[The application of thyroid alar cartilage in the reconstruction of subglottic stenosis for children].

Objective: To explore the application value of thyroid alar cartilage(TAC) in the laryngotracheal reconstruction of subglotticstenosis in the paediatric population. Methods: Twelve patients(7 males,5 females; range from 2.3 to 12.0 years) with subglotticstenosis who had undergone laryngotracheal reconstruction procedures at our hospital fromSeptember 2016 to July 2018 were analyzed retrospectively.The degree of stenosis was classified according to Myer-Cotton classification system:grade Ⅱ(n=4),grade Ⅲ(n=6) and grade Ⅳ(n=2). The stenosis planes were subglotticbut did not exceed the 3rd tracheal cartilage ring. Results: Of all 12 patients, 11 were decannulated and 1 failed. All patients with grade Ⅱ and Ⅲ patients were decannulated at one procedure. There were no severe complications such as tube dislogement,asphyxia and unhealed wound. Conclusions: The TAC for widening laryngotracheal lumen is relatively simple and reliable for laryngotracheal reconstruction in the pediatric population with subglottic stenosis. This would't cause any structural damage to the laryngeal cavity.

Use of autologous adipose-derived mesenchymal stem cells for creation of laryngeal cartilage.

OBJECTIVES/HYPOTHESIS: Adipose-derived mesenchymal stem cells (ASCs) are an exciting potential cell source for tissue engineering because cells can be derived from the simple excision of autologous fat. This study introduces a novel approach for tissue-engineering cartilage from ASCs and a customized collagen oligomer solution, and demonstrates that the resultant cartilage can be used for laryngeal cartilage reconstruction in an animal model. STUDY DESIGN: Basic science experimental design. METHODS: ASCs were isolated from F344 rats, seeded in a customized collagen matrix, and cultured in chondrogenic differentiation medium for 1, 2, and 4 weeks until demonstrating cartilage-like characteristics in vitro. Large laryngeal cartilage defects were created in the F344 rat model, with the engineered cartilage used to replace the cartilage defects, and the rats followed for 1 to 3 months. Staining examined cellular morphology and cartilage-specific features. RESULTS: In vitro histological staining revealed rounded chondrocyte-appearing cells evenly residing throughout the customized collagen scaffold, with positive staining for cartilage-specific markers. The cartilage was used to successfully repair large cartilaginous defects in the rat model, with excellent functional results. CONCLUSIONS: This study is the first study to demonstrate, in an animal model, that ASCs cultured in a unique form of collagen oligomer can create functional cartilage-like grafts that can be successfully used for partial laryngeal cartilage replacement. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:E123-E129, 2018.

Laringoplastía con interposición de cartílago del ala del tiroides en pacientes adultos / Laryngoplasty with interposition of cartilage thyroid wing in adult patients

Establecer la estabilidad y resistencia del cartílago tiroideo para la ampliación de la subglotis en pacientes estenosados, y comparar los resultados funcionales entre laringoplastías con cartílago de ala tiroidea y cartílago costal. Diseño: estudio comparativo retrospectivo. Método: desde 2003 al 2010, se realizaron laringoplastías con interposición de cartílago a 17 pacientes con estenosis subglótica. Los mismos se distribuyeron en dos grupos: grupo A: 7 pacientes operados con laringoplastía e interposición de cartílago del ala del tiroides; grupo B: grupo control de 10 pacientes con laringoplastía e interposición de cartilago costal. Los puntos de análisis fueron las complicaciones intra y post quirúrgicas, y el éxito de la técnica quirúrgica logrado al decanular al paciente. Resultado: en el grupo A (ala tiroidea) la complicación más frecuente fue la disnea, ya sea temprana, la cual se presentó en el 42% de los pacientes por obstrucción del stent con tapón mucoso; o bien tardías en el 57% de los casos debido a el desarrollo de granulomas. En ambos casos se realizó abordaje endoscópico y corticoides sistémico. En el grupo B (cartilago costal) la disnea temprana se presento en el 10% de los pacientes, mientras que la tardía por granulomas se hizo presente en el 20% de los casos. Así también se presento un caso de neumotórax intraoperatorio el cual se resolvió inmediatamente de forma quirúrgica. Conclusión: el uso del cartílago del ala tiroidea en las laringoplastías por estenosis, permite una ampliación del diámetro subglótico tan segura como la que se ha comprobado con el cartílago costal. El cartílago del ala tiroidea es un injerto con un grosor suficiente, capaz de mantener la estructura de la vía aérea sin alterar la función laríngea y acortando los tiempos quirúrgicos con respecto a la obtención e interposición del cartílago costal...

To establish the stability and resistance of the thyroid ala cartilage to expand adult's subglottis stenosis, and to compare the functional results between laringoplastias with thyroid ala cartilage (TAC) and costal cartilage (CC) graft. Design: Retrospective comparative study. Method: 17 patients with subglottic stenosis were operated using cartilage interposition graft from 2003 to 2010. They were divided into two groups: group A: 7 patients with anterior laryngoplasty using thyroid ala cartilage - group B: control group of 10 patients with laryngoplasty and interposition of costal cartilage. The analysis points were intra and post surgical complications, and the success of the surgical procedure following the patient's decannulation. Results: Group A (TAC) the most frequent complication was dyspnea which appeared at an early stage in 42% of patients with mucus plug stent obstruction, or dyspnea either appeared at a later stage in 57% of the cases due to the development of granulation tissue. In both cases endoscopic approach and systemic corticosteroids were performed. Group B (costal cartilage) complications: early dyspnea appeared in 10% of patients, while dyspnea at a later stage due to granulomas appeared in 20% of cases. An intraoperative pneumothorax complication occurred and was resolved immediately. Conclusion: The use of thyroid ala cartilage graft in laryngeal stenosis allows an expansion of subglottic diameter as sale as it has been verified with the use of costal cartilage. The thyroid ala cartilage graft is thick enough to keep the airway structure preserving laryngeal function and shortening surgical time in comparison to the costal cartilage technique...

Removal of cartilage rings prevents graft stenosis in extended tracheal allotransplantation with omentopexy and immunosuppression: an experimental study.

BACKGROUND: One of the serious problems in longer size tracheal transplantation is severe stenosis of the graft, probably caused by an inadequate blood supply. We have previously reported that removal of some cartilage rings of the graft and omentopexy helps to provide sufficient blood flow to the graft mucosal tissue and results in satisfactory survival and non-significant graft stenosis in extended tracheal autotransplantation. However, it is unclear whether this method can be applied to extended tracheal allotransplantation that requires immunosuppression. In this report, we describe midterm results of extended tracheal allotransplantation with the technique. METHODS: Twenty-four adult mongrel dogs were used. In 18 dogs, a nine-cartilage-ring length of the trachea was allotransplanted when five cartilage rings of the graft were removed, leaving two rings intact at both ends of the graft for simple fixing to the recipient. Two artificial tracheal rings outside the graft and a stent inside the graft were used for maintaining the lumen width. Omentopexy was done for sufficient blood supply to the graft. FK 506 (0.1 mg/kg) was given on each day after the operation in Group A (n = 10), but was not given at all in Group B (n = 8). In Group C (n = 6), a nine-cartilage-ring length of the trachea, without removal of any cartilage ring, was transplanted into the recipient dog and covered with an omental pedicle flap. The same dose of FK 506 as that used in Group A dogs was given to Group C dogs. RESULTS: In Group A, 2 dogs died of graft stenosis within 9 weeks after surgery and 1 died of emaciation without tracheal stenosis. Seven dogs (70%) survived until time of killing. Among the 8 dogs in Group B, 6 died of graft stenosis within 9 weeks after surgery, with 1 dying of pneumonia and only 1 (13%) surviving for >1 year until killing. In Group C, all 6 dogs died of graft stenosis within 6 weeks after surgery. Survival at 16 weeks after surgery was 70% in Group A, 13% in Group B and 0% in Group C (p < 0.01, A vs B and C). No significant graft stenosis was found in 6 dogs and mild stenosis was found in 2 dogs at the time of death or killing in Group A (80%), whereas mild stenosis was found in only 2 dogs in Group B (25%) (p < 0.05). Mucosal blood flow of the graft in Group A was higher than that in Group C and was the same as that in Group B within 4 weeks after surgery; however, it remained unchanged to ultimately be higher than in Group B at 6 and 8 weeks after surgery. CONCLUSIONS: Removal of some cartilage rings, omentopexy and immunosuppression improved blood supply to the graft and resulted in good survival and non-significant tracheal stenosis in extended tracheal allotransplantation.

Effect of harvesting autogenous laryngeal cartilage for laryngotracheal reconstruction on laryngeal growth and support.

OBJECTIVE: Determine the effect of harvesting autogenous thyroid cartilage on subsequent laryngeal growth and stability in a kitten model. STUDY DESIGN: Prospective controlled trial in animals. METHODS: Seventeen kittens were divided into three groups. Group one (n = 5) included kittens that underwent a unilateral thyroid cartilage resection. Group two (n = 5) included kittens that underwent a bilateral cartilage resection. Group three (n = 7) comprised kittens that did not undergo any surgical procedure (controls). All animals underwent endoscopic examination followed by the surgical procedure designated for that group. Kittens were then assessed daily for 2.5 months. At the end of that period the now "adolescent" cats were examined endoscopically then euthanized. The larynx was removed for gross and histopathologic analysis. RESULTS: All kittens tolerated the surgical procedure without airway compromise. Subsequent endoscopic examination 2.5 months after surgery revealed normal vocal cord function. Measurements of the true vocal cord and aryepiglottic and subglottic diameter did not differ significantly (one-way analysis of variance, P = .05) with respect to the side or the group. Histopathologic evaluation of the laryngeal sections indicated a patent airway, stable and viable thyroid cartilage, and no evidence of cartilaginous regrowth. CONCLUSIONS: The removal of unilateral and bilateral superior thyroid alar cartilage can be performed in kittens without postoperative respiratory or wound problems. The harvesting of autogenous thyroid cartilage has no apparent effect on subsequent laryngeal growth and stability in a kitten model.

Vocal function following vertical hemilaryngectomy: comparison of four reconstruction techniques in the canine.

The goals of laryngeal reconstruction have been prevention of aspiration, production of a functional voice, and maintenance of an adequate airway for decannulation. A number of procedures for partial laryngeal reconstruction have accomplished these objectives. However, few studies have attempted to compare patients' vocal characteristics following different reconstruction procedures. In this study, an in vivo canine model was used to compare acoustic and aerodynamic measures of vocal function for the following vertical hemilaryngectomy reconstruction techniques: 1) a superiorly based sternohyoid muscle flap, 2) a modified epiglottic laryngoplasty, 3) a new procedure using a layered vascularized buccal mucosal flap and a transversely oriented sternohyoid muscle flap, and 4) hemilaryngeal transplantation combined with arytenoid adduction. Hemitransplantation provided the most efficient phonation of the four techniques. The vascularized buccal mucosa flap produced the best phonation of the autologous tissue techniques examined. Both vascularized buccal mucosa flap and hemilaryngeal transplantation subjects demonstrated a mucosal wave on stroboscopy. The results indicate that vocal function will improve as the layered structure of the vocal fold is more accurately replicated in a reconstructed hemilarynx. Endoscopic findings and whole organ sections are presented.

The relevance of using tragal cartilage in tympanoplasty.

Chronic endotympanic depression is a pathological situation which leads to tympanic atelectasis, retraction pockets and cholesteatoma. It is also at the origin of tympanoplasty failure. Tragal composite perichondrium-cartilage graft is a procedure which gives good results in these difficult surgical cases.

Application of the external perichondrium of the ala of the thyroid cartilage of the nondiseased side in laryngeal surgery.

Since 1976, in our department, the external perichondrium of the ala of the thyroid cartilage of the nondiseased side has been successfully applied in repairing endolaryngeal defects and reconstructing the laryngeal wall in 22 cases. The postoperative result was good in the most cases.

Glottic reconstruction by implant of homologous laryngeal cartilages.

This paper describes a case of reconstructive laryngectomy in a patient with epidermoid carcinoma of the glottis. Reconstruction of the skeletal laryngeal architecture was carried out by implanting homologous cartilages, whilst the glottis was reconstructed with sternohyoid muscle. Laryngeal function was restored within 30 days of the operation.

[Modifications of the technic of endolaryngeal extirpation. The author's own functional technic of laryngectomy]. / Modificaciones a la técnica del vaciado endolaríngeo. Técnica personal funcional de laringuectomía.

A brief summary of the original technique will be made incorporating the following modifications and additions: glottis substituted by neoglottis muscles, sternohyoid or external perichondrium. Supraglottis substituted by remaining tissues of the epiglottis or neoepiglottis. Hypopharynx, section medium line of the pharynx constrictor. Suturing of cartilage with homologous donor cartilage. An evaluation will be made of the functional results.

Delayed cricoid reconstruction by use of a free graft of autogenous "patient banked" cartilage.

Avulsed cartilage may be "banked" or preserved by subcutaneous implantation in the traumatized patient for delayed reconstruction of the defect when immediate reconstruction is contraindicated. The perichondrium of the avulsed cartilage should be preserved if possible. In the reconstructive procedure the cartilage graft must be surrounded by vascularized flaps developed from adjacent neck tissue. These vascularized flaps increase the local vascular supply for revascularization of the free graft. In addition, they allow complete separation of the free graft from the airway to minimize the possibility of secondary infection arising from the airway. Mucosal coverage of the defect does not appear to be necessary as long as well-vascularized soft tissue is available for complete coverage of the defect. The use of this technique may be considered for patients with avulsion of portions of the laryngeal cartilages when immediate reconstruction is contraindicated or when the viability of adjacent soft tissue necessary for reconstruction is uncertain. The success of this procedure may be related to the adequacy of the closure or separation of the airway from the free cartilage graft, and the ability to provide coverage of the graft with vascular tissue to allow graft revascularization. This new technique follows the traditional principles vital for successful management of laryngotracheal injuries. This procedure provides an additional method of therapy for those patients with an avulsion injury of the laryngeal cartilage. Additional surgical procedures must be performed utilizing the indications and principles presented here before this method is universally accepted for the management of severe laryngotracheal injury.

Surgical treatment of laryngotracheal stenosis by a trough technique.

Many methods have been tried and reported in the treatment of laryngotracheal stenosis. Among them, a trough technique seems universal at present. To date, we have tried several methods of this technique, but each method had its own demerits. We used, as a cartilagenous framework, a homograft or tracheal ring cartilages for the last four cases of laryngotracheal stenosis. These tracheal ring cartilages were resected from relatively young patients with laryngeal carcinoma. Total laryngectomy was done just below the level of the fourth tracheal ring, then the fourth tracheal ring was resected and stored in 70% alcohol. The cartilage was used after it was made certain pathologically that there was no invasion of carcinoma at the third tracheal ring level. The operative procedure of this trough technique is as follows. In the first stage, a trough is created at the stenosed region and the trough is maintained by placing a Quick Set Silicone (Q.S.S.) stent mold over it. While waiting for scar formation of the tissues surrounding the trachea, the second stage reconstruction is performed four weeks after the first. The trough is closed with hinged skin flaps on both sides, and the reserved tracheal ring cartilages are sutured every 5 mm onto the outer surface of the hinged skin flaps to make a cartilagenous framework. The neck is closed with advanced neck skin flaps. A more ideal tracheal lumen is created by this technique. Our four patients are doing well two years or more after the operation.

An assessment of grafts in the posterior cricoid lamina.

Subglottic stenosis is a recognized complication of prolonged intubation. To date, there is no uniformly successful operative procedure for severe subglottic stenosis, fulfilling the criteria of decannulation and a serviceable voice. The surgical ideals for such a procedure should include the use of autogenous grafting material, avoidance of internal stenting, and limited manipulation of the mucosa. This study was intended to assess the fate of isolated hyoid and thyroid alar grafts interposed in the posterior cricoid lamina. Additionally, anterior/posterior splits with and without anterior grafting were evaluated. Seventeen dogs were used in the determinate animal model. Vocal cord mobility was evaluated by direct laryngoscopy prior to sacrifice. Graphic gross anatomical specimens depict the effects of anterior/posterior splitting on the cricoid cartilage. Clinical correlations are suggested.

[Valve-neoglottis after laryngectomy by cartilage implantation into the trachea (author's transl)]. / Ventilneoglottis nach Laryngektomie durch Knorpelimplantat in die Trachea.

After laryngectomy the opening of the upper trachea is closed up to 3/4--4/5 by implantation of a cartilage plate (if possible from the epiglottis). The anterior part is left open. During exspiration the oesophago-pharyngeal flap is pressed upwards, whereas the position of the cartilage plate does not change much. The air can be expired by a 90 degrees turned 6--8 mm fistula (Staffieri) in the flap opposite of the cartilage plate (valve opened). As well as by its own weight as by flow of saliva, eating, drinking and vomiting the fistula is pressed on the cartilage plate (valve closed). By aid of this valve mechanism the patient can drink 1 week postoperatively without suffering from flow of saliva into the trachea. The patient's ability to speak developes well 10--14 days postoperatively.

Replacement of the arytenoid following vertical hemilaryngectomy.

A considerable body of literature advocates and defines treatment of vocal cord cancer with posterior extension by hemilaryngectomy. The present study was carried out to determine the feasibility of using a newly devised pedicle flap, composed of thyroid cartilage and inferior constrictor muscle, to replace the ablated arytenoid cartilage. Animal investigation revealed satisfactory viability of the pedicle flap in canines, and in humans, five patients with T2 glottic carcinoma demonstrated excellent postoperative deglutition and return of voice. The results of the study indicate that this surgical technique merits consideration for its use in minimizing protracted glottic incompetence following hemilaryngectomy. The thyroid cartilage-inferior constrictor muscle pedicle flap may also prove useful as partial cricoid replacement in selected cases of subglottic extension and in cricoid reconstruction following trauma.

Cricoid arch replacement in dogs. Further studies.

Published reports by Delahunty et al and Alonso et al described the feasibility of correcting subglottic defects with cricoid arch transplantation. Using normal dogs, satisfactory results, including airway patency and vocal cord function, were reported. This report describes a second series of dogs in which subglottic stenosis was first induced by an open procedure and was subsequently repaired with an allotransplanted cricoid arch. The resulting subglottic defect in the donor dogs was repaired by autogenous hyoid arch transposition. No immunosuppressive measures or stents were used in either group. The animals were followed for periods up to one year prior to histologic study. Satisfactory results were obtained in both groups.