Laryngotracheal reconstruction is a surgical procedure that involves expanding or removing parts of the airway to widen a narrowing within it, called

laryngotracheal stenosis Laryngotracheal stenosis refers to abnormal narrowing of the central air passageways. This can occur at the level of the larynx, trachea, carina or main bronchi. In a small number of patients narrowing may be present in more than one anatomical ...

subglottic stenosis Subglottic stenosis is a congenital or acquired narrowing of the subglottic airway. It can be congenital, acquired, iatrogenic, or very rarely, idiopathic. It is defined as the narrowing of the portion of the airway that lies between the vocal cor ...

Types

Anterior and Posterior grafts

Anterior grafts can be performed using tissue from the thyroid ala cartilage or the

costal cartilage Costal cartilage, also known as rib cartilage, are bars of hyaline cartilage that serve to prolong the ribs forward and contribute to the elasticity of the walls of the thorax. Costal cartilage is only found at the anterior ends of the ribs, pr ...

. Posterior grafts are generally made using costal cartilage.

Resection Techniques

Cricotracheal resection

Trachea The trachea (: tracheae or tracheas), also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all animals' lungs. The trachea extends from ...

l resection Slide tracheoplasty

Combined Expansion and Resection Techniques

Slide tracheoplasty into cricoid split Slide tracheoplasty with tracheal resection

History

The first description of the anterior cricoid split appears in the early 1900s by Killian and the first description of the posterior cricoid split is credited to Galebsky in 1927. In 1938, Looper rotated the hyoid bone to augment a stenotic adult laryngeal fracture sustained in a railroad accident. In 1968, Lapidot used this principle in piglets to show that a flap of thyroid cartilage rotated on

perichondrium The perichondrium (from Greek and ) is a layer of dense irregular connective tissue that surrounds the cartilage of developing bone. It consists of two separate layers: an outer fibrous layer and inner chondrogenic layer. The fibrous layer conta ...

to replace a segment of resected

cricoid cartilage The cricoid cartilage , or simply cricoid (from the Greek ''krikoeides'' meaning "ring-shaped") or cricoid ring, is the only complete ring of cartilage around the trachea. It forms the back part of the voice box and functions as an attachment sit ...

could survive, suggesting that laryngeal growth could continue after reconstruction without restenosis. Great advances in open airway reconstruction were made in the 1970s, many of which occurred in Toronto, Canada. In 1971, Fearon and Ellis described a child with severe

who, after failed dilatations and anterior cricoid split with auricular cartilage graft augmentation, eventually underwent tracheotomy, placement of an anterior costal cartilage graft with

buccal mucosa The oral mucosa is the mucous membrane lining the inside of the mouth. It comprises stratified squamous epithelium, termed "oral epithelium", and an underlying connective tissue termed ''lamina propria''. The oral cavity has sometimes been describ ...

and a stent and was eventually decannulated. Fearon and

Cotton Cotton (), first recorded in ancient India, is a soft, fluffy staple fiber that grows in a boll, or protective case, around the seeds of the cotton plants of the genus '' Gossypium'' in the mallow family Malvaceae. The fiber is almost pure ...

further investigated tracheal augmentation using thyroid cartilage (harvested from the inferior border) in African green monkeys and proved that the cricoid could be divided without inhibition of laryngeal growth. In 1976, Fearon and Cinnamond reported on 35 patients operated on using this technique between 1970 and 1976, noting that free thyroid grafts were more feasible than pedicled grafts and that costal cartilage was most suitable for repairing long segment stenoses. They also proposed that shaping anterior costal cartilage grafts with flanges might prevent them from being displaced inward into the trachea. Cotton would later be the first to describe in detail the process of harvesting, carving and insetting an anterior costal cartilage graft along with his success using this technique in 11 children after moving to Cincinnati. In 1973, Crysdale visited Grahne in Helsinki, Finland, to observe an anterior-posterior cricoid split with stent placement and was the first to perform this procedure in a child in North America. A search for less morbid sources of cartilage for anterior cricoid augmentation in neonates allowed Park and Forte (1999) to demonstrate that bilateral cartilaginous grafts could be harvested from the superior aspect of the thyroid cartilage in kittens without airway compromise. Success using this technique was later demonstrated in 2001 by Forte, Chang, and Papsin in a series of 17 children. For more severe subglottic stenoses, Gerwat and Bryce (1974) described the first cricotracheal resection with preservation of the recurrent laryngeal nerves. Pearson and

Gullane Gullane ( or ) is a town on the southern shore of the Firth of Forth in East Lothian on the east coast of Scotland. There has been a church in the village since the ninth century. The ruins of the Old Church of St. Andrew built in the twel ...

would later report their success using this procedure over the ensuing 22 years in 80 consecutive adults with benign

. Impressed by the results of Gerwat and Bryce, Monnier, Savary, and Chapuis performed the first cricoid resection with primary anastomosis in a child in 1978.

References

{{Respiratory system surgeries and other procedures Trachea surgery Larynx surgery