Composite Nasal Septal Graft Research Articles

Subglottic widening using a rotated H-shaped cricotracheal split for composite nasal septal cartilage grafting

IntroductionVarious open surgical techniques have been previously described for subglottic stenosis. These techniques usually involve steroid injections, endoscopic dilatations, flaps, and placement of intraluminal stents. A retrospective review was conducted on 20 patients with subglottic stenosis who underwent surgical widening using composite nasal septal grafts utilizing a rotated H-shaped cricotracheal split and temporary tracheotomy without stenting. Tracheotomy was performed for patient safety. All patients maintained patent airways with wide subglottic area throughout the follow-up period. All of them were extubated or decannulated 28–33 days after surgery by removing the tracheostomy tubes. All patients started antireflux treatment on the first postoperative day and steroid inhalation 2 weeks after surgery, which was maintained for 3 months. No patients underwent further procedures. All 20 patients were decannulated and were doing well at the time of writing. To conclude, composite nasal septal cartilage grafts with a rotated H-shaped cricotracheal split for subglottic stenosis in selected cases is a viable and effective option.ContextThe most common sequel after reconstructive procedures may be restenosis of different degrees. Recurrent narrowing may be due to healing by marked fibrosis, which is a result of postoperative infection, perichondritis in the graft or recipient site, with resorption of the augmenting cartilage graft. Intraluminal stenting predisposes to infection, subperichondrial abscesses, and devitalization of the cartilage graft by friction and infection. Inadequate graft size, thickness, or method of fixation may be other factors for failure.AimThe aim of the study was to present the indications, surgical technique, and results of composite nasal septal cartilage grafts using a rotated H-shaped cricotracheal split for patients with subglottic stenosis.Patients and methodsThis is a retrospective review. A series of 20 patients who underwent composite nasal septal cartilage grafts without stenting from 2009 to 2014 were reviewed. They suffered from subglottic and upper tracheal stenosis: 13 patients had subglottic stenosis due to rhinolaryngeoscleroma (seven male and six female patients), five patients had postintubation upper tracheomalacia and stenosis (one male and four female patients), and two male children had congenital subglottic stenosis. Postoperative data included mortality and morbidity rate, success of decannulation, need for repeat tracheotomy or Montgomery T-tube placement, and number of additional airway procedures.ResultsThe operative time ranged from 1.5 to 3.25h with a mean of 2.2 h. Blood loss ranged from 85 to 290 cm3, with a mean of 150 cm3. Hospitalization was 3 days in all patients with discharge on the third postoperative day, except for two children with congenital subglottic stenosis who stayed for 1 week. There were no major complications. Wound infection in two patients around the tracheotomy tube was evident 10 days after surgery, which was well controlled by parentral antibiotic and local antiseptic measures. Chest infection was recorded in five patients as mild to moderate tracheobronchitis, which resolved 1 week after surgery, except for the case of a 53-year-old female patient who progressed to bronchopneumonia after discharge, which resolved after 10 days. Return to normal life activity or work was possible in all patients after 2–3 weeks; however, 14 patients preferred home stay until tube removal. Weaning started 4 weeks after surgery and was successful within 1 week in all patients except for the two children, whose tubes were removed after 2 weeks of gradual weaning. Five patients experienced mild shortness of breath shortly after extubation, which increased with effort. They received steroid inhalation two to three times a day for 2 weeks with improvement in symptoms. During the follow-up period all patients sustained normal breathing, except for seven scleroma patients who after 4–7 months complained of mild dyspnea, which increased slightly with effort and prevailed thereafter. Follow-up flexible laryngoscopy detected mild mucosal edema and little granulation tissue around the grafted area at the time of extubation. These granulations were more evident and encroached slightly on the airway in the five patients who suffered from mild dyspnea shortly after extubation and regressed markedly after 2 weeks of steroid inhalation. There was rapid mucosal healing of nasal septal mucosa and laryngeal mucosa, which was nearly complete at 6 weeks after surgery, with a markedly wide subglottic area. Later on, endoscopic examination detected mild lumen narrowing in seven scleroma patients who complained of mild dyspnea 4–7 months after surgery. These patients showed no more narrowing on endoscopic examination through their subsequent months of follow-up. No other new symptoms developed in the follow-up period. No patient needed further surgical intervention.ConclusionComposite nasal septal cartilage grafting with a rotated H-shaped cricotracheal split is a viable and successful option for selected cases of laryngotracheal stenosis. The use of a stent with its associated morbidities is avoided with this technique. No additional endoscopic or open procedures were needed in any of the cases; successful decannulation in less than 1 month could be achieved.

Tracheal reconstruction with autogenous composite nasal septal graft

We describe lateral resection of tracheal tumors and repair of the defect with a composite graft of nasal septal mucosa and cartilage. The preliminary experience with this technique in 3 patients was satisfactory. The procedure can be used for patients who are not candidates for standard resection and end-to-end anastomosis.

Single‐Stage Adult Laryngotracheal Reconstruction Without Stenting

To present the indications, surgical technique, and results of single-stage laryngotracheal reconstruction (SSLTR) without stenting for laryngotracheal stenosis (LTS) in adults. Various open surgical techniques have been previously described for LTS in adults; however, these techniques usually involve placement of intraluminal stents. The practice of early extubation without stenting is common for pediatric SSLTR. The success of this technique in the pediatric population has led to a trial of the same technique in selected cases of adult LTS. Retrospective review. A retrospective review was conducted on 15 patients with glottic, subglottic, or tracheal stenosis or a combination of these, who underwent SSLTR with composite nasal septal grafts or costal cartilage grafts without stenting. All patients were extubated or decannulated 1 to 7 days after surgery. Three of the 15 patients had no further procedures. Three patients had a second SSLTR to repair stenosis at a different level with no further difficulties. Eight patients had additional endoscopic airway procedures after extubation or decannulation, and one patient died in the immediate postoperative period. All 14 surviving patients are decannulated and well at the time of writing. For LTS in selected adult cases, SSLTR without stenting is a viable option. Indications, surgical technique, and complications are presented.

Reconstruction of the Glottis by Composite Nasal Septal Graft

Educational objectives: To review the indication of partial vertical laryngectomies for carcinoma of the anterior commissure of the larynx and selected Tl of the vocal cords, and to acquire a better understanding of how to use the nasal septal graft in the glottis reconstruction.

Free composite nasal and auricular grafts for laryngotracheal reconstruction

Use of free auricular grafts for repair of laryngeal and tracheal stenosis preceded that of free composite nasal septal grafts by a few years. These grafts in theory fit well with the concept of vertical anterior opening of the stenotic segment and placing a tissue graft similar to that which had been diseased and scarred. Anterior and posterior vertical division of laryngotracheal stenosis following by dilation was performed in the 1920s by Rethi and others. Rethi noted that Galebsky, in 1927, performed an anterior and posterior cricoid split and wedged a portion of the sternocleidomastoid muscle into the anterior defect, followed by dilation to relieve patients of their stenosis. Rethi, in 1956, noted the most important principle for extensive stenoses was that “the scars of the larynx should remain untouched.” He departed from this principle only when total atresia was present.1 In the 1970s there were many reports of use of autogenous grafts, interposed anteriorly in the airway, leaving the scars untouched. This form of lumen augmentation usually resulted in airway improvement and decannulation. Today the most commonly used autogenous grafts are cartilage and bone either free, composite, or pedicled with soft tissue from various anatomic sites. The purpose of this article is to discuss the use of free composite auricular and nasal septal grafts for the repair of the stenotic larynx and trachea. Use of free auricular grafts for repair of laryngeal and tracheal stenosis preceded that of free composite nasal septal grafts by a few years. These grafts in theory fit well with the concept of vertical anterior opening of the stenotic segment and placing a tissue graft similar to that which had been diseased and scarred. Anterior and posterior vertical division of laryngotracheal stenosis following by dilation was performed in the 1920s by Rethi and others. Rethi noted that Galebsky, in 1927, performed an anterior and posterior cricoid split and wedged a portion of the sternocleidomastoid muscle into the anterior defect, followed by dilation to relieve patients of their stenosis. Rethi, in 1956, noted the most important principle for extensive stenoses was that “the scars of the larynx should remain untouched.” He departed from this principle only when total atresia was present.1 In the 1970s there were many reports of use of autogenous grafts, interposed anteriorly in the airway, leaving the scars untouched. This form of lumen augmentation usually resulted in airway improvement and decannulation. Today the most commonly used autogenous grafts are cartilage and bone either free, composite, or pedicled with soft tissue from various anatomic sites. The purpose of this article is to discuss the use of free composite auricular and nasal septal grafts for the repair of the stenotic larynx and trachea.

Laryngotracheal reconstruction with composite nasal septal cartilage grafts.

The composite nasal septal graft has been used successfully by us to reconstruct patients with high tracheal and laryngotracheal stenosis. We have treated ten patients and have been able to decannulate seven of these patients. When these ten cases are added to the six original cases presented in an earlier report (1981), certain conclusions can be drawn. The success or failure of these procedures, which is judged by the ability to decannulate the patient, appears to be related to the extent of the initial injury. We discuss the indications for the composite nasal septal graft and the use of additional treatment, including stents, steroid injections, dilatations, and flaps. In conclusion, the addition of these ten cases to the original six cases of composite nasal septal grafts now provides the opportunity to review indications and contraindications for the use of this graft in the management of advanced laryngotracheal stenosis.

Panel discussion: the management of advanced laryngotracheal stenosis. Composite nasal septal graft in the management of advanced laryngotracheal stenosis.

Reconstruction of the larynx and trachea is most often needed after conventional methods of repair have failed. The advanced stenotic lesion can be adequately corrected with a composite nasal septal graft in a one stage procedure. Severe glottic stenosis from crush injuries or following partial laryngectomy, subglottic stenosis, and high tracheal stenosis are most amenable to this type of reconstruction. The surgical technique is presented, and six cases of clinical utilization are reviewed.

Reconstruction of Congenital Subglottic Stenosis with a Composite Nasal Septal Graft

An 18 year-old male was admitted to the authors' hospital for the treatment of a difficulty in decannulation for 16 years after tracheostomy, which had been made for a subglottic stenosis due to congenital malformation of the laryngeal cartilage.The stenosis was removed by laryngofissure, and a “trough” was made in the operated area by using a silicone T-tube as a stent. Seven months postoperatively, transplantation of a composite graft of the nasal septum was made to cover the anterior defect of the subglottic airway. Reconstriction of the airway has not been observed for seven months after the second operation.

Composite nasal septal graft reconstruction of the partial laryngectomized canine.

Composite nasal septal grafts provide excellent autogenous replacement tissue for the partial laryngectomy defect. The added factor of a mucosa similar to that removed appears advantageous for preservation of the airway. Arytenoid preservation or replacement tends to improve glottic rehabilitation by pseudocord formation. It is believed that the composite nasal septal graft would be of special advantage in the patient who had received previous irradiation.