Subglottic widening using a rotated H-shaped cricotracheal split for composite nasal septal cartilage grafting

Abstract

Introduction

Various open surgical techniques have been previously described for subglottic stenosis. These techniques usually involve steroid injections, endoscopic dilatations, flaps, and placement of intraluminal stents. A retrospective review was conducted on 20 patients with subglottic stenosis who underwent surgical widening using composite nasal septal grafts utilizing a rotated H-shaped cricotracheal split and temporary tracheotomy without stenting. Tracheotomy was performed for patient safety. All patients maintained patent airways with wide subglottic area throughout the follow-up period. All of them were extubated or decannulated 28–33 days after surgery by removing the tracheostomy tubes. All patients started antireflux treatment on the first postoperative day and steroid inhalation 2 weeks after surgery, which was maintained for 3 months. No patients underwent further procedures. All 20 patients were decannulated and were doing well at the time of writing. To conclude, composite nasal septal cartilage grafts with a rotated H-shaped cricotracheal split for subglottic stenosis in selected cases is a viable and effective option.

Context

The most common sequel after reconstructive procedures may be restenosis of different degrees. Recurrent narrowing may be due to healing by marked fibrosis, which is a result of postoperative infection, perichondritis in the graft or recipient site, with resorption of the augmenting cartilage graft. Intraluminal stenting predisposes to infection, subperichondrial abscesses, and devitalization of the cartilage graft by friction and infection. Inadequate graft size, thickness, or method of fixation may be other factors for failure.

Aim

The aim of the study was to present the indications, surgical technique, and results of composite nasal septal cartilage grafts using a rotated H-shaped cricotracheal split for patients with subglottic stenosis.

Patients and methods

This is a retrospective review. A series of 20 patients who underwent composite nasal septal cartilage grafts without stenting from 2009 to 2014 were reviewed. They suffered from subglottic and upper tracheal stenosis: 13 patients had subglottic stenosis due to rhinolaryngeoscleroma (seven male and six female patients), five patients had postintubation upper tracheomalacia and stenosis (one male and four female patients), and two male children had congenital subglottic stenosis. Postoperative data included mortality and morbidity rate, success of decannulation, need for repeat tracheotomy or Montgomery T-tube placement, and number of additional airway procedures.

Results

The operative time ranged from 1.5 to 3.25h with a mean of 2.2 h. Blood loss ranged from 85 to 290 cm³, with a mean of 150 cm³. Hospitalization was 3 days in all patients with discharge on the third postoperative day, except for two children with congenital subglottic stenosis who stayed for 1 week. There were no major complications. Wound infection in two patients around the tracheotomy tube was evident 10 days after surgery, which was well controlled by parentral antibiotic and local antiseptic measures. Chest infection was recorded in five patients as mild to moderate tracheobronchitis, which resolved 1 week after surgery, except for the case of a 53-year-old female patient who progressed to bronchopneumonia after discharge, which resolved after 10 days. Return to normal life activity or work was possible in all patients after 2–3 weeks; however, 14 patients preferred home stay until tube removal. Weaning started 4 weeks after surgery and was successful within 1 week in all patients except for the two children, whose tubes were removed after 2 weeks of gradual weaning. Five patients experienced mild shortness of breath shortly after extubation, which increased with effort. They received steroid inhalation two to three times a day for 2 weeks with improvement in symptoms. During the follow-up period all patients sustained normal breathing, except for seven scleroma patients who after 4–7 months complained of mild dyspnea, which increased slightly with effort and prevailed thereafter. Follow-up flexible laryngoscopy detected mild mucosal edema and little granulation tissue around the grafted area at the time of extubation. These granulations were more evident and encroached slightly on the airway in the five patients who suffered from mild dyspnea shortly after extubation and regressed markedly after 2 weeks of steroid inhalation. There was rapid mucosal healing of nasal septal mucosa and laryngeal mucosa, which was nearly complete at 6 weeks after surgery, with a markedly wide subglottic area. Later on, endoscopic examination detected mild lumen narrowing in seven scleroma patients who complained of mild dyspnea 4–7 months after surgery. These patients showed no more narrowing on endoscopic examination through their subsequent months of follow-up. No other new symptoms developed in the follow-up period. No patient needed further surgical intervention.

Conclusion

Composite nasal septal cartilage grafting with a rotated H-shaped cricotracheal split is a viable and successful option for selected cases of laryngotracheal stenosis. The use of a stent with its associated morbidities is avoided with this technique. No additional endoscopic or open procedures were needed in any of the cases; successful decannulation in less than 1 month could be achieved.