Partial Cricotracheal Resection Research Articles

Swallowing outcomes after tracheal resection and anastomosis: full versus mini infrahyoid laryngeal drop

IntroductionTracheal resection anastomosis has been established as the definitive surgery for high grade postintubation subglottic stenosis. To achieve a relaxed tension-free anastomosis, various laryngeal release techniques were discussed in literature with potential effect on postoperative swallowing dysfunction. This study aims to compare the difference in swallowing outcomes following two methods of infrahyoid laryngeal release: with and without fracture of the superior thyroid horns.MethodsA retrospective cohort study was carried out at our tertiary referral hospitals including cases with grade III and IV subglottic stenosis treated by partial crico-tracheal resection with thyro-tracheal anastomosis. The patients were divided into two groups according to the method used in laryngeal release; mini infrahyoid release (group A) or infrahyoid full release (group B) where full means with fracture of the superior thyroid horn bilaterally while mini means their preservation. Swallowing assessment preoperatively and postoperatively was done by comparing swallowing dysfunction symptoms, Gugging swallowing screen (GUSS) score and fiberoptic endoscopic evaluation of swallowing (FEES) according to penetration aspiration scale (PAS).ResultsA total of 71 patients were included; 46 in Group A and 25 in Group B. Clinical swallowing evaluation one week postoperatively showed statistically significant difference between the two groups being affected in 80.04% and 100% of patients in group A and B, respectively. The mean postoperative GUSS were 18 ± 1.32 in group A patients in comparison to 8.84 ± 5.18 in group B (p-value < 0.001). With FEES assessment, group A had full improvement of their swallowing abilities one month after the surgery while patients in group B had significantly lower PAS scores. Unfavourable scores for both the GUSS test and PAS were associated with increasing patients’ age in group B.ConclusionIn this retrospective cohort study, cases with mini infrahyoid laryngeal release had significantly better swallowing outcomes and full resolution of dysphagia in comparison to full laryngeal release. Also, full laryngeal release is associated with delayed resolution of swallowing difficulty in older patients. This point should be considered during preoperative patient selection and counselling.

Analysis of Complications in (Crico-) Tracheal Resection Anastomosis in Adults: A Multicenter Study.

The gold standard treatments for advanced laryngotracheal stenosis (LTS) are represented by partial crico-tracheal (PCTRA) or tracheal resection and anastomosis (TRA). These procedures are potentially burdened by high postoperative complication rates. We investigated the impact of the most common stenosis and patient-related characteristics on the onset of complications in a multicentric cohort. We retrospectively analyzed patients who underwent PCTRA or TRA for LTS of different etiologies in three referral centers. We tested the effectiveness of these procedures, the impact of complications on the outcomes, and identified factors causing postoperative complications. A total of 267 patients were included in the study (130 females; mean age, 51.46 ± 17.64 years). The overall decannulation rate was 96.4%. Altogether, 102 (38.2%) patients presented at least one complication, whereas 12 (4.5%) had two or more. The only independent predictor of post-surgical complications was the presence of systemic comorbidities (p=0.043). Patients experiencing complications needed additional surgery more frequently (70.1% vs. 29.9%, p < 0.001), and had a longer duration of hospitalization (20 ± 10.9 vs. 11.3 ± 4.1 days, p < 0.001). Six of 102 (5.9%) patients with complications had restenosis, although this event did not occur among patients without complications. PCTRA and TRA have an excellent success rate even when performed for high-grade LTS. However, a significant percentage of patients may experience complications associated with a longer duration of hospitalization or the need for additional surgeries. The presence of medical comorbidities was independently related to an increased risk of complications. 4 Laryngoscope, 133:2910-2919, 2023.

Revision surgery for laryngotracheal stenosis in children: A single center's 44 years experience.

Outcome measures of revision open airway surgery in pediatric laryngotracheal stenosis (LTS) are reported. Data on 46 pediatric LTS patients undergoing revision open airway surgery were collected retrospectively. The measured outcomes were decannulation rate, time to decannulation, postoperative complications, additional surgery to achieve decannulation, and functional results. The most common revision surgery was partial cricotracheal resection (PCTR) in 21/46, followed by extended PCTR (ePCTR) in 20/46, and laryngotracheal reconstruction (LTR) in 5/46 patients. A 90.7% overall decannulation rate (ODR) and a 74.4% operation-specific decannulation rate (OSDR) were achieved. Delayed decannulation was identified in children aged 5 years or less (p= 0.038) and in patients with previous primary open airway surgery (p= 0.039). Complications were observed in 52.2% of patients. To achieve optimal airway patency, additional open or endoscopic airway surgeries were necessary in 30.4% and 47.7% of patients, respectively. Age 5 years or less (p= 0.034), multiple comorbidities (p= 0.044), revision ePCTR (p= 0.023), and laryngeal stenting (p= 0.018) were risk factors requiring additional open surgery to achieve age-appropriate airway. Failed primary open airway surgery (p= 0.034) and comorbidities (p= 0.044) were risk factors for a higher rate of additional endoscopic surgeries. Postoperatively 63.0% of patients achieved normal breathing, 82.2% were dysphonic and 91.1% were orally fed. In this report, the patient's age under 5 years, previous primary open airway surgery, medical comorbidities, and laryngeal stenting had a significant negative impact on revision open airway surgery outcomes. Level 4 Laryngoscope, 133:3200-3207, 2023.

Partial Cricotracheal Resection - Our Experience.

Introduction: The incidence of acquired laryngotracheal stenosis is on rise, being caused usually due to prolonged intubation or trauma. Its management has thus become a common clinical challenge for Otolaryngologists and Head and Neck surgeons. Further, with advances in Critical care medicine, Cardiopulmonary surgery and Neurosurgery, the number of intubation-related laryngotracheal injuries is increasing. Objectives: To assess the outcome of patients who underwent Partial Cricotracheal Resection (PCTR) for subglottic stenosis on basis of pre-defined parameters. Design of Study: This is a prospective study. Materials and Methods: Four patients who came to Ear Nose Throat (ENT) department, All India Institute of Medical Sciences (AIIMS) Patna with complaints of either difficult decannulation or stridor, for which PCTR was planned, were included in the study. Surgical resection was done and all patients were followed up for a minimum of 6 months. Postoperatively certain parameters, such as respiration, voice, difficulty in swallowing, feeding and personal satisfaction, were used to evaluate the patients and analyse the efficacy of the surgery. Results: Three out of four cases came up with complete cure with no dyspnoea, dysphagia, hoarseness of voice. Only one patient could not be extubated and was continued on Ryle's tube for longer duration compared to other patients. Conclusion: PCTR is an effective and reliable procedure for management of laryngotracheal stenosis caused due to trauma.

Moderate grade subglottic stenosis in children: Laryngotracheal reconstruction versus cricotracheal resection and anastomosis.

ObjectiveThe surgical treatment of choice of pediatric moderate subglottic stenosis (major grade II and minor grade III SGS or 60–80% lumen obstruction) remains controversial. Laryngotracheal reconstruction (LTR) (with anterior ± posterior grafts for airway expansion) and partial crico-tracheal resection (PCTR) are the mainly described open surgical techniques. We reviewed our pediatric cases with moderate subglottic stenosis to determine the efficacy of LTR versus PCTR.MethodsA retrospective study of all children between 0 and 18 years that underwent open reconstructive airway surgery between 2012 and 2019. Children who had either acquired or congenital moderate subglottic stenosis (late grade II and early grade III: 60–80% lumen obstruction) were selected.ResultsTwenty-six children with moderate-grade subglottic stenosis were included. Seventeen were treated with LTR and nine with PCTR. No significant differences were observed between LTR and PCTR-treated cases. Decannulation rates were similar, as well as the functional results.ConclusionBoth LTR and PCTR are valid treatment options for moderate subglottic stenosis. This study indicates to perform the surgery that is most suitable for the characteristics of the patients’ stenosis, the surgeons’ expertise and preference, and the working infrastructure.

Clinical Outcomes in Partial Cricotracheal Resection and Anastomosis in Subglottic and Upper Tracheal Stenosis: A 10-year Institutional Study

Clinical Outcomes in Partial Cricotracheal Resection and Anastomosis in Subglottic and Upper Tracheal Stenosis: A 10-year Institutional Study

Pediatric Open Airway Reconstruction

Subglottic stenosis (SGS) and tracheal stenosis (TS) can be congenital or acquired. Ongoing improvements in neonatal care have led to an increased number of infants with prolonged intubation and tracheostomy. Both of these interventions have led to an increase in SGS and TS and management of these lesions can be challenging. A wide array of endoscopic and open techniques exist to manage these issues. This article aims to review previous and current literature on open airway reconstruction to guide care for these children. Experience and expertise in airway surgery have shifted recent research towards non-airway outcome measures such as swallowing and voice, though the primary treatment objective remains decannulation. Various open surgical options as slide tracheoplasty, laryngotracheal reconstruction, and partial cricotracheal resection and anastomosis are available for correcting laryngotracheal stenosis. The choice of the surgery should be based on demography and characteristics of the stenosis found during endoscopy and the associated comorbidities of the patient. Open airway reconstruction for treatment of LTS is effective but careful preoperative evaluation and patient selection are important. Ongoing research focuses on improving swallowing and voice outcomes.

Partial cricotracheal resection for congenital subglottic stenosis

Partial cricotracheal resection for congenital subglottic stenosis

Postoperative management of partial cricotracheal resection (PCTR) for subglottic stenosis with 15 cases in children

Postoperative management of partial cricotracheal resection (PCTR) for subglottic stenosis with 15 cases in children

Extended Partial Cricotracheal resection with thyrotracheal anastomosis in Grade IV subglottic stenosis with posterior glottic involvement

Extended Partial Cricotracheal resection with thyrotracheal anastomosis in Grade IV subglottic stenosis with posterior glottic involvement

Diagnosis and treatment of pediatric subglottic stenosis: evaluation of our treatment protocol

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The aim was to describe our experience in management of pediatric subglottic stenosis and formulate a management scheme based on our experience.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective study and follow-up was conducted in children diagnosed with subglottic stenosis (SGS) (both congenital and acquired) from January 2016 to January 2019 (36 months). We have proposed further subcategorization of each grade of SGS into mild and severe depending on absence or presence of the described “hard signs” respectively. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; A total of 28 patients with SGS were identified. 8 had congenital while 20 had acquired SGS. There were 16 cases of grade II, 7 cases of grade III and 5 cases of grade I stenosis. None had grade 4 stenosis. Most common surgical intervention was microlaryngoscopy and bronchoscopy which had both diagnostic and therapeutic role (in conjunction with other intervention). Other interventions were balloon dilatation, combined laser and balloon dilatation, anterior cricoid split, laryngotracheal reconstruction and Partial cricotracheal resection. As of July 2019, overall recovery rate was 89.2% and decannulation rate was 81.2%. One patient succumbed to death due to because unrelated to SGS. Two patients are still under follow-up.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Number of procedures increases with increasing severity of stenosis. Further subcategorization of SGS as mild or severe guides in selecting endoscopic or open surgical management scheme. The type of procedure for each patient needs to be tailored according to requirement.&lt;/p&gt;

Effect of partial cricotracheal resection and extended cricotracheal resection for severe laryngotracheal stenosis

Objective: To assess the outcomes of partial cricotracheal resection (CTR) and extended cricotracheal resection (ECTR) for severe laryngotracheal stenosis. Methods: From November 2009 to September 2017, 18 patients underwent CTR and ECTR at the Department of Otorhinolaryngology Head and Neck Surgery, Tangdu Hospital, Air Force Medical University for severe laryngotracheal stenosis were reviewed retrospectively. There were 12-male and 6-female patients, with the age ranged from 4 to 56 years (median 25 years). The causes were postintubation in 11 cases, cervical trauma in 4, idiopathic in 3. The stenosis located in subglottic and tracheal (n=12), glottic and subglottic and tracheal (n=3), subglottic (n=2), and glottic and subglottic (n=1). Two patients had concurrent unilateral vocal cord palsy.One patient had undergone previous endoscopic balloon dilation and 8 patients had previous laryngotracheal reconstruction. The stenosis was graded according to modified Myer-Cotton classification as follows: Ⅲb (n=1), Ⅲc(n=1), Ⅳa (n=2), Ⅳb (n=12), Ⅳc (n=2). The surgical outcomes and complications were recorded. Results: Among 18 patients,11 of the 12 patients undergoing CTR were decannulated. Five of the 6 patients undergoing ECTR were decannulated. Resected airway length ranged from 1.5 to 4.0 cm (median 2.8 cm). Surgical complications included infection of incision wound in 2 cases, anastomotic granulation in 2, cervical subcutaneous emphysema in 1, aspiration in 1, and unilateral arytenoid prolapse in 1. No recurrent laryngeal nerve injury or tracheoesophageal fistula occurred. The median follow up was 11 months. Conclusions: CTR is efficient for severe subglottic and upper tracheal stenosis while ECTR is efficient for subglottic stenosis extended to the glottis. Both procedures also provide a salvage therapy for patients with previous failed treatments.

Surgical emphysema leading to respiratory distress following partial cricotracheal resection for subglottic stenosis in a paediatric patient

Surgical emphysema leading to respiratory distress following partial cricotracheal resection for subglottic stenosis in a paediatric patient

Application of Surgiflo® in Tracheal Resection Anastomosis: Not Just a Hemostatic Agent But May Have a Potential Impact on the Healing Process

Background: Partial cricotracheal resection (PCTR) is considered the treatment of choice for high grade subglottic/tracheal stenosis. One of the principal surgical concern is non-tension water tight anastomosis with proper healing. Surgiflo® (Ethicon, Somerville, USA) is a commonly and safely used active flowable hemostatic matrix that may cause significant histopathological alterations, such as inflammation, adhesion and fibrosis, which may facilitate healing at the anastomotic site. Methods: We have reviewed our experience in Mansoura University Hospitals, Egypt; with the use of Surgiflo® in cases of PCTR. This study included 1 female patient with upper tracheal adenoid cystic carcinoma and 11 male patients with severe post-traumatic subglottic/tracheal stenosis. Significant comorbidities were reported in 6 adult patients (50%) in the form of neurological problems (n=3), COPD (n=2), OSAS (n=1), unilateral vocal fold paralysis (n=1) and morbid obesity (n=2). Eight patients (66.7%) had a history of previous airway surgery. The adopted surgical technique was standardized by the authors for all patients and Surgiflo® was applied at the end of surgery over the whole operative field including the anastomotic area. Findings: At the end of proper surgical intervention, 11 patients were successfully extubated with effortless breathing. None of the frequently reported complications like granulation tissue formation at the site of anastomosis, restenosis, surgical emphysema requiring intervention or wound seroma were reported in this series. On a follow up period of 6 - 12 months, 91.7% of the studied patients didn't have any further surgical intervention and all of them returned to their usual life activity. Interpretation: Direct Surgiflo® application in the operative field can be recommended as an adjuvant to surgery in patients undergoing PCTR especially when associated with comorbidities. Funding Statement: The authors stated: No. Declaration of Interests: No competing interest to declare. Ethics Approval Statement: A written consent was obtained from either the patient or the patient’s guardian. The study was approved by Mansoura faculty of Medicine Institutional Research Board (IRB: R.19.08.597).

Lyell’s syndrome as a factor which escalates the risk of laryngotracheal stenosis and atresia after intubation

Toxic epidermal necrolysis (TEN) also known as Lyell’s Syndrome is a rare, acute hypersensitivity reaction characterized by cutaneous and mucosal necrosis. Lyell’s syndrome is self limited, but potentially recurrent disease. The mortality for toxic epidermal necrolysis is approaching to 30%.[1] Subglottic stenosis is the most common anomaly of larynx and trachea requiring tracheostomy in pediatric population. Subglottic part of larynx is the narrowest section of laryngotracheal area of airways in childhood.[5] It is estimated that most of subglottic stenosis cases is acquired and developed as a result of injury caused by long-term use of endotracheal tube. A 2-year-old patient admitted to our Clinic of Children’s Otolaryngology after long treatment for TEN because of problems with breathing without tracheostomy tube. Because of the results of bronchofiberoscopy patient has been sent to our Clinic of Children’s Otolaryngology. We performed laryngotracheoscopy which showed transglottic, subglottic and proximal part of tracheal stenosis and complete atresia of trachea above tracheostomy tube. Result of MRI examination was described as complete atresia of trachea which was 4 mm long and located above tracheostomy tube. Our patient was classified for open surgery intervention- partial cricotracheal resection with reconstruction (CTR). Latest improvements about construction of endotracheal tube and rules of procedures reduced frequency of subglottic stenosis to less than 1%.[11] There are no statistics or medical reports about tracheal atresia caused by intubation or Lyell’s syndrome. This situation forced us to recognise Lyell’s syndrome and endotracheal intubation overlapping on each other as a cause of medical state of our patient.

Predictors of recurrence after surgical treatment of idiopathic progressive subglottic stenosis.

SUMMARYIdiopathic progressive subglottic stenosis is a rare cause of tracheal narrowing. Partial cricotracheal resection and anastomosis can cure idiopathic stenosis, even if some patients may require multiple interventions and experience voice and swallowing deterioration. We investigated risk factors for retreatment and assessed the impact of crico-tracheal resection on functional parameters. We conducted a retrospective multicentric study on 44 female patients (mean age 52.6 ± 13.1 years) affected by idiopathic stenosis and treated by crico-tracheal resection between 2002 and 2016. Functional outcomes after crico-tracheal resection were assessed by the airway-dyspnoea-voice-swallowing score (range 1-5, with “1” expressing normal and “5” completely altered function). Previous treatments, grade of stenosis, site, airway comorbidities, age and resection length were tested as predictors of postoperative complications and number of additional treatments, using bivariate and multivariate analysis. The overall decannulation rate was 97.3%. The dyspnoea score improved (mean variation 1.4 ± 1.0; p < 0.001), while voice and swallowing were negatively affected (mean variation 1.6 ± 0.9 and 0.5 ± 0.7, respectively; p < 0.001). Airway comorbidities were associated with a higher rate of complications (p < 0.05). Retreatments were more frequent in patients with postoperative complications (p < 0.05). The length of resection correlated with the number of subsequent treatments (R = 0.52; p < 0.01). At multivariate analysis, post-operative complications were predicted by comorbidities and disease stage (p < 0.05); number of retreatments was linked to the length of resection (p < 0.05) as well as with the application of mitomycin C (p < 0.001). Crico-tracheal resection for idiopathic progressive subglottic stenosis offers good functional results in terms of airway patency. These data suggest that a higher complication rate can be expected in patients affected by comorbidities. Moreover, more extensive surgical resection seems to be associated with the occurrence and number of subsequent retreatments. On the contrary, the local application of an anti-proliferative drug does not seem to be of use in preventing recurrences.

Experimental validation of laryngotracheal growth and recurrent laryngeal nerve preservation after partial cricotracheal resection in a growing rabbit model.

The aim of this study was to confirm laryngotracheal growth and recurrent laryngeal nerve (RLN) preservation after partial cricotracheal resection (PCTR) in a growing rabbit model by performing the procedure in pediatric animals. Six female Japanese white rabbits, 12weeks of age, underwent PCTR. The course of the RLN was evaluated during surgery (n = 3). Endoscopic and histologic examinations were performed at 22weeks of age (n = 6). Four non-operated rabbits, 22weeks of age, underwent endoscopic and histologic examinations as controls. The RLN was preserved at the esophageal side and entered the larynx behind the cricothyroid joint after PCTR. Endoscopic examination showed normal vocal cord movements and the large reconstructed subglottis. Histologically, sufficient submucosal vessels and cartilage growth were identified at the reconstructed larynx. The median inside luminal area at the anastomotic site in the PCTR group was 24.8mm2 (range 21.8-29.0mm2), and that at the cricoid cartilage and trachea in the control group was 23.4mm2 (range 20.0-26.6mm2) and 25.6mm2 (range 22.9-28.8mm2), respectively. No interference with laryngotracheal growth was seen, and RLN preservation was confirmed after PCTR. Use of PCTR in the pediatric age group seems appropriate.

Single-stage tracheal and cricotracheal segmental resection with end-to-end anastomosis: Outcome, complications, and risk factors

ObjectiveManagement of tracheal stenosis remains controversial. Endoscopic interventions commonly provide immediate relief of symptoms, but are associated with high recurrence rates. In contrast, high success rates have been reported in patients undergoing tracheal resection. However, well-defined indications and contraindications for tracheal resection are lacking and previous studies commonly ignore patient-related outcomes (e.g. dyspnoea). We aimed to evaluate the outcome of tracheal resection at our institution and identify risk factors for complications. MethodsAll adult patients undergoing tracheal resection at Aarhus University Hospital between January 2009 and September 2016 were included ResultsTwenty-seven patients were included. The most frequent aetiologies for tracheal stenosis were previous tracheostomy (n=8), prolonged intubation (n=3), a combination of the two (n=5), and intraluminal tumour (n=7). Sixteen patients underwent high tracheal resection, seven patients low tracheal resection, and four patients partial cricotracheal resection. Surgical success (no dyspnoea and no need for additional intervention) was achieved in 74% of patients. Four of six patients undergoing resection because of malignant disease were recurrence-free during the follow-up period. Fifteen (56%) patients suffered complications (transient or permanent). Four (15%) patients had recurrent stenosis and underwent reintervention. Other permanent complications included idiopathic hoarseness (15%), unilateral recurrent nerve palsy (11%), and dysphagia (7%). Previous treatment (endoscopic and open surgery) (OR=5.5, p=0.06) and chronic diseases (OR=8.3, p=0.02) were associated with increased risk for complications. ConclusionsTracheal resection was efficient treatment for the alleviation of dyspnoea in adults with tracheal stenosis. However, complications were frequent and careful preoperative patient selection and information are crucial.

Partial cricotracheal resection: an effective treatment for severe laryngotracheal stenosis

Partial cricotracheal resection: an effective treatment for severe laryngotracheal stenosis

Management of benign laryngotracheal stenosis – A 5-year experience of Indian tertiary care setup

Introduction: Laryngotracheal stenosis (LTS) implies a partial or complete cicatricial narrowing of the larynx and/or trachea. Surgical management is technically challenging owing to complex anatomy and delicate nature of airway structures. The present study aims to study clinical profile, management, and surgical outcome of LTS in a tertiary care setup of India. Materials and Methods: All patients with LTS treated between 2011 and 2016 were included in this study. They underwent endoscopic assessment followed by definitive management which included endoscopic and external surgical techniques. The success of treatment was defined by decannulation, acceptable voice quality, and glottic competence. Results: A total of 106 patients with benign LTS were treated. Prolonged intubation was the single largest cause (70.7%). Tracheal stenosis formed the largest group (43.4%) followed by subglottic stenosis (26.4%). About 37.7% of patients underwent endoscopic management. Among external approaches, 32.07% of patients underwent resection-anastomosis surgeries including partial cricotracheal resection (PCTR) and tracheal resection with end-to-end anastomosis. Nearly 12.3% ofpatients underwent various forms of laryngotracheoplasties. About 7.5% of patients underwent both in the form of extended- PCTR or reconstruction surgery followed by resection-anastomosis. Nearly 7.5% of patients required Montgomery T-tube insertion while three underwent hyo-epiglottopexy for laryngomalacia. A total of 100 patients (94.3%) have been successfully decannulated. Conclusions: The use of appropriate size, low pressure cuffed tubes, and early tracheostomy will go a long way in preventing LTS. The precise assessment of laryngotracheal complex is the cornerstone of management. Choice of treatment depends on location, severity, and length of stenosis, as well as on patient comorbidities, history of previous interventions, and expertise of the surgical team. Goal of any treatment modality should be to achieve a patent airway, glottic competence and acceptable voice quality.