Primary Reconstruction of Airway after Resection of Subglottic Laryngeal and Upper Tracheal Stenosis

Eighteen patients with low subglottic laryngeal stenosis and upper tracheal stenosis underwent resection of the anterior and lateral cricoid cartilage and upper trachea with reconstruction by primary laryngotracheal anastomosis. The posterior cricoid plate and recurrent laryngeal nerves were preserved. The distal trachea was tailored obliquely with an anterior prow and was anastomosed to the thyroid cartilage anteriorly and to the residual cricoid posteriorly. Where the stenosis was circumferential, scarred mucosa was resected from the anterior surface of the posterior cricoid lamina and the defect covered with a tailored flap of membranous tracheal wall.In 14 patients the lesions followed intubation injury. In 2 the stenosis was idiopathic. One stenosis resulted from inhalation burn and one from localized amyloidosis. Many patients had undergone previous surgical repairs.Sixteen patients had good to excellent results from six months to five and one-half years later. Reconstruction of the burned airway failed. One additional patient is still under treatment with a T tube.     

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)     

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.     

Bilateral adductor vocal cord paresis following endotracheal intubation for general anaesthesia

Recurrent laryngeal nerve palsy is a rare complication of endotracheal intubation. We report a case of bilateral vocal cord palsy following endotracheal intubation for general anaesthesia. The clinical picture was of hoarseness and aspiration suggestingpartialparesis, as complete bilateral recurrent laryngeal nerve palsy usually causes acute airway obstruction due to unopposed vocal cord adduction. Compression of the anterior branch of the recurrent laryngeal nerve between the cuff of the endotracheal tube and the posterior part of the thyroid cartilage was the likely mechanism. Ensuring that the cuff of the endotracheal tube is distal to the cricoid cartilage and that the pressure in the cuff is kept to the minimum required to prevent a gas leak should prevent this complication.     

THE MANAGEMENT OF POSTERIOR GLOTTIC STENOSIS FOLLOWING ENDOTRACHEAL INTUBATION

Four patients with bilateral vocal cord fixation due to isolated posterior glottic stenosis that developed following endotracheal intubation are presented. Two patients had previously undergone multiple endoscopic surgical procedures without obtaining a satisfactory airway. All four were treated by posterior cricoid split and costal cartilage interposition and were successfully decannulated. The assessment of vocal cord immobility following endotracheal intubation is presented and the surgical management of posterior glottic stenosis discussed.     

Applied anatomy for cricothyrotomy and tracheostomy

If upper respiratory obstruction cannot be cleared by other means, puncture of the cricothyroid ligament offers rapid access to the airway via the gap between the cricoid and thyroid cartilages; both of which can be readily palpated in the midline of the fully extended neck. The opening can be made with a knife, a wide bore needle or trocar, or by means of a special intubation kit. It is important to be able to identify the midline structures of the fully extended neck: the hyoid bone, at the level of the third cevical vertebra; the laryngeal notch and the laryngeal prominence, at the fourth cervical vertebra; below which lies the isthmus of the thyroid cartilage; with the depression of the cricothyroid membrane below this. This depression lies above the easily felt cricoid cartilage (the only complete ring of cartilage in the respiratory tree) at the level of the sixth vertebra. Below this can be felt the rings of the trachea. The isthmus of the thyroid gland usually crosses the second to fourth rings but cannot normally be felt unless enlarged. Formal tracheostomy is a relatively major surgical operation and is seldom indicated as an emergency. However, a mini-tracheostomy kit is now available for a percutaneous emergency procedure.     

声门下喉气管良性狭窄的临床分型及外科治疗

目的探讨良性声门下喉气管狭窄(SLTS)的临床分型和外科治疗方法。 方法回顾2010年1月至2014年8月上海交通大学附属胸科医院治疗的30例良性SLTS患者,其中男性21例,平均年龄47岁,合并气管食管瘘3例。根据病变上缘位置分为4型：Ⅰ型-环状软骨下缘、Ⅱ型-环状软骨前壁、Ⅲ型-环状软骨环周、Ⅳ型-临近或累及声带。 结果所有患者中,Ⅰ型6例、Ⅱ型10例、Ⅲ型13例、Ⅳ型1例。治疗方式包括1例内镜保守治疗、3例气管切开、11例T管置入、15例SLTS节段切除并一切吻合重建。一期根治手术的15例患者中,Ⅰ型病变5例,Ⅱ型4例,Ⅲ型5例,Ⅳ型1例,其中1例Ⅱ型患者术后出现再狭窄,T管支撑6个月后成功脱管,1例Ⅲ型和1例Ⅳ型患者手术失败,分别转为T管支撑和气管切开,总体脱管率86.7%(13/15)。单纯T管治疗患者通气满意。全组无死亡病例。 结论声门下部分喉气管联合切除手术可有效治愈Ⅰ～Ⅲ期良性SLTS,对于无法耐受外科手术治疗的,Montgomery T型硅酮支架是很好的临时或终末治疗手段。     

Resection of thyroid carcinoma infiltrating the trachea.

We have treated surgically 11 patients with thyroid carcinoma that had infiltrated into the trachea. Three patients had primary tumours, and eight had recurrent tumours after previous operations. Sleeve resection of trachea was performed where thyroid carcinoma had proliferated; the trachea was reconstructed by end-to-end anastomosis. In two patients 10 rings of the trachea were resected. In three patients the anterior half of the cricoid cartilage was resected along with the cervical trachea. In one patient tracheoplasty was performed using partial extracorporeal circulation because severe tracheal stenosis prevented endotracheal intubation. Two of the 11 patients died from the surgery and one from disseminated metastases. One patient who had undergone tracheal resection for thyroid carcinoma three years and five months previously had a recurrence of the tumour in the trachea adjacent to the anastomosis, and a second tracheal resection was performed. In three patients postoperative laryngeal stenosis occurred. Five patients are alive and well two years and one month to four years and seven months after their operations. The histological pattern of the tumour was papillary adenocarcinoma in all 11 patients.     

Thyroidectomy Using Pure Natural Orifice Transluminal Endoscopic Surgery in a Porcine Model

Surgical procedures for thyroid disease that provide cosmetically acceptable results are in demand. Natural orifice transluminal endoscopic surgery (NOTES) is performed through natural orifices and thus avoids incision of the body wall. This study aimed to develop an incision‐free surgical procedure for thyroid lobectomy using pure NOTES with an oral approach. In six pig carcasses, an incision was made between the mandible and subcutaneous tissue under direct vision. After subcutaneous dissection and identification of the hyoid bone, the operative field was developed under endoscopic view. After the thyrohyoid membrane was identified, dissection was continued along the thyroid cartilage until the cricoid cartilage was identified and the thyroid isthmus was reached. An original retractor was inserted between dissected tissues to lift and fix the carcass. The thyroid gland was successfully removed through the incision. Similar macroscopic and histological findings were observed on the normal and treated sides, with no damage to the recurrent laryngeal nerves. The times required for securing the operative field and thyroidectomy improved with each operation. This study suggests the feasibility and safety of using pure NOTES for thyroidectomy through a subcutaneous route with an original retractor.     

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.     

A case of subglottic tracheal stenosis following tracheostomy successfully treated with laryngo-tracheal anastomosis]

A 77-year-old male patient underwent laryngo-tracheal anastomosis for subglottic tracheal stenosis. He developed exertional dyspnea 10 month after tracheostomy. Anterior and lateral wall of the cricoid cartilage and the first two tracheal cartilages were resected, preserving the recurrent laryngeal nerves. The distal trachea was anastomosed to the thyroid cartilage primarily and tracheostomy was made at 6th tracheal ring. Postoperatively, anterior flexion of the neck was maintained for a week. Oral intake was started on the 2nd postoperative day. The patient showed smooth recovery. The important points of this operation are: 1) preoperative evaluation of the residual subglottic space, 2) intraoperative care for preservation of the recurrent nerves, especially at the lateral sides of the crycoid cartilage, and 3) postoperative maintenance of the cervical anterior flexion.     

Vascular-pedicled costal cartilage graft for the treatment of subglottic and upper tracheal stenosis

Background/purpose

Free costal cartilage graft for the treatment of subglottic and tracheal stenosis is widely used, but postoperative granulation formation is a problem. To reduce the risk of granulation formation after free costal graft, a new operation of costal cartilage graft with vascular pedicle was introduced.

Methods

A vascular pedicled fifth costal cartilage graft is prepared using internal thoracic artery and vein and intercostal artery and vein as a vascular pedicle. The prepared graft is brought to the upper trachea. The anterior wall of cricoid is split, and the costal cartilage graft is implanted to the split part and tracheostomy. Extubation on the next day is possible if the general condition of the patient permits.

Results

In 3 cases of subglottic or upper tracheal stenosis, this operation was performed. All the patients had tracheostomy made during early infancy. The postoperative course was uneventful, and all the patients were extubated soon after the operation. No granulation tissue was obserbed by postoperative bronchoscopic examinations.

Conclusions

Costal cartilage graft with vascular pedicle is a safe and useful new operation for the treatment of subglottic and upper tracheal stenosis. There also is a possibility of using this procedure for the treatment of long segment tracheal stenosis.     

Cricoid split for subglottic stenosis in infancy

Historically, tracheostomy has been used for infants with airway obstruction caused by congenital or acquired subglottic stenosis. Postoperative morbidity and mortality with this provisional operation led Cotton, in 1980, to substitute anterior cricoid split as the primary definitive procedure. Within the past three years, anterior cricoid split has been performed in 4 infants, aged 3 to 9 months, with acquired (3 patients) or congenital (1 patient) subglottic stenosis requiring ventilation through an endotracheal tube. Following cricoid split, the trachea is stented for 12 to 14 days by a nasotracheal tube, with extubation and rigid bronchoscopy in the operating room with the patient under anesthesia to confirm healing and patency. During an 18- to 24-month follow-up in these 4 patients, morbidity has been minimal, patency has persisted, and stridor has not recurred. Accordingly, a conclusive operation, cricoid split, rather than a temporizing tracheostomy may be employed for certain obstructive tracheal lesions early in life.     

Aerocele, an unusual complication of anterior cricoid split.

Since its introduction, the anterior cricoid split has proven to be a safe and effective procedure for the management of infants with acquired subglottic stenosis. In this article we report an unusual complication--an aerocele, which occurred on the 14th day following an anterior cricoid split on a 9-month-old child. The possible etiology and successful management of the aerocele are reviewed.     

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.     

Pediatric laryngotracheal stenosis

Severe laryngotracheal stenosis (LTS) in children is a problem of increasing incidence in the past 15 years, following the widespread adoption of prolonged endotracheal intubation for respiratory support. Rarer cases of stenosis secondary to external trauma, high tracheotomy, thermal and chemical burns, and dystrophic cartilage are seen. In contrast to congenital subglottic stenosis, where conservative therapy is generally indicated, severe, mature LTS often requires surgical correction--either endoscopic or external reconstruction. The prevailing attitude has been to perform a tracheotomy and hope for decannulation after 1 or 2 years, due to the expected growth of the larynx. This attitude developed from experience with congenital subglottic stenosis. Unfortunately, acquired LTS tends to be a much more severe problem than congenital subglottic stenosis; the degree of obstruction is usually greater and loss of cartilaginous support of the airway commonly occurs. Some of the acquired lesions are so severe that often no lumen is demonstrable. In such cases no amount of growth will allow extubation. A variety of endoscopic methods such as dilation, with or without resection using diathermy, cryotherapy, or laser, or steroid injection are certainly helpful in the early phases of wound healing while granulation tissue is still present or while the scar tissue is still soft and pliable. To deal with the mature, hard, fibrous unresponsive scar, various authors have proposed different approaches both endoscopic and external reconstruction. The present study discusses a unique experience of external laryngotracheal reconstruction (LTR) in 100 children. In the evaluation of LTS, a thorough endoscopic evaluation is required using both flexible and rigid endoscopic techniques.(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.     

Fracture of the cricoid cartilage after Sellick's manoeuvre

We report a case of fracture of the cricoid cartilage associated with cricoid pressure during rapid sequence tracheal intubation in a patient with status asthmaticus. This patient had a history of laryngeal trauma 48 yr previously. Fracture of the cricoid cartilage has not been reported previously after cricoid pressure.      

A case of thyroid carcinoma required the incision of the thyroid cartilage for inserting the silicone T tube after extensive tracheal resection and reconstruction

A 57-year-old female with thyroid carcinoma, who had developed tracheal stenosis, underwent extensive tracheal resection and reconstruction. After the tracheal sleeve resection 5.2 cm in length, primary tracheal reconstruction was performed. Although complication did not occur at the anastomotic site, the patient had dyspnea due to cord dysfunction by bilateral recurrent nerve paralysis. After 20 days transnasal intubation we reoperated to perform a tracheostomy under neck incision. But the reconstructed trachea was too short to pull out from the mediastinum. In order to insert the silicone T tube, the incision of thyroid cartilage must be done and vocal cords were injured. The patient inserting the T tube through the laryngeal stoma had no dyspnea and no aspiration about two years after the operation in spite of palliative operation. It seemed likely that the trouble that tracheostomy could not be done would occur in some patients who had undergone extensive tracheal resection and reconstruction. But the insertion of silicone T tube through the laryngeal stoma provided a satisfactory result for airway problem.