The mainstay for repair of severe laryngotracheal stenosis is either laryngotracheal reconstruction (LTR) with cartilage expansion using autologous cartilage or partial cricotracheal resection (CTR) where the scarred segment is excised and the trachea is brought up to replace the resected portion of the cricoid leaving a normal intact posterior cricoid plate. Both procedures are useful in specific clinical situations. The workup, indications, relative contraindications, as well as step-by-step surgical approach is reviewed.
50 Partial Cricotracheal Resection
Severe grades of stenosis, including Grades III and IV (complete stenosis), involving the larynx and upper trachea.
Normal glottic function and ability to phonate and protect the airway.
Competent larynx and swallow.
Some degree (at least 5 mm) of separation from the glottis.
Resectable portion—less than 50% of trachea.
Better pulmonary function for older children being considered for single stage (SS).
50.2 Relative Contraindications
Mild grades of subglottic stenosis (Cotton Grades I and II).
Poor glottic function or glottic scarring.
Active gastroesophageal reflux disease (GERD) or eosinophilic esophagitis (EE).
Active inflammatory airway.
Multiple previous surgeries making mobilization difficult.
Previous tracheoesophageal fistula (TEF) or laryngeal cleft repair.
Bilateral vocal cord (VC) paralysis or fixation.
At least five to seven normal tracheal rings.
Poor pulmonary or cardiac function.
Extensive length of disease where resection would not be possible (greater than 50% of the trachea).
Severe cervicospine neck problems or scarring limiting mobilization.
50.3 Comparison to LTR Best Handles
50.4 Grades of Stenosis III, IV
50.4.1 Diagnostic Evaluation
Outpatient clinical evaluation: The evaluation starts with the multidisciplinary aerodigestive clinic where the patient is screened by phone call triage and care is coordinated ahead of time. Previous studies, as well as the parent’s goal, are reviewed (i.e., “The goal is to get the tracheotomy out”). The patient is then seen by otolaryngology, gastroenterology, pulmonary, speech, nutrition, and a nurse practitioner. Awake flexible laryngoscopy is performed to examine the nasopharynx, pharynx, and larynx, and the results are recorded. The exam is performed to detect enlarged adenoids, tonsils, tongue base collapse, and pooling of secretions. The larynx is examined awake to determine vocal fold mobility and supraglottic stenosis.
Swallow evaluation: First clinical evaluation in the aerodigestive clinic by a speech and swallow therapist (SLP). He/she will take a feeding history and may observe the child swallowing, looking for signs such as aspiration and congestion. Functional endoscopic evaluation of swallowing (FEES) or modified barium swallow is then performed to detect gross or silent aspiration.
GERD workup: The gastroenterologist will take an extensive history and physical examination. He/she may order a number of diagnostic studies including upper gastrointestinal tract radiography (upper GI), esophagogastroduodenoscopy (EGD), and/or impedance. During triple scope, EE and uncontrolled GERD are ruled out.
Triple endoscopy: Pulmonary laryngoscopy, bronchoscopy, and EGD. The otolaryngologist will place the patient into suspension and perform a detailed examination of the pharynx, larynx, and trachea. First, tongue base collapse, enlarged lingual, and/or pharyngeal tonsils are ruled out or in. Then the supraglottis is examined dynamically during the flexible laryngoscopy under general anesthesia (sleep endoscopy) for epiglottic prolapse or supraglottic stenosis. During rigid microlaryngoscopy, the larynx is suspended and the vocal folds are evaluated for normal mobility versus fixation or paralysis. The arytenoids may be palpated for fixation or prolapse. The stenosis is then examined with a thin telescope. In severe Grade III stenosis, a 2.7-mm Hopkins rod telescope may be placed. If possible, the approximate distance from the end of the stenosis to the tracheotomy site is determined. Evidence of normal distal tracheal rings is examined. Also the trachea and bronchi are examined for tracheobronchomalacia. Appropriate surveillance cultures of the distal right middle lobe bronchus are taken during the pulmonary lavage for preoperative antibiotic planning. EGD is performed with multilevel biopsies and then an impedance probe is placed. 3 – 5
50.4.2 General Surgical Approach
Single stage (SS) vs. double stage (DS).
Microlaryngoscopy and bronchoscopy (MLB).
Surgical procedure (Standard pCTR). 6
The patient undergoes an initial MLB. The stenosis and surgical plan are reviewed with the team. The airway is also checked for infection and distal secretions. The airway is then secured with either an oral endotracheal tube that fits the stenosis or a cuffed flexible anode tube in the stoma, if an in-dwelling trach is present. The patient is given IV antibiotics consisting of appropriate anti-pseudomonas and anaerobic coverage, such as IV ceftazadime and clindamycin. The patient is placed in a hyper-extended position and an esophageal bougie is placed (▶ Fig. 50.1).
After prepping and draping a standard wide-field apron, the incision is made and a superior and inferior subplatysmal flap is elevated and sutured in place. The laryngotracheal complex is then dissected free. Under endoscopic control, a midline cricoid incision is made in case a decision is made to convert to LTR. The final decision is made intraoperatively (▶ Fig. 50.2). CTR would be necessary if the cricoid block was not expandable with rib grafts.
The airway is inspected and, if it appears that the segment would do better with resection, lateral cuts are made removing the anterior of the cricoid leaving the lateral buttress (▶ Fig. 50.3). This depends on whether the airway can be best expanded or it must be resected.
The lateral shelves are shaved down and the posteri- or cricoid is drilled flat as well. All firm scar tissue is simply removed with the drill. The airway is sculpted and the cricoid is taken down to a thin plate. This prepares the posterior cricoid plate for acceptance of the trachea (▶ Fig. 50.4).
If necessary, a suprahyoid release is performed to relieve tension on the suture line (▶ Fig. 50.5). The distal trachea is mobilized as well and a hilar release may be performed if necessary.
The common party space is entered and the esophagus is separated from the trachea going down to the mediastinum (▶ Fig. 50.6).
The trachea is brought up to replace the cricoid and two traction sutures are placed on both lateral tracheal rings (▶ Fig. 50.7).
The posterior tracheal mucosa is sutured to the superior cricoid with 4–5 interrupted vicryl sutures, which are first placed and then tied. The suture is placed through the trachealis mucosal flap and anchored to the posterior cricoid cartilage (▶ Fig. 50.8).
The ventilating tube is taken out when the sutures are tied and then replaced.
A decision is made whether to do the procedure single stage over an endotracheal tube or double stage over a Montgomery T-tube.
Next the lateral tracheal suture is placed through the lateral cricoid shelve taken care to avoid the recurrent laryngeal nerve (RLN). These are placed and then tied to pull up the tracheal segment (▶ Fig. 50.9).
The anterior lateral sutures are placed in vertical mattress fashion. They are placed and tied at the end (▶ Fig. 50.10).
Fibrin glue on the suture line.
The polydioxanone suture (PDS) suture is used to reduce internal tension. This is done by suturing the lateral trachea to the thyroid cartilage with two 2.0 PDS sutures (▶ Fig. 50.11).
Repeat scope and nasotracheal intubation with an age-appropriate tube.
External chin to chest (Grillo suture) or neck immobilization collar (▶ Fig. 50.12).
The child is kept intubated with the neck in a flexed or neutral position for 7 to 10 days and then rescoped and extubated if single stage.