The rotary door flap a breakthrough in laryngotracheal reconstruction.

The sternohyoid myocutaneous vascularized flap--the Rotary Door Flap (RDF),--is optimally oriented to serve in laryngotracheal reconstruction. It provides immediate highly vascularized lining and structural support to the augmented airway. Therefore it is one of the most versatile alternative methods available for surgical reconstruction of the stenosed larynx and trachea. This technique has been applied in 46 patients, of whom 14 were in the pediatric group. The features of the flap and the surgical technique are described.     

胸锁乳突肌肌骨膜瓣喉气管重建术动物实验与临床应用

为探讨胸锁乳突肌肌骨膜瓣在喉气管重建术中的作用，切除狗环状软骨弓及部分气管前壁造成缺损，取胸锁乳突肌肌骨膜瓣修复，分别于术后２个月～８个月处死动物，观察修复情况，并取材作光镜及扫描电镜检查。结果发现：胸锁乳突肌肌骨膜瓣行喉气管重建具有良好支撑力，修复的呼吸道通畅，无瘢痕及肉芽组织形成，移植骨膜表面为粘膜上皮覆盖，深层有新骨组织形成。临床治疗５例患者，均拔除气管套管，恢复正常呼吸功能。胸锁乳突肌肌骨膜瓣是理想的喉气管重建材料。     

Single-stage laryngotracheal reconstruction

The mainstay for repairing subglottic and tracheal stenosis has been the rib graft with prolonged stenting. A refinement of this treatment was the use of the anterior cricoid decompression (split). We present single-stage reconstruction of the airway as an additional refinement of the laryngotracheoplasty. This article describes the experience of two institutions with single-stage reconstruction and offers some observations on the principles of the technique.     

胸锁乳突肌肌骨膜瓣喉气管重建术动物实验与临床应用

为探讨胸锁乳突肌肌骨膜瓣在喉气管重建术中的作用，切除狗环状软骨弓及部分气管前壁造成缺损，取胸锁锁乳突肌肌骨膜瓣修复，分别于术后２个月￣８个月处死动物，观察修复情况，并取材作光镜及扫描电镜检查，结果发现：胸锁乳突肌肌骨瓣膜行喉气管重建具有良好支撑力，修复的呼吸道通畅，无瘢痕及肉芽组织形成，移植骨膜表面为粘膜上皮覆盖，深具有新骨组织形成。临床治疗５例患者，均拔除气管套管，恢复正常呼吸功能。胸锁乳突肌肌     

The rotary door myocutaneous flap. A reliable technique for laryngotracheal reconstruction

We examined the possible uses of the "rotary door" sternohyoid myocutaneous flap (RDF) in laryngotracheal reconstruction. This well-vascularized myocutaneous flap, when rotated axially, can replace or widen the anterolateral walls of the airway. It provides a large epithelial surface, together with bulky structural support. The flap is readily available within the immediate surgical field and can replace large defects in the airway, from the level of the glottis to the cervical trachea. After extensive structural and soft-tissue loss of the larynx and trachea were produced to simulate commonly encountered traumatic and postsurgical stenotic conditions, the RDF was employed in 23 dogs in a single-stage laryngotracheal reconstruction. A stable, widely patent airway was achieved. The dogs were followed up for periods varying from three to six months. No complications or secondary stenoses were encountered. Photographic, radiologic, and endoscopic examinations demonstrated the viability and usefulness of this newly described flap. Long-term tracheostomy was used so that intraluminal stents and cannulas could be avoided. Histopathologic studies confirmed the integration of the RDF into the framework of the larynx and trachea. Application of this technique in cases of tumors, trauma, and stenosis of the airway is suggested.     

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。     

Pitfalls in laryngotracheal reconstruction.

OBJECTIVE: To determine the causes of laryngotracheal reconstruction (LTR) failures. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: Seventeen pediatric patients who underwent revision LTR from October 1, 1986, to December 31, 1998. INTERVENTION: Laryngotracheal reconstruction. MAIN OUTCOME MEASURE: Decannulation. RESULTS: Seventeen patients required a total of 42 LTRs for decannulation. There were 17 primary LTRs and 25 revision LTRs. The primary LTRs were done either at our or other institutions. Two patients died after initial LTR failed, one because of tracheotomy tube plugging and the other because of a severe respiratory syncytial virus pneumonia. All 15 remaining patients have been decannulated. There were 27 failed LTRs with 17 being primary and 10 revision LTR failures. In 3 of the 27 failed procedures, no obvious causes for failure could be found. In the remaining 24 procedures, 1 or more factors that contributed to LTR failure could be found. Poor preoperative evaluation with subsequent failure to address the airway lesion was seen in 6 procedures. Intraoperative reasons for LTR failure included inappropriate choice of graft in 2 procedures; inappropriate stent in 7; inappropriate stent length in 1; and inappropriate duration of stent in 8. In 6 procedures, the airway abnormalities identified at endoscopy were not adequately addressed at LTR. Postoperative factors for failure were poor follow-up in 2, anterior suprastomal collapse in 2, and slipped or broken stent in 2. Other factors that contributed to LTR failures included intractable gastroesophageal reflux disease in 1 procedure and keloid formation in 5. CONCLUSIONS: Although some LTRs may fail secondary to factors that are not under the surgeon's control, many LTR failures can be avoided by accurate preoperative and intraoperative assessment of the stenosis, correct choice of surgical procedure, and close postoperative monitoring.     

Long-term results of the sternohyoid myocutaneous rotary door flap for laryngotracheal reconstruction.

In the past 8 years, 45 patients with laryngotracheal stenosis have undergone reconstruction with the sternohyoid myocutaneous rotary door flap (RDF) technique at Tang Du Teaching Hospital in Xi'an, China. All patients were tracheostomy-dependent before reconstruction. Thirty-six patients had previously undergone 2 to 7 surgical procedures. Forty-one of the 45 patients (91%) were successfully decannulated. Decannulation failed in the other 4 because of RDF prolapse into the tracheal lumen or because of hypertrophic scar in the operative region. The follow-up period ranged from 1 to 8 years. Forty of the 41 patients had a stable airway and effective voice, and 1 patient had restenosis 3 years after decannulation. The results demonstrate that the RDF technique is a relatively simple and effective way to treat patients with laryngotracheal stenosis.     

Revision pediatric laryngotracheal reconstruction

Surgeons who make airway reconstruction a major part of their practice inevitably are faced with children in whom initial surgical management fails. Searching for the possible causes of failure and determining how best to minimize the risk of repeated failure is often an exhaustive process. Establishing a framework and guidelines for approaching and managing these failures can improve the chances of success significantly. The aim of this article is to provide such a framework.     

Combined rotary door flap and epiglottic laryngoplasty for reconstruction of large laryngotracheal defects in dogs

Reconstruction of large laryngotracheal defects may require simultaneous application of more than one surgical technique. This paper reports the advantages gained by combining epiglottic laryngoplasty with the myocutaneous sternohyoid muscle rotary door flap. The two procedures complement each other in achieving structural and functional rehabilitation of extensive defects in the larynx and trachea. Avoidance of intraluminal stents and use of a tracheostomy procedure that does not require an indwelling cannula have yielded improved results.     

探讨肋软骨瓣移植成形术治疗重症喉气管狭窄成败原因

目的探讨应用肋软骨移植喉气管成形术治疗重症喉气管狭窄成败原因,提高喉气管狭窄成形术技术.方法回顾分析第四军医大学唐都医院1983～2001年采用喉气管裂开移植肋软骨治疗重症喉气管狭窄患者36例病情及治疗结果,研究其成败原因及解决方法.结果 36例中29例(80.5%)一次成形术成功治愈,拔除气管切开套管,恢复正常呼吸,经1～10年随访,疗效巩固.7例失败未愈.失败原因局部皮肤血循环差(大剂量放射治疗后,反复多次手术局部瘢痕重),伤口感染软骨坏死排出,T形管损伤黏膜形成新的瘢痕狭窄和瘢痕体质.结论用肋软骨瓣移植术治疗严重或比较严重的喉气管狭窄方法简单,带T形管时间短,疗效好.缺点是增加一个手术切口,游离肋软骨容易发生缺血性坏死,颈部皮肤放射治疗后及瘢痕体质者慎用此法.选择好适应证,术后加强护理,正确应用支撑器可以提高疗效.     

Minimally invasive techniques in laryngotracheal reconstruction

The treatment of laryngotracheal stenosis has evolved over the past several decades. Advances in technology, equipment and medication have increased our ability to treat some airway stenosis in a minimally invasive manner, and at times by an endoscopic method. With improved precision, our results with postoperative voice and swallowing should improve.     

Revision single-stage laryngotracheal reconstruction in children

In this report, we discuss indications, technique, outcome, and complications of revision single-stage laryngotracheal reconstruction (SSLTR), formulate guidelines to avoid or prevent procedure failure, and establish a protocol for the management of procedure failure. We retrospectively reviewed the charts of 122 patients between the ages of 8 months and 9 years who underwent SSLTR between January 1992 and September 2001 in 2 tertiary care children's medical centers in different cities and assessed the outcomes of patients who underwent revision SSLTR. A total of 122 patients underwent SSLTR, of whom 48 patients underwent anterior and posterior grafting. Of the 122 patients, 13 had revision SSLTR; 8 of these 13 underwent the initial laryngotracheal reconstruction at another institution. Five patients had anterior grafting laryngotracheal reconstruction without stenting, 7 had anterior and posterior grafting with 1 to 21 days of endotracheal intubation, and I had cricotracheal resection and anastomosis. Of the 13 patients, 5 had anterior wall or graft collapse (grade IV stenosis), 4 had subglottic stenosis (grade IV), 2 had circumferential subglottic stenosis (grade III), and 2 had subglottic and glottic stenosis (grade IV). The overall success rate for all patients was 86% (105 of 122). The success rates for the 122 patients were as follows: anterior grafting, 100%; anterior and posterior grafting, 83% (40 of 48); and revision cases, 70% (9 of 13). We conclude that laryngotracheal reconstruction with a costal cartilage rib graft should be considered the procedure of choice for the management of subglottic stenosis. We believe that patients in whom the first procedure fails should have a high chance of success with revision SSLTR if strict guidelines and protocols are followed.     

Microbiology of stents in laryngotracheal reconstruction

OBJECTIVES: Granulation tissue often forms around a laryngotracheal stent, tracheostomy tube, or other airway prosthesis, especially if infection occurs. We studied the types and frequency of organisms colonizing stents used in pediatric laryngotracheal reconstruction. STUDY DESIGN: This prospective study included 21 patients undergoing 23 consecutive laryngotracheal reconstructions with stents between 1991 and 1999. METHODS: After endoscopic removal, each laryngotracheal stent was placed immediately in a sterile container and transported to the laboratory. Specimens for culture were obtained from biofilms on the stents and plated on agars for growth of aerobic, anaerobic, and fungal organisms. Culture results were analyzed with regard to patient age, duration of stenting, and graft type. RESULTS: All stents were colonized with more than one pathogen (range 2-7). The most frequent aerobic isolates were Streptococcus viridians, Pseudomonas aeruginosa, Staphylococcus aureus,Haemophilus influenza, and Neisseria species. Anaerobic organisms were isolated in 26% of cases. Candida species were isolated in 57% of the cases; patients whose stents were colonized with Candida were significantly (P =.007) older (mean 77.5 months) than those not colonized with this organism (mean 26.1 months) CONCLUSIONS: The antibiotic agents currently used for children undergoing laryngotracheal reconstruction target mainly aerobic organisms. Despite prophylactic measures, the incidence of granulation tissue formation is clinically significant, and the prevalence of anaerobic, including fungal, pathogens is high. Antibiotic therapy directed toward controlling anaerobic and fungal organisms could help in controlling local inflammation and thus granulation tissue formation.     

羟基磷灰石气管重建的实验研究

目的探讨富含微孔的管状羟基磷灰石(hydroxyapatite,HA)人工气管用于长段气管环形缺损修复的可行性.方法采用实验动物为健康家犬,共12只.切除环状软骨弓、部分软骨板以及颈段10个气管环,将长约5cm管型HA人工气管分别与环甲膜、残存的环状软骨板和气管断端吻合固定,6个月后处死存活的实验动物8只,取出植入的HA管及其周围组织,进行组织病理学和扫描电镜检查.结果HA管植入6个月后,植入位置无明显改变.显微镜下见纤维结缔组织、新生血管及组织细胞长入HA管微孔,占据HA管微孔壁的外2/3,HA内管壁未见上皮覆盖.吻合口周围出现不同程度肉芽组织增生和瘢痕形成,但气管管腔无明显狭窄,实验动物均未出现呼吸困难和窒息.结论通过确切地手术吻合固定,喉气管的正常活动不影响自体组织长入HA管,气管粘膜上皮未见移行于HA管内壁表面.单纯采用HA管型材料修复较长的环形气管缺损能维持实验动物正常的呼吸功能,吻合口附近纤维结缔组织增生和瘢痕形成等问题有待于进一步解决.     

Hydroxylapatite for laryngotracheal framework reconstruction

Hydroxylapatite plates and rings were employed for reconstruction of the laryngotracheal framework in 12 patients. The cause of the framework defect was surgery for stenosis in nine cases and removal of malignancy in the other three. The trough method associated with a two-stage procedure was tolerated in all 12 cases. Hydroxylapatite plates or rings were used to reconstruct the framework during the second stage. The implant was well taken in all cases, without any infection or rejection. Nine of the 12 cases resulted in excellent airways.     

History of pediatric laryngotracheal reconstruction

In the early twentieth century, John Winslow wrote that there was no more difficulty in laryngology than treating chronic stenosis of the larynx and trachea. Winslow described cases as "excessively rebellious to treatment" and treatment requiring "patience, persistence, self-sacrifice and skill on the part of the surgeon" and "discomfort or even suffering by the patient." Three decades later, Chevalier Jackson wrote that curing patients required perseverance over a period of time rarely as short as 3 months and as long as 7 years. Significant strides in surgical technique have been made; this article chronicles the development of laryngotracheal reconstruction in children.     

探讨肋软骨瓣移植成形术治疗重症喉气管狭窄成败原因

目的 探讨应用肋软骨移植喉气管成形术治疗重症喉气管狭窄成败原因，提高喉气管狭窄成形术技术。方法 回顾分析第四军医大学唐都医院1983－2001年采用喉气管裂开移植肋软骨治疗重症喉气管狭窄患者36例病情衣治疗效果，研究其成败原因及解决方法。结果 36例中29例（80．5％）一次成形术成功治愈，拔除气管切开大管，恢复正常呼吸，经1－10年随访，疗效巩固。7例失败未愈。失败原因：局部皮肤血管循环差（大剂量放射治疗后，反复多次手术局部瘢痕重），伤口感染软骨坏死排出，T形管损伤黏膜形成新的瘢痕狭窄和瘢痕体质。结论 用肋软骨瓣移植术治疗严重或比较严重的喉气管狭窄方法简单，带T形管时间短，疗效好。缺点是增加一个手术切口，游离肋软骨容易发生缺血性坏死,颈部皮肤放射治疗后及瘢痕体质者慎用此法。选择好适应证，术后加强护理，正确应用支撑器可以提高疗效。