Panel discussion: The management of advanced laryngotracheal stenosis. Staged tracheal reconstruction

A staged method of repair of extended tracheal and combined laryngotracheal stenosis is presented. This entails creation of a trough by exteriorization of the involved segment, implantation of an alloplastic material adjacent to it, and the subsequent hinged rotation of the embedded implant over the trough to create a semi-rigid anterior wall to the airway. The development, indications, technique and complications of this method of tracheal reconstruction are discussed.     

Management of subglottic stenosis in infancy and childhood

During the 12-year period between June 1987 and June 1999, 141 children underwent curative treatment for subglottic laryngeal stenosis at La Timone Children’s Hospital in Marseille, France. Ninety-six children (68%) were under the age of 5 years; 106 (75%) presented with acquired stenosis and 93 had narrowing involving over 70% of the subglottic lumen. Endoscopic laser surgery was performed in 25 cases and open surgery in 116. Open surgical techniques included laryngotracheoplasty with autologous cartilage interposition in 83 cases, laryngotracheal split in 22, and cricotracheal resection in 11. After decannulation, 132 children (94%) were able to breathe normally through the upper airway. Perspectives for development of new techniques and improvement of conventional methods are discussed. Received: 10 November 1999 / Accepted: 16 December 1999     

Panel dicussion: The management of advanced laryngotracheal stenosis. Composite nasal septal graft in the management of advanced laryngotracheal stenosis

Reconstruction of the larynx and trachea is most often needed after conventional methods of repair have failed. The advanced stenotic lesion can be adequately corrected with a composite nasal septal graft in a one stage procedure. Severe glottic stenosis from crush injuries or following partial laryngectomy, subglottic stenosis, and high tracheal stenosis are most amenable to this type of reconstruction. The surgical technique is presented, and six cases of clinical utilization are reviewed.     

声门下喉气管狭窄外科治疗

目的探讨复杂声门下喉及气管狭窄的外科治疗,提高喉气管狭窄的手术疗效。方法对20例因环状软骨和气管软骨环部分缺损或声门下瘢痕组织增生所致的声门下喉气管狭窄患者分别实施了胸骨舌骨肌蒂舌骨瓣(7例)、胸锁乳突肌锁骨骨膜瓣(12例)、游离皮片(1例)转移重建术,术后放置T型管。结果20例患者均于术后6个月顺利拔除T型管,恢复了较满意的呼吸和发音功能。结论胸骨舌骨肌蒂舌骨瓣、胸锁乳突肌锁骨骨膜瓣、游离皮片转移加T型管植入修复声门下喉气管狭窄的重建手术,具有较高的成功率和较好疗效。     

Panel dicussion: The management of advanced laryngotracheal stenosis. Use of the hyoid graft for treatment of laryngotracheal stenosis

The most common cause of laryngotracheal stenosis is trauma. The stenotic area may involve the larynx, subglottis, or trachea. A hyoid bone graft has been used in 22 cases for reconstruction of the stenotic area. The hyoid graft may be used with other concomitant laryngeal procedures. A vascularized sternohyoid — hyoid graft has been used in some cases. Of the 22 cases all but 3 have been successful. The advantages of the hyoid graft are:

• 1 Firm graft to maintain the architecture of the lumen.
• 2 Accessibility in the same operating field.
• 3 Patient's own graft material decreases immune rejection possibility.
• 4 The vascularized pedicle graft decreases possibility of hyoid resorption.

     

Endolaryngeal dilatation versus laryngotracheal reconstruction in the primary management of subglottic stenosis

Objectives

The scope of the study is to compare endolaryngeal dilatations (ED) with laryngotracheal reconstruction with cartilage grafting (LTRCG) in terms of restenosis.

Methods

Pediatric subglottic stenosis patients treated in Hacettepe University, between 2002 and 2012 were retrospectively evaluated. Patients who had ED or LTRCG as primary management were included in the study. EDs were grouped into bronchoscopic dilatation (BD), laser incision and balloon dilatation (LBD) and cold knife incision and balloon dilatation (CKBD). The groups were evaluated in terms of restenosis and decannulation rates.

Results

There were 35 patients (9 females, 26 males; mean age 4.42). LTRCG was performed in 16 patients (9 anterior and 7 anterior and posterior grafts). EDs were performed in 19 patients with 6 CKBDs, 7 LBDs and 6 BDs. There were 3 grade II, 13 grade III cases in the LTRCG group while 4 grade I, 6 grade II, 8 grade 3 and 1 grade 4 in the ED group. Overall decannulation rate was 97% (34/35) in all patients. Restenosis was higher in the ED group (63.2%) than the LTRCG group (31.3%) with rates of CKBD 16.7% (1/6), LBD 71.4% (5/7) and BD 100% (6/6). Restenosis rates were found to be increasing with higher grades (grade I–25%, grade II–66%, grade III–85%).

Conclusion

ED may need more repetitive interventions than LTRCG due to restenosis. Less restenosis might be observed when balloon is used for dilatation and cold knife for mucosal incisions.     

小儿喉气道阻塞的诊断与处理

目的：探讨小儿喉气道阻塞的病因、临床特点及其处理方法。方法：分析6例不同原因引起喉气道阻塞息儿的临床资料,总结其临床特点及处理方法。结果：6例患儿中先天性喉囊肿3例;先天性喉蹼（声门型）1例;先天性舌根囊肿1例,先天性环状软骨畸形1例。除1例先天性舌根囊肿外余例均于术前或术中行气道切开,2例先天性喉囊肿行支撑喉镜下囊肿切除术,1例行喉裂开囊肿切除术。1例先天性舌根囊肿,表面麻醉后直接喉镜下穿刺抽取囊液。1例先天性喉蹼行支撑喉镜下CO2激光切除喉蹼,4例患儿均于术后1周堵管,堵管2周拔管。1例先天性环状软骨畸形予喉裂开置喉模术,术后7周堵管,现术后2个月,堵管随访中。结论：小儿喉气道阻塞在明确病因后应早期积极采取适当的手术治疗方法,去除狭窄、重建气道,对改善通气和发音、恢复小儿正常的喉气道功能极其重要。     

Surgical management of laryngotracheal stenosis in adults

The purpose was to evaluate the outcome following the surgical management of a consecutive series of 26 adult patients with laryngotracheal stenosis of varied etiologies in a tertiary care center. Of the 83 patients who underwent surgery for laryngotracheal stenosis in the Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital of Lausanne, Switzerland, between 1995 and 2003, 26 patients were adults (16 years) and formed the group that was the focus of this study. The stenosis involved the trachea (20), subglottis (1), subglottis and trachea (2), glottis and subglottis (1) and glottis, subglottis and trachea (2). The etiology of the stenosis was post-intubation injury ( n =20), infiltration of the trachea by thyroid tumor ( n =3), seeding from a laryngeal tumor at the site of the tracheostoma ( n =1), idiopathic progressive subglottic stenosis ( n =1) and external laryngeal trauma ( n =1). Of the patients, 20 underwent tracheal resection and end-to-end anastomosis, and 5 patients had partial cricotracheal resection and thyrotracheal anastomosis. The length of resection varied from 1.5 to 6 cm, with a median length of 3.4 cm. Eighteen patients were extubated in the operating room, and six patients were extubated during a period of 12 to 72 h after surgery. Two patients were decannulated at 12 and 18 months, respectively. One patient, who developed anastomotic dehiscence 10 days after surgery, underwent revision surgery with a good outcome. On long-term outcome assessment, 15 patients achieved excellent results, 7 patients had a good result and 4 patients died of causes unrelated to surgery (mean follow-up period of 3.6 years). No patient showed evidence of restenosis. The excellent functional results of cricotracheal/tracheal resection and primary anastomosis in this series confirm the efficacy and reliability of this approach towards the management of laryngotracheal stenosis of varied etiologies. Similar to data in the literature, post-intubation injury was the leading cause of stenosis in our series. A resection length of up to 6 cm with laryngeal release procedures (when necessary) was found to be technically feasible.     

Laryngotracheoplasty in the management of subglottic stenosis

Laryngotracheoplasty (LTP) has revolutionized the surgical management of subglottic stenosis in children. A 10-year review of patients at the Children's Hospital of Philadelphia yielded 27 patients who had undergone a LTP. LTP with an anterior cartilage graft was utilized in over 80% of procedures. Morbidity was minimal, and there were no deaths. In this series, 78% of patients have been successfully decannulated. LTP has reduced the time necessary for decannulation in children with chronic tracheostomies as a result of subglottic stenosis.     

Non-intubation traumatic laryngotracheal stenosis: management policies and results

Traumatic laryngotracheal stenosis (LTS) is increasing in clinical practice. Causes include external trauma, post-intubation, and iatrogenic injuries. It is a complex problem and many patients undergo multiple procedures to achieve a stable and well-protected airway with adequate voice. We present our experience at Ain-Shams University Hospitals on 15 patients followed-up for 7 years. All patients had traumatic LTS excluding post-intubation injuries. Patients were aged 4–58 years. Nine were the victims of road traffic accidents; five were occupational trauma victims; and one tried to commit suicide by strangulation. The patients underwent a total of 53 procedures (mean 3.5 per patient). A total of seven laryngotracheal reconstruction, six partial cricotracheal resection, and four laser recanalization with stenting were performed. Six patients have mean follow-up of 26.5 months (3–60 months). Six patients had normal speech (GRBAS 0–5), three had a moderate degree of voice disturbance (GRBAS 5–10), and five had severe dysphonia (GRBAS > 10). As regards tolerance for daily activities, we used a modification of the McMaster University asthma quality of life questionnaire [Rea et al. Eur J Cardiothorac Surg 22(3):352, 2002] (using the activities and emotional scores total 112). Four patients could perform above the 90th percentile; all the remaining patients were above the 50th percentile. No patient was totally handicapped as a result of their airway problem and they could tend for their basic activities. The aim of this work is to demonstrate that non-intubation traumatic LTS is a complex problem that usually needs a longer time for reconstruction and a different way of approach. However, most of the patients can be finally rehabilitated with a stable, protected airway and adequate voice albeit at the price of a prolonged series of interventions and a long follow-up.     

Management of subglottic stenosis in the adult

Twenty-one adult patients were surgically treated for severe subglottic stenosis refractory to endoscopic treatment. Patients were treated by anterior or anterior and posterior cricoid division with costal cartilage grafting. Seventy-six percent of the patients were successfully decannulated. Success of treatment was not dependent on cause of the stenosis or age or sex of the patient. There was a significantly better outcome (p less than .05) in patients with isolated subglottic stenosis versus those with combined glottic and subglottic stenosis.     

The management of subglottic stenosis in patients with wegener's granulomatosis

Wegener's granulomatosis (WG) is a multisystem inflammatory disease characterized by vasculitis, granuloma formation, and necrosis. Among 158 patients treated at the National Institutes of Health during the past 24 years, 145 (92%) had an otolaryngologic manifestation of their disease and 25 (16%) had subglottic stenosis (SGS). SGS varied from asymptomatic to life-threatening. Sixteen (80%) of 20 patients with fixed SGS required surgical intervention, including manual dilations, carbon-dioxide laser resections, and laryngotracheoplasty (LTP). LTP was performed with and without microvascular reconstruction. Thirteen of the patients required tracheostomy and all 13 were ultimately decannulated. Five patients who repeatedly failed dilations and/or endoscopic laser surgery underwent LTP. Since 1987, two patients have undergone LTP with microvascular free flaps. Both patients were subsequently decannulated. The authors' experience demonstrates that management of SGS in WG is complex, requiring individualized frequent multimodality interventions to achieve satisfactory results. Microvascular laryngotracheal reconstruction should be considered in the surgical armamentarium for patients with persistent stenoses.     

Chronic subglottic and tracheal stenosis: endoscopic management vs. surgical reconstruction

Laryngotracheal stenosis has been and remains one of the most vexing problems in the field of head and neck surgery. Two treatment modalities prevail, endoscopic and external. The indication for each modality is not yet clearly defined. This undefined situation motivated our current work, and we decided to assess laser-assisted endoscopy (with or without stenting) vs. open surgery for treating chronic laryngotracheal stenosis. Our study included 28 cases of chronic laryngotracheal stenosis that were classified according to treatment in two main groups: group I included 13 patients who were endoscopically treated and group II included 15 patients with surgical reconstruction. The mean follow-up period was 12.58 months for group I and 27.43 months for group II. Respiratory function tests (RFT) were carried out preoperatively, 1-month postoperatively and on completion of follow-up. Except for age, which was significantly higher in group I (P<0.001), there was no significant difference between both groups. Although the incidence of complications was higher in group I (69%) than in group II (47%), it was nonsignificant. The postoperative RFT improved significantly in both groups. Although the improvement was higher in group I than group II, the difference was nonsignificant. The correlation between preoperative stridor and all other variables demonstrated that preoperative stridor correlated with the diameter of the stenosed segment (rs=-0.631, P<0.001) and the peak expiratory flow rate (PEFR) (rs=-0.488, P=0.030). Our results indicate that open surgery is the treatment of choice. Compared with endoscopic treatment, it provides a higher success rate and better functional results, especially long term. However, if contraindications to open surgery exist, whether local or general, laser-assisted endoscopy with stenting can offer good palliative results.     

Wegener's granulomatosis and subglottic stenosis: management of the airway

Wegener's granulomatosis is a multisystemic disease characterized by foci of necrotizing vasculitis and granuloma formation. Subglottic stenosis may occur either as a presenting feature or a late-stage manifestation of the disease, but will occur in approximately 10-20 per cent of cases. We present a series of seven cases of Wegener's granulomatosis with subglottic stenosis and discuss our management of this condition. Where there is active disease, tracheostomy is the first-line surgical treatment of respiratory obstruction, as an adjunct to full medical therapy. More aggressive or elaborate surgical treatments should be reserved for non-active cases in which patients have not required medical treatment for one year.