Introduction

Airways are part of the respiratory system and are responsible for moving air through mouth and trachea into the lungs. Additionally, they have other responsibilities such as regulating the air’s temperature and humidity, protecting against harmful substances entering the body, and helping you to speak. Issues within the airway are very common in children and can greatly affect their breathing, sleep quality, and overall growth and development.¹

With children, especially those who are still developing their speech, it can be hard to recognise when there is an issue with their airways. However, common signs include:

• mouth breathing
• snoring
• sleepwalking
• frequent ear infection or congestion in sinuses
• speech difficulties
• feeding difficulties²

While it is paramount to recognise these symptoms and get attention as soon as possible in children, understanding the long-term impact of potential airway surgery is also important, as common surgeries can carry risks and potential side effects.

Common types of airway surgery in children

Common types of airway surgery in children include tracheostomy, laryngotracheal reconstruction, and cricotracheal resection.³ The choice between these procedures depends on the location and severity of the airway obstruction, as well as the age and overall health of the child. In some cases, children may require multiple interventions or staged surgeries over several months or years.

Tracheostomy is a procedure which involves a surgeon making a hole in the front of the neck, and in this hole a tube is inserted and goes into the windpipe (trachea). The purpose of this is to ultimately help the patient breathe. This surgery is usually planned in advance, but it can be performed as an emergency if required. There are several reasons why tracheostomy is performed on a patient, which include helping them breathe if the throat is blocked, removing excess fluid or mucus from the lungs, or to deliver oxygen to the lungs.⁴

Laryngotracheal reconstruction is a procedure which widens the narrowed section of the windpipe. The narrowing makes it hard for the individual to breathe. This is done by implanting grafts of cartilage into the narrowed windpipe which are held by a plastic stent. The cartilage is extracted from the child's ribcage to avoid rejection by the immune system. After the grafts are healed, they can be removed and the child should be able to breathe comfortably.⁵

Cricotracheal resection involves the removal of the narrow part of the airway called the larynx, which is removed and then the voice box (larynx) and the windpipe are sewn back together. This procedure is done when there is narrowing of the airway, and depending on where the narrowing is, this may be a single- or multi-step surgery. Any implant in the airway from previous surgery, such as a tracheostomy tube and stent, would be removed prior to this surgery.⁶

Immediate post-surgical recovery and complications

After any type of surgery, patients are usually carefully monitored for several days to check for any urgent complications. Especially in the case of airway surgery, patients’ breathing and oxygen levels are carefully monitored before they can be safely discharged. However, unfortunately, there are several complications that can arise immediately post-surgery. The most common complications include infection, swelling or granulation tissue, and breathing struggles.

Some airway surgery, as described previously, involves incision of the skin, which can lead to surgical wound infection. Though healthcare professionals work hard to make sure infections don’t occur by keeping the environment as sterile as possible, there is always a small possibility this may occur when your skin is exposed to the air and bacteria can go into your body. Infections can be cleared with antibiotics.⁷

Swelling is a common response after surgery, and it results from the body’s natural inflammatory response to try and heal the surgery area. During inflammation, white blood cells are transported to the region of interest in attempts to fight off infection. As well as that, another healing response is the formation of granulation tissue, which is tissue at the wound site that appears red/pink, moist, and granular. Granulation tissue generally indicates a positive healing process; however, excessive or abnormal growth of it can impede healing and require intervention.⁹

All the interference with the airway, though better long-term to help breathing, can initially cause complications immediately after and can result in hypoxaemia. This is when there are concerningly low levels of oxygen in your blood, which cause headaches, shortness of breath, fast heartbeat, and coughing. It is important that these symptoms are recognised immediately and oxygen and ventilators are provided to the patient to overcome this issue.¹⁰ 

Long-term health outlook

Most children can breathe normally again after surgery. However, some studies have found that even after years of the surgery, a portion of children still face deficits in health-related quality of life. The studies found that these children have abnormal spirometry results (a test which measures how well your lungs work)¹¹ and many display a lower endurance level than the healthy level, which reflects physical impairment despite surgery to resolve issues. As a result, the children may need ongoing respiratory support.¹²

Airway surgery can alter a person's voice by changes in their pitch, resonance, and quality. This is especially relevant in the first few weeks, but it can return mostly back to normal over time.¹³ Speech therapy plays a vital role in helping patients regain communication methods. If the natural voice is lost, then the patients may be taught electrolarynx or oesophageal speech, which are alternative ways to speak. Children may experience difficulties swallowing after the surgery, but speech therapy can help them to regain swallowing abilities. Despite these issues, the overall physical growth of the child remains the same.¹⁴

Some children, depending on their condition and recovery, may require special accommodations at school. These can include adjusted physical education, speech therapy during school hours, or assistance from school nurses for airway care. Regular respiratory follow-ups, spirometry tests, and ENT evaluations may become part of their routine for years to ensure that airway function remains stable.¹⁵

The severity of post-airway surgery can vary significantly between patients, and it greatly depends on the intensity of the original surgery and overall patient health. Those with a more complex surgery tend to have more persistent complications afterwards.¹⁶ 

Emotional considerations

These physical issues which result from airway surgery can have a detrimental impact on the child. For example, trouble speaking can severely impact a child’s confidence and self-image. Additionally, the effects on a child’s lungs and ability to exercise can potentially cause setbacks in day-to-day life and have an impact on the child's mental health. For example, not being able to keep up with peers during physical activity can lead them to feeling excluded. This can consequently impact the mental health of parents or caregivers. 

Follow-up care and support services

Due to the long-term outlooks for children who have had airway surgery, it is pivotal to have a strong multidisciplinary team and a good support network. Those involved in the multidisciplinary team can include speech therapists and paediatricians to regularly check up on the child and help resolve any issue wherever possible.

Other specialists involved may include occupational therapists, dietitians for feeding issues, or child psychologists for emotional resilience. The overall goal of long-term care is not only physical recovery but also helping the child achieve a good quality of life, strong social integration, and confidence in communication.¹⁷

Summary

In summary, healthy and functional airways are responsible for healthy respiration for the body. Without this, individuals may struggle to breathe, have trouble regulating temperature, or be unable to prevent harmful bacteria from entering the body. When the airways are faulty, sometimes surgery is necessary and some common airway surgeries include tracheostomy, laryngotracheal reconstruction, and cricotracheal reconstruction.

With these airway surgeries, the long-term outlook for children needs to be well-considered and understood as it can have a lasting impact on the rest of their lives. Some of these complications include loss of the natural voice, reduced lung function and trouble swallowing. A strong multidisciplinary team and supportive system is paramount to aid the child through these and improve these complications wherever possible. Despite these complications of airway surgery, the benefits of having working lungs outweigh the long-term complications.