Secrets in Cricotracheal Resection for Benign Laryngotracheal Stenosis

Research Article

Austin ENT Open Access. 2018; 2(1): 1004.

Secrets in Cricotracheal Resection for Benign Laryngotracheal Stenosis

Mettias ADB¹*, Mosleh M² and Elbestar MF²

¹ENT Lecturer, Fayoum University, Fayoum, Egypt

²ENT Professor, Cairo University, Egypt

*Corresponding author: Bassem A D Mettias, ENT Lecturer, Fayoum University, Fayoum, Egypt, 8 Stanborough Green, Welwyn Garden City, UK

Received: December 19, 2017; Accepted: January 02, 2018; Published: January 09, 2018


Background: Benign Laryngotracheal stenosis is a challenging airway disease. Laser and reconstructive surgeries are less successful in severe stenosis. Method: A retrospective evaluation of 29 patients with laryngotracheal stenosis who had segmental resection with end-to-end anastomosis. Patients were Cotton’s grade 3-4 and McCaffrey stage III. The approaches were tracheatracheal, cricotracheal, thyrocricotracheal in 14, 10 and 5 respectively. Patients underwent laryngeal release procedures according to length of resection. Results: 22 patients had successful outcome. 5 patients (17.2%) failed. The success rate was higher (90%) in short segment compared to 68% in long segments. 15 patients didn’t have further intervention while 6 patients did; one had repeat resection and the rest dilatation. 10.3% had postoperative vocal cord paralysis. Conclusion: The tips for successful segmental resection in airway surgery should start with patient selection, surgical approach to the stenosis and tension free anastomosis. Segmental resection has very successful outcome in severe laryngotracheal stenosis for short and long term.

Keywords: Subglottic; Trachea; Stenosis; Ruyesection; Anastomosis


The causes of adult laryngeal and upper tracheal stenosis vary between traumatic, idiopathic, chronic inflammatory disease, collagen vascular disease, benign and malignant neoplasms [1]. The most common cause is iatrogenic internal injury [2]. Patients typically present with months to years of exertional dyspnea or cough, which has often been misdiagnosed as asthma. Others are diagnosed in intensive care with failure of weaning of endotracheal tube [3]. An endotracheal cuff pressure greater than 30mm Hg exceeds the mucosal capillary perfusion pressure, causing mucosal ischemia, which may lead to ulceration and chondritis of the tracheal cartilages. These circumferential lesions heal with fibrosis, leading to a progressive tracheal stenosis [4].

In 1994, Myer-Cotton System modified the original Cotton System in 1984. He classified the horizontal stenosis into 4 grades; depending on the percentage of narrowing of the lumen [5]. McCaffrey designed another clinical staging depending on the vertical length and the location of the stenotic segment [6]. Monnier et al. designed another staging system with considering the co-morbidities and glottis involvement that can affect the prognosis [7].

Surgical options for laryngotracheal stenosis are closed or open techniques. In closed operation, dilatation, endoscopic laser ablation or laryngotracheal stents can be used. In the open approach, different procedures are used such as cricoid splitting procedures, Laryngotracheaplasty (LTP), vascularized myo-osseus flap, slide tracheoplasty, tracheal transplantation, Cricotracheal Resection (CTR) [8]. The standard technique used in the curative treatment of laryngotracheal stenosis is the segmental resection and anastomoses, by means of tracheotracheal anastomsis through the Küster operation and cricotracheal resection through the Pearson operation. The Rethi operation is reserved for cases of glottic and subglottic stenosis [9]. During the 1980s and 1990s, it became apparent, notably through the work of Grillo, and Laccourreye, that resection of laryngotracheal stenosis with primary anastomotic reconstruction could achieve decannulation rates up to 97% [10,11].

The advantages of CTR are preservation of the normal framework of the larynx and trachea, may improve postoperative voice abilities and laryngeal function, near normal-mucosalized airway without granulation tissue formation, which is seen after the use of cartilage grafting and longer-term stenting and finally avoidance of donor site morbidity [12].

The potential complications of partial cricoid resection include difficulty with deglutition and aspiration, vocal cord paralysis, suture granulomas, anastomotic dehiscence, and re-stenosis [13].

Material and Methods

This study is a retrospective case series of 9 years experience (Level III evidence). It was done at Kasr Al Ainy hospital of the Cairo University between January 2001 and April 2010. 29 patients were recruited; who presented with chronic airway obstruction due to combined Subglottic (SGS) and tracheal stenosis.

Every patient was evaluated by history of presenting symptoms, cause of stenosis and past medical history for fitness of general anesthesia with emphasizing on diabetes mellitus, pulmonary function. Any previous treatment was evaluated regarding the type of surgery, the duration of postoperative free symptoms.

Full head and neck examination and degree of respiratory distress were done. Every patient had flexible laryngoscopy to assess the mobility of the vocal cords and the diameter of airway according to Cotton classification. Every patient had axial CT neck of 2mm cuts with saggital reconstruction. The vertical length of stenosis from imaging and flexible laryngoscopy was calculated according to McCaffrey criteria.

Patients were selected for CTR according to following criteria

• Length of stenosis < 6cm of subglottic and/or upper tracheal wall.

• Severe stenosis (grade III or IV) as classified by Cotton grading.

Exclusion criteria are stenosis extending to less than 5mm below the true vocal cords, associated gottic and/or supraglottic stenosis, long segment stenosis more than 6cm, associated bilateral vocal cords paralysis or bilateral arytenoid fixation, mild stenosis (Cotton I, II) candidate for laser dilatation or other methods, neoplasia and tracheomalacia.

Direct laryngoscopy under general anesthesia for endoscopic calculation of stenosis according to Cotton was done for all patients either during initial preoperative tracheostomy or before the definitive surgery. 4mm Hopkin rod 0° bronchoscope was used with Photo-documentation (Figure 1).