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This video provides an elucidation of the surgical steps involved in performing a single-stage endoscopic posterior cricoid split & rib graft placement in infant with congenital subglottic stenosis.
The patient is placed under general anesthesia utilizing total intravenous agents with spontaneous ventilation and insufflation technique. Direct laryngo-bronchoscopy is performed using a Parsons laryngoscope (Karl Storz GmbH & Co KG, Tuttlingen, Germany) with placement of the laryngeal vocal fold spreader in an inverted fashion. Airway examination is performed using a 4-mm, 0-degree Hopkins rod-lens telescope. The posterior cricoid plate is locally infiltrated with a xylocaine:adrenaline with a concentration ratio of 1:100,000. Endoscopic posterior midline cricoidotomy is performed using the cold steel technique (round or sickle knife) until the entire length of the posterior cricoid lamina is divided. Subsequently, balloon dilation of the cricoid cartilage is performed to allow expansion of the divided cricoid ring. The balloon is positioned to cover the supraglottic, glottic, and subglottic levels; it is inflated for 40 seconds unless there was desaturation necessitating earlier balloon deflation. The divided cricoid lamina is separated with alligator forceps to assess the space between the divided cricoid ends, which determines the graft width needed. Then, the airway is secured with an endotracheal tube, and the laryngoscope is removed.
Rib graft harvest is performed from the fifth rib. The graft is shaped by carving a groove laterally on each side, and a safety suture (3–0 silk suture) is temporarily applied to the superior part of the graft.
The patient is placed in suspension, and the endotracheal tube is removed to continue the insufflation technique. The graft is placed into the cricoid split with the graft's perichondrium on the laryngeal lumen side. Correct graft position and alignment with the laryngeal lumen are then confirmed with a right-angle probe prior to removal of the safety suture.
Nasotracheal intubation is performed under endoscopic guidance, and the patient is transferred to the intensive care unit (ICU).
Pediatric bilateral vocal fold paralysis, posterior glottic stenosis and/or subglottic stenosis.
Difficult laryngeal exposure. Grade IV subglottic stenosis. Not fit for general anesthesia.
Pediatric laryngoscopy with suspension. Spontaneous breathing aided by side port insufflation.
Chest X-ray, instrumental swallowing assessment (modified barium swallow (MBS) or fiberoptic endoscopic evaluation of swallowing (FEES)), complete blood count, coagulation profile and blood chemistry.
Anatomical Landmarks:
Cricoid Cartilage:
- The only complete cartilaginous ring of the airway.
- The posterior lamina serves as an important reference point for the procedure.
Arytenoid Cartilages:
- Located at the superior border of the cricoid.
Interarytenoid muscles:
- lies between the arytenoid cartilages at the posterior aspect of the larynx.
Alternative procedures:
Open laryngotracheal reconstruction with posterior rib graft, partial cricotracheal resection and anastomosis, and tracheostomy.
Advantage: Reduced operative time, minimal morbidity, and does not necessitate a neck incision. Disadvantage: requires an adequate endoscopic laryngeal view and laryngopharyngeal reflux control.
Graft extrusion and failure, granulation tissue formation, aspiration, and voice changes. The procedure also carries the risks of prolonged intubation if performed as a single-stage.
No disclosure.
N/A.
Inglis AF Jr, Perkins JA, Manning SC, Mouzakes J. Endoscopic posterior cricoid split and rib grafting in 10 children. Laryngoscope. 2003;113(11):2004-2009. doi:10.1097/00005537-200311000-00028
Gerber ME, Modi VK, Ward RF, Gower VM, Thomsen J. Endoscopic posterior cricoid split and costal cartilage graft placement in children. Otolaryngol Head Neck Surg. 2013;148(3):494-502. doi:10.1177/0194599812472435
Review Single- Stage Endoscopic Posterior Cricoid Split & Rib Graft Placement in Infant.