Effect of mechanical reinforcement on stability of the rotary door flap laryngotracheal reconstruction: a canine study

OBJECTIVE/HYPOTHESIS: The rotary door flap (RDF) laryngotracheal reconstructive procedure uses a 180 degrees rotation of the sternohyoid muscle into a laryngofissure. Despite excellent clinical results, there are concerns of flap inspiratory prolapse. This study examined RDF stability and the efficacy of ancillary materials in providing additional support. METHODS: Seventeen dogs underwent endoscopic induction of subglottic stenosis and delayed RDF reconstruction. Animals received 1) traditional RDF (control), 2) RDF with titanium screen implant, 3) RDF with porous polyethylene implant, or 4) RDF with hydroxyapatite cement (HAC) injection. Four weeks postoperatively the flaps were tested for stability. On qualitative assessment, endoscopic visualization was completed with quiet respiration and then following endotracheal tube occlusion. On quantitative assessment, after animals were killed, the RDF segment was isolated and subjected to negative pressure (maximum pressure, -50 mm Hg). The pressure-causing collapse was measured. RESULTS: In the traditional RDF animals (control), five of six flaps were stable in vivo and with negative pressures. In the titanium screen, porous polyethylene group, and HAC groups, respectively, four of four, three of four, and two of three flaps were stable in vivo and under negative pressure. Flaps that demonstrated instability had granulation, dehiscence, and poor healing. These occurred in 1 of 6 animals in the traditional RDF group and in 2 of 11 animals in the implant groups. In addition, 13 of 24 animals assigned to the implant groups died, compared with 2 of 8 of those in the traditional RDF group. CONCLUSIONS: The RDF is stable and maintains the airway under physiological conditions. Support materials did not improve stability, render flap harvest more difficult, or increase morbidity and mortality.     

Lateral thyrotomy with strap muscle transposition for Teflon granuloma

Lateral thyrotomy and strap muscle transposition have been used independently before. However, the published literature does not record the coordinated use of both procedures in the treatment of Teflon granuloma. In this paper, we present a case of vocal fold paralysis that had been treated successfully by Teflon injection in 1999. Two years later, however, the patient developed a host of symptoms that included a husky voice, shortness of breath and suffocation, which indicated Teflon granuloma. He underwent surgery to excise the Teflon granuloma via a lateral thyrotomy. The affected paraglottic space was then reconstructed using strap muscle transposition. One year postoperatively, the glottis had closed completely on phonation, and the voice retained a moderate roughness due to a scarring change from the earlier Teflon reaction. The patient had no problems with aspiration or shortness of breath during speaking. Our experience indicates that a physician can remove the entire granuloma and create a smooth, straight vibratory surface with complete glottic closure during phonation by using a combination of lateral thyrotomy and strap muscle transposition.     

The modified temporalis muscle flap in reconstruction of palate and temporal deformity

Purpose: The purpose of this article was to introduce a modified temporalis muscle flap (TMF) which was used to reconstruct palate and temporal deformity.

Patient and methods: This was a retrospective review of the use of the modified TMF in reconstruction of palate and temporal deformity. We evaluated the result which included operative time, bleeding, necrosis, infection, facial nerve deficit, and cosmetic deformity.

Results: All the 16 patients accepted the modified TMF surgery successfully. There were no complications. All of them were satisfied with the postoperative appearance.

Conclusions: The modified TMF was a reliable and safe flap that can be used to reconstruct the surgical defect of plate and fill the temporal fossa.     

Contralateral Hemilaryngotracheal Flap Reconstruction of the Hypopharynx in Pyriform Carcinoma Resection

Objectives: To simplify the approach and reconstruction for advanced hypopharyngeal cancer, a modified technique—laryngotracheal fissure approach and laryngotracheal flap reconstruction—is presented. Study Design: Prospective. Methods: From August 1991 to December 1995, 44 consecutive patients with advanced hypopharyngeal cancer, mostly involving pyriform sinus, were operated on with this technique. The functional and oncologic results and complications were evaluated. Results: Reconstruction was completed by using the laryngotracheal flap in 75% of patients, while the other 25% required ddditional patch-on pectoralis major myocutaneous flaps. Pharyngoesophageal stenosis occurred in one patient after radiotherapy and pharyngocutaneous fistula was noted in two. No local recurrence was noted. Seven cervical metastases developed in the follow-up period and six over the contralateral neck not treated surgically. The 5-year Kaplan-Meier disease-free survival was 46.8%. Conclusions: The authors' experience indicates that this is a simplified, radical treatment for most advanced hypopharyngeal cancer, with high applicability, good oncologic results, and low complication.     

带蒂胸锁乳突肌锁骨膜瓣在喉气管缺损修复中的应用

目的：观察带蒂胸锁乳突肌锁骨膜瓣作为移植物修复较大范围喉气管缺损的效果。方法：较大范围喉气管缺损患者49例,其中喉气管缺损原因为喉气管狭窄31例,甲状腺癌侵犯气管手术18例。所有患者均采用取带蒂胸锁乳突肌锁骨膜瓣作为移植物修复喉气管缺损,T形硅胶管支撑3～6个月。结果：49例患者全部治愈拔管,恢复正常呼吸功能及功能性发声。随访2～10年,疗效可靠。结论：对于较大范围的喉气管缺损,带蒂胸锁乳突肌锁骨膜瓣取材方便,支撑力强,疗效肯定,是一种理想的移植物。     

Paediatric airway stenosis: laryngotracheal reconstruction or cricotracheal resection?

Modern surgical management of paediatric laryngotracheal stenosis includes a wide variety of surgical procedures. These can broadly be divided into two groups. First, laryngotracheal reconstruction (LTR) procedures in which the cricoid cartilage is split and the framework is expanded with various combinations of cartilage grafts and stents; and second, cricotracheal resection (CTR) where a segmental excision of the stenotic segment is done and an end‐to‐end anastomosis is performed. In this article we review the literature and our experience and discuss the relative indications for CTR and LTR in children. High decannulation rates have been reported for CTR; however, it remains a more extensive procedure than LTR involving extensive tracheal mobilization. If the tracheostomy site is included in the resection then a significant length of trachea is excised. Alternatively, LTR with cartilage grafting can precisely correct a specific stenosis with minimum morbidity and high decannulation rates for grade 2 and selected grade 3 stenosis. For the more severe stenosis treatment with LTR has been less successful. Retrospective data from this institution suggests that the children with grade 4 stenosis treated with LTR are more likely to require a subsequent open procedure to achieve decannulation than those treated with CTR. LTR is a less extensive procedure and is preferred for grade 2, selected grade 3 stenosis. CTR is the preferred option for grade 4 and severe grade 3 stenosis with a clear margin between the stenosis and the vocal cords.     

Margins of partial cricotracheal resection in children.

OBJECTIVE: To review the surgical margins of partial cricotracheal resection in our series of patients. This includes specific anatomic detail as to each superior and inferior resection margin. To apply this information and access the utility of partial cricotracheal resection for the treatment of subglottic stenosis. STUDY DESIGN/METHODS: A retrospective review was performed of 38 children with severe subglottic stenosis who underwent partial cricotracheal resection. Information was obtained with regard to the specific anatomic location of the superior and inferior resection margins, the grade of subglottic stenosis preoperatively, the type of stenting material used postoperatively, and other surgical details specific to each procedure. RESULTS: The superior resection margins were generally to the superior aspect of the cricoid cartilage but as high as the undersurface of the true vocal folds in a minority of patients. Inferior resection margins were generally to the second tracheal ring. Length of resection varied, but was as long as 3.0 cm in one patient. Overall surgical success based on decannulation was > 86%. CONCLUSION: Partial cricotracheal resection is a safe and successful procedure for the treatment of subglottic stenosis. The margins and length of resection should be tailored specifically for each patient; and special considerations must be taken when extensive resection to the level of the true vocal folds is required. Safe airway management in the postoperative period is essential.     

Composite myo-mucosal reconstruction of the vocal fold

It is well established that after cordectomy or radiation therapy for early glottic carcinomas varying disturbances of the voice occur. This has led some clinicians to consider the need for surgical reconstruction of the vocal fold. Since functional results desired have still not been achieved, vocal fold reconstruction was performed using a combination of the muscular flap described by Pogosov and the free mucosal transplant reported by Isshiki. This surgical approach has now been performed on 11 cases with excellent functional results. The technique has provided a suitable mass of the reconstructed vocal fold and also allows very close contact between the vocal folds during the closed phase of the vibratory cycles. Postoperative voice quality has been almost within physiological limits.     

Results of full-thickness laryngotracheal wall reconstruction: a survey of the literature

Full-thickness reconstruction of the laryngotracheal wall is needed after tumour removal, and also in patients where lumen augmentation is required to resolve laryngotracheal stenosis. For repairing such defects, several techniques are available. All techniques are more successful when small defects are reconstructed and less successful when there is a major deficit. The main problem with most methods of reconstruction is their unreliable blood supply which becomes most obvious in repairing larger areas.     

The temporalis muscle flap for reconstruction after head and neck oncologic surgery.

OBJECTIVE: To explain the applications, technique, and potential complications of the temporalis muscle flap used for immediate or delayed reconstruction of head and neck oncologic defects. STUDY DESIGN: Fresh cadaver dissection and 5-year retrospective chart review. METHODS: A fresh cadaver dissection was performed to illustrate the surgical anatomy of the temporalis muscle flap with attention to specific techniques useful in avoiding donor site morbidity (facial nerve injury and temporal hollowing). A chart review was performed for 13 consecutive patients from the last 5 years who underwent temporalis muscle flap reconstruction after oncologic resection of the lateral and posterior pharyngeal wall, hard and soft palate, buccal space, retromolar trigone, and skull base. RESULTS: Patient follow-up ranged from 2 to 45 months. Nine patients had radiation therapy. There were no cases of flap loss. Resection of the zygomatic arch followed by wire fixation facilitates flap rotation and minimizes trauma to the flap during placement into the oropharynx. Preservation of the temporal fat pad attachment to the scalp flap decreases temporal hollowing and protects the facial nerve. Replacing the zygoma and preserving the anterior third of the temporalis muscle in situ further diminishes donor-site hollowing. CONCLUSIONS: Compared with other regional flaps, such as the pectoralis myocutaneous flap, the temporalis muscle flap is associated with low donor-site esthetic and functional morbidity and offers great flexibility in reconstruction. The temporalis muscle flap is a useful, reliable flap that belongs in the armamentarium of surgeons who are involved with reconstruction of head and neck tissue defects.     

喉咽癌外科切除后应用喉气管瓣及其复合瓣重建上消化道

目的探讨喉咽癌病变被切除后应用喉气管瓣及其复合瓣重建上消化道的合理性、可靠性、有效性及其近远期疗效。方法回顾性分析我科自2002年12月～2010年11月共94例喉咽癌患者的临床资料,男92例,女2例。临床诊断为梨状窝癌者69例,下咽后壁癌11例,环后癌9例和下咽及颈段食管癌5例。I期1例,II期9例,III期27例,IV期A 53例,IV期B 4例。单纯应用喉气管瓣重建上消化道者33例,应用喉气管瓣与胸大肌皮瓣复合瓣重建者61例。结果所有患者无1例手术死亡,多数患者在术后10～14 d开始经口进食,X线钡餐透视检查通过顺利。发生咽瘘15例（16.0%）,无一例发生狭窄或消化道梗阻。中位随诊期3.5年,1、3、5年生存率分别为94.4%,60.5%和39.3%。结论本术式是一个根治性手术,喉气管瓣及其复合瓣重建上消化道手术简便易行,功能效果良好,有高度实用性和良好的肿瘤效果以及低的并发症,适合于大多数晚期喉咽癌患者。     

Effects of artificial tracheal fixation on tracheal epithelial regeneration and prevention of tracheal stenosis

Conclusion: Tight fixation of the artificial trachea is important for epithelialization and tracheal stenosis.

Objective: The authors have developed an artificial trachea and have used it for tracheal reconstruction. Although various studies on tracheal reconstruction have been conducted, no studies have examined the effect of artificial tracheal fixation on tracheal stenosis and regeneration. Therefore, the purpose of the present study was to evaluate the effect of artificial tracheal fixation.

Study design: Preliminary animal experiment.

Methods: Artificial tracheae were implanted into rabbits with partial tracheal defects. Tracheal stenosis and regeneration of the tracheal epithelium on the artificial tracheae were evaluated by endoscopic examination, scanning electron microscopic analysis, and histological examination. The artificial tracheae fixed to the tracheal defects were classified into three groups (0-point, 4-point, and 8-point) by the number of fixation points.

Results: At 14 and 28 days post-implantation, the luminal surface of the implantation area was mostly covered with epithelium in all fixation groups. However, a small amount of granulation tissue was observed in the 0-point fixation group at 14 days post-implantation. Moreover, tracheal stenosis did not occur in the 8-point fixation group, but stenosis was detected in the other groups.     

Airway Growth After Cricotracheal Resection in a Rabbit Model and Clinical Application to the Treatment of Subglottic Stenosis in Children

Objective To evaluate the effects of a partial resection of the anterior cricoid arch on the growth of the laryngotracheal complex in an animal model and to study the lumen caliber and cross sectional surface area following resection as the animals are allowed to grow. Laryngeal, subglottic, and tracheal measurements in the infant and pediatric larynges in autopsy specimens are also investigated. Design A controlled animal study was done comparing the operated rabbit group to the nonoperated group. Twenty‐nine infant rabbits were compared to a control group of ten rabbits. In addition, autopsy dissections were performed on infant and pediatric larynges to obtain measurements of various laryngeal and cricoid relationships. Methods Thirty‐nine pasteurella‐free New Zealand white female rabbits between the ages of 8 and 11 weeks were used in this study. In the experimental group, cricotracheal resections were performed by removing the anterior cricoid cartilage and the first tracheal ring. A primary anastomosis was then performed. The animals were kept alive for 4 months and then humanely euthanized. The laryngeal complex was then removed and histological sections of the cricotracheal region were mounted on glass slides and stained with H&E. Measurements were taken of the cricoid and upper tracheal lumen and cross‐sectional area. Results Twenty‐seven of the study group survived until the time of sacrifice. All of the control group survived during the study period. The two groups were comparable in regard to weight, lumen size, and cross‐sectional area. There were no statistical differences between the groups. Conclusions The e‐perimental data support the hypothesis that partial cricotracheal resections can be performed safely and effectively in young rabbits. The potential clinical significance is described in light of the autopsy data.     

Simple and new surgical procedure for laryngotracheal separation in pediatrics

Objectives: In children with severe physical and mental disabilities who repeatedly develop aspiration pneumonia due to intractable aspiration, laryngotracheal separation/tracheoesophageal anastomosis or laryngotracheal separation has been performed in many institutions for the prevention of aspiration, and good results have been reported. However, families sometimes show a marked reluctance to give consent to these surgical techniques because of tracheal transection. A purpose of this study is to evaluate a new surgical procedure for laryngotracheal separation without tracheal transection. Study Design: Case‐series study. Methods: As a new, simple, less invasive surgical technique for the prevention of aspiration without tracheal transection, we performed tracheal closure (tracheal flap method) in six children. A U‐shaped flap of the tracheal anterior wall from the 2nd to the 4th/5th tracheal ring was produced, bent toward the tracheal lumen, and sutured to the tracheal posterior/lateral walls by mattress stitches for tracheal closure. In addition, the closure was covered with a cutaneous U‐shaped flap for reinforcement and a permanent tracheal stoma was constructed. Results: In all six patients, aspiration pneumonia could be prevented without severe complications. Conclusions: Tracheal closure (tracheal flap method) has effects comparable to those of other surgical techniques for the prevention of aspiration, and may be useful for aspiration prevention in children with severe physical and mental disabilities.     

带蒂胸骨舌骨肌瓣及舌骨修复喉气管狭窄

目的:评价带蒂胸骨舌骨肌瓣及舌骨修复喉气管狭窄的疗效.方法:用单蒂或双蒂胸骨舌骨肌瓣及舌骨重建喉气管软骨支架缺损、缺失及软组织塌陷.结果:21例喉气管狭窄及缺损患者,16例1次手术治愈,3例2次手术治愈,全部拔管出院,1例失败,1例失访.结论:对于喉气管软骨支架缺损、缺失及塌陷等所致狭窄,采用带蒂舌骨肌瓣及舌骨重建取材方便、损伤小、支撑作用好、成活率高.