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Tracheal Sleeve Resection with Suprahyoid and Infrahyoid Release

last modified on: Sun, 04/14/2024 - 21:11

Transcervical Tracheal Sleeve Resection

With Suprahyoid and Infrahyoid Release

return to: Trachea Surgical Protocols; Tracheostomy and Upper Airway Management Symposium July 30 2016 IAO and SOHN Iowa City Iowa

Subglottic stenosis

see also mediastinal anatomy: Case Example Mediastinal Tracheostomy with Anatomic Diagrams

GENERAL CONSIDERATIONS

  1. Indications
    1. A separate protocol addresses the issue of upper tracheal stenosis involving the subglottic area. This protocol is written to address the problem of isolated, circumferential tracheal stenosis. Tracheal stenoses, located between the sternal notch and cricoid, which have failed endoscopic management with laser ablation, dilation, and steroid injection are an indication for this procedure. The long-term utility of conservative measures for tracheal stenoses, which are circumferential and greater than 1 cm in length, is questionable. Stenoses up to 3.5 to 4.5 cm are amenable to transcervical resection and primary anastomosis utilizing only transcervical tracheal mobilization procedures. For longer stenoses or for patients in whom cervical extension for exposure and cervical flexion will present a problem, intrathoracic maneuvers (mobilization of right hilum, dissection of pulmonary artery/vein, left bronchus reimplant) to mobilize additional trachea may be required. Stenoses that extend greater than 1 to 2 cm below the sternal notch may require limited thoracotomy for adequate exposure, particularly in more elderly patients. Controversy persists regarding the relative value of open tracheal resection and anastomosis when compared to endoscopic techniques. Nouraei the al (2007) describe tracheal resection: "while its efficacy in selected cases is not disputed, it is a treatment approach that even in the very best o hands can lead to significant morbid and prolonged hospitalization, and carries major risks, including preoperative mortality"
  2. Contraindications
    1. Severe pulmonary dysfunction or other medical problems, which present a high likelihood of requiring a tracheostomy in the future, are relative contraindications to this procedure. Patients with laryngeal stenoses as a separate problem should have that problem addressed prior to attempting tracheal sleeve resection.
    2. An incompetent larynx due to sensory, anatomic, or motor disturbance is a relative contraindication depending on the severity of the disturbance.
    3. Tracheal stenoses involving the intrathoracic trachea or stenoses greater than 4 to 4.5 cm should be done in conjunction with the cardiothoracic surgery service.
    4. Obstruction due to immature granulation tissue or very thin webs should be dealt with using endoscopic procedures. This procedure is reserved for circumferential, mature scar tissue with a vertical dimension greater than 0.5 to 1 cm.
  3. Pertinent Anatomy
    1. The trachea is a fibromuscular tube supported by 18 to 22 incomplete cartilaginous rings. There are approximately 2 rings per cm. The average length of the adult trachea from cricoid to carina is 11 cm (9 to 15 cm). The length of trachea above the sternal notch is approximately 6 to 9 cm. For young adults, a gap of 3 cm can be readily closed between tracheal stumps.
    2. For increased mobilization, a variety of transcervical maneuvers may be used. The amount of mobilization obtained with these maneuvers varies substantially among published series. The amount of trachea that can safely be excised also varies substantially between patients. The most frequently reported tracheal mobilization maneuvers include:
      1. Extreme flexion of the neck (1 to 6 cm)
      2. Incising the annular ligaments between tracheal rings (1 to 2 cm)
      3. Suprahyoid or infrahyoid release of the upper laryngotracheal unit (2.5 to 5 cm)
      4. Blunt dissection and mobilization of the lower tracheal segment (0.5 to 1 cm). A combination of laryngeal release procedures, blunt mobilization of the lower tracheal segment, and neck flexion will yield about 4 to 6 cm of mobilization depending upon the patient's age and range of neck motion.

PREOPERATIVE PREPARATION

  1. Evaluation
    1. Define etiology of stenosis through detailed history. If there is no etiology present from history (eg, tracheostomy, endotracheal intubation, trauma, etc) a work-up to evaluate for potential autoimmune disorders should be undertaken.
    2. All patients should have a CT or MRI scan of the trachea and larynx to define the location and length of the stenosis. A study or reconstruction in the sagittal plane is helpful.
    3. The patient should have a direct laryngoscopy and bronchoscopy to assist in defining the exact location of the lesion, to rule out laryngeal pathology, and to determine the tissue nature of the stenosis.
    4. Preoperatively all patients should have an exam of the larynx - ideally with video imaging recorded.
    5. Note that Dr. Funk routinely employs jet ventilation with the Cook endotracheal tube changer as per:
      1. During a portion of the case, the patient will be jet ventilated. The tube used for jet ventilation is a Cook endotracheal tube changer. Discuss the need for this with the anesthesia team, and discuss the sequence of the case as outlined below. The patient only needs to be jet ventilated for a short period of time during the suturing of the posterior trachea.
    6. Note that Dr. Hoffman uses jet ventilation for these cases only to establish an airway permitting oral endotracheal intubation with a small endotracheal tube (usually 5-0 MLT) - as per protocol for Subglottic stenosis
  2. Potential Complications
    1. Failure of the procedure to secure an adequate airway is the major potential complication, and all patients are at risk for requiring a permanent tracheostomy following the procedure. The degree of this risk depends on a variety of factors including age, anatomy of the stenosis, comorbid illnesses, and history of prior neck surgery.
    2. Patients with diabetes and comorbid conditions that frequently require a tracheostomy have a high failure rate for laryngotracheal reconstruction procedures, and this should be discussed with the patient.
      1. Somewhat restrictive indications have been reported (Gelbard et al 2015) limiting 'open surgical reconstruction' of stenosis to patients less than 45 years of age, without diabetes or connective tissue disease, and with stenosis 2 cm or more below the glottis and less than 2 cm in length  
    3. The potential for recurrent nerve injury, esophageal injury, and the likelihood of temporary difficulty swallowing postoperatively should be discussed with the patient.
    4. Patients should be advised that they will have sutures securing the chin to the chest for 2 weeks following the procedure.

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Endoscopy Room Setup
      1. Back table x 2
      2. Mayo x 2
  2. Instrumentation and Equipment
    1. Standard
      1. Direct Laryngoscope Tray
      2. Bronchoscopy Tray, Adult
      3. Major Instrument Tray 1, Otolaryngology
      4. Major Instrument Tray 2, Otolaryngology
      5. Bipolar Forceps Trays
    2. Special
      1. Bronchoscopy Tray, Child
      2. Weitlander retractor
      3. Telescope, Storz, Hopkins straight forward, 0°, wide-angle, 5.5 mm x 20 cm
      4. Telescope, Storz, Hopkins straight forward, 0°
      5. Stortz fiberoptic light cable, 3.5 mm x 230 cm
      6. Tracheotomy Tray
  3. Medications (specific to nursing)
    1. 1% lidocaine with 1:100,000 epinephrine
    2. 4% lidocaine solution, topical (draw up in syringe to secure Abbocath)
    3. Oxymetazoline HCL nasal spray, 0.05%
    4. FRED (fog reduction elimination device)
  4. Prep and Drape
    1. Standard prep, 10% providone iodine
      1. After the endoscopic portion of the procedure and intubation, the patient should be prepped from the mouth to below the nipples. The patient will need to be draped so that the anesthesiologist can reach the endotracheal tube easily to partially withdraw and reinsert it at critical times during the case. The anesthesiologist also needs easy access to the endotracheal tube, through which the jet ventilation tube will be placed (if done by Funk's rather than Hoffman's method).
    2. Drape
      1. Head drape
      2. Square off neck with towels
      3. Towel, plastic (sticky drape) placed on chin to isolate mouth if endoscopy procedure
      4. Split sheet
  5. Drains and Dressings
    1. Varidyne vacuum suction drains, 10 mm x 2
    2. Adaptic
    3. Fluffs x 3
    4. Vaseline gauze
    5. Tegaderm x 2
  6. Special Considerations
    1. This procedure is indicated for tracheal stenosis at or above sternal notch not greater than 3.5 to 4 cm length. For longer stenosis below sternal notch, a combined thoracic procedure need be considered.
    2. Anesthesia 
      1. (Hoffman's approach) will intubate with a small ETT (ideally 4-0 MLT, 5-0 MLT is acceptable). 
      2. Others (Funk) will use jet ventilation. May use a Cook pediatric (or adult if endotracheal tube is at least a 7.5 cm) airway exchange catheter for the jet ventilation through the endotracheal tube. Have bronchoscopy setup to start with selection of bronchoscopes (4, 5, 6, 7 and 8).
        1. Jet ventilation apparatus.
        2. Cook endotracheal tube changer. This is a long, relatively stiff hollow tube that will be passed through the partially withdrawn endotracheal tube during the jet ventilation component of the case. The size and rigidity of this tube are ideal for these cases
        3. Be sure that the jet ventilation apparatus is in the room and functioning before the patient is put to sleep. All of the laryngoscopes and bronchoscopes should be ready when the patient is brought into the room.
    3. May use Cryo-glue. See Recipe for cryoprecipitate tissue glue.

ANESTHESIA CONSIDERATIONS

  1. General
    1. The patient should be supine with arms tucked and head toward the anesthesiologist for the operative part of the case.
    2. After the airway is secured and the patient asleep, confirmation of adequate neck extension may include either trial of neck extension with or without a very large shoulder roll should be placed for maximal neck extension.
  2. Specific
    1. The patient should receive a perioperative dose of antibiotics and 8 to 10 mg of Decadron IV before the start of the case.
      1. Hoffman: standard approach to securing the airway as per patients with subglottic stenosis (mask/jet/radial cuts/dilate/intubate) warranting full relaxation (usually 40-50 mg of rocuronium) before jetting is done in patients without preexisting tracheotomy. Intubate with small ETT
      2. Funk: The patient is induced with mask anesthesia, breathing spontaneously, not paralyzed. A bronchoscope is introduced that will likely pass through the stenosis; have several sizes available. When the airway is secure, patient may be paralyzed. Determine the exact length of the stenosis and distance from vocal cords. Determine that procedure is possible. The patient is then intubated with the largest tube that will pass through the stenosis. This is done by the otolaryngologist, and the tube is placed so that the cuff is distal to the stenosis.

OPERATIVE PROCEDURE

  1. The patient is placed in extreme neck extension and the neck is prepped and draped.
  2. Transverse collar incision from lateral border of sternocleidomastoid muscle to contralateral side at the level of the cricoid, subplatysmal flaps raised from above hyoid to below sternal notch. Divide straps in the midline, divide thyroid at isthmus, and bluntly dissect the thyroid lobes laterally away from the trachea. Do not attempt to find or dissect the recurrent laryngeal nerves. All tracheal dissection is done medial to them; attempts at localization will increase the chance that they will be injured.
  3. Skeletonize the anterior cartilaginous trachea from the cricoid to as far into the chest as possible using finger and blunt dissection. Measuring from the middle of the thyroid cartilage, determine where the middle of the stenosis will be. Vertically incise 1 or 2 tracheal rings at that location so that the stenosis can be visualized through the tracheotomy. Adjust the endotracheal tube if needed so that the balloon is distal to the stenosis and working area. When the length of the stenosis and its location are visualized, incise the annular ligament below and above the stenosis. Try not to make these circumferential incisions through cartilage as this will potentially predispose to reformation of the stenosis.
  4. Using careful sharp dissection under loupe magnification, excise the stenotic segment of trachea. Be careful posteriorly that the esophagus is not injured. Circumferential dissection of the trachea is confined to the area of stenosis and no more than 1 to 2 cm of normal trachea above and below the stenosis. This method of detailed dissection preserves the lateral segmental blood supply of the trachea (Mutrie CJ 2011)
  5.  If a stoma is present, then it is usually incorporated into the collar incision; however, if it is higher than normal, then it can be excised and closed separately.
  6. After the stenotic segment is removed, cross-field ventilation is achieved in the distal trachea. Stay sutures are placed laterally two rings above and below the planned resected segment, and with neck flexion of the patient, assessment of the tension on the completed anastomosis is carried out.
  7. Mobilization of the trachea is performed only on the anterior surface before resection from the cricoid to the carina
  8. Oppose the ends of the sectioned trachea and determine that an anastomosis is possible; further release can be obtained with gentle upward traction on the distal trachea and further finger dissection. Place 2 2-0 vicryls through the distal trachea 2 rings distal to the sectioned end and 2 rings above the anastomosis. These are stay/control sutures and are placed laterally 180° from each other. Leave the needles attached (protected) and use these same "traction sutures" as as "bolstering sutures" tied after placing through cartilage two rings away from the anastomosis.
  9. Cervical neck flexion and anterior mobilization to the carina will allow, in the majority of cases, a tension-free anastomosis of the cervical trachea. If additional length is required, a suprahyoid laryngeal release can be performed by the Montgomery technique [16].
  10. Suprahyoid release: Separate the straps and identify upper border of thyroid cartilage from superior horn to superior horn. Be careful not to injure the superior laryngeal neurovascular bundle. Sharply incise the thyrohyoid membrane along the upper surface of the thyroid cartilage; extend this cut out to the superior horns. Pre-epiglottic fat should be visible at the depth of the incision. Using heavy Mayo scissors, transect both superior horns (this releases the lateral thyroid ligament to the hyoid and is a crucial maneuver). Identify digastric tendons. Using Bovie dissection, skeletonize the hyoid from lesser cornu to lesser cornu. This will also include division of the strap muscles in this area. Using bone cutters or heavy Mayo scissors, divide the hyoid just lateral to both lesser cornu and remove intervening segment.The suprahyoid and infrahyoid release is now complete.
    • DSC_0061-new
  11. Airway management
    1. Hoffman: work around the small ETT in place
    2. Funk: Prepare the jet ventilation apparatus and tube. Intermittently suction the distal trachea so that blood does not run into the lungs. Withdraw the endotracheal tube into the upper trachea and advance the Jet ventilation tube through the endotracheal tube into the distal trachea. At no time during the procedure is the endotracheal tube completely withdrawn. Be sure that air egress is possible during jet ventilation. 
  12. Bring the patient's neck out of flexion. Oppose the back wall of the trachea and begin the anastomosis with 4-0 vicryl sutures; do not struggle trying to place the knots extraluminally. If that is not easily done, place the knots intraluminally and cut the sutures short. It is helpful to place most of the back wall sutures before tying them. Bibas et al (2014) recommend closure of the membranous tracheal wall with continuous running polydioxanone 4-0 (PDS II; Ethicon, Bridgewater, NJ) and using separate polyglactin 3-0 (Vicryl, Ethicon) in the cartilaginous wall.
  13. Once the majority of the back wall is done, replace the 2-0 silk sutures used for traction with 2-0 vicryl sutures. Once the anastomosis reaches the cartilaginous trachea, switch to 3-0 vicryl sutures. These are placed through the annular ligament 1 ring above and below the cut ends of the trachea. Across the anterior 180° of the trachea, place 3-0 vicryl sutures as before and several more 2-0 vicryl bolstering sutures, 2 rather than 1 ring from the anastomosis.
  14. At a point when visualization into the trachea is still possible, remove the jet ventilation tube and advance the endotracheal tube so that the balloon is below the anastomosis. Complete the anastomosis.
    • DSC_0069-new
  15. Place 2 large suction drains along the lateral trachea and up into the suprahyoid area. Be sure that hemostasis is meticulous. Close the neck incision with a minimal number of subcutaneous 4-0 vicryl sutures and Steristrips. May alternatively consider use of passive penrose drains.
    • tracheal sleeve 1 trach resect
  16. For placement of the chin-to-chest Grillo stitches (named for Dr. Hermes C. Grillo; also called "guardian" chin stitch or "sentinel" chin stitch), bring the neck into maximum flexion. Place two 2-0 prolene sutures around the mandible and deeply into the upper chest subcutaneous tissue to maintain the neck in maximum flexion. Gomez-Caro et al (2011) recommends leaving these in place to maintain neck flexion for 5-14 days, "depending on the segment of trachea resected and the outcome of the first days after the operation."
  17. Note from Mutrie et al:  Today, we only do a chin stitch if the resection is greater than 4 cm or if the procedure is a re-resection. Other methods for prevention of neck extension is mechanical ventilation, neck brace (360 degrees), posterior plaster splint, or upper body cast, all of which can prolong hospital stay and increase morbidity.
  18. See excellent on-line article with videos: Gomez-Caro A (2011): http://mmcts.oxfordjournals.org/content/2011/1111/mmcts.2010.004945.full

POSTOPERATIVE CARE

  1. May extubate in the OR and ensure a good airway without leak before transfer to SICU
  2. Alternatively, the patient could go to the ICU intubated. Plan to extubate the patient the following morning. At extubation have headlights and tracheostomy tray out and ready for immediate use. Flexible scope is used after extubation to evaluate larynx. Perioperative antibiotics should continue for 48 hours, and the patient should get 3 more doses of Decadron every 8 hours after surgery. After this the patient begins a Medrol Dose-Pack of oral steroids or equivalent.
  3. Heavy cool mist at all times for 4 days. Begin clears and advance as tolerated on postoperative day 2. Prolene chest sutures to remain for 10 days. These patients may develop some granulation around the anastomotic site several weeks following surgery. This should be anticipated if there is any evidence of airway compromise following surgery. They should be readmitted, placed on antibiotics, steroids, and cool mist, and bronchoscopy should be scheduled.

REFERENCES

Dedo HH, Fishman NH. Laryngeal release and sleeve resection for tracheal stenosis. Ann Otol Rhinol Laryngol. 1969;78:285-296

Lano CF, Duncavage JA, Reinisch L, et al. Laryngotracheal reconstruction in the adult: a ten year experience. Ann Otol Rhinol Laryngol. 1998;107:92-97.

Montgomery WW. Suprahyoid release for tracheal anastomosis. Arch Otolaryngol Head Neck Surg. 1974;99:253-260.

Peskind SP, Stanley RB, Thangathurai D. Treatment of the compromised trachea with sleeve resection and primary repair. Laryngoscope. 1993;103:203-211.

Zitsch RP, Mullins JB, Templer J, Davis WE. Suprahyoid and inferior constrictor release for laryngeal lowering. Arch Otolaryngol Head Neck Surg. 1995;121:1310-1313. 

Wright CD, Grillo HC, Wain JC, Wong DR, Donahue DM, Gaissert HA and Mathisen DJ: Anastomotic complications after tracheal resection: Prognostic factors and management. The Jouranl of Thoracic and Cardiovascular Surgery Nov 2004 vol 128, Number 5 pp 731-739

Bibas BJ, Terra RM, Oliverira AL Jr., Tamagno FL et al: Predictors for Postoperative Complications After Tracheal Resection Ann Thorac Surg 2014;98:277-82

Mutrie CJ, Eldaif SM, Rutledge CW,Force SD, Grist WJ, Mansour KA, and Miller DL: Cervical Tracheal Resection; New Lessons Learned. The Annals of Thoracic Surgery Vol 91, Issue 4, April 2011, PGES 1101-1106

Nouraei SAR, Ghufoor K, Patel A, Ferguson T, Howard, DJ, and Sandhu GS: Outcome of Endoscope Treatment of Adult Postintubation Tracheal Stenosis. The Laryngoscope 117:1073-1079, 2007

Gomez-Caro A, Morcillo A, Wins R, Molins L, Galan G, and Tarrazona V: Surgical management of benign tracheal stenosis. Multimedia Manual Cardio-Thoracsc Surgery 2011: Volume 2011, Issue 1111 http://mmcts.oxfordjournals.org/content/2011/1111/mmcts.2010.004945.full

Gelbard A, Francis DO, Sandulache VC, Simmons JC, Donovan DT, and Ongkasuwan: Causes and Consequences of Adult Laryngotracheal Stenosis   Laryngoscope 2015 May;125(5):1137-1143