© Borgis - New Medicine 3/2006, s. 58-59
Lidia Zawadzka-Głos, Mieczysław Chmielik
Laryngotracheal reconstruction using a costal cartilage graft
Department of Paediatric Otorhinolaryngology, Medical University, Warsaw, Poland
Head of Department: Prof. Mieczysław Chmielik MD, PhD
The management of paediatric laryngotracheal stenosis is a difficult problem and often involves multiple surgical procedures. Many surgical procedures, including laryngotracheal expansion with or without grafting, have been suggested for repairing laryngotracheal stenosis in children. The authors describe laryngotracheal reconstruction using a costal cartilage graft in an 8-year-old girl with severe subglottic and tracheal stenosis.
Acquired laryngotracheal stenosis is a serious long-term complication of tracheal intubation with an incidence of 0.7 to 8% in intubated children. Increased awareness and better treatment of intubated neonates helped to decrease the incidence of subglottic stenosis .
Many surgical procedures, including laryngotracheal expansion with or without grafting, have been suggested for repairing laryngotracheal stenosis in children. They can be divided into two groups: first, laryngotracheal reconstruction (LTR) procedures in which the cricoid cartilage is split and the framework is expanded with various combinations of cartilage grafts and stents; and second, cricotracheal resection (CTR), where a segmental excision of the stenotic segment is done and an end-to-end anastomosis is performed [1, 4].
Surgical reconstruction is recommended when conservative efforts to establish an adequate airway have failed. Cotton grade III (>90%), and grade IV (100%) lesions require external methods. Grade II (70% to 90%) may be amenable to either method .
Treatment must be individualized according to the pathological findings, age and general condition of the patient. Treatment in adults may differ from that in children, and some operations that are useful in children are not applicable to adults. All cases of moderate or severe laryngeal stenosis will require a tracheotomy. Once the airway is secured, endoscopic or external treatment modalities can be considered. In general, the less severe cases respond to endoscopic methods, and the more severe cases require external reconstruction.
Before surgery is done, vocal cord paralysis must be ruled out. Surgery is contraindicated if the patient has an underlying condition which necessities the patient to be tracheotomy-dependent despite adequate patency of the airway (for example a chronic pulmonary disease or neurological disease) [4, 5].
The first external reconstruction (Cotton reconstruction) in our department was performed in 1987 by Kossowska. The authors performed a double-stage procedure of reconstruction laryngotracheal stenosis using a costal cartilage graft in an 8-year-old girl in 2006. The patient had grade III stenosis as a result of prolonged intubation. The patient had a preexisting tracheotomy. The surgical technique has already been described. The procedure consists of exposing the upper trachea and larynx. An endotracheal tube is placed through the stoma. After incision suprastomal skin flaps are raised up to the level of the hyoid proximally and clavicles distally. The straps are divided in the midline, the thyroid isthmus divided, and the anterior trachea exposed. The stenotic segment is identified and split along the midline. This is split from the stoma site, through the cricoid cartilage, and up to the lower third of the thyroid alar, with care being taken to stay in the midline, and below the level of the anterior commissure. The child is then nasally intubated. The length and width of the anterior cricoid split is measured.
A chest incision is made over the right sixth rib. A segment of costal cartilage is harvested, preserving the inner perichondrium, while leaving the outer perichondrium attached to the graft. The graft is then carved into a boat shape of the desired width and length, with an outer flange that will prevent prolapse of the graft into the airway. The perichondrium should face the airway. The graft is sutured into place with interrupted 4-0 nonabsorbable sutures placed in a mattress fashion. The wound is closed in layers over a drain.
Our patient was extubeted 7 days later. No complications occurred. After surgery the patient began a regimen of intravenous antibiotics and steroids. Postoperative endoscopy will be performed 3 months after surgery.
Intraoperative complications are usually airway related. The endotracheal tube may be displaced, or secretions in the distal airway may compromise ventilation. Pneumothorax may occur during harvest of costal cartilage.
Early postoperative complications include bleeding and infection and also air leak from the repair site. As long as a drain remains in place, subcutaneous emphysema or pneumothorax can be avoided.
The late postoperative complication of most concern is restenosis, occurring in 10% of cases in most series [4, 5].
The goal of management of subglottic stenosis is decannulation. Success rates are dependent on the cause of the stenosis, the number of previous failed attempts, the status of the remainder of the airway, especially the glottis, and the severity of the stenosis. Cotton has reported an overall laryngotracheal reconstruction success rate of 92%-97% for grade II, 91% for grade III, and 72% for grade IV [1, 2].
1. Cotton R.T., Myer C.M.: "Contemporary surgical management of laryngeal stenosis in children". Am. J. Otolaryngol., 5: 360, 1984. 2.Myer C.M., et al.: "Proposed grading system for subglottic stenoses based on endotracheal tube sizes". Ann. Otol. Rhinol. Laryngol., 1994; 103: 319-2. 3.Strong R.M., Passy V.: "Endotracheal intubation: complications in neonates". Arch. Otolaryngol., 1977; 103; 329-35. 4.Zalzal G.H., et al.: "the survival of costal cartilage graft in laryngotracheal reconstruction". Otolaryngol Head Neck Surg., 94: 204, 1986. 5.Zalzal G.H., Cotton R.T.: "A new way of carving cartilage grafts to avoid prolapse into the tracheal lumen when used in subglottic reconstruction". Laryngoscope 1986; 96: 1039.