Michael Rutter

335 statements · 5 topics · summaries given as host listed separately

Featured statements

You had a stenosis, you put through a small dilator, cat tail dilator, a bougie, a endotracheal tube, and then you put a slightly bigger one through, and then a bigger one through, and you slowly stretch up the stenosis. A lot of shear forces, quite a lot of mucosal damage. And so this wasn't enormously successful, but it was the best that we had for a long time.

quote · Aerodigestive / ENT

The reason for the two minutes is if you dilate a balloon on a bench, it goes to pressure and stays there. If you dilate it in a stenosis, you keep having to add water to the syringe pump as the pressure keeps dropping for about 90 seconds as the fibrous tissue is stretched open.

quote · Aerodigestive / ENT

Use part of the trachea to repair the esophagus, slide the trachea over the top of it, quite often with a little interposition graft of periosteum.

quote · Tracheoesophageal Fistula

And so if you use nerve hooks and you just take your time slowly tightening up the multiple throws you've already done, it slowly comes together.

quote · Tracheoesophageal Fistula

I'm having a really bad day.

quote · CHARGE Syndrome

Button batteries can cause ongoing tissue injury for weeks after ingestion, even if 'dead' (they retain ~2 volts); institutional protocol mandates removal within 2 hours of identification.

guideline · CHARGE Syndrome

Nothing matches these filters — clear the search or widen the filters.

Michael's statements about Aerodigestive / ENT 141 statements

Open the Aerodigestive / ENT collection →

Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula

Statement Most children who aspirate have a functional or neurological problem (cerebral palsy, CHARGE syndrome); some have anatomical problems (TEF, laryngeal cleft, pharyngeal scar, esophageal stenosis). Open

Statement A 3-French bugbee cautery is a smooth, excellent probe for identifying subtle tracheoesophageal fistulas. Open

Statement A 70-degree endoscope is a difficult tool to use but can visualize TEFs that are otherwise hard to see with standard forward-viewing scopes. Open

Statement Pediatric surgery fellows at Cincinnati Children's complete a one-month attachment with ENT to perform bronchoscopies and gain airway expertise. Open

Statement Endoscopic TEF closure requires demucosalization of the tract (mucosa is a non-stick surface); the goal is raw-against-raw apposition with minimal fibrin glue (0.1 mL) to seal the tract while scarring occurs. Open

Quotation You don't want to give the mucosa a fright, you want to destroy it. Open

Statement Positive-pressure air insufflation (30 cm H₂O) via an endotracheal tube in the esophagus can reveal a TEF by causing air to bubble out of the tracheal opening. Open

Statement Endoscopic TEF repair success rate is approximately 80%, typically requiring 2 attempts; after 3–4 failed attempts, open repair should be considered. Open

Statement When cauterizing in the airway with a bugbee, oxygen concentration should be kept below 30% to minimize fire risk; brief periods of lower oxygen saturation are tolerable. Open

Statement Injection of an inert material (e.g., Radiesse voice gel) into the walls adjacent to a TEF tract can obliterate the potential space and promote raw-on-raw apposition; the material is absorbed over a few weeks. Open

Statement Slide tracheoplasty for TEF involves transecting the trachea above and below the fistula, beveling the edges, turning in the tracheal wings to repair the esophagus, interposing sternal periosteum, and reconnecting the trachea; it is a three-layer repair. Open

Statement Sternal periosteum is an excellent interposition graft material: it is abundant, in the surgical field, and extremely strong ('like Kevlar'), though difficult to suture. Open

Statement Button batteries can cause ongoing tissue injury for weeks after ingestion, even if 'dead' (they retain ~2 volts); institutional protocol mandates removal within 2 hours of identification. Open

Statement Two slide tracheoplasty repairs for button battery TEF both dehisced (one at 10 days, one at 3 months); both were successfully revised. This may be more than coincidence, suggesting button battery injuries pose unique challenges. Open

Statement Transtracheal repair technique: anterior tracheotomy, identify the fistula from within the trachea, separate tracheal and esophageal layers, three-layer closure (esophageal mucosa with knots in lumen, sternal periosteum, tracheal wall with knots in lumen). Open

Statement Transtracheal TEF repair is a two-dimensional operation with lower complication risk than slide tracheoplasty; the primary complication is re-fistulization, whereas slide tracheoplasty dehiscence is a more serious event. Open

Statement Slide tracheoplasty appears to be a learning-curve, surgeon-dependent operation; revision cases have been necessary as experience was gained. Open

Statement When repairing a high TEF from a thoracic approach, ligation of the fistula on the esophageal side can leave a large tracheal pouch; if the patient has tracheomalacia and requires a tracheostomy, the tube may enter the pouch, causing life-threatening obstruction. Open

Quotation You can actually lubricate the needle with a copious amount of swear words. I found that really helpful. Open

Quotation If it barks like a dog and it wags its tail, it's probably a dog. Open

Statement In patients with retroesophageal subclavian artery, the right recurrent laryngeal nerve is non-recurrent and at higher risk during neck dissection; awareness is critical during transtracheal or slide tracheoplasty approaches. Open

Statement After 7 years of aspiration through a TEF, a child may have significant bronchiectasis; repair of the fistula does not immediately resolve lower airway disease, and ongoing chest physiotherapy and airway clearance are required. Open

Statement Hearing aid molds are radiolucent and can be missed on chest X-ray; high clinical suspicion is required when a foreign body ingestion is reported but not visualized. Open

Statement Pectus excavatum can worsen tracheobronchomalacia; placement of a pectus bar can improve airway support and reduce the need for stenting or tracheostomy. Open

Statement Airway stents can erode into the esophagus, creating secondary fistulas; long-term stent management requires vigilance and may necessitate alternative strategies (e.g., Y-stent with tracheostomy tube within the stent). Open

Statement A Y-shaped airway stent from both bronchi into the trachea, with the tracheostomy tube sitting within the stent, can effectively bypass a bronchoesophageal fistula and allow clinical stability when further repair is not feasible. Open

Quotation Sometimes the first domino falls, and they just keep falling. Open

Statement Endoscopic closure of bronchoesophageal fistulas is feasible but challenging; proximity to large vessels (e.g., pulmonary artery branches) may preclude safe cautery and necessitate surgical resection. Open

Statement Tracheal pouches (diverticula) can be marsupialized endoscopically using a Storz ClickLine laparoscopic biopsy forceps with cautery at 40 watts; the technique is quick, well-tolerated, and eliminates the risk of tracheostomy tube misplacement. Open

Aerodigestive Management of Pediatric Aspiration - FULL SHOW

Statement A radionucleotide spit scan (placing radioactive tracer on tongue) can test for saliva aspiration but involves radiation and is a one-off window in time. Open

Statement Impedance probe is the best test for gastroesophageal reflux but is not necessarily widely available. Open

Statement Medication for reflux generally stops acid but does not stop reflux events. Open

Statement CT scanning is excellent for evaluating long-term consequences of aspiration but shows damage already done (tells about the past, not the present) and requires anesthesia, radiation, and radiologic expertise. Open

Statement Laryngotracheal separation guarantees no aspiration but eliminates voice, and attempts to restore voice with speaking valves (Blom-Singer) are not effective in children because the larynx remains in the way—complete laryngectomy with cricopharyngeal myotomy is required for voice restoration. Open

Statement The Cincinnati laryngotracheal separation technique involves peeling mucosa up subperichondrially within the cricoid, purse-string closure, splitting cricoid laterally at 3 and 9 o'clock, quilting sutures to sandwich cricoid, tisseal in subglottis, and crisscrossing medial heads of SCM over the laryngeal stump—this has eliminated fistula formation and stomal stenosis. Open

Statement In children, laryngotracheal separation stomas will stenose without a tube until growth stops, so a relatively big, wide, short tube must remain in the tracheal stoma. Open

Statement Tracheoesophageal fistulas can be surprisingly challenging to find and require high index of suspicion, angled telescopes, probing, and positive pressure breath with endotracheal tube in esophagus to visualize bubbling. Open

Quotation Better to skip a tag than to hallucinate a specialty. Open

Quotation If you think there's a problem, you've got to go looking for it, be it a TEF or a cleft. Open

Statement Endoscopic TEF repair is ideal for long skinny tracts (usually recurrent TEFs after congenital repair); the concept is to demucosalize the tract with Bugby cautery to get raw-against-raw, inject filler beside the tract to compress it, and place fibrin glue. Open

Quotation Mucosa is a non-stick surface, so you have to remove the mucosa. Open

Quotation You should always go in with an index of suspicion in any child who's had a TEF repair and is still aspirating. Is there a laryngeal cleft? Open

Quotation When the child first has the TEF repaired, that's the time you should be proactively checking for a cleft. Open

Quotation You have to accept with this that you have a failure rate, and you have to be prepared to come back and do it again. Open

Statement Endoscopic TEF repair has a recognized failure rate and surgeons must be prepared to repeat the procedure multiple times. Open

Quotation You have to accept with this that you have a failure rate, and you have to be prepared to come back and do it again. Open

Statement Congenital H-type tracheoesophageal fistulas, with very few exceptions, do not do well with endoscopic repairs and typically require open repair. Open

Statement For H-type TEFs, the upper 2/3 of trachea is accessible through the neck, the lower third is easier through the chest, and the middle third is no-man's land where whoever has better expertise (pediatric surgery or ENT) should do it. Open

Statement Slide tracheoplasty technique for large or multiply-failed TEFs involves transecting trachea above and below the hole, peeling trachea off esophagus, using the tracheal segment attached to the hole to repair the esophagus, and reconnecting the trachea over the top with a slide technique that oversizes the airway and reduces tension. Open

Statement For the case of isolated esophagus with multiple TEFs connecting to trachea, leaving the esophagus isolated at both ends prevents aspiration through the holes while the holes prevent mucocele formation by allowing drainage. Open

Statement Flexible bronchoscopy is not a good tool for evaluating posterior laryngeal clefts—rigid bronchoscopy is required for diagnosis. Open

Statement For long type 4 clefts, the Cincinnati technique involves transecting trachea at cricoid, peeling trachea off esophagus to beyond the cleft, repairing esophagus, placing sternal periosteum interposition graft, reconnecting trachea, and placing tracheostomy 2-3 weeks later after healing. Open

Statement Almost all children under 4 kg who had type 4 cleft repairs died; waiting until the child is over 5 kg improves outcomes. Open

Statement The greatest risk with laryngotracheoesophageal clefts is that the distal end of the repair may form a tracheoesophageal fistula. Open

Statement For severe pharyngeal stenosis, management is a step ladder approach: voice, breathing without trach, no aspiration, swallowing without G-tube—typically cannot achieve all four, usually one or two steps up the ladder, rarely three. Open

Quotation Expectations matter. Counseling the family at the start is important. Open

Statement Composite stents (suprastomal stent with silastic sheet wrapped around it supraglottically) are effective for severe pharyngeal stenosis—the stent goes through vocal cords and locks in trachea while the silastic holds open the supraglottic raw areas during re-mucosalization. Open

Laryngotracheal Stenosis

Quotation In the 21st century, we're seeing a resurgence of interest in endoscopic airway surgery, and this often complements open surgery. Some patients still need the open airway operations, and deciding who to offer what operation, that's the first step. Open

Statement Prior to the 1970s, bougie dilation using progressively larger dilators was the mainstay of airway stenosis management but caused significant shear forces and mucosal damage. Open

Statement The development of open airway surgery in the 1970s allowed for costocartilage grafts and laryngotracheal reconstruction. Open

Statement In the 21st century, endoscopic airway surgery is experiencing a resurgence and often complements open surgery. Open

Quotation You had a stenosis, you put through a small dilator, cat tail dilator, a bougie, a endotracheal tube, and then you put a slightly bigger one through, and then a bigger one through, and you slowly stretch up the stenosis. A lot of shear forces, quite a lot of mucosal damage. And so this wasn't enormously successful, but it was the best that we had for a long time. Open

Statement The balloon is inflated to rated burst pressure and held for two minutes or until oxygen saturations drop to 90%, whichever happens first. Open

Statement When dilating a balloon in a stenosis, pressure keeps dropping for about 90 seconds as the fibrous tissue is stretched open, requiring continuous addition of water to the syringe pump. Open

Quotation The reason for the two minutes is if you dilate a balloon on a bench, it goes to pressure and stays there. If you dilate it in a stenosis, you keep having to add water to the syringe pump as the pressure keeps dropping for about 90 seconds as the fibrous tissue is stretched open. Open

Statement Kenalog injection with orotracheal injector set followed by division of scar bands in a Mercedes-Star incision with a blitzer knife is used as an adjunctive procedure. Open

Quotation The technique I like to do is to place it with the point away from the airway, get it into the stenosis, and then turn it 180 degrees and cut towards the lumen. You get a much better result. Open

Statement The technique for scar division is to place the blitzer knife with the point away from the airway, get it into the stenosis, turn it 180 degrees and cut towards the lumen for a better result. Open

Statement Endoscopic dilation works for stenosis at multiple levels - if you can do it in the larynx, you can do it in the trachea. Open

Quotation If you can do it in the larynx, you can do it in the trachea. Open

Statement Current knowledge gaps include what size balloon to select, how much pressure is appropriate, how long to leave it inflated, when to repeat it, how often to repeat it, who should not be dilated, and when to use adjunctive procedures. Open

Quotation We don't know what size balloon to select. We don't know how much pressure is appropriate to put in that balloon. We don't know how long to leave it inflated, when to repeat it, how often to repeat it, who we shouldn't dilate, and when to use adjunctive procedures. Open

Quotation And if after five dilations, you are not winning, you should take a step back and think, should I be doing something else? Open

Quotation The protocol for dilation, we usually dilate three or four times at seven to ten day intervals for established scar. Open

Statement The protocol for dilation is usually three or four times at seven to ten day intervals for established scar. Open

Statement On the second dilation, adjunctive procedures may include Kenalog injection, scar tissue division, increasing balloon size, or nebulizing cipridex if there are significant raw areas after dilation. Open

Statement If after five dilations you are not winning, you should take a step back and think about doing something else. Open

Statement The ideal candidate for balloon dilation has thin scar and young scar; thicker or established scar may require adjunctive procedures like scar division or steroid injection. Open

Quotation The ideal candidate, thin scar, young scar. And if it's something that's a little thicker or quite established, that's when you may want to think about adjunctive procedures, scar division, steroid injection, for example. Open

Statement The formula for balloon sizing is to take the outer diameter of an age-appropriate endotracheal tube and add one millimeter for the larynx or two millimeters for the trachea. Open

Quotation The formula I used was you take the outer diameter of an age-appropriate and tracheal tube. You add one millimeter for luck for the larynx and two millimeters for luck for the trachea. Open

Statement A free app has been developed to help choose the right size balloon to minimize risk. Open

Statement Open airway reconstruction requires an easily exposed larynx and is easier in a patient with a tracheotomy, but not required as long as the child can be kept spontaneously breathing under anesthesia. Open

Statement The open procedure involves harvesting rib, exposing the larynx, placing vocal cord spreaders, dividing the posterior cricoid with a sickle knife and micro scissors, and may require dividing the inter-arytenoid muscle. Open

Statement A balloon can be placed anteriorly and inflated to push the cartilage graft into place during open reconstruction. Open

Statement For minor laryngeal webs, endoscopic repair is feasible and does not necessarily require a tracheotomy tube. Open

Statement After dividing web scar tissue with a sickle knife, a keel must be placed to prevent raw mucosal surfaces from re-adhering. Open

Statement The keel placement technique uses a keith needle threaded through silastic, taken out using a hollow angiocath as a guide. Open

Statement The keel is kept in place for 10 days to allow tissue to re-mucosalize without re-adherence or risk of re-stenosis from scar tissue. Open

QUAD #6 Slide Tracheoplasty for TEF, Otolaryngology Approach with Dr. Mike Rutter

Statement Slide tracheoplasty can be used as a method of repairing challenging tracheoesophageal fistulas Open

Quotation You've got a very tight ring segment with a fistula behind the ring segment, and you can see how narrow the distal trachea is. Open

Quotation We went on and repaired both at the same time because we really didn't have an option Open

Statement In a case with complete tracheal rings and TEF, both conditions were repaired simultaneously because there was no other option Open

Statement The slide tracheoplasty technique involves transecting the trachea above and below the hole with a bevel to avoid losing too much trachea Open

Quotation The technique is that we basically transect the trachea above and below the hole with a sort of a bevel, so we're not losing too much trachea. Open

Statement Part of the trachea is used to repair the esophagus, then the trachea is slid over the top of it, often with a periosteal interposition graft Open

Quotation Use part of the trachea to repair the esophagus, slide the trachea over the top of it, quite often with a little interposition graft of periosteum. Open

Quotation She's had thoracotomies, tracheal resections, flaps, because they couldn't get rid of the hole, they just left a T tube in place and, and she aspirates chronically. Open

Statement In the slide tracheoplasty repair, a flap of trachea is sewn onto the esophagus so the front wall of the esophagus becomes a piece of trachea, using a quick running suture technique with 4-0 PDS Open

Quotation And so this is a slight tracheoplasty technique, and you can see the bougie in the esophagus, we've transected the trachea above and below, and we're sewing this flap of trachea onto the esophagus, so the front wall of the esophagus is now gonna be a piece of trachea, just a a quick running suture technique with 4 OPDS. Open

Quotation And so if you use nerve hooks and you just take your time slowly tightening up the multiple throws you've already done, it slowly comes together. Open

Statement When the distance between trachea and esophagus is large, using nerve hooks and slowly tightening multiple throws brings the structures together Open

Statement In the Swedish patient case, esophagoscopy at one month post-op showed the suture line where trachea was sewn to esophagus with the front wall being a piece of trachea Open

Statement The Swedish patient returned to eating and drinking everything despite having a very short trachea Open

Quotation She went back to Sweden, she's eating and drinking everything, she's got a really short trachea, and she's doing fine. Open

Quotation She was referred to us aspirating on high flow with a chest tube in place. Open

Quotation There's suture material everywhere to the point you don't actually know where the lumen is in the esophagus. Open

Statement In the 4-year-old case, initial stabilization was achieved by placing an esophageal stent, which did not fix the holes but eliminated the mediastinal communication Open

Quotation She's had two thoracotomies, you couldn't mobilize her esophagus, and so we stabilized her initially by putting in an esophageal stent, bought her some time, that didn't fix the holes, but got rid of the mediastinal communication. Open

Statement A transsternal, transtracheal approach provides fantastic exposure to the esophagus Open

Quotation You get fantastic exposure to the esophagus. Open

Quotation We went transternal, transtracheal, and we took a little bit of tibial periosteum as a nice interposition graft. Open

Statement Tibial periosteum serves as a good interposition graft Open

Statement Periosteum is effective at protecting one lumen from another Open

Quotation Periosteum is really good at protecting one lumen from another. Open

Quotation For challenging tracheoesophageal fistulas, a slight tracheoplasty can be a very valuable addition to the options available for repair. Open

Quotation You're not gonna do this for everyone, it's just useful knowing that there are options available. Open

Statement Slide tracheoplasty is not appropriate for every TEF case, but it is useful to know the option is available Open

Michael's statements about Aspiration 24 statements

Open the Aspiration collection →