Ann Oral 84: 1975

HYOID AUTOGRAFT REPAIR OF CHRONIC SUBGLOTTIC STENOSIS DOUGLAS MATTHEW

L.

A.

FINNEGAN, M.D. HASKINS

WONG, M.D.

K.

KASHIMA, M.D.

BALTI:\!ORE, MARYLAND

SUMMARY - A previously unreported surgical technique has been evaluated for the correction of chronic subglottic (cricoid) stenosis. The principle of skeletal support as the primary means of repair was examined. Severe stenoses were created in sixteen adult, mongrel dogs. One to three months later a hyoid bone autograft on a sternohyoid muscle pedicle was employed for repair. The dogs were sacrificed at regular intervals from two weeks to six months. The majority of the animals maintained a widely patent lumen after repair. Vocal f'ord mobility remained normal in every case. The results are illustrated by photographs and histologic sections. This study convincingly demonstrates a successful surgical technique for correcting a most difficult laryngeal lesion.

Chronic subglottic stenosis of various etiologies has been a most difficult problem to correct. Several recent cases of infant and adult chronic subglottic ( cricoid) stenosis at our affiliated hospitals have reiterated the difficulty o.f managing such lesions. The basic problem involved is the reestablishment of a permanent airway without compromise of vocal cord function. Primary resection of the stenosis with direct tracheothvroid anastamosis has been successfully accomplished.>? Careful review of case reports, however, generally reveals that the great majority had bilateral adductor vocal cord palsies preoperatively. An arytenoidpexy was usually part of the procedure. Voice quality generally seemed to be poor in these patients postoperatively, and the chance of new or further recurrent laryngeal nerve injuries was great. Other clinical and experimental reports have described less radical surgical repairs of this lesion. Bennett? reported the partially successful repair of chronic cricoid stenosis using an auto-

genous free hyoid bone graft in one patient. Alonso, et al8 reported one patient repaired with an interposed free autogenous hyoid graft. No final conclusion could be made, however, as the intraluminal stent was still in place at the time of publication. Lapidot, et al9 reported an experimental study on piglets using a thyroid alar chondroperichondrial "trap door" flap to immediately repair a cricoid defect created by resecting part of the anterior arch. This surgery seemingly did not adversely affect normal growth in this area, and the airway apparently was maintained. However, there was no mention of vocal cord function, and the number of experimental animals was too small to draw firm conclusions. Delahunty, et al10 and Alonso, et al1l reported an experimental study on anterior cricoid arch homotransplantation in four dogs. Six months follow-up showed some resorption of the transplants, and at one year the homo grafts had been completely replaced by fibrous tissue. Vocal cord function had

Presented at the l3eeting of The American Broncho-Esophagologtcal Association, Atlanta, Georgia, April 7-8,1970.

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FINNEGAN ET AL.

Fig. 1. The anterior 40-50% of the cricoid arch has been resected and mucosal!submucosal tissues electrocoagulated. Fig. 2. Resultant severe chronic subglottic stenosis. Fig. 3. Subglottic stenosis with absent anterior cricoid cartilage and cicatricial intraluminal scarring.

been preserved. It is quite obvious today that the problem of tissue rejection has not been solved. Additionally, the availability of appropriate donors remains a most difficult problem. Fearon-" reported an experimental study on monkeys using a thyrochondral Rap similar to Lapidot's. He enlarged the lumen by interposing the Rap between two cut ends of the anterior cricoid arch. In most of his models, the repair was immediate with no stenosis created. Apparently, the lumens remained widely patent but no length of

follow-up was given. Alonso, et all 3 reported the autotransplantation of free hyoid grafts in four dogs immediately after resecting the anterior cricoid arch. Again, however, no stenosis had been created before repair. Our study was initiated to test the efficacy of skeletal support as the primary means of permanently correcting severe chronic cricoid stenosis, while at the same time maintaining vocal cord function.

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REPAIR OF SUBGLOTTIC STENOSIS

Fig. 4. Hyoid bone-sternohyoid muscle pedicle graft. Fig. 5. Cricoid stenosis incised, opened, and cartilage ends dissected. Fig. 6. Graft interposed anteriorly.

METHODS AND MATERIALS

Thirty-five adult mongrel dogs weighing between 11 and 30 kgs, were used. Of these, 19 died after the initial surgical procedure of creation of subglottic stenosis. The remaining 16 were used for the repair. Nembutol®" (22 mgs zkgs ), intravenously, and 1% Xylocaine®"" with 1:100,000 Epinephrine®"" ", locally, were used for anesthesia. Intravenous Ringer's lactate was given intraoperatively and in the immediate postoperative period. Intramuscular penicillin (300,000 Ii.) and streptomycin (400 mgs ) were administered postoperatively for seven days. First, a severe cricoid stenosis was created. Through a vertical midline incision the larynx, cricoid, and trachea were exposed. A permanent tracheostomy was performed excising an anterior window including tracheal rings 7 through 10. The trachea was then sutured to the skin. The origins of the anterior cricoarytenoid muscles were sharply detached, and the anterior 40-50% of the cricoid arch was resected. The posterior cricoid arch was then incised sharply in the midline. Next, the subglottic mucosal and submucosal tissues were electrocoagulated to effect maximum scarring (Fig. 1). Lastly, the remaining cricoid ring was crushed and sutured together with 0 Chromic catgut. Examples of resultant stenoses are well shown in Figures 2 and 3.

Between one and three months later the stenoses were repaired. The middle third of the hyoid bone was resected (including periosteum) with one sternohyoid muscle attached (Fig. 4). The cricoid stenosis was incised and opened anteriorly. The ends of the remaining cricoid cartilage were dissected free of scar tissue and the hyoid muscle pedicle graft interposed (Figs. 5 and 6). Finally, the autograft was sutured into place with two 28 gauge stainless steel wires. The wound was then closed in layers including the tracheostomy. No intraluminal stenting or steroids postoperatively were used. Two animals each were sacrificed at the following intervals: 2 weeks. 1, 2, 3, 4, 5 and 6 months. Two animals will be sacrificed at one year. The larynges were removed for serial sectioning and photomicrographs. Luminal measurements were made of the original cricoid areas, after creation of the stenoses, immediately after repair, and upon sacrificing. RESULTS

The resultant lumens after stenosis ranged from 6% to 50% of the original cricoid areas. 12 dogs (86%) had at least 67% stenosis. The mean percent remaining lumen after stenosis was 23%. The repaired subglottic areas ranged from 54% to 148% of the original lumens.

" Abbott Laboratories, N. Chicago, III. "" Astra Pharmaceutical Products, Inc., Worcester, Mass. """ SMP Division, Cooper Laboratories, San German, P.R.

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TABLE I SUBGLOTTIC AREAS AFTEH CREATION OF STENOSIS AND AFTER REPAIH % Lumen

Dog No.

Original Area (mm 2 )

Stenosis Area (mms)

6 73 22 28 77 66 74 27 69 12 55 23 53 76 Mean:

452 201 314 380 414 28.3 380 283 282 314 314 314 456 369 340mm2

60 50 104 78 60 70 190 50 28 20 52 70 228 60 80mm 2

The mean percent restoration of the original lumen was 91% with four dogs overcorrected (Table I). Nine of fourteen animals (64%) maintained the initial repair. Five (36%) demonstrated later reduction of cricoid area (Table II). There was no correlaTABLE II % HEDUCTION OF SUBGLOTTIC AHEAS AFTER REPAIR Immediate Follow-Up Repair Repair % Reduction Dog. of Repair No. Area (mm 2 ) Area (mm 2)

6 73 22 53 76 74 12 66 77

246 132 260 396 330 314 201 420 462

246 132 260 396 330 314 201 394 420

55 28 69 23 27

247 525 190 288 306

192 375 120 180 160

0 0 0

0 0 0 0 6 9 22 29 37 38 48

After Stenosis

Repair Area (mmt )

1.3 25 33 21 14 25 50 18

% Lumen After Repair

246 1.32 260 525 462 420 314 306 190 201 247 288 396 330 308mm2

10 6 17

22 50 16 2.'3%

54 66 83 138 112 148 83 108 67 64 79 92 87 89 91%

tion between the severity of the original stenosis and the incidence of later reduction (Table III). Moreover, there was no correlation between loss of cricoid area and length of follow-up (Table IV). TABLE III OHIGINAL % STENOSIS AS COMPAHED TO % REDUCTION OF HEPAIR Dog No.

6 73 22 53 76 74 12 66 77 55 28 69 2.3 27

% Luminal Stenosis

87 75 67 50 84 50 94 75 86 Mean 74% 83 79 90 78 82 Mean 82%

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% Reduction of Repair

0 0 0 0 0 0 0

6 9 22 29 37 38 48

REPAIR OF SUBGLOTTIC STENOSIS

TABLE IV LENGTH OF FOLLOW-UP AS COMPARED TO % REDUCTION OF REPAIR Dog No.

Length af Follow-Up

% Reduction of Repair

6 7:3 22 77 66 74 12 53 76

2wks. 2wks. 1 mo. 2 mos. 2 mos. 3 mos. 4 mos. 6 mos. 6 mos.

0

28 27 69 55 23

1 mo. 3 mos. 4 mos. 5 mos. 5 mos.

29 48 37 22 38

0 0

9 6 0 0 0

0

The successful restoration of the subglottic airway is clearly demonstrated in Figures 7, 8, and 9. Cross sectional photomicrographs of three and six months repairs are shown in Figures 10 and 11, which illustrate the intact hyoid muscle pedicle autograft. The lining epithelium is normal ciliated pseudostratified columnar (Fig. 12). Vocal cord mobility was examined prior to sacrificing. In every animal mobility was nonnaI. DISCUSSION

The use of hyoid bone grafts for cor-

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rection of glottic stenosis is not new. Looper,"! Woodward." and Ogura and Biller'" have used this technique with success. Only Bennett" and Alonso, et al8 have attempted subglottic stenosis repair with hyoid bone. These repairs have utilized free autografts. Conley'? has reported the successful use of bonemuscle pedicle grafts in mandibular and facial reconstruction. In an attempt to insure a more reliable blood supply, we selected a muscle pedicled hyoid autograft. This selection also provided us with a rigid graft which could be interposed to correct a stenotic subglottis. \"1e reasoned that skeletal support could be provided without intraluminal stenting, thus reducing postoperative morbidity and avoiding further procedures. Likewise, recurrent laryngeal nerve damage could hopefully be avoided. The data presented confirm our impressions about the appropriateness of an autogenous hyoid bone muscle pedicle graft. Approximately two-thirds of our repairs showed no significant resorption. In the dogs with resorption, all had a resultant restenosis less than 50%. No consistent reason could be detennined for the restenosis. Gross examination of the larynges upon sacrificing revealed all the muscle pedicles to be viable. All 14 animals were able to breathe easily throughout the follow-up period. Recurrent laryngeal nerve function was not disturbed.

Fig. 7. Dog. No. 22. One month after repair. Fig. 8. Dog. No. 74. Three months after repair. Fig. 9. Dog. No. 76. Six months after repair.

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FINNEGAN ET AL.

Fig. 10. Dog. No. 74. Note the widely patent lumen and intact hyoid bone. Fig. 11. Dog. No. 76. a - Interposed hyoid bone with intact mucosa. Fig. 12. Dog. No. 76. respiratory mucosa.

a - Normal

CONCLUSIONS

sis or length of time following repair.

From the previous study the following conclusions can be drawn.

Normal vocal cord mobility is maintained.

Skeletal support with a hyoid bone muscle pedicle autograft is an effective means of correcting chronic subglottic ( cricoid) stenosis.

Intraluminal stenting is not necessarily required. This experimental operation seems applicable for adults with this lesion.

The problem of restenosis is not severe and appears to be a sporadic occurrence unrelated to severity of steno-

A parallel study has been initiated with puppies to ascertain the feasibility of such surgery on the infant larynx.

ACKNOWLEDGMENT-The authors would like to express their gratitude to Mr. Richard Evans and Mr. Joseph Claggett for their excellent technical assistance and to Mr. Donald Meyers for his preparation of the histologic sections. Request for reprints should be sent to Douglas A. Finnegan, M.D., Department of Otolaryngology, The Johns Hopkins Hospital, Baltimore, Md. 21205.

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REFERENCES 1. Conley JJ: Reconstruction of the subglottic air space. Ann Otol Rhinal Laryngol 62:477- 495,1953

2. Shaw RR, Paulson DL, Kee JL: Traumatic tracheal rupture. J Thorac Cardiovasc Surg 42:281-297, 1961 3. Rush BF Jr: Repair of the injured larynx following destruction of the cricoid cartilage. Surg Gynec Obst 112:507-510, 1961 4. Ogura JR, Roper CL: Surgical correction of traumatic stenosis of larynx and pharynx. Laryngoscope 72:468-480, 1962 5. Morrow RC, Muldowny TJ: One-stage correction of subglottic stenosis. The Eye, Ear, Nose and Thorat Monthly 49:119-124, 1970 6. Gerwat J, Bryce DP: The management of subglottic laryngeal stenosis by resection and direct anastomosis. Laryngoscope 84:940957, 1974 7. Bennett T: Laryngeal strictures. South Med Jour 53:1101-1104, 1960 8. Alonso WA, Pratt LL, Zollinger W.K., et al: Complications of laryngotracheal disruption. Laryngoscope 84:1276-1290, 1974 9. Lapidot A, Sodogar R, Ratanaproshtporn S, et al: Experimental repair of sub-

glottic stenosis in piglets. 88:529-535, 1968

Arch Otolaryngol

10. Delahunty J, Alonso WA, Bordley JE: Cricoid arch transplantation. Laryngoscope 80:137-144, 1970 11. Alonso WA, Bridger GP, Youngblood J, et al: Cricoid arch transplantation. Long term follow-up. Laryngoscope 81:1968-1970, 1971 12. Fearon B, Cotton R: Surgical corrections of subglottic stenosis of the larynx. Ann Otol Rhinol Laryngol 81:508-513, 1972 13. Alonso W A, Druck NS, Griffiths CM. et al:Cricoid arch replacement in dogs. Arch Otolaryngol1Ol:42-45, 1975 14. Looper EA: Use of the hyoid bone as a graft in laryngeal stenosis. Arch Otolaryngol 28:106-111, 1938 15. Woodward FD: The surgical correction of cicatricial stenosis of the larynx. Ann Otol Rhinal Laryngol 59:488, 1950 16. Ogura JR, Biller RF: Reconstruction of the larynx following blunt trauma. Ann Otol Rhinol Laryngol 80:492-506, 1971 17. Conley JJ: Regional bone - muscle skin pedicle Haps in surgery of the head and neck. Trans Amer Acad Ophthalmol Otolaryngol 76:963-967, 1972

RADIOLOGY CONFERENCE A Conference on Radiology in Otolaryngology and Ophthalmology will be held on November 28 and 29, 1975, under the guidance of Galdino E. Valvassori, M.D. For further information write to: G. E. Valvassori, M.D., Radiology Department, Abraham Lincoln School of Medicine, P.O. Box 6998, Chicago, Illinois 60680.

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Hyoid autograft repair of chronic subglottic stenosis.

A previously unreported surgical technique has been evaluated for the correction of chronic subglottic (cricoid) stenosis. The principle of skeletal s...
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