Influence of Tracheostomy Level on Surgical Management of Pediatric Airway Stenosis

OBJECTIVES: To assess whether pre-existing tracheostomy location influences outcomes of open airway surgery for pediatric laryngotracheal stenosis (LTS) and to propose a pragmatic framework for tracheostomy placement. METHODS: A retrospective review included 104 tracheostomized children who underwent open airway surgery for LTS between 1978 and 2022. Collected variables included stenosis characteristics, comorbidities, tracheostomy location, surgical technique, decannulation outcomes, complications, and revision surgery. Tracheostomy location was independently reviewed by two experienced pediatric airway surgeons and categorized as optimal, suboptimal, or nonoptimal based on stenosis characteristics and patient comorbidities. Surgical outcomes were compared across groups. RESULTS: Most suboptimal tracheostomies were in a classic position (60/62, 97%). In cricotracheal resection, the suboptimal group required a greater extent of resection (median 5 rings [IQR 4-5]) compared with the optimal (4 rings [3-4], p = 0.027) and nonoptimal groups (3 rings [2.5-4], p = 0.004). Among double-stage procedures, time to decannulation was longest in nonoptimal patients (median 11.7 months [IQR 4.6-19.8]) compared with suboptimal (4 months [2.5-8.6], p = 0.032) and optimal groups (3.8 months [2-4.9], p = 0.027). Tracheostomy relocation was less frequent in the optimal group (29% vs. 57%-67% in the other groups). Tracheostomy-related complications and revision procedures were more frequent in the suboptimal group. CONCLUSIONS: Preoperative tracheostomy location influences surgical complexity (single-stage vs. double-stage procedure), resection length, need for tracheostomy relocation, complication rates, and time to decannulation in pediatric LTS surgery. Planning tracheostomy location with the anticipated reconstructive pathway in mind may reduce morbidity and improve outcomes.