MANAGEMENT OF ACQUIRED TRACHEAL STENOSIS.pptx

Clinical features etiology

1. MANAGEMENT OF LARYNGEAL STENOSIS PRESENTER DR.FASIHULLA POSTGRADUATE DEPT OF ENT NARAYANA MEDICAL COLLEGE MODERATOR DR.INDRANEEL REDDY ASST PROFESSOR DEPT OF ENT NARAYANA MEDICAL COLLEGE

2. INTRODUCTION Laryngeal stenosis is a rare but life-threatening condition in children, with the subglottis being the most common site of narrowing. Stenosis can be congenital or acquired, with congenital cases often linked to other abnormalities or syndromes. Acquired stenosis is frequently caused by accidental or iatrogenic injuries to the airway.

3. ETIOLOGY Congenital High Airway Obstruction Syndrome (CHAOS) is a rare and severe congenital condition caused by the complete failure of airway recanalization, often occurring at the larynx (laryngeal atresia), but can also involve subglottic or tracheal atresia. The obstruction leads to symptoms such as large, echogenic lungs, flattened or inverted diaphragm, dilated airways distal to the obstruction, fetal ascites, and hydrops,Without prenatal detection and intervention, CHAOS was historically fatal.

4. However, advances in prenatal imaging and procedures like ex utero intrapartum treatment (EXIT) have improved survival rates by allowing for prenatal planning and airway management after birth. The EXIT (Ex Utero Intrapartum Treatment) procedure is a specialized delivery method used to secure a baby's airway before separating them from the placenta. It involves a planned cesarean section under general anesthesia for the mother, ensuring uterine relaxation. The baby's head is delivered while still attached to the placenta, allowing continuous placental oxygenation. A pediatric surgeon evaluates the airway using a bronchoscope and attempts to intubate. If successful, the baby is delivered and the umbilical cord is cut. If intubation fails due to an obstruction, a tracheostomy is performed to establish a direct airway. After airway stabilization, the baby is fully delivered and cared for by the NICU team.

5. Congenital Glottic Stenosis occurs due to incomplete recanalization of the embryologic larynx, leading to laryngeal webs, which are thin membranes that obstruct the airway. These webs account for 5% of congenital laryngeal anomalies, typically forming at the glottic level. The severity ranges from thin webs causing mild voice issues to more extensive webs leading to airway obstruction and aphonia. There is also an association between anterior glottic webs and chromosome 22q11.2 deletion, making genetic evaluation essential.

6. Bilateral true vocal fold immobility (BTVFI), which affects 30% to 60% of pediatric laryngeal anomalies, is characterized by the inability of the vocal cords to move. This condition may result from trauma, surgery, neurological issues, or have an idiopathic cause. Symptoms include stridor, respiratory distress, and voice changes. There is a high rate of spontaneous recovery, so interventions should not cause long-term damage to vocal function.

7. Congenital Subglottic Stenosis (SGS) Prevalence: Congenital SGS is the third most common laryngeal anomaly in newborns, after laryngomalacia and bilateral vocal fold paralysis. Classification: Holinger classified congenital SGS into two types: Cartilaginous stenosis: Results from incomplete recanalization of the laryngeal lumen after the 8th week of gestation. The cricoid cartilage may appear too small for the infant’s size or exhibit abnormalities such as thickening, a large anterior or posterior lamina, or an elliptical shape. Soft tissue stenosis: Another form that involves soft tissue narrowing of the subglottis. Diagnosis: Congenital SGS is diagnosed when the subglottic lumen diameter is less than: 4 mm in full-term infants. 3 mm in premature infants.

8. Associated Conditions: Congenital SGS is associated with mediastinal malformations, such as cardiovascular, tracheobronchial, or esophageal anomalies, in about 50% of cases. Before treating mediastinal malformations, a bronchoesophagoscopy is often recommended to rule out minor asymptomatic SGS.

9. Acquired Subglottic Stenosis (SGS) Causes: The most common cause of acquired SGS in the pediatric age group is prolonged intubation, which can lead to trauma in the subglottic area. Risk factors for acquired SGS include: Traumatic intubation, especially for resuscitation or in cases of severe cranial injuries. Difficult laryngoscopy due to anatomical challenges. Unrecognized mild congenital SGS, which can worsen after intubation. Systemic conditions that diminish capillary perfusion (e.g., shock, anemia) or increase susceptibility to infection (e.g., diabetes, immunosuppression). Gastroesophageal reflux, which can exacerbate subglottic damage caused by an endotracheal tube.

10. Acquired Subglottic Stenosis Subglottis can be affected by various conditions like blunt trauma, inhalation injuries, high tracheotomy, Wegener’s granulomatosis, and idiopathic causes, but postintubation injury is the most common cause of Subglottic Stenosis (SGS) that can be treated through resection and reconstruction. Sequelae of endotracheal intubation are usually minimal in the supraglottic region, while in the glottis, scar tissue bands can tether the vocal cords posteriorly, leading to posterior glottic stenosis (PGS) or cricoarytenoid ankylosis. Fusion of vocal cords can also occur less frequently. In the subglottis, ulcerations can cause granulation tissue formation, which can develop into contracting scars, ultimately resulting in Subglottic Stenosis (SGS).

11. Cicatricial sequelae of endotracheal intubation. (a) Interarytenoid adhesion. (b) Posterior glottic stenosis. (c) Cicatricial fusion of the vocal cords. (d) Subglottic stenosis

12. Acquired laryngeal stenosis can affect different parts of the larynx and is usually the result of trauma, surgery, or prolonged intubation. It can be classified based on the site of stenosis: Anterior Glottic Stenosis: Most commonly arises from endoscopic laryngeal surgery, especially when both true vocal folds are involved. Healing of opposing mucosal surfaces leads to scarring and the formation of a scar band, restricting movement. Rarely occurs in isolation and is often accompanied by supraglottic stenosis (SGS). In children, causes include prolonged endotracheal intubation, ingestion of corrosive substances like lye, or thermal injuries.

13. Posterior Glottic Stenosis (PGS): Most often caused by prolonged intubation, leading to pressure necrosis of the mucosa at the vocal processes of the arytenoids. This can lead to ulceration, granulation, and scar formation in the interarytenoid space. Scar formation can limit the mobility of one or both cricoarytenoid joints, narrowing the airway. Patients with Down syndrome have a higher incidence of PGS. PGS is classified into four grades, but it can be challenging to clinically differentiate between Grade II, III, and IV. The condition primarily affects breathing, but voice quality remains relatively unaffected due to the adduction of the vocal cords. Severe cases may necessitate a tracheotomy for respiration.

14. Supraglottic Stenosis (SGS): Less common and poorly studied, it primarily occurs in adults. Causes include congenital anomalies, iatrogenic injuries (such as from surgical instrumentation), autoimmune diseases (e.g., sarcoidosis, polyangiitis with granulomatosis, cicatricial pemphigoid, lupus, lichen planus), infections (like rhinoscleroma), radiation exposure, chemical or thermal burns, trauma, and laryngopharyngeal reflux. External beam radiation is the most common cause, followed by autoimmune disorders. Supraglottic stenosis can severely narrow the airway, affecting breathing and requiring medical intervention.

15. DIAGNOSIS History and Physical Examination Symptoms: Patients with mild to moderate laryngeal stenosis may be asymptomatic, but respiratory distress often emerges during an upper respiratory tract infection. Common symptoms include: Stridor: Supraglottic stenosis causes inspiratory stridor, while glottic and subglottic stenosis causes biphasic stridor (inspiration and expiration). Voice changes: Hoarseness, breathiness, or complete loss of voice (aphonia) can occur. Feeding difficulties: Coughing, choking, or fatigue during feeding, as well as failure to thrive. Recurrent respiratory infections: These may reflect acute airway narrowing or aspiration pneumonia.

16. History: Important to consider previous intubations, laryngeal trauma, surgeries, and congenital anomalies. Congenital stenosis presents shortly after birth, whereas acquired stenosis typically shows symptoms 2-4 weeks after the inciting event. Physical Examination Flexible fiberoptic laryngoscopy: Performed in the clinic to assess vocal fold function and visualize anterior and posterior glottic stenosis. Full visualization can be challenging. Signs: Patients may show signs of respiratory distress (suprasternal and subcostal retractions) and abnormal vocal function. Radiographic Evaluation Soft tissue radiograph: Useful for children, with an anteroposterior high-kilovoltage technique to highlight the tracheal air column. Airway fluoroscopy: Can assess tracheal dynamics.

17. CT scans: Best for evaluating bone anatomy and can be obtained quickly, though it involves radiation exposure. MRI: Provides excellent soft tissue detail without radiation exposure but requires more time and may necessitate anesthesia. Modified Barium Swallow Study (MBSS): Useful for assessing swallowing function and risk of aspiration, though not always tolerated by children. Salivagram: Can assess aspiration of oral secretions in children unable to tolerate MBSS.

18. Endoscopic Examination Gold standard for diagnosis: Direct laryngotracheobronchoscopy (rigid or flexible) is the definitive method to evaluate and plan treatment for laryngeal stenosis. This examination is typically performed under general anesthesia in the operating room. Assessment: The endoscopy measures the airway lumen, often using progressively larger endotracheal tubes (ETTs), to gauge the severity of the stenosis. Document findings: The length, diameter, and location of stenosis relative to the vocal folds and carina should be recorded. Synchronous airway lesions: The entire airway should be evaluated for the presence of other lesions (e.g., laryngotracheal cleft). Cricoarytenoid joint mobility: Assessed to rule out posterior glottic stenosis (PGS).

19. Pulmonary Function Tests Flow-volume loops: These may show characteristic changes in upper airway stenosis and are useful in comparing pre- and post-operative function. Pulmonologist involvement: Important for evaluating distal airway disease and managing comorbid respiratory conditions. This thorough approach ensures proper diagnosis and treatment planning, particularly since symptoms can range from mild to life-threatening. Immediate airway management may be necessary before a full evaluation, particularly in emergency cases.

20. Endoscopic Approaches: Balloon Dilation: A commonly used method that applies radial pressure to the stenotic airway. The balloon size is age-appropriate, and the pressure is carefully regulated to avoid exceeding its burst limit. Rigid Dilation: Uses mechanical force to widen the stenosis but carries a higher risk of trauma due to the shearing forces involved. Radial Incisions: These are performed with a CO₂ laser or cold knife, making cuts through scar tissue at specific clock-face positions (12, 3, and 9 o’clock), while ensuring the cricoid cartilage is not damaged. This is often followed by dilation to increase the airway diameter. Steroid Injection: Controversially used, steroids are injected locally to reduce scar formation by affecting collagen production during wound healing. However, they can also delay epithelial repair, increase the risk of infection, and cause cartilage resorption, leading to further complications. Endoscopic Stent Placement: Rarely used, stents may be placed to keep the airway open after dilation or other procedures.

21. Laryngeal stents are crucial in airway reconstruction surgeries like laryngotracheal reconstruction (LTR) or posterior cricoid split with costal cartilage grafts. Their primary role is to maintain airway patency, support cartilage grafts, and immobilize mucosal grafts to ensure proper healing. However, stents can sometimes cause complications, such as mucosal injury, ulceration, granulation tissue formation, and restenosis, especially when they don't conform anatomically to the laryngeal contours or are too rigid. Historically, primitive custom-made stents like the finger cot and rolled Silastic sheets were used but have been replaced by more advanced options, including: Aboulker stent Montgomery T-tube Healy pediatric T-tube Montgomery or Eliachar laryngotracheal stents These stents, while more advanced, are still associated with risks of complications.

22. To address these issues, the LT-Mold was designed. It is a silicone stent molded from cadaver larynges, reflecting the natural contours of an abducted larynx. Its softness (50 Shore-A silicone) helps prevent pressure necrosis, especially at the arytenoids. Additionally, it features a silicone cap to prevent granulation tissue formation at its distal extremity. Available in 10 sizes, the LT-Mold can be used in both pediatric and adult patients and can be utilized in both open and endoscopic surgeries. Experience with the LT-Mold in 28 patients has shown promising results, with no evidence of erosion, granulation tissue formation, or other complications when used with the distal cap. This indicates a significant improvement over older stent designs in preventing the common complications associated with airway reconstruction stenting.

23. Mitomycin-C Application: Mitomycin-C (MMC) is an antineoplastic agent applied topically after dilation or scar excision to prevent scar formation. It works by inhibiting DNA and protein synthesis, which helps control scar tissue growth. Although animal studies show its benefits on fresh injuries, the effectiveness of MMC in treating mature scars remains uncertain. Acute airway obstruction is a potential complication due to fibrinous exudate accumulation after MMC application.

24. Anterior Cricoid Split (ACS): This procedure, originally developed for infants who could not be extubated after long-term intubation, involves splitting the cricoid cartilage in the midline to expand the airway. It can be done endoscopically or via an open approach. Grafts made from auricular or thyroid cartilage are sometimes used to improve success rates. While ACS was once a common treatment for congenital SGS, its use has declined due to improvements in neonatal care and the reduced incidence of severe SGS.

25. Laser Techniques: The CO₂ laser is often used to remove scar tissue precisely without damaging healthy surrounding structures. It is particularly effective for early stenosis and can improve airway patency with minimal bleeding or swelling. Fiber-based lasers (such as thulium) provide more accuracy and access to difficult anatomical sites, while radiofrequency coblation and Nd:YAG lasers are alternative options. However, repeated use of the CO₂ laser in unsuccessful cases can worsen the stenosis.

26. Steroids in SGS Management: The use of systemic or locally injected corticosteroids remains a subject of debate. While steroids can help reduce inflammation and scar formation, evidence of their long-term benefit is mixed. Overuse may lead to complications such as delayed wound healing, increased infection risk, and cartilage damage. Each surgical approach has its pros and cons, and the choice of technique depends on factors like the type of stenosis, patient age, and overall health. The risks of airway obstruction, infection, and scar recurrence require close post-operative monitoring.

27. Posterior Cricoid Split (PCS): The endoscopic posterior cricoid split is used to treat stenosis in the posterior glottic area or bilateral vocal fold immobility. The procedure involves dividing the posterior cricoid cartilage and inserting a costal cartilage graft to widen the airway. The use of suspension microlaryngoscopy allows for precise division and graft placement. Patients typically undergo a period of observation in the ICU after the surgery, with plans for extubation or decannulation within a few days.

28. Endoscopic Posterior Cricoid Split Procedure: In 2003, the endoscopic posterior cricoid split procedure was introduced to address certain throat conditions like PGS, SGS, and BTVFI. The procedure can be done with or without a tracheotomy under general anesthesia and suspension microlaryngoscopy for exposure. The technique involves dividing any significant scarring between the vocal cords using micro instruments or a CO2 laser. The posterior cricoid lamina is also divided, and a T-shaped costal cartilage graft is inserted to widen the cricoid circumference without the need for stent placement. The graft is secured in place by placing its flanges into tunnels made behind the divided cricoid on both sides. A safety suture can be added to the graft during placement for easy retrieval if dislodged. Following the procedure, the child is monitored in the ICU and undergoes extubation or decannulation after 2 to 3 days for observation.

29. Management Strategies for BTVFI Assessment and Treatment Options: Observation In cases where spontaneous recovery is anticipated. Botulinum Toxin Injections: Targeting the thyroarytenoid and lateral cricoarytenoid muscles to improve mobility. Recurrent Laryngeal Nerve (RLN) Innervation: Aimed at restoring vocal fold function. Laryngeal Pacing: An emerging technique for stimulating vocal fold movement. Surgical Approaches: Combined Anterior and Posterior Endoscopic Cricoid Split: This novel approach allows for the treatment of bilateral vocal cord paralysis without prior tracheotomy. The anterior cricoid lamina is divided to allow expansion, and the airway is dilated with a balloon. A 74% success rate in avoiding tracheotomy has been reported, although postoperative aspiration remains a risk.

30. Management of Concurrent Stenosis: When vocal cord paralysis accompanies stenosis (anterior, posterior, or complete glottic), additional surgical procedures may be required. Partial and Total Arytenoidectomy: These irreversible procedures can have lasting effects on speech and swallowing; unilateral approaches are often sufficient, but bilateral may be necessary in more severe cases. Endoscopic Laser Arytenoidectomy: A viable option for later interventions.

31. Management of Posterior Glottic Stenosis (PGS) Management of PGS varies based on the stenosis's location and extent. Different approaches are needed for simple interarytenoid adhesions versus more complex cases involving cricoarytenoid joint scarring. Grade-Specific Management: Bogdasarian Grade I PGS: Treatment: Endoscopic lysis of adhesions and scar. Rationale: Intact mucosa prevents scar reformation. Grades II to IV PGS: Treatment: More complex laryngoplasty is needed due to high restenosis risk. Techniques: Keels, stents, microflaps may be utilized to prevent recurrence. Partial laryngofissure: Common approach for advanced cases with cricoarytenoid joint fixation. Severe PGS with Joint Fixation or Subglottic Extension: Approach: Laryngofissure with midline division of the posterior cricoid lamina. Grafting: Insertion of free autogenous costal cartilage graft.

32. Endoscopic Techniques: Recent studies show microrotational flaps have promising outcomes for high-grade PGS. Novel strategies include incising cricoarytenoid joints to mobilize arytenoids and create microflaps to prevent restenosis. Complete Glottic Stenosis: Management: Incising scar anteroposteriorly, grafting posterior cartilage, and placing a stent, often staged. Voice Outcomes: Generally poor due to significant scarring of vocal cords. Caution: Avoid cartilage grafts in anterior commissure to prevent adverse vocal outcomes. Success Rates and Factors: Endoscopic Success Rate: Ranges from 40% to 90%, influenced by: Etiology and extent of stenosis. Congenital causes yield better outcomes than acquired ones. Acute acquired stenosis generally has better outcomes than chronic.

33. Specific Findings: CO2 laser scar destruction effective in 92% of Grade I SGS, but only 46% in Grade II and 13% in Grade III. Risk Factors for Failure: Iatrogenic causes, Grade III or IV stenosis, circumferential scarring, vertical scar dimensions >1 cm, multilevel stenosis, tracheomalacia, bacterial infection, and PGS with arytenoid fixation increase failure risk. Studies show no significant advantage of dilation over laser techniques. PCS with graft placement reports success rates of 60% to 80%. Long-term Outcomes : Patients with isolated PGS have better decannulation rates than those with SGS or BTVFI. Higher-grade stenosis (Grades III and IV) correlates with poorer outcomes, increased need for long-term tracheostomy, and likelihood of requiring more procedures in shorter intervals.

34. Open Surgical Reconstruction Overview Indications: Open surgical reconstruction is considered when conservative airway management fails. The primary goal is early decannulation while minimizing impacts on voice and swallowing. Techniques Expansion Surgery : Aims to widen the glottic and subglottic lumens. Techniques include laryngofissure, cricoid splits, cartilage grafts, and stenting. High success rates (>90%). Resection Surgery: Involves excision of diseased airway portions with primary anastomosis of healthy segments. Typically used when expansion techniques are insufficient.

35. Specific Procedures Posterior Cricoid Split (PCS): Used for various stenosis types, particularly when endoscopic management is inadequate. Involves lateral distraction of the divided cricoid lamina and cartilage grafting. Stenting is crucial during healing to prevent complications like dislodgment. Single-Stage Laryngotracheal Reconstruction (SSLTR) : Combines airway expansion with immediate decannulation. Involves a vertical incision and cartilage graft placement. Requires careful postoperative management to avoid complications.

36. Double-Stage Laryngotracheal Reconstruction (DSLTR): Performed with the tracheotomy in place; decannulation occurs after weeks/months. Suitable for complex cases or patients at risk of complications. Cricotracheal Resection (CTR): Indicated for specific grades of stenosis not involving the glottis. Resects portions of the cricoid with end-to-end anastomosis, yielding good results, even in smaller patients. Postoperative Considerations Complications: Common issues post-surgery include dysphagia, aspiration risks, and voice changes. Monitoring and follow-up are essential for recovery. Voice and Swallowing: A multidisciplinary approach is important for optimizing outcomes related to speech and swallowing, often involving speech-language pathologists.

37. Partial cricoid resection with thyrotracheal anastomosis. (A) Anterior view of the stenotic area to be resected, including the anterior cricoid lamina. (B) Lateral view of the same area. (C) After resection. The trachea is beveled and approximated to the subglottis. (D) Suturing is completed (3-0 polyglactin 910). (E) If a thick scar is present posterior to the subglottis, it is resected with reservation of the posterior cricoid cartilage and a mucosal flap is developed from the posterior tracheal wall. (F) The mucosal flap is sutured and the raw areas are covered.

38. Partial cricotracheal resection. (a) After careful preparation and mobilization of the trachea and larynx, the superior resection line is made at the inferior margin of the thyroid cartilage. The inferior resection line is carried out one ring below the first normal tracheal ring to harvest an anterior pedicled wedge of cartilage that will be used to enlarge the subglottic lumen. The lateral resection line is made just anterior to the cricothyroid joint on both sides. The recurrent laryngeal nerve is shown here for anatomical purposes only; it is deliberately not identified during the surgery.

39. (b) After resection of the anterior arch of the cricoid, the fibrous tissue constituting the posterior aspect of the stenosis is fully resected. The uppermost posterior section of the mucosa passes immediately below the cricoarytenoid joints. The denuded cricoid plate is then flattened with a diamond burr. This allows better adaptation of the tracheal stump to the subglottis. The cartilaginous wedge of the anterior trachea will be used to enlarge the subglottic lumen.

40. (c) Except for the most posterolateral suture, which is placed between the trachea and the cricoid plate, all lateral and anterior stitches are passed between the tracheal ring and the thyroid cartilage. The adaptation of the large tracheal ring to the narrower subglottic space is facilitated by enlargement of the subglottic lumen with the partial inferior midline thyrotomy. The triangular defect is then filled in with the cartilaginous wedge pedicled to the tracheal ring used for the anastomosis

41. Endotracheal stents play a critical role in maintaining airway patency by providing structural support, particularly in cases of airway obstruction or malacia. They can be classified into metal and silicone stents, each with distinct characteristics and uses. Metal stents: Available with or without silastic or polyurethane coverings. Covered stents minimize tissue growth, but uncovered ends help anchor the stent and reduce migration. However, metal stents, particularly older models, have been associated with complications like airway ischemia, granulation tissue formation, perforation, and migration. Modern titanium stents are lighter, easier to insert, and self-expand more uniformly, minimizing some of these risks. Nevertheless, metal stents are often considered permanent due to the risk of epithelialization and granulation tissue growth. Silicone stents: These cause less inflammation and granulation tissue formation, making them easier to remove, but they carry a higher risk of migration. Their use is more common in cases where temporary stenting is necessary.

42. Complications: Granulation tissue formation: Can result from both metal and silicone stents, potentially leading to airway obstruction. Treatment often involves laser therapy. Infections: Stents disrupt mucociliary clearance, which can lead to recurrent infections and mucus impaction. Stent migration: Particularly with silicone stents, which lack firm anchoring. Migration can be dangerous, especially if it threatens the vocal cords or airway patency . Indications: Malignant disease: Stents are commonly used in malignant tracheal disease to alleviate symptoms of airway obstruction or to manage tracheal fistulae. Benign disease: Their use in benign diseases like tracheomalacia or stenosis is more controversial. Due to better long-term prognosis and the challenges in stent removal, metal stents are often avoided in benign cases unless absolutely necessary. Silicone stents are more commonly considered for benign conditions but are typically only used when other interventions fail.

43. Stent Removal: Metal stents: Once integrated into the airway, they are difficult to remove. Rigid or flexible bronchoscopy may be used for removal, but the chances of successful extraction decrease over time. Silicone stents: These are easier to remove but are often avoided due to their tendency to migrate. Current Practices: Prophylactic antibiotics: Some centers, like the one mentioned in your text, routinely offer five days of prophylactic oral antibiotics to prevent infection after stent placement. Surveillance: Regular bronchoscopy is critical for early detection and management of complications like granulation tissue, infection, or stent displacement.

44. Extended Partial Cricotracheal Resection (PCTR) is an effective surgical procedure for treating combined subglottic and glottic pathologies, including various conditions like posterior glottic stenosis, cicatricial fusion of the vocal cords, and scarring in different parts of the larynx. The modified extended PCTR involves creating a complete laryngofissure, removing scar tissue causing posterior glottic stenosis, sometimes sectioning the transverse interarytenoid muscle, and using costal cartilage grafting to address the issue of subglottic stenosis. In both adults and children, a pedicled flap of membranous trachea is created during the procedure to reconstruct the airway. In adults, stenting is usually not necessary, whereas children may require an LT-Mold to restore the laryngotracheal airway to normal. A cartilaginous wedge pedicled to the tracheal ring is inserted to enlarge the subglottic lumen without impacting voice quality in children, followed by resuturing the isthmus of the thyroid gland to optimize vascular supply over the anastomosis.

45. Extended PCTR. (a) PCTR is performed according to the conventional technique. A temporary midline thyrotomy gives access to the cricoid plate. A posterior midline incision of the cricoid plate is made, and a costal cartilage graft is interposed between the divided cricoid laminae (blue arrow).

46. (b) A pedicled flap of membranous trachea is obtained by removing one or two more rings of the tracheal stump distally. This allows delineation of the anterior cartilaginous wedge that will be used to fill in the triangular defect resulting from the inferior midline thyrotomy.

47. (c) The trachea is advanced upward, and its membranous portion is sutured to the mucosa of the posterior commissure of the larynx. The lateral and anterior anastomosis is completed as in conventional PCTR with a pedicled wedge of tracheal cartilage filling in the triangular defect of the inferior midline thyrotomy. Precise repositioning of the anterior commissure is essential to preserve a good voice when suturing the alae of the thyroid cartilage together

48. Specific Recommendations The location of the tracheostoma is crucial for surgical success in cases of subglottic stenosis (SGS) and tracheal stenosis. Placing the tracheostoma between the cricoid and the first tracheal ring allows for easier single-stage surgeries such as Posterior Cricoid Tireoplasty (PCTR) or Laryngotracheoplasty (LTR). Alternatively, placing the tracheostoma lower, at the fifth or sixth tracheal ring, facilitates double-stage PCTR with shorter tracheal resection, leading to better outcomes during reconstructive surgery for SGS. Proper placement of the tracheostoma is essential to minimize the risk of complications like anastomotic dehiscence.

49. Placing the tracheostoma correctly, especially in cases of incipient tracheal stenosis, is crucial to avoid causing additional harm to the normal trachea. Surgeons adhering to these fundamental principles could significantly enhance the outcomes of surgeries for subglottic and tracheal stenoses. Better education in the medical field is essential to ensure that these principles are widely practiced for improved surgical results.

50. The safety of extensive airway resection , specifically regarding the amount of trachea that can be resected and reanastomosed, varies depending on factors such as the patient's age, body build, height, and previous surgeries. For instance, a young adult with a long neck and a high larynx can have a larger segment of the trachea safely resected compared to an older patient with a kyphotic posture and a lower positioned cricoid ring. In experimental studies involving dogs and human cadavers, no definitive answer has been found regarding the maximum length of trachea that can be resected safely. Current surgical experience suggests that approximately half of the pediatric or adult trachea can be removed and reconstructed safely, but the final decision depends on the surgeon's experience and judgment for each patient, considering factors like laryngeal, hilar, and pericardial release.

51. Recapturing tracheal length is crucial for procedures like partial cricotracheal resection (PCTR) and segmental resection of the trachea, especially when reducing tension on the suture line. Various techniques are employed depending on the patient’s anatomy and the length of the resected tracheal segment. In children, advancing the distal tracheal stump is typically easier due to their anatomy and flexibility. In cases where additional tracheal length is needed, laryngeal release techniques are used. A common approach is: Sectioning the thyrohyoid muscle at its insertion on the thyroid cartilage. The thyroid cartilage is pulled caudally (downward) using a laryngeal hook at the thyroid notch. The thyrohyoid membrane is then incised along the upper thyroid cartilage border, leading laterally to its upper cornu, which is sectioned with Mayo scissors. This technique can provide a laryngeal drop of 1.5–2 cm, relieving tension.

52. Laryngeal release procedure. (a) At the level of the second layer of the strap muscles. The sternohyoid muscle is preserved. The thyrohyoid muscle is cut bilaterally just above its insertion on the thyroid cartilage. Then, the thyrohyoid membrane is cut in the midline and along the upper edge of the thyroid cartilage, leading laterally to the upper cornu, which is cut bilaterally with a pair of straight Mayo scissors.

53. (b) Result of the laryngeal drop: a distance of 1.5–2.0 cm has been obtained. In adults, if further tracheal release is required, a more invasive hilar and pericardial release may be performed, often through a sternotomy with an incision into the left fourth interspace. While this method significantly increases the surgical extent, it can provide an additional 2 cm of length, facilitating a tension-free thyrotracheal anastomosis. Preoperative planning, including a thorough endoscopic and radiological assessment, is essential to anticipate the need for such procedures, especially in adults where tension-free anastomosis is more challenging.

54. Postoperative Care and Follow-Up In Laryngotracheal Reconstruction (LTR), particularly for patients with long-standing tracheotomies, there are several important considerations for postoperative care: Preoperative Colonization: Patients often have colonization with bacteria such as Pseudomonas aeruginosa or Staphylococcus aureus. Preoperative bacteriological smears are important to identify these pathogens. Appropriate antibiotics should be administered, often continuing until the subglottic airway is fully healed. Reflux Management: If the patient has gastroesophageal reflux, proton pump inhibitors (PPIs) may be prescribed and continued for up to six months after the surgery to protect the airway during the healing process.

55. Single-Stage LTR: After single-stage LTR, patients are typically intubated for 7–14 days, depending on whether the reconstruction involved an anterior or posterior graft. Paralysis is avoided to allow spontaneous breathing while maintaining airway patency. Endoscopic evaluations are performed on the day of extubation to assess healing, with another evaluation at 3 months if there are no clinical signs of airway obstruction.

56. Double-Stage LTR: For patients with double-stage LTRs who remain tracheotomized, they are often returned to the ward on the first postoperative day, as their caregivers are already experienced in tracheotomy care. The first endoscopy occurs at the time of stent removal, followed by another at 3 weeks. Early plugging of the tracheotomy cannula helps assess the airway’s patency above the tracheostoma. If early plugging is not possible due to complications like suprastomal collapse, an additional endoscopy should be scheduled 10 days later to check for potential subglottic stenosis.

57. Tracheostoma Closure: Once the subglottic area is fully healed and stable, the process of downsizing the tracheotomy cannula over several days is initiated, facilitating the eventual closure of the tracheostoma.

58. Postoperative Management in Children: Children undergoing single-stage Partial Cricotracheal Resection (PCTR) or Segmental Tracheal Resection require careful postoperative management due to their smaller airways compared to adults. Nontracheotomized children are closely monitored in the intensive care unit until they can breathe independently. Broad-spectrum antibiotics and antireflux medication are administered until healing at the surgery site is evident. Use of Medications: Proton pump inhibitors are given for up to 6 months postoperatively. Corticosteroids are initiated before extubation and may continue based on the child's condition.

59. Extubation and Monitoring: Extubation decisions are made based on endoscopic evaluations at 5, 7, or 10 days postoperatively. Heliox, a mixture of helium and oxygen, can be used to reduce postoperative laryngeal edema and stridor. Double-Stage PCTR without Stenting: Children breathing through the tracheostoma after a double-stage PCTR without stenting necessitate a postoperative endoscopy at the third week to evaluate healing progress. In case of suboptimal healing leading to incipient restenosis, a laryngeal stent should be placed endoscopically.

60. Extended PCTRs and Stenting: Extended PCTRs and double-stage PCTRs with stenting require the tracheostoma to remain until the healing of the subglottic anastomosis is complete. Stenting duration may vary from 3 weeks to 6 months or longer, especially in complex reconstruction cases.

61. LTR Outcomes: Grades I and II SGS, the decannulation rate is just under 90%. Grade III SGS, the rate drops to around 80%. Grade IV SGS, the rate falls to 50% or less, suggesting the need for revision surgery in many cases. PCTR Outcomes: In six international centers for severe SGS (grades III and IV), the overall decannulation rate reached 96% (258 out of 269 cases). The two largest centers reported a decannulation rate of 98% for primary PCTR and 93% for salvage PCTR after failed previous airway reconstruction.

62. Extended PCTRs (for SGS with glottic involvement): Decannulation rate of 91% was achieved. However, a significant number of patients needed more than one open procedure (44% in the Cincinnati group and 29% in the Lausanne group), reflecting the complexity of these cases. Long-term outcomes of PCTR: In a recent study with a median follow-up of 5.1 years, 96% of the 57 patients were decannulated. Only one patient experienced moderate exertional dyspnea, while others could participate in sports without restrictions. Voice quality showed an improvement by 1.0 ± 1.34 grade according to the GRBAS system

63. Rib Cartilage Tracheoplasty: First performed by Kimura et al. in 1982, it involves using rib cartilage to reconstruct the anterior tracheal wall in children with long-segment congenital tracheal stenosis (CTS). It initially showed favorable outcomes, but complications like anastomotic leakage, necrosis, granulation tissue formation, and recurrent stenosis at the suture line were common. DeLorimier et al. found that using rib cartilage for more than 30% of the airway circumference resulted in excessive granulation tissue. High rates of reintervention and late mortality due to airway complications were also noted.

64. Pericardial Patch Tracheoplasty: Idriss et al. were the first to report the use of pericardial patches for tracheal reconstruction. This technique involves placing a harvested autologous pericardial patch over the stenosed tracheal segment, often requiring cardiopulmonary bypass. Advantages include the pliability of the pericardial patch and the establishment of an airtight suture line, but complications like granulation tissue formation were significant. This tissue often required multiple bronchoscopic debridement procedures. The largest data series, such as those by Backer et al. and Fanous et al., showed a need for reoperation or airway reintervention in a substantial percentage of patients and a notable rate of early and late deaths.

65. Slide Tracheoplasty: This method, introduced by Tsang and Goldstraw in 1989, involves a horizontal division of the trachea and sliding the two ends over each other to increase the circumference of the stenosed trachea. It has several advantages over other techniques, including less risk of granulation formation, preserved blood supply, and a repair that uses native tracheal cartilage. This technique allows for shorter postoperative intubation periods, satisfactory tracheal growth, and a low incidence of complications like anastomotic leakage or stenosis recurrence. Recent studies show lower mortality and airway complication rates compared to other methods. However, some patients still require balloon dilatation or tracheal stenting postoperatively.

66. Slide tracheoplasty technique. A, Extent of stenosed trachea is identified. Stenotic segment is divided transversely in its midpoint. The upper stenotic segment is incised vertically posteriorly and thelower segment is incised anteriorly for the full length of stenosis. B, Right-angled corners producedby these divisions are trimmed above and below. C, The 2 ends are slid together after placement ofrunning sutures around the entire oblique circumference of the tracheoplasty. D and E, The trachealcircumference is doubled, resulting in quadrupled cross-sectional area.

67. Adult PCTR results match pediatric outcomes: Published studies from 1972 to 2000 showed similar success rates for adult patients (237/249 cases) compared to pediatric patients. Success rate: 95% Mortality rate: 1% Segmentation Tracheal Resection: Dr. Grillo's study on 503 patients revealed a 94% success rate in postoperative results, with good outcomes enabling sports activities without breathing issues and satisfactory outcomes allowing normal activities but inducing stress during exercise. Comparison with Other Studies: The findings align with smaller studies on tracheal resections in adults, affirming the effectiveness of the procedure. Incidence of Failure and Death: From the cases studied, failure was observed in 3.9% of cases, leading to death in 2.4% of the patients.

68. Tips for Avoiding Complications in Airway Stenosis Management: Conduct a thorough preoperative assessment of the patient's medical condition. Provide a detailed endoscopy report on various sites of obstruction, vocal fold mobility, and airway stenosis characteristics. Treat only mature cicatricial stenosis definitively through endoscopic or open surgical procedures. Perform workup studies for gastroesophageal reflux. Importance of Precision and Care in Stenosis Management: Adhere to specific indications for managing different types of stenosis and deciding between single-stage or double-stage procedures. Utilize precise techniques for procedures like LTR, PCTR, and tracheal resection. Ensure close postoperative monitoring of patients for successful outcomes. Warning Against Inappropriate Management of Laryngotracheal Stenosis (LTS): Emphasize that improper initial treatment of LTS can result in permanent complications. Highlight the significance of the first operation in providing the best outcome for the patient.

69. NEW FRONTIERS Current investigative efforts focus on understanding the disease process and refining procedures for airway stenosis. Recent developments in regenerative medicine show promise in treating airway stenosis by using tissue engineering from human stem cells. A recent review using congenital laryngotracheal agenesis as a model discussed the successes and setbacks of tissue engineering in the past 15 years. The review serves as a valuable primer for the field of regenerative medicine and highlights its potential application in airway surgery.

70. THANK YOU