Synthetic Simulator for Surgical Training in Tracheostomy and Open Airway Surgery.

OBJECTIVE(S): To create and validate a synthetic simulator for teaching tracheostomy and laryngotracheal reconstruction (LTR) using anterior costal cartilage and thyroid ala cartilage grafts. METHODS: A late adolescent/adult neck and airway simulator was constructed based on CT scans from a cadaver and a live patient. Images were segmented to create three-dimensional printed molds from which anatomical parts were casted. To evaluate the simulator, expert otolaryngologists - head and neck surgeons performed tracheostomy and LTR using anterior costal cartilage and thyroid ala cartilage grafts on a live anesthetized porcine model (gold standard) followed by the synthetic simulator. They evaluated each model for face validity (realism and anatomical accuracy) and content validity (perceived effectiveness as a training tool) using a five-point Likert scale. For each expert, differences for each item on each simulator were compared using Wilcoxon Signed-Rank tests with Sidak correction. RESULTS: Nine expert faculty surgeons completed the study. Experts rated face and content validity of the synthetic simulator an overall median of 4 and 5, respectively. There was no difference in scores between the synthetic model and the live porcine model for any of the steps of any of the surgical procedures. CONCLUSION: The synthetic simulator created for this study has high face and content validity for tracheostomy and LTR with anterior costal cartilage and thyroid ala cartilage grafts and was not found to be different than the live porcine model for these procedures. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E2378-E2386, 2021.

A novel surgical treatment for posterior glottic stenosis using thyroid ala cartilage - A case report and literature review.

Posterior glottic stenosis (PGS) describes a laryngeal disorder in which worsening degrees of scarring limit abduction of the vocal folds and/or arytenoids. It can be congenital or acquired. Generally, the acquired form is the result of chronic endotracheal tube trauma to the posterior larynx. Symptoms of acquired PGS usually begin four to eight weeks after extubation, and present as gradually worsening stridor and shortness of breath as the laryngeal obstruction becomes more severe. Without intervention, PGS can cause total obstruction and respiratory failure. The mainstay of treatment for PGS is surgery. We present a case in which an infant patient with PGS was treated with a posterior cricoid split and insertion of a thyroid ala graft. The graft was bolstered in place with an appropriately-sized endotracheal tube during a six-day period of postoperative intubation. We report this as a novel surgical approach, as a literature review did not uncover that this technique has been previously described. Our patient has had excellent airway and voice outcomes. His swallow outcomes have been difficult to assess, as the patient has shown signs of global delay.

Autologous thyroid cartilage graft implantation in medialization laryngoplasty: a modified approach for treating unilateral vocal fold paralysis.

Medialization laryngoplasty is the standard surgical treatment for unilateral vocal fold paralysis. This study presents a modified approach in which a thyroid cartilage graft is implanted in medialization laryngoplasty. 22 patients who underwent this approach were included in the study. The results revealed that glottal incompetence and vocal performance were markedly improved following surgery, and the follow-up period ranged from 6 to 74 months (mean, 21.4 months). Acoustic analysis revealed significant improvements in the maximum phonation time (from 3.51 to 7.89 seconds, p < 0.001), F0 (from 221.7 to 171.0 Hertz, p = 0.025), and jitter (from 7.68 to 3.19, p < 0.001). Perceptual assessment revealed a significant decrease in voice grading (from 2.59 to 1.41, p < 0.001), roughness (from 1.82 to 1.23, p = 0.004), and voice breathiness (from 2.55 to 1.23, p < 0.001). None of the patients exhibited severe wound infection, tissue rejection, or other complications attributed to the surgical procedure. In conclusion, autologous thyroid cartilage implantation in medialization laryngoplasty medializes the vocal cord, minimizes the glottal gap, and improves the voice of patients with vocal fold paralysis. This procedure is characterized by simplicity, safety, and acceptable results.

[Removal of laryngeal cancer with thyroid cartilage membrane excision and repair of laryngeal cavity with outside thyroid cartilage membrane flap of healthy side: oncologic and functional outcomes].

OBJECTIVE: To study the efficacy and feasibility of removal of laryngeal cancer with thyroid cartilage membrane excision and repair of laryngeal cavity by the outside thyroid cartilage membrane flap of healthy side. METHODS: A total of 28 patients were reviewed who underwent the removal of laryngeal cancer with thyroid cartilage membrane excision combined with the repair of laryngeal cavity by the outside thyroid cartilage membrane flap in our hospital between 2005 and 2011. Respiratory function, swallowing function, and voice quality of patients after surgery were evaluated. Survival and recurrence were observed with the follow up of five years. RESULTS: The decannulation rate was 96.4%. Aspiration rate was 10.7%, but aspiration was completely revolved by swallowing training in the patients. All patients had the voice quality required for communication although they complained of hoarseness after surgery. Tumor recurrence was found in one patient and cervical lymph node metastasis in 2 patients. The three-year and five-year survival rates were 89.3% and 85.7% respectively. CONCLUSION: This surgical procedure was applicable in some of patients with T2 laryngeal cancer, with good laryngeal functions after surgery.

The role of larygotracheal reconstruction in the management of recurrent croup in patients with subglottic stenosis.

OBJECTIVES: To determine the role of laryngotracheal reconstruction for recurrent croup and evaluate surgical outcomes in this cohort of patients. METHODS: Retrospective chart review at a tertiary care pediatric hospital. RESULTS: Six patients who underwent laryngotracheal reconstruction (LTR) for recurrent croup with underlying subglottic stenosis were identified through a search of our IRB-approved airway database. At the time of diagnostic bronchoscopy, all 6 patients had grade 2 subglottic stenosis. All patients were treated for reflux and underwent esophageal biopsies at the time of diagnostic bronchoscopy; 1 patient had eosinophilic esophagitis which was treated. All patients had a history of at least 3 episodes of croup in a 1 year period requiring multiple hospital admissions. Average age at the time of LTR was 39 months (range 13-69); 5 patients underwent anterior graft only and 1 patient underwent anterior and posterior grafts. Patients were intubated for an average of 5 (range 3-8) days and hospitalized for an average of 12 (range 7-20) days post-operatively. One patient experienced narcotic withdrawal post-operatively, but there were no other post-operative complications. All patients underwent follow-up airway endoscopy within 4 weeks and none required any further dilation procedures. Average post-operative follow-up was 24 months (range 10-48) and none of the patients experienced any further episodes of croup. CONCLUSIONS: Single stage LTR is a safe and effective treatment for recurrent croup in the setting of underlying subglottic stenosis, and should be considered in patients who are refractory to medical management.

Optimal Management of a 2-Hour-Old Newborn With Severe Congenital Subglottic Stenosis and Multiple Congenital Heart Diseases.

INTRODUCTION: Congenital subglottic stenosis (C-SGS) is the third most common congenital anomaly of the larynx. It necessitates tracheotomy in newborns if it causes severe airway obstruction. When the negative impact of tracheostomy cannot be tolerated, as in presence of congenital heart disease requiring further surgical intervention, other alternative procedures are required. This case report is the first of its kind reporting airway expansion in a neonate in the first few hours after birth. CASE REPORT: A 38-week-fetus male was born with multiple congenital heart anomalies and C-SGS of grade III. Single-stage laryngotracheoplasty (SS-LTP) with anterior thyroid alar cartilage (TAC) grafting was performed. Our team was fully aware of all potential risks during SS-LTP procedure in such debilitated patient. DISCUSSION: Treatment of C-SGS in premature neonates is tracheostomy to avoid prolonged intubation. In some cases, tracheostomy is not a good option as in presence of congenital heart disease necessitating urgent further surgical interventions. Among all surgical procedures to augment the airway without tracheostomy, SS-LTP with placement of anterior TAC graft was our choice. CONCLUSION: This case report demonstrated that SS-LTP with anterior TAC graft can be performed in a newborn with severe C-SGS and congenital heart disease. It can alleviate the need for tracheostomy and avoid unnecessary delay for subsequent cardiac interventions. However, further study is likely needed to make a definitive statement of its safety and efficacy.

Open airway surgery for subglottic hemangioma in the era of propranolol: Is it still indicated?

OBJECTIVES: With the emergence of propranolol as the primary treatment for hemangiomas the indications for surgical intervention have been greatly reduced. There remains a role for surgical management in those patients who fail medical therapy, particularly for hemangiomas involving the airway. Detailed is our experience with subglottic hemangiomas, including three patients who failed propranolol treatment and were successfully treated with surgical excision and single stage laryngotracheoplasty (LTP) with thyroid ala graft. METHODS: Retrospective case series (level of evidence: 4). RESULTS: Six patients were treated with propranolol for subglottic hemangiomas over a 6 year period (2008-2014). Three patients responded to propranolol therapy and required no adjunctive surgical procedures. Three patients failed propranolol treatment, and required open resection of their subglottic hemangiomas and thyroid ala graft placement. Indications for resection were complete lack of response to propranolol in one patient, and initial response to propranolol with subsequent regrowth in the other two patients. All three patients were treated with submucosal extirpation of their hemangioma and single stage LTP; hemangioma was confirmed in all cases by positive GLUT-1 staining. All three surgical patients were successfully extubated post-operatively and none had hemangioma regrowth. CONCLUSIONS: Fifty percent of patients in our series did not have long-term response to propranolol for subglottic hemangioma, highlighting the importance of close follow-up. When identified early, subglottic hemangiomas refractory to propranolol treatment can be successfully addressed with single stage LTP and tracheotomy can be avoided.

Functional and Histological Evaluation following Canine Vocal Fold Reconstruction Using Composite Thyroid Ala Perichondrium Flaps.

OBJECTIVES/HYPOTHESES: We evaluated the effects of vocal fold reconstruction using a composite thyroid ala perichondrium flap (CTAP) after unilateral vocal fold stripping in beagles. We hypothesized that CTAP would improve glottic closure, decrease phonation threshold pressure, and decrease perturbation. In addition, vocal folds with CTAP would exhibit neovascularization and fat with increased von Willebrand factor (vWF) and smooth muscle actin (SMA), reflecting neoangiogenesis and flap viability. STUDY DESIGN: Randomized controlled trial using beagles. SETTING: University laboratory. METHODS: Ten beagles underwent unilateral vocal fold stripping. Dogs in the scar-only group (n = 5) were sacrificed at 1 month. Dogs in the CTAP group (n = 5) underwent ipsilateral reconstruction with CTAP at 1 month and were sacrificed at 2 months. Excised larynx experiments evaluated vocal fold vibration using aerodynamic, acoustic, and mucosal wave measurements. Qualitative evaluation of vocal fold morphology and quantitative analysis of elastin, collagen, glycosaminoglycans, vWF, SMA, and hyaluronic acid were performed. RESULTS: Phonation threshold pressure (P = .005), percent jitter (P = .010), percent shimmer (P = .007), and open quotient (P = .007) were lower in the CTAP group. Neovascularization (P = .0079) and fat (P = .1667) occurred more with CTAP, although the difference in fat was not significant. von Willebrand factor was higher with CTAP vs contralateral normal fold (P = .110), although not statistically significant. Smooth muscle actin was higher with CTAP vs contralateral normal fold (P = .038) and scarred vocal folds (P = .022). CONCLUSIONS: Composite thyroid ala perichondrium flap restored glottic closure and vibratory periodicity following vocal fold scarring. Additional investigation on biologic response is warranted. Composite thyroid ala perichondrium flap offers an autologous, vascularized implant that can improve both vocal fold structure and function.

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...

Type IIB thyroplasty for phonic tics in a pediatric patient with autism spectrum disorder: a case report.

OBJECTIVES/HYPOTHESIS: Autism spectrum disorders (ASDs) are commonly associated with Tourette syndrome (TS). TS is classically associated with tic production. A tic is defined as sudden, brief, involuntary production of movement (motor tics) or sound (phonic tics). STUDY DESIGN: Case report. METHODS: We present a case report of a 14-year-old boy with ASD and vocal tics. Vocal tic frequency was nearly 2000 per day and 90 dB in volume. He presented to our laryngology clinic after multiple failed attempts of pharmacologic management of vocal fold botulinum toxin injection. After evaluation in our clinic, we recommended a lateralization (type IIB) thyroplasty. An autologous cartilage graft from the superior thyroid ala was used and held in place with a bioresorbable mesh. Using 4-0 prolene sutures, the mesh was secured in place. The operation was well tolerated with minimal signs of aspiration, and he was discharged to his home within 48 hours. RESULTS: Six months postoperatively, there was 90% reduction in tic frequency and 50% reduction in intensity. Additionally, he has shown improved ability to converse with his peers, participate in school activities, and even has improved nutritional status. CONCLUSIONS: Alteration of laryngeal geometry could serve as an effective site of intervention for intractable phonic tics. Reduction of phonic tic frequency and intensity may also stimulate language development in patients ASD. We also demonstrate additional use of bioresorbable plates in pediatric laryngeal framework surgery. Additional neurophysiologic studies are needed to explore the mechanism by which midline lateralization thyroplasty influences phonic tic generation.

Thyroid ala cartilage graft laryngotracheoplasty for closure of large pediatric tracheocutaneous fistula.

We describe a novel technique for closure of a large, persistent, pediatric tracheocutaneous fistula using a thyroid ala cartilage graft. Case report and review of the literature. We report 2 cases of large (>4mm), pediatric tracheocutaneous fistulas, in which primary closure of the tracheal defect would have caused critical airway narrowing and were managed with an anterior laryngotracheal reconstruction with a thyroid ala cartilage graft and closure of the tracheocutaneous fistula. The patients were extubated immediately postoperatively and maintained successfully closed fistulas with no clinically significant airway compromise. One of the considerations in pediatric tracheocutaneous fistula closure is to assess how the airway luminal diameter will be affected by primary closure of the tracheal defect. If primary closure of the tracheal opening causes critical airway narrowing because of a large tracheocutaneous fistula, a thyroid ala cartilage graft may be used for laryngotracheoplasty and allow for primary closure with a layered closure of the overlying strap muscles and soft tissue.

Thyroid alar cartilage graft laryngotracheal reconstruction in adults.

OBJECTIVE: To assess the outcomes of laryngotracheal reconstruction using thyroid alar cartilage grafting in adult patients with laryngotracheal stenosis. STUDY DESIGN: Case series with chart review. SETTING: Tertiary university hospital. SUBJECTS AND METHODS: Twelve adults who underwent thyroid alar cartilage graft laryngotracheal reconstruction from April 1997 to April 2009 for laryngotracheal stenosis were analyzed. The mean age of the study population was 29 years. Using the Myer-Cotton grading system, 3 patients had grade II stenosis, 7 had grade III, and 2 had grade IV. Seven of the 12 patients had subglottic stenosis, 3 had tracheal stenosis, and 2 had subglottic and upper tracheal stenosis. RESULTS: Nine of 12 (75%) patients were decannulated. Of the patients in whom laryngotracheal reconstruction failed, 2 had grade IV stenosis and 1 had severe grade III stenosis with a long segment of stenotic tissue. The postoperative complications were hematoma of the left laryngeal ventricle at the donor site in 1 patient, granulation tissues in the supraglottic and suprastomal region and at the graft site in 4 patients, and neck wound infection in 1 patient. Ossification of the thyroid alar cartilage was observed in 2 patients. A Ttube remained in situ for 6 to 18 months. CONCLUSION: Laryngotracheal reconstruction with thyroid alar cartilage graft could be a viable alternative for the treatment of laryngotracheal stenosis in adults. However, it should be used only in cases of limited and minor subglottic or tracheal stenosis.

Quality of life and voice outcomes after thyroid ala graft laryngotracheal reconstruction in young children.

OBJECTIVES: (1) To assess the long-term impact of thyroid ala cartilage laryngotracheal reconstruction (TAC-LTR) on health-related quality of life (QOL) in infants using 4 validated instruments: Health Utility Index version 3 (HUI3), Pediatric Voice-Related QOL (PVRQOL), Impact on Family Questionnaire, and a visual analog scale and (2) to perform acoustic and perceptual voice assessments to evaluate longterm voice quality outcomes. STUDY DESIGN: Prospective study. SETTING: Tertiary academic pediatric hospital. SUBJECTS: Eligible children who received TAC-LTR before the age of 24 months between 1995 and 2007. METHODS: Interviews with parents and children using 4 validated instruments, voice analyses, and endoscopic evaluation were performed. RESULTS: Twelve patients (7 male, 5 female, median age 10 years) were enrolled over a 6-month period. The mean age at LTR was 5 months (range, 1-20 months), and the mean study followup period was 9 years (range, 2-14 years). The average speech HUI3, PVRQOL, and Impact on Family scores were 0.83 (95% confidence interval = 0.74, 0.92), 0.93 (interquartile range [IQR] = 0.81, 1.00), and 0.65 (IQR = 0.54, 0.92), respectively. All acoustic scores were either normal or mildly abnormal for the variables jitter, shimmer, noise-to-harmonic ratio, peak amplitude variation, and fundamental frequency. The Consensus Auditory-Perceptual Evaluation of Voice overall severity score was in the normal to mildly abnormal range for 8 of 9 patients. CONCLUSION: This is the first study to explore and quantify longterm QOL and voice quality in children following LTR with thyroid ala graft at a very young age. Most patients had very good functional voice outcome as evidenced by the HUI3 and PVRQOL scores. This was corroborated by acoustic and perceptual voice assessments.

Comparison of early and late extubation following single-stage anterior laryngotracheoplasty.

OBJECTIVE: To compare the outcomes of early versus late extubation after primary single-stage anterior laryngotracheoplasty (LTP) using thyroid ala graft performed at our tertiary care academic children's hospital. METHODS: Twenty-five pediatric patients underwent single-stage anterior LTP using thyroid ala grafts between September 2002 and June 2009. Initial trials of extubation were attempted in 15 patients on or prior to postoperative day (POD) 2 and in 10 patients on or after POD 3. The main outcome measures analyzed in this retrospective comparison study were complication rate, length of hospitalization, reintubation during hospitalization, need for additional airway procedures, and overall decannulation rate. RESULTS: The rates of various complications in each group were not statistically significant, with the exception of methadone taper. No patients in the early extubation group and four patients in the late extubation group required methadone taper [p<0.05]. The average length of hospitalization after extubation for the early extubation group was 16.5 days [SD=14.0] and 14.6 days [SD=7.7] for the late extubation group [p>0.05]. Six patients (40%) in the early extubation group and two (20%) in the late extubation group needed reintubation at some point during hospitalization post-LTP [p>0.05]. Ten patients [66.7%] in the early extubation group and eight [80%] in the late extubation group required additional airway procedures post-LTP [p>0.05]. Ultimately, 12 (80%) of the early extubation group and nine (90%) of the late extubation group were successfully decannulated at the time of most recent follow-up [p>0.05]. CONCLUSIONS: The differences in length of hospitalization, need for additional procedures, reintubation during hospitalization and overall decannulation rate between the early and late extubation groups after single-stage anterior LTP with thyroid ala graft were not statistically significant. Methadone taper was the only complication that was statistically significantly higher in the late extubation group.

Pediatric primary anterior laryngotracheoplasty: Thyroid ala vs costal cartilage grafts.

OBJECTIVE: To compare outcomes with the use of thyroid ala cartilage (TAC) and costal cartilage (CC) grafts in pediatric primary anterior laryngotracheoplasty (LTP). DESIGN: Retrospective comparison study. SETTING: Tertiary, academic children's hospital. PATIENTS: Of 45 laryngotracheal operations performed between June 2001 and October 2008 for laryngotracheal stenosis, 29 were primary anterior LTPs. The procedures used either TAC (n = 24) or CC (n = 5) grafts and were planned as either single-stage (TAC group, 22 patients; CC group, 2 patients) or multistage (TAC group, 2 patients; CC group, 3 patients). MAIN OUTCOME MEASURES: Operative time, length of intubation, graft-specific complications, need for additional airway procedures, and overall decannulation rate. RESULTS: The mean (SD) operative times were 222 (56) minutes for TAC grafts and 363 (59) minutes for CC grafts (P = .005). For single-stage LTPs that were decannulated, the mean (range) length of intubation was 3.3 (1-11) days for TAC grafts (n = 18) and 3 (1-5) days for CC grafts (n = 2) (P = .90). Graft-specific complications occurred in 17% of TAC grafts (n = 4) and 20% of CC grafts (n = 1) (alpha > 0.05). Symptomatic stenosis requiring additional surgical intervention occurred in 43% of TAC grafts (n = 10) and 60% of CC grafts (n = 3) (alpha > 0.05). Patients underwent decannulation in 83% of TAC grafts (n = 19) and 80% of CC grafts (n = 4) (alpha > 0.05). CONCLUSIONS: In primary anterior LTPs, TAC grafts require significantly less operative time than CC grafts (P = .005). There were no statistically significant differences in length of intubation, frequency of graft-specific complications, or decannulation rates between TAC and CC grafts in primary anterior LTPs.

Thyroid alar cartilage graft in paediatric laryngotracheal reconstruction.

OBJECTIVE: To evaluate the potential indications of thyroid alar cartilage (TAC) graft in the paediatric laryngotracheal reconstruction (LTR) population based on observations obtained in a case series of 27 consecutive infants referred to our tertiary care center. METHODS: Thyroid alar cartilage grafting was performed for limited Myer grade II and grade III subglottic stenosis requiring a single-stage laryngoplasty and for laryngeal enlargement after translaryngotracheal resection of endolaryngeal tumors. The evolution of the grafted area was evaluated prospectively during endoscopic follow-up. RESULTS: Twenty-five patients (92.5%) were successfully extubated after a mean of 5.1 days. No perioperative or postoperative complications were observed. The mean duration of graft harvesting was 7.7 min. Follow-up of the grafted area revealed one case of partial necrosis without prolapse into the lumen. The mean duration of graft epithelialization was 18.1 days (range: 12-30 days). Development of granulation tissue was observed in eight patients (32%) with a mean duration of granulation tissue persistence of 61.5 days (range: 7-155 days). Endoscopic follow-up did not demonstrate any pharyngolaryngeal asymmetry or feeding difficulties. CONCLUSION: This study demonstrated that the use of thyroid alar cartilage grafting is feasible for pediatric laryngotracheal reconstruction. The indications of thyroid alar cartilage graft should be reserved for moderated subglottic stenosis. The use of TAC reduced the operative time and cosmetic sequelae significantly. The healing of the grafted area was similar to those obtained with other types of graft. The TAC removal did not induce laryngeal deformation but longer follow-up is necessary to confirm this.

[Thyroid cartilage flap reconstruction of cricoid in the management of subglottic carcinoma].

OBJECTIVE: To evaluate the effect of conservative surgical management on patients with subglottic cancer. METHODS: Nine cases with subglottic carcinoma were treated surgically from 1984 to 1999. There were T2N0 lesions in 2 cases, T3N0-1 in 3 cases and T4N0-1 in 4 cases. All the cases underwent partial laryngectomy including partial cricoid resection. Variations of a pedicled thyroid cartilage flap were used for reconstruct the cricoid defect. The pedicle based muscle was thyrohyoid, sterno-thyroid or inferior constrictor. Unilateral neck dissection was performed on 7 cases and bilateral on two. RESULTS: The function of phonation were preserved in all cases. Eight of nine 8/9 were decanulated. Normal deglutition were achieved for all patients. The 3 and 5 year survival rates were 8/9 and 6/9, respectively. CONCLUSION: Pedicled thyroid cartilage flap is appropriate for reconstruction of the cricoid defect in the conservative surgery of selected subglottic carcinoma.

Repair of chronic subglottic stenosis with autogenous thyroid cartilage.

Chronic subglottic stenosis continues to be a difficult management problem. Conservative management with bougienage, laser therapy, mitomycin-C, and/or steroid injections frequently fails. Definitive resection of the subglottis with thyrotracheal anastomosis has increased in popularity, but carries significant operative risks and postoperative complications. In the past 9 years, we have used a modification of a technique to successfully widen the subglottis, which we previously published 20 years ago. By a laryngocricotracheofissure approach, the cricoid cartilage is split vertically, both anteriorly and posteriorly. Cartilage grafts, obtained from the upper thyroid laminae anteriorly, are inserted in these splits. The posterior graft is fixed in place with specially designed pins, which improves graft fixation by adding rigidity and shortens the procedure. The repair is held in place for 3 to 4 weeks with either a silicone T tube or a conforming laryngeal stent. The charts of 21 consecutive patients treated with open repair of chronic subglottic stenosis were reviewed. The overall decannulation rate was 95%. We conclude that autogenous grafting is a useful tool in the treatment of chronic subglottic stenosis. Posterior cartilage graft fixation with our pin technique offers a significant advantage over suture fixation by improving graft stability and decreasing operative time, and has a high rate of decannulation.

Thyroid alar cartilage graft in laryngoplasty: anatomical study in premature and newborn babies.

The aim of this prospective anatomical study was to determine the place of the thyroid alar cartilage graft (TAC) in the laryngotracheoplasty in a population of premature and newborn babies. Ninety-eight fresh larynges, collected from autopsies, were included in the study. After measurement of cartilage dimensions and thickness, the potential dimensions of TAC and its widening capacity were calculated for each specimen. The results showed that TAC thickness was similar to the anterior cricoid arch but was significantly less than the posterior cricoid arch. The maximal degree of stenosis which could be normalized by TAC ranged between 47.8 and 74.3%. The height of the TAC allowed a widening, from the level of the glottis to the inferior part of the second tracheal ring in 100% of cases and to the inferior part of the third tracheal ring in more than 70% of cases. In conclusion, the TAC could be used for anterior grafting in laryngotracheoplasty. Its indications should be limited to grade II and a few grade III of the Myer subglottic stenosis classification without glottic or tracheal extension. Moreover, variability of TAC dimensions leads to peroperatively reassess its indication.

Surgical voice rehabilitation after laser surgery for glottic carcinoma.

Transoral laser surgery today is the mainstay of treatment for T1 and T2 glottic carcinoma. The vocal ability remains sufficient in the majority of patients. However, in some cases, a significant glottic gap may persist, leading to poor voice quality. We report a special technique of medialization thyroplasty using autologous cartilage specifically adapted for vocal rehabilitation after laser resection. Six patients with a significant glottic gap following laser surgery were treated. For vocal rehabilitation, a special medialization technique was performed. The superior rim of the thyroid cartilage of the resected side was exposed. A 1 x 2-cm piece of cartilage was harvested and reimplanted into a subperichondrial pouch created on the inner side of the thyroid cartilage. When phonation was optimal, this cartilaginous strut was sutured and/or glued in place. In all 6 cases, the vocal function improved significantly. The dysphonia index (0 = normal, 3 = aphonia), which includes objective parameters as well as expert voice ratings and the patient's perception, increased by 1.1 on average (range, 0.4 to 1.6). The results have been lasting. The established medialization techniques are of limited value in a larynx scarred by laser surgery. Injection augmentation is often futile because the tight scar tissue does not lend itself to augmentation. Implantation of nonorganic material may cause problems if revision surgery for tumor recurrence should become necessary or if the implant protrudes into the scarred endolarynx. The technique reported avoids these pitfalls and leads to voice quality improvement comparable to that of established medialization procedures.