Primary Reconstruction of Airway after Resection

Transcription

1 ORIGINAL ARTICLES Primary Reconstruction of Airway after Resection of Subglottic Laryngeal and Upper Tracheal Stenosis Hermes C. Grillo, M.D. ABSTRACT Eighteen patients with low subglottic laryngeal stenosis and upper tracheal stenosis underwent resection of the anterior and lateral cricoid cartilage and upper trachea with reconstruction by primary laryngotracheal anastomosis. The posterior cricoid plate and recurrent laryngeal nerves were preserved. The distal trachea was tailored obliquely with an anterior prow and was anastomosed to the thyroid cartilage anteriorly and to the residual cricoid posteriorly. Where the stenosis was circumferential, scarred mucosa was resected from the anterior surface of the posterior cricoid lamina and the defect covered with a tailored flap of membranous tracheal wall. In 14 patients the lesions followed intubation injury. In 2 the stenosis was idiopathic. One stenosis resulted from inhalation burn and one from localized amyloidosis. Many patients had undergone previous surgical repairs. Sixteen patients had good to excellent results from six months to five and one-half years later. Reconstruction of the burned airway failed. One additional patient is still under treatment with a T tube. Resection and reconstruction of the upper trachea presents few problems when the pathological process does not involve the subglottic larynx [l]. When postintubation stenosis and other inflammatory or nonneoplastic 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 point of entry of the two recurrent laryngeal nerves into the larynx medial and posterior to the inferior cornua of the thyroid cartilage along the back of From the General Thoracic Surgical Unit, Massachusetts General Hospital and the Department of Surgery, Harvard Medical School, Boston, MA. Presented at the Seventeenth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26-28,1981. Address reprint requests to Dr. Grillo, Massachusetts General Hospital, Boston, MA the posterior cricoid lamina. While portions of the inferior part of the cricoid cartilage anteriorly may be resected in the course of a more conventional resection and a standard technique of anastomosis applied, the problem increases if the lesion extends above the upper border of the anterior cricoid so that the integrity of the complete circle of cricoid cartilage must necessarily be lost in the course of resection. When the disease extends circumferentially within the lower larynx to lie anterior to the posterior cricoid plate, straightforward resection is manifestly impossible with conservation of laryngeal function. Numerous surgical solutions have been proposed for the management of inflammatory lesions in the subglottic larynx that extend into the trachea and do not respond to conservative measures. These include the placement of stents, mucosal and skin grafts, free grafting of cartilage and hyoid bone, and pedicled grafting of the hyoid bone. Gerwat and Bryce [2] and Pearson and colleagues [3] described procedures for primary anastomosis of the airway after partial resection of cricoid cartilage with preservation of recurrent laryngeal nerves. Between 1975 and 1980, I have employed a similar reconstructive procedure in 18 patients. While there are variations in my technique, the basic principles are the same. This report supports the use of such a one-stage procedure for the management of selected lesions in this area. I have not included neoplasms in this series since the technique of operation in those patients is necessarily individualized for each. Ten such patients have undergone operation. Material and Methods Fourteen of the patients suffered from postintubation lesions of the subglottic larynx and upper trachea. Since most of them had undergone varying vicissitudes of treatment of both the original respiratory failure and the subsequent stenosis, the precise origin of the de by The Society of Thoracic Surgeons

2 4 The Annals of Thoracic Surgery Vol 33 No 1 January 1982 structive lesion was difficult to trace in every instance. The following factors appear to be prominent causes of these difficult stenoses: (1) circumferential erosion at the cricoid level by a large-bore endotracheal tube; (2) a high tracheostomy stoma with retrograde erosion of the cricoid cartilage; and (3) cricothyroidostomy with erosive damage to the subglottic larynx. Insofar as it was possible to isolate the factors, damage by an endotracheal tube appears to have been the primary cause in 7 patients, erosion of a tracheostomy stoma in 5, and cricothyroidostomy in 2. In at least one instance, the patient had an immune type of collagen-vascular disease and had shown other evidence of cartilaginous degeneration (including nasal cartilage). Nine of the 14 patients with postintubation airway injury were included in a previous report [4] describing experiences with 208 patients surgically treated for postintubation injuries. The detailed management of these 9 patients was not given. One patient had sustained an inhalation burn of the subglottic larynx and upper trachea following explosion of a television set, and experienced subsequent fibrosis unrelated to intubation. Two patients were seen with idiopathic stenosis of the laryngotracheal junction. A last patient had isolated involvement of the lower larynx and trachea by amyloid disease, which had been treated for more than twenty years. There were 10 female and 8 male patients. The age range was as follows: 14 to 19 years, 5 patients; 22 to 28, 4 patients; 53 to 54, 3 patients; 61, 2 patients; and 70 to 76, 4 patients. The causes of respiratory failure in those patients who had postintubation injuries ranged over a wide spectrum of diseases. Only 1 patient, l of the 2 with idiopathic stenosis, was referred without prior treatment. Many of the patients had undergone minor procedures including dilation, resection of granulomas, local and systemic application of steroids, stenting, and tracheostomy. Eight patients had undergone major procedures including resection and reconstruction in 4, reconstruction over stents with or without laryngoplasty in 2 patients, laryngoplasty with free hyoid bone graft in 1, and cutaneous tube reconstruction of the upper trachea in the patient with amyloid disease. Ten of the patients had open tracheostomies when referred. In a number of patients these represented secondary tracheostomies placed at a lower level than the original one. Selection of Patients 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. Therefore, I have reserved this operation for patients who, on radiological study and on direct laryngoscopy using a magnifying telescope, have residual subglottic space (Fig 1). It is particularly important to assess the involvement of mucosa overlying the posterior cricoid plate and the posterior portion of the subglottic larynx. Fortunately, this area is often relatively intact when the lesion is due to an erosive stoma at the cricoid or cricothyroid level. The airway was evaluated radiologically by our usual techniques, with removal of a tracheostomy tube at the time of the examination. Figure 2 demonstrates roentgenographic studies of a 15-year-old patient with idiopathic hypertrophic subaortic stenosis and postintubation stenosis following cardiac arrest. The airway stenosis resulted from endotracheal tube injury and had been treated by resection of five tracheal rings with subsequent dilation and then stenting following failure of that procedure and occurrence of a second lower stenosis. Vocal cord function was assessed by fluoroscopic examination of the larynx and also by direct examination, often with the aid of a laryngologist. Such evaluation is essential not only as a baseline for postoperative comparison of function but also to avoid performing subglottic airway reconstruction in a patient who has, additionally, obstruction at the glottic level due to a preexistent bilateral palsy. Roentgenographic studies were made prior to endoscopy. Figure 3 shows roentgenograms of a 24-year-old woman who had subglottic stenosis from ventilation with an endotracheal tube for three to four weeks for respiratory failure following complicated abdominal sepsis. The stenosis was treated by tracheostomy,

3 5 Grillo: Reconstruction after Subglottic Laryngeal and Upper Tracheal Stenosis Resection A B C D Fig 1. Upper 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. (0 Stenosis of the lower subglottic larynx and upper trachea. The extent of the lesion anteriorly is so great that correction requires removal of the 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. stenting, free hyoid bone graft, and multiple dilations plus intralesional steroid injection. Lateral soft-tissue roentgenogram of the airway of a 70-year-old man who had been ventilated with an endotracheal tube for respiratory failure following chronic obstructive disease is shown in Figure 4. Subsequent stenosis had been treated with more than one tracheostomy. Figure 5 shows roentgenograms of a 71- year-old patient with stoma1 stenosis following ventilation after mitral valve replacement. He required multiple dilations and removal of granulomas prior to reconstruction. Figure 6 illustrates stenosis due to cricothyroidostomy. Endoscopy usually was done under general anesthesia to allow adequate time for a careful assessment. Magnifying telescopes have given a much better picture of the detailed anatomy than the flexible instruments. Since it is often difficult to tell in advance whether or not there is adequate space beneath the glottis for repair, examination was made with an otolaryngologist, who would take over management if a onestage reconstruction could not be done. It is for this reason also that I depart from my usual policy of performing the endoscopic examina- tion and the resection at a single sitting, as in the usual upper tracheal stenosis. A factor in the decision for operation has been the degree of inflammatory change present in the area where anastomosis would have to be carried out. A surgical procedure was delayed in 5 patients. In 2 patients the operation was delayed six months and ten months, respectively, to allow a massive inflammatory process to subside. In 2, the procedure was delayed one month and three months to allow weaning from steroids, which were administered in a dose high enough potentially to inhibit healing. The shorter period was necessitated by the need to resume prednisone as part of the management of the patient s chronic lymphatic leukemia. In a fifth patient, one with a previously untreated idiopathic stenosis, the disease was followed for two years until it became sufficiently symptomatic to require correction. Operative Technique When a tracheostomy tube is in place, it may be replaced with an endotracheal tube for induction. When there is no tracheostomy, induction is made slowly with halothane. While a tight tracheal stenosis is usually dilated to provide a satisfactory airway, I am hesitant to perform dilation of these upper airway strictures for fear of disrupting and confusing the anatomy to be corrected. On occasion, however, this is required. A small endotracheal tube is passed through the lesion. A collar incision is usually adequate for the

4 6 The Annals of Thoracic Surgery Vol 33 No 1 January 1982 B A C D E

5 7 Grillo: Reconstruction after Subglottic Laryngeal and Upper Tracheal Stenosis Resection A icr Fig 3. (A) Anteroposterior view with line interpretation and (B) lateral view with line interpretation of subglottic stenosis at the interface with the uppermost trachea. In both roentgenograms the upper arrow is at the level of the true vocal cord. In the anteroposterior view, the lower arrow points to the maximal stenosis intrala yngeally. The wire sutures are from the hyoid bone graft. The graft had sequestrated. The broken line outlines the cricoid cartilage. In the lateral view, the ventricle is clearly seen. The lower arrow points to the inferoposterior margin of the cricoid cartilage. exploration. An existing tracheotomy may be included in the incision or separately excised. If a laryngeal release is required, I prefer to do it through a short transverse incision over the hyoid bone if exposure is inadequate through the collar incision. The anterior surface of the airway is exposed from the thyroid notch to the carina. Dissection is kept close to the airway in order to avoid injury to the recurrent laryngeal nerves. The nerves are not identified but injury is avoided by staying away from their courses. Fig 2. (A) Anteroposterior tomographic cut shows true vocal cords, a narrowed subglottic la ynx, and an irregular passage below this with the additional stenosis below. (B) Lateral view. Two white arrows mark the ventricle just above the true vocal cords and the cricoid level. There is subglottic stenosis of the intralaryngeal airway. Below lies a segment of plastic tube inserted to hold open the stenosis in an area of previous tracheal resection. (C) Anteroposterior view of trachea made preoperatively with a copper filter. Stenosis in the narrowed subglottic larynx and in the upper portion of trachea is clearly seen. (D) Anteroposterior view made postoperatively utilizing a copper filter. Upper arrow in both C and D is at theglottic level. Vertical inferior arrow points to spur of carina. (E) Line interpretations of roentgenograms in A and B showing a plastic tube through the distal stenosis (left) and postoperative airway (right). Anterolateral Stenosis The distal end of the lesion is identified first. The trachea is dissected circumferentially at this point, and transection is performed immediately below the lesion. This may include a tracheostomy just distal to the lesion. In only 1 patient had the tracheostomy for management of the stenosis been placed sufficiently distal to the original lesion that there was a segment of trachea above that could be employed in the reconstruction. The patient is intubated across the operative field into the distal trachea, which has been secured with lateral traction sutures. The end of the proximal tracheal segment, which is confluent with the laryngeal portion of the stenosis, is grasped with two Allis forceps, and dissection is carried upward to the cricoid cartilage. Particular care is taken to stay close to the airway as 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 [3]. The airway is entered anteriorly, cutting transversely across at the top of what appears to be obviously pathological tissue. It is always possible to resect additional tissue. Occasionally the decision has been so difficult that the diseased airway has been divided vertically in the midline from below upward for better determination of level of transection. Lateral traction sutures are placed on either side of the larynx, often in the lower and lateral portions of the thyroid cartilage to allow the larynx to be lifted upward for better examination. Once it is clear that the anterior cricoid cartilage must indeed be removed, the line of entry is placed de-

6 8 The Annals of Thoracic Surgery Vol 33 No 1 January 1982 Fig 4. Arrows on the roentgenogram indicate the diameter of the airway at the level of the lower border of the cricoid cartilage. Tracing shows thyroid and cricoid cartilages above, the outline of the airway (broken line), and the location of the tracheostomy tube. Resection required cervicomediastinal incision, removal of 6 cm of airway, and suprahyoid la yngeal release. liberately quite 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 (Fig 7A-D). 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 also 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 lowermost 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 in itself creates a larger subglottic airway than would 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. 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 (see Fig 7A, B). Shaping helps to soften the angulation necessary when direct anastomosis is done

7 9 Grillo: Reconstruction after Subglottic Laryngeal and Upper Tracheal Stenosis Resection A B C D Fig 5. Roentgenograms of 71-year-old patient with stoma1 stenosis following ventilation for respiratory failure after mitral valve replacement for ruptured papillary muscle. (A) Preoperative view in a tomographic cut and (B) postoperative view in a soft-tissue roentgenogram. Arrows indicate the diameter of the airway at the level of the lower border of the cricoid plate. The airway does not appear markedly narrowed in the preoperative view, although a granuloma appears just below the larynx. (C) Marked narrowing of the airway from front to back, intralaryngeally above the border of the cricoid cartilage and immediately below in the trachea at the site of a high stoma. (D) Postoperative lateral view shows an adequate lumen in the airway. to the beveled transection of larynx. No effort is made to create a groove in the cricoid plate nor is an effort made to narrow the proximal end of the trachea as described by Pearson and coworkers [31. Once 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 reextended and the anastomotic sutures are placed in the usual manner using interrupted 4-0 coated Vicryl sutures (Fig 7E, F). 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

8 10 The Annals of Thoracic Surgery Vol 33 No 1 January 1982 A B C D Fig 6. (A, B) Selected preoperative fluoroscopic spot applied to it and then part way through - the carroentgenograms and (C, D) postoperative spot tilaginous portion. roentgenograms. Cords are seen in adduction in A and C. In B and D, the glottis is oven and the vocal cords With the cervical spine flexed, the lateral are in abduction. Akows maik theglottic level. traction sutures are tied and then all of the anastomotic sutures are tied from front to back in the usual manner. Traction sutures are then approximated to the angles of the posterior removed. On occasion it is necessary to use one cricoid plate. The midline of the thyroid carti- or more 3-0 Vicryl sutures anteriorly in the lage is approximated to the midline of the peak midline to affect a good approximation of rigid of the "prow," which has been fashioned in the cartilage. most proximal cartilage of the trachea. Other In most cases the thyroid isthmus is rejoined sutures are appropriately apportioned. It is not in the midline to cover the anastomosis. If there necessary that sutures pass through the full is any question about the anastomosis and thickness of the cricoid cartilage but only there is sufficient length of trachea available, a through the full thickness of the mucosa small tracheostomy is placed well distal to the

9 11 Grillo: Reconstruction after Subglottic Laryngeal and Upper Tracheal Stenosis Resection 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 some 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 made. 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 (Fig 7G). A triangular portion of 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. Circumferential Stenosis 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. The line of mucosal division is carried up higher on the cricoid plate in order to excise the involved mucosa and submucosa (Fig 8A, B). The posterior cricoid plate itself has not 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 (see Fig 8B). This is gently rounded at each corner so that blood supply will be perfect. 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 (Fig 8C, D). Once again the knots are placed outside of the lumen. This portion of the anastomosis is per- formed with 4-0 Vicryl, as previously discussed. Sutures are appropriately tagged to the drapes of the operative field as previously described [l]. 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. For these four sutures, I have used 4-0 Tevdek sutures since the sutures are extraluminal. Two sutures are led out on either side and are tagged to the drapes. 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 (see Fig 8D). While this may seem complex, it is a simple technique for replacement of the mucosa. In those instances when the extent of resection is great so that there would be tension on the anastomosis, laryngeal release is recommended. My preference is for suprahyoid release by the technique described by Montgomery [51. Postoperative Management of Airway Although these anastomoses have proved to be surprisingly competent initially, they may achieve only a percentage of a normal crosssectional airway area due to the amount of disease involvement that is present submucosally even at the immediate subglottic level. It seemed judicious to utilize a small tracheostomy temporarily as an alternative airway. In a few patients it was necessary to leave this airway in place for some time until the edema subsided sufficiently to permit extubation. In a few patients it was impossible to place such a tracheostomy tube without danger either to the anastomosis or to the innominate artery. In these patients an area has been walled off and marked as noted (see Fig 7G). Such patients have been extubated in the operating room. If the airway is adequate, they are allowed to breathe on their own and are followed 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

10 12 The Annals of Thoracic Surgery Vol 33 No 1 January 1982 A B RESIDUAL CRlCOlD C D usually required since there is no insult to the bated. If a tracheostomy tube is placed too close pulmonary parenchyma. If required, a cuff may to the anastomosis, erosion may lead to recurbe placed well below the anastomotic area with rent subglottic stenosis, which probably will safety. The endotracheal tube is left in place for not be reparable. We have not thought it necesa number of days. It is usually withdrawn in the sary to splint the anastomosis with an inlying T operating room. If the patient does not breathe tube or other type of tube. When a tracheosadequately, it is replaced, the wound is re- tomy tube is placed at the original operation, opened, and a tracheostomy tube is placed at the anastomosis and innominate artery are then the premarked position. By this time the anas- walled off. tomosis and the innominate artery are walled off. In 1 patient in whom there was no room for Operative Management of Patients a safe tracheostomy, the endotracheal tube was Of the 18 patients who underwent operation, 13 again replaced until the patient could be extu- required only anterolateral resection. Five pa-

11 13 Grillo: Reconstruction after Subglottic Laryngeal and Upper Tracheal Stenosis Resection E F G Fig 7. Operative repair of anterolateral stenosis of the subglottic larynx and upper trachea. (A) Anteroposterior view. (B) Lateral view, showing the extent of disease involvement and the ultimate lines of transection. (C, D) Laynx and trachea after removal of the specimen. Recurrent nerves have been left intact. Mucous membrane of la ynx has been transected sharply at same level of division as cartilage. (E, F) Anteroposterior and lateral views of reconstruction. (G) Thyroid isthmus has been approximated to cover the anastomosis. Strap muscle, and occasionally thymus, is brought over to shield innominate arte y from open area of anterior tracheal wall. Area is walled off for possible placement of tracheostomy tube. tients had circumferential stenosis in the subglottic area which required excision of scar and posterior mucosa and submucosa anterior to the posterior lamina of the cricoid. In these 5, tailored flaps of membranous wall were advanced. In 16 patients cervical incision alone was used, and in 2, upper sternal division was required for access. The length of excision ranged from 2 to 6.5 cm as measured from the inferior border of the thyroid cartilage to the superior margin of the cartilage below. Three patients required suprahyoid laryngeal release. All 3 were more than 70 years old. Although 1 of them had only a short segment of trachea removed, he had undergone a previous resection and reconstruction elsewhere. The other 2 had 5.5 and 6 cm of airway resected, respectively. In 10 patients a preexisting tracheal stoma was excised with the specimen. In another pa- tient the preexisting stoma was low enough within normal trachea to be utilized postoperatively for an accessory airway. The remaining 7 did not have tracheostomies present. In 10 patients a tracheostomy tube was put in place at the time of operation. Either a No. 4 or a No. 5 uncuffed metal Jackson tracheostomy tube was used. Two of these patients were discharged with tracheostomy tubes in place, which were removed two months later after complete subsidence of edema. The other tubes were removed from seven to nineteen days postoperatively. Stoma1 healing was very slow in a patient with chronic lymphatic leukemia treated with prednisone. In 1 patient a tracheostomy tube was desirable but could not be placed because of the patient s anatomy and the great shortening of the trachea. An endotracheal tube was placed for a total of thirteen days with one attempt at removal and exploration for a tracheostomy on the sixth day. In 5 patients the anastomoses were done with 4-0 Tevdek prior to selection of 4-0 Vicryl as the suture of choice. Results The results in these selected patients are distinctly encouraging. Fifteen of the patients can be classified as having good to excellent results on the basis of functional ability. One patient is classified as satisfactory in that she leads a

12 14 The Annals of Thoracic Surgery Vol 33 No 1 January 1982 TRUE VOCAL CORD THYROID -- CRlCOlD A B THYROID CRlCOlD C Fig 8. Resection and reconstruction of circumferential stenosis of subglottic laynx and upper trachea. (A) External line of cartilaginous division of both la y nx and trachea is the same as in anterolateral stenosis. (B) Interior view of laynx and trachea demonstrates modifications necessa y where stenosis involves mucosa and submucosa just in front of the posterior cricoid plate. Superior dotted line indicates external cartilaginous division of the la ynx. Dashed line against the anterior wall of the cricoid plate indicates that the mucosa with its scarring will be cut back to within a short distance, if necessary, of the a ytenoid cartilages. Inferiorly the D posterior membranous wall has been retained as a broad-based flap. (C) Resection leaves bare an area of the intraluminal portion of the lower part of the cricoid posterior lamina. The flap of membranous wall of the trachea will be fitted into defect to provide prompt and complete mucosal coverage. (D) Mucosa of larynx has been anastomosed to mucosa of membranous wall of trachea. External to lumen, connective tissue of membranous wall has been fixed with four sutures to inferior margin of cricoid cartilage to assure that flap will stay firmly applied to surface.

13 15 Grillo: Reconstruction after Subglottic Laryngeal and Upper Tracheal Stenosis Resection normal life and has since completed a normal pregnancy but who describes some shortness of breath on major exertion. Geographical imperatives made it impossible to obtain quantitative follow-up studies on all patients. There were no poor results. Failure occurred in the patient with a laryngotracheal burn. The specimen showed marked submucosal fibrosis. This patient was an early experience in management of severe airway burns and probably was inappropriately selected for the first procedure of this type. She was managed subsequently by placement of a tracheal silicone rubber T tube. She had subsequent attempts at cryosurgical treatment elsewhere. She has been lost to follow-up, but three years after operation she still required a T tube for airway function. One patient with a good operative result died later of chronic lymphatic leukemia. In 1 patient the result remains uncertain. The patient had undergone innumerable operative procedures since infancy for restitution of an airway. Extensive resection including laryngeal release was performed in March, Postoperatively she required bronchoscopy on several occasions for removal of granulations and for dilation. A T tube was placed in the hope that the circumferential cartilage present at this level would eventually permit permanent reorganization of the airway. The final result is not yet clear. In 2 foreign patients current follow-up has not been achieved but when 1 was examined at six months and 1 at one year following operation, the results were excellent. In all patients who have been followed to date, regression has not occurred when results were initially good. Except for the vicissitudes described, postoperative complications have been minimal. No recurrent laryngeal nerve palsy was seen. One patient had a presternal wound infection which healed. Two patients in their 70s who had laryngeal releases and extensive resections aspirated on deglutition. In 1 of them the aspiration cleared in two weeks. The other had aspiration and required a gastrostomy for feeding for two months. This patient also required bronchoscopy on three occasions to remove aspirated secretions which she could not clear with ease in the postoperative period. Her hospitalization was prolonged. She has since made an excellent recovery. One other patient required bronchoscopy for removal of granulations on three occasions. This was the last reconstruction done with nonabsorbable Tevdek sutures. Since that time, granulations have not been a problem. Comment The variety of methods used for treatment of subglottic stenosis and the frequent failure to obtain lasting and consistent relief are measures of the difficulty of the problem. There is no effort here to provide a thorough review of this problem but rather to provide a sampling of approaches that have been used as background for the one-stage primary anastomotic approach described. Conservative, nonoperative measures have been successful principally in less severe degrees of stenosis where there has been little deformity or destruction of the cartilages. Techniques include dilation [61, intubation [7], stenting [8], and intralesional steroid injection [9]. Recently, cryotherapy and laser beam surgery have been added to these modalities. Excision of scar tissue, incision of the stenotic area, and the placement of split skin grafts or buccal mucosal grafts with stenting of various types have also had variable success. Montgomery [lo] developed laryngeal stents and silicone rubber T tubes for this purpose. Rethi [ll] employed vertical bisection of the posterior lamina of the cricoid with stenting and subsequent dilations over many months. Complex repairs have been described using skin with cartilage grafts for restitution of laryngotracheal wall. Meyer [121 described a two-stage procedure for laryngotracheal stenosis. He resected scar, divided the cricoid anteriorly, utilized a posterior incision closed by mobilization of mucosa and ultimately closed the anterior defect with a previously prepared cutaneous flap with a buccal graft supported by cartilage rib grafts. Fearon and Cotton [131 and Fearon and Cinnamond 1141 treated patients who did not respond to dilation by interposition of autogenous free cartilaginous grafts originally taken from the thyroid ala and later from costal cartilage. Success was lim-

14 16 The Annals of Thoracic Surgery Vol 33 No 1 January 1982 ited. Toohill and co-workers [15] utilized nasal septa1 grafts experimentally and cited a single clinical case. Zehm [16] described one of the largest series-12 patients with subglottic stenosis-treated in a two-stage procedure by resection of cricoid, preparation of a vertical midline cutaneous gutter, and later closure of this gutter with a composite graft of auricular cartilage and skin. Segments of the hyoid arch have been transposed to the cricoid after resection of a stenotic, damaged area. Alonso and colleagues [171 had five successful results in 6 patients by transposing the hyoid arch as a free graft wired into place. The endolarynx was resurfaced with skin or buccal mucosal grafts placed over a stent, which was left in place for two months. Ward and associates [18] described the use of a composite stemohyoid muscle graft that brought the pedicled segment of hyoid into the cricoid arch with its own blood supply. Three out of four operations were successful. Resection of the cricoid with preservation of the recurrent laryngeal nerves was described by Conley [19] in He performed subperichondrial dissection and used a stent. Shaw and associates [20] resected the cricoid and did direct anastomosis to trachea in patients who had nerve palsy from trauma. Ogura and Powers [21] and Ogura and Biller [221 approached 17 patients wth chronic subglottic stenosis by resection of the cricoid cartilage subperichondrially leaving a rim of posterior superior cartilage. The subperichondrial dissection protected the integrity of the recurrent laryngeal nerves. Three weeks of stenting followed. There were fourteen successes in this series. More recently Gerwat and Bryce [2] and Pearson and colleagues [3], all from the Toronto General Hospital, described the management of subglottic stenosis by resection and direct anastomosis. The former group resected the anterior arch of the cricoid and part of the lateral laminas. The recurrent laryngeal nerves were exposed and dissected. A thyrohyoid laryngeal release was used in all of the patients. A stent was placed as needed, and a tracheostomy was left in place for seven days if no stent had been placed. The results in 4 patients were reported. The latter group reported the results in 6 patients. The recurrent nerves were dis- sected. The anterior arch and lateral laminas of the cricoid were resected, and the inferior part of the posterior cricoid plate was removed subperichondrially. The mucous membrane could thus be removed higher posteriorly if scarring was present posteriorly. In order to obtain an exact anastomosis and also to provide a ring of cartilage that would support the airway, the authors plicated the membranous trachea to create a complete cartilaginous circle. They also added a laryngeal release and planned to leave a tracheostomy tube from one to two weeks in all patients until the edema had regressed. They obtained excellent functional results in 5 of the 6 patients. The remaining patient had a T tube stent introduced because of postoperative restenosis; the original pathological process had been an inhalation burn. Couraud and his colleagues [23] performed five partial cricoidal resections and two total resections of cricoid in accordance with this technique. One total resection failed and the two later total removals SUCceeded after long-term intubation. The authors noted that tracheostomy was not routinely required and that it was not necessary to plicate the trachea posteriorly. The present series confirms the validity of the one-stage reconstructive approach. The operation is difficult in comparison with segmental resection of the trachea. However, the procedure has many advantages over the complex and frequently unsuccessful previous methods. There are points of technical difference between the procedures of the Toronto General Hospital and the Massachusetts General Hospital. In our procedure no effort was made to identify the recurrent nerves but rather to leave them embedded in their scar, carrying out the dissection against the trachea and larynx in such a way that the nerves were not damaged. The posterior cartilaginous plate of cricoid was not grooved or resected except occasionally for a tiny inferior margin. The posterior part of the cricoid is rarely injured by the disease process, and there usually is no need to resect it. Instead, scarred mucosa was resected at a higher point toward the arytenoid cartilages from the surface of the plate and the mucosa was restored by a broad-based flap of membranous wall of distal trachea. There was no need to plicate the trachea and make it smaller in diameter

15 17 Grillo: Reconstruction after Subglottic Laryngeal and Upper Tracheal Stenosis Resection since, if anything, laying on the obliquely divided trachea produces a larger lumen anteriorly. Since the cricoid plate was left intact, there was no need to create a ring of cartilage for posterior support. Laryngeal release was not needed. except in some lengthy resections. This avoids aspiration problems, which can occur even with suprahyoid release. In several patients in whom a tracheostomy could not be placed because of the length of resection, it proved to be totally unnecessary. In the future, tracheostomy will be eliminated except in special cases. Addendum As of October, 1981, the patient with the T tube had not yet been extubated. However, 4 additional patients were successfully operated on. Two of these had circumferential stenosis which required membranous flaps. References 1. Grillo HC: Surgery of the trachea. In Keen G (ed): Operative Surgery and Management. Bristol, J Wright and Sons, 1981, pp Gerwat J, Bryce DP: The management of subglottic laryngeal stenosis by resection and direct anastomosis. Laryngoscope 84:940, Pearson FG, Cooper JD, Nelems JM, Van Nostrand AWP: Primary tracheal anastomosis after resection of cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 70:806, Grillo HC: Surgical treatment of postintubation tracheal injuries. J Thorac Cardiovasc Surg 78: 860, Montgomery WW: Suprahyoid release for tracheal stenosis. Arch Otolaryngol 99:255, Schofield J: Conservative treatment of subglottic stenosis of the larynx. Arch Otolaryngol 95: 457, Finney D, Torda T, Winkler P: The treatment of chronic subglottic stenosis by long-term intubation. J Laryngol Otol 84:275, Birch HG: Endoscopic repair of laryngeal stenosis. Trans Am Acad Ophthalmol Otolaryngol 74:140, Cobb WB, Sudderth JF: Intralesional steroids in laryngeal stenosis. Arch Otolaryngol 96:52, Montgomery WW: The surgical management of supraglottic and subglottic stenosis. Ann Otol Rhinol Laryngol 77:534, Rethi A: An operation for cicatricid stenosis of the larynx. J Laryngol Otol 70:283, Meyer R: New concepts in laryngotracheal reconstruction. Trans Am Acad Ophthalmol Otolaryngo1 76:758, Fearon B, Cotton R: Surgical correction of subglottic stenosis of the larynx in infants and children. Ann Otol Rhinol Laryngol 83:428, Fearon B, Cinnamond M: Surgical correction of subglottic stenosis of the larynx: clinical results of the Fearon-Cotton operation. J Otolaryngol 5:475, Toohill RJ, Martinelli DL, Janowak MC: Repair of laryngeal stenosis with nasal septa1 grafts. Ann Otol Rhinol Laryngol 85:600, Zehm S: The use of composite grafts for reconstruction of the trachea and subglottic airway. Trans Am Acad Ophthalmol Otolaryngol 84:934, Alonso WA, Druck "3, Ogura JH: Clinical experiences in hyoid arch transposition. Laryngoscope 86:617, Ward PH, Canalis R, Fee W, Smith G: Composite hyoid stemohyoid muscle grafts in humans. Arch Otolaryngol 103:531, Conley JJ: Reconstruction of the subglottic air passage. Ann Otol Rhinol Laryngol62:477, Shaw R, Paulson DL, Kee JL Jr: Traumatic tracheal rupture. J Thorac Cardiovasc Surg 42:281, Ogura JH, Powers WE: Functional restitution of traumatic stenosis of the larynx and pharynx. Laryngoscope 74:1081, Ogura JH, Biller HF: Reconstruction of the larynx following blunt trauma. Ann Otol Rhinol Laryngol 80:942, Couraud L, Martigne C, Houdelette P, et al: InterGt de la resection cricoidienne dans le traitement des stenoses crico-tracheales apr& intubation. Ann Chir Thorac Cardiovasc 33:242,1979 Discussion DR. F. G. PEARSON (Toronto, Ont, Canada): I have some comments to make on the technicalities of the operative technique, and will report on the application of the Montgomery silicone T-tube as an adjunct to these operations in selected patients. The 18 patients with subglottic resection discussed by Dr. Grillo fall into two groups. In the first group of 13 patients, the injury was restricted to the anterolateral aspect of the subglottic airway, with preservation of the mucosa covering the posterior cricoid plate. At the Toronto General Hospital, we have used the identical procedure described by Dr. Grillo for patients with a similar condition, and I agree that plication of the membranous trachea is not necessary or desirable for an anastomosis at this level. Dr. Grillo's second group of 5 patients had a circumferential subglottic stenosis, which I believe represents a technically more difficult anastomosis in the narrowest part of the subglottic airway. When circumferential stenoses are present, I believe there may be an advantage in adding a subperichondrial resection of the posterior cartilaginous plate. When the upper end of the lesion requires a transverse re-

16 18 The Annals of Thoracic Surgery Vol 33 No 1 January 1982 section of the mucosa at the level of the inferior border of the thyroid cartilage, then the extra mucosal perimeters of the airway at this level are rigid and cartilaginous. If a subperichondrial shell of cartilage is rongeured or curetted away from the luminal aspect of the posterior and lateral parts of the cricoid cartilage, then the rigid margins of the airway at this level are actually widened. The subglottic mucosa at the upper resection margin is somewhat elastic and will be stretched to some degree at the time of subsequent anastomosis with the distal tracheal stump, since the tracheal lumen (even with the ends of the tracheal cartilage approximated posteriorly) will still be larger than that of the original subglottic airway. It may be, therefore, that a more predictably widely patent anastomosis is obtained by this maneuver. These anastomoses lie within 1 cm of the inferior surface of the true vocal cords. Between 1972 and 1981, we performed 14 of these high subglottic resections for circumferential lesions of the second type. The etiology in these 14 patients was as follows: postintubation stenosis, 5; blunt trauma with cricotracheal disruption and cricoid fracture, 5; chemical inhalation injury, 2; stenosis due to Wegener s granulomatosis, 1; and adenoid cystic carcinoma, 1. A good subglottic airway was obtained in all patients. Both recurrent nerves were preserved in those patients with intact recurrent nerves prior to resection; 4 of the 5 patients with blunt trauma had complete transection of both recurrent nerves from the original injury. The Montgomery silicone T-tube has been used as an adjunct to resection in 4 of our patients. In 3 patients, there was an associated pathological process at the level of the cords and larynx itself, and the T- tube was used to stent and mold this region postoperatively. These tubes remained in place for twelve to fifteen months, and in no patient was it necessary to change the tube during this long period of stenting. All 3 of these patients now have a good laryngeal and subglottic airway. In the patient with Wegener s granulomatosis involving the subglottic airway, a Montgomery T-tube was used as a stent for thirteen months, during which time the disease was brought into complete remission. When the T-tube was removed, the subglottic stricture promptly recurred, but there was no longer active inflammation and a resection was done at that time. I thoroughly enjoyed your paper, Dr. Grillo. DR. H. ESCHAPASSE (Toulouse, France): It is difficult to discuss Dr. Grillo s work not only because of the excellence of his presentation but also because of his tremendous experience with this difficult group of patients in whom the surgeon has to restore the patency of airways and if possible maintain adequate phonation, often after other attempts have failed. We have treated 12 patients with various techniques mostly because of differences in the case histories or evolution in our thinking about the problem. Five patients had a cricotracheal anastomosis following partial resection of the anterior portion of the cricoid, endoluminal resection of scar tissue in the posterior part of the cricoid, and circular resection of the upper trachea. Because of failure of surgical treatment, a T-tube was used in 1 patient and a skin graft in the other. The end result was good in 3 patients but mediocre (phonation) in the other 2. Two patients had an anterior stricture repair (one of which was a reoperation). Following resection, the repair was successfully accomplished with a Gebauer skin graft. In selected patients, this technique may be a valuable alternative. In 4 patients we did a Pearson type of resection without identification of the recurrent nerves because of scar tissue. Three required postoperative endotracheal intubation (small tube). One patient with tracheomalacia involuntarily extubated himself three weeks later and subsequently died. The other 3 did well. As shown by Dr. Grillo, the one-stage reconstruction is the best approach to the problem but each patient needs special consideration. I have two questions for Dr. Grillo. (1) In general, these lesions must be treated when they are no longer inflammatory. In our series, 2 patients needed emergency operation. What do you do in such situation? (2) What do you think of the Gebauer skin graft for selected patients? DR. GRILLO: Thanks, Dr. Pearson. I hope I made it eminently clear that this paper is a postscript to the work of Pearson, Cooper, Nelems, and Van Nostrand. I still like my flap procedure. I think it is simpler in concept and execution. However, the results of the Toronto group are as good (or as poor) as mine. Both routes reach the same goal with these differences in technique. I appreciate the way shown by the Toronto group in this very difficult problem. Professor Eschapasse, I have a couple of comments on the questions you raised. Five patients were operated on after a delay. Two had such marked inflammation that I preferred to wait until it subsidedalmost a year for 1 patient and about six months in the other. In 2 others I waited in order to wean them from high-dose prednisone. In the fifth, I waited two years while an idiopathic stenosis declared itself as requiring an operation. In those patients with airway emergencies, if the lesion were of the type that could be repaired, I would certainly do so as an emergency measure. The majority of these patients either were borderline or had had previous tracheostomies done to handle such an obstructive emergency. If there is any question, I perform tracheostomy, placing it so it can be resected with the lesion later or be so far away from the lesion that it will not interfere with resection. The Gebauer dermal graft is a technique that has been used. Many techniques have been developed. There are some successes with almost any technique. Gebauer grafts have a number of particular negatives.