Учебники / Operative Techniques in Laryngology Rosen 2008

performed to provide greater visualization and to permit resection closer to the vocal folds and enables the surgeon to complete the anastomosis. Posterior glottic stenosis can be treated by division of interarytenoid adhesions and advancement of posterior tracheal mucosa into the interarytenoid region (Figs. 46.6, 46.7).

7.Once proximal and distal clearance has been achieved, an anastomosis is performed approximating the proximal margin of the trachea to the immediate subglottic area, using no. 35 gauge wires posteriorly and 4-0 Vicryl laterally and anteriorly (Fig. 46.8).

8.During the completion of the anastomosis, a T-tube is inserted and placed at least 6–7 mm cephalic to the vocal folds, through a tracheostomy that is located inferior to the anastomotic site (Fig. 46.9).

9.The proximal end of the T-tube is occluded to permit ventilation distally through its horizontal arm. This can be accomplished with a bronchial block or a Fogarty catheter placed into the proximal end of the T-tube (Chap. 29, “Subglottic/Tracheal Stenosis: Laser/Endoscopic Management”). Occasionally, a no. 4 distal tracheostomy tube is used rather than a T-tube.

10.At the end of the procedure, a heavy suture is placed from the submental area to the anterior chest wall to maintain the patient’s cervical spine in a flexed position and to eliminate tension on the tracheal anastomosis, thereby minimizing the risk of dehiscence.

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Fig. 46.9  Indwelling T-tube. Note that the proximal end of the tube extends beyond the true vocal folds into the supraglottis

11.The closure includes reapproximation of the strap muscles, the platysma, and the soft tissue in the subcutaneous plane using 4-0 Vicryl. The skin is closed in standard fashion.

46.6Postoperative Management

Postoperative care involves the following:

■Airway patency is maintained and the suture line protected by a soft Silastic T-tube. The T-tube must be kept capped to prevent drying of secretions and obstruction of the tube.

■To protect the anastomosis, the chin suture is removed 4–5 days after surgery.

■Dietary intake is initiated 48 hours postoperatively, beginning with carbonated fluids and progressed gradually as tolerated.

■The T-tube is removed 3–6 weeks postoperatively, depending on the extent and complexity of the resection.

Complications can comprise:

■Patients with significant comorbidities (i. e., diabetes mellitus) are at an increased risk of complications, and these comorbidities should be treated and/or considered preoperatively to minimize this risk.

■Dehiscence of the anastomotic suture line

■Restenosis of the airway

■Recurrent laryngeal nerve injury

■Granulation tissue from the T-tube

■Post-operative decrease in pitch (speech) can occur and is related to cricothyroid muscle division.

■Dysphagia

■A moderate number of patients develop dysphagia for up to 2 weeks postoperatively, especially when the tracheal resection exceeds 4 cm.

Key Points

■In the authors’ experience, definitive decannulation of 92% of patients with no evidence of recurrence, and excellent airway and vocal function supports the efficacy of cricotracheal resection with primary thyrotracheal anastomosis. A successful outcome depends on the following factors:

■Patient selection is critical and must include the consideration of the level, site, and extent of the lesion and the known patient comorbidities.

■This procedure should be performed only in patients with mature cricotracheal stenosis in which the acute inflammatory stage has subsided.

■A complete segmental cricotracheal resection of the stenotic tissue is essential.

■The addition of a laryngofissure provides excellent exposure for patients with a cricotracheal stenosis that is located close to the vocal folds. This therefore permits excision of all pathologic tissue and meticulous anastomosis of the trachea to the immediate subglottic region

in close proximity to the vocal folds. Another advantage of a laryngofissure includes the accurate placement of the T-tube, which decreases the risk of postoperative complications associated with T-tube misplacement. Correct placement of the T-tube is imperative to maintain a patent airway and provide support to the anastomosis in the early postoperative period.

■Release of the suprahyoid or infrahyoid muscles is not routinely performed, as it appears to exacerbate dysphagia postoperatively.

■To avoid injury to the recurrent laryngeal nerves, it is imperative to perform the dissection on the inner aspect of the remaining cricoid cartilage after excision of its anterior arch.

■In general, the use of a T-tube is superior to a tracheostomy because is provides a physiologic airway stent and is less traumatic to the airway.

Selected Bibliography

1Ashiku SK, Kuzucu A, Grillo HC, Wright CD, Wain JC, Lo B, Mathisen DJ (2004) Idiopathic laryngotracheal stenosis: Effective definitive treatment with laryngotracheal resection. J Thorac Cardiovasc Surg 127:99–107

2Couraud L, Brichon PY, Velly JF (1988) The surgical treatment of inflammatory and fibrous laryngotracheal stenosis. Eur J Cardiothorac Surg 2:410–415

3Delaere PR, Blondeel PN, Hermans R, Guelinckx PJ, Feenstra L (1997) Use of a composite fascial carrier for laryngotracheal reconstruction. Laryngoscope 106:175–181

4Gerwat J, Bryce DP (1974) The management of subglottic laryngotracheal stenosis by resection and direct anastomosis. Laryngoscope 84:940–947

5Grillo HC (1982) Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 33:3–18

6Grillo HC, Mark EJ, Mathisen DJ, Wain JC (1993) Idiopathic laryngotracheal stenosis and its management. Ann Thorac Surg 56:80–87

7Grillo HC, Mathisen DJ, Ashiku SK, Wright CD, Wain JC (2003) Successful treatment of idiopathic laryngotracheal stenosis by resection and primary anastomosis. Ann Otol Rhinol Laryngol 112:798–800

8Maddaus MA, Toth JL, Gullane PJ, Pearson FG (1992) Subglottic tracheal resection and synchronous laryngeal reconstruction. J Thorac Cardiovasc Surg 104:1443–1450

9Pearson FG, Cooper JD, Nelems JM, Van Nostrand AW (1975) Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 70:806–816

10Pearson FG, Gullane PJ (1996) Subglottic resection with primary tracheal anastomosis: including synchronous laryngotracheal reconstructions. Semin Thorac Cardiovasc Surg 8:381–391

47.1Fundamental and Related Chapters

Please see Chaps. 6, 29, 45, and 46 for further information.

47.2Background Information

and Diagnosis of Tracheal Stenosis

Tracheal stenosis is a complex and difficult problem to manage. Patient health and comorbidities, degree and length of stenosis, and propensity for restenosis need to be considered when determining the best treatment option for tracheal stenosis. Most cases of benign tracheal stenosis are caused by prolonged tracheal intubation or tracheotomy. Patients will typically present with reports of exertional dyspnea or progressive shortness of breath along with a history of previous intubation(s) or tracheotomy.

Diagnostic information can be obtained from CT scans to determine the length, site, and degree of tracheal involvement. This information should be used in conjunction with tracheobronchoscopy to identify the extent and length of stenosis, and the number of tracheal rings or length proximal and distal to the site of stenosis. It is also important to determine if multilevel obstruction exists. Flexible laryngoscopy should be performed to determine the status of vocal fold mobility. This allows for surgical planning to determine the manner and extent of the surgical resection.

47.3Surgical Indications and Contraindications

Indications for tracheal resection with primary anastomosis include:

■Symptomatic tracheal stenosis after failure of endoscopic management

■Focal (short-segment) tracheomalacia/cartilage collapse

■Primary tracheal neoplasm

Contraindications can comprise:

■Stenotic tracheal segment > 5 cm (without the use of additional laryngeal releasing maneuvers)

■Subglottic stenosis with involvement of vocal cords (see Chaps. 45, “Glottic and Subglottic Stenosis: Laryngotracheal Reconstruction with Grafting” and 46, “Glottic and Subglottic Stenosis: Cricotracheal Resection with Primary Anastomosis” for the treatment of this condition)

■Multiple levels of tracheal stenosis or configuration not amenable to primary anastomosis

■Uncontrolled mucosal inflammation secondary to LPR, Wegener’s disease, or infection

47.4Surgical Equipment

Surgical equipment needed includes:

■Monopolar and bipolar electrocautery

■Standard soft tissue or neck dissection tray

■A no. 15 scalpel (occasionally no. 10 or 20 for severely scarred, calcified tracheal wall, particularly during tracheotomy under local anesthesia)

47.5Surgical Procedure

1.Intubation

a) Patients without tracheotomy are orotracheally or nasotracheally intubated with appropriately sized endotracheal tubes (4.0 MLT) if possible.

b) Some patients with severe stenosis must be managed with bronchoscopic dilation, jet ventilation, or tracheotomy under local anesthesia until safe intubation of the distal trachea is achieved.

2.Positioning of patient

Patients are placed in a supine position with shoulder roll for full neck extension.

3.Incision

a) A low collar or U-shaped incision is made that extends from the anterior borders of the sternocleidomastoid muscles.

b) If the stenotic segment involves the tracheotomy site, then the incision should include the tracheotomy tract and will be removed with the stenotic tracheal segment. c) Preserve the tracheotomy in patients that have an unre-

lated stenotic tracheal segment.

Fig. 47.5  Blunt dissection of posterior tracheoesophageal party wall, with complete removal of stenotic region. Note placement of an endotracheal tube into the distal trachea

Fig. 47.7  Completed anastomosis with additional sutures externally spanning two tracheal rings for additional support

typically not required for tracheal stenosis segments less than 5 cm and are not included in this chapter.

f)Prior to closing the anterior and lateral portion of the anastomosis, the distal endotracheal tube is withdrawn and the oral or nasotracheal tube is passed distally to bridge the anastomosis and eventual primary closure.

g)The anastomotic closure is then leak tested by flooding the field with saline solution and deflating the cuff on the endotracheal tube while ventilating the patient.

7.Closure

a)A Penrose drain is used and positioned at the anastomosis.

b)The wound is then closed in three layers. The strap muscles are reapproximated, followed by platysma and dermis, and finally skin closure.

c)A 2-0 Prolene suture is placed between the submentum and anterior chest wall to keep the neck in a flexed position.

8.Extubation

a)Patients are extubated the following day in the operating room or monitored intensive care unit. Many surgeons prefer immediate extubation. One theoretical advantage to overnight intubation is to reduce air leak at the closure site in case of cough or need for ventilatory support.

advanced as tolerated.

■ Penrose drain removal on day 3 if no complications or evidence or air leak/crepitus.

■ Skin sutures are removed at 1 week.

■ Chin flexion suture is removed at 2 weeks.

Complications can comprise:

■Wound dehiscence/infection. This is minimized by the use of perioperative antibiotics and by maintaining cervical flexion.

■Stenosis at site of anastomotic closure

■Tracheobronchoscopy may be used to identify and treat. Granulation tissue can be removed, and stenotic sites can be dilated.

Key Points

■Cervical flexion is necessary to decrease anastomotic tension during the initial phases of wound healing.

■Minimize the amount of tracheal dissection that is performed superior and inferior to the anastomotic site. This will decrease the amount of devascularization and improve healing.

■All sutures for closure are placed with the knots extraluminally.

■For select patients with sites of stenosis < 5 cm, tracheal resection with primary anastomosis can be performed without the need for additional laryngeal releasing maneuvers. The need for laryngeal release needs to be made intraoperatively and depends on the degree of anastomotic tension.

Selected Bibliography

1Grillo HC, Mark EJ, Mathisen DJ, Wain JC (1993) Idiopathic laryngotracheal stenosis and its management. Ann Thorac Surg 56:80–87

2Grillo HC, Mathisen DJ, Ashiku SK, Wright CD, Wain JC (2003) Successful treatment of idiopathic laryngotracheal stenosis by resection and primary anastomosis. Ann Otol Rhinol Laryngol 112:798–800

3Laccourreye O, Brasnu D, Cauchois R et al (1996) Tracheal resection with end-to-end anastomosis for isolated postintubation cervical trachea stenosis: long-term results. Ann Otol Rhinol Laryngol 105:944–948

4Har-El G, Chaudry R, Shaha A et al (1993) Resection of tracheal stenosis with end-to-end anastomosis. Ann Otol Rhinol Laryngol 102:670–674

5Merati AL, Rieder AA, Patel N, Park DL, Girod D (2005) Does successful segmental tracheal resection require releasing maneuvers? Otolaryngol Head Neck Surg 133:372–376

48.1Fundamental and Related Chapters

Please see Chaps. 1, 3, 4, 8, 23, and 36 for further information.

48.2General Considerations

The Gray minithyrotomy offers:

■Access to physiologically important subepithelial vocal fold tissue without epithelial incision

■The ability to carry out delicate dissection of areas of adhesion/fibrosis under excellent visualization

■A means of introducing shorter dissecting instruments into the vocal fold mucosa that may be easier to handle than the usual microlaryngoscopic tools

■Dissection orientation in a practical direction along the long axis of the vocal fold

The Gray minithyrotomy is designed for access to subepithelial tissue planes of the membranous vocal fold. The integrity of the layered structure of the membranous vocal fold, essential for normal phonation, is compromised in sulcus vocalis, vocal fold scar, and other clinical conditions. Surgical repair is challenging because of the possibility of additional tissue injury and the technical difficulty of placing and stabilizing appropriate replacement tissue or grafts via a mucosal incision using microlaryngoscopic instrumentation.

The Gray minithyrotomy requires a skin incision, and does not correct epithelial abnormalities, such as changes associated with the sulcus vergeture deformity. The procedure does not permit substantial medialization of the vibratory margin, as the implant space is limited in volume. It has also not been used to remove subepithelial lesions; its principal utility has been to divide epithelial-deep tissue adhesion and implant appropriate replacement tissue or grafts.

The Gray minithyrotomy is named for Steven Gray, M.D., who, together with his colleagues, developed the operation in anticipation of the availability of bioengineered superficial lamina propria replacement material.

48.3Surgical Indications and Contraindications

The patient with a loss of pliability of the mucosal cover of the vocal fold, but with normal gross vocal fold motion is an ideal candidate for this procedure. Conditions meeting these criteria include:

■Vocal fold scar

■Sulcus vocalis

■Mild vocal fold bowing, especially when associated with age-related alterations in lamina propria thickness and pliability

The Gray minithyrotomy is not intended to provide substantial medialization, as required to correct typical cases of glottic insufficiency related to vocal fold paralysis and vocal fold atrophy for example.

48.4Surgical Equipment

Equipment for the Gray minithyrotomy need is:

■Suspension microlaryngology equipment (see Chap. 10)

■Zero degree endoscope (30 and 70° are also useful), camera, and video monitor (Chap. 10)

■C-mount camera and video monitor

■Standard neck surgery instrument set, including small self-retaining retractor

■22-g needle

■Powered drill with 3-mm cutting burr

■Mastoid curette

■Tympanoplasty instrument tray, especially:

■Duckbill and Gimmick elevators

■Blunt probes

■Bellucci scissors, straight and angled

■Alligator forceps

48.5Surgical Procedure

1.Preoperative measures and anesthesia a) Anesthesia

The procedure is performed under a general anesthetic, as the delicate and precise nature of the dissection places

a premium on patient immobility and optimal visualization via rigid rod-lens endoscope or surgical microscope.

b)Intubation

The patient should be intubated with a 5.0 (female) or 5.5 (male) cuffed endotracheal tube so as not to obstruct visualization of the membranous vocal fold from the anterior commissure to the vocal process of the arytenoid cartilage.

c)Intravenous steroids

d)Because the minithyrotomy usually involves dissection of the lamina propria along the entire length of the vocal fold, edema begins early and accumulates quickly, rendering the effects of surgery difficult to assess by the end of the typical case. To minimize this, 10–12 mg of intravenous Decadron is administered intravenously before the case begins.

2.Patient positioning and surgical exposure

a)Laryngoscopy

A laryngoscope which offers exposure of the full length of the membranous vocal folds is introduced and stabilized using a Lewy-type arm on a table-mounted Mayo stand or suspended using a Boston gallows, in the same manner as if performing laryngeal phonomicrosurgery (see Chap. 10, “Principles of Phonomicrosurgery”).

b)Prep and drape.

The neck is prepped and draped, anticipating a 2-3cm horizontal incision overlying the thyroid cartilage. The arm of the laryngoscope suspension/stabilization device overlies the surgical field and must be draped, as inadvertent contact with it is almost inevitable during the procedure. The primary surgeon will be most comfortable working from the patient’s right if right-handed, and from the left if left-handed.

Fig. 48.1  The patient is placed under suspension laryngoscopy and a horizontal incision is made overlying the thyroid cartilage

c)Visualization

The assistant introduces a 0° endoscope connected to a camera into the laryngoscope and performs a preliminary inspection to:

i.Correlate the appearance of the vocal folds with that noted on preoperative stroboscopy and confirm preoperative diagnosis

ii.Check laryngoscope position. The leading tip of the laryngoscope must not interfere with the anatomy of the anterior commissure. If positioned too distally, then the tip can slightly evert the vocal folds and give a false impression of the location of their vibratory margin.

The video monitor must be positioned so that it may be seen by both surgeon and assistant. The video tower is best placed on the side of the patient contralateral to the surgeon, at the level of the thorax, rotated slightly cephalad.

iii.Video monitoring of internal view of the anterior commissure and the vocal folds can be done throughout the procedure via microlaryngoscopy with a camera attached to the microscope or try an assistant using a zero or thirty degree telescope with

Fig. 48.3  A 22-g needle is passed through thyroid cartilage to localize the level of the vocal folds

(Fig. 48.2). Fascial fibers or bands are trimmed from the grafts, and the graft is placed into saline to await implantation.

4.Making the minithyrotomy

a)Perichondrial elevation

The external perichondrium of the thyroid cartilage is incised in the midline and elevated superiolaterally to expose an area about 1 cm2 on each side of the prow of the cartilage.

b)Needle localization of vocal fold level

Using gentle pressure, a 22-g needle is passed through the anterior midline of the thyroid cartilage at the anticipat-

folds)

ed level of the vocal folds. Using a zero degree endoscope the assistant visualizes the needle as it enters the larynx near the anterior commissure. The needle is reinserted as necessary under endoscopic guidance to definitively establish the level of the glottis, and the surgeon marks this on the thyroid cartilage (Figs. 48.3, 48.4). As greater experience is gained with placement of the minithyrotomy, the needle localization angle can be done to simulate/ identify the optimal path of the minithyrotomy. Thus,

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Fig. 48.6  Subepithelial dissection of the vocal fold through the minithyrotomy (endoscopic view)

instead of placing the localizing needle perpendicular to the thyroid cartilage in the midline, the needle is passed at the suspected angle and level of the anterior commissure while visual inspection is performed to provide feedback on the needle placement.

c)The minithyrotomy

The minithyrotomy is centered some 3–5mm off the midline at the level of the vocal fold (Fig. 48.5). A powered drill with a 3-mm cutting burr is used to create a tunnel through the thyroid cartilage. Once the “give” of penetra-

Fig. 48.5  A cutting burr is used to gain access to the subepithelial space of the vocal fold. Note the special angle of the minithyrotomy to allow longitudinal access to the vocal fold

tion through the internal cartilaginous cortex is felt, the drill is promptly withdrawn. A mastoid curette may be used to finish the inside margin of the minithyrotomy to avoid a “saucerized configuration.” It is important that the minithyrotomy be oriented to the long axis of the vocal fold (and thus somewhat obliquely—not perpen- dicular—to the plane of the thyroid lamina) so as not to restrict the mobility of the dissecting instruments.

5.Endolaryngeal dissection

a)Entering the correct tissue plane

Initial entry into the subepithelium is best made gently with a blunt instrument such as a probe. The tip of the dissecting instrument should be visible endoscopically underneath the epithelium of the vocal fold.

b)Subepithelial dissection

A tympanoplasty set contains a variety of instruments of the right size and length for efficient dissection via the minithyrotomy. It is usually possible to do most of the dissection with blunt instrumentation of varying thickness, like a Gimmick elevator. Bellucci scissors are used in only the most severe cases of adhesion. Surgeons who do not routinely use the tympanoplasty set should note that the duckbill is usually kept quite sharp, and may easily tear the mucosa if used in a cavalier manner (Fig. 48.6).

c)Creating the implant pocket

The surgeon should have a good idea of the size and shape of the implant pocket preoperatively from careful study of the patient’s stroboscopic examination. The extent of defects in mucosal pliability may be very difficult to assess during surgery, when the vocal fold mucosa is not engaged in phonatory oscillation. The implant pocket should be limited as much as possible to the area of pathology. This takes considerable lightness of touch, as normal superficial lamina propria offers little resistance to dissecting instruments. It is not difficult to elevate too widely, and this creates areas into which a fat graft may migrate under phonatory forces, away from where it is needed. This is a particular problem if dissection proceeds too far laterally along the superior surface of the vocal fold.