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To the Zoom Academic Meeting of the Department of Pediatric Surgery in East London, South Africa. Uh Today we are presenting this uh lecture webinar in association with Global initiative for Children's Surgery, Giggs as a part of Ent webinar. And uh the topic is an approach to pediatric laryngotracheal obstruction and uh the the lecturers and the speakers will be Professor Shazia Pir and Doctor Isa Berner. So, Professor Peel is associate professor and head of the pediatric ear nose throat department or laryngology at Red Cross War Memorial Children's Hospital in Cape Town in South Africa. And she's also affiliated with the University of Cape Town. Um She did a two year pediatric ent fellowship at Sick Kids Hospital in Toronto. She has formed a pediatric reconstructive airway surgery team which she will talk about. She is the program director of the first pediatric Ent fellowship in Sub Saharan Africa. She's also the chair of Pent Africa, which is the Pediatric Ent Society in Africa and founder of Center for Advanced pediatric Ent and she's an advocate for ent related conditions affecting African Children. And uh doctor is Berner is a pediatric ent fellow at the University of Cape Town Red Cross Children's Hospital. Uh He's almost finishing his fellowship. He is a basically ent specialist from Ghana. He is a fellow of the Ghana College of Surgeons, a part time lecturer at the School of Medical Sciences in Kumasi in Ghana. And his current research focuses on parent reported outcomes in Children with symptomatic laryngomalacia who have undergone supraglottoplasty. So Shaya and Isaac uh welcome. I will stop sharing. You can start sharing and, and deliver your talk. Thank you. Can you see our screen there, Melinda? Yes, we can. OK. Well, good afternoon, everybody. And uh once again, thank you very much for this uh opportunity to speak. Um I uh I'm, I'm very grateful that uh many people have shown up and it's a multi sort of disciplinary discussion today. So uh please enjoy, I'm here with Isaac and so I will first do a little bit of the introduction into the topic and he will follow on with some specific conditions. So without further ado, um I have no disclosures apart from the ones on the screen. And I specifically wanna thank me for the opportunity to speak today and to uh uh also all the Pent Africa colleagues who joined a shout out to you and in particular, the global initiative for Children Surgery team, I think it's wonderful that we can actually have a webinar that crosses surgical disciplines. So thank you all for uh this opportunity. As you know, I'm based at Red Cross Children's Hospital. And we're the first largest standalone functional hospital for child health care in Southern Africa. Um It is affiliated to the University of Cape Town and we get referrals from all over uh Africa as well as you know, uh across uh different sectors like the private sector and uh nationally. Um So just to give you a basic idea about pediatric airways and uh even though you all are specialists, I thought we just start at the very beginning. Um What do we already know about the airway? Well, the airway is either upper and lower and as you know, at the top that exists from the nasal ala, right at the top, which extends into the nose and the back of the nose and then unites with the oropharynx which comes from the oral cavity. And that further then unites into the hypopharynx, which is the back of the upper airway that then becomes the upper esophageal inlet. The airway is then limited by the epiglottis and that's the laryngeal inlet which extends into the trachea. Um and then the lower airways is managed typically by the pulmonologist. So even by the cardiothoracic which involves the bronchi, the bronchioles and, and A a and those that further subdivided into L bi, what we always wanna put a shout out to is the Children are not just small adults. And for those of us who start in the adult world and progress to subspecialized in Children. A lot of our general colleagues always say, oh, you know, just treat them like a small adults. And this certainly isn't the case. What we do know is that the bodies grow, the anatomy changes and there's developing physiology and a lot of the diseases they're variable and they occur as early as in utero and what I've noticed and in many cases, many people notice is that the syndromes of those inborn errors may not manifest immediately. They may take a few, a few months or even a few years to show themselves. Uh This is a good schematic diagram of the adult airway and how it relates to the child airway. And if you just look at that side view from the very beginning, you can see actually that the child's airway has a funnel inlet and the funnel inlet is what gives you this perception of a wide opening that actually then narrows down. It's a high anterior lax. And we always mention this in the premature kids. In the very small Children, you actually have to really bend that laryngo, that laryngoscope very high. In order to see it, the cric cord is the narrowest. Um although with very swollen, true vocal cords, you may also get gra stenosis and we know that the that the trachea is very flexible in Children. This is a view of the laryngeal inlet. And for those of you who've done a few intubations in adults, uh you can see on the left, there's a very big opening and the vocal cord makes majority of the inlets. If you look in a child, you've got already supraglottic or area above the much more crowded and much more uh floppy, a short um uh curled epiglottis, sometimes shorter epiglottic folds. And the very obvious contrast is this bulky arytenoid tissue with short vocal cords in relation to that posterior arytenoid area. And so swelling can sometimes manifest much more dramatically. This is another schematic diagram of a trachea. And you can see from the child at birth to two years, the trachea is only 5.4 centimeters. And you know, as one grows, the trachea will lengthen, extend and also widen. And so 11 wants to bear that in mind, especially for those of us who do tracheostomies in neonates. Uh and to bear in mind that, you know, there isn't much to Corina in length. This is a very, very important thing to note and and airway resistance in Children is actually much more dramatic Children tank much faster than adults. And one of the reasons is because the airway and edema of the airway results in dramatic decrease in the cross sectional area. So if you just take one millimeter shown in this picture, you can just see how dramatic it is and take that with some viscous mucus with difficulty expelling air and mucus and clearance and coughing, you've got much higher lamina flow and you've got such increase, 32 times increase in turbulent flow. Um When we look at pediatric airway, we always consider three different functions. And the big cog is breathing and then there's swallowing inflammation. And the reason why it's like this is you have to be able to breathe, to be able to swallow and talk. Uh breathing is the first and most important function followed by swallowing in information with breathing. They manifest with symptoms like sterle noises around the nose and area above the larynx and then Stridor which is laryngotracheal and so on. The swallowing, they, they manifest with dysphagia or difficulty swallowing and aspiration and laryngeal penetration. And then with phonation, it's really dysphonia. And when one looks at specifically the swallowing and the phonation, is it secondary upper airway obstruction? So for example, a cleft is a secondary upper airway obstruction, things that give you obstruction only because they're trying to swallow or feed questions to ask when you're taking a history specifically is the nature of the, of the noises, you know, is it inspiratory expert? Is it happening only when sleeping or feeding, eating exertion and the and or baseline? And then with regards to your aspiration, is it dysphagia with aspiration? Is it continuous? Is the VPI which is velopharyngeal insufficiency of milk coming up the back of the nose. And then we talk about difficulty feeding, choking, coughing, reflux, et cetera. The dysphonia is relevant for whether it's intermittent, meaning it comes and goes, for example, with a chronic cough or a cleft or if it's persistent in terms of like um uh laryngo papillomatosis, something like that. Common conditions common in the world, 60% is laryngomalacia and the rest decreases down the down the pathway. But certainly in our population in developing world centers and all across Africa Papilloma is still very high up with 30 to 40%. We found this to be a very good picture just to describe the laryng, the tracheal obstruction. And as we know, tracheal obstruction could be in the lumen itself or along the wall or in the wall itself or outside the wall. And so Luminal mural or extrinsic can present with this pathology and they all will have airway obstruction um to bear in mind that it's more helpful to know what the pathology is before going in. But sometimes that's not always um possible just in the interest of time, we won't be talking about foreign body. Although in different parts of Africa, different people manage these cases. Uh certainly for us, the ent would manage um all of Africa. But in South Africa, cardiothoracic usually manage these and then we will not be talking about esophageal forster because that specifically um is for um the uh gi surgeons and the pediatric surgeons. But we, we try and focus on the others. So when we look at pathology based on age, we can see that in the neonatal um uh in the neonatal age group, these are the pathologies. Once you get to 2 to 3 months, you get the congenital conditions as well as a quiet conditions. So this acquire condition in this case would be something that is done to fix a child or that's instrumented foreign bodies and croup exist in infants and then in young adults, it's a cause and effect. So, infection trauma, things like that. This is a, a really important graph to contextualize when you look at airway disease in the context of age. So in a child naught to three months, they'll have a congenital airway disease. But in the premature group because we're trying to keep them alive through intubation, that's usually the cause of the airway disease. An exit for those of you who don't know is an exut intrapartum treatment. It's an entire program aimed at alleviating an obstruction before the child takes the first breath, which may compromise breathing. This is a child with chaos, congenital high airway obstruction syndrome. And this is when delivered, we did an exit on this child delivered intubated, half delivered intubated, then fully delivered. The size of that lesion was bigger than some of the kids in the next, in the next incubator. So about 6, 700 K GS uh 6 700 g, sorry. And then oops is an operation of placental support. This is with complete atresia and conditions like that. The mom works as a heart lung machine, um and the baby is delivered on, on the thighs. So how do we evaluate pediatric airways? Well, we wanna obviously start with a good history and examination. We wanna obviously exclude anything that's congenital and um make sure that we understand where the noises are coming from, what the degree of, of failure is or respiratory uh effort. And then we always in our context, wanna do an awake, flexible fiber optic nasal endoscopy. If possible, that's a flexible scope down the nose and both sides to exclude c anal atresia and to have a good assessment while the child is awake, if we need more information or we think it's necessary to we do a direct line, go check your bronchoscopy. You may have heard of a DLT B for those of you who've been to Red Cross and then if it's something functional uh but um but physiologically um uh disease, then we always want a flexible bronchoscopy with a pulmonologist. Um And so the clues that we always wanna take note of is lesions, masses, anomalies, any recurrent condition. So, recurrent chronic, prove they wait all the time and then failure to thrive. Um If we're only worried about the airway, we're not concerned about anything else. We usually would, for example, do A DLT B. This is seen with kids with papillomas or sub stenosis, tracheal stenosis. And then if there's any doubts of any feeding issues, if it's, if the child is old enough. A barium swallow a milk scan to exclude reflux and where indicated an esophagoscopy or a triple scope. Um, uh, airway surgery actually has evolved over the years. So we don't use the candle and light method. But what we do have now the Hopkins rods and they're really sophisticated. There are many sizes and we've even evolved to, um, to the video laryngoscopies where anybody at the bedside can basically record a video of the airway and send it to us or even manage further drugs and anesthesia. And the perioperative care has also changed over time. So for those of you who have managed to walk into um an ent uh or an ent surgeon doing a suspension microlaryngoscopy. This is what you will see. The airway is suspended on a uh mayo table. Uh And uh on the left, you can see that on the right. Um You can see a tracheostomy, tracheostomy in the child. And uh this is bypassing a very, very bad obstruction, which is laryngeal papillomatosis in the airway on the left, you will note that we always want to see the anesthetic machine. We always want to see the SATS and we ourselves wanna be monitoring that because the patient is being ventilated. So even though they're asleep, they're breathing spontaneously. So, so this is um uh just a Hopkins Rod. It's a very, very tiny one. It's a 2.7 millimeter telescope that we use to railroad, um a small et tube in the event that we need to rescue and incubate. There's quite a difference between this and the ventilating bronchoscope at the bottom which helps to ventilate, providing oxygen at the top. That's really just to intubate. So you want to preoxygenate. This is a, a video of one of my registrars from many moons ago and he's looking at a patient with um uh just treated uh TB And you can see that we get a very, very good view of the airway just like that. And that's just a couple of seconds. Other investigations, for example, ct imaging, you can see tracheal stenosis there in Children who are unstable where they can't be extubated, they can't go for an anesthetic to have the tube taken out. They can't go down to CT scan, we can do a fluoroscopic tracheal assessment showing tracheal stenosis. Um And so, so how do we manage these kids at Red Cross? We certainly do a lot of laryngoscopies. Um And uh these are, you know, sort of the elective ones, but we also have emergent ones um that we do at a regular basis. Most of them are with laryngotracheal stenosis. We also see papillomatosis, we'll continue to see it because the rollout program for HPV, vaccination prevention is, is not adequate for the strains that we see. Uh and then we also see other diseases as well like bilateral vocal cord palsy, et cetera when we decide to take someone to theater. We discuss it with the anesthetic team and intraoperatively before we start, we wanna know, do you have a plan ABC? What's the endpoint? We always communicate even though it's very hard because they are inlaws. We always try our best to keep an open communication. We adapt if anything has changed because the airways are always unpredictable. And we discussed from the beginning, what, what's gonna happen at the end? Are we doing definitive surgery? Are we just going to intubate? Are we going to stage a disease? And then postoperatively, where is this child going to the ward to ICU? Are we gonna have them breathing spontaneously? Are they gonna wake up? And these are important questions because you wanna know that, you know, you're not gonna do harm. This is a combined airway assessment with one of my colleagues uh who uh former colleagues, Fiona Kritzinger doing a flexible bronchoscopy. And why is it good to do a combined airway assessment? Is because you have physiology, dynamic movements with a flexible like tracheomalacia with the rigid you have, you can assess the vocal cords, you can assess the cric latino joints, you can size the airway and you can intervene if you need to. Sometimes we do a triple scope with some of our colleagues um uh in, in private and uh that's an esophagoscopy and we're able to get much more information in that regard. Everybody is present at the same time and decisions can also be made. So, airway conditions are challenging, what you do now can have lifelong implications and really, it's not about doing nothing or doing no harm, but it's about doing less harm now than if you were gonna do nothing at all. So any surgical intervention at whatever level of upper airway, even if it's taking a tonsil and an adenoid out for obstructive sleep apnea must aim to improve function. So all of these things have to work to to one goal. For example, this was a child who was born with a huge a huge neck mass, not planned for exit but came out uh and deteriorated rapidly. All we needed to do was establish a safe airway. We took this child to theater debulked and excised. Most of this matter was a teratoma. The child did fine on the right. We have a child with a large head and neck mass that was extending into the brain. We intubated and discussed this as a very aggressive teratoma which is considered malignant and opted for oncology to take over and not to do a tracheostomy or anything like that. So sometimes just establishing an airway is all we need to decide on what to do next. So the treatment is one like we mentioned before, optimized breathing. So this will alleviate the obstruction and sometimes um O SAS, it also will optimize breathing if you've got a compressive head and neck mass and if there's stenosis within the airway, you want to improve quality. So releasing webs and removing anything on the cord like papillomas and to address aspiration, once confirmed a laryngeal cleft repair, cleft palate repair and anything like that would be helpful. The main thing really is if you wanna fix the airway and you can't, you can do a tracheostomy. If you need a peg, you may need that to protect the airway to avoid a tracheostomy. Or you may need both in some cases with complex Children. We do know they're vulnerable and we always want to consider the parent and the home environment as much as the child, early treatment may be an option or we may opt to just wait it out with a tracheostomy. We always worry about complications, doing things early and about the implications for development and growth. So we wanna pretty much get a tracheostomy out and definitively cared pathology. By the time they get to school, we want to start a speaking well and speaking early on. So they can get socialization and speech and language acquisition. A tracheostomy for upper airway obstruction. Is there to alleviate an obstruction? It's either temporary or definitive, but it's not there for tracheal disease. It's really for laryngeal or upper airway. Um and it does provide laryngeal rest and, and bypass the obstruction. So, thank you very much. I'm gonna hand over to Isaac who's gonna do the fun part, which is all the specific conditions. Let's go for it. Thank you. So I'll be looking at some of the specific uh conditions um that lead to ruction in, in uh in Children. Um I've already been uh introduced uh earlier, so I'm not gonna talk much uh on this slide. So I'm actually from Ghana from a hospital called Sa Peter's Hospital. All I just want to say is that ent is a very young discipline in Ghana with a population of 32 million, we only have, we have less than 100 ent seven. So we will first of all, start with laryngomalacia. Laryngo, malaria is the most common congenital laryngeal. Normally we see and it's uh characterized by the inward collapse of the structures on inspiration. Um 80% of Children relying on malaria also experience what we call gastroesophageal reflux disease. And this um um um stri or airway um obstruction is a by things like crying, agitation, feeding or placing the child in a supine position. The good thing about Malaysia are that most of it, about 90% of them are self limiting. Uh resolving in just about 12 to 24 months. Um But some severe cases uh which are characterized by striatal failure and SAS will then go on to need or require surgical intervention, which is either a supral autoplasty or a trachys toy. So the management of mania, as I already said is individual. So it depends on the level uh or the type of uh ignacia that the, the child has. So we have the conservative and then the surgical, another conservative we can do active uh observation where we do regular foot followups until it resolves. As we also monitor the central growth charts. We also uh give medical therapy such as the PPS or the A two A antagonist. Because remember I told you that is associated with a lot of dial reflux disease. And then the speech and language therapist also help in the management. And then we also teach position adjustment. What are the indications for this uh surgery? As I said, about 10% may require surgery. And um if the diagnosis is confirmed on the D or TB, which is the digo bronchoscopy or either um the child is not responding to the reflux treatment or they are developing the signs of a severe laryngo maac. Uh then we have to go in to do osteoplasty. So as you can see on this video, this is um a patient who, who has laryngomalacia. I can see from the CT pigs, the shortened A four and then the um flat of the as uh the patient uh ins so we always have excellent results close to about 98% of resolution when the Children undergo uh vertoplasty. As, as you can see on the image on the right, see how um on the left, the epiglottis is all cured up. Arts are pushing in the totally occluding the, the glottis or the laryngeal inlet. But on the right side, following the supraglottoplasty, you can see how everything opens up nicely. As I said, Lyn Maac ISD with a lot of reflux disease. So, um we need to uh these two are closely um related and if untreated this uh gastroesophageal reflux disease often worsen their symptoms and may also delay wound healing following gastro electro plasties. So we'll quickly look at recurrent ptosis. As pro said is something that we see is one of the common causes of laryngeal airway um obstruction, we see. And as we can see those uh ploo lesions completely occlude the airway or the larynx in this uh patient. So you see all these vegetations completely good in the airway. This is also a number. So in some of the Children, uh unfortunately, we um develop um papillomas down the trick here. I mean, which is uh an extensive airway disease. But uh we found out that um if we are to um advocate for the um prevention of the, the, the HPV pre prevention programs to expand, they are net to cover the types, the subtype six and 11, which are usually the, the the types uh indicated in the papillomas. It goes a long way uh to actually relieve Children of this uh especially in Children in Africa of these uh papillomatous lesions. So let's quickly look at laryngeal clefts which are uh also very, very um important in some of the uh common uh causes of secondary airway, um, obstruction. We see. And this is associated with an abnormal communication um between the larynx or between the airway and then the, the, the gi tract. Um, so there's a defect in the pa wall and this is a very rare condition as you can see, one to about 20,000. But they are actually uh things that we see and it's characterized mainly by the dysphagia, difficult, swallowing, choking, aspiration. And some Children always come in with recurring chest infections and chronic cough at night. Um Treatment is usually of two types. Um We, we, we have uh the medical and then the surgical but the medical and the surgical before you, you choose the type of treatment depends on the type of the cleft. We have four major types of cleft from type 1 to 4. The type one and type two are usually um the defect is usually above the, the C and then the type three and four are usually be low, but the type four is usually within the mediastinum. So the type one is actually treated is mostly treated conservatively by using the PPR as the antibiotics and then the modified feets. Um we watch the growth curve but then if there are recurrent admissions, it is cough at night or the patient is still experiencing bad signs of uh dysphasia which is affecting the growth. Then we opt for a closure or surgical intervention. So the surgical intervention could be done either endoscopically or with an open approach or a combination. So, um depending on the type of cleft, we choose uh what type of um um surgical um option to go for. Um sometimes to also reduce um the reflux. Um the Children undergo um A PEC which is a percutaneous uh gastrostomy which may or may not be associated with a fundoplication. All these are aimed at reducing the reflux and sometimes we do this in, in Red Cross as a way of optimizing the the Children before surgery. Um definitive surgery is carried out. So as you can see from these uh images, this is uh on, on the left, this is a child with a type one Cleft who was having a lot of uh um um laryngeal and feeding um issues. So was taken to the where the uh cleft was closed. And then on the right, you see the postal. So for some of our um airway um surgeries, POSTOP, we use uh this combination, we call uh CD or Clod, which is a combination of uh Cipro floxacin with dexa dexa metha. And this helps us uh to actually uh avoid scarring to um aid in the healing and also to prevent the the formation of biofilms. And then we also give our PPI S and steroids as part of our POSTOP care. So let's quickly look at congenital um glottic subglottic stenosis uh which is also something hor that we also see here. And this is due to an abnormality um in the embryogenic period in this period, there's failure of complete reconation of the primitive uh larynx. And this uh involves an expression of laryngo aom as as as as as you already see, this is not a subglottic. So from the video you see down. So this is um um a child with a laryngeal cleft, a type four a web sorry, which is associated with a subglottic um involvement as we see in the type three and then the type four, but we'll be focusing mainly on the um stenosis, not the webs. So, and uh the congenital stenosis could be membras or cartilage genus. The membranous ones are usually stuff and can easily be popped even during the intubation. So most of them can even go unnoticed by the cartilage genus once involves the framework that is the uh the car framework and this usually needs uh some form of surgical intervention to fix. So the acquired subglottic stenosis um as I said, so, so sub stenosis could be congenital, acquired or could be mixed. But so let's quickly look at the acquire. So they acquired before 19 seventies uh as a as a result of uh poor neonatal intensive care practices, uh poor um intubation and little knowledge on the effects of poor um intubation. There were there was increased prevalence of a pile bloody stenosis. But currently, we, we're just looking at incidents of about 0 to 2% as a result of change in these uh habits. We're now using appropriate sizes of the neonates based on the weight and age and we are allowing some air leak around the 80 tubes. So, these are all um um um um reducing the incidences of uh the acquired sarcomeric stenosis. The pathophysiology generally involves uh inflammation as a result of maybe using a bigger tube or inflating the calf. It leads to damage of the mucosa that leads to inflammation, swelling and all that. Sometimes it can, there can be a cartilage and then in the healing process, there is fibrous uh proliferation and then remodeling that leads to the sub stenosis or even cyst formation, which also leads to a lot of uh obstruction uh image you see here, you can actually see a huge cyst in the subglottic space which is also obstructing the airway. And in this case, we do the roofing of the cysts and then sometimes uh er dilatation to actually open up the sub space. So what are some of the risk factors for subglottic stenosis? We try to stress on this so that um all of us will be mindful of this. So the increased um the the number one risk factor, as we see is the intubation injury uh every five extra days of intubating. Um A child increases the risk by 50.3% which is quite significant. So, premature Children, Children who have aspiration, Children who, uh, who have had an inhalation or injuries from BS and those having gastro reflux disease or have an increased risk of developing or pass up blood or tube, you know, injury. And then, um, there are these two papers that shows that under sedation is also a serious risk factor. So, in our various, um, practices, we should ensure that when Children are intubated in the ICU, they should be sedated and sedated. Well, so that the there's little movement that leads to um um uh injuries um in uh in the airway leading uh eventually to the stenosis to both the larynx and then the trachea. And then there's also a study done which, which also showed the um association between the length of intubation and then the formation of subverted stenosis in Children. So this is something which really occurs. So, as you can see on the left, there is a child who was intubated for just five days following a band, we can see the exposed cartilage and know as a result of tube injury. And then on the right, as the video progresses, you can see this uh posterior blotic band. And then we can also see the subglottic cysts which all occur as a result of intubation. So, subglottic stenosis is actually stage using the coin uh system and we have four grades, grade 1 to 4, grade one, from no obstruction to about 50% obstruction and before where there's no dictator do. So, how do we manage subotic stenosis? It's um to manage it. You depend on the disease factors. As in the stage of the disease is it is applied as in me, is a frame work, the surgical skill that is the skill of the surgeons, the and then the the center if there's a center um available to also carry out this task. And then patient practice can also uh also looked at the simplest way of treating the subglottic stenosis, which is actually the mainstay in many of the centers, as we see in the lower middle income countries is because I mean that is the safest because you are bypassing the pathology, you are allowing time for the uh child to uh maybe probably outgrow the condition. And then um it's it's the safest and simplest uh solution, but we should be mindful of the morbidities and complications which are associated with tracheostomies. So as I said, the management of subglottic stenosis could be um as it's mainly surgical, um we have the uh could be an endoscopic or open airway approach or a combination of both. So, the endoscopic involves incision or cutting the, the, the uh obstruction, the and, and balloon in it in some centers. They see this as even the only way of uh repairing uh clo stenosis or we can do the open air where, where we actually open up, put um a graft and then um or an uh or a stent and then later on um take out the stent. But then in like the grade four, you can also do a complete uh resection, which is a hypotrichia resection with a laryngotracheal um anastomosis. And then sometimes we do the comp complaint, but then these are not mutually exclusive choices. One always complements the other. Um Luckily, uh we are in an age where we have, we've made a lot of um advancements in end laryngeal um um surgeries. Now, we have balloon dilators, uh the suspension laryngoscopes. We have the stents called the di co lasers. And these are all improved endoscopic laryngeal service. So as you see from this uh image, the on on the left is a subglottic narrowing. As you can clearly see there's about a great three. And then on the, in the middle, from that short, with, this was a balloon dilatation and this balloon um likely is locally produced and was invented by one of our own professor Daa from at the uh from the University of Cape Town and this is a non occlusive balloon. So as you dilate the airway is not obstructed, so the child can still be receiving um ventilation as the dilation goes on. Now, the right post dilation, you can see how wide the cell is looking up. The other surgical option available to us for when, when it comes to um stenosis is li tracheal reconstruction or open airway surgeries. And these are aimed at expanding the cartilaginous framework. So you can either do an anterior split or uh and then put in um a cartilage, a costal cartilage or a car or do an anterior and posterior. Depending on how narrow the airway is, this can be done as a single stage or a double stage. So these are images showing how it is done. So there's the anterior split and then the posterior is also split and then the grafts are placed and we see that it widens. So as you can see, this is uh a patient that we did. So the graft is harvested and then it is shipped and then it is used in the widening or the repair. So in summary, the management of sub stenosis in a variety of options and these are not mutually of each other. The decision making is always key. We must know when what and how to do it. And the correct or the right patient selection must be always um uh be uh advocated and always refer uh such a cases to specialized centers for revision or advanced surgeries. So we'll quickly look at trichas stenosis, which is also one of the um um um important things we're looking at now and this involves narrowing of the trachea and that of um this um started of earlier. This could be Luminal or it could be extrinsic or we could have something compressing the, the trachea from, from the outside, which is the um an example being the vascular, this could also be congenital or acquired the uh um acquired ones, as I've already stated, are usually due to intubation injury or from trauma from a trst. So how do they present they present with other airway symptoms and or non airway symptoms? So, Stridor difficulty in breathing and the stridor is that causes washing machine quality is a diphasic type of Stridor. They have a Stridor baseline or on exertion, persistent cough, recurrence infections and they always experience um acute lifethreatening events. And then some of the non airway symptoms include difficulty in feeding or failure to drive. So how do we evaluate um Children with uh tracheal um stenosis? So, obviously, a good history and examination is very important. We do a flexible nasoendoscopy in the OPD also to rule out other um larynges pathologies that may coexist. An imaging is also very, we're given an uh a simple X ray if you are in a center that uh you, you don't have easy access to your CT or even an Mr even a, just a chest X or neck x-ray is enough for you to even capture um a narrowing of the airway. And then the DLT B and SMR which is a suspension micro. So always a good time that also helps us to actually identify and actually site and then a CT scan we, we can also have a 3D reconstruction and this helps in surgical planning. And then if there are any issues, we can also conduct a swallow or neck swallow ory. So, one of the, one of the treatments available for long segment stenosis is a slight trachops. As you can see from the images is a surgical procedure done to actually widen the diameter or the lumen. But in doing so, you end up also reducing the length of the trachea by how that is actually very good in widening the lumen. And it also has fewer um complications. The blood supply is preserved and then there's a short intubation period and there's also healthy trachea growth. So as you can see from the images, this is a a six month old who had a complete rinse hyperplastic or and ap uh pulmonary artery sling. So we see the complete rinse as we go down the video can see complete rings, you know that tr should have a horse or the sea sea shaped rings, but these are complete s and then this is um a slight intra up endoscopic view as you can see the trachea opened up. And then this is push or surveillance of two years after we can see how wide the tracheal is looking. For the sake of time. I won't be able to show the most of the full extent of the videos. Um some uh short segments, um trach stenosis can also be treated with resection and end to end anastomosis. So, as you can see, this is one of the anastomotic um parts, you know, take uh anastomosis about four and before and five. And uh this sweet scar we're seeing here, your child with myasthenia gravis, who developed two injury as a result of prolonged intubation, developed uh trach and stenosis. So help ans and um luckily he also regained her uh uh sorry Guillain Barre syndrome. And uh luckily he also regained her ability to walk severe tracheomalacia is also something that we also encounter is also one of the leading causes of uh tracheal obstruction. And um this is one of the dynamic that we um obstructions. As you can see, it's a result of uh the whole Tricia seems to be obstructed as a result of uh this uh weakness in the Tricia war. And um they are usually characterized by uh Children have such Children have failure to drive. Sometimes they need bipap at night and all day were sick and they have acute life threatening events. And um we had such a case in a nine month old and it was discussed with our airway reconstruction team and the posterior TRPL was performed. So TRPL is one of the surgeries performed to actually correct tracheal malacia where the anterior wall is actually um suspended um to push you out of the stent to keep the airway open. So this is um so tracheopexy was ongoing. And then seven days postop, you can see how well the woman let's open up. So we are not seen the collapse as we saw in the previous images. So quickly, look at some head and neck conditions that also cause tracheal or fraction. And these are also categorized into congenital, developmental, infectious or inflammatory or neoplastic. And uh 90% of all head and neck masses are found to be benign with the and a less down the the commonest malignancies we see in Children, usually the the fullness, I mean for em carcinomas. So this is a list of the congenital, the inflammatory and then your plastic masses as we see in the head and neck really. So clinical work up will also include in include a, a comprehensive history, good examination, a flexible neo endoscopy, you know, as we don't go anywhere without uh endoscopies. So the imaging involves the chest X ray, uh the the chest X rays to rule out any uh STB the lymph adenopathies, we can have the ultrasound CT with IV contrast or the MRI S and that we can see uh the pros and cons, I mean, all the advantages and disadvantages of using the ultrasound. The CT and the MRI and MRI offers a superior contrast uh resolution in evaluating masses and when it comes to vascular lesions and he found to be the gold standard. Um as surgeons, we all know the benign and the malignant characteristic of um head and neck masses. So I'm not going to do much on that. Investigations will include the following laboratory um in investigations which is a full blood count. And then uh we can also do fine aspirate for cytology and also for um microbiology, culture and sensitivity. So I'll quickly look at some specific ones. There are, these are main uh images and then uh so we have one which is a circular cyst. As you can see there's a, a cyst with uh from the sle of the larynx. And from the video you are seeing this is huge cyst which is completely including the laryngeal inlet. And this is treated by um excision or incision uh drainage or musculation. And then we have the bronchial um anomalies which are also um especially the cystic types can also lead to loss of um um obstruction. The type twos, we have the plate in the to the type three have the in the preform fossa. So these are images showing some of the bra the bronchial uh signal with a cyst which and then I'll show on the, on this video if, if you look closely, you can see some fluid squirting from the tonsillar fossa. And that is the from the, the plate on the type two. So other congenital masses, Bronchia, the moist teratoma, these are all masses that can really um ract the airway. And then we have a congenital primate masses which can also obstruct the airway. Now, this component was clear from the anterior mediastinum and you know, mediastinal mass always compress the airway, especially in Children diary cyst. This was found in a six year old girl who was otherwise healthy but always uh experiences acute stri or when breastfeeding and this is followed by rapid ner swelling. So this is was also excised successfully and then lymphatic malformations are also one of the commonest things that we see here also causing a lot of airway obstruction. As you can hear in this chart, you can actually see how it's really obstructing the airway of this three hour game cut uh to use bipap at home that was started on climus which fantastic um results. So on top, before the, the climus was given, this is a sleep study. You could actually see the dips in the oxygen saturation and then the mass very large on the MRI. But on the bottom post dose of the climus, we can see how the sleep studies improve. There are no and then the mass seems to have also resolved nicely. A bronchogenic cyst is also one of the cysts, uh the head uh cyst that we also see which also compresses the airway. And uh yeah. So for lack of time, we are not going to show a lot of images. So I invite from here back in to summarize and then end the presentation to us. Thanks very much Isaac. So it's uh it's a big uh cohort of patients. Unfortunately, we can't take up all the time, but that was great. That was lovely. I mean, you went through a lot of the pathology that we manage and that can be managed. So, just to summarize just in a second really or a few seconds, it's always challenging these airway obstructions. We do need to enlist a group of people and um our endoscopic and open, open management is complementary, but we do need an aerodigestive team if it involves dysphagia and aspiration and so on. We always, you are very fortunate to have an excellent P ICU anesthesia team and surgical specialties. We don't know what it's like everywhere else. And so for us, we always advocate for best outcomes in few high volume centers with good referral pathways and that have training programs that we're fortunate enough to have at Red Cross. Um So thank you very much. Um I just want to put a shout out for our summit that's in November. Um And then you just give it back to you. Um Melinda. Yes. Uh JAA and uh is a wonderful, really, very, very interesting. Your videos are super quality and uh they, they were very illustrative. So II don't know if there are any ent surgeon specialist in the audience. I and Doctor P can identify Doctor Suraj who is a register in Ent from East London. So surge, do you want to ask any question or want to make a comment. Have you seen any of these pathologies in East London? Mm. Um and thank you. Thank you, Doctor Sidney. And Hi Pro. Hi. Um Isaac. How it uh sorry, my camera, my camera is off. I can turn it on though if you wanna see my face, but it's not, it's not, it hasn't improved much since I last was there. Um Thank you very much for the presentation. It was, it was, it was an excellent presentation as, as it does. Um I like the overview of everything. Uh the brief little overviews of everything and um from my side, II thought it was a very good um presentation, especially for people who aren't just to get a bit of an idea of the way that we sort of manage them and how we should work up to towards these patients. Um Yeah, I don't have any other comments to make except for thank you very much and uh good to see you guys again. Yes. Thank you. Suresh. Um Then I'll just ask our three consultants to comment one after the other and do Noo Ma is our junior consultant. So, Knox uh any comments, any questions for pro um good evening. And thank you so much for the wonderful and informative presentation. Um Just out of curiosity um in regards to subglottic stenosis after balloon dilatation, um What are the stenosis rates um post the, the dilatation and do need to maybe um infiltrate like steroids um or any in anti-inflammatories post the dilatation just to reduce the, the recurrence rate. Um I was gonna say I can ask Isaac to answer, but I don't know if you want me to answer it. OK. So it is a good question because it's a complex question. And the one thing that is difficult to answer and I can tell you uh just from my own experience is su the subglottis is it's a ring of cartilage. And so if you have subglottic stenosis and your cartilage is small. So if the ring of the cartilage is small, no steroids or no dilation is gonna work, you have to cut it open. So you have to do an anterior cricoid split or an anterior and a posterior cricoid split. And you may have to put a spacer on interposition graft if your cartilage is of the correct size, but your lumen is just swollen, then you can dilate and you can dilate twice sometimes three times. If your lumen is not swollen or the swelling has gone down and has resulted in scar formation, fibrosis, then you can cut, you can uh do what we call it a Mercedes Benz sign and you can inject some steroids and you can dilate. But the expectation that the fibrous tissue has hardened and become more firm, means that you're unlikely to get the best results. So again, you may need to open it and put in a spacer to give yourself an expansion. If you have acute edema, a child who comes in with croup and you know that the airway is just swollen. How do you release a ring from your finger? You cut it open to release it. So the swelling of your finger goes down in the same way in the acute setting. If you have Luminal swelling, that's so, so swollen that a tube even barely gets in there, then you have to crack that open, release it again and do a split and it allows the edema a passage out and it can heal in a little bit more of an expanded way. So it's a bit of an unfortunate answer that I'm giving you so many answers, but it really does depend on what you start with. Uh Thank you so much. Um You're welcome. Uh um uh Knox. Any more questions or comments? No problem. Thank you. Thank you kn I see. Doctor Nilesh T is here and Doctor Nilesh is a pediatric surgeon in Jodhpur, India. Uh Nilesh. Any experience? Uh Do you um uh work together with your ent colleagues there? Uh uh Thank you, Doctor Jitney. Uh That was a really wonderful presentation from the speakers. Uh The thing which I want to ask uh was speaker is, you know, with the advancement in the diagnosis and the ultrasound machines, we do see a lot of patients of prenatal, high high airway obstructions during the 1st and 2nd trimester of the pregnancy. So, I mean, do these speakers have any experience of uh you know, seeing such patients uh during the period and if they do see such patients, how do they uh prognosticate such babies in front of their parents? Hm. It's very hard, you know, because you're already past the trimester where you can abort. So you have to be very careful how you manage it with the parents. So we do, we have a fetal assessment unit at and we do fetal MRI s and you need to assess one is the baby normal and is it just a lesion in the neck that's obstructing or is the baby part of having a, is, is it a syndrome that may have more complications with time? Um If it is a chaos where you can see a lumen below and the lungs are growing normally, then you would measure it out and you would see how much of it is volume versus how much of it is soft tissue and fibrosis and things like that because when you do deliver and you think of resection, the last thing you want is third, the third volume loss or fluid loss and things like that. So if it is that you can actually resect this, then you would deliver as an exit. So, exut intrapartum and you would do a partial um delivery incubate and then uh release the baby from the placenta, uh cut the umbilical cord and take the patient uh next door for surgery or otherwise prepare in the next few days. It just depends on what that is if it's a teratoma or if it's something more benign. So there are those options available. But counseling and preparation for both the patient, the um the parents of the patient, as well as the surgical team doing, it is extremely important because you wanna have, you know, you wanna know this is a good, good patient selection and a good parent and you know that you can actually manage this child afterwards. So I think the fetal assessment unit is quite important with that and having a good quality obstetrician who's invested in that. We have a multidisciplinary team with pediatric surgery, us, uh pulmonology and even the the obstetrician sits with the family and discusses it and we only really discuss prognosis after the latest fetal scan because things change, you know, as the baby grows. But it's a difficult question because it's quite resource driven and it can cost a lot. And, you know, you have to know that if you deliver the baby, that you're not gonna have any issues with the delivery and when they are delivered, you got to know that that brain is normal before because you don't want any issues with the brain. And then when you decide on resection, you've got to have everything there. Um So I think it is quite important to have a good head and neck surgeon, we have Johan F in here. So for the ones that we've done, he's been involved. And uh the one of the ones that Red Cross I did with Sharon Cox a long, long time ago, the one in the picture, one of those in the picture. And certainly if you can, if you have the skill set with surgeons, anything is possible you can put this together with four people. You just need to have an invested radiologist and a good counselor for the parents. Good luck. OK. Any other question? No, sir. No. Thank you so much for joining us from so far. Um uh I we have other medical offices and some registers. So any one of them wants to ask a question because this is not a, a thing which we see or deal with that. That's the specific reason we wanted uh the specialist to talk about it. So any of our doctor, can I ask one question, please? Yes. Yes, it's all right. No, please. Can I ask one question? Yeah, sure. Um So to uh pro here and uh Isaac I just wanted to ask about, we have uh one patient that uh came in uh recently um and had uh is known with job um has been to us a few times. Unfortunately, our cardic service here isn't excellent, but they are available when, if emergency. But I wanted to just ask cause this um patient had quite extensive Papilloma and the Papilloma when we took for DLT B and debulking for the, for airway concerns. Uh We found the Papilloma going all the way down to the Carina. And I just wanted to ask, what is your approach to Papilloma that goes all the way down? Do you chase it all the way down to the bronchial as far as we can see from the EMT side? Because, I mean, I mean, not bronchial to the Bronchus because that's as far as we can go. Um, do you, would you go all the way down? Um, how, how would you generally manage it? And in that case, would you then just ask thoracic to take over with management? And what would you suggest? You know, it's very tricky because we don't really go beyond Corina personally. If you have to, you can with a rigid, the main thing with papillomatosis that extends distally is to only pick the ones that are obstructing. So if you've got mural ones or if you've got fronds extending from all over, you know, they're gonna all come back. You have to, you have to relieve the obstruction and what's happening beyond that because they can get an obstructive picture and say they left me in Bronchus and then the entire lung will collapse. So you want to relieve any complete obstruction. That's what you really wanna do. Um And then just consider a jun therapy for patients like that because the moment you start entering areas that are beyond our space, you can get injuries, you can get bleeding and you can get death. So if it is something that's obstructive in a single space, you treat it like a foreign body and you remove it, but you wouldn't change every single lesion. You'd start considering a ju therapy for those kids because that already has converted them to a s if you go to beyond your system, that's multisystem disease. So you can just Avastin. Ok. Yeah, because from our side, we usually go just until the uh Corona and that's exactly what you said. That's when we stopped. Um, and just that our card, thoracic services here weren't willing to go further and check further for us. So, um, I just wanted to know, yeah, we can do that and, and that, that is actually our, our plan if, if the child has any more symptoms. So if you can do a high resolution CT scan, you can tell at what point if there is an obstruction versus a cavitation or an abscess or something worse. Right? Yeah. Sorry. Good. Thank you very much. You're welcome. Thanks for the presentation. Thanks, Isaac. Sorry. Yeah, go ahead. No, I was just gonna say there is, um, De Hunt is online and II don't know if she wants to say anything. I know that we sometimes do something called Triple Scopes together. We share patients and Angela Valisa is an ent surgeon uh from um yeah, he's, he's a current fellow but he originates from Madagascar. If there's time. I don't know if either of them or not, there's absolutely time. So maybe BCA can, can comment or um um um make a uh I is she there? Uh she wants, ok. Uh Is she still there uh any comments from you? Any combined experience in private? Not sure whether she's able to hear us. Um So you can ask the other colleague to unmute and, and uh uh comment, who is the other colleague? Angelo Valisa Angelo Angelo? You can unmute yourself and make a comment. Sorry to put you on the spot. Uh Good everybody. Good even. Uh hello. Hello Isaac. Uh Do you hear me? Yeah. Yeah. Yeah. Yeah. Thank you very much for that uh excellent presentation. It is uh very interesting as usual. Yeah. Mm The, the management of uh that uh airway seems to be abuse but it's very tricky and very difficult to manage for, for sure. Um It, it, it depends on the abstraction or the, the, the, the defect but um from uh our perspective uh in the neck surgery, um we, we used to, for, for, for me personally, we, we used to mhm to excise something blocking or something uh uh like a huge mess but dealing with an obstruction inside a very tiny area, very um um tricky anatomy and um unforgivable um mistake can be made and um my, my question and uh maybe a is when do you decide to over to, to hand over to the cardio thoracic or um uh uh keep on, on managing as an ent uh surge and with those kind of very difficult case of narrowing or um a tracheal lesion. Mm. Yeah. Back home we, we have cardio thoracic and most of them deal we, we all of trachea um lesion, particularly for trach malaria or tracheal stenosis. We don't have so much experience as an ent to do uh an an anastomosis or um a resection of trachea even in uh up on the cervical area. So my question is at what point, particularly at the Red Cross do you and over to the thoracic team when it comes to deal with narrowing trachea or that kind of um a malformation. I think it's a reasonable question cause I think we blur those lines quite a lot. Um Yeah, I think we often are the gatekeepers of acute airway obstruction, acute biphasic stride or any deterioration in breathing. That's something that we've taken ownership of here. And I think that's why we sort of feel the need to be the entry point for patient uh sort of patient care. And then with the help of pulmonology, cardiothoracic, you know, general searching, we then would either hand over the patient or transfer or do it together. We would manage endoluminal disease until Corina depending on the age. Uh If it's open airway. If it bypasses the Thoracic Inlet, they manage it. But because so many things are vague and uncertain when the patient comes in, we manage all airway obstruction until we give it up. Any mediastinal disease in that same light is managed by them. So Thoracic Inlet would be the division of, of uh of, of the in-laws, so to speak. But we would manage the trick here together because there's only so few people in this hospital, so few people in the country and so few people in Africa, we tend to pour over into other disciplines because because there's so few of us and that doubles the numbers. So I think it is a tricky question and probably unfair anywhere else, you know, up north unless you have cardiothoracic, willing to come help you with the subglottic stenosis one day, you're willing to help them with the bronchial stenosis in interluminal. So I think that's the relationship that we've developed here for now. Mhm It's very numb. OK. And, and, and, and maybe one more question or uh or have you ever experienced an uh a pa pa disease? Very uh very extended papillary papillomatous disease. And uh you do have to consider palliation for, for the child. We've got one in the ward now actually. Oh, you already said we've lived with her for six years and now she's got cavitations in her lungs. So she's needing, you know, uh oxygen home oxygen, which is not something that we've, you know, considered because, you know, we can fix the upper airway by debulking like so just said, but what do you do lower down? And what do you do if it's alveolar? Yeah. So, so there is, we always get a, it's a, it's a group of uh pediatricians called pets, pal palliative care. So, yeah, is not gonna die tomorrow, but they're on a pathway of care that may be palliative or may not be active basically. So we will stop her Avastin because she's got more complicated and see where that takes us from supportive oxygen and supportive care. But it is very smart of us because we don't see it. Thank you. Uh Thank you very much. Thank you again for that pre uh excellent presentation. Thank you, Isaac. Yeah. Thanks for your questions. Uh My question to you is uh does Pilato not uh respond to Antal? No, it doesn't. Oh yeah, doesn't respond. Oh yeah. I wish, I wish we had something that it could respond to. But there's now been a lot of the growth in the, in in the field of treatment which is gene therapy and then biologics, but there are 100s of thousands of dollars, like $200,000 for just three weeks. So we would never see that. Uh So there isn't really any treatment for it. It's really sad. Ok. Uh I have one question for Isaac. Uh the posterior tracheoplasty where, where do you suture, the, the wall of the trachea? I just didn't gather it. Yeah. Uh uh Is, is it a trach? Yeah. So it's for the tralia you? Yeah. Yeah. So the wall uh trachea in the posterior wall of the trachea? It's, it's a, you the, which one, which one are you on the posterior one? The posterior one? So where do you suture it onto the anterior spinal ligament? Oh, and just spinal ligament. Ok. So you have to move the esophagus away. Oh, so you have to, you basically release where the fistula would have been. You release all of that, immobilize the anterior spinal ligament and then you put your stitches there. OK? But you have to do a flexible bronch just to see exactly where the, the, the malacia is. Yeah. Yeah. So you, you basically balloon it back. Yeah. Yeah. Yeah, I understand. OK. What you mean? Ok. Ok. Um I'll ask doctor sell b our senior pediatric surgical consultant. Uh sell any comments. All right. Uh Thanks Shazia, thanks Isaac for the talk. Um that for tracheal plex, that's what we also do for um recurrent uh tracheoesophageal fistulas. Apparently that's the invoked thing now, instead of putting in tissues and everything in, in between. But the, the last time I was involved in uh tracheomalacia, we were doing more aortopexy um than uh posterior tracheal uh tracheoplasty. So, yeah. So it depends if it's anterior intru, anterior compression or, or posterior intrusion. So if, if it is posterior intrusion, you can do an anterior pexy, but you may, well, they are very good resolve the tracheomalacia from the tracheal, it intruding. So you'll have to do something for the back all. So it just depends where the intrusion is coming from if it's posterior or anterior or both. So you can do either or, or both depending on where the obstruction is here and depending on how severe the posterior component is. The thing is because the fistula is from the posterior component, you're robbing Peter to pay Paul. So you've got less cartilage, less tissue. So it na naturally wants to bulge into the lumen. But for those that have an anterior like a ceiling compression, then yes, the otopexy would help. It's the less invasive you can go anterior mediastinum. You can sort it out. Obviously, the posterior check your va involves the thoracotomy going back into that space. So, you know, you either, you know, you weigh your options. Yeah, but if it is posterior, the anterior pexy won't necessarily fix your problems. Uh S please continue. Yes, thanks. Um I was wondering, is there still a role for the cricothyroidectomy? Uh instead of just going upfront doing tracheostomies. Um because I remember in adults, um particularly with acute upper airway obstruction um in, in casualty. Um You would, and you needed a, a quick uh to establish a quick airway, you would opt for that. Is there still a role, um, particularly in kids. Um, does it serve a function? You mean a cricothyroidotomy? Like a yes in pediatric population. So, uh, do you want to answer? Well, well, I ii wouldn't, um, advocate for that, especially in case because, you know, they have very, uh, you know, case everything seems to be, uh, having an overlap, the thyroid cartilage and then the cricoid uh cartilage there, the thyroid membrane is not as wide as you find in adults. So doing that, I mean, uh unless maybe you are dealing with a bigger kid, but then um generally we don't really go for that or advocate that and in doing so, you know, it's a, it's a, it's a, it's a, it's a small space even if you are able to do it. The resulting complication of the costal um chondritis or the um inflammation of the cricoid cartilage will eventually lead to a subglottic narrowing in such a chart. So we don't really go for it. But uh as you know, in medicine, there are lots of gray areas, sometimes you may find yourself needing to save the child. So you will have no option than to do it. But if you can avoid it, uh we would uh advocate that you, you do avoid it and go for a proper track your story. So, yeah, I to I totally support Isaac's comment is that there is no Cricothyroid membrane that's as visible or that's palpable as it is in an adult or at least in a younger bigger child. But sometimes if you're saving a life and you can't get in, then you can do whatever you think is necessary. Front of neck, fauna, front of neck, access is advocated for those Children where you go where you think the cricoid is and you go below that. And the reason is that the larynx is anterior. So if the, if the larynx is anterior, if you presume where the cricothyroid membrane is, you may end up hitting a vocal cord or worse. So you may not actually go in and down, you may actually go in and out or in and through to the back. So yeah. So, so you actually you want to just sort of learn a bit about the front of neck, neck access in the event that you need to do it in Children, it's just safer and it's a once off adults. Certainly, the cricothyroid is your like movie style. You know, you go straight into the membrane, but in Children, it's not that easy. Ok, thanks. And last, last question about the contrast you use when you use, when you're doing a tracheal bronchogram, what do you use? Because um we always avoid or try to avoid any kind of contrast being aspirated but clearly with this particular investigation, you are putting it straight into the airway. Um So what that's under very, very rare circumstances, that's why we've recorded the video to show people. It's only in, you know, cases where we can't get any imaging. We can't risk taking the tube out. That was a child who was born with the tetralogy of fellow unrepaired and was intubated and was, you know, that tube was stuck, stuck on the stenosis. So we had no other options. So we basically get that from our radiologist and they give it to us and we use it very, very diluted. So you can see that it's not dark. It's just something that just literally slips down. That's all it does is it slips down. So you're giving yourself al almost like a tracing and that's all we really needed was, do we have the right diagnosis here? And are we ok? Because even to put someone on, you know, to take that tube out, you have to put them on bypass and all of that. So we just needed a diagnosis. Really? Sure. Thank you. Thanks for your questions. Uh The last comment I'll ask is uh our senior consultant, pediatric surgeon doctor. Yy, any comments? I uh thank you for the talk. It was really good and engaging with the videos and the pictures. Um My question or comment would be about the quiet subglottic stenosis. I think we're seeing them a little bit more frequently than we'd like. And then Isaac was talking about how to prevent and my take home was um something that we could improve on is sedation, uh, during ventilation. But I just wanted to ask if there was a time period for prolonged ventilation where you would consider a tracheostomy or would you just do, uh, get the ent s to do, uh, a, a fiber optic scope before, um, yeah, after you, uh, extubate them. Mm. I mean, I think, um, is it that you want to know how long a patient can stay intubated or, or what or what do we classify as prolonged intubation? Exactly. Depends on the cause. Yeah, depends on the cost and it's actually one of the indications for a trachys is if you anticipate. Um So you, it's going to be a prolonged intubation, then you don't even wait 56 days but in some conditions where you cannot treat it but maybe trauma or something where a patient can be intubated, maybe just 23 days. This is not really an indication for a tracheal stomach. So as for said, it depends on the cost. Yeah, if you wanted to know if, if we could actually scope the patient intubated. Yeah, if you can. No, I mean, should you get an e one of these are, I mean, what we're saying is not an exact science. Uh So please, you know, we say it from our own experience. So these are real questions and so many people ask these questions and they're so real. Um And we feel for you because we're lucky that we are the people who can advice. But when you're with the patient, it's hard to make the call. I would say anything over five days where you have in the initial period, swelling and you're waiting for the swelling to go down. You wouldn't, you would track you. Then if you've got an infection in the neck or something that you're treating in the neck also, again, five days, you'll know if you're winning or not. And if you expose anything in the neck, you don't want to track you there. So burns things like that. You'll know if you're winning. If somebody has burns on their neck, you can't put a trachea there if you need to graft and keep them fixed and things like that. So we take the hit for patients like that and we keep the tube for a bit longer if they have a severe head injury and they've been sedated and you want to wake them up and you need to know if their brain is ok, then you take the hit because the sedation lightened or a tube in the airway may give them, you know, the subglottic issues. So I think it's patient selective. But certainly if you've got a reversible condition, it's under five days, I wouldn't worry too much. II think the main thing is what this is what we say, which is one of the soft rules is if you extubate someone, if they have Stridor and it goes away after, you know, 48 hours, then you should be ok. But if they have ongoing stridor after you extubate them, then you need someone to see that. And I would say say after, if they, if they don't cope after one day and you think you need to reintubate them, you call the ent. But if they don't, if the Stridor doesn't go away after two days, you need someone to come see them. So you base it on the symptoms after extubation. Ok. Sure. Thank you. That, yeah, that was very helpful. You can take forever. Sorry. It's one of those things. Yeah. Yes. OK. Thank you. Thanks. Yes. Uh Usually what we do uh Shazia and Isaac is if somebody needs to be intubated beyond a week or so, then we start getting the ENT S involved and, and sometimes uh these difficult where we anticipate problems, we actually then extubate in presence of the ent surgeons so that if something needs to be done, then they are there and it can be done. Uh Yeah, that's fantastic. And you know, that's there you go. You've got your aero multidisciplinary team, aerodigestive team. You've already done it. You don't need any fancy title. Yes. Yes. OK. I think, I think it's, it's very wonderful uh discussion that that I have enjoyed. Um is uh you need to encourage your colleagues from Ghana Pediatric Surgeons to join these Zoom meetings, which happen usually on the second Tuesday of every month. And uh, so thank you for coming to South Africa and, and for your talk, I think one last take home message from Isaac. Ok. So, huh, so my take home is um just as uh Doctor Valeo said, managing airway conditions, especially in Children, as also said, Children are not just uh small adults, it's quite complex and um, you actually need to consult the right people so that you can actually um give the right um um um option or the right help to the child. Because any little thing that you do, you may think that you helping the child. But if you don't learn and you don't ask you end up actually causing more harm to the child than you would actually uh have uh anticipated. So, uh I would just hope that we, we will be able to train more um ent pediatric ent airway specialist. It's unfortunate that we are few. Uh But hopefully we can also train others and then we can bring such um trainings and webinars to also um create a um awareness out there so that all of us can learn how to manage uh properly the airways of Children. Thank you very much. Thank you very much. Uh What I will do is I will edit the recording of this uh session and then I will upload it on my youtube channel and uh we will share it. Uh so you people can also share it amongst your ent colleagues. Um We the next talk will be on the first Tuesday of October. That's the first of October where we are expecting a talk about Achalasia of the Cardia by Dr D who is a pediatric surgeon from UK and for the pediatric surgical colleagues. Uh We are going to host the South African Association of Pediatric Surgeon Conference um uh from the first to the Fourth of May in at Beach Resort near East London. There are eight international faculty who have confirmed their presence. So uh the registrations will open in November. So thank you all. Thank you, Shazia Isaac and all those who attended and asked questions and you have a good evening further. Thank you. Thank you very much. Bye bye bye. I'm a singing.