(see Chapter 14, "Infectious, Inflammatory, Infiltrative, Idiopathic, and Miscellaneous Tracheal Lesions"). Reconstructive procedures must be applied cautiously in certain diseases of unknown origin, such as Wegener's granulomatosis, which may have a progressive course despite surgery.
If the stenosis abuts the vocal cords without any free space in the immediate subglottic larynx (Figure 25-1E), it is not possible to perform a single-stage operation for correction. One must then resort to older, multistaged procedures which use the following elements in various combinations: laryngofissure, excision of scar tissue, placement of skin graft or buccal mucosal graft, insertion of a
figure 25-1 (continued) C, When subglottic damage involves the entire extent of the anterior cricoid, this portion of cricoid arch and lateral laminae must be excised. The distal trachea is tailored to repair the anterior arcuate defect. There is minimal or no involvement of the posterior cricoid. The membranous wall of the trachea may or may not be damaged. D, Circumferential stenosis involving the lower subglottic larynx posteriorly as well as anteriorly. Proximal extent of the stenosis varies widely and determines the feasibility of single-stage repair. The anterior portion of the stenosis is excised with the anterior cricoid arch. The posterior cricoid lamina is preserved in order to protect the recurrent laryngeal nerves. The internal ring of scar is excised from the posterior cartilaginous plate. The distal line of tracheal division fashions an anterior "prow" of cartilage, but preserves a broad-based flap of posterior membranous wall to resurface the bared posterior cricoid plate.
stent, anterior or posterior cricoid division, costal cartilage or hyoid bone grafts (pedicled or not).8,12 Such otolaryngological procedures are not within the scope of this discussion.
Otolaryngological consultation should be sought to assess subglottic strictures that involve the larynx. Complete and accurate assessment of vocal cord function and glottic adequacy must be made preop-eratively. In addition, it is important to identify and assess the severity of additional lesions that may be present, such as posterior commissural interarytenoid stenosis, and to appraise the size and quality of the subglottic space. If procedures are required to assure glottic competence (eg, vocal cord lateralization, figure 25-1 (continued) E, Extreme subglottic stenosis that extends circumferentially up to the vocal cords. No residual "atrium" remains beneath the glottis to which the distal airway can be satisfactorily anastomosed. Such lesions are treated surgically by laryngo-fissure, excision of scar, and resurfacing with buccal mucosa or skin, held with a temporary stent. Tracheal repair and reconnection usually is best done in a second procedure.
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