Single Stage Laryngotracheal Reconstruction with Anterior Cartilage Graft
Leandro Socolovsky BA1, Rhea Singh BS1, Rajanya S. Petersson MS, MD1,2
1Virginia Commonwealth University School of Medicine, Richmond, VA
2Children’s Hospital of Richmond at VCU, Richmond, VA
This is a case of a 3-year-old male, former preterm infant born at 24 weeks with a past medical history of bronchopulmonary dysplasia and tracheomalacia status post tracheostomy for ventilator dependence. He had also developed subglottic stenosis from prolonged intubation.
The patient was decannulated with grade 1 subglottic stenosis, and initially did well. However, over several months, the stoma remained fairly patent, prompting repeat direct laryngoscopy and bronchoscopy now demonstrating low grade 2 subglottic stenosis.
The decision was made to proceed with laryngotracheal reconstruction with anterior rib cartilage graft, expanding the airway size from a 3.5 uncuffed endotracheal tube (ETT) to a 5.0 uncuffed ETT.
The patient was transferred to the ICU and kept intubated and sedated until extubation on post-operative day 3.
At 6 weeks postoperatively, direct laryngoscopy showed a well-mucosalized graft, with the airway still sized to a 5.0 ETT.
Direct laryngoscopy and bronchoscopy on the day of the reconstruction confirmed low grade 2 subglottic stenosis. The patient was intubated with a size 3.5 cuffed ETT for the procedure.
Right rib cartilage harvest was performed after the endoscopic airway evaluation, followed by carving of the cartilage graft on the back table. The cartilage was carved into a modified tear drop shape to accommodate the tracheal stoma, with a length of 25mm and a width of 7mm. The intraluminal depth of the graft was sized to the bevel of a 15-blade.
A fusiform incision was marked around the previous tracheostomy site. Scar tissue was dissected until the previous tracheostomy tract was clearly visualized and then excised. Once the patent tracheostomy was seen, the trachea and thyroid cartilage were skeletonized superiorly until the thyroid notch was reached. An incision site was marked from the superior aspect of the tracheostomy to the inferior border of the thyroid cartilage to avoid the anterior commissure. The marked incision site was then measured for confirmation of adequate sizing of graft, and confirmed to be 25 mm.
A 15-blade was used to make the incision into the airway. An oral RAE tube was trimmed and placed at the inferior aspect of the tracheal incision, after the ETT was backed out, and ventilation continued through the modified oral RAE. The incision was then advanced into the inferior 2mm of the thyroid cartilage without performing laryngofissure, ensuring not to go through the anterior commissure.
The patient was nasotracheally intubated with a 5.0 uncuffed ETT in preparation for graft placement, and the modified oral RAE was removed. The nasotracheal tube was advanced just beyond the graft site.
The cartilage graft was placed using 4-0 Vicryl pop-off sutures on RB-1 needles in simple interrupted fashion. The sutures were first placed into the graft through the extraluminal side and coming out at the junction of the intraluminal depth and cartilage that would overlap the airway. Then the sutures were placed submucosally through the cartilaginous rings of the trachea, taking care to avoid entering the airway lumen to prevent granulation tissue. A total of 8-12 sutures are typically placed, left untied, and tagged. The graft was then parachuted into position, and all sutures tied to ensure knots are squared. The wound was filled with saline, and a Valsalva at 20cm H2O was performed to ensure there was no air leak. The strap muscles were then loosely closed, and a split Penrose drain was placed with one limb under the strap muscles and the other subcutaneously. The skin was closed in layered fashion with 4-0 Monocryl deep inverted interrupted sutures and 5-0 Monocryl in a running subcuticular manner.
The patient was kept intubated and sedated for 3 days per protocol for anterior graft at our institution. Extubation was performed in the pediatric intensive care unit on post-operative day 3. A bronchoscopy was performed through the nasotracheal tube, and the patient was extubated over the bronchoscope. The graft site was visualized on the way out, and noted to be intact, mucosalizing, and without granulation tissue.and ensure it is intact. Humidified support was given via a nasal cannula following extubation.
At 6 weeks postoperatively a direct laryngoscopy was performed, noting well-mucosalized graft, and airway still sized to a 5.0 uncuffed ETT.
Indications/contraindications for single stage anterior cartilage graft reconstruction
Subglottic stenosis (SGS); high grade 1 to grade 2 SGS, failed decannulation for lower grade SGS, suprastomal collapse
Proximal tracheal stenosis
Other potential indications for rib cartilage grafting (with or without posterior grafting):
Vocal cord paralysis
Acute upper or lower respiratory tract infection
Untreated concurrent airway obstruction (vocal cord paralysis, tracheomalacia, bronchopulmonary dysplasia, adenotonsillar hypertrophy, choanal atresia)
Congestive heart failure (>30% oxygen requirements, weight < 1500g) Instrumentation Setup Patient placed supine with shoulder roll with head facing the anesthesia team. The neck and right anterior chest are prepped and draped in sterile fashion. If tracheostomy tube is present, modified cut down oral RAE, is sewn to chest wall opposite the planned cartilage donor site The anesthesia circuit is placed under sterile drapes in a manner to allow access by the anesthesia team during the procedure Preoperative workup Endoscopic examination of supraglottis, glottis, subglottis, trachea, and bronchi to confirm location of obstruction or stenosis and identify any other lesions or airway concerns. True vocal fold mobility is assessed and palpation of cricoarytenoid joint is performed to determine integrity of posterior glottis. Laryngopharyngeal reflux control may be considered prior to surgery. Discussion and communication with anesthesiologist before, during, and after the case to ensure smooth transitions between airways and during transport to the PICU. Weighted nasogastric feeding tube, if not already present, should be placed prior to beginning procedure, especially if posterior graft is planned. Anatomy and Landmarks Strap musculature Hyoid bone Thyroid cartilage Cricoid cartilage Proximal trachea Advantages Single stage procedure does not require decannulation at later date. Single stage allows for reconstructing the potentially weak area of the anterior tracheal wall at the trach site itself. Disadvantages For single stage procedure patients must be intubated and sedated in an intensive care unit for graft stenting for an adequate period of time. This requires sedation and occasionally paralysis, depending on the patient. Typically, the intubation is 3 days at our institution, but can be up to 5 for anterior grafting. Complications/risks Bleeding, infection, reaction to anesthesia, abnormal scarring, granulation, need for further procedures Graft dislodgement or failure Need for tracheostomy Pneumonia Pneumothorax Vocal cord injury if laryngofissure is performed