Laryngotracheal Resection and Reconstruction

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Just as reconstruction of the carina presented unusual difficulties, so did the proximal end of the airway. When tracheal lesions also affect the subglottic larynx, the anatomic and functional characteristics of that structure offer special problems. Many otolaryngologic procedures were developed to manage inflammatory stenosis at this level, when conservative measures failed. The latter measures included dilation, stents, intubation, steroid injection, cryotherapy, and laser surgery. Surgical procedures that were devised included anterior and posterior cricoid splits, placement of stents, mucosal and cutaneous grafts, free grafts of cartilage and hyoid, pedi-cled hyoid, cutaneous flaps variously supported with cartilage, and multistage "trough" procedures. These many operations will not be reviewed here, but, in general, success was limited.161

A one-stage approach to subglottic stenosis characterized by cricoid involvement developed slowly. The initial work was done by otolaryngologists, but full development of the techniques was accomplished by thoracic surgeons who faced the problem of subglottic stenosis as it presented in the spectrum of post intubation tracheal stenosis. Conley removed the entire cricoid in 1953 for a chondroma, preserving the mucoperichondrium, which was held in place by a foam rubber stent.67 Great care was taken to avoid injury to the recurrent laryngeal nerves. Shaw and colleagues resected damaged or stenotic cricoids in 2 patients with anastomosis to the thyroid cartilage.27 Existing vocal cord paralysis simplified the problem in these patients. Ogura and Roper apposed the second tracheal ring to thyroid cartilage after subtotal excision of traumatically scarred and stenotic cricoid in 2 patients.94 The recurrent nerves were paralyzed, ary-tenoidectomy was done, and a stent was used postoperatively. The distal trachea was mobilized and the thyrohyoid muscles and constrictors, which are attached to the thyroid cartilage, were divided to assist in approximation. Subperichondrial cricoid resection avoided injury to the recurrent nerves.95 Six of 7 patients with chronic subglottic stenosis were helped by this procedure.

In 1974, Gerwat and Bryce placed the upper line of resection for stenosis at the lower border of the thyroid cartilage anteriorly, and through the posterior cricoid lamina below the cricothyroid joints posteriorly.162 Thyrohyoid release was added and believed to be important. Four patients were so treated. In 1975, Pearson and colleagues followed the same line of cricoid resection, but rongeured all but a thin shell of posterior lower cricoid plate, sutured the ends of the first intact cartilaginous ring of trachea together, and inset this into the rongeured groove to form the laryngotracheal anastomosis (Figure 5).163 Recurrent nerves were preserved. Superior laryngeal release was done, and a splinting T tube was added postopera-tively. Six patients were successfully treated. Couraud and colleagues, in 1979, added 4 patients, all but one successful (Figure 6).164 They pointed out that there was no use in disturbing the recurrent nerves, that sometimes the posterior cricoid cartilage did not need to be tailored, and that tracheostomy was not regularly necessary. Grillo, in 1982, described 18 patients with subglottic stenosis treated with a somewhat modified procedure.161 In patients with anterolateral stenosis, a simple bevelled cricoid resection was sufficient, and the tracheal cartilage to be anastomosed was obliquely tailored to fit easily. For circumferential stenosis, scar over the posterior cricoid plate was excised and the raw area resurfaced with a broad-based flap of posterior membranous tracheal wall shaped for this purpose. Neither laryngeal release nor tracheostomy was routinely needed.

In 1992, Grillo and colleagues reviewed 80 patients who underwent one-stage laryngotracheal resection and reconstruction for subglottic stenosis by these techniques: 50 with postintubation lesions, 7 from trauma, 19 idiopathic, and 4 others.165 Thirty-one patients required circumferential resection with posterior flap resurfacing. There were 2 failures. If glottic correction was also needed, it was done initially as a separate procedure. Maddaus, with Pearson's group, proposed synchronous glottic reconstruction where that was

Laryngotracheal Reconstruction

figure 5 F. Griffith Pearson, MD, Chief of Thoracic Surgery and Surgeon-in-Chief Emeritus, Toronto General Hospital, and Professor of Surgery Emeritus, University of Toronto. Dr. Pearson, who founded and led the Thoracic Surgical Division in the Toronto General Hospital, early became interested in tracheal surgery. He contributed richly to the understanding and treatment of postintubation stenosis, to the development of one-stage laryn-gotracheal reconstruction, and to our knowledge ofadenoid cystic carcinoma.

figure 5 F. Griffith Pearson, MD, Chief of Thoracic Surgery and Surgeon-in-Chief Emeritus, Toronto General Hospital, and Professor of Surgery Emeritus, University of Toronto. Dr. Pearson, who founded and led the Thoracic Surgical Division in the Toronto General Hospital, early became interested in tracheal surgery. He contributed richly to the understanding and treatment of postintubation stenosis, to the development of one-stage laryn-gotracheal reconstruction, and to our knowledge ofadenoid cystic carcinoma.

also required, reporting 15 such cases of 53 subglottic repairs.166 They also adopted the posterior tracheal membranous wall flap described by Grillo and his colleagues.161,165 Monnier and colleagues proved this type of repair to be useful in children.167

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