Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present.

BACKGROUND: Subglottic stenosis is an ancient but persistent problem as a cause of airway obstruction. The etiology and the results of surgical treatment with thyrotracheal anastomosis were reviewed. METHODS: Fifty-six patients with subglottic stenosis were studied. All were subjected to laryngotracheal reconstruction by thyrotracheal anastomosis with partial resection of the cricoid. RESULTS: Of all 56 cases of subglottic stenosis, 48 (86%) had history of previous tracheal intubation, and only 8 (14%) had different non-neoplastic obstructive processes such as scleroma, direct injury, hamartoma, and amyloidosis. Immediate results were good in all cases. After 1 year follow-up, results of thyrotracheal anastomosis were successful in 44 (91%). In 4 other cases a restenosis was observed. Eight patients were lost to follow-up. CONCLUSIONS: Subglottic stenosis is still frequent after tracheal intubation, but other causes must be considered. Laryngotracheal reconstruction with thyrotracheal anastomosis with partial cricoid resection was feasible with good results in 91% of the cases with follow-up, but this procedure must be performed by a skilled surgical team.     

Laryngotracheal resection and reconstruction by Grillo's technic for postintubation stenosis]

BACKGROUND: Tracheal resection and reconstruction is the standard treatment for postintubation stenosis. However, when the stenosis extends proximally to the subglottic larynx surgical treatment is particularly difficult. Specific surgical techniques have to be used in order to preserve the recurrent laryngeal nerves. The aim of this study is to evaluate the results obtained at our Department with laryngotracheal resection and reconstruction with the Grillo technique for postintubation stenosis. METHODS: From January 1984 to December 1997, 83 patients with tracheal and laryngotracheal lesions underwent surgical treatment. Eighteen patients had postintubation stenosis of the upper trachea and subglottic larynx and underwent single-stage laryngotracheal resection and reconstruction. Mean stenosis length was 3.5 cm (range 3-5 cm). Twelve patients underwent anterolateral laryngotracheal reconstruction, and 6 patients had a circumferential laryngotracheal reconstruction. A Montgomery suprahyoid laryngeal release was required in 4 cases. RESULTS: There was no surgical mortality. Surgical results were excellent or good in 17 cases and satisfactory in one case. No recurrence of stenosis has been observed. CONCLUSIONS: Cricoid cartilage involvement in postintubation stenosis should not be considered a contraindication to surgical treatment. However, laryngotracheal resection and reconstruction is technically difficult and should be performed only in selected cases.     

Laryngotracheal stenosis

Laryngotracheal stenosis is a nonspecific term implying the presence of airway compromise involving the larynx, trachea, or both. This is usually the result of scar formation with the associated morbidity dependent on the location, extent, and thickness of the tissue. Because of this variability, a single treatment protocol cannot be recommended. The procedure used to correct the stenosis must be tailored to the case in question. This paper reviews the treatment of laryngotracheal stenosis. specifically focusing on the variables in the preoperative assessment that must be considered in selecting an appropriate treatment plan.     

Laryngotracheal stenosis

Laryngotracheal stenosis is a nonspecific term implying the presence of airway compromise involving the larynx, trachea, or both. This is usually the result of scar formation with the associated morbidity dependent on the location, extent, and thickness of the tissue. Because of this variability, a single treatment protocol cannot be recommended. The procedure used to correct the stenosis must be tailored to the case in question. This paper reviews the treatment of laryngotracheal stenosis, specifically focusing on the variables in the preoperative assessment that must be considered in selecting an appropriate treatment plan.     

Thyroid alar cartilage laryngotracheal reconstruction for severe pediatric subglottic stenosis

BACKGROUND/PURPOSE: Laryngotracheoplasty has become an accepted treatment alternative for subglottic stenosis. However, the best autogenous material for laryngotracheoplasty remains controversial. Autogenous superior thyroid alar cartilage (TAC) has been used successfully in single stage laryngotracheal reconstruction in children with subglottic stenosis. METHODS: This is a retrospective study of 6 children (mean age, 16.6 months) undergoing TAC graft laryngotracheoplasty between September 1995, and June 1999. Two children had immediate tracheal intubation for congenital subglottic stenosis. Four others had previous tracheostomy: 3 for severe postintubation subglottic stenosis and 1 for congenital subglottic stenosis. After an anterior cricoid split, a piece of TAC was sutured between the cut ends of the cricoid, with the graft perichondrium facing intraluminally. Endotracheal intubation was maintained postoperatively. RESULTS: Four children underwent successfully extubation 9 to 21 days (mean, 15.5 days) postoperatively. Two required tracheostomy, which was maintained because of severe laryngomalacia and laryngotracheobronchomalacia. One child was treated with CO2 laser because of symptomatic recurrence of the subglottic stenosis 3 weeks after the surgery; another required fundoplication for gastroesophageal reflux 12 months after laryngotracheoplasty. There were no donor site complications in any of the 6 cases. Repeat laryngoscopy and bronchoscopy showed a patent subglottic airway. All of them are without symptoms after a mean follow-up of 26 months. CONCLUSIONS: (1) This preliminary experience indicates that the TAC graft technique is a viable option for laryngotracheal reconstruction; (2) the TAC graft has significant advantages, including a single operative incision and absence of donor-site morbidity.     

Total cricoidectomy and laryngotracheal reconstruction for subglottic stenosis with glottic involvement

We present a case of subglottic stenosis involving the glottis with inflammatory destruction of the cricoid cartilage after prolonged endotracheal intubation. Total cricoidectomy and laryngotracheal anastomosis were performed with T-tube placement that was retained for five months postoperatively. After decannulation of the T-tube, the airway was well restored, with good vocal cord opening. Good respiratory and phonatory results were obtained during normal daily activity, although a slightly hoarse voice was present, but no aspiration was observed. Total cricoidectomy and laryngotracheal reconstruction may be considered suitable for subglottic stenosis with glottic involvement, if accompanied by inflammatory destruction of the cricoid cartilage.     

Tracheal resection and reconstruction for tracheal stenosis

Five patients underwent surgery for tracheal stenosis. The cause of stenosis was congenital tracheal stenosis in 1 case, post-intubation tracheal stenosis in 1 case, and tracheal stenosis due to thyroid cancer invasion in 3 cases. All 5 patients required circumferential tracheal resection and end-to-end anastomosis using 4-0 or 5-0 absorbable sutures. The number of tracheal rings removed ranged from 3 to 6. There was no anastomotic complication. Technical points of this procedure were summarized as follows : 1) the circumferential dissection of the trachea should be made only at the level of the lesion that is to be excised, 2) preserve at least one side of recurrent nerve, 3) the traction sutures facilitate tensionless knot of the sutures, 4) prevention of excessive extension of the neck in the immediate postoperative period.     

Effect of stenting after laryngotracheal reconstruction in a subglottic stenosis model.

OBJECTIVES: This study addresses the impact of stenting on early wound healing after laryngotracheal reconstruction (LTR) in a rabbit model with established subglottic stenosis. METHODS: Subglottic stenosis was created in 42 New Zealand white rabbits through a transoral, endoscopic technique. Three weeks later, endoscopy and axial CT were performed to document and grade the degree of stenosis. Subsequently, LTR was performed in all animals, with half of the animals receiving an intraluminal stent. Four rabbits from each group were euthanized on postoperative days 6, 9, 14, 21, and 28. Measurements of graft vascularization were obtained with a computerized image measurement program, and a comparison was made regarding the rate of vascularization. RESULTS: There was a statistically significant increase in the rate of vascularization in the stented group (mean 75% +/- 5% vs 56% +/- 3% at day 14; P < 0. 05). However, clinical and radiographic comparisons of the stented and nonstented specimens revealed a trend toward increased mucosal edema and granulation tissue in the stented group at later time intervals (days 21 and 28). CONCLUSION: This analysis suggests that stenting does not inhibit graft vascularization in the early postoperative period after LTR; however, complications were seen in the stented group at longer time intervals.     

Partial cricotracheal resection for pediatric subglottic stenosis: long-term outcome in 57 patients

OBJECTIVE: We sought to assess the long-term outcome of 57 pediatric patients who underwent partial cricotracheal resection for subglottic stenosis. METHODS: Eighty-one pediatric partial cricotracheal resections were performed in our tertiary care institution between 1978 and 2004. Fifty-seven patients had a minimal follow-up time of 1 year and were included in this study. Evaluation was based on the last laryngotracheal endoscopy, the responses to a questionnaire, and a retrospective review of the patient's data. The following parameters were analyzed: decannulation rates, breathing, voice quality, and deglutition. RESULTS: A single-stage partial cricotracheal resection was performed in 38 patients, and a double-stage procedure was performed in 19 patients. Sixteen patients underwent an extended partial cricotracheal resection (ie, partial cricotracheal resection combined with another open procedure). At a median follow-up time of 5.1 years, the decannulation rates after a single- or double-stage procedure were 97.4% and 95%, respectively. Two patients remained tracheotomy dependent. One patient had moderate exertional dyspnea, and all other patients had no exertional dyspnea. Voice quality was found to improve after surgical intervention for 1 +/- 1.34 grade dysphonia (P < .0001) according to the adapted GRBAS grading system (Grade, Roughness, Breathiness, Asthenia, and Strain). CONCLUSIONS: Partial cricotracheal resection provides good results for grades III and IV subglottic stenosis as primary or salvage operations. The procedure has no deleterious effects on laryngeal growth and function. The quality of voice significantly improves after surgical intervention but largely depends on the preoperative condition.     

Anterior cricoid split for subglottic stenosis

Subglottic stenosis is a common problem that often results from ventilatory support necessary in the premature infant. Previous methods of treatment include tracheostomy with dilatation of the stenosis, steroid injections, and procedures to stent the trachea. Results of these methods have been unsatisfactory because of the multiple procedures needed to obtain an adequate airway as well as the high mortality from long-term tracheostomy in infants. In the past 2 years, seven infants have undergone an anterior cricoid split for tight subglottic stenosis and airway obstruction. Of the seven patients, six were premature, five of whom required ventilatory support ranging from 4 to 30+ days. Each child presented in respiratory distress with symptoms present in five children from 1 to 11 months (mean 3.8) after birth. Bronchoscopy identified the site of obstruction in each case as subglottic, with a narrow lumen, usually less than 2.5 mm in diameter. Anterior cricoid split was performed at ages ranging from 2 to 11 months (mean 5.0). All children were extubated at 10 to 14 days and subsequently discharged home asymptomatic; none required postoperative tracheostomy. Complications developed in five children, including atelectasis, otitis media, phlebitis, and tracheocutaneous fistula in two, one of whom required operative closure. One child was rebronchoscoped at 3 weeks postoperatively for bronchospasm, which resolved on aminophylline. The subglottic trachea was normal. At follow-up ranging from 2 to 21 months (mean 8.3), no child has symptoms referrable to the subglottic region. In one patient, a brief period of respiratory distress recurred 3 months postoperatively due to tracheomalacia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Changing trends in neonatal subglottic stenosis.

OBJECTIVES: To determine whether there are any changes in the incidence and management of neonatal subglottic stenosis (SGS). METHODS: A retrospective chart review of 416 infants who were admitted to the neonatal intensive care unit of the Children's National Medical Center between July 1, 1995, and June 30, 1996, was carried out. The incidence of airway obstruction requiring anterior cricoid split or placement of tracheotomy tube was determined and compared with the incidence studied 10 years ago at the same institution. RESULTS: One of 416 neonates required surgical intervention for airway obstruction caused by SGS, for an overall neonatal SGS incidence of 0.24%. When only the neonates who were intubated for 48 hours or longer were considered, the incidence of SGS was 0.49% (1/204). In neonates who were intubated for 48 hours or longer and survived, the incidence of SGS was 0.63% (1/160). This is in comparison with the incidences of 0.65% (3/462), 1.5% (3/195), and 1.9% (3/159), respectively, seen in a study done at the Children's National Medical Center 10 years ago. Five infants in this current study required placement of a tracheotomy tube for reasons other than SGS. Two infants needed tracheotomy tube placement for micrognathia, and 3 others for central hypotonia, an omphalocele that required multiple surgical procedures, and choanal atresia with a serious heart anomaly, which was a manifestation of CHARGE association. None of these 5 infants had evidence of SGS at rigid endoscopy preceding the tracheotomy tube placement. CONCLUSION: The incidence and management of neonatal SGS remain unchanged during this study period when compared with those of 10 years ago.     

Laryngotracheal reconstruction in congenital laryngeal webs and atresias.

OBJECTIVE: To review the role of open laryngotracheal reconstruction (LTR) in congenital laryngeal webs and atresias. STUDY DESIGN AND SETTING: A retrospective chart review was undertaken in a specialist otorhinolaryngology unit in an academic tertiary referral paediatric hospital. Twenty-one patients with congenital laryngeal subglottic stenosis (SGS) underwent LTR between 1993 and 2003. Two groups were identified; one group had SGS alone (n = 6) and the other group had SGS associated with a laryngeal web (n = 15). Information recorded included presenting features, classification of lesion, surgery performed, and whether decannulation was achieved. RESULTS: All grades of stenosis (Myer-Cotton classification) and webs of type 2, 3, and 4 (Cohen's classification) were recorded. Fifteen patients had a staged reconstruction and 6 patients had a single-stage LTR. Complications included 2 revision procedures, 3 tracheocutaneous fistulas, and 1 death (cause unrelated). All appropriate patients were successfully decannulated at between 3 and 18 months post-LTR (median, 5 months). CONCLUSION: This series illustrates the effective role of open LTR in both congenital SGS alone and that in association with glottic webbing.     

Relief of subglottic stenosis by anterior cricoid resection: an operation for the difficult case

Anterior cricoid resection is an effective procedure to relieve subglottic stenosis. This is well documented in adults, although reports of the procedure in growing airways are limited. Over an 11-year period, seven pediatric patients underwent anterior cricoid resection for recalcitrant subglottic stenosis. In four patients, the stricture was secondary to prolonged intubation, one developed subglottic stenosis following a high placement of tracheostomy for epiglottitis and another had congenital subglottic stenosis. One child had subglottic stenosis combined with laryngotracheoesophageal cleft and more distally located tracheoesophageal fistula. All patients had failed to respond to previous treatment: dilatations (3 to 20), steroid injection (3 patients), and Evan's tracheoplasty (2 patients). All patients had an excellent result from anterior cricoid resection. The median age of children undergoing anterior cricoid resection was 3 years. There was no mortality. Tracheostomy decannulation was accomplished within 12 weeks following operation in all patients. It was necessary to remove a tracheal granuloma in one patient. Anterior cricoid wedge resection leaving the posterior portion of the cricoid in place is done to avoid recurrent nerve injury. It is a relatively simple and effective procedure. There has been minimal morbidity and no mortality. Follow-up from 1 to 11 years shows no recurrence of stenosis. There has been normal laryngeal and airway growth.     

Early and late dilatation for acquired subglottic stenosis

There has been widespread use of periodic dilatations in the management of subglottic stenosis. However, some authorities have questioned the value in the overall rehabilitation of patients affected by this disorder. The first phase of this study included fourteen large dogs in which acute subglottic lesions were created by use of a high-speed electric drill and electrocautery. Twelve animals served as the experimental group and two animals were controls. Obstructing lesions developed in all the animals within 7 to 21 days. When at least a 50% obstruction developed in an animal, a treatment plan was instituted that included at least weekly dilatation, removal of granulations, and administration of intralesional steroids and/or systemic steroids and antibiotics. The two control animals became totally obstructed and were killed. Varying degrees of subglottic stenosis developed in all twelve experimental animals after 8 weeks of dilatation, but none required a tracheotomy. These twelve animals were then subjected to 8 additional weeks of dilatation and antibiotics, and supplemental steroids were used in some animals from this study. It can be concluded that early periodic dilatation and granulation removal in the acutely injured subglottis is effective in prevention of severe stenosis, late periodic dilatations in chronic subglottic stenosis are not helpful in further alleviation of obstruction, the concomitant use of antibiotics and systemic steroids did not appreciably prevent or alter the development of subglottic stenosis, and the concomitant use of intralesional steroids appeared to be of benefit in the management of chronic acquired subglottic stenosis.