Management of Suprastomal Collapse

Educational Objectives

The goal of this program is to improve the diagnosis and management of suprastomal collapse and tracheal granulation tissue formation in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. Explain use of the sphenoid punch to excise excess granulation tissue in pediatric patients after tracheostomy.
2. Cite the 2020 consensus statement by the International Pediatric Otolaryngology Group regarding imaging use in diagnosis of suprastomal collapse in pediatric patients after tracheostomy.

Summary

Introduction: suprastromal collapse is a combination of obstruction and collapse; granulation tissue may cause obstruction, and the actual collapse of the stoma can occur simultaneously; these 2 conditions often coexist and require slightly different management strategies; suprastomal collapse poses significant safety risks, especially in case of accidental decannulation, and may impede the use of speaking valves, affecting the child’s quality of life; it may obstruct decannulation efforts; there is lack of clear evidence on the incidence of both conditions; they primarily affect the anterior tracheal wall; suprastomal collapse may involve the lateral wall

Etiology: the exact cause of granulation tissue is unknown; it is associated with factors, eg, tracheal tube irritation, foreign body reactions, inflammation, chronic low-grade infection, which are common in children who are chronically tracheostomy dependent; suprastomal collapse is associated with chondritis, a weakening of the cartilage over time, and external pressure from the tracheostomy tube and breathing circuit, especially in patients who are ventilator-dependent patients

Grading: study from University of Washington (Suresh et al [2023]) studied 175 pediatric patients with tracheostomy over a 5-yr period, and revealed that 96 developed suprastomal collapse; patients with longer tracheostomy durations were more prone to collapse; younger age at tracheostomy placement was associated with a higher risk for suprastomal collapse, possibly because of smaller and weaker tracheal structures and a longer duration of tracheostomy use

Management of granulation tissue: mild cases may not require intervention; moderate to severe cases are managed with endoscopic techniques, eg, cauterization, ablation, microdebridement, cryotherapy to ablate the tissue; in rare, severe cases, open surgical removal may be necessary to restore a patent airway; ciprofloxacin- dexamethasone used off label to reduce granulation tissue; Reddy et al (2024) found a decreased occurrence of episodes of granulation tissue after initiation of therapy with nebulized ciprofloxacin-dexamethasone; the study showed no difference in antibiotic resistance in patients who were chronically on ciprofloxacin-dexamethasone

Sphenoid punch: this technique involves removing the tracheostomy tube and using the endoscope to guide the punch through the stoma to excise the excess tissue; it is crucial to have visual guidance to avoid accidentally damaging the cartilage or the tracheal wall; this technique is particularly suitable for firmer, more fibrous granulation tissue

Optical cup: is useful to remove softer, pedunculated granulation tissue; the technique involves a “push-pull” motion, where the instrument is pushed deeper into the airway before retraction to loosen the tissue and facilitate easier removal

Delivery technique: involves reaching through the stoma with a small instrument, eg, a Guthrie hook to externally deliver the tissue for removal; this method is particularly useful in smaller children with smaller stomas or those with subglottic stenosis where larger instruments cannot be used; clinicians often use some adjuvant therapy to optimize removal of the tissue; cryotherapy minimizes damage to surrounding tissue; poor care of tracheostomy tube and the presence of a long skin tract may impede the reinsertion of the tracheostomy tube; open surgical procedure may be necessary in such instances

Management of suprastomal collapse: minor cases may not require intervention; mild to moderate cases are managed endoscopically or with laser; for more severe cases, open surgical approach is necessary, eg, anterior graft resection combined with slide tracheoplasty

Guidelines: the International Pediatric Otolaryngology Working Group’s 2020 consensus statement on suprastomal collapse highlights endoscopy as the gold standard for diagnosis of suprastomal collapse; the location and severity of collapse determines the appropriate management approach

Readings

Brown CS, Ryan MA, Ramprasad VH, et al. Coblation of suprastomal granulomas in tracheostomy-dependent children. Int J Pediatr Otorhinolaryngol. 2017;96:55-58. doi:10.1016/j.ijporl.2017.03.004; Doody J, Alkhateeb A, Balakrishnan K, et al. International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population. Int J Pediatr Otorhinolaryngol. 2020;139:110427. doi:10.1016/j.ijporl.2020.110427; Onder SS, Ishii A, Sandu K. Surgical options in suprastomal collapse-induced severe airway obstruction. Eur Arch Otorhinolaryngol. 2020;277(12):3415-3421. doi:10.1007/s00405-020-06339-3; Reddy PD, Eljamri S, Shaffer AD, et al. Impact of ciprofloxacin/dexamethasone on pediatric tracheostomy outcomes. Am J Otolaryngol. 2024;45(5):104406. doi:10.1016/j.amjoto.2024.104406; Suresh R, Dabbous H, Alahari S, et al. Tracheal A-frame deformity and suprastomal collapse after pediatric tracheostomy. Laryngoscope Investig Otolaryngol. 2023;9(1):e1202. Published 2023 Dec 14. doi:10.1002/lio2.1202.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Hart's lecture contains information related to the off-label or investigational use of ciprofloxacin-dexamethasone.

Acknowledgements

Dr. Hart was recorded at the SENTAC 52nd Annual Meeting, held November 7-9, 2024, in Denver, CO, and presented by the Society for Ears Nose and Throat Advancement in Children. For information on upcoming CME activities from this presenter, please visit www.sentac.org. Audio Digest thanks the speakers and the Society for Ears Nose and Throat Advancement in Children for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

OT580302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.