Contemporary surgery of tracheomalacia

During the past 7 years, 41 infants were treated for tracheomalacia. The etiology was primary/congenital in 28 patients and secondary/acquired in 16 patients, of which three patients were originally in the primary group. The primary group consisted of patients with pulsatile tracheomalacia but normal vascular anatomy, idiopathic disease, or tracheomalacia associated with tracheoesophageal fistula. The secondary group consisted of patients with tracheal compression due to great vessel abnormalities, or tracheostomy-tracheomalacia. Diagnosis was made by bronchoscopic demonstration of major (greater than 40%) collapse of the trachea. Treatment consisted of conservative therapy, tracheostomy, aortopexy, or tracheal reconstruction. The 15 patients with mild primary tracheomalacia treated conservatively had gradual resolution of symptoms by the age 2 years. All five patients with primary tracheomalacia treated by tracheostomy developed secondary tracheomalacia and/or cicatrix at the tracheostomy site. In the 9 patients with primary tracheomalacia treated by aortopexy, 5 are symptom free, 1 is improved, 1 had recurrent apnea, and 2 died, 1 from unrelated complications. Of the 10 patients in the acquired group treated by aortopexy, 6 were cured, 2 were improved, and 2 failed. Of 6 patients with tracheostomy-tracheomalacia, 3 were eventually extubated, 1 had major reconstruction, and 2 had tracheostomies when lost to follow-up at 1 and 5 years. Our conclusions are that, when feasible, conservative therapy in milder cases is preferred, and no perfect operation currently exists for severe tracheomalacia although aortopexy may have less long-term morbidity than tracheostomy.