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Laryngotracheal Reconstruction with Costal Cartilage Grafting

last modified on: Mon, 12/14/2020 - 15:21

see also:  Protocol with Video of Single Stage Laryngotracheal Reconstruction with Anterior Costal Cartilage Graft

With Costal Cartilage Grafting (Laryngotracheoplasty)

return to: Trachea Surgical Protocols and
Pediatric Airway 

  1. GENERAL CONSIDERATIONS
    1. Indications
      1. Symptomatic patients with greater than 50% stenosis
      2. Grade of stenosis determined endoscopically, preferably by determining size of endotracheal tube with leak pressure between 10 cm and 25 cm H2O
    2. Contraindications
      1. Ventilator-dependence
      2. Acute upper or lower respiratory tract infection
      3. Untreated concomitant airway obstruction (such as bilateral vocal cord paralysis, choanal atresia, severe tracheomalacia, severe bronchopulmonary dysplasia, or marked adenotonsillar hypertrophy)
      4. CHF, greater than 30% oxygen requirements, weight less than 1500 g
    3. Anatomic Considerations
      1. Laryngotracheal stenosis may be congenital or acquired in etiology. Use of a costal cartilage graft may provide widening of the airway, and, in tracheotomized patients, allow 1 stage decannulation. The following protocol illustrates the general technique of laryngotracheal reconstruction. Management should be individualized according to the level and degree of stenosis.
  2. PREOPERATIVE PREPARATION
    1. Evaluation
      1. Assess vocal cord mobility preoperatively by flexible fiberoptic laryngoscopy.
      2. Measure preoperative weight.
    2. Consent
      1. Describe procedure: "Expanding the voice box and windpipe with a piece of rib"
      2. Describe potential complications
        1. Bleeding, infection, reaction to anesthesia, scarring
        2. Graft dislodgment, loss of airway
        3. Need for tracheotomy (failure to decannulate)
        4. Infection of graft
        5. Pneumonia
        6. Pneumothorax
        7. Death
  3. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
        1. Back table x 2
        2. Basic soft tissue supply pack x 2
        3. Audio-visual unit
        4. Double shelf back table with Pilling light source
    2. Instrumentation and Equipment
      1. Standard
        1. Major Instrument Tray 1, Otolaryngology
        2. Major Instrument Tray 2, Otolaryngology
        3. Bipolar Forceps Trays x 2
        4. Minor Instrument Tray, Otolaryngology
        5. Direct Laryngoscope Tray
        6. Bronchoscopy Tray, Adult
      2. Special
        1. Hall Micro Sagittal Saw Tray (Pneumatic)
        2. Richards double fork self-retaining retractors
        3. Sterile anesthesia breathing circuit, adult
        4. Rib Resection Tray, Adult
        5. Telescope, Storz, Hopkins straight forward 0-degree
        6. Storz fiberoptic light cable
    3. Medications (specific to nursing)
      1. 1% lidocaine with 1:100,000 epinephrine
      2. 1:100,000 epinephrine
      3. Antibiotic ointment
    4. Prep and Drape
      1. Standard prep, 10% providone iodine
      2. Drape
        1. Head drape
        2. Towels to square off rib graft site and neck incision
        3. Plastic drape (1010 drape) over lower jaw to isolate mouth if endoscopy procedure is done and/or reintubation during the procedure is necessary
        4. Medium sheet above and below rib graft site
        5. Split sheet
    5. Drains and Dressings
      1. Varidyne vacuum suction drain: 7 mm or 10 mm
      2. Adaptic, large,
      3. Fluffs, sterile, 5 pack x 3
      4. Tegaderm transparent dressing, 20 x 30cm x 2
      5. Vaseline gauze, 1/2 in x 72 in
    6. Special Considerations
      1. Two setups, neck and rib graft
      2. Endoscopy setup available
      3. If rib graft is not harvested first, will need a separate sterile setup
      4. Pleur-vac and thoracic catheters (chest tubes) should be available in case of pneumothorax.
      5. Tissue glue (mixture of Thrombin and cryoprecipitate) may be used to reinforce the tracheal suture line.
      6. A selection of endotracheal tubes to be available to ventilate from the sterile field, including Roush Laryngoflex 7 mm endotracheal tube.
      7. In the event that a sternal split may be done to gain exposure, order a Major instrument tray, chest, for the cardiothoracic team.
      8. Special instrumentation
        1. Carving block
        2. Scalpel blades: #10, #15, #12
        3. Ruler and measuring calipers
        4. Culture supplies
        5. Double-armed 5-0 vicryl suture
        6. Vascular clip
  4. ANESTHESIA CONSIDERATIONS
    1. Close cooperation with the anesthesiologist is especially important for laryngotracheal reconstructions.
    2. Anesthesia
      1. Initially give general anesthesia by face mask or tracheotomy tube.
      2. Perform direct laryngoscopy and bronchoscopy to assess the degree, location, and length of airway stenosis/stenoses and to exclude other airway anomalies such as distal tracheomalacia.
      3. Intubate the patient
        1. Orally, with an appropriate size endotracheal tube or
        2. Via the tracheotomy site, with a modified RAE tube
      4. After incising the airway and performing the laryngotracheofissure, intubate with age-appropriate endotracheal tube.
      5. Apply positive-pressure ventilation to assess for pneumothorax and air leak around graft.
    3. Medications (specific to nursing)
      1. 1% lidocaine with 1:100,000 epinephrine
      2. Antibiotics
      3. FRED (Fog Reduction Elimination Device)
    4. Positioning
      1. Supine position with shoulder roll, eye protection, and head drape
      2. Turn table 90°
  5. OPERATIVE PROCEDURE FOR ANTERIOR LARYNGOTRACHEAL RECONSTRUCTION
    1. A direct laryngoscopy and bronchoscopy (DL/B) with general anesthesia is performed, while maintaining spontaneous ventilation.  This is to determine the degree, location, and length of airway stenosis.  The patient is then intubated with an appropriately sized oral endotracheal tube (OET) or ventilated through an existing tracheotomy tube.
    2. Mark sternal notch, cricoid cartilage, thyroid cartilage notch, strap muscles, and horizontal neck incision in skin crease; mark costal cartilage donor site incision over the seventh or eighth rib just lateral to the synchondrosis; inject sites with 0.5% lidocaine with 1:200,000 epinephrine.
    3. A horizontal incision is created in a crease overlying the cricoid cartilage (usually about 0.5 cm below the cricoid).  Superior and inferior flaps were elevated in a subplatysmal plane to expose the thyroid cartilage superiorly, and the thyroid inferiorly.
    4. Expose larynx and trachea by dividing strap muscles at the midline raphe.
    5. Place 2-0 silk through strap musculature to facilitate retraction and exposure.
    6. A thyroid isthmusectomy is performed at this point in time. 
      1. The superior border of the thyroid gland is identified and released from the anterior tracheal wall.
      2. The inferior border was then also identified, and released
      3. At this point in time, hemostats were slide under the gland.  The gland was then separated using monopolar cautery.
    7. The anterior tracheal wall is then fully exposed.
    8. Insert 20-gauge needle through exposed anterior tracheal wall, visualized by bronchoscopy to confirm precise location of stenosis (as needed).
    9. Enter airway and incise stenosis precisely in midline using a #15 or #12 blade.
    10. If needed, divide true vocal folds precisely in the midline.
    11. After completing incision of stenotic cartilage segment, secure mucosal edges to cartilage edges with 6.0 vicryl to prevent mucosal retraction.
    12. Obtain tracheal aspirate for aerobic and anaerobic culture and gram stain.
    13. Place epinephrine-soaked or cocaine-soaked pledgets along mucosal edges for hemostasis. L. Determine length of rib graft necessary to repair stenosis. Determine if a posterior graft may also be needed, as for severe stenosis or marked interarytenoid scarring with limited vocal fold motion.
    14. Re-intubate patient with endotracheal tube of size appropriate for age and sex.
    15. Cover wound and obtain rib graft using separate instruments. Complete donor site incision through skin, subcutaneous tissue, and rectus abdominis muscle to expose costal cartilage while carefully preserving outer perichondrium.
      1. Outline rectangular segment 1 cm longer than measured stenosis and mark.
      2. Harvest additional cartilage if needed for posterior graft.
      3. Carefully elevate rib from inner perichondrium to prevent pneumothorax.
      4. Check donor site for air leak by placing saline in the wound and applying 40 cm positive-pressure ventilation.
      5. Close wound over Penrose drain in layered fashion.
      6. Place Marcaine intercostal block to decrease postoperative pain and splinting.
    16. Carve costal cartilage graft
      1. Carve an elongated boat-shaped graft to fill the expanded airway defect.
      2. Carve sides of the graft to prevent its retrusion into airway.
      3. Preserve perichondrium to line airway.
    17. Secure graft to the anterior open defect with 5-0 vicryl suture such that perichondrium lines expanded airway.
      1. Place all interrupted mattress sutures, then float graft down onto defect and secure.
      2. Ideally, place sutures through cartilage graft then airway without breaching the perichondrium or mucosa.
      3. Perichondrium should be flush with airway mucosa; usually external surface of graft will project above adjacent trachea.
    18. Verify adequacy of seal by administering 20 cm positive-pressure ventilation
    19. Place additional interrupted 5-0 vicryl sutures to assure closure.
    20. Place a vascular clip over the inferior end of the graft to later radiographically verify that tip of endotracheal tube projects below costal graft.
    21. If tracheotomy is present, tracheotomy site may be incised and fistula closed in layered fashion for 1 stage repair.
    22. wound and assure hemostasis.
    23. Close wound in layers over 16-gauge butterfly catheter drains.
      1. Place 1 drain deep to strap muscles and 1 superficial to strap muscles.
      2. Insert needle into a vacuum blood tube.
      3. Approximate platysma muscles.
    24. Close skin in layers with Steristrips.
  6. MODIFICATIONS TO OPERATIVE PROCEDURE FOR POSTERORIOR GRAFT
    1. Obtain exposure of laryngeal and tracheal stenosis (see previous description).
    2. Make vertical incision over posterior cricoid cartilage 5 mm away from midline.
    3. Carry incision through the cricoid perichondrium.
    4. Elevate subperichondrial pocket medially with Cottle elevator.
    5. Create laterally based mucoperichondrial flap by incising mucosa and perichondrium at superior and inferior edge of cricoid plate; extend incisions 1 mm past midline.
    6. Divide cricoid in midline.
    7. Separate cricoid halves with Freer elevator.
    8. Measure size of posterior defect (typically 2 mm).
    9. Carve posterior graft.
      1. Graft width should be slightly smaller than defect.
      2. Graft height should be equal to cricoid height.
    10. Suture graft into position at 4 corners if possible.
    11. Suture laterally based flap over the graft (5-0 vicryl). A small amount of cartilage will be exposed laterally.
    12. Place anterior graft and close (VM-VW).
    13. For 1-stage procedures, return to operating room to examine airway at time of extubation.
  7. POSTOPERATIVE CARE
    1. Immediate Extubation
      1. Extubate in operating room and observe for respiratory distress.
      2. Transfer to intensive care unit.
        1. Tracheotomy Tray at bedside
        2. Prominent sign to call ENT for any respiratory distress
      3. Medications
        1. Intravenous broad-spectrum antibiotics, as guided by intraoperative cultures
        2. Omeprazole and promotility agent
        3. Decadron 0.25 mg per kg intravenously every 8 hours for 48 hours
    2. Delayed Extubation
      1. Transfer to intensive care unit, intubated.
      2. Patient remains paralyzed and ventilated to avoid mucosal trauma from ET motion.
        1. Discontinue paralysis for 4 to 6 hours daily to prevent accumulation of neuromuscular agent and reduce atelectasis.
      3. Initiate nasogastric or nasoduodenal tube feedings and institute gastric reflux precautions.
      4. Ensure aggressive chest physical therapy and log rolling every 4 hours.
      5. Follow daily chest x-ray to assess atelectasis.
      6. Continue intravenous antibiotics and adjust according to intraoperative cultures.
      7. On postoperative day 5, assess the presence of an air leak around the endotracheal tube with 20 cm H20 of positive pressure.
        1. Initiate Decadron, 0.25 mg per kg every 6 hours to reduce edema.
        2. Diurese patient to his or her dry weight with Lasix 2 days prior to planned extubation.
        3. Stop all paralytics hours before planned extubation.
        4. Wean ventilatory support as tolerated.
        5. Reassess for air leak less than 20 cm H20 of positive pressure (excellent prognostic sign).
      8. Extubate when patient is awake and alert.
        1. Respiratory therapist should be available for nebulized racemic epinephrine treatment as needed.
        2. Intubation supplies should be available (use half-size smaller than previous endotracheal tube for reintubations).
      9. Monitor patient on continuous pulse oximetry.
      10. Continue Decadron for 2 days and taper over 1 week.
      11. Stop antibiotics at 1 week postoperative.
      12. Wean narcotics.
      13. Discharge when stable and tolerating regular diet.
      14. Remove subcuticular sutures at 5 to 7 days.
  8. SUGGESTED READING
    1. Bauman NM, Oyos TL, Murray DJ, Kao SCS, Biavati MJ, Smith RJ. Postoperative care following single-stage laryngotracheoplasty. Ann Otol Rhinol Laryngol. 1996;105:317.
    2. Cotton R, Myer C. Innovations in pediatric laryngotracheal reconstruction. J Pediatr Surg. 1992;27:196.
    3. Cotton R. Pediatric laryngotracheal stenosis. J Pediatr Surg. 1984;19:699.
    4. Myer CM 3rd, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol. 1994;103:319
    5. Smith RJ, Catlin FI. Laryngotracheal stenosis: a 5-year review. Head Neck. 1991;13:140.
    6. Gustafson LM, Hartley BE, Liu JH, Link DT, Chadwell J, Koebbe C, Myer CM 3rd, Cotton RT.  Single-stage laryngotracheal reconstruction in children: a review of 200 cases.  Otolaryngol Head Neck Surg. 2000 Oct;123(4):430-4.
    7. Biavati MJ, Wood WE, Kearns DB, Smith RJH.  One-stage repair of congenital laryngeal webs.  Otolaryngol Head Neck Surg 112:447-452, 1995.
    8. Goudy S, Bauman NM, Manaligod J, Smith RJH. Congenital laryngeal webs: surgical course and outcomes.  Ann Otol Rhinol Laryngol 119(10):704-7, 2010