population, that temporize might mean a couple of years even, but then you follow them 10 years, and now you've operated on them eight times and you go, "Is this okay?" It's such a personal decision in the adult group. So, that's one area that I struggle with a little bit. I feel like I might continue longer with endoscopic approaches even if they're needing them every couple of years just because they do so well with them. It's an outpatient surgery, and the patients themselves are hesitant to take that risk. As far as patients with or without a trach, I mean, I'd rather not put a trach in just for surgical ease. I find it much easier to do the case if I can do it based only on where that stenosis is and not have to worry about the trach positioning. But it is true. If you have a patient who's already trach-dependent, you sure have a lot less to lose in doing that open reconstruction. And then, just as Dr. Gerber said, there's absolutely patients who you're just so fearful of them being out in the world with a trach. You know they don't really understand it, and they don't have any kind of... All the teaching and education you do just isn't landing, and those are patients who were, yeah. I've operated on some when they still weren't as healthy as I wanted them to be, and we got them through it. Boy, it's a nuanced decision. It's not easy.

[Romaine Johnson MD]
Dr. Gerber mentioned earlier protocols. He had mentioned in children, I want to do a voice analysis, I want to get a swallow study, I want to do an EGD. Do you do the same thing in the adult world? I haven't heard of that sort of thinking? Is that something that's also done with adult airway reconstruction?

[Laura Matrka MD]
Yeah, to a degree, not maybe in the same way. Actually, believe it or not, when I was at Cincinnati as a student, I did a project on whether clearing kids for EoE before open airway reconstruction was financially solvent or not. And there's another mentor, Ravi Elluru, when he was with you guys. And so, we're not looking for EoE. I'm not doing voice analysis in men. Now in women where I think they might need a CTR, yes, I think that's very important. And maybe it's not even the analysis that's important so much as the counseling because they will get a deeper voice. And even men, you need to tell them that. Sometimes, they're a little alarmed by it, by how manly they sound. They usually like it though. So, the recent change in my practice is that more and more often, I'm doing formal pH probes in my patients first, especially if they have that, you talked about the ventricular effacement, if we're seeing a lot of signs of inflammation. I've had a few patients in my practice who were requiring recurrent endoscopic attempts, and in preparation for open, we went ahead. They ended up getting a Nissen because they had such significant reflux, and they stopped needing anything. I dilated them at the beginning of the case. The general surgeon came in, did the Nissen and they flew. So, I'm relying more and more heavily on that, but they are good protocols in our world.

[Romaine Johnson MD]
Do you use PFTs?

[Laura Matrka MD]
I use them really heavily. It's sort of a thing, a research interest of mine. But again, I don't know that others are. I mean, we stopped peak flow devices in my clinic. Our airway patients get... We used to keep a box with everyone's peak flow, and we pull out the individual patients. Now, we just give a new one every time but yeah, personally, I love peak flows, full PFTs when I can get them and peak flows every visit.

[Romaine Johnson MD]
So, Dr. Gerber, besides just making sure you don't injure the recurrent laryngeal nerve, do you think there are things you can do in particular to reduce the incidence of post-airway reconstruction dysphonia?

[Mark Gerber MD]
I think it's really choosing the right operation in a way, right? So, part of it is don't try to do a third rib graft when there is no good solid cartilage to attach that to because you're only going to get more scarring and collapse, and that's going to affect the voice quality. Minimize manipulation of the supraglottic tissue. So, I try to stay away from that cricoarytenoid joint unless I have to be there. I worry a lot about the extended cricotracheal resection. I tend to actually try to do it separate. So, if I've got a combined posterior glottic issue along with a severe stenosis distally, there are times I'll do an endoscopic posterior graft. Knowing I've not fixed the child, but I've just fixed the posterior glottic aspect and then go in later, open and do my CTR, that separates it. I know it's two operations. I've not written about it yet, but to me, I think that I've had good outcomes with it because I'm not trying to get all that healing going at once and all those forces that I think collapsed inward. So, minimizing manipulation of mucosal surfaces, being very cognizant of that cricoarytenoid area when you're doing an open reconstruction, and of course, the anterior commissure as well, right? So, it really depends on what you're starting with, but nothing makes me more upset at myself if I've started with a good looking glottic aperture, and then I end up with something that's worse following reconstruction because of unrecognized difficulties with the healing process, whether it's infection or inflammatory. The things we don't quite yet understand in terms of how these children heal. If we can only predict how the kids are going to heal just like adults. I get frightened of that adult. I still think rib grafts would work well in adults. I have some experience in adult rib grafts, but I think adults are much more difficult to predict how they're going to heal than some of the kids.