Laryngotracheal Resection and Reconstruction for Subglottic Stenosis Hermes C. Grillo, MD, Douglas J. Mathisen, MD, and John C. Wain, MD General Thoracic Surgical Unit, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts
Eighty patients with inflammatory stenoses of the subglottic larynx and upper trachea were treated by singlestage laryngotracheal resection and reconstruction. Fifty stenoses originated from postintubation lesions (endotracheal tubes, tracheostomy, cricothyroidostomy), 7 originated from trauma, 19 were idiopathic, and 4 were miscellaneous. Repair consisted of resection of the anterolateral cricoid arch in all patients, plus resection of posterior laryngeal stenosis where present, with salvage of the posterior cricoid plate, appropriate resection and
tailoring of the trachea, and primary anastomosis using a posterior membranous tracheal wall flap to resurface the bared cricoid cartilage in 31 patients. One postoperative death resulted from acute myocardial infarction. Longterm results were excellent in 18 patients, good in 48, satisfactory in 8, and failure in 2. Three additional patients had good results at discharge but were followed up for less than 6 months.
I
contrast, in those patients with tumors, resections are individualized for the specific location of the tumor and frequently are done in the presence of unilateral paralysis of a recurrent laryngeal nerve; most importantly, once excision of tumor has been accomplished, the line of anastomosis lies in normal tissues. This almost guarantees success in procedures performed for tumors [6, 71.
nflammatory stenosis of the upper trachea that also involves the subglottic larynx cannot be treated by simple circumferential resection because this would destroy the function of the recurrent laryngeal nerves. Many procedures, often complex and multistaged, have been devised to solve this problem [l]. In an effort to improve the often indifferent results obtained by such operations, single-stage procedures involving partial resection of the subglottic larynx and immediate plastic reconstruction by varying techniques have evolved. Systematic approaches to this problem have been made by Ogura and Roper [Z], Gerwat and Bryce [3], Pearson and associates [4], Couraud and colleagues [5], and Grillo [l]. All reported surprisingly good results using single-stage plastic procedures. We describe here our experiences in treating 80 consecutive patients in whom the subglottic larynx was partially resected with trachea for inflammatory stenotic processes and in whotn primary reconstruction was performed. The anterior cricoid arch was resected in all patients. The technique of operation was previously described [11. We have excluded cases of laryngotracheoplasticresection done for primary and secondary tumors [6, 71 because we believe that the problem is a very different one. In inflammatory disease, whatever the cause, the process frequently extends above the stenosis in the subglottic larynx, nearly to the vocal cords. Resection, therefore, cannot be carried proximally to include all of the inflammation. Standardized operative techniques that remove the anterior subglottic larynx and also excise scar circumferentially posteriorly are applicable to these patients. In Presented at the Twenty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Feb 18-20, 1991. Address reprint requests to Dr Grillo, Massachusetts General Hospital, Boston, MA 02114. 0 1992 by The Society of Thoracic Surgeons
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Material and Methods Characteristics of Patients Fifty of the 80 patients had lesions that resulted from intubation done for ventilatory support in all but 1 (Fig 1). Thirty-one of these had endotracheal tubes only; in 16 the lesion was believed to result from stoma1 erosion of the cricoid cartilage, and in 3 the originating trauma was an elective cricothyroidostomy for ventilatory support. In 7 patients the stenosis was of traumatic origin. In 4 of these it was due to blunt trauma, usually with separation of larynx and trachea and with injury to the lower lamyx, and in 1 it was due to gouging of the anterior laryngotracheal wall by a flying object. A patient suffering from an inhalation bum was the first treated in this series. One patient was referred from another institution with a postoperative stenosis after an attempt at a complex laryngotracheal repair with a hyoid graft, performed to correct deformity due to goiter. Of the 23 remaining patients, 19 had idiopathic laryngotracheal stenosis (Figs 2, 3). One patient had localized amyloid disease. Two had a long history of stenosis commencing with diphtheria in childhood (Figs 4, 5). Whether successive intubations and tracheostomies contributed to or actually initiated stenosis was impossible to determine. One patient had clinical stigmata of relapsing polychondritis. One patient with stenosis after endotracheal intubation and ventilation was believed to suffer 0003-4975/92/$3.50
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Fig 1 . Tomogram showing stenosis of the subglottic larynx and upper trachea resulting from ventilation through an endotracheal tube. Below the asymmetric vocal cords lies a small "atrium" of subglottic larynx just above the stenosis. The airway achieves normal diameter at the level of the open arrows. In this patient the lesion zuas extended by multiple laser treatments and by a tracheostomy done in conjunction with that treatment.
from a poorly defined connective tissue disease. An additional patient with similar stenosis was an achondroplastic dwarf. All patients with postintubation stenoses except 1, whether from endotracheal tubes alone or from tracheostomy tubes, were referred from other institutions. This made it impossible to gather precise information on the circumstances of intubation and, in particular, on the size and type of tubes used, as well as data about cuff inflation pressures. It was our clinical impression that many of the male patients with lesions resulting from endotracheal intubation were of small stature and hence had tracheas of similar diameter. They may well have been intubated with larger tubes. It is also possible that some of the patients with eroded cricoid cartilages in relation to their tracheostomy stomas had also suffered from prior circumferential damage from an endotracheal tube cuff. It was not possible in every case to sort this out from available history or from pathological findings. The original diseases for which intubation and ventilation were used presented a usual spectrum. These included intracranial
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trauma, Guillain-Barrk syndrome, multiple sclerosis, seizure disorder, acute cardiac disease, post-cardiac surgical support, respiratory failure from obstructive pulmonary disease, pneumonia in the presence of leukemia, asthmatic crisis with bronchospasm, allergic respiratory arrest, postabdominal surgical complications, toxic ingestion, and postesophagectomy respiratory failure. Forty-nine of the 80 patients were female. This preponderance reflects the fact that 18 of 19 patients with idiopathic stenosis were female. The traumatic stenoses resulted from cable injury in 2, steering wheel injury in 1, hanging in 1, and a flying object in 1. All were young and male. The ages of the patients ranged from 11 to 85 years, with an even spread in the second through eighth decades (n = 11-14) except for the fifth decade (only 3 patients). One patient was 85 years old. Many patients, of course, suffered from systemic diseases such as arteriosclerotic heart disease, diabetes mellitus, and chronic obstructive pulmonary disease. Five patients had tracheoesophageal fistulas when first seen. In 2 the fistula had resulted from blunt trauma and in 3 from intubation and ventilation with tracheoesophageal erosion (Figs 6-9). In 16 patients, paralysis or paresis of one or both vocal cords was identified preoperatively. In numerous others there was malfunction of one or both vocal cords. Most postintubation patients and many others had undergone varied treatment before referral. At least 8 and probably many more had undergone multiple dilations. Forty-two of the patients had a tracheostomy in place upon arrival. The tracheostomy had either been placed for management of the stenosis or could not be removed because of the stenosis. An additional 2 had had prior tracheostomy which had been removed. At least 5 were treated with dilation and T tubes before referral. More than 10 patients had single or multiple laser treatments. Fulguration and cryosurgery were also used. In a number of patients, local and systemic steroids had been used. One patient received 4,000 cGy of irradiation in a misguided attempt to reduce scar tissue. More important from the standpoint of a potential surgical procedure were prior failed attempts in 23 patients to correct the stenosis or injury by open operation. These attempts had been of wide variety, including laryngotracheal resection and reconstruction, interposition of hyoid bone graft, laryngofissure with excision of scar, cutaneous or mucosal graft with stenting, Rethi procedure, cutaneous reconstruction, closure of tracheoesophageal fistula, and numerous additional procedures directed to the glottic aperture itself. Some had at least three open surgical attempts before referral. All patients were evaluated by systematic radiological studies [8], including fluoroscopic examination of vocal cord function (see Figs 1-9).
Operative Correction In 9 patients surgical correction was delayed after referral for the following reasons: initial glottic repair (including arytenoidectomy and cord lateralization), 4; subsidence of local inflammation, 2; weaning from steroids, 2; and
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Fig 2. ldiopathic layngotracheal stenosis. (A) Tomogram showing the vocal cords, a somewhat narrowed immediate subglottic la y n x , and maximal stenosis below this. ( B ) Postoperative roentgenogram of trachea, with filter. The arrow is at the glottic level. The anastomosis between the slightly narruzued la y n x and the trachea is widely patent.
A
observation for progression of idiopathic stenosis, 1. Three patients with bilateral vocal cord paralysis had cord lateralization done. Seven others with unilateral paralysis had an adequate glottic aperture. All patients underwent bronchoscopy under general anesthesia, most often immediately before resection and reconstruction, using rigid bronchoscopes and magnify-
B
ing telescopes. Anesthesia was induced by inhalation, using either a face mask or a flexible endotracheal tube placed in an existing stoma. If a stoma was available, no effort was made to dilate the proximal stenosis, because the resulting trauma can make identification of the lesion more difficult. Where no stoma was present, gentle dilation was carried out to a point sufficient to avoid hyper-
Fig 3. Lateral views of the airway of the patient from Figure 2. (A) Preoperative view. ( B ) Postoperative roentgenogram. Arrows indicate the anterior and posterior walls of the airway at the stenotic and anastomotic levels, respectively.
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Anastotnotic Level -tracheal stenosis
Mild Tracheal stenosis
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I C Fig 4 . Roentgenograms of a patient who had diphtheria at age 2 years and carried a tracheostorny until age 7 years. At age 68 years he was discovered to have an impossibly tight stenosis for intubation for coronary artery bypass grafting and had emergency tracheostorny. ( A ) Tomogram showing tight glottic aperture, stenotic immediate subglottic larynx, exceedingly tight stenosis below this, and a relative stenosis in the upper trachea. The patient had one paralyzed vocal cord and both anterior and posterior commissural stenoses with, however, a functional glottis. (B)Postoperative tomogram. The subglottic larynx has been widened by the tracheal anastomosis. A posterior membranous tracheal flap was used. (0Tracings from the roentgenograms to clarify the anatomy.
carbia and potential arrhythmia, but not beyond that. A small-diameter endotracheal tube (No. 5 or 6) was accepted for the initial phase of the operation. Operative approach was through a cervical collar incision in all but 2 patients, who required upper sternal division through a short vertical limb. If the level was appropriate, an existing stoma was excised through the
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center of the collar incision. In the 43 patients in whom a stoma was present, 40 stomas were excised with the resected specimen, one was used postoperatively for a temporary tracheostomy and later allowed to close, and two, more remote from the stenotic segment, were closed surgically at the time of resection. The length of resection measured between 1.5 and 6.5 cm, with most falling in the range of 2.0 to 4.5 cm. Only 1 patient had a resection of 1.5 cm, and 9 had resections greater than 4.5 cm. In 7 patients, a Montgomery suprahyoid release [9] was performed to relieve tension on the anastomosis. In those patients in whom the stenotic process involved only the anterior portion of the subglottic larynx, resection of this portion of the cricoid arch in an arcuate line extending up to a point just short of the midline of the thyroid cartilage anteriorly sufficed. The posterior margin of resection was along the lower border of the cricoid cartilage [l]. This series does not include patients who merely had a partial resection of the lower margin of the anterior cricoid cartilage. In patients in whom the subglottic process was circumferential, extending in front of the posterior plate of the cricoid, the line of posterior mucosal resection was incised above the level of stenosis, approaching the arytenoid cartilages. All involved mucosa and scar tissue was excised from the front of the posterior cricoid plate, leaving the cartilage intact posteriorly, to be surfaced by a broad-based flap of membranous trachea advanced from below (Fig 10). The margin of the anterior defect in the subglottic larynx was sutured in both types of resection to a prow-shaped segment of one distal tracheal ring, shaped to fit. The details of this operation have been described previously [l]. The posterior membranous flap of tracheal wall was required for resurfacing of the bared cricoid in 31 patients. In 49 it was possible to perform an anastomosis without resecting the tissues overlying the posterior cricoid plate. Mucosal anastomoses were performed in 75 patients with 4-0 Vicryl sutures. The 5 earliest cases were anastomosed with 4-0 Tevdek. In the 5 patients with tracheoesophageal fistula, including 1 with three adjacent fistulas, the esophagus was closed in two layers with inverting sutures, and a pedicled flap of strap muscle was interposed between the esophageal closure and the laryngotracheal anastomosis anteriorly [lo]. Three of these patients had undergone prior attempts at closure of the fistula, with multiple attempts in 2. Because most of the patients had inflammation of the subglottic larynx extending above the area of maximum stenosis, which often reduced the potential for correction to 50% or less of normal cross-sectional area at that level, and because of our fear of postoperative glottic edema, we initially planned to place a small tracheostomy tube distal to the anastomosis quite routinely (or an endotracheal tube where the distal trachea was inaccessible for tracheostomy). It became evident that an accessory airway was necessary only in those patients whose airway was of borderline adequacy immediately after operation. In the first 20 patients, tracheostomy was used in 14 at the time of the original operation and an endotracheal tube in 1. In
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Fig 5. Lateral roentgenograms of patient from Figure 4. (A) A tight and irregular stenosis may be traced through the subglottic la ynx past the distorted and calcified cricoid cartilage. The stoma1 tract may be seen eroding against the cricoid margin and further deforming the subglottic laynx and upper trachea. (B)The reconstructed airway. (C) Tracings of the lateral airway preoperatively and postoperatively to clarify the anatomy. Dotted lines indicate cartilaginous outlines. The solid lines trace the a i m y margins.
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the subsequent 60 patients, tracheostomy was used only nine times. This represented a drop in use of protective airway devices from 75% to 15%.A postoperative airway was required for less than a month in 14 patients (average, 10 days; median, 8 days) and between 1and 12 months in 10 patients (average, 4 months; median, 3 months). One patient was decannulated after 3 years, and 2 remain intubated.
Results One postoperative death occurred in a 66-year-old woman with severe heart disease who had incurred a stenosis
from an endotracheal tube placed for the management of a stormy course after coronary artery bypass grafting in another institution. She suffered a fatal myocardial infarction immediately postoperatively. Two patients suffered early and long-term failure of treatment. One was the only male patient who was retrospectively classified as having idiopathic laryngotracheal stenosis. He underwent prior resection and reconstruction at another institution. Stenosis recurred after our reconstruction also. He carries a permanent tracheostomy and has rejected any further attempt at reconstruction. The other patient had had a tracheostomy in infancy and had undergone multiple
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C
Fig 6 . Patient with laryngotracheal stenosis and tracheoesophageal fistula resulting from prolonged ventilation with an endotracheal tube, followed by a tracheostomy and with subsequent erosion to produce a fistula. Prior attempts to close the fistula surgically had failed. The left vocal cord was paralyzed and the right moved poorly. (A) Anteroposterior roentgenogram of the larynx and trachea showing immediate subglottic narrowing with severe stenosis in the larynx below this. The esophageal dilation commencing at stoma1 level is characteristic. (B)Postoperative view. The anastomosis is widely open. (C) Tracings of roentgenograms (A, B ) to clarify the radiologic anatomy.
reconstructions and T tube splinting before attempted repair here. Her tracheal process continues to require a T tube. One patient who had an early failure of operation was decannulated successfully after nearly 3 years. She was the first patient in the series who was operated on for stenosis that followed a severe inhalation burn. We have since preferred to treat burn injury of the upper airway by prolonged T tube splinting. The hypertrophic nature of burn scar endangers early surgical reconstruction. One patient had successful repair of a laryngotracheal stenosis but years later required a tracheostomy for progressive distal chondromalacia related to her achondroplasia. In classifying the results obtained, we have deemed as excellent a normal voice and no limitation of respiration at rest or on exercise. Patients were considered to have a good result if they suffered only slight lessening of maximum volume of voice, slight hoarseness that did not impede vocal use, slight weakness of voice after prolonged use, diminished ability to sing, and adequate breathing for all normal activities. Patients labeled as having a satisfactory result were those with a hoarse voice and either slight wheezing or shortness of breath on exercise, not sufficient to impair usual activities. Eighteen patients achieved an excellent result, 48 a good result, and 8 had results classified as satisfactory. As noted, there
were two failures and one immediate postoperative death. Three patients are listed as uncertain despite initial good results because their follow-up was for less than 6 months. Late deaths from other causes included heart disease in 2 patients, pneumonia in chronic lymphatic leukemia, gastrointestinal carcinoma in 3, and neurologic death in 1. These deaths were recorded between 4 months and 9% years after operation. Forty-nine patients were contacted in late 1990 in follow-up from 6 months to 12 years. In 13 additional patients, follow-up was available for between 2 and 10 years after operation, and in 4 for between 1 and 2 years. In 3, follow-up data were available at between 6 months and 1 year, and in 3 less than 6 months. To be emphasized is the fact that no patient who achieved an excellent or good status was found to deteriorate in subsequent months or years. In contrast, an apparent failure improved over 3 years, as noted earlier, and most who required tracheostomies eventually were successfully decannulated. It may be concluded that, if anything, the long-term results indicated represent a minimum statement. Early complications, in addition to the need for prolonged intubation due to glottic edema or anastomotic edema, included superficial wound infection that re-
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Fig 7. Tomographic detail of the lesion shown in Figure 6A. The arrow indicates the point of maximum stenosis.
quired drainage in 1 patient, suture granuloma in the incision that required removal of the suture in a second patient, and reexploration for air leak in 1 patient. A pinhole leak was closed with a local muscle flap and healed promptly. Eight patients had difficulty with deglutition or with aspiration postoperatively. All had undergone extensive resection, and 4 of them had suprahyoid laryngeal release performed. One required a gastrostomy tube for treatment and 2 others had such tubes placed at the time of operation in anticipation of difficulty, especially as 1 of these 2 had also undergone reclosure of a recurrent tracheoesophageal fistula. With time and retraining in swallowing, it was possible to remove all gastrostomy tubes. Tracheal granulations were removed bronchoscopically in 2 patients who had anastomoses performed with Tevdek and in 5 who had anastomoses performed with Vicryl. One of these patients has restenosis. A polyp of the vocal cord was treated by laser in 1 patient. The patient with leukemia required a prolonged period for healing of the tracheal stoma, which had been made at the time of reconstruction. Twenty-two patients had a persistent hoarse voice in varying degrees and 16 had weakness of the voice when attempting to project their speech. In 4 patients, these were expected consequences of bilateral vocal cord paralyses due to trauma, and in some others, of unilateral paralyses that were preexistent. Eight complained of an alteration of singing voice.
Comment Otolaryngological literature is filled with descriptions of multiple modes of treatment of nonneoplastic stenosis
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involving subglottic larynx and upper trachea [l]. Conservative measures include dilation, intubation, stenting, steroid injection, cryotherapy, electrocoagulation, and laser therapy. Operative procedures, often complex, include scar excision, incision of cricoid anteriorly or posteriorly, grafts of buccal mucosa or skin, free cartilage inserts, pedicled hyoid grafts, and creation of cutaneous gutters variously supported-all often stented for a prolonged period and usually accompanied by tracheostomy. More procedures than encouraging results have been recorded. Conley [ l l ] in 1953 noted a single instance of posterior cricoid resection for tumor to the ”inner surface of the thyroid cartilage,” thus preserving the recurrent laryngeal nerves and suturing “mucoperichondrium” of the trachea over the cricoid bed. He commented, “It is perhaps a procedure that should be used more often in surgery on the trachea,” but he believed resection of trachea must be limited to two rings. In 1961, Shaw and associates [12] resected cricoid and performed tracheal anastomosis successfully, but this was in patients with recurrent laryngeal nerve palsy after trauma. Ogura and Roper [2] in 1962 detailed a single-stage procedure for infraglottic stenosis, resecting the anterior and lateral cricoid and the inferior portion of the posterior cricoid. Their initial 3 patients with posttraumatic stenosis all had paralyzed cords. In subsequent reports, Ogura and Powers [13] emphasized subperichondrial resection of the stenosis from posterior cricoid to preserve recurrent laryngeal nerve function, and Ogura and Biller [14] in 1972 noted success in 14 of 17 patients so treated for chronic subglottic stenosis. All patients had accompanying thyrohyoid laryngeal release, anastomotic stenting, and protective tracheostomy. Gerwat and Bryce [3] in 1974 reported good results in 4 patients who underwent oblique resection of anterior and lateral cricoid to the cricothyroid joints. Stenosis had resulted from tracheostomy, probable endotracheal intubation, trauma, and unknown cause. Thyrohyoid release was used in all and visualization of recurrent nerves advised. Pearson and co-workers [4] added partial subperichondrial resection of the posterior cricoid to remove posterior stenotic scar, narrowed the trachea by suturing the ends of cartilage together, and intususscepted the trachea into the groove created by the subperichondrial resection. A follow-up report [15] in 1986 of 21 patients with nonneoplastic stenosis (postintubation, traumatic, burn, and idiopathic) and 7 with neoplasm so treated produced a good airway in 26 and limitation in 2. A T tube was used postoperatively in 10, and 13 had laryngeal release. Couraud and associates [16] updated their experience between 1978 and 1988 with laryngotracheal resection for stenosis resulting from intubation or trauma, including 27 patients who had a Pearson-type procedure and 7 who had total or subtotal cricoid plate resection with stenting. All had good results. The initial report by Grillo [ l ] in 1981 described 16 good or excellent results in 18 patients with nonneoplastic laryngotracheal stenoses treated by our variation of oblique resection of cricoid, adding a membranous tracheal wall flap to resurface cartilage where scar had been
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Fig 8. Lateral views of larynx and trachea corresponding to Figure 6. (A) Preoperative. ( B ) Postoperative. (C) Diagrams of the roentgenographic anatomy. Solid lines trace the airway. Dotted lines outline the cartilages. The effective airways, preoperatively and postoperatively, are constructed from measured diameters in the roentgenogram.
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0 A
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Effective Airway
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Fig 9. Barium studies showing (A) the tracheoesophageal fistula and ( B ) the postoperative repaired trachea and esophagus. The open arrow in (A) points to the fistula.
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TRUE VOCAL CORD CRlCOlD
d
Fig 10. Technique of layngotracheal resection and reconstruction. (a) external lines of division of the l a y n x and trachea are indicated by dashed lines. The anterior cricoid arch is removed. (b) When the subglottic intralayngeal stenosis is circumferential, scar is removed from the front of the posterior cricoid lamina, baring the cartilage, as shown. The residual posterior cricoid lamina protects the recurrent laryngeal nerves. Distally, the trachea is beveled over the length of one cartilage, as shown, to fit the anterolateral subglottic defect that has been created. A broad-based flap of membranous tracheal wall is fashioned to resurface the bared cricoid plate. (c) The posterior pap is fixed to the lower margin of the cricoid plate with four extraluminal sutures (4-0 Tmdek). The lateral traction sutures (2-0 V i c y l ) are also shown in the l a y n x proximally and in the trachea distally. ( d ) Posterior mucosal anastomotic sutures (4-0 V i c y l ) are placed with knots to lie behind the mucosa. Traction sutures are omitted in this diagram for simplicity. (e) After placement of all the posterior and posterolateral anastomotic sutures as far anteriorly as the lateral stay sutures, the patient's neck is flexed, the stay sutures are tied, the external fixing Tmdek sutures are tied, and then the posterior mucosal sutures. The anterior and anterolateral anastomotic sutures are then placed and finally tied serially. (Figures a and b are reproduced with permission from: Grillo HC. Primary reconstruction of airway after resection of subglottic layngeal and upper tracheal stenosis. Ann Thorac Surg 1982;33:3-18.)
excised from the front of the posterior cricoid lamina. The series has now grown to 80 patients and results continue to be encouraging, as described here. The similar and generally good results obtained in this difficult group of patients by units employing similar single-stage operations suggest that many complex procedures still used might well be abandoned. However, diagnostic precision is essential, operative timing must be carefully judged, operative technique is exacting, and postoperative care early and late must be meticulous. These are not operations to be done occasionally.
References 1. Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 1982;33>18. 2. Ogura JH, Roper CL. Surgical correction of traumatic stenosis of the larynx and pharynx. Laryngoscope 1962;72:468-80.
3. Gerwat J,Bryce DP. The management of subglottic stenosis by resection and direct anastomosis. Laryngoscope 1974;84: 940-7. 4. Pearson FG, Cooper JD, Nelems JM, Van Nostrand AWP. Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 1975;7080&16. 5. Couraud L, Martigne C, Houdelette P, et al. Inter& de la rbsection cricoidienne dans le traitement des sthoses cricotrachkales a p r h intubation. Ann Chir Thorac Cardiovasc 1979;332424. 6. Grill0 HC, Zannini P. Resectional management of airway invasion by thyroid carcinoma. Ann Thorac Surg 1986;Q 287-98. 7. Grill0 HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac Surg 1990;4969-77. 8. Momose KJ, Macmillan AS Jr. Roentgenologicinvestigations of the larynx and trachea. Radio1 Clin North Am 1978;16 32141.
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9. Montgomery WW. Suprahyoid release for tracheal stenosis. Arch Otolaryngol 1974;99:255-9. 10. Grillo HC, Moncure AC, McEnany MT. Repair of inflammatory tracheoesophageal fistula. Ann Thorac Surg 1976;22 112-9. 11. Conley JJ. Reconstruction of the subglottic air passage. Ann Otol Rhinol Laryngol 1953;62477-95. 12. Shaw R, Paulson DL, Kee JL Jr. Traumatic tracheal rupture. J Thorac Cardiovasc Surg 1961;42:281-97. 13. Ogura JH, Powers WE. Functional restitution of traumatic
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stenosis of the larynx and pharynx. Laryngoscope 1964;74 1081-110. 14. Ogura JH, Biller HF.Reconstruction of the larynx following blunt trauma. Ann Otol Rhinol Laryngol 1971;80492506. 15. Pearson FG, Brito-Filomeno L, Cooper JD. Experience with partial cricoid resection and thyrotracheal anastomosis. Ann Otol Rhinol Laryngol 1986;95:582-5. 16. Couraud L, Brichon PY, Velly JF. The surgical treatment of inflammatory and fibrous laryngotracheal stenosis. Eur J Cardiothorac Surg 1988;2:410-5.
DISCUSSION DR JOEL D. COOPER (St. Louis, MO): Before congratulating Dr Grillo and his co-workers, I would like to be excused a moment of personal nostalgia. Dr Grillo, it was 25 years ago last month that as a resident I was stimulated by you to undertake a study of the causes of postintubation tracheal stenosis, and that tutelage of yours kindled an interest in airway problems that has persisted over 25 years. I might point out, however, that neither of us has gotten very far since those days of working on the complications of tracheostomy together. You have managed to go upstream about 4 cm now, as you have worked on subglottic problems, and we have gone downstream about 8 cm working on problems of bronchial anastomosis. But it has been great fun. I do want to congratulate Dr Grill0 and his co-workers on this very important presentation. To me the most important aspect is that it reflects very well the methodical, the careful, the systematic, very meticulous approach that is so characteristicof Dr Grillo and his work, and it is this type of systematic approach that allows the transmittal of this rather uncommon type of procedure across the country and around the world to those who have an interest in surgery of the airway. It is too bad, that the ear, nose, and throat surgeons have not caught on a little bit more, and then you would not have to see so many patients who have had preliminary procedures before hand. To me there were several features of this current update that were important: the consistent, good results and the fact that the results do not deteriorate. If anything, they get better with time. I think that is another important message of the current presentation by you and your group. I would like to ask you just a few questions. You mentioned the level to which you go. I know you are familiar with the work of Dr Couraud, who has done some anastomoses to the vocal cord or perhaps even above the vocal cord, and I would like to ask you your opinion. Have you had any experience with lesions at that particular level? In the same vein, I have occasionally used a laryngofissure to get high up in the larynx, though I suspect with your flap modification you can do the posterior anastomosis more simply at a higher level. But I did want to know whether you ever employed a laryngofissure to complement this particular procedure. Also, you and I have discussed over the years the potential perils of cricothyroidotomy, and yet your group has recently presented a series of safe, postoperative cricothyroidotomies with the use of the minitracheostomy and I would like to know your current views on that procedure, particularly with reference to injury in the subglottic region. Finally, regarding the mysterious disease of idiopathic subglottic stenosis, of which I believe you had a very large series here, 18
or 19, do you have any clues as to what is causing that very unusual condition, which so often is thought to be a malignancy until multiple biopsies fail to reveal its origin? Once again thank you very much for the privilege and opportunity of discussing this presentation.
DR GRILLO: I must thank Dr Cooper for his insightful comments. He was one of the originators of what we call the Toronto procedure, so he is as familiar as anyone with this problem. I have mixed feelings about the otolaryngologist not taking this procedure on. We have encouraged them to do so. I share a mixed feeling of regret that they do not do it but perhaps a little pleasure that they leave it to thoracic surgeons who perhaps do anastomoses of this type better. We have gone higher and higher in the larynx as the years have gone by, up to just below the arytenoids, but I have not resected the vocal cords or gone up to the supraglottic larynx as Louis Couraud has done. I am very much aware of his excellent and very interesting work. I simply have left supraglottic and glottic problems to the otolaryngologists. We often examine these patients endoscopicallyjust before operation in association with a senior otolaryngologist. If the larynx is stenosed right up to the vocal cords, correction is usually done by the otolaryngologist. Tracheal repair is performed subsequently, usually in a separate stage. Laryngofissure has not been necessary with this exposure because you can reach way up, basically to the arytenoids. I still deplore elective cricothyroidostomy. I know statistically you can get away with it most of the time, but it is a deliberate insult to the larynx. Although stenosis from a deliberate insult to the trachea-tracheostomy-is usually correctable the first time around, some injuries to the larynx are uncorrectable at the outset; they simply cannot be straightened out. This is too big a price to pay for a dubious gain. Minitracheostomy, on the other hand, is done through a very small incision in the cricothyroid membrane. As you know, Dr John Wain in our institution has followed up these cases carefully and simply has not seen any serious injuries. We report 19 patients with idiopathic stenosis at the laryngotracheal level. We have quite a few others at lower levels, tracheal and carinal. The diagnosis is by exclusion, and I am not sure all cases are of the same origin. They have been studied very carefully by the pathologists and by other diagnostic techniques. We do not have final answers. A more detailed discussion of this problem was offered in an abstract submitted for this meeting, but because it was not accepted, you will have to wait for another year to hear the rest!
Eighty patients with inflammatory stenoses of the subglottic larynx and upper trachea were treated by singlestage laryngotracheal resection and reconstruction. Fifty stenoses originated from postintubation lesions (endotracheal tubes, tracheostomy, cricothyroidostomy), 7 originated from trauma, 19 were idiopathic, and 4 were miscellaneous. Repair consisted of resection of the anterolateral cricoid arch in all patients, plus resection of posterior laryngeal stenosis where present, with salvage of the posterior cricoid plate, appropriate resection and
tailoring of the trachea, and primary anastomosis using a posterior membranous tracheal wall flap to resurface the bared cricoid cartilage in 31 patients. One postoperative death resulted from acute myocardial infarction. Longterm results were excellent in 18 patients, good in 48, satisfactory in 8, and failure in 2. Three additional patients had good results at discharge but were followed up for less than 6 months.
I
contrast, in those patients with tumors, resections are individualized for the specific location of the tumor and frequently are done in the presence of unilateral paralysis of a recurrent laryngeal nerve; most importantly, once excision of tumor has been accomplished, the line of anastomosis lies in normal tissues. This almost guarantees success in procedures performed for tumors [6, 71.
nflammatory stenosis of the upper trachea that also involves the subglottic larynx cannot be treated by simple circumferential resection because this would destroy the function of the recurrent laryngeal nerves. Many procedures, often complex and multistaged, have been devised to solve this problem [l]. In an effort to improve the often indifferent results obtained by such operations, single-stage procedures involving partial resection of the subglottic larynx and immediate plastic reconstruction by varying techniques have evolved. Systematic approaches to this problem have been made by Ogura and Roper [Z], Gerwat and Bryce [3], Pearson and associates [4], Couraud and colleagues [5], and Grillo [l]. All reported surprisingly good results using single-stage plastic procedures. We describe here our experiences in treating 80 consecutive patients in whom the subglottic larynx was partially resected with trachea for inflammatory stenotic processes and in whotn primary reconstruction was performed. The anterior cricoid arch was resected in all patients. The technique of operation was previously described [11. We have excluded cases of laryngotracheoplasticresection done for primary and secondary tumors [6, 71 because we believe that the problem is a very different one. In inflammatory disease, whatever the cause, the process frequently extends above the stenosis in the subglottic larynx, nearly to the vocal cords. Resection, therefore, cannot be carried proximally to include all of the inflammation. Standardized operative techniques that remove the anterior subglottic larynx and also excise scar circumferentially posteriorly are applicable to these patients. In Presented at the Twenty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Feb 18-20, 1991. Address reprint requests to Dr Grillo, Massachusetts General Hospital, Boston, MA 02114. 0 1992 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;53:54-63)
Material and Methods Characteristics of Patients Fifty of the 80 patients had lesions that resulted from intubation done for ventilatory support in all but 1 (Fig 1). Thirty-one of these had endotracheal tubes only; in 16 the lesion was believed to result from stoma1 erosion of the cricoid cartilage, and in 3 the originating trauma was an elective cricothyroidostomy for ventilatory support. In 7 patients the stenosis was of traumatic origin. In 4 of these it was due to blunt trauma, usually with separation of larynx and trachea and with injury to the lower lamyx, and in 1 it was due to gouging of the anterior laryngotracheal wall by a flying object. A patient suffering from an inhalation bum was the first treated in this series. One patient was referred from another institution with a postoperative stenosis after an attempt at a complex laryngotracheal repair with a hyoid graft, performed to correct deformity due to goiter. Of the 23 remaining patients, 19 had idiopathic laryngotracheal stenosis (Figs 2, 3). One patient had localized amyloid disease. Two had a long history of stenosis commencing with diphtheria in childhood (Figs 4, 5). Whether successive intubations and tracheostomies contributed to or actually initiated stenosis was impossible to determine. One patient had clinical stigmata of relapsing polychondritis. One patient with stenosis after endotracheal intubation and ventilation was believed to suffer 0003-4975/92/$3.50
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Fig 1 . Tomogram showing stenosis of the subglottic larynx and upper trachea resulting from ventilation through an endotracheal tube. Below the asymmetric vocal cords lies a small "atrium" of subglottic larynx just above the stenosis. The airway achieves normal diameter at the level of the open arrows. In this patient the lesion zuas extended by multiple laser treatments and by a tracheostomy done in conjunction with that treatment.
from a poorly defined connective tissue disease. An additional patient with similar stenosis was an achondroplastic dwarf. All patients with postintubation stenoses except 1, whether from endotracheal tubes alone or from tracheostomy tubes, were referred from other institutions. This made it impossible to gather precise information on the circumstances of intubation and, in particular, on the size and type of tubes used, as well as data about cuff inflation pressures. It was our clinical impression that many of the male patients with lesions resulting from endotracheal intubation were of small stature and hence had tracheas of similar diameter. They may well have been intubated with larger tubes. It is also possible that some of the patients with eroded cricoid cartilages in relation to their tracheostomy stomas had also suffered from prior circumferential damage from an endotracheal tube cuff. It was not possible in every case to sort this out from available history or from pathological findings. The original diseases for which intubation and ventilation were used presented a usual spectrum. These included intracranial
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trauma, Guillain-Barrk syndrome, multiple sclerosis, seizure disorder, acute cardiac disease, post-cardiac surgical support, respiratory failure from obstructive pulmonary disease, pneumonia in the presence of leukemia, asthmatic crisis with bronchospasm, allergic respiratory arrest, postabdominal surgical complications, toxic ingestion, and postesophagectomy respiratory failure. Forty-nine of the 80 patients were female. This preponderance reflects the fact that 18 of 19 patients with idiopathic stenosis were female. The traumatic stenoses resulted from cable injury in 2, steering wheel injury in 1, hanging in 1, and a flying object in 1. All were young and male. The ages of the patients ranged from 11 to 85 years, with an even spread in the second through eighth decades (n = 11-14) except for the fifth decade (only 3 patients). One patient was 85 years old. Many patients, of course, suffered from systemic diseases such as arteriosclerotic heart disease, diabetes mellitus, and chronic obstructive pulmonary disease. Five patients had tracheoesophageal fistulas when first seen. In 2 the fistula had resulted from blunt trauma and in 3 from intubation and ventilation with tracheoesophageal erosion (Figs 6-9). In 16 patients, paralysis or paresis of one or both vocal cords was identified preoperatively. In numerous others there was malfunction of one or both vocal cords. Most postintubation patients and many others had undergone varied treatment before referral. At least 8 and probably many more had undergone multiple dilations. Forty-two of the patients had a tracheostomy in place upon arrival. The tracheostomy had either been placed for management of the stenosis or could not be removed because of the stenosis. An additional 2 had had prior tracheostomy which had been removed. At least 5 were treated with dilation and T tubes before referral. More than 10 patients had single or multiple laser treatments. Fulguration and cryosurgery were also used. In a number of patients, local and systemic steroids had been used. One patient received 4,000 cGy of irradiation in a misguided attempt to reduce scar tissue. More important from the standpoint of a potential surgical procedure were prior failed attempts in 23 patients to correct the stenosis or injury by open operation. These attempts had been of wide variety, including laryngotracheal resection and reconstruction, interposition of hyoid bone graft, laryngofissure with excision of scar, cutaneous or mucosal graft with stenting, Rethi procedure, cutaneous reconstruction, closure of tracheoesophageal fistula, and numerous additional procedures directed to the glottic aperture itself. Some had at least three open surgical attempts before referral. All patients were evaluated by systematic radiological studies [8], including fluoroscopic examination of vocal cord function (see Figs 1-9).
Operative Correction In 9 patients surgical correction was delayed after referral for the following reasons: initial glottic repair (including arytenoidectomy and cord lateralization), 4; subsidence of local inflammation, 2; weaning from steroids, 2; and
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Fig 2. ldiopathic layngotracheal stenosis. (A) Tomogram showing the vocal cords, a somewhat narrowed immediate subglottic la y n x , and maximal stenosis below this. ( B ) Postoperative roentgenogram of trachea, with filter. The arrow is at the glottic level. The anastomosis between the slightly narruzued la y n x and the trachea is widely patent.
A
observation for progression of idiopathic stenosis, 1. Three patients with bilateral vocal cord paralysis had cord lateralization done. Seven others with unilateral paralysis had an adequate glottic aperture. All patients underwent bronchoscopy under general anesthesia, most often immediately before resection and reconstruction, using rigid bronchoscopes and magnify-
B
ing telescopes. Anesthesia was induced by inhalation, using either a face mask or a flexible endotracheal tube placed in an existing stoma. If a stoma was available, no effort was made to dilate the proximal stenosis, because the resulting trauma can make identification of the lesion more difficult. Where no stoma was present, gentle dilation was carried out to a point sufficient to avoid hyper-
Fig 3. Lateral views of the airway of the patient from Figure 2. (A) Preoperative view. ( B ) Postoperative roentgenogram. Arrows indicate the anterior and posterior walls of the airway at the stenotic and anastomotic levels, respectively.
A
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Anastotnotic Level -tracheal stenosis
Mild Tracheal stenosis
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I C Fig 4 . Roentgenograms of a patient who had diphtheria at age 2 years and carried a tracheostorny until age 7 years. At age 68 years he was discovered to have an impossibly tight stenosis for intubation for coronary artery bypass grafting and had emergency tracheostorny. ( A ) Tomogram showing tight glottic aperture, stenotic immediate subglottic larynx, exceedingly tight stenosis below this, and a relative stenosis in the upper trachea. The patient had one paralyzed vocal cord and both anterior and posterior commissural stenoses with, however, a functional glottis. (B)Postoperative tomogram. The subglottic larynx has been widened by the tracheal anastomosis. A posterior membranous tracheal flap was used. (0Tracings from the roentgenograms to clarify the anatomy.
carbia and potential arrhythmia, but not beyond that. A small-diameter endotracheal tube (No. 5 or 6) was accepted for the initial phase of the operation. Operative approach was through a cervical collar incision in all but 2 patients, who required upper sternal division through a short vertical limb. If the level was appropriate, an existing stoma was excised through the
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center of the collar incision. In the 43 patients in whom a stoma was present, 40 stomas were excised with the resected specimen, one was used postoperatively for a temporary tracheostomy and later allowed to close, and two, more remote from the stenotic segment, were closed surgically at the time of resection. The length of resection measured between 1.5 and 6.5 cm, with most falling in the range of 2.0 to 4.5 cm. Only 1 patient had a resection of 1.5 cm, and 9 had resections greater than 4.5 cm. In 7 patients, a Montgomery suprahyoid release [9] was performed to relieve tension on the anastomosis. In those patients in whom the stenotic process involved only the anterior portion of the subglottic larynx, resection of this portion of the cricoid arch in an arcuate line extending up to a point just short of the midline of the thyroid cartilage anteriorly sufficed. The posterior margin of resection was along the lower border of the cricoid cartilage [l]. This series does not include patients who merely had a partial resection of the lower margin of the anterior cricoid cartilage. In patients in whom the subglottic process was circumferential, extending in front of the posterior plate of the cricoid, the line of posterior mucosal resection was incised above the level of stenosis, approaching the arytenoid cartilages. All involved mucosa and scar tissue was excised from the front of the posterior cricoid plate, leaving the cartilage intact posteriorly, to be surfaced by a broad-based flap of membranous trachea advanced from below (Fig 10). The margin of the anterior defect in the subglottic larynx was sutured in both types of resection to a prow-shaped segment of one distal tracheal ring, shaped to fit. The details of this operation have been described previously [l]. The posterior membranous flap of tracheal wall was required for resurfacing of the bared cricoid in 31 patients. In 49 it was possible to perform an anastomosis without resecting the tissues overlying the posterior cricoid plate. Mucosal anastomoses were performed in 75 patients with 4-0 Vicryl sutures. The 5 earliest cases were anastomosed with 4-0 Tevdek. In the 5 patients with tracheoesophageal fistula, including 1 with three adjacent fistulas, the esophagus was closed in two layers with inverting sutures, and a pedicled flap of strap muscle was interposed between the esophageal closure and the laryngotracheal anastomosis anteriorly [lo]. Three of these patients had undergone prior attempts at closure of the fistula, with multiple attempts in 2. Because most of the patients had inflammation of the subglottic larynx extending above the area of maximum stenosis, which often reduced the potential for correction to 50% or less of normal cross-sectional area at that level, and because of our fear of postoperative glottic edema, we initially planned to place a small tracheostomy tube distal to the anastomosis quite routinely (or an endotracheal tube where the distal trachea was inaccessible for tracheostomy). It became evident that an accessory airway was necessary only in those patients whose airway was of borderline adequacy immediately after operation. In the first 20 patients, tracheostomy was used in 14 at the time of the original operation and an endotracheal tube in 1. In
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Fig 5. Lateral roentgenograms of patient from Figure 4. (A) A tight and irregular stenosis may be traced through the subglottic la ynx past the distorted and calcified cricoid cartilage. The stoma1 tract may be seen eroding against the cricoid margin and further deforming the subglottic laynx and upper trachea. (B)The reconstructed airway. (C) Tracings of the lateral airway preoperatively and postoperatively to clarify the anatomy. Dotted lines indicate cartilaginous outlines. The solid lines trace the a i m y margins.
A
B
C
the subsequent 60 patients, tracheostomy was used only nine times. This represented a drop in use of protective airway devices from 75% to 15%.A postoperative airway was required for less than a month in 14 patients (average, 10 days; median, 8 days) and between 1and 12 months in 10 patients (average, 4 months; median, 3 months). One patient was decannulated after 3 years, and 2 remain intubated.
Results One postoperative death occurred in a 66-year-old woman with severe heart disease who had incurred a stenosis
from an endotracheal tube placed for the management of a stormy course after coronary artery bypass grafting in another institution. She suffered a fatal myocardial infarction immediately postoperatively. Two patients suffered early and long-term failure of treatment. One was the only male patient who was retrospectively classified as having idiopathic laryngotracheal stenosis. He underwent prior resection and reconstruction at another institution. Stenosis recurred after our reconstruction also. He carries a permanent tracheostomy and has rejected any further attempt at reconstruction. The other patient had had a tracheostomy in infancy and had undergone multiple
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B
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C
Fig 6 . Patient with laryngotracheal stenosis and tracheoesophageal fistula resulting from prolonged ventilation with an endotracheal tube, followed by a tracheostomy and with subsequent erosion to produce a fistula. Prior attempts to close the fistula surgically had failed. The left vocal cord was paralyzed and the right moved poorly. (A) Anteroposterior roentgenogram of the larynx and trachea showing immediate subglottic narrowing with severe stenosis in the larynx below this. The esophageal dilation commencing at stoma1 level is characteristic. (B)Postoperative view. The anastomosis is widely open. (C) Tracings of roentgenograms (A, B ) to clarify the radiologic anatomy.
reconstructions and T tube splinting before attempted repair here. Her tracheal process continues to require a T tube. One patient who had an early failure of operation was decannulated successfully after nearly 3 years. She was the first patient in the series who was operated on for stenosis that followed a severe inhalation burn. We have since preferred to treat burn injury of the upper airway by prolonged T tube splinting. The hypertrophic nature of burn scar endangers early surgical reconstruction. One patient had successful repair of a laryngotracheal stenosis but years later required a tracheostomy for progressive distal chondromalacia related to her achondroplasia. In classifying the results obtained, we have deemed as excellent a normal voice and no limitation of respiration at rest or on exercise. Patients were considered to have a good result if they suffered only slight lessening of maximum volume of voice, slight hoarseness that did not impede vocal use, slight weakness of voice after prolonged use, diminished ability to sing, and adequate breathing for all normal activities. Patients labeled as having a satisfactory result were those with a hoarse voice and either slight wheezing or shortness of breath on exercise, not sufficient to impair usual activities. Eighteen patients achieved an excellent result, 48 a good result, and 8 had results classified as satisfactory. As noted, there
were two failures and one immediate postoperative death. Three patients are listed as uncertain despite initial good results because their follow-up was for less than 6 months. Late deaths from other causes included heart disease in 2 patients, pneumonia in chronic lymphatic leukemia, gastrointestinal carcinoma in 3, and neurologic death in 1. These deaths were recorded between 4 months and 9% years after operation. Forty-nine patients were contacted in late 1990 in follow-up from 6 months to 12 years. In 13 additional patients, follow-up was available for between 2 and 10 years after operation, and in 4 for between 1 and 2 years. In 3, follow-up data were available at between 6 months and 1 year, and in 3 less than 6 months. To be emphasized is the fact that no patient who achieved an excellent or good status was found to deteriorate in subsequent months or years. In contrast, an apparent failure improved over 3 years, as noted earlier, and most who required tracheostomies eventually were successfully decannulated. It may be concluded that, if anything, the long-term results indicated represent a minimum statement. Early complications, in addition to the need for prolonged intubation due to glottic edema or anastomotic edema, included superficial wound infection that re-
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Fig 7. Tomographic detail of the lesion shown in Figure 6A. The arrow indicates the point of maximum stenosis.
quired drainage in 1 patient, suture granuloma in the incision that required removal of the suture in a second patient, and reexploration for air leak in 1 patient. A pinhole leak was closed with a local muscle flap and healed promptly. Eight patients had difficulty with deglutition or with aspiration postoperatively. All had undergone extensive resection, and 4 of them had suprahyoid laryngeal release performed. One required a gastrostomy tube for treatment and 2 others had such tubes placed at the time of operation in anticipation of difficulty, especially as 1 of these 2 had also undergone reclosure of a recurrent tracheoesophageal fistula. With time and retraining in swallowing, it was possible to remove all gastrostomy tubes. Tracheal granulations were removed bronchoscopically in 2 patients who had anastomoses performed with Tevdek and in 5 who had anastomoses performed with Vicryl. One of these patients has restenosis. A polyp of the vocal cord was treated by laser in 1 patient. The patient with leukemia required a prolonged period for healing of the tracheal stoma, which had been made at the time of reconstruction. Twenty-two patients had a persistent hoarse voice in varying degrees and 16 had weakness of the voice when attempting to project their speech. In 4 patients, these were expected consequences of bilateral vocal cord paralyses due to trauma, and in some others, of unilateral paralyses that were preexistent. Eight complained of an alteration of singing voice.
Comment Otolaryngological literature is filled with descriptions of multiple modes of treatment of nonneoplastic stenosis
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involving subglottic larynx and upper trachea [l]. Conservative measures include dilation, intubation, stenting, steroid injection, cryotherapy, electrocoagulation, and laser therapy. Operative procedures, often complex, include scar excision, incision of cricoid anteriorly or posteriorly, grafts of buccal mucosa or skin, free cartilage inserts, pedicled hyoid grafts, and creation of cutaneous gutters variously supported-all often stented for a prolonged period and usually accompanied by tracheostomy. More procedures than encouraging results have been recorded. Conley [ l l ] in 1953 noted a single instance of posterior cricoid resection for tumor to the ”inner surface of the thyroid cartilage,” thus preserving the recurrent laryngeal nerves and suturing “mucoperichondrium” of the trachea over the cricoid bed. He commented, “It is perhaps a procedure that should be used more often in surgery on the trachea,” but he believed resection of trachea must be limited to two rings. In 1961, Shaw and associates [12] resected cricoid and performed tracheal anastomosis successfully, but this was in patients with recurrent laryngeal nerve palsy after trauma. Ogura and Roper [2] in 1962 detailed a single-stage procedure for infraglottic stenosis, resecting the anterior and lateral cricoid and the inferior portion of the posterior cricoid. Their initial 3 patients with posttraumatic stenosis all had paralyzed cords. In subsequent reports, Ogura and Powers [13] emphasized subperichondrial resection of the stenosis from posterior cricoid to preserve recurrent laryngeal nerve function, and Ogura and Biller [14] in 1972 noted success in 14 of 17 patients so treated for chronic subglottic stenosis. All patients had accompanying thyrohyoid laryngeal release, anastomotic stenting, and protective tracheostomy. Gerwat and Bryce [3] in 1974 reported good results in 4 patients who underwent oblique resection of anterior and lateral cricoid to the cricothyroid joints. Stenosis had resulted from tracheostomy, probable endotracheal intubation, trauma, and unknown cause. Thyrohyoid release was used in all and visualization of recurrent nerves advised. Pearson and co-workers [4] added partial subperichondrial resection of the posterior cricoid to remove posterior stenotic scar, narrowed the trachea by suturing the ends of cartilage together, and intususscepted the trachea into the groove created by the subperichondrial resection. A follow-up report [15] in 1986 of 21 patients with nonneoplastic stenosis (postintubation, traumatic, burn, and idiopathic) and 7 with neoplasm so treated produced a good airway in 26 and limitation in 2. A T tube was used postoperatively in 10, and 13 had laryngeal release. Couraud and associates [16] updated their experience between 1978 and 1988 with laryngotracheal resection for stenosis resulting from intubation or trauma, including 27 patients who had a Pearson-type procedure and 7 who had total or subtotal cricoid plate resection with stenting. All had good results. The initial report by Grillo [ l ] in 1981 described 16 good or excellent results in 18 patients with nonneoplastic laryngotracheal stenoses treated by our variation of oblique resection of cricoid, adding a membranous tracheal wall flap to resurface cartilage where scar had been
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Fig 8. Lateral views of larynx and trachea corresponding to Figure 6. (A) Preoperative. ( B ) Postoperative. (C) Diagrams of the roentgenographic anatomy. Solid lines trace the airway. Dotted lines outline the cartilages. The effective airways, preoperatively and postoperatively, are constructed from measured diameters in the roentgenogram.
B
A
P
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0 A
-0 P
Effective Airway
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Fig 9. Barium studies showing (A) the tracheoesophageal fistula and ( B ) the postoperative repaired trachea and esophagus. The open arrow in (A) points to the fistula.
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TRUE VOCAL CORD CRlCOlD
d
Fig 10. Technique of layngotracheal resection and reconstruction. (a) external lines of division of the l a y n x and trachea are indicated by dashed lines. The anterior cricoid arch is removed. (b) When the subglottic intralayngeal stenosis is circumferential, scar is removed from the front of the posterior cricoid lamina, baring the cartilage, as shown. The residual posterior cricoid lamina protects the recurrent laryngeal nerves. Distally, the trachea is beveled over the length of one cartilage, as shown, to fit the anterolateral subglottic defect that has been created. A broad-based flap of membranous tracheal wall is fashioned to resurface the bared cricoid plate. (c) The posterior pap is fixed to the lower margin of the cricoid plate with four extraluminal sutures (4-0 Tmdek). The lateral traction sutures (2-0 V i c y l ) are also shown in the l a y n x proximally and in the trachea distally. ( d ) Posterior mucosal anastomotic sutures (4-0 V i c y l ) are placed with knots to lie behind the mucosa. Traction sutures are omitted in this diagram for simplicity. (e) After placement of all the posterior and posterolateral anastomotic sutures as far anteriorly as the lateral stay sutures, the patient's neck is flexed, the stay sutures are tied, the external fixing Tmdek sutures are tied, and then the posterior mucosal sutures. The anterior and anterolateral anastomotic sutures are then placed and finally tied serially. (Figures a and b are reproduced with permission from: Grillo HC. Primary reconstruction of airway after resection of subglottic layngeal and upper tracheal stenosis. Ann Thorac Surg 1982;33:3-18.)
excised from the front of the posterior cricoid lamina. The series has now grown to 80 patients and results continue to be encouraging, as described here. The similar and generally good results obtained in this difficult group of patients by units employing similar single-stage operations suggest that many complex procedures still used might well be abandoned. However, diagnostic precision is essential, operative timing must be carefully judged, operative technique is exacting, and postoperative care early and late must be meticulous. These are not operations to be done occasionally.
References 1. Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 1982;33>18. 2. Ogura JH, Roper CL. Surgical correction of traumatic stenosis of the larynx and pharynx. Laryngoscope 1962;72:468-80.
3. Gerwat J,Bryce DP. The management of subglottic stenosis by resection and direct anastomosis. Laryngoscope 1974;84: 940-7. 4. Pearson FG, Cooper JD, Nelems JM, Van Nostrand AWP. Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 1975;7080&16. 5. Couraud L, Martigne C, Houdelette P, et al. Inter& de la rbsection cricoidienne dans le traitement des sthoses cricotrachkales a p r h intubation. Ann Chir Thorac Cardiovasc 1979;332424. 6. Grill0 HC, Zannini P. Resectional management of airway invasion by thyroid carcinoma. Ann Thorac Surg 1986;Q 287-98. 7. Grill0 HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac Surg 1990;4969-77. 8. Momose KJ, Macmillan AS Jr. Roentgenologicinvestigations of the larynx and trachea. Radio1 Clin North Am 1978;16 32141.
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9. Montgomery WW. Suprahyoid release for tracheal stenosis. Arch Otolaryngol 1974;99:255-9. 10. Grillo HC, Moncure AC, McEnany MT. Repair of inflammatory tracheoesophageal fistula. Ann Thorac Surg 1976;22 112-9. 11. Conley JJ. Reconstruction of the subglottic air passage. Ann Otol Rhinol Laryngol 1953;62477-95. 12. Shaw R, Paulson DL, Kee JL Jr. Traumatic tracheal rupture. J Thorac Cardiovasc Surg 1961;42:281-97. 13. Ogura JH, Powers WE. Functional restitution of traumatic
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stenosis of the larynx and pharynx. Laryngoscope 1964;74 1081-110. 14. Ogura JH, Biller HF.Reconstruction of the larynx following blunt trauma. Ann Otol Rhinol Laryngol 1971;80492506. 15. Pearson FG, Brito-Filomeno L, Cooper JD. Experience with partial cricoid resection and thyrotracheal anastomosis. Ann Otol Rhinol Laryngol 1986;95:582-5. 16. Couraud L, Brichon PY, Velly JF. The surgical treatment of inflammatory and fibrous laryngotracheal stenosis. Eur J Cardiothorac Surg 1988;2:410-5.
DISCUSSION DR JOEL D. COOPER (St. Louis, MO): Before congratulating Dr Grillo and his co-workers, I would like to be excused a moment of personal nostalgia. Dr Grillo, it was 25 years ago last month that as a resident I was stimulated by you to undertake a study of the causes of postintubation tracheal stenosis, and that tutelage of yours kindled an interest in airway problems that has persisted over 25 years. I might point out, however, that neither of us has gotten very far since those days of working on the complications of tracheostomy together. You have managed to go upstream about 4 cm now, as you have worked on subglottic problems, and we have gone downstream about 8 cm working on problems of bronchial anastomosis. But it has been great fun. I do want to congratulate Dr Grill0 and his co-workers on this very important presentation. To me the most important aspect is that it reflects very well the methodical, the careful, the systematic, very meticulous approach that is so characteristicof Dr Grillo and his work, and it is this type of systematic approach that allows the transmittal of this rather uncommon type of procedure across the country and around the world to those who have an interest in surgery of the airway. It is too bad, that the ear, nose, and throat surgeons have not caught on a little bit more, and then you would not have to see so many patients who have had preliminary procedures before hand. To me there were several features of this current update that were important: the consistent, good results and the fact that the results do not deteriorate. If anything, they get better with time. I think that is another important message of the current presentation by you and your group. I would like to ask you just a few questions. You mentioned the level to which you go. I know you are familiar with the work of Dr Couraud, who has done some anastomoses to the vocal cord or perhaps even above the vocal cord, and I would like to ask you your opinion. Have you had any experience with lesions at that particular level? In the same vein, I have occasionally used a laryngofissure to get high up in the larynx, though I suspect with your flap modification you can do the posterior anastomosis more simply at a higher level. But I did want to know whether you ever employed a laryngofissure to complement this particular procedure. Also, you and I have discussed over the years the potential perils of cricothyroidotomy, and yet your group has recently presented a series of safe, postoperative cricothyroidotomies with the use of the minitracheostomy and I would like to know your current views on that procedure, particularly with reference to injury in the subglottic region. Finally, regarding the mysterious disease of idiopathic subglottic stenosis, of which I believe you had a very large series here, 18
or 19, do you have any clues as to what is causing that very unusual condition, which so often is thought to be a malignancy until multiple biopsies fail to reveal its origin? Once again thank you very much for the privilege and opportunity of discussing this presentation.
DR GRILLO: I must thank Dr Cooper for his insightful comments. He was one of the originators of what we call the Toronto procedure, so he is as familiar as anyone with this problem. I have mixed feelings about the otolaryngologist not taking this procedure on. We have encouraged them to do so. I share a mixed feeling of regret that they do not do it but perhaps a little pleasure that they leave it to thoracic surgeons who perhaps do anastomoses of this type better. We have gone higher and higher in the larynx as the years have gone by, up to just below the arytenoids, but I have not resected the vocal cords or gone up to the supraglottic larynx as Louis Couraud has done. I am very much aware of his excellent and very interesting work. I simply have left supraglottic and glottic problems to the otolaryngologists. We often examine these patients endoscopicallyjust before operation in association with a senior otolaryngologist. If the larynx is stenosed right up to the vocal cords, correction is usually done by the otolaryngologist. Tracheal repair is performed subsequently, usually in a separate stage. Laryngofissure has not been necessary with this exposure because you can reach way up, basically to the arytenoids. I still deplore elective cricothyroidostomy. I know statistically you can get away with it most of the time, but it is a deliberate insult to the larynx. Although stenosis from a deliberate insult to the trachea-tracheostomy-is usually correctable the first time around, some injuries to the larynx are uncorrectable at the outset; they simply cannot be straightened out. This is too big a price to pay for a dubious gain. Minitracheostomy, on the other hand, is done through a very small incision in the cricothyroid membrane. As you know, Dr John Wain in our institution has followed up these cases carefully and simply has not seen any serious injuries. We report 19 patients with idiopathic stenosis at the laryngotracheal level. We have quite a few others at lower levels, tracheal and carinal. The diagnosis is by exclusion, and I am not sure all cases are of the same origin. They have been studied very carefully by the pathologists and by other diagnostic techniques. We do not have final answers. A more detailed discussion of this problem was offered in an abstract submitted for this meeting, but because it was not accepted, you will have to wait for another year to hear the rest!
