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The cricoid split: an alternative to paediatric tracheostomy
1Department of Otolaryngology, Singapore General Hospital.
Insights
The Anterior Cricoid Split (ACS) offers an alternative to tracheostomy for preterm infants with subglottic stenosis, achieving a 77% extubation success rate. Careful patient selection and intensive care are crucial for this procedure.
Area of Science:
- Neonatal Medicine
- Pediatric Otolaryngology
- Critical Care
Background:
- Neonatal intensive care advances improve preterm infant survival but increase cases of acquired subglottic stenosis.
- Respiratory Distress Syndrome and other cardiopulmonary issues necessitate ventilatory support, leading to extubation difficulties.
- Traditionally, tracheostomy was performed after failed extubation attempts, with later definitive treatment.
Purpose of the Study:
- To evaluate the Anterior Cricoid Split (ACS) as an alternative to tracheostomy in managing acquired subglottic stenosis in neonates.
- To determine the efficacy and indications for ACS in improving extubation success rates.
- To highlight the importance of patient selection and intensive care support for ACS.
Main Methods:
- Review of outcomes following Anterior Cricoid Split (ACS) procedures since its first report in 1980.
- Analysis of extubation success rates across multiple centers performing ACS.
- Assessment of the expanded indications for ACS, including glottic pathology and existing tracheostomy.
Main Results:
- The average extubation success rate following Anterior Cricoid Split (ACS) is approximately 77%.
- ACS serves as a viable alternative to tracheostomy when performed with appropriate indications and strict patient selection.
- The procedure is believed to decompress the laryngotracheal area, relieving pressure and edema of the cricoid ring.
Conclusions:
- Anterior Cricoid Split (ACS) is an effective alternative to tracheostomy for specific cases of acquired subglottic stenosis in neonates.
- Successful ACS implementation requires meticulous patient selection and access to excellent intensive care facilities.
- Tracheostomy remains a safer option when optimal intensive care is unavailable.
Abstract:
Advances in neonatal intensive care has increased the salvage rate of preterm infants. Many of these require ventilatory support for Respiratory Distress Syndrome or other cardiopulmonary problems. This has lead to an apparent increase in the incidence of acquired subglottic stenosis with difficulties in extubation. In the past, after several attempts at extubation, a tracheostomy is performed with definitive therapy instituted later. Since the first report of the Anterior Cricoid Split (ACS) in 1980, the extubation success rate of all centres average about 77%. The ACS is thus an alternative to tracheostomy, provided it is done for the correct indications and strict selection criteria are applied. How it works is still unclear, but certainly it achieves laryngotracheal decompression with relief of tension and oedema of the cricoid ring. The original indication was for cases of non-fibrous subglottis stenosis; these have now been expanded in recent years to include children with glottic pathology and with a tracheostomy in situ. The availability of excellent intensive care facilities is a prerequisite to doing an ACS; otherwise a tracheostomy is a safer option.