Pediatric partial cricotracheal resection: A new technique for the posterior cricoid anastomosis

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1 Otolaryngology Head and Neck Surgery (2006) 135, ORIGINAL RESEARCH Pediatric partial cricotracheal resection: A new technique for the posterior cricoid anastomosis Mark E. Boseley, MD, and Christopher J. Hartnick, MD, Boston, Massachusetts OBJECTIVE: Partial cricotracheal resection has become a more popular procedure in the pediatric population as a treatment for severe subglottic stenosis. We describe a new technique for the posterior cricoid anastomosis. STUDY DESIGN AND SETTING: This is a case series of 4 pediatric patients with a Myer-Cotton grade III or IV subglottic stensosis. SETTING: Tertiary care hospital with a pediatric intensive care unit. RESULTS: All 4 patients were decannulated and there were no observed complications to include posterior mucosal dehiscence and/or recurrent laryngeal nerve injury. CONCLUSIONS: Placing sutures through the cricoid cartilage is technically less difficult than previously described techniques for treating subglottic stenosis near the undersurface of the true vocal folds and affords a more stable posterior mucosal suture line. SIGNIFICANCE: This technique provides a surgical means to treat high subglottic stenosis that closely approximates the true vocal folds by enabling a stable posterior mucosa to mucosa apposition. EBM rating: Grade C American Academy of Otolaryngology Head and Neck Surgery Foundation. All rights reserved. Pediatric subglottic stenosis has been seen more commonly since the 1970s in part due to the increased length of intubations in neonatal intensive care units. 1 A particularly difficult subgroup of these patients are those with Myer-Cotton grade III and grade IV stenosis. 2 Partial cricotracheal resection (PCTR) has become a more popular option for treating pediatric patients with severe subglottic stenosis in recent years. This technique offers the potential of removing the scarred portion of the airway and prevents the need to harvest a rib graft. Gerwat and Bryce 3 were the first to describe the technique for treating subglottic stenosis. Grillo et al 4,5 and Pearson et al 6 then popularized the procedure in the adult population and have reported a high success rate with minimal complications. Several studies 8-15 have more recently modified these techniques for use in children. Pediatric PCTR is a more technically difficult procedure than laryngotracheal reconstruction (LTR). There has been historic concern raised about risk of recurrent laryngeal nerve injury, anastomotic dehiscence, and possible inhibition of laryngeal growth. These risks appear to be less than once thought. Recurrent laryngeal nerve injury has been reported to be between 0% and 3% Anastomotic dehiscence has been as high as 12% in 1 study, 7 but was 5% in the largest case series published to date. 8 Finally, the concern over airway growth after PCTR appears now to be unwarranted. Monnier et al 9-11 described normal airway growth in 8 patients that they had followed for at least 10 years after surgery. Ward and Triglia 17 also recently published a study that showed normal subglottic growth after PCTR in a rabbit model. The indications for pediatric PCTR continue to be modified. All reported series in the literature have limited the use of PCTR to children with grade III or IV subglottic stenosis 8-16 with the exception of 1 series that included a single patient with a grade II stenosis. 7 Other important aspects to consider are the length of stenosis and the distance from the undersurface of the true vocal folds. Walner et al 12 have published the only case series that looks specifically at the margins of PCTR. They conclude that ideally there should be a 3 mm margin of normal trachea below the true vocal folds. However, their series included 14 patients who had resections that extended to the level of the true vocal folds. We report on the use of a new technique that is a modification o f what has previously been described. 4,5,8-11,12-15 This involves placing full thickness sutures through the posterior cricoid plate when performing the posterior anastomosis. The primary hypothesis is that this should make the From the Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. Reprint requests: Christopher Hartnick, MD, 243 Charles Street, Boston, MA address: Christopher_Hartnick@meei.harvard.edu /$ American Academy of Otolaryngology Head and Neck Surgery Foundation. All rights reserved. doi: /j.otohns

2 Boseley and Hartnick Pediatric partial cricotracheal resection: A new Figure 1 Posterior anastomosis suture placement. A, Cotton/Monnier technique; B, Grillo technique, C, described technique. posterior anastomosis less difficult in children with a stenosis that approximates the undersurface of the vocal folds. A secondary hypothesis is that this technique should make the posterior mucosal flap more stable and therefore less susceptible to restenosis. METHODS Patients The study was a prospective case series and institutional IRB approval was obtained before beginning. There were 3 girls and 1 boy included in the series. Their ages ranged from 13 months to 4 years. All of the children had a grade III or IV subglottic stenosis; 3 of the 4 had a grade IV stenosis. The stenotic segment in each was within 1 mm of the undersurface of the true vocal folds and measured between 1 and 2 cm in length. Two of the patients had previous open airway procedures. Operative Technique A curvilinear collar incision was performed and the previous tracheotomy stoma was removed where applicable. The airway was managed by either an endotracheal tube through the old tracheotomy site or by a new tracheal incision below this site. The cricoid cartilage was then vertically split and the extent of the stenotic segment was assessed. It is important to note here that there must be at least 1 intact ring between the most inferior aspect of the resection and the stoma in order to consider leaving it in place. This is required to have a stable tracheal anastomosis. Traction sutures were placed on either side of the trachea below the lower limit of our resection. The anterior and lateral portions of the cricoid cartilage were then removed; care was taken not to extend the excision posterior to the cricoarytenoid joint. The membranous trachea was dissected free from the underlying esophagus. A bougie was used to help identify the esophagus during this portion of the procedure. The posterior anastomosis was then performed. The suture placement that had been popularized by Grillo can be seen in Figures 1A and B. Our anastomosis consisted of four 4.0 Vicryl sutures through the posterior tracheal mucosal flap and then full-thickness through the posterior cricoid cartilage (Figs 1C, 2A and B). The suture was placed as superiorly as possible within the posterior cricoid cartilage so that the 2 mucosal surfaces were in direct apposition. All sutures were tied on the intraluminal surface of the trachea. Nasotracheal intubatation was carefully performed before completion of the lateral and anterior anastomosis. The anterior and lateral anastomosis was completed with the remaining sutures tied on the extraluminal surface of the tracheal wall. The final sutures were placed between the anterior thyroid cartilage and the trachea to relieve any anastomotic tension that might exist (Figs 3A and B). Two chin-to-chest

3 320 Otolaryngology Head and Neck Surgery, Vol 135, No 2, August 2006 Figure 2 Anterior views of posterior anastomosis suture placement. sutures maintained the neck in a neutral position during the postoperative period. These were removed at the time of the first postoperative endoscopy. The patients were typically intubated in the intensive care unit for less than 1 week (depending on the child s overall health status). They were maintained on broad spectrum antibiotics and a proton pump inhibitor during that time. Steroids were reserved for the night before the anticipated extubation. RESULTS Three of four patients were decannulated within a 1-week period, having had their tracheotomy site resected at the time of the PCTR (single stage procedure) (Figs 4A and B). We left the tracheotomy in 1 child, and this was subsequently removed after 3 months (2-stage procedure). The length of follow-up periods ranged from 6 months to 4 years. All 4 patients remain decannulated and have no evidence of exertional dyspnea. We had no incidence of recurrent laryngeal nerve injury or anastomotic dehiscence. DISCUSSION The specific aim of this case series is to report preliminary results of a new technique for cricotracheal anastomosis. The important variance in the technique that we describe when compared with what has been described previously for pediatric PCTR is the placement of the posterior sutures through the cricoid cartilage. All previous series that report on PCTR in pediatric patients have described placing this Figure 3 Anterior (A) and posterior (B) anastomosis suture placement.

4 Boseley and Hartnick Pediatric partial cricotracheal resection: A new Figure 4 Preoperative bronchoscopy shows superior extent of stenosis (A) and postoperative bronchoscopy shows widely patent subglottis (B) in the same patient. posterior suture between the membranous trachea and the mucosa overlying the posterior cricoid plate Monnier 8-11 and Hartley 14 have placed sutures between the membranous trachea and mucosa overlying the posterior cricoid plate (Fig 1A). Grillo 4,5 used the same intraluminal suture technique, but also placed extraluminal sutures between the posterior cricoid and trachea (Fig 1B). The particular pediatric patient who should benefit from this modification would be a child with a grade III or grade IV subglottic stensosis that extends to the undersurface of the true vocal folds. These patients would have typically required a LTR with rib graft if previous techniques for PCTR were used. Our hypothesis was that a more stable posterior mucosal flap should make the PCTR technically less difficult and should decrease the risk of restenosis due to decreased incidence of exposure of the underlying cricoid cartilage; this makes it a viable alternative to a LTR. PCTR has been difficult in these patients because there is often no superior mucosal flap. None of the 4 patients described here had a superior flap and therefore would have been very difficult to repair with the standard techniques that have been described. The second implication is that the placement of sutures between the membranous trachea and the cricoid cartilage should provide for improved coverage of the underlying cricoid cartilage. Exposed cartilage can lead to granulation tissue formation and subsequent stenosis. We saw no evidence of exposed cartilage on repeat airway endoscopies. CONCLUSION PCTR continues to be a viable option to treat children with grade III and grade IV subglottic stenosis. However, there still exists controversy over which lesions are best suited for this procedure. We present a series of 4 children who had grade III or grade IV stenosis and who had a PCTR with a new posterior anastomosis technique. All of these children had resections that approached the undersurface of the true vocal folds. Each child is now decannulated and free of airway symptoms. The question as to whether PCTR results in less postoperative restenosis when compared with LTR has yet to be answered. This will require more patients and longer follow-up. However, the fact that PCTR allows for removal of the airway scar and alleviates the need for a rib graft cannot be disputed. Although we realize that this is a small group of patients and that definitive conclusions cannot be reached, we feel that it is important to publish our experience to date. We are currently enrolling additional patients and plan to report on our continued experience. We would like to thank Bob Galla for his illustrations used in Figures 1A and C, 2A and B, and 3A and B. REFERENCES 1. Papsidero MJ, Pashley NRT. Acquired stenosis of the upper airway in neonates: an increasing problem. Ann Otol 1980;89: (Grade C). 2. Myer CM, O Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol 1994;103: (Grade C). 3. Gerwat J, Bryce DP. The management of subglottic laryngeal stenosis by resection and direct anastomosis. Laryngoscope 1974;84(6): (Grade C). 4. Grillo HC, Mathisen DJ, Wain JC. Laryngotracheal resection and reconstruction for subglottic stenosis. Ann Thorac Surg 1992;53: (Grade C). 5. Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 1982; 33:3 18. (Grade C). 6. Pearson FG, Cooper JD, Nelems JM, et al. Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 1975;70: (Grade C).

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