儿童喉气管狭窄的治疗

分析19年来42例儿童后天性喉气管狭窄，年龄自15个月到14岁，平均8岁。主要病因有气管切开术后；喉气管外伤；复发性喉乳头状瘤术后；气管内插管等。全部病例狭窄严重，依靠气管切开呼吸。采用不同的喉气管重建术。结果40例病人经1～18年随访，36例（90．0％）拔除气管套管，治愈。结论：①提高气管切开术技术，可以减少儿童喉气管狭窄发病率；②3岁以上儿童可以进行喉气管重建术；③手术方式的选择必须根据喉气管狭窄病变而定。     

儿童喉气管狭窄的病因分析及治疗方法的选择

目的:为提高儿童喉气管狭窄、闭锁的治疗效果,总结了不同部位和范围的狭窄、闭锁患儿的手术方法。方法:共分析了58例儿童喉气管狭窄,年龄15个月-15岁,最多见病因是气管切开术后,其次有喉气管外伤;复发性喉乳头状瘤术后;气管内插管等。全部病例依靠气管切开通道呼吸。根据喉气管狭窄的范围和程度,采用了不同的喉气管重建术。结果:58例中53例(91.4%)经1-5次手术后治愈,拔除气管套管,恢复正常的呼吸功能,随访1-10年,手术效果巩固,儿童发育正常。结论:正确的掌握气管切开技术可以减少儿童喉气管狭窄的发病率。由于儿童喉气管狭窄病情更加复杂多变,术中应根据病变的范围和程度选择适当的手术方法,方能获得满意效果,重建喉气管支架和消除粘膜创面是提高疗效的关键。     

喉硬结病的临床特点与治疗

目的　探讨喉硬结病的临床特点和治疗方法。方法　回顾性分析 1981年 5月～ 2 0 0 2年12月收治的 4 3例经病理证实的喉硬结病患者的临床资料和治疗方法。结果　 4 3例中声嘶 4 3例次、呼吸困难 19例次。喉部病变以萎缩期为主 2例 ,肉芽肿期为主 35例 ,瘢痕期为主 6例。主要病变局限于声门区 13例 ,局限于声门下区 1例 ;累及声门上区和声门区 18例 ,累及声门区和声门下区 8例 ,声门上区、声门区和声门下区均受累 3例。采用抗生素治疗 2 4例 ,手术治疗 7例 ,放射治疗 2例。采用抗生素治疗 2 4例中 ,18例治愈 ,另 2例复发后再进行抗生素治疗治愈 ;2 4例中 4例伴 2度或 3度喉阻塞者行预防性气管切开术。 1例伴 2度喉阻塞的肉芽肿期患者采用手术和抗生素结合的方法治愈。 6例伴喉狭窄的瘢痕期患者通过手术成形治愈。 1例采用放射治疗后 4年复发 ,1例抗生素治疗无效的患者采用放射治疗与抗生素结合的方法治愈。结论　硬结病可侵犯喉部导致发声困难和喉阻塞 ,抗生素治疗对多数喉硬结病患者有效 ,治疗后有必要进行长期随访。对喉硬结病导致瘢痕性喉狭窄的患者需手术成形。     

Dynamic tissue expansion of the larynx in a canine model

OBJECTIVES: To test whether staged, progressive, monitored, dynamic tissue expansion is possible in the larynx and to evaluate its effectiveness in dilating and augmenting constricting cicatricial lesions. DESIGN: Animal study. SETTING: Research facility, tertiary care medical center. SUBJECTS: Thirteen dogs, 3 with laryngotracheal stenosis. INTERVENTIONS: Dogs underwent laryngeal splits, tracheostomy, and insertion of inflatable stents. In 7 normal dogs, stents were progressively inflated by air in predetermined increments during 11 days. In 3 normal dogs and 3 with laryngotracheal stenosis, stents were gradually expanded by water. Stents were kept in place for 21 days. After removal, dogs were observed for 25 days. Five died of complications of tracheostomy. MAIN OUTCOME MEASURES: Airway diameter measured by endoscopy before the induction of stenosis, before the laryngeal splitting procedure, after stent removal, and before euthanasia. RESULTS: The lumen increased, then shrank somewhat after stent removal. In 2 surviving dogs with laryngotracheal stenosis and water-expanded stents, the lumen was 82.5% larger than baseline at stent removal and 71.0% larger at euthanasia. In 2 surviving normal dogs with water-expanded stents, lumen size increased by 50.0% at stent removal, and in 1 dog surviving to day 46, it was 17.0% larger. In 5 surviving dogs with air-inflated stents, lumen size was 39.0% larger at stent removal and 8.0% larger at day 46. Histologically, fibrous tissue developed in the gaps between the splayed margins of the laryngeal cartilages. CONCLUSIONS: The larynx may be dynamically expanded. Although the maximal diameter is not maintained, final cross-sectional areas are larger.     

手术治疗呼吸道硬结病19例报告

为探讨手术治疗呼吸道硬结病的疗效，对经手术治疗的19例呼吸道硬给病患者的临床资料进行回顾分析。结果提示，对病变严重，且增殖致鼻腔、咽部阻塞或病变侵及鼻窦的肉芽肿期患者，手术与抗生素配合使用有助于提高疗效；对伴Ⅱ度以上喉阻塞者应行气管切开术；对后遗鼻腔、咽、喉及气管瘢痕性狭窄或闭锁的患者需手术成形。并就手术注意事项进行讨论。     

喉硬结病的临床特点与治疗

目的探讨喉硬结病的临床特点和治疗方法。方法回顾性分析1981年5月～2002年12月收治的43例经病理证实的喉硬结病患者的临床资料和治疗方法。结果43例中声嘶43例次、呼吸困难19例次。喉部病变以萎缩期为主2例，肉芽肿期为主35例，瘢痕期为主6例。主要病变局限于声门区13例，局限于声门下区1例；累及声门上区和声门区18例，累及声门区和声门下区8例，声门上区、声门区和声门下区均受累3例。采用抗生素治疗24例，手术治疗7例，放射治疗2例。采用抗生素治疗24例中，18例治愈，另2例复发后再进行抗生素治疗治愈；24例中4例伴2度或3度喉阻塞者行预防性气管切开术。1例伴2度喉阻塞的肉芽肿期患者采用手术和抗生素结合的方法治愈。6例伴喉狭窄的瘢痕期患者通过手术成形治愈。1例采用放射治疗后4年复发，1例抗生素治疗无效的患者采用放射治疗与抗生素结合的方法治愈。结论硬结病可侵犯喉部导致发声困难和喉阻塞，抗生素治疗对多数喉硬结病患者有效，治疗后有必要进行长期随访。对喉硬结病导致瘢痕性喉狭窄的患者需手术成形。     

Traumatic laryngotracheal stenosis--an alternative surgical technique

Reconstruction of combined laryngotracheal stenosis requires complex techniques including resection and incorporation of grafts and stents that can be performed as single or multistaged procedure. A complicated case of traumatic laryngotracheal stenosis was managed by us, surgical technique is discussed. A 16-year-old male presented with Stage-3 laryngotracheal stenosis of grade-3 to 4 (>70% of the complete obstruction of tracheal lumen) of 5 cm segment of the larynx and trachea. Restoration of the critical functions of respiration and phonation was achieved in this patient by resection anastomosis of the trachea and with subglottic remodeling. Resection of 5 cm long segment of trachea and primary anastomosis in this case would have created tension at the site of anastomosis. So we did tracheal resection of 3 cm segment of trachea along with subglottic remodeling instead of removing the 5 cm segment of stenosed laryngotracheal region and doing thyrotracheal anastomosis. In complicated long segment, laryngotracheal stenosis, tracheal resection and subglottic remodeling with primary anastomosis can be an alternative approach. Fibrin glue can be used to support free bone/cartilage grafts in laryngotracheal reconstructions.     

Management of suprastomal tracheal obstruction following : a case report

To demonstrate the importance of proper pre operative assessment of laryngotracheal stenosis especially if it acquired one. It also demonstrates the fact that the available treatment modalities for laryngotracheal obstruction can be easily modified as per the clinical presentation for better post operative results. Here we present a case of tracheal stenosis following percutaneous tracheostomy where there was suprastomal tracheal obstruction which was managed in an interesting way to give good post operative results. The obstruction was due to impaction of the first tracheal ring in the stoma which was fused to the posterior tracheal wall. The obstructing tissue was excised and tracheal lumen was established. New tracheostomy was made lower down and the previous stoma was closed. By proper pre operative evaluation and assessment of the unique pathomechanism of stenosis in this case we could operate the above case by simply excicing the obstructing tissue and establishing a lumen instead of resorting to other demanding operations for stenosis of larynx that often lead to complications.     

喉气管狭窄的手术治疗

目的 探讨喉气管狭窄的手术方法及疗效。 方法 回顾分析山东省千佛山医院耳鼻咽喉头颈外科2009至2015年16例喉气管狭窄手术的临床资料,其中3例喉气管钝性挫伤、1例喉乳头状瘤术后反复狭窄、1例喉癌术后肉芽生成分别实施支撑喉镜下CO₂激光切除术。1例喉癌术后气管内鳞癌、多形性腺瘤及气管腺样囊性癌在鼻内镜下行切除术。1例长时间气管内插管致气管狭窄及1例气管囊腺癌者行气管袖状切除断端吻合术。1例气管腺样囊性癌、2例甲状腺癌及1例气管外伤后狭窄行喉气管重建术。1例食管癌晚期致喉狭窄及1例喉气管外伤老年患者行镍钛记忆合金支架植入术。 结果 随访12~24个月,除2例外,其余患者均手术后拔管。其中1例喉气管重建术放置T形管后肉芽再次生长;另1例镍钛记忆合金支架植入术后出现排异反应,取出支架,此2例均无法拔管,自动出院后失访。 结论 喉气管狭窄的手术治疗应根据狭窄的位置及程度选择不同的手术方法,可获得良好的效果。     

Glottic and subglottic stenosis from endotracheal intubation

As a result of increased use of prolonged endotracheal intubation, complications of intubation are now being seen more often. Stenosis of the airway may develop at the level of the glottic or subglottic larynx, or in the trachea. Discussions of management do not always distinguish clearly between laryngeal stenosis and tracheal stenosis. Yet, these are two separate entities. Discussions of laryngeal stenosis usually deal with subglottic stenosis, with less emphasis on obstruction at the glottic level. Of 20 patients, 14 adults and six children, with stenosis of the larynx secondary to intubation, we were successful in establishing adequate airways in 16. An analysis of these 20 patients leads to the following conclusions:

• 1 Scarring in the glottic posterior commissure between the arytenoid cartilages is a frequent cause of laryngeal stenosis after intubation.
• 3 Endoscopic management can be successful in many cases if it is started early enough, and repeated as often as is necessary. The earlier it is begun, the better the results will be.
• 3 Indwelling stents which are extremely valuable in laryngeal stenosis from external trauma, may not be as useful in stenosis from endotracheal tube trauma.

     

Laryngotracheal stenosis and restenosis. What has the influence on the final outcome?

The aim of this study is to analyze the impact of various parameters on the course and treatment outcome in patients with laryngotracheal stenosis and recurrent stenosis. Two groups of patients were compared: Group I included 29 patients with primary stenosis, and Group II included 22 patients with recurrent stenosis. The most frequent etiological factor for the development of stenosis was prolonged endotracheal intubation (79.3:77.3%), with subglottic-tracheal (44.8:45.5%) and tracheal (48.3:36.4%) localization being the most affected. Subglottic-tracheal stenosis was more common in men. There were no significant differences between the groups in regard to the grade of lumen obstruction and the length of the resected segment. In male patients, the length of the resected stenotic segment was significantly longer. Subglottic-tracheal stenoses were longer than tracheal ones. Various surgical procedures were performed, with additional management of recurrent laryngeal nerve paralysis, if necessary. Laryngotracheal reconstruction (LTR) with costal cartilage grafting (CCG) was statistically significantly more often performed in Group II, while cricotracheal resection (CTR) was more common in Group I. The incidence of complications in Group I was 24.1%, and in Group II it was 31.8%. Satisfactory airway lumen with undisturbed breathing was achieved in 93.1% of patients in Group I, and in 95.3% in Group II. Since the success rate was similar in both groups of the patients, it could be concluded that treatment outcome depends less on the factors associated with the stenosis, and more on adequate choice of surgical procedure and surgical team know-how.     

Buccal mucosa graft for laryngotracheal reconstruction in severe laryngeal stenosis

Objective

An operative technique is described as a salvage treatment for severe subglottic and supraglottic laryngeal stenosis. In addition to expansion of the laryngeal framework with an anterior cartilage graft, as used in a classical laryngotracheal reconstruction, the scar tissue obliterating the airway lumen is excised and a mucosal graft is placed to reconstruct the inner lining of the airway. The graft is harvested from buccal mucosa.

Methods

The operative technique is outlined. Three cases, 2 paediatric and one adult, with complete or near complete laryngeal stenosis are presented where this operative technique was employed. In all patients several surgeries had been performed previously which were unsuccessful.

Results

In all 3 patients a patent airway was achieved with decannulation of the tracheostomy in the 2 paediatric patients.

Conclusions

In patients with severe subglottic or supraglottic airway stenosis where other surgeries have failed, excision of endoluminal scar tissue and placement of a buccal mucosal graft, in addition to conventional laryngotracheal reconstruction, is a promising technique. In revision cases of subglottic stenosis cricotracheal resection might not be an option because of scarring from previous surgeries. This operation is an alternative, which allows an increase in the airway lumen by excising the scar tissue then re-lining the exposed internal lumen. The buccal mucosa reduces granulation formation and re-stenosis.     

Ten-year review of laryngotracheal reconstruction for paediatric airway stenosis

OBJECTIVES: To review the outcomes of paediatric patients with laryngotracheal stenosis treated at our institution by laryngotracheal reconstruction (LTR). METHODS: A single surgeon personal series retrospective review of case notes over a 10-year period from a single site tertiary referral paediatric otolaryngology department in patients with laryngotracheal stenosis treated with laryngotracheal reconstruction. Evaluation was based on the last laryngotracheal endoscopy, and a retrospective review of the patient's data. RESULTS: Seventy-three open laryngotracheal procedures were undertaken for paediatric laryngotracheal stenosis from the period 1995-2005. Fourteen were cricoid split operations and will be described elsewhere. The remaining 59 procedures were cartilage graft laryngtracheal reconstructions, performed on 53 patients (37 single stage and 16 staged) with 6 having required revisions. CONCLUSIONS: LTR provides good results for subglottic stenosis (SGS) as primary or salvage operations. The procedure has no deleterious effects on laryngeal growth. The causes of failed procedures are discussed.     

Isolated adult supraglottic stenosis: surgical treatment and possible etiologies

Isolated supraglottic stenosis in adults without a history of laryngeal injury is a rare and poorly described clinical entity. We report a case of a 61-year-old woman who presented with near total airway obstruction and a diagnosis of an epiglottic mass. She required a tracheotomy for definitive airway control. Initial diagnostic laryngoscopy and biopsies revealed isolated supraglottic stenosis due to fibrosis with acute and chronic inflammation. The patient had a medical history of gastroesophageal reflux disease and hiatal hernia and no history of laryngeal trauma. Transoral supraglottic laryngectomy was required for definitive treatment. Isolated supraglottic stenosis may be seen in children with congenital laryngotracheal anomalies, as a sequelae of prolonged orotracheal intubation or after laryngeal trauma or tumor surgery. Other causes may include autoimmune and inflammatory disorders. Gastroesophageal reflux disease may also contribute to the disease process of isolated supraglottic stenosis. Supraglottic laryngectomy is a feasible treatment option for isolated supraglottic stenosis and may allow for tracheostomy decannulation.     

Update of the Cincinnati experience in pediatric laryngotracheal reconstruction

Surgical endeavors in the field of laryngotracheal reconstruction in children have received much interest in the past 15 years. A unique experience with laryngotracheal reconstruction in 203 children is reviewed. The majority (194) of the cases were classified as acquired; only nine were classified as congenital. Excluded from the study were those cases of stenoses managed endoscopically, all resections and end-to-end anastomoses, all anterior cricoid split procedures, and all cases of anterior glottic stenosis repaired by a laryngeal keel. The degree of stenosis was graded into four categories. Five different methods of laryngotracheal reconstruction were used depending on the pathologic lesion in the larynx and trachea. Of the 203 children, 186 (92%) were decannulated. The results support the use of laryngotracheal reconstruction in children with grades 2, 3, and 4 laryngeal stenosis.     

Surgical treatment of children with cicatricial stenoses of the larynx and trachea

The present authors recommend a modification of Ivanov's method suggested by their treatment of 41 children, aged 4 to 15 years; 12 patients suffered from stenosis and 29 patients from atresia of the larynx and trachea, which resulted from surgical intervention required by the complications of extended nasotracheal intubation and subsequent tracheotomy. The modified procedure is as follows. In order to enlarge the laryngeal or tracheal lumen, skin is cut and one or two triangle-shaped skin flaps are dissected; their tops are sutured to the anterior wall of the above organs cut along the median line. In order to distend the larynx, redressment of the cricoid cartilage is needed. He-Ne laser irradiation (of 20 mW/cm2 with a wavelength of 632.8 nm) and collagenase and elastase enzymes stimulate repair and prevent secondary cicatrization of post-operative wound. The lumen is formed using a T-shaped silicon tube. Out of 4 patients followed-up during the last 5 years, 21 were decannulated, 12 developed good laryngotracheostoma, 5 of which required suture of wound. Only 8 patients who had laryngotracheostoma needed surgical intervention due to repeated cicatrization. In 4 of these patients, allogenic cartilage was used for support, and polymer paste Polytel was applied to eliminate laryngeal, tracheal or esophageal fistulas.     

Outcome of endoscopic management of extensive laryngotracheal stenosis

OBJECTIVES: When performing endotracheal intubation or tracheotomy in unconscious patients in emergent situations, one should consider the possibility of the later complication of laryngotracheal stenosis, which can result in difficulties with decannulation. We analyzed the clinical features of laryngotracheal stenosis to search for its possible etiologic factors and its proper preventive methods. METHODS: The medical records of 249 cases of laryngotracheal stenosis out of 2,208 patients who underwent tracheotomy in our hospital during the past 12 years were retrospectively reviewed regarding several parameters, such as the duration of endotracheal intubation, site of tracheostoma, site of stenosis, treatment method, and so forth. RESULTS: Non-otolaryngologists had a tendency to place the tracheostoma at a higher level of the trachea. We identified technical precautions that should be taken into consideration in performing an emergency tracheotomy. Bronchoscopic evaluation and tracheal stent insertion was the most commonly used treatment method. Successful decannulation was achieved in about 70%, and was especially frequent in patients whose endotracheal intubation was less than 20 days. CONCLUSIONS: It is desirable that the duration of endotracheal intubation be limited to less than 20 days. A database of patients who undergo tracheotomy should be submitted to careful follow-up to diagnose early development of laryngotracheal stenosis and to prevent long-term complications.     

Clinical application of in situ tissue engineering using a scaffolding technique for reconstruction of the larynx and trachea

OBJECTIVES: The objective of the present study was to demonstrate the efficacy of the clinical application of in situ tissue engineering using a scaffolding technique for laryngeal and tracheal tissue. METHODS: We have developed a tissue scaffold made from a Marlex mesh tube covered by collagen sponge. Based on successful animal experimental studies, in situ tissue engineering with a scaffold implant was applied to repair the larynx and trachea in 4 patients. RESULTS: In 1 patient with subglottic stenosis, the thyroid cartilage, cricoid cartilage, and cervical trachea with scarring and granulation were resected and reconstructed by use of the scaffold. In 3 patients with thyroid cancer, the trachea and cricoid cartilage with tumor invasion were resected and the scaffold was implanted into the defect. Postoperative endoscopy during the observation period of 8 to 34 months showed a well-epithelialized airway lumen without any obstruction. CONCLUSIONS: Our current technique of in situ tissue engineering using a scaffold shows great potential for use in the regeneration of airway defects.     

The endoscopic treatment of postintubation laryngeal stenosis in children,using argon plasma coagulation

Laryngeal stenosis of the larynx in children is becoming a more frequent problem. Endoscopic dilation of the lumen of the larynx is one of the many methods of treatment. The authors present their own method for the treatment of postintubation laryngeal stenosis by argon plasma coagulation (APC). The investigation was based on ten children with postintubation laryngeal stenosis from I to IV degrees according to the Myer-Cotton grading system. The method of treatment, and the advantages and disadvantages of the new method of endoscopic treatment of postintubation laryngeal stenosis, are discussed in the article.     

严重颈部闭合性损伤致喉气管断裂的救治体会(附8例报告)

从1976年12月到1996年9月,我们救治了8例严重闭合性损伤致喉气管断裂的患者,男6例,女2例,年龄13～36岁,平均24岁。结果2例死亡,1例死于出血窒息,另1例尚未来得及手术而死亡;1例因救治不当发生喉气管狭窄而需进一步整复,其余5例恢复了喉的功能。强调在修复术中应最大限度地保留破碎的软骨膜、软骨和粘膜。本文重点讨论严重颈部闭合性损伤致喉气管断裂的发病机理、临床特点及急救原则。