Advertisement

Subglottic Tracheal Resection

  • Douglas J. Mathisen
    Correspondence
    Address reprint requests to Douglas J. Mathisen, MD, General Thoracic Surgical Unit, Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA 02114
    Affiliations
    From the Department of Surgery, Harvard Medical School, Boston, MA
    Search for articles by this author
      The most common indication for tracheal resection is stenosis secondary to cuff injury from either tracheostomy tube or endotracheal tube or tracheostomy stomal injury. These injuries occur in the upper, middle, or distal trachea and are amenable to resection and reconstruction with excellent results. Techniques have been devised to allow resection of up to one half of the adult trachea.
      When postintubation stenosis and other inflammatory processes extend from the upper trachea into the subglottic larynx, the problem becomes more complex. If the lesion extends well above the lower border of the cricoid cartilage, circumferential resection is not possible because of the entry location of the recurrent laryngeal nerves into the larynx medial and posterior to the inferior cornua of the thyroid cartilage along the back of the posterior cricoid lamina (Figure I). The stenosis may involve only the anterolateral portion of the cricoid. When circumferential stenosis exists involving the posterior cricoid plate as well, the problem is much more formidable. The closer the stenosis comes to involving the vocal cords, the less suitable it is for resection, reconstruction, and preservation of laryngeal function.
      Figure thumbnail gr1
      Fig IThe pertinent anatomy (lateral view) of the larynx and the subglottic and upper tracheal airways. (Reprinted.
      • Maddaus M
      • Pearson FG
      Subglottic resection.
      )

      Classification

      Grillo
      • Grillo HC
      Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.
      in 1979 devised a radiological classification of upper airway stenosis based on the amount of involvement of the subglottic space (Figure II). Type A is a high tracheal stenosis not involving the cricoid. This lesion is easily treated by segmental resection and tracheotracheal anastomosis. In type B, stenosis reaches the lower border of the cricoid cartilage and involves anastomosis between the trachea and cricoid cartilage. Type C involves inflammation of the anterior portion of the cricoid cartilage. Correction requires resection of the anterior portion of the cricoid cartilage and may require resurfacing of the posterior portion of the cricoid surface if the mucosa is severely scarred. Type D involves inflammation and stenosis of the glottis and has insufficient subglottic space for reconstruction. There currently is no reliable single stage method of reconstruction for stenosis at this level.
      Figure thumbnail gr2
      Fig IIUpper airway stenosis. (A) High tracheal stenosis, easily treated by segmental resection and tracheotracheal anastomosis; (B) stenosis that reaches to the lower border of the cricoid cartilage; (C) stenosis of the lower subglottic larynx and upper trachea (the extent of the lesion anterior portion of the cricoid cartilage); (D) stenosis that reaches to the glottis. There is no subglottic space to which an effective anastomosis can be made. (Reprinted with permission from the Society of Thoracic Surgeons.
      • Grillo HC
      Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.
      )

      Origin

      There is no single factor responsible for subglottic stenosis. The vast majority of subglottic stenoses result from complications of endotracheal or tracheostomy tubes. In our experience, only endotracheal intubation was responsible for the largest number of subglottic stenoses. The point of greatest pressure from oral endotracheal tubes is the posterior cricoid plate (Figure III). The size of the larynx varies from individual to individual. It is recognized that women have a smaller larynx than men, and smaller adults have a proportionately smaller larynx. Larger endotracheal tubes will exert circumferential pressure at the glottic, subglottic, and cricoid levels and, if left in place long enough, may lead to circumferential necrosis at these levels. The aforementioned factors would seem to be responsible for the subglottic stenosis seen in patients that have been intubated with an oral endotracheal tube, as well as for posterior commissure stenosis. Tracheostomy tubes placed through the first tracheal ring or upward pressure by the tube in kyphotic patients may lead to retrograde erosion of the cricoid cartilage. Cricothyroidostomy through the cricothyroid membrane can also result in subglottic stenosis.
      Figure thumbnail gr3
      Fig IIIDiagram shows point of greatest pressure from an endotracheal tube to be the posterior cricoid plate.
      The next most common cause of subglottic stenosis results from idiopathic stenosis.
      • Grillo HC
      • Mark EJ
      • Mathisen DJ
      • et al.
      Idiopathic laryngotracheal stenosis and its management.
      This poorly understood phenomenon occurs predominantly in women and most often involves the subglottic larynx. There is no known cause.
      Blunt trauma to the upper airway can lead to subglottic stenosis, especially if the cricoid cartilage is damaged.
      • Mathisen DJ
      • Grillo HC
      Laryngotracheal trauma.
      Failed attempts at repair or delayed recognition of injuries can result in subglottic stenosis.
      There are a variety of other inflammatory or infectious problems that are extremely rare but have resulted in subglottic stenosis.

      Selection of Patients

      Patients determined to have subglottic stenosis should be carefully evaluated by an otolaryngologist to assess glottic function and the need for glottic procedures.
      In many patients with subglottic laryngeal inflammatory processes, the inflammation extends to just below the vocal cords. If resection is to be carried into the subglottic area, it cannot extend all the way to the vocal cords with hope of uniformly good results. The operation we propose is reserved for patients who on radiological study and direct laryngoscopy have an adequate residual subglottic space (Figures IIA–C). It is particularly important to assess the involvement of mucosa overlying the posterior cricoid plate and the posterior portion of the subglottic larynx. The airway is evaluated radiologically by the usual techniques, and the tracheostomy tube is removed at the time of examination (Figures IVA–B).
      • Weber A
      Symposium on the larynx and trachea.
      Figure thumbnail gr4
      Fig IV(A) The typical features of an idiopathic subglottic stenosis. The arrows show the narrowing best seen in this lateral projection. (B) A much longer subglottic stenosis secondary to a postintubation injury. The tracheostomy tube is still in place in this patient.
      Vocal cord function is assessed by fluoroscopy of the larynx and by direct examination. Such evaluation is essential not only as a baseline for postoperative conparison of function but also to avoid performing subglotic airway reconstruction in a patient who, in addition has obstruction at the glottic level because of preexising bilateral palsy. Endoscopy with magnifying telescopes are used to evaluate the anatomy in detail (Figure V). It is most important to determine if there is adequate space beneath the glottis for repair because it is often difficult to determine this beforehand. The degree of inflammation in the area where the anastomosis would be carried out is carefully assessed. Inflammation is one of the important factors determining timing of resection and reconstruction. If inflammation does exits, it is best to dilate the stenosis and delay reconstruction. Careful endoscopic measurements should be taken to determine the exact length of involvement and the amount of normal trachea available for reconstruction.
      Figure thumbnail gr5
      Fig VBronchoscopic view of subglottic stenosis with lumen of about 4 to 5 mm.

      Airway Management

      Airway management is critical to a successful outcome. It requires close cooperation and patience between the anesthesiologist and surgeon.
      • Wilson RS
      Tracheostomy and tracheal reconstruction.
      Previous radiologica evaluation is invaluable in understanding the degree and extent of involvement of the airway. The most important aspect to successful management of these difficult airways is the attainment of a deep level of anesthesia with spontaneous ventilation by the patient. A satisfactory level of anesthesia may take 15 to 20 minutes for induction. When this level of anesthesia is reached, the upper airway is evaluated with a laryngoscope, or rigid bronchoscope, and a straight magnifying telescope. The glottis should be inspected very carefully before dilation to properly evaluate the degree of mucosal involvement, especially of the posterior commissure. Active inflammation with friable mucosa may preclude reconstruction at this time. Dilation is initiated by small woven bougies through a large rigid bronchoscope. Subsequent dilations are performed with small pediatric rigid bronchoscopes used as dilators under direct vision. Dilation is performed with gentle forward pressure in a corkscrew fashion under direct vision at all times. If resection is planned, it is only necessary to dilate to a diameter that will allow placement of a no. 6 endotracheal tube. If reconstruction is to be delayed, it should be possible to dilate to the size of a 7 or 8 rigid bronchoscope. This should be satisfactory for days to weeks depending on the origin of the stenosis. Patients should be made aware of this and know to seek medical attention before critical stenosis develops. Because of the complexities involved in reconstruction, tracheostomy is best avoided because it will only complicate subsequent reconstruction. Primary reconstruction or repeat dilation are the best ways to manage patients with subglottic stenosis.

      SURGICAL TECHNIQUE

      A collar incision is usually adequate for exploration. An existing tracheotomy may be included in the incision or separately excised. It is preferable to do a laryngeal release through a short transverse incision over the hyoid bone if exposure is inadequate through the collar incision. The anterior surface of the airway is expose from the thyroid notch to the carina. Dissection is kept close to the airway to avoid injury to the recurrent laryngeal nerves. The nerves are not identified but injury is avoided by staying away from their course.
      Figure thumbnail fx6a
      1(A) The distal end of the lesion is identified first. (B) The trachea is dissected circumferentially at this point, the transection is performed immediately below the lesion.
      The end of the proximal tracheal segment, which is confluent with the laryngeal portion of the stenosis, is grasped with two toothed clamps, and dissection is carried upward to the cricoid cartilage. Particular care is taken to stay close to the airway when the posterolateral angles of the cricoid lamina are approached. At this point, the recurrent laryngeal nerves are next to the posterior cricoid plate behind the cricothyroid articulations. The airway is entered anteriorly, cutting transversely across at the top of what appears to be obviously diseased tissue. It is always possible to resect additional tissue. Occasionally the decision is difficult and it is preferable to divide the diseased airway vertically in the midline from below upward for a better determination of the level of transection. When it is clear that the anterior cricoid cartilage must indeed be removed, the line of entry is placed deliberately close to the midline of the inferior border of the thyroid cartilage so that there will be a rigid structure for suturing.
      The line of resection is carried laterally and inferiorly across the cricothyroid membrane on either side until the superior lateral borders of the lateral lamina of the cricoid cartilage are reached. Transection continues to bevel downward and backward, transecting the cricoid cartilage until the inferior border is reached anterior to the posterior cricoid plate itself. Posteriorly, the line of transverse incision lies at the level of the lower border of the cricoid cartilage plate. The mucosa is sharply transected here. The membranous wall of trachea is thus detached. It is critically important in these last maneuvers that the recurrent nerves are not injured. Dissection behind the cricoid plate is never carried more than 1 to 2 mm above the lower most border and often not even this far.
      Submucosal fibrosis often is found laterally in the subglottic larynx to a degree that seems to be greater than that suggested by preoperative examination or roentgenograms. This is handled in various ways. The oblique line of division of the larynx itself creates a larger subglottic airway than simple horizontal transection. The anterior stenosing process where cricoid has been destroyed by the inflammatory process may pull the lateral laminas of the cricoid cartilage together to produce sharper angulation laterally. In these cases, the lateral laminas of the cricoid are resected further posteriorly so that the anastomosis will not be narrowed by the distortion.
      (B-D) The distal end of the trachea is inspected to be sure that the cartilage just below the line of transection is of good quality. This cartilage is trimmed back in a gentle curve on either side from full width anteriorly to a sloping angle at the lateral posterior ends of the cartilage. Shaping helps to soften the angulation necessary when direct anastomosis is performed to the beveled transection of larynx.
      When it is clear that the ends of the airway will approximate by traction on the lateral holding sutures accompanied by cervical flexion, the neck is re-extended and the anastomotic sutures are placed in the usual manner using interrupted 4–0 coated Meryl sutures (Ethicon, Inc, Somerville, NJ). Despite the irregularity of the two ends being anastomosed and their apparently discrepant sizes and shapes, the sutures are placed by eye so that they will generally correspond. The junction points of the tapered tracheal cartilage and the membranous wall on either side are approximated to the angles of the posterior cricoid plate. The midline of the thyroid cartilage is approximated to the midline of the peak of the prow, which has been fashioned in the most proximal cartilage of the trachea. Other sutures are appropriately apportioned. It is not necessary that sutures pass through the full thickness of the cricoid cartilage but, only through the full thickness of the mucosa applied to it and then part way through the cartilaginous portion.
      (E-F) With the cervical spine flexed, the lateral traction sutures are tied and then all of the anastomotic sutures are tied from front to back in the usual manner. Traction sutures are not removed. On occasion it is necessary to use one or more 3-Vicryl sutures (Ethicon, Inc) anteriorly in the midline to affect a good approximation of rigid cartilage, particularly if calcification has occurred.
      (G) In most cases, the thyroid isthmus is rejoined in the midline to cover the anastomosis. If there is any question about the anastomosis and there is sufficient length of trachea available, a small tracheostomy is placed well distal to the anastomosis. It should be at least two complete rings below the anastomosis. If this positions the tube too close to the innominate artery, one of the adjacent strap muscles is sutured carefully to the trachea over the artery to provide buffering.
      If the trachea has been shortened too much or if the patient's anatomy is such that the tracheotomy would be too close either to the anastomosis or to the artery, a tracheostomy is not performed. The anastomosis is covered, if possible, with thyroid isthmus, and strap muscle or even thymus is placed over the artery, suturing it to the anterior surface of the trachea. A triangular portion of the tracheal wall, which is left bare, is marked with a fine silk suture in the midline at a point where a tracheostomy may be placed in the future, if needed. ( are reprinted with permission from the Society of Thoracic Surgeons.
      • Grillo HC
      Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.
      )
      Figure thumbnail fx6b
      1(A) The distal end of the lesion is identified first. (B) The trachea is dissected circumferentially at this point, the transection is performed immediately below the lesion.
      The end of the proximal tracheal segment, which is confluent with the laryngeal portion of the stenosis, is grasped with two toothed clamps, and dissection is carried upward to the cricoid cartilage. Particular care is taken to stay close to the airway when the posterolateral angles of the cricoid lamina are approached. At this point, the recurrent laryngeal nerves are next to the posterior cricoid plate behind the cricothyroid articulations. The airway is entered anteriorly, cutting transversely across at the top of what appears to be obviously diseased tissue. It is always possible to resect additional tissue. Occasionally the decision is difficult and it is preferable to divide the diseased airway vertically in the midline from below upward for a better determination of the level of transection. When it is clear that the anterior cricoid cartilage must indeed be removed, the line of entry is placed deliberately close to the midline of the inferior border of the thyroid cartilage so that there will be a rigid structure for suturing.
      The line of resection is carried laterally and inferiorly across the cricothyroid membrane on either side until the superior lateral borders of the lateral lamina of the cricoid cartilage are reached. Transection continues to bevel downward and backward, transecting the cricoid cartilage until the inferior border is reached anterior to the posterior cricoid plate itself. Posteriorly, the line of transverse incision lies at the level of the lower border of the cricoid cartilage plate. The mucosa is sharply transected here. The membranous wall of trachea is thus detached. It is critically important in these last maneuvers that the recurrent nerves are not injured. Dissection behind the cricoid plate is never carried more than 1 to 2 mm above the lower most border and often not even this far.
      Submucosal fibrosis often is found laterally in the subglottic larynx to a degree that seems to be greater than that suggested by preoperative examination or roentgenograms. This is handled in various ways. The oblique line of division of the larynx itself creates a larger subglottic airway than simple horizontal transection. The anterior stenosing process where cricoid has been destroyed by the inflammatory process may pull the lateral laminas of the cricoid cartilage together to produce sharper angulation laterally. In these cases, the lateral laminas of the cricoid are resected further posteriorly so that the anastomosis will not be narrowed by the distortion.
      (B-D) The distal end of the trachea is inspected to be sure that the cartilage just below the line of transection is of good quality. This cartilage is trimmed back in a gentle curve on either side from full width anteriorly to a sloping angle at the lateral posterior ends of the cartilage. Shaping helps to soften the angulation necessary when direct anastomosis is performed to the beveled transection of larynx.
      When it is clear that the ends of the airway will approximate by traction on the lateral holding sutures accompanied by cervical flexion, the neck is re-extended and the anastomotic sutures are placed in the usual manner using interrupted 4–0 coated Meryl sutures (Ethicon, Inc, Somerville, NJ). Despite the irregularity of the two ends being anastomosed and their apparently discrepant sizes and shapes, the sutures are placed by eye so that they will generally correspond. The junction points of the tapered tracheal cartilage and the membranous wall on either side are approximated to the angles of the posterior cricoid plate. The midline of the thyroid cartilage is approximated to the midline of the peak of the prow, which has been fashioned in the most proximal cartilage of the trachea. Other sutures are appropriately apportioned. It is not necessary that sutures pass through the full thickness of the cricoid cartilage but, only through the full thickness of the mucosa applied to it and then part way through the cartilaginous portion.
      (E-F) With the cervical spine flexed, the lateral traction sutures are tied and then all of the anastomotic sutures are tied from front to back in the usual manner. Traction sutures are not removed. On occasion it is necessary to use one or more 3-Vicryl sutures (Ethicon, Inc) anteriorly in the midline to affect a good approximation of rigid cartilage, particularly if calcification has occurred.
      (G) In most cases, the thyroid isthmus is rejoined in the midline to cover the anastomosis. If there is any question about the anastomosis and there is sufficient length of trachea available, a small tracheostomy is placed well distal to the anastomosis. It should be at least two complete rings below the anastomosis. If this positions the tube too close to the innominate artery, one of the adjacent strap muscles is sutured carefully to the trachea over the artery to provide buffering.
      If the trachea has been shortened too much or if the patient's anatomy is such that the tracheotomy would be too close either to the anastomosis or to the artery, a tracheostomy is not performed. The anastomosis is covered, if possible, with thyroid isthmus, and strap muscle or even thymus is placed over the artery, suturing it to the anterior surface of the trachea. A triangular portion of the tracheal wall, which is left bare, is marked with a fine silk suture in the midline at a point where a tracheostomy may be placed in the future, if needed. ( are reprinted with permission from the Society of Thoracic Surgeons.
      • Grillo HC
      Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.
      )
      Figure thumbnail fx7a
      2(A) Operation is modified in those patients in whom stenosis is circumferential, affecting the subglottic area anterior to the cricoid plate in the posterior wall of the larynx. (B) The line of mucosal division is carried up higher on the cricoid plate in order to excise the involved mucosa and submucosa.
      The posterior cricoid plate itself has not often been found to be involved significantly. Usually the plane between mucosa and cartilage is dissected easily enough with a scalpel or bluntly with a fine dental spatula. One must stop short of the superior border of the cricoid plate, which is immediately below the arytenoid cartilages. No attempt is made to groove or otherwise alter the posterior cricoid cartilage itself. Subperichondrial resection of cartilage is not necessary.
      Division of the trachea is also carried out differently. The rostrum or bow of the proximal cartilage is shaped as before. Posteriorly, a flap of membranous wall is fashioned. This is gently rounded at each corner so that blood supply will be perfect. (C) When the anastomosis is made, the posterior mucosal sutures pass only through the full thickness of mucosa and submucosa of the posterior wall of the larynx and then through the full thickness of the membranous wall of the trachea.
      Once again the knots are placed outside of the lumen. This portion of the anastomosis is performed with 4-0 Vicryl sutures (Ethicon, Inc), as previously discussed. Sutures are appropriately tagged to the drapes of the operative field as previously described. (D) Four sutures are placed through the cartilaginous portion of the inferior margin of the cricoid plate and the outer portion of the membranous wall of the trachea below the proximal edge of the flap. Two sutures are led out on either side and are tagged to the drapes. (C-D) These sutures will fix the membranous wall posteriorly to the inferior edge of the cricoid plate and thus help to lay in the mucosal flap, which is replacing the resected laryngeal mucosa.
      (E) Although this may seem complex, it is a simple technique for replacement of the mucosa. The remainder of the sutures are carefully spaced and placed circumferentially as described before.
      In those instances when the extent of resection is great such that there would be tension on the anastomosis, laryngeal release is recommended. The suprahyoid release by the technique described by Montgomery
      • Montgomery WW
      Suprahyoid release for tracheal stenosis.
      is the preferred method. ( are reprinted with permission from the Society of Thoracic Surgeons
      • Grillo HC
      Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.
      ; are reprinted with permission from the Society of Thoracic Surgeons.
      • Grillo HC
      • Mathisen DJ
      • Wain JC
      Laryngotracheal resection and reconstruction for subglottic stenosis.
      )
      Figure thumbnail fx7b
      2(A) Operation is modified in those patients in whom stenosis is circumferential, affecting the subglottic area anterior to the cricoid plate in the posterior wall of the larynx. (B) The line of mucosal division is carried up higher on the cricoid plate in order to excise the involved mucosa and submucosa.
      The posterior cricoid plate itself has not often been found to be involved significantly. Usually the plane between mucosa and cartilage is dissected easily enough with a scalpel or bluntly with a fine dental spatula. One must stop short of the superior border of the cricoid plate, which is immediately below the arytenoid cartilages. No attempt is made to groove or otherwise alter the posterior cricoid cartilage itself. Subperichondrial resection of cartilage is not necessary.
      Division of the trachea is also carried out differently. The rostrum or bow of the proximal cartilage is shaped as before. Posteriorly, a flap of membranous wall is fashioned. This is gently rounded at each corner so that blood supply will be perfect. (C) When the anastomosis is made, the posterior mucosal sutures pass only through the full thickness of mucosa and submucosa of the posterior wall of the larynx and then through the full thickness of the membranous wall of the trachea.
      Once again the knots are placed outside of the lumen. This portion of the anastomosis is performed with 4-0 Vicryl sutures (Ethicon, Inc), as previously discussed. Sutures are appropriately tagged to the drapes of the operative field as previously described. (D) Four sutures are placed through the cartilaginous portion of the inferior margin of the cricoid plate and the outer portion of the membranous wall of the trachea below the proximal edge of the flap. Two sutures are led out on either side and are tagged to the drapes. (C-D) These sutures will fix the membranous wall posteriorly to the inferior edge of the cricoid plate and thus help to lay in the mucosal flap, which is replacing the resected laryngeal mucosa.
      (E) Although this may seem complex, it is a simple technique for replacement of the mucosa. The remainder of the sutures are carefully spaced and placed circumferentially as described before.
      In those instances when the extent of resection is great such that there would be tension on the anastomosis, laryngeal release is recommended. The suprahyoid release by the technique described by Montgomery
      • Montgomery WW
      Suprahyoid release for tracheal stenosis.
      is the preferred method. ( are reprinted with permission from the Society of Thoracic Surgeons
      • Grillo HC
      Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.
      ; are reprinted with permission from the Society of Thoracic Surgeons.
      • Grillo HC
      • Mathisen DJ
      • Wain JC
      Laryngotracheal resection and reconstruction for subglottic stenosis.
      )

      Postoperative Management of Airway

      Although these anastomoses have proved to be surprisingly competent initially, they may achieve only a percentage of a normal cross-sectional airway area because of the amount of disease involvement that is present submucosally even at the immediate subglottic level. In some patients, it is judicious to use a small tracheostomy temporarily as an alternative airway. It may also be necessary to leave this airway in place for some time until the edema subsides sufficiently to permit extubation. For some patients, it is impossible to place such a tracheostomy tube without endangering either the anastomosis or the innominate artery. In these patients, an area should be walled off and marked as noted. Such patients should be extubated in the operating room. If the airway is adequate, they are allowed to breathe on their own and are watched carefully for the next few days. If they do not breathe adequately or if they develop trouble in the immediate postoperative period, a small endotracheal tube is gently inserted between the vocal cords into the trachea. Ventilation is not usually required because there is no insult to the pulmonary parenchyma. If required, a cuff may be placed well below the anastomotic area with safety. The endotracheal tube is left in place for a number of days. It is usually withdrawn in the operating room. If the patient does not breathe adequately, it is replaced, the wound is reopened, and a tracheostomy tube is placed at the premarked position. By this time the anastomosis and the innominate artery are walled off. In some patients where there is no room for a safe tracheostomy, the endotracheal tube can again be placed until the patient can be extubated. If a tracheostomy tube is placed too close to the anastomosis, erosion may lead to recurrent subglottic stenosis, which probably will not be reparable. We have not found it necessary to splint the anastomosis with an inlaying T-tube or other type of tube. When a tracheostomy tube is placed at the original operation, the anastomosis and innominate artery are walled off by local strap muscles. Figure VI shows the radiographic appearance after surgical correction of the subglottic stenosis seen in Figure IVA.
      Figure thumbnail gr8
      Fig VIPostoperative film after resection and reconstruction of patient seen in .

      RESULTS

      We have treated 80 patients in whom the subglottic larynx was partially resected with trachea for inflammatory stenotic processes and in whom primary reconstruction was performed.
      • Grillo HC
      • Mathisen DJ
      • Wain JC
      Laryngotracheal resection and reconstruction for subglottic stenosis.
      The anterior cricoid arch was resected in all patients. This series excludes patients with primary and secondary tumors because this is a much different problem than inflammatory stenosis. In inflammatory disease, the process frequently extends above the stenosis in the subglottic larynx, nearly to the vocal cords. Resection, therefore, cannot be carried proximally to include all of the inflammation. For tumors, once the excision of tumor has been accomplished, the line of anastomosis lies in normal tissue.
      Fifty of the 80 patients had lesions that resulted from intubation done for ventilatory support. (Table 1). Thirty-one of these had endotracheal tubes only; in 16, the lesion was believed to result from stomal erosion of the cricoid cartilage, and in three the originating trauma was an elective cricothyroidostomy for ventilatory support. In five patients, the stenosis was of traumatic origin. In four of these it was because of blunt trauma, usually with separation of larynx and trachea and with injury to the lower larynx, and in one it was because of gouging of the anterior laryngotracheal wall by a flying object. A patient suffering from an inhalation burn was the first treated in this series. One patient was referred from another institution with a postoperative stenosis after an attempt at a complex laryngotracheal repair with a hyoid graft, performed to correct deformity because of a goiter.
      TABLE 1Results of Surgical Treatment of Subglottic Stenosis
      ResultsNo. of Patients
      Excellent18
      Good48
      Satisfactory8
      Failure2
      Death1
      Uncertain3
      Total80
      Mortality (%)1.3
      Of the 23 remaining patients, 19 had idiopathic laryngotracheal stenosis. We have now seen over 60 patients with idiopathic subglottic stenosis and operated on over 50 (unpublished data, April 1998).
      Five patients had tracheoesohageal fistulas when first seen. In two, the fistula had resulted from blunt trauma and in three, from intubation and ventilation with tracheoesophageal erosion. In 16 patients, paralysis or paresis of one or both vocal cords was identified preoperatively. In numerous others there was malfunction of one or both vocal cords.
      In those patients in whom the stenotic process involved only the anterior portion of the subglottic larynx (49 out of 80), resection of this portion of the cricoid arch in an arcuate line extending up to a point just short of the midline of the thyroid cartilage anteriorly sufficed. The posterior margin of resection was along the lower border of the cricoid cartilage. In patients in whom the subglottic process was circumferential, extending in front of the posterior plate of the cricoid, the line of posterior mucosal resection was incised above the level of stenosis, approaching the arytenoid cartilages. All involved mucosa and scar tissue was excised from the front of the posterior cricoid plate, leaving the cartilage intact posteriorly, to be surfaced by a broad-based flap of membranous trachea advanced from below. The margin of the anterior defect in the subglottic larynx was sutured in both types of resection to a prow-shaped segment of one distal tracheal ring, shaped to fit. The posterior membranous flap of tracheal wall was required for resurfacing of the bared cricoid in 31 of 80 patients. In 49 patients, it was possible to perform an anastomosis without resecting the tissues overlying the posterior cricoid plate.
      In the five patients with tracheoesophageal fistula, including one with three adjacent fistulas, the esophagus was closed in two layers with inverting sutures, and a pedicled flap of strap muscle was interposed between the esophageal closure and the laryngotracheal anastomosis anteriorly.

      Mathisen DJ, Grillo HC, Wain JC, et al: Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg (in press)

      In the first 20 patients, tracheostomy was used in 14 at the time of the original operation and an endotracheal tube in one. In the subsequent 60 patients, tracheostomy was used only nine times. This represented a drop in use of protective airway devices from 75% to 15%.
      There was only a single postoperative mortality in 80 patients. This was related to a fatal myocardial infarction. Two patients suffered early and long-term failure of treatment. One was the only man who was retrospectively classified as having idiopathic laryngotracheal stenosis. The other patient had had a tracheostomy in infancy and had undergone multiple reconstructions and T-tube splinting before attempted repair here.
      In classifying the results obtained (Table 1), we have deemed as excellent the patient with a normal voice and without any limitation of respiration at rest or on exercise. Patients were considered to have a good result if they suffered only slight lessening of maximum volume of voice, slight hoarseness that did not impede vocal use, slight weakness of voice after prolonged use, diminished ability to sing, and if their breathing was adequate for all normal activities. Patients labeled as having a satisfactory results were those with a hoarse voice, and either slight wheezing or shortness of breath on exercise not sufficient to impair usual activities. Eighteen patients achieved an excellent result, 48 a good result, and eight were classified as satisfactory. As noted, there were two failures and one immediate postoperative death. Three are listed as uncertain despite initial good results, because their follow-up was for less than 6 months.
      Forty-nine patients were contacted in late 1990 in follow-up from 6 months to 12 years. In 13 additional patients, follow-up was available between 2 to 10 years after operation, and in four between 1 to 2 years. In three, follow-up data was available at between 6 months and 1 year, and in three less than 6 months. The fact that no patient who achieved an excellent or good status was found to deteriorate in subsequent months or years should be noted. In contrast, an apparent failure improved over 3 years, as noted earlier, and most who required tracheostomies eventually were successfully decannulated. It may be concluded that, if anything, the long-term results represent a minimum statement.
      Early complications, in addition to the need for prolonged intubation because of glottic edema or anastomotic edema, included superficial wound infection in one patient that required drainage, suture granuloma in the incision of a second patient that required removal of the suture, and re-exploration for air leak in one patient. A pinhole leak was closed with a local muscle flap and healed promptly. Eight patients had difficulty with deglutition or with aspiration postoperatively. All had undergone extensive resection, and four of them had suprahyoid laryngeal release performed. One required a gastrostomy tube for nutrition and two others had such tubes placed at the time of surgery in anticipation of difficulty, especially because one of these two had also undergone reclosure of a recurrent tracheoesophageal fistula. With time and retraining in swallowing, it was possible to remove all gastrostomy tubes. Tracheal granulations were removed bronchoscopically in two patients who had anastomoses performed with Tevdek (Dernatel, Inc, Fall River, MA) and in five who had anastomoses performed with Vicryl (Ethicon, Inc). One of these patients restenosed. A polyp of the vocal cord was lasered in one patient. The patient with leukemia required a prolonged period for healing of the tracheal stoma, which had been made at the time of reconstruction. Twenty-two patients had a persistent hoarse voice in varying degree and 16 had weakness of the voice when attempting to project their speech. In four cases, these were expected consequences of bilateral vocal cord paralyses because of trauma and, in some others, of unilateral paralyses that was preexisting. Eight complained of an alteration of singing voice.

      COMMENTS

      Otolaryngological literature is filled with descriptions of multiple modes of treatment of non-neoplastic stenosis involving subglottic larynx and upper trachea. Conservative measures include dilatation, intubation, stenting, steroid injection, cryotherapy, electrocoagulation and laser therapy. Operative procedures, often complex, include scar excision, incision of cricoid anteriorly or posteriorly, grafts of buccal mucosa or skin, free cartilage inserts, pedicled hyoid grafts, and creation of cutaneous gutters variously supported; all are often stented for a prolonged period and are usually accompanied by tracheostomy. More procedures than encouraging results have been recorded.
      Pearson et al
      • Pearson FG
      • Cooper JD
      • Nelems JM
      • et al.
      Primary tracheal anastomosis after resection of cricoid cartilage with preservation of recurrent laryngeal nerves.
      described a single-stage repair using partial subperichondrial resection of the posterior cricoid to remove posterior stenotic scar, narrowing of the trachea by suturing the ends of cartilage together and intusussception of the trachea into the groove created by the subperichondrial resection. A follow-up report
      • Maddaus M
      • Pearson FG
      Subglottic resection.
      in 1986 of 28 patients with non-neoplastic stenosis (postintubation, traumatic, burn, and idiopathic) and seven with neoplasm so treated, produced a good airway in 26 and a limitation in two. A T-tube was used postoperatively in 10, and 13 had laryngeal release. Couraud et al
      • Couraud L
      • Brichon PY
      • Velly JF
      The surgical treatment of inflammatory and fibrous laryngotracheal stenosis.
      updated their experience between 1978 and 1988 with laryngotracheal resection for stenosis resulting from intubation or trauma, including 27 patients who had a Pearson-type procedure (F.G. Pearson, MD, Toronto, Canada)
      • Pearson FG
      • Cooper JD
      • Nelems JM
      • et al.
      Primary tracheal anastomosis after resection of cricoid cartilage with preservation of recurrent laryngeal nerves.
      • Pearson FG
      • Brito-Filomeno L
      • Cooper JD
      Experience with partial cricoid resection and thyrotracheal anastomosis.
      and seven who had total or subtotal cricoid plate resection with stenting. All had good results.
      The similar and generally good results obtained in this difficult group, of patients by units employing similar single-stage operations suggest that many complex procedures still used might well be abandoned. However, diagnostic precision is essential, operative timing must be carefully judged, operative technique is exacting, and postoperative care early and late must be meticulous. These are not operations to be done occasionally.

      References

        • Maddaus M
        • Pearson FG
        Subglottic resection.
        in: Pearson FG Deslauriers J Ginsburg RJ Thoracic Surgery. Churchill Livingstone, New York, NY1995: 322
        • Grillo HC
        Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis.
        Ann Thorac Surg. 1982; 33: 3-11
        • Grillo HC
        • Mark EJ
        • Mathisen DJ
        • et al.
        Idiopathic laryngotracheal stenosis and its management.
        Ann Thorac Surg. 1993; 56: 80-87
        • Mathisen DJ
        • Grillo HC
        Laryngotracheal trauma.
        Ann Thorac Surg. 1987; 43: 254-262
        • Weber A
        Symposium on the larynx and trachea.
        Radiol Clin N Am. 1978; Vol 16
        • Wilson RS
        Tracheostomy and tracheal reconstruction.
        in: Kaplan JA Thoracic Anesthesia. Churchill Livingstone, New York, NY1983: 421-445
        • Montgomery WW
        Suprahyoid release for tracheal stenosis.
        Arch Otolaryngol. 1974; 99: 255-260
        • Grillo HC
        • Mathisen DJ
        • Wain JC
        Laryngotracheal resection and reconstruction for subglottic stenosis.
        Ann Thorac Surg. 1992; 53: 54-63
      1. Mathisen DJ, Grillo HC, Wain JC, et al: Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg (in press)

        • Pearson FG
        • Cooper JD
        • Nelems JM
        • et al.
        Primary tracheal anastomosis after resection of cricoid cartilage with preservation of recurrent laryngeal nerves.
        J Thorac Cardiovasc Surg. 1975; 70: 806-816
        • Pearson FG
        • Brito-Filomeno L
        • Cooper JD
        Experience with partial cricoid resection and thyrotracheal anastomosis.
        Ann Otol Rhinol Laryngol. 1986; 95: 582-585
        • Couraud L
        • Brichon PY
        • Velly JF
        The surgical treatment of inflammatory and fibrous laryngotracheal stenosis.
        Eur J Cardiothorac Surg. 1988; 2: 410-415