Introduction
Basic functions of the larynx include being the conduit for air, protecting the airway from aspiration, phonating, coughing, fixing the chest for straining activities, maintaining positive end-expiratory pressure, and swallowing. All these functions can be impaired in patients with laryngeal stenosis.
Acquired laryngeal stenosis is a rare condition. It may be a result of external or iatrogenic trauma, systemic diseases, infections, and neoplasms. The degree of laryngeal dysfunction varies widely, with a diversity of treatment methods to address the physical abnormalities and associated symptoms.
Injury to the laryngeal soft tissue or its cartilaginous framework can lead to scarring and loss of support, with subsequent collapse of the airway and stenosis. The laryngeal cartilaginous framework depends on the perichondrium for its blood supply. Cartilage deprived of its blood supply necroses rapidly and acts as a foreign body that induces an inflammatory reaction and causes further tissue destruction and scarring. After injury, the soft tissue planes of the larynx are disrupted and filled with blood, which may develop into an organized hematoma and further fibrosis. The site of injury also influences the development of stenosis. Different areas of the larynx have intrinsic characteristics that protect or predispose to various injuries, as mentioned previously.
- 1.
Surgical anatomy
- a.
The larynx is composed of three distinct regions:
- 1)
Supraglottic
- 2)
Glottic
- 3)
Subglottic
- 1)
- b.
All of these regions are covered with mucosa, which is susceptible to injury from direct trauma, radiation, systemic diseases, or infections. Therefore any of these regions can become stenotic from different etiologies.
- c.
In general, the supraglottis has more soft tissue and redundant mucosa, making it less dependent on external support than the glottis or subglottis. The supraglottic region includes:
- 1)
Epiglottis
- a)
The epiglottis is a cartilaginous structure that acts like a rudder to deflect food and liquid away from the glottis and into the piriform sinuses during swallowing. The epiglottis has no muscle; therefore it inverts by the interaction of tongue base retraction and hyolaryngeal elevation during swallowing.
- a)
- 2)
Aryepiglottic folds
- a)
Aryepiglottic folds are ligaments covered by mucosa that connect the epiglottis to the arytenoid cartilages.
- a)
- 3)
Arytenoids
- a)
The cricoarytenoid joints allow for rotation of the arytenoids on the cricoid in three different axes, resulting in lengthening, foreshortening, abduction, and adduction of the vocal folds.
- b)
The arytenoid mucoperichondrium is exquisitely sensitive to injury, induced when the capillary perfusion pressure of the overlying mucosa is overcome by the external compression of an endotracheal tube cuff.
- a)
- 4)
False vocal folds
- a)
The false vocal folds are soft tissue structures, containing a superior fan of thyroarytenoid muscle.
- a)
- 1)
- d.
The glottis is defined as the area between the true vocal folds and is the narrowest portion of the adult airway. Thus the surrounding anatomic structures are responsible for maintaining a patent and functional air passage.
- 1)
The glottis depends on cartilaginous support, cricoarytenoid joint mobility, and neuromuscular coordination for normal function.
- 2)
The true vocal folds are multilayered, with the thyroarytenoid muscle and vocalis muscle (most medial aspect of the thyroarytenoid muscle) covered by the lamina propria and an external layer of mucosa.
- 3)
Intrinsic muscles of the larynx move the vocal folds to:
- a)
adduct (lateral cricoarytenoid muscle, interarytenoid muscle, and thyroarytenoid muscle)
- b)
abduct (posterior cricoarytenoid muscle)
- a)
- 4)
Primary innervation is by the recurrent laryngeal nerve with variable collateral innervation by Galen nerve, the human communicating nerve, and the interarytenoid plexus.
- 1)
- e.
The subglottis is defined as the area within 1 cm below the glottis.
- 1)
This is the narrowest segment of the pediatric airway.
- 2)
The subglottic region:
- a)
includes the cricoid, the only complete ring within the human airway
- b)
is lined with respiratory epithelium over a submucosa composed of loose areolar tissue
- i)
Respiratory epithelium is easily disrupted and is thus not well suited to tolerate trauma.
- i)
- a)
- 3)
Subglottic injuries often heal by secondary intention and scarring.
- a)
Therefore the subglottis is more susceptible to stenosis than any other region of the larynx.
- a)
- 1)
- f.
Outcomes
- 1)
Outcomes after surgery for acquired laryngeal stenosis vary greatly, depending upon the location, etiology, and severity of disease.
- 2)
The expected outcome of any of these surgeries is to achieve improvement of the stenosis and decannulation, if applicable.
- 3)
Complete resolution of stenosis is not expected. Fortunately, patients can tolerate a small amount of stenosis without adversely affecting breathing during normal activities.
- 4)
Each patient perceives airway restriction differently, so the surgeon must individualize the treatment plan and timing of surgery based upon each patient’s unique needs, concerns, and medical comorbidities.
- 1)
- g.
Prognosis
- 1)
The prognosis for patients with acquired laryngeal stenosis depends upon location, etiology, and extent of disease.
- a)
Supraglottic stenosis from caustic ingestion or radiation therapy often recurs, requiring repeated surgeries.
- b)
In the case of an autoimmune etiology, treatment of the underlying autoimmune disease improves and sometimes reverses the stenosis (e.g., Wegener granulomatosis).
- a)
- 2)
Anterior glottic webs often restenose to some extent after treatment, regardless of technique.
- a)
Placement of a keel improves the airway result.
- b)
Restoration of the mucosal wave is not expected after lysis of the web.
- a)
- 3)
Treatment of posterior glottic stenosis (PGS) is fraught with challenges due to the compromise of voice quality and the possibility of aspiration when the posterior glottis is surgically opened.
- a)
Due to the nonreversible nature of the posterior glottic augmentation surgeries, conservative surgery is initially advocated, especially if the patient already has a tracheostomy tube for airway management.
- b)
The patient often needs to come to terms with the voice and swallowing repercussions from these surgeries because these functions may be less than normal.
- c)
Repeat surgery is often required, depending upon healing and airway requirements according to the patient’s activity level.
- a)
- 4)
Subglottic stenosis can also recur, thus requiring several surgical interventions. Gastric acid reflux should be considered as a contributing factor.
- 5)
In general, open procedures to address laryngeal stenosis are more effective than endoscopic procedures.
- 6)
However, open procedures have increased morbidity, including tracheostomy, and longer recuperation times.
- 7)
Endoscopic “touch up” surgeries are sometimes needed even after open resection.
- 1)
- a.
Key Operative Learning Points
- •
Intraoperative control of the airway by either endotracheal intubation or tracheostomy is paramount in any surgery for laryngotracheal stenosis.
- •
Dilatation can be successfully used as primary treatment in select cases of thin congenital webs, as adjuvant therapy for endoscopic microsurgical techniques, or as palliation in patients who are medically unsuited for major reconstructive surgery.
- •
Endoscopic microsurgical techniques, with or without adjunctive procedures such as intralesional steroid injection or application of mitomycin C, are ideally suited for the management of thin webs or other less severe stenoses with good cartilage support.
- •
Anterior glottic webs less than 1 cm in height are usually amenable to endoscopic excision with subsequent placement of a stent or keel.
- •
Treatment success of the PGS depends on the degree and depth of scarring, mobility of the cricoarytenoid joints, and the patient’s acceptance of dysphonia and dysphagia in turn for improved airway restriction.
- •
Endoscopic microsurgery for acquired laryngeal stenosis is likely to fail when used in patients with multiple stenotic sites, when the stenosis is associated with loss of cartilaginous support, when it is wider than 1 cm, when the lesion is circumferential, and when accompanied by the presence of bacterial infection.
- •
Failure to control gastroesophageal reflux in the perioperative period may contribute to persistent or recurrent laryngeal stenosis.
- •
Inadequate preoperative, intraoperative, and postoperative communication with the anesthesia and surgical and recovery room staff can result in catastrophic airway events.
- •
Changing to a cuffless tracheotomy tube too soon after laryngotracheal reconstruction may result in subcutaneous emphysema, contamination of the cervical wounds, and even a laryngocutaneous fistula.
- •
A persistent postoperative laryngocutaneous fistula usually signifies inadequate wound drainage and underlying infection.
Preoperative Period
- 1.
History
- a.
Symptoms
- 1)
Shortness of breath
- 2)
Dyspnea on exertion
- 3)
Stridor
- 4)
Hoarseness
- 5)
Difficulty swallowing
- 6)
Aspiration
- 7)
Difficulty clearing secretions
- 8)
Any combination of these symptoms and signs
- 1)
- b.
Etiology
- 1)
External trauma
- a)
Civilian violence and motor vehicle accidents have led to an increase in the incidence of posttraumatic laryngeal stenosis.
- i)
The incidence of laryngeal stenosis after external trauma varies from 0% to 59%.
- i)
- b)
Even when an adequate and immediate repair is accomplished, a severe disruption of supporting structures or laryngotracheal separation is accompanied by some degree of airway narrowing.
- a)
- 2)
Intubation
- a)
The incidence of laryngeal stenosis after prolonged or repeated intubation has been estimated to range from 3% to 8% in both adults and children. Figures as high as 44% have been cited for low-birth-weight neonates and those with respiratory distress syndrome. Higher rates of stenosis are expected after inhalation injury.
- b)
Causes of laryngeal stenosis after intubation are multifactorial, including:
- i)
Duration of intubation
- ii)
Endotracheal tube size
- iii)
Pressure and rubbing of the endotracheal tube against the larynx
- iv)
Repeated intubation
- v)
Foreign body reaction to the tube
- vi)
Anatomic differences between the sexes
- i)
- c)
An appropriately sized endotracheal tube for each patient’s anatomy, correlating with patient height, is strongly recommended. An appropriately sized endotracheal tube should decrease the risk of laryngeal stenosis, which more frequently affects the posterior glottis.
- d)
PGS results from disruption of the mucosa between the arytenoids.
- i)
Patients often complain of slowly progressive dyspnea beginning 4 to 8 weeks after extubation.
- ii)
Incidence of PGS increases with:
- (1)
Uncontrolled diabetes
- (2)
Excessively large diameter endotracheal tube in relation to the tracheal lumen
- (3)
Tube movement (especially if the patient is not sedated)
- (4)
Prolonged intubation
- (5)
Multiple medical comorbidities
- (1)
- iii)
Therefore elective tracheostomy is recommended when intubation is expected to be needed for longer than 10 days.
- i)
- e)
Cuff pressure has been found to be more important than the duration of intubation.
- i)
The use of high-volume, low-pressure cuffs has helped to prevent ischemic injury; however, maintenance of an appropriate cuff pressure is important.
- ii)
The microcirculation of the laryngeal mucosa is disrupted at cuff pressures greater than 22 mm Hg (30 cm H 2 O), resulting in cartilage necrosis and eventual cricoid or tracheal stenosis or malacia.
- i)
- a)
- 3)
Tracheotomy
- a)
A high tracheotomy may injure both the glottis and subglottis.
- i)
A high tracheotomy through the first tracheal ring or the cricoid cartilage leads to cricoid chondronecrosis with resultant fibrosis and stenosis.
- ii)
Ideally, a tracheotomy should be performed between the second and third tracheal ring; however, tracheal windows or Björk flaps are ideally performed through the third tracheal ring.
- i)
- b)
Similarly, a cricothyroidotomy has been associated with a higher incidence of laryngeal stenosis than tracheotomy.
- i)
The height of the cricothyroid membrane in adults ranges from 8 to 13 mm (average of 9 mm).
- ii)
Therefore tracheotomy tubes are poorly suited to intubate the subglottic larynx because the outer diameter of most tracheotomy tubes is larger than the normal height of the cricothyroid membrane.
- i)
- a)
- 4)
Endoscopy
- a)
The effects of endoscopic instruments on the laryngeal airway reflect the care and skill of the operator.
- b)
Rough handling of tissue, overenthusiastic biopsies, inadvertent or inaccurate laser ablation, and oversized instruments all promote tissue fibrosis and stenosis.
- a)
- 5)
Caustic burns
- a)
Caustic burns are characterized by extensive destruction of mucosa, submucosa, and muscles. The subsequent wound contracture and fibrosis may result in dysfunction.
- b)
The sphincteric action of the supraglottis often impedes contact of an ingested caustic agent with the glottis.
- c)
Consequently, severe caustic burns of the supraglottis usually occur without any involvement of the glottis.
- d)
However, the pharyngeal walls are commonly injured as the chemical passes into the cervical esophagus.
- a)
- 6)
Radiation therapy
- a)
Radiation therapy and especially concurrent chemoradiation produce damage to the microcirculation with progressive death of the soft tissues and subsequent replacement by scar tissue.
- i)
Ensuing fibrosis of the mucosa, submucosa, and muscles can lead to both a mechanical and functional stenosis of the supraglottic and glottic areas.
- ii)
Severe mucositis leads to loss of the epithelium and fibrosis, sometimes resulting in severe pharyngolaryngeal stenosis.
- (1)
In severe situations, a patient may require a tracheostomy and gastrostomy.
- (1)
- i)
- a)
- 7)
Nasogastric intubation
- a)
Nasogastric tubes are an often overlooked source of trauma.
- b)
Nasogastric intubation produces inflammation secondary to:
- i)
A foreign body reaction to the tube
- ii)
Swallowing impairment with pooling of secretions
- iii)
Pressure necrosis
- iv)
Gastropharyngeal reflux
- i)
- c)
All these factors play a role in the development of postcricoid ulceration with resultant perichondritis and subsequent fibrosis and contracture.
- d)
The trauma associated with the nasogastric tube may be synergistic with the trauma induced by an endotracheal tube.
- e)
This is termed nasogastric tube syndrome, or Sofferman syndrome.
- a)
- 8)
Infectious and granulomatous diseases
- a)
Tuberculosis, histoplasmosis, blastomycosis, leprosy, and syphilis are endemic in many areas of the world.
- i)
They share a common phase of erythema and edema that progresses to chondritis, necrosis, and scarring.
- ii)
Laryngeal syphilis and tuberculosis ( Fig. 10.1A ), as well as diphtheria, although seldom encountered nowadays in the United States, were common causes of stenosis in the past.
Fig. 10.1
Laryngeal involvement.
A, Tuberculosis: ulceration and granulation tissue (arrowheads) in the right false vocal cord; edema (arrow) of the left false vocal cord. T, Endotracheal tube placed over the posterior glottis. B, Wegener granulomatosis: subglottic stenosis. C, Wegener granulomatosis: epiglottic ulceration. D, Sarcoidosis: epiglottic scarring (arrowheads) . T, Tongue.
- i)
- b)
Granulomatous polyangiitis (GPA; previously termed Wegener granulomatosis) (see Fig. 10.1B and C ) and sarcoidosis (see Fig. 10.1D ) may involve the larynx.
- i)
Subglottic stenosis occurs in 10% to 20% of patients with Wegener granulomatosis.
- ii)
The mainstay of treatment remains nonsurgical (e.g., cyclophosphamide, steroids). Surgical therapy, which usually consists of dilatation and adjuvant modalities, such as injectable steroids and topical mitomycin C, is typically reserved for patients who have failed medical treatment and is performed only during remission of the disease.
- i)
- a)
- 9)
Autoimmune diseases
- a)
Autoimmune diseases, such as relapsing polychondritis, may destroy the cartilaginous framework, such as the cricoid, leading to collapse or stenosis of the airway, or affect the laryngeal joints resulting in cricoarytenoid joint fixation ( Fig. 10.2 ).
- i)
Cricoarytenoid joint fixation may be the initial manifestation of rheumatoid arthritis.
Fig. 10.2
Computed tomography scan of a patient with active relapsing polychondritis demonstrating edema of the perichondrium of the cricoid cartilage and resorption of the cartilage (arrows) .
- i)
- a)
- 10)
Lymphoproliferative disorders
- a)
Amyloid of the larynx can also result in supraglottic stenosis, usually with deposition in the false vocal folds or aryepiglottic folds.
- b)
These patients require a complete evaluation for systemic causes of amyloid, such as multiple myeloma.
- a)
- 11)
Gastropharyngeal reflux
- a)
Repeated exposure to pepsin and acid from gastric reflux produces mucosal and submucosal injury and thereby leads to more scarring ( Fig. 10.3 ).
Fig. 10.3
Lower right, vocal cord edema, pachyderma laryngis, and granuloma at the vocal processes. The other photographs show punctate and erosive esophagitis at different levels of the esophagus.
- b)
Prophylaxis with acid suppression medications is recommended after any injury to the larynx.
- i)
Patients should be carefully monitored for gastroesophageal reflux, and those with recalcitrant stenosis must be assumed to be suffering from gastroesophageal reflux and be treated accordingly.
- i)
- c)
With the recent concerns of adverse side effects from proton pump inhibitors (such as osteoporosis, heart disease, kidney disease, infections, and dementia), the risks and benefits of using these medications must be considered.
- d)
Antireflux surgery is considered in high-risk patients.
- a)
- 1)
- c.
Medical comorbidities
- 1)
The patient’s medical comorbidities must be considered when planning for appropriate surgical treatment. This includes, but is not limited to, the following:
- a)
Uncontrolled diabetes will result in poor wound healing. Hemoglobin A1C provides the surgeon information on the patient’s serum glucose levels in the recent past. Optimizing this is required before surgery.
- b)
Immunocompromised patients have a higher risk of infection and often slower wound healing. This must be considered for patients with immunosuppression for rheumatologic conditions.
- c)
Anticoagulation medication must be reversed before undergoing airway surgery. Hematoma within the surgical site can result in airway obstruction and the need for emergent airway management.
- d)
Pulmonary status can help guide appropriate surgical treatment. If patients have poor pulmonary clearance and require supplemental oxygen, this must be considered as a risk for the formation of mucus plugs. Providing a safe, patent airway is the goal of treatment.
- a)
- 1)
- a.
- 2.
Physical examination
- a.
Office
- 1)
Flexible nasopharyngeal laryngoscopy is essential for evaluating the site and degree of stenosis, as well as vocal fold mobility.
- 2)
Videolaryngoscopy and still photographs provide objective documentation that can be discussed with the patient.
- 3)
Electromyography helps differentiate neuromuscular deficits from cricoarytenoid joint fixation or subluxation.
- 4)
An awake, flexible bronchoscopy can be performed in the office or surgical suite, with topical anesthesia.
- a)
When performed in the office, this helps to characterize the stenosis before evaluation in the operating room.
- b)
Visualization through the main stem bronchi is recommended to evaluate for synchronous areas of stenosis.
- c)
This information helps the surgeon prepare for airway management when the patient is under general anesthesia.
- d)
If there is a concern for tracheal or laryngeal malacia, which is a dynamic collapse of the airway, then fiberoptic laryngotracheal endoscopy must be performed with the patient breathing spontaneously.
- i)
Distinction of malacia from stenosis is critical because it directly impacts treatment and prognosis.
- i)
- a)
- 1)
- b.
Operating suite
- 1)
Rigid direct laryngoscopic and bronchoscopic examination with rigid endoscopes, with the patient under general anesthesia, complements the office examination.
- 2)
Rigid direct laryngoscopy allows evaluation of the passive motion of the arytenoids and circumferential examination of the subglottis and provides an idea of the firmness of the scar tissue.
- 1)
- a.
- 3.
Imaging
- a.
Although imaging is important to delineate the cartilaginous framework, it does not obviate the importance of both flexible and rigid endoscopy in determining appropriate treatment.
- b.
Computed tomography (CT) is considered the standard imaging technique to corroborate the integrity of the cartilaginous framework ( Fig. 10.4 ) and evaluate the cricoarytenoid joint.
Fig. 10.4
Computed tomography scan, axial view, demonstrating fractures involving the thyroid and cricoid cartilage (arrows) .
- c.
Other pertinent imaging modalities include magnetic resonance imaging (MRI), ultrasound, and fluoroscopy.
- 1)
MRI is useful in the evaluation of extensive laryngotracheal stenosis and does not involve any radiation exposure.
- a)
However, a major limitation of MRI is that the patient must remain supine for a long time, which is not tolerated by patients with significant orthopnea due to airway obstruction.
- a)
- 2)
Ultrasound may provide a convenient, well-tolerated, noninvasive method of assessing subglottic airway diameter.
- 3)
Fluoroscopy is most helpful in evaluating areas of tracheomalacia that collapse on inspiration but look normal during rigid direct endoscopy performed under general anesthesia.
- 1)
- d.
Soft tissue radiographs are rarely used in the evaluation of adult acquired laryngeal stenosis.
- a.
- 4.
Indications
- a.
The most common indications for a surgical intervention to correct an acquired laryngeal stenosis are dyspnea and dysphagia.
- b.
Patients with supraglottic stenosis often complain of difficulty swallowing and experience dyspnea only when it is severe.
- c.
Conversely, patients with glottic and subglottic stenosis have complaints of dysphagia less frequently. In contrast, difficulty breathing drives the timing of surgical intervention.
- a.
- 5.
Contraindications
- a.
Uncontrolled anticoagulation
- b.
Uncontrolled diabetes
- c.
Current smoker
- d.
Relative contraindications: immunosuppression, poor overall health
- e.
There is no strict contraindication for performing an emergency tracheotomy.
- a.
- 6.
Preoperative preparation
- a.
The site and extent of the stenosis dictate appropriate surgical treatment.
- b.
Occasionally, the patient’s condition is so dire that a tracheostomy is required to bypass the stenosis.
- c.
Administration of corticosteroids in the perioperative period, although their benefit has not been scientifically proven, may help minimize the postoperative edema, which is critical in patients without a tracheostomy.
- a.
Operative Period
- 1.
Anesthesia
- a.
Establishing a secured airway is the keystone to all procedures in the correction of laryngeal stenosis.
- 1)
The airway may be secured with an endotracheal tube or a tracheostomy.
- 2)
A tracheostomy performed with the patient under local anesthesia is recommended for patients with significant airway compromise (e.g., stridor) and for those who require a transcervical approach.
- 3)
Select patients with supraglottic, glottic, and subglottic stenosis may be intubated.
- a)
Intermittent removal of the endotracheal tube, with the patient apneic, is sometimes required to perform surgery.
- a)
- 1)
- b.
Jet pressure ventilation (e.g., Venturi system) can be used if there is enough air outflow; otherwise the patient is at risk for increased lung pressures and tension pneumothorax.
- 1)
Subglottic jet ventilation can often be used in the treatment of subglottic stenosis, delivered through the rigid laryngoscope.
- 2)
However, both the anesthesiologist and surgeon must be very familiar with the functionality and risks of jet ventilation.
- 3)
If there is limited exposure and familiarity with jet ventilation, then it should not be performed, and rather use endotracheal intubation or a tracheotomy.
- 1)
- a.
- 2.
Positioning
- a.
For endoscopic procedures: The patient is placed in a supine “sniffing” position.
- 1)
Neck flexion, head extension
- 2)
Shoulder rolls are not used. Rather, a head “donut” is used to stabilize the head.
- 3)
“Ramp” position is sometimes used for obese patients. Blankets and/or towels are placed below the patients’ shoulders and head such that the tragus is horizontal to the manubrium. This can facilitate proper laryngeal exposure.
- 1)
- b.
Surgeon positioning
- 1)
Important to reduce musculoskeletal injuries to the surgeon
- 2)
After the larynx is exposed, proper surgeon ergonomic position is achieved by moving the bed angle (usually Trendelenburg; “head down”) so the laryngoscope is approximately 40 degrees off the horizontal plane.
- 3)
The surgeon’s neck should be in a neutral position or slightly flexed but never extended.
- 4)
Arm rest support while operating is important.
- 5)
Sometimes lowering the height of the bed is necessary to allow for more comfortable placement of the surgeon’s arms and hands.
- 1)
- c.
For open procedures: The patient is supine with the neck extended. This brings the laryngotracheal complex into the cervical area.
- a.
- 3.
Perioperative antibiotic prophylaxis
- a.
Laryngeal surgery is classified as a clean-contaminated procedure, for which perioperative prophylactic antibiotics are recommended.
- b.
A prolonged therapeutic course of antibiotics may be indicated in special circumstances (e.g., active chondritis).
- 1)
The theoretical value of a prolonged course of antibiotics is to control the infection, thus stopping a vicious cycle of chondritis, necrosis, granulation tissue formation, and scar deposition.
- 2)
There is a highly significant association between stent colonization with specific bacteria ( Staphylococcus aureus and Pseudomonas aeruginosa ) and the development of airway granulation.
- 3)
Azithromycin has been used not for its antimicrobial effects but rather its anti-inflammatory effects.
- 1)
- c.
Nebulized ciprofloxacin/dexamethasone otologic preparation (5 drops/1 mL saline, twice daily) can also be used as an adjunctive treatment.
- a.
- 4.
Instruments and equipment to have available
- a.
Endoscopic surgery
- 1)
Laryngeal suspension device
- 2)
Various sizes of laryngoscopes
- 3)
Surgical microscope
- 4)
Microlaryngeal surgical set
- 5)
Rigid telescopes (0, 30, and 70 degrees; 30 cm length, 5 to 10 mm diameter): These are used to better visualize the extent of lateral extension of the surgical field.
- 6)
Orotracheal injector
- 7)
Fiber-based CO 2 laser with micromanipulator airway dilators
- 1)
- b.
Open surgery
- 1)
Head and neck or plastic surgery set
- 2)
Self-retaining retractors (e.g., Weitlander)
- 3)
Double prong retractors
- 4)
Insulated bipolar cautery
- 5)
Rib harvesting set
- 1)
- c.
Tracheostomy surgical set
- a.
- 5.
Key anatomic landmarks
- a.
Intimate knowledge of supraglottic, glottic, and subglottic anatomy, depending upon the type and location of the laryngeal stenosis
- a.
- 6.
Prerequisite skills
- a.
Endoscopic surgery skills
- b.
Open surgery skills
- c.
Laser certification
- d.
Airway dilation
- e.
Tracheostomy
- f.
Comfort with complex airway manipulation before, during, and after surgery
- a.
- 7.
Operative risks
- a.
During CO 2 laser surgery, the safety of the patient and operating room personnel is a primary consideration. Laser safety precautions include the following:
- 1)
All operating room personnel should use protective eyewear.
- 2)
The patient’s eyes are kept closed with adhesive dressing (e.g., Tegaderm) and then covered with eye pads soaked in saline solution or protective eye shields.
- 3)
The face, the upper part of the chest, and the laryngoscope are covered with surgical towels soaked in saline solution ( Fig. 10.5 ). A saline-filled bulb syringe should be within reach of the surgeon in the event of an airway fire.
- 1)
- a.
