Partial Cricotracheal Resection Research Articles

Refashioned lamb tissue as an animal model for training complex techniques of laryngotracheal stenosis surgery.

Open reconstructive upper airway surgery for laryngotracheal stenosis (LTS), whether for subglottic or tracheal stenosis, constitutes a group of complex approaches. LTS requiring open reconstruction is overall rare and primarily performed at tertiary centres. This poses an obvious challenge for the acquisition and maintenance of surgical skills for this group of complex approaches. In this context, animal models provide a unique opportunity for open reconstructive airway surgery training. Such models ought to take into consideration ethical aspects, be easily available and easy to maintain, and have similar macroscopic anatomical features to the human laryngotracheal frame. Here, we provide a brief surgical guide for the use of refashioned lamb tissue as a training model for surgery of adult and pediatric reconstructive airway surgery. The techniques of laryngotracheal reconstruction, partial cricotracheal resection, tracheal resection with end-to-end anastomosis, and slide tracheoplasty are presented. Proper training in open LTS surgery is challenging, time consuming and its complexity further lengthens the learning curve. The lamb larynx and trachea model is an effective model for practising various airway reclaiming surgeries.

Partial cricotracheal resection for severe upper tracheal stenosis: Potential impacts on the outcome

ObjectiveThe aim of this study was to investigate the potential impact of multiple preoperative and intraoperative variables on the outcome of partial cricotracheal resection and tracheal resection anastomosis (PCTR/TRA). MethodsThe study was conducted on 35 consecutive patients of grade III and IV upper tracheal stenosis with or without subglottic involvement. The indication of PCTR/TRA was post intubation stenosis in all patients. Overall complications (major and minor) occurred in 18 patients. Perioperative mortality occurred in 1 patient. Anastomotic complications do not always mean failure of surgery. They may indicate one or more interventions; such as removal of granulation tissue or dilatation of restenosis, with good results in most cases. ResultsAt the end of treatment, 30 (85.7%) patients were decannulated successfully with effortless breathing and with good phonation and swallowing. Several perioperative factors were found to have a significant impact on the outcome of PCTR/TRA. Of these factors, comorbidities had the most significant negative impact, and indeed all the three patients who had comorbidities, were not successfully decannulated. Duration of intubation, length of resected segment and previous open airway interventions was reported to have a significant negative impact on the outcome of surgery. ConclusionPCTR/TRA for treatment of post traumatic subglottic or upper tracheal stenosis has a high success rate, especially in healthy patients without comorbidities, and without previous open airway interventions.

Management of severe congenital laryngeal webs – a 12 year review

ObjectiveThe aim of this study was to investigate respiratory and voice outcomes after open surgery for severe congenital laryngeal web. MethodsIncluded were all patients treated for severe congenital glottic web (Cohen type 3 and 4) between 2002 and 2014. Demographic data, symptoms, endoscopic findings, type of operation, outcome and complications were analyzed. Open surgery was performed with division of the web and enlargement of the subglottis by a laryngotracheal reconstruction or an extended partial cricotracheal resection. ResultsFourteen patients were included. Information on the pre-operative voice was available in 11 patients. Aphonia was present in 6 patients (55%), dysphonia was severe in 1 (9%), moderate in 2 (18%) and mild in 2 (18%). Median age at operation was 19.3 months. As a first line treatment, laryngotracheal reconstruction was performed in 12 patients, and an extended partial cricotracheal resection in 2. Median follow-up was 9.5 months. All patients were successfully decannulated in a median time of 4 months after first surgery. Voice was improved in 10/11 (91%). Post-operatively, 3 patients (27%) had good voice. Dysphonia was severe in 2 (18%), moderate in 3 (27%) and mild in 3 patients (27%). ConclusionOpen surgery for Cohen type 3 and 4 glottic web allowed establishing a patent airway with successful decannulation in all cases. Quality of voice was improved in 91%, however, voice results were variable. In our opinion a delicate operative technique described in the paper is important for optimal voice results.

Summarized institutional experience of paediatric airway surgery

The management of paediatric airway stenosis is complex, and requires a dedicated team, consisting of thoracic surgeons, phoniatricians, logopaedics, paediatricians and anaesthetists. The majority of paediatric laryngotracheal stenosis is a sequela of prematurity and prolonged post-partal intubation/tracheostomy. Surgical correction is often difficult due to a frequent combination of glottic and subglottic defects. In 2012, the Laryngotracheal Program Vienna was launched. Since then, 18 paediatric patients were surgically treated for (laryngo-)tracheal problems. The median age of our patients was 26 months (range 2-180 months). Laryngotracheal stenosis extending up to the level of the vocal cords was evident in 9 patients. Three children were diagnosed with an isolated subglottic, and four with a short-segment tracheal stenosis or malacia. Two patients had a long-segment congenital malformation together with vascular ring anomalies. Five children were pretreated by rigid endoscopy before surgical correction, 12 of our 18 patients had a tracheostomy, 3 children were intubated at the time of operation. Different techniques of corrections were applied: laryngotracheal reconstruction (n = 4), extended partial cricotracheal resection (n = 4), cricotracheal resection with or without anterior split or dorsal mucosal flap (n = 4), slide tracheoplasty (n = 2), tracheal resection (n = 4). In 8 patients, a rib cartilage interposition was necessary in order to obtain a sufficient lumen enlargement and in 7 of these patients, an LT-Mold was placed to stabilize the reconstruction. We lost 2 patients, who were referred to our institution after failure of multiple preceding interventions, 2 and 3 months after the operation. Twelve patients are currently in an excellent condition, one is in an acceptable condition without a need for an intervention. Two patients required an endoscopic reintervention 18 and 33 months after the operation, 1 child is currently still cannulated. Paediatric airway surgery is complex, and requires a dedicated interdisciplinary team. An armamentarium of different resection and reconstruction techniques is necessary in order to achieve good long-term results.

Pediatric Laryngotracheal Stenosis Management: 10 Years’ Experience at the Hacettepe University Otorhinolaryngology Department

Objectives: Analyze surgical treatment modalities for pediatric laryngotracheal stenosis. Methods: We retrospectively reviewed patients that underwent laryngotracheal surgery for stenosis between 2002 and 2012. Age, sex, etiologic factors, stenosis grades, comorbidities, surgical techniques, decannulation rates, and complications were evaluated. There were subglottic stenosis (SGS), posterior glottis stenosis (PGS), and tracheal stenosis (TS). Surgical details and outcomes were examined for endolaryngeal procedures, laryngotracheal reconstruction (LTR), partial cricotracheal resection (PCTR), and tracheal resection (TR). Results: There were 44 patients. Prolonged intubation because of trauma was the leading primary cause of stenosis. Congenital stenosis and congenital heart disease operations were also present frequently. There were 20 LTRs, 13 endolaryngeal balloon dilatation, 7 PCTRs, and 4 TRs. Decannulation was successfully accomplished in 27 of 32 patients (84%). Overall success rate in airway management was 91% (40/44). Restenosis was observed after 8 LTRs and 2 PCTRs. Major complications were bilateral recurrent nerve paralysis, postoperative death due to sepsis, and accidental extubation with an overall rate of 6% (3/44). Conclusions: Pediatric airway surgery needs good multidisciplinary cooperation. Correct indication and precise surgical technique are important factors in determining the results. Endolaryngeal procedures should be performed only for membranous and/or low grade stenosis cases, otherwise they cause more tissue damage, leading to fibrosis that complicates the pathology. LTR with anterior and/or posterior grafting is suitable for grade II and III stenosis, while PCTR should be the first choice of treatment for grade IV stenosis. Open surgical procedures should be performed as a single stage surgery if possible.

Partial cricotracheal resection for paediatric subglottic stenosis: update of the Lausanne experience with 129 cases.

Partial cricotracheal resection (PCTR) is widely accepted for treating severe paediatric laryngotracheal stenosis (LTS). However, it remains limited to a few experienced centres. Here we report an update of the Lausanne experience in paediatric PCTR performed or supervised by a senior surgeon (Philippe Monnier). An ongoing database of 129 paediatric patients who underwent PCTR for benign LTS between March 1978 and July 2012 at our hospital was retrospectively reviewed. Demographic characteristics and information on preoperative status, stenosis and surgery were collected. Primary outcomes were measured as overall and operation-specific decannulation rates (ODR and OSDR, respectively), and secondary outcomes as morbidity, mortality and postoperative functional results. A total of 129 paediatric patients [79 males and 50 females; mean age, 4.1 years (1 month-16 years, median age of 2 years old)] underwent PCTR during the study period. ODR and OSDR were 90 and 81%, respectively. The decannulation rates were significantly superior for single-stage PCTR compared with double-stage PCTR in both ODR and OSDR. Eight patients died postoperatively for reasons unrelated to surgery. Partial anastomotic dehiscence was seen in 13 patients, 9 of whom were successfully treated by revision surgery. Respiratory, voice and swallowing functions were near normal or only minimally impaired in 86, 65 and 81% of patients, respectively. PCTR is effective and feasible with good ODR and OSDR for highgrade / severe LTS. Glottic involvement and the presence of comorbidities were negative predictive factors of decannulation. Early detection and reintervention of postoperative incipient dehiscence contribute to avoiding the progress to late restenosis; however, voice improvement remains a challenge.

Post-intubation Subglottic Stenosis in Children. Diagnosis, Treatment and Prevention of Moderate and Severe Stenosis

Introduction and objectivesSubglottic stenosis is one of the most common causes of upper airway obstruction. Almost 90% of them result from endotracheal intubation. Therapy depends on the degree of stenosis, among other factors. Therapeutic approaches range from watchful waiting, in mild stenosis, to complex surgery for severe cases. We report our experience on the surgical management of post-intubation subglottic stenosis in children, emphasising the need for recognition and prevention of predisposing factors of post-intubation stenosis. MethodsWe retrospectively evaluated 71 patients with moderate to severe post-intubation subglottic stenosis, operated in the Respiratory Endoscopy Service in a period of eight years. The clinical variables analysed were age at surgery, degree of stenosis, surgical technique, complications and outcome. ResultsIn 84.5% of patients, only 1 surgical approach was required to achieve decannulation. Three surgical techniques were implemented as therapy: laryngotracheal reconstruction, partial cricotracheal resection and anterior cricoid split. Decannulation was achieved in 70 cases. In 71.8%, ventilation, swallowing and voice qualities were good; 23.9% presented dysphonia; and 2.8% presented a mild respiratory distress. One patient died. ConclusionIn patients with subglottic stenosis, selection of the most accurate treatment is the key to success, reducing the number of surgeries and preventing complications.

Estenosis subglótica postintubación en niños. Diagnóstico, tratamiento y prevención de las estenosis moderadas y severas

Introduction and objectivesSubglottic stenosis is one of the most common causes of upper airway obstruction. Almost 90% of them result from endotracheal intubation. Therapy depends on the degree of stenosis, among other factors. Therapeutic approaches range from watchful waiting, in mild stenosis, to complex surgery for severe cases. We report our experience on the surgical management of post-intubation subglottic stenosis in children, emphasising the need for recognition and prevention of predisposing factors of post-intubation stenosis. MethodsWe retrospectively evaluated 71 patients with moderate to severe post-intubation subglottic stenosis, operated in the Respiratory Endoscopy Service in a period of eight years. The clinical variables analysed were age at surgery, degree of stenosis, surgical technique, complications and outcome. ResultsIn 84.5% of patients, only 1 surgical approach was required to achieve decannulation. Three surgical techniques were implemented as therapy: laryngotracheal reconstruction, partial cricotracheal resection and anterior cricoid split. Decannulation was achieved in 70 cases. In 71.8%, ventilation, swallowing and voice qualities were good; 23.9% presented dysphonia; and 2.8% presented a mild respiratory distress. One patient died. ConclusionIn patients with subglottic stenosis, selection of the most accurate treatment is the key to success, reducing the number of surgeries and preventing complications.

Surgical management of scleromatous laryngotracheal stenosis

Scleroma is a chronic specific granulomatous disease of the upper respiratory tract caused by Klebsiella Rhinoscleromatis. It usually affects the subglottic region and upper trachea resulting in various degrees of stenosis. Patients with laryngotracheal stenosis may present with stridor, shortness of breath or exercise intolerance and may be tracheostomy dependent. In this work, we presented the experience of our Institute in the management of patients with scleromatous laryngotracheal stenosis using the already designed procedures for traumatic laryngotracheal stenosis. The study was a non controlled prospective study. It was conducted in Oto-Rhino-Laryngology and Head and Neck Surgery Department of Zagazig University Hospitals, Egypt. It included 38 patients with scleromatous subglottic stenosis and/or upper tracheal stenosis. The patients were classified into four grades according to Myer-Cotton's scale. The surgical treatment modalities included endoscopic CO2 laser surgery with dilatation, laryngotracheal reconstruction, and partial cricotracheal resection with thyrotracheal anastomosis. The average follow-up period was 32.1 months. Twenty four patients (63%) had an excellent outcome. Nine patients (24%) had a good outcome. Five patients (13%) were still tracheostomy dependent. Eleven patients (29%) developed postoperative granulation tissue. The overall success rate was 87%. Scleromatous laryngotracheal stenosis is considered a challenging surgical problem. It requires a multidisciplinary approach by well-trained personnel. The surgical techniques designed for cases of laryngotracheal stenosis of a traumatic etiology can be applied for cases of scleroma with approximately the same success rates.

Osteocutaneous radial forearm reconstruction of large partial cricotracheal defects

Single-stage procedures for reconstruction of large cricotracheal defects have been limited in success and malignant immature teratomas in the larynx of an adult have never been reported. This was a case report and literature review. A 27-year-old man presented with 2 weeks of new-onset stridor and was found to have a mass obstructing 80% of the subglottis and trachea. He underwent a noncircumferential partial cricotracheal resection with a resultant 7-cm luminal defect, followed by osteocutaneous radial forearm flap semi-rigid reconstruction. A novel technique was used to allow a functional and patent airway, which may be applied to other partial luminal reconstructive defects. Postoperatively, the patient was decannulated and has good speech quality and swallowing function. This work was performed at the Henry Ford Health System. This project was reviewed and was granted full approval by the Henry Ford Health System Institutional Review Board. This is the first reported case of malignant immature teratoma to involve the larynx, trachea, and recurrent laryngeal nerve in an adult patient, and the first single-stage technique described to use free tissue transfer without prefabrication for a 7-cm airway defect.

Cricotracheal reconstruction with free radial forearm flap and titanium mesh

Reconstruction after partial cricotracheal resection is technically demanding and is seldom reported in literature. The purpose of this study was to report a technique of reconstruction of such a defect with a radial forearm flap supported by a titanium mesh. A 75-year-old man who was diagnosed with a case of papillary carcinoma thyroid, underwent excision of the tumor with a partial cricotracheal resection. The defect was reconstructed with a free radial forearm flap with fascia suspended on a titanium mesh. At a follow-up of 6 months after treatment, the patient has normal nasal breathing and an acceptable voice. This reconstructive technique enabled us to maintain the integrity of the subglottic airway. Our technique was unique in that we used the skin-lined part of the radial forearm flap to line the airway and the fascia to cover the titanium mesh outside, thereby preventing plate exposure.

Partial cricotracheal resection for subglottic histiocytoma in a child. Case report and literature review

Partial cricotracheal resection for subglottic histiocytoma in a child. Case report and literature review

Partial cricotracheal resection with tracheal intussusception and cricoarytenoid joint mobilization: Early experience in a new technical variant

Partial cricotracheal resection with tracheal intussusception and cricoarytenoid joint mobilization: Early experience in a new technical variant

Modified endotracheal tube: emergency alternative to paediatric tracheostomy tube

In an emergency, the non-availability of a conventional paediatric tracheostomy tube is a therapeutic challenge for the attending surgeon. To describe a simple alternative to a paediatric tracheostomy tube for use in an emergency situation. Case report of a 14-year-old boy who developed tracheomalacia following partial cricotracheal resection for subglottic stenosis. As a suitably sized tracheostomy tube (with a long narrow segment) was not available, an endotracheal tube was modified and used successfully. Details of the modification, and a relevant literature review, are also discussed. In the paediatric age group, when an appropriately sized tracheostomy tube is not available, a modified endotracheal tube is a simple temporary alternative; this may be especially useful in an emergency.

Single-stage laryngotracheoplasty in children

To review the outcomes of pediatric patients with laryngotracheal stenosis treated by single-stage laryngotracheoplasty. A single surgeon personal series retrospective review of 15 children undergoing single-stage laryngotracheoplasty for laryngeal stenosis over 4-year period (2004-2008). 15 patients (9 boys and 6 girls), with ages ranging from 1 month to 18 years, were operated. Using the Myer-Cotton grading system, 2 patients were diagnosed with grade 4 stenosis, 6 patients with grade 3 and 7 patients with grade 2. In10 cases, an LTP with anterior costal cartilage graft was performed; in one case an anterior and posterior LTP; in one case a partial cricotracheal resection and in 3 cases an anterior cricoids split. The overall success rate was 94%. Single stage laryngotracheoplasty is a safe and effective method for laryngotracheal stenosis in children.

Malignant Immature Teratoma of the Larynx and Trachea with Functional Osteocutaneous Free Flap Reconstruction

Malignant Immature Teratoma of the Larynx and Trachea with Functional Osteocutaneous Free Flap Reconstruction

Partial cricotracheal resection for subglottic histiocytoma in a child. Case report and literature review

Summary Benign fibrous histiocytoma is a rare tumor of mesenchymal origin, and its occurrence in the head and neck is infrequently encountered. Most of the reported cases in the laryngeal region in the literature are of malignant nature, and mainly in adults. Fibrous histiocytoma can occur anywhere in the body. Fibrous histiocytoma represented 0.5% of all benign neoplasms of the larynx. A subglottic benign fibrous histiocytoma in a 5 year-old girl who underwent a single stage partial cricotracheal resection as a primary management. Up to our knowledge, this is the first report of such surgical management in this kind of tumors.

Partial cricotracheal resection in children weighing less than 10 kilograms

Objectives To assess the long-term outcome, safety, and efficacy of partial cricotracheal resection (PCTR) for subglottic stenosis in a group of children and infants weighing less than 10 kg at the time of the surgery. Study Design Historical cohort study. Setting Academic tertiary medical center. Subjects and Methods Thirty-six children weighing less than 10 kg at the time of the surgery were compared to a group of 65 children who weighed more than 10 kg. The Kaplan Meier method and Cox regression were carried out to detect differences in decannulation time and rates and to examine the influence of various parameters (i.e., comorbidities, type of surgery, and complications requiring revision surgery) at the time of decannulation. Evaluation of the long-term outcome was based on questionnaires assessing breathing, voice, and swallowing. Results Decannulation rate was 92 percent (33/36) for the group of children weighing less than 10 kg. No significant differences were found between the two body weight groups with respect to the aforementioned covariates. The median follow-up period was nine years (range, 1-23 yrs). Questionnaire responses revealed completely normal breathing and swallowing in 72 percent and 90 percent of the children, respectively. Seventy-one percent of the patients considered their voice to be rough or weak. Conclusion PCTR in infants and children weighing less than 10 kg is a safe and efficient technique with similar long-term results when compared to results seen in older and heavier children.

Cricotracheal resection and reanastomosis

Partial cricotracheal resection (CTR) for the treatment of subglottic stenosis has been reported, in children, with decannulation rates of 90% for refractory grades 3 and 4 stenoses. In view of these findings, it has become imperative for pediatric otolaryngologists to add CTR to their surgical armamentarium for the management of severe subglottic stenosis. The authors have described preoperative evaluation, patient selection, operative technique, and possible complications of CTR in this article. Partial cricotracheal resection (CTR) for the treatment of subglottic stenosis has been reported, in children, with decannulation rates of 90% for refractory grades 3 and 4 stenoses. In view of these findings, it has become imperative for pediatric otolaryngologists to add CTR to their surgical armamentarium for the management of severe subglottic stenosis. The authors have described preoperative evaluation, patient selection, operative technique, and possible complications of CTR in this article.

Long-term voice outcome following partial cricotracheal resection in children for severe subglottic stenosis

Objective To correlate the postoperative voice outcome to preoperative glottic involvement, following partial cricotracheal resection (PCTR) in children. The glottic involvement was analysed based on the extent of subglottic stenosis (SGS) in the endoscopic image and functional dynamic assessment using flexible endoscopy. Methods We conducted an interobserver study in which two ENT surgeons, blinded to one another's interpretation, independently rated the extent of SGS based on the endoscopic image along with the dynamic functional airway assessment, of 108 children who underwent PCTR for grade III or IV stenosis. Based on the observation, the glottic involvement was rated into 4 categories: A. SGS clear from vocal cords (3–4 mm below vocal cords). B. SGS reaching the free border of vocal cord and/or the posterior commissure with slightly limited abduction with no true posterior glottic stenosis (PGS). C. SGS with associated PGS or vocal cord fusion without cricoarytenoid ankylosis (CAA). D. Transglottic stenosis with/or without bilateral CAA. Evaluation of the voice was based on a parent/patient proxy questionnaire sent in 2008 to assess the current functional status of the patient's voice. Results Among the 77 patients available for long-term outcome with a minimum 1-year follow-up, 31 patients had isolated SGS free from vocal cords (group A) and 30 had SGS reaching the under surface of vocal cords with partial or no impairment of abduction of vocal cords (group B). Twelve patients belonged to group C with posterior glottic stenosis and/or vocal cord fusion (without cricoarytenoid ankylosis) and 4 patients had transglottic stenosis and or/bilateral cricoarytenoid ankylosis (group D). The long-term voice outcome following PCTR as perceived by the parent or patient was normal in 18% (14 of 77 patients) and the remaining 63 patients demonstrated mild to severe dysphonia. Patients belonging to group A and B exhibited either normal voice or mild dysphonia. Patients in group C demonstrated dysphonia, which was moderate in severity in the majority (83%). All patients in group D with transglottic stenosis and/or CAA showed severe dysphonia. Conclusion Children with associated glottic involvement are at high risk for poor voice outcome following PCTR. The severity of dysphonia was found to be proportional to the preoperative glottic involvement. Preoperative rating of the extent of glottic involvement based on endoscopic image and dynamic assessment was found to be useful in prognosticating the voice outcome.