Endoscopic anterior cricoid split with balloon dilation in infants with failed extubation.

Subglottic injury (SGI) is a known complication of prolonged intubation in neonates and infants and can lead to failed extubation. SGI is a spectrum that includes mucosal edema, ulceration, granulation perichondritis, and mature scar formation. Although medical management aimed at treating mucosal edema and extraesophageal reflux is successful in treating a majority of patients, some require surgical intervention to successfully achieve extubation. The surgical options for these patients include tracheostomy, open anterior cricoid split (ACS), and laryngotracheal reconstruction with cartilage grafting. Open ACS is performed through an external incision requiring placement of a drain for a few days. Extubation success rates in the 70% to 80% range have been widely reported. In this article we describe an endoscopic technique for ACS, in which after an endoscopic airway assessment confirms isolated SGI, the cricoid cartilage is divided transluminally with cold steel. Balloon dilation (BD) is then performed with an appropriately sized angiography balloon. We describe preliminary results in which two of three patients were successfully extubated after endoscopic ACS with BD. We believe that this novel technique is a promising alternative to open ACS with similar indications. In addition to the avoidance of a skin incision, endoscopic ACS with BD may enable extubation with comparably shorter lengths of postprocedure intubation than open ACS. Larger series will be required to further establish outcomes of this procedure, including success and complication rates.