Double Stage Laryngotracheal Reconstruction with Anterior and Posterior Rib Graft

Abstract: Procedure: Double-stage Laryngotracheal Reconstruction with Anterior and Posterior Rib Cartilage grafts. Introduction: Laryngotracheal reconstruction (LTR) is the standard of care in patients requiring expansion of subglottic stenosis (SGS). The procedure is completed as a single- or double-stage, and thyroid or rib cartilage may be used to expand the airway. Double-staged LTR (dsLTR) places a stent in the airway to allow for healing of the cartilage grafts, while a tracheostomy is present to secure the airway. Indications/Contraindications: dsLTR is preferred in patients with a complex medical history, severe SGS, complex multilevel stenosis, or as a salvage procedure in those who have failed airway reconstruction. Ventilator or tracheostomy dependence is a contraindication for this procedure. Other contraindications are conditions that impair graft healing, including upper respiratory tract infection, uncontrolled reflux disease, or eosinophilic esophagitis. Materials and Methods: Patients undergo surgical planning with a complete history and physical in the clinic and airway view via direct laryngoscopy and bronchoscopy. The procedure accesses the airway externally where incisions are made the length of stenosis in the anterior and/or posterior cricoid-tracheal wall. Rib cartilage grafts are used to expand the airway with a Mehta laryngeal stent in place. Results: A 34-month-old female with acquired grade IV subglottic stenosis and tracheostomy with a history of failed single-stage LTR, underwent dsLTR with anterior and posterior rib cartilage graft placement. Surgery and postoperative care were uncomplicated with healed grafts and without airway stenosis. The patient is ready to decannulate five-months after this procedure. Conclusion: DsLTR is successful in patients with severe SGS and failed prior airway reconstruction surgery.

Laryngotracheal reconstruction (LTR) is the standard of care in patients requiring expansion of a stenotic airway, commonly subglottic stenosis (SGS). The procedure is completed as a single- or double-stage, and rib cartilage is used to expand the airway. Double-staged LTR (dsLTR) places a stent in the airway with a tracheostomy present to secure the airway. After surgery, the stent and tracheostomy are removed at separate times, respectively. DsLTR is preferred in patients with severe SGS, complex multilevel stenosis, or as a salvage procedure in those who have failed airway reconstruction surgery.1 Complex multilevel stenosis include bilateral vocal cord paralysis and suprastomal collapse. This procedure is ideal for patients with a complicated clinical history with comorbidities of neurologic deficits, significant pulmonary or cardiac disease, and craniofacial or vertebral anomalies.2 Ventilator dependence due to chronic pulmonary disease or neurologic impairment is a contraindication to surgery. Other considerations are the stability of medical conditions and patient weight >1500g. This comprises co-existing airway obstruction of severe tracheomalacia or bilateral vocal cord paralysis and disease that impairs graft healing such as acute upper respiratory tract infection, uncontrolled reflux, or eosinophilic esophagitis.2,3 Performing a dsLTR reduces postoperative management risk of complications from prolonged neuromuscular blockade or sedation.4 Graft dislodgement and scar contracture is less common with the presence of a laryngeal stent. Another advantage is a secure airway in those difficult to intubate who otherwise may require an emergency tracheostomy. Disadvantages include the requirement of an additional procedure, and use of a laryngeal stent that is shown to promote granulation tissue, a complication that delays or prevents decannulation.4,5 As with all procedures, there is a risk of bleeding, infection, damage to the airway, vessels and nerves, and need for additional procedures. Bleeding and damage to the nerves that control the voice box are rare. Postoperative antibiotics help prevent graft infection, and proton-pump inhibitors and steroids are used to reduce laryngeal edema which will interfere with graft healing.6 A laryngeal stent is intraoperatively transfixed for four weeks to allow for healing and avert graft dislodgement. Other complications from the procedure are due to postoperative medical care. Chest physiotherapy is encouraged to avoid atelectasis and pneumonia. Prior to discharge, endoscopy is performed to assess and remove granulation tissue or hemangiomas. Assessments of the airway continue months afterward to ensure proper healing and readiness for decannulation. Late complications consist of arytenoid prolapse, surgical airway collapse, and change in voice quality.7,8

Special instrumentation used in this procedure was the Mehta laryngeal stent (Hood E Benson Laboratories Inc).9 For procedure set-up, the rib and neck are prepped and draped as two separate surgical fields. The rib harvest must be done under sterile conditions whereas the neck is considered a clean-contaminated field. A separate direct laryngoscopy setup with telescope and camera is situated at the head of the bed for use throughout the case. The patient is placed supine with shoulder roll, eye protection, and head drape with the table turned 90°. Preoperative workup of the patient includes review of patient history including symptoms of exercise intolerance, recurrent croup, and if a tracheotomy is present. All patients must have vocal cord mobility assessed with a fiber-optic laryngoscopy in the clinic. Direct laryngoscopy and bronchoscopy (DLB) is indicated prior for surgical planning to assess for degree of stenosis and other potential contraindications to surgery. The presence of other pulmonary co-morbidities, usage of supplemental oxygen at baseline, and adequate pulmonary clearance with a good cough are vital pre-requisites to a successful operation. Other considerations include feeding tube dependency, oral aversion, neurological dyscoordination, preoperative vocal quality and presence of other anatomical defects.10 It is important to understand the length and area of stenosis on DLB and if present its relation to the tracheostomy site. This will determine the length of the cartilage graft necessary to open up the airway. Posterior graft placement is indicated when anterior graft alone does not adequately expand the airway or in the presence of bilateral vocal cord paralysis and/or posterior subglottic stenosis. Landmarks in all airway procedures include thyroid cartilage, cricoid cartilage, and trachea. In the operating room (OR) direct laryngoscopy is performed first to assess the degree, location, and length of airway stenosis. Airway landmarks are identified and an injection of 0.5% lidocaine with 1:200,000 epinephrine is placed into marked skin incision lines. After prepping and draping the neck, an incision is made around the tracheal stoma. Superior and inferior flaps are elevated and lateralized, exposing the laryngotracheal framework. The anterior trachea is skeletonized and the skin and stoma of the tracheostomy are removed. A vertical incision is made from the tracheostomy stoma to the most superior part of the subglottic stenosis. The posterior split is made by dividing the posterior cricoid along the midline. Separation of the split posterior cricoid is confirmed. Oxymetazoline-soaked pledgets are used along the mucosal edges for hemostasis. The airway is then sized with an endotracheal tube to select the appropriate Mehta Laryngeal Stent. Rib graft harvest is next, which requires re-scrubbing to access the clean area. Detailed steps of rib cartilage graft harvest can be viewed in Dr. Yim’s CSurgeries video.11 After harvesting the grafts, the grafts are carved to appropriately fit the incision made in the airway. The posterior graft height should be equal to the cricoid height. A wedge is carved into the superior and inferior edges with preservation of the perichondrium along the anterior surface. The anterior graft is carved into an elongated boat shape. Next, a step-off is created in the anterior graft along the superior and inferior edges of the rib, which will become the lateral edges of the airway. The step-off is created to allow an adequate airway seal and prevent graft protrusion into the airway. The narrower side of the step-off should contain the perichondrium and will face into the airway. After closure of the chest incision, the procedure is transitioned to the neck again. The posterior graft is placed between the split cricoid, with the perichondrium lining the airway. The graft should easily snap with the wedges fitting between the split cricoid, confirming a tight fit. Length of the Mehta Laryngeal Stent is then measured to protrude at the level of the aryepiglottic folds superiorly and to the upper end of the tracheal stoma inferiorly. Prolene suture is used to secure the Mehta Laryngeal Stent. The suture is placed through the strap muscles on one side, airway on the same side, through the stent, airway on the other side, and the strap muscles on the opposite side. This suture is closed over a small angiocath with numerous knots for identification during later removal. Next, the anterior graft is secured with the perichondrium lining the airway. Prolene suture is placed through the anterior to posterior (with perichondrium) faces of the graft, exiting at the step-off juncture. Approximately six interrupted mattress sutures are placed around the anterior graft. Adequate seal of the anterior graft is verified with a Valsalva maneuver and saline flush around the airway. A neck drain is placed prior to skin closure. The endotracheal tube is then replaced with the patient’s tracheostomy tube. Four-weeks after surgery the patient is taken to the OR. Incisions are made in the lateral neck and the angiocath marking the stent stay sutures are removed. Then direct laryngoscopy is performed with removal of the Mehta Laryngeal Stent and assessment of airway patency and graft healing.

A 34-month-old female with secondary acquired grade IV SGS with extension to the glottis and tracheostomy status-post failed single-stage LTR (ssLTR) underwent dsLTR. Anterior and posterior rib cartilage grafts were used for reconstruction of her airway. Postoperatively a Mehta laryngeal stent was in place and tracheostomy present. The procedure and postoperative care were uncomplicated. DLB during admission showed well healing grafts without granulation tissue. DLB was repeated one-month postoperatively showing grafts in place with mucosalization of the airway surface. No granulation tissue was present at that time. The patient has a fully healed patent airway, without any stenosis, and is successfully capped and ready for decannulation five-months after the first procedure. The second procedure will involve decannulating the patient in the PICU after an inspection in the OR.

Standard management of laryngostenosis includes balloon-dilation, single or double-stage LTR, and cricotracheal reconstruction (CTR). LTR is the standard of care in patients requiring expansion of the glottis and subglottis. DsLTR is advantageous in those with multilevel stenosis, patients with complex medical history, or have failed airway reconstruction. Other techniques such as tracheoplasty and CTR is more challenging in those with stenosis extending to the glottis. CTR is demonstrated to be superior in those who have grade IV SGS without involvement of the glottis.1,4 Critical steps of dsLTR are creation and placement of the cartilage grafts.1 It is paramount the posterior cricoid is completely split, and can be missed at the most superior edge of the cartilage.3 However, split extension of the tissue too superiorly can result in a laryngeal cleft. The surgeon must assure there is a separation between the split cricoid to allow easy placement of the posterior graft. Appropriate size and depth of wedges in the posterior graft will allow an easy snap of the graft into the posterior split. This removes the need for suture posteriorly, reducing the chance of graft dislodgement and granulation tissue formation. Inappropriate anterior graft size may not adequately seal the airway causing a leak, delaying the ability to decannulate a patient. Furthermore inappropriate fit of the grafts may cause protrusion into the airway causing graft dislodgement or inadequate expansion of the airway. Suture that is placed in the airway during anterior graft placement may lead to granulation tissue formation and delay in decannulation. Modifications that can be performed during this procedure is predominately dependent on availability and surgeon preference. Other stents that may be used include Montgomery T-tubes, silastic stents, and Aboulker stents.3 We believe the Mehta Laryngeal stent is just as effective as and easier to use than other stents. Graft donor sites that are used include rib cartilage, thyroid ala cartilage, auricular cartilage, septal cartilage and cadaver cartilage of these sites. Common variation in the described procedural steps is the use of suture to secure the posterior cartilage graft. We present a patient who had grade IV SGS who had underwent a prior ssLTR and now presented for dsLTR. Here we describe the placement of anterior and posterior rib cartilage grafts, with transfixation of a Mehta Laryngeal stent intraoperatively. The patient’s course was uncomplicated and is successfully capped and ready for decannulation. DsLTR with anterior and posterior rib cartilage grafts is successful and should be considered in patients with severe SGS and failed prior airway reconstruction surgery.

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