Ann Otol Rhinol Laryngol 97:1988

PROTOCOL FOR MANAGEMENT OF THE INTERPOSITION

CARTILAGE GRAFT LARYNGOTRACHEOPLASTY

C . A. J . P R E S C O T T , F R C S ( E N G )
CAPE TOWN, SOUTH AFRICA

This report presents the results of laryngotracheoplasty surgery using both the Evans and Cotton techniques on 27 children with con­
genital or acquired subglottic stenosis. Failure to obtain early decannulation after surgery has resulted in the formulation of a new protocol
for the operative and postoperative management of infants undergoing cartilage graft tracheoplasty. Excision and closure of the
tracheostoma at surgery, with postoperative nasoendotracheal intubation providing the necessary support for the graft, now has reduced
this period to approximately 2 weeks. A series of six infants for whom this protocol was followed is presented.
K E Y W O R D S — cartilage graft laryngotracheoplasty, endotracheal intubation, tracheostoma closure.

INTRODUCTION tic stenosis usually presents when patients have

Upper airway obstruction is a common problem been intubated in uncontrolled circumstances for
in pediatric otolaryngology. Of the children af­ some other reason — often head injury. Airway
fected, those with laryngeal obstruction tend to pre­ obstruction becomes apparent soon after extubation
sent a more acute problem than those with nasal or when e d e m a develops in the underlying d a m a g e d
pharyngeal obstruction. When there is an underly­ mucosa of the larynx. Granulation tissue thereafter
ing laryngeal stenosis, tracheotomy is usually re­ appears in the ulcerated areas, and as this heals over
quired and m a y have to be maintained for a pro­ a period of time, scarring and contracture per­
longed period, according to Fearon and Ellis' and manently narrow the airway.
Holinger et a l . ' A chronic tracheotomy represents a
major management problem both in terms of pro­ EVANS AND C O T T O N PROCEDURES
longed hospitalization and the risks attendant on
At this hospital, surgical correction of subglottic
tracheotomy in infancy. In recent years, efforts
laryngeal stenosis in children was undertaken first
have been directed toward surgical correction of
in 1978. Between 1978 and the end of 1984, 27 chil­
subglottic stenosis in order to reduce the period of
dren underwent corrective surgery. T h e method de­
time for which tracheotomy is required. In 1974,
scribed by E v a n s and T o d d ' was used until the be­
several authors published pioneering work on this.
ginning of 1984, after which time a change was
Andersen et al^ described a vertical midline split
m a d e to that described by C o t t o n . '
through the stenotic area with subsequent distrac­
tion maintained with an endotracheal stent. Fearon Thirteen children h a d congenital subglottic ste­
and Cotton" similarly described a vertical midline nosis. In correction of ten of these, the Evans sur­
split through the stenotic a r e a , but maintained gical technique was used: seven were extubated at
distraction with a cartilage interposition graft. times ranging from 6 weeks to 3 years after surgery.
Evans and T o d d ' described a castellated vertical in­ (One child required a second procedure.) One child
cision through the stenotic area, which was sutured with Hurler's syndrome was lost to follow-up after
to maintain distraction. transfer to another hospital. A second child devel­
oped necrosis of the anterior aspect of the upper
At the Red Cross War Memorial Children's Hos­
tracheal cartilages, and eventually, after 5 years,
pital in C a p e T o w n , the usual mode of presentation
this was corrected successfully using a cartilage
of congenital subglottic stenosis is that critical air­
graft. A third child, who after removal of the stent
way obstruction is precipitated by acute laryngotra­
developed a thin upper tracheal w e b , still wears a
cheobronchitis (croup). This is a common condition
corked tracheotomy tube for occasional aspiration
here, 500 to 600 such children being seen each year,
of accumulated secretions. Of the three children
of whom half will require admission and one in
operated on by the Cotton technique, all were de-
five, endotracheal intubation. Tracheotomy is per­
cannulated between 4 and 6 months postopera­
formed either when congenital subglottic stenosis is
tively.
suspected strongly at intubation or when it subse­
quently manifests as failure of successful extuba­ Fourteen children h a d acquired subglottic steno­
tion. "This occurs in 3% to 5% of these patients, of sis. In correction of 11 of these, the Evans surgical
whom one in three will require corrective surgery technique was used: nine were successfully decan-
before successful decannulation. Acquired subglot­ nulated at periods ranging from 6 weeks to 3 years
From the Department of Otolaryngology, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
239

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240 Prescott, Interposition Cartihge Graft Laryngotracheoplasty

Patient at
Admission
Age Indication for Underlying Duration of Surgical
Sex (mo) Tracheotomy Disorder Tracheotomy Procedure
Μ 14 Laryngotracheobroncholitis Congenital subglot­ 6 mo Laryngotracheoplasty with an­
tic stenosis terior cartilage graft, 4-mm en­
dotracheal tube
Μ 24 Laryngotracheobroncholitis re­ Congenital subglot­ 2 mo Laryngotracheoplasty with an­
quiring tracheotomy on 3 occa­ tic stenosis terior cartilage graft, 4-mm en­
sions dotracheal tube
F 5 Laryngotracheobroncholitis Congenital subglot­ 18 mo; failed laryngotra­ Laryngotracheoplasty with an­
tic stenosis cheoplasty 6 mo after pri­ terior cartilage graft, 4-mm en­
mary admission dotracheal tube
Μ 3 Postintubation airway obstruction. Acquired subglottic 7 mo Laryngotracheoplasty with an­
(Inguinal hernia repair. Postoper­ stenosis terior cartilage graft, 4-mm en­
ative pneumonia requiring inter­ dotracheal tube
mittent positive pressure ventila­
tion.)
Μ 9 Postintubation stridor. (Inguinal Congenital subglot­ Primary laryngotracheoplasty
hernia repair.) tic stenosis with anterior cartilage graft,
4-mm endotracheal tube

after surgery. (One child required a second pro­ this infection was the colonized tracheotomy site.
cedure.) One child was lost to follow-up after Infection from the stomal area followed the lines of
transfer to another hospital. Another child devel­ exposed r a w tissue left by the procedure. With the
oped a posterior commissure stricture, which still Evans technique, this was visible in the form of
requires correction before attempting decannula- localized granuloma formation in the anterior tra­
tion. Three children were operated on using the cheal wall after removal of the stent, and with the
Cotton technique. One was decannulated after 3 Cotton technique by the presence of granulation tis­
months. A second h a d restenosis after removal of sue around the margins of the cartilage graft.
the stent and required a second procedure before
successful decannulation. T h e third, who has a NEW OPERATIVE AND POSTOPERATIVE
tendency to keloid scarring, has redeveloped a MANAGEMENT PROTOCOL
dense fibrous stricture.
In an attempt to overcome the problems men­
These results were not encouraging, in terms of tioned above, the surgical technique and postopera­
reducing the period of time for which a tracheot­ tive management have been revised since the begin­
omy was required. The major problem experienced ning of 1985. At surgery, the infant is anesthetized
was persistent inflammatory induration of the soft via the existing tracheotomy tube. During prepara­
tissues within the lumen of the larynx and upper tion and d r a p i n g for surgery, this is changed for a
trachea, often with associated granuloma forma­ sterile anesthetic tube and connections. A portion of
tion. This reaction only gradually resolved to the sixth costal cartilage is harvested and stored in nor­
point at which the lumen was of sufficient diameter mal saline, and that incision is closed and dressed.
T h e larynx and trachea are exposed through an inci­
to allow decannulation.
sion incorporating the tracheostoma. A midline ver­
With the Evans technique, it was found that the tical incision through the tracheal cartilages above
Silastic Swiss roll excited profuse granulation tissue the stoma is extended superiorly through the steno­
formation, particularly about its upper end. When sis and overlying cricoid cartilage.
a change was m a d e to a simple Silastic tube stent,
the reaction was less but still present. With a T h e anesthetist then passes a soft nasoendotra-
change to the Cotton technique and a Teflon stent, cheal tube of a diameter that fits snugly, but not
it was hoped that this problem would b e resolved, tightly, in the lower trachea, and the anesthetic
but the granulation tissue reaction about its upper tube in the tracheostoma is removed. T h e stomal
end proved to be even worse. Why these problems tissue and any peristomal granulations are excised.
should have occurred at this institution, not having T h e cartilage previously harvested is shaped and
been reported as occurring from other centers, was sutured in place as described by Cotton' to distend
a cause for major concern and reflection. the cricoid and upper tracheal cartilages over the
endotracheal tube, which then acts as the stent. T h e
It was concluded that the underlying cause was wound is washed well, sprayed with an antiseptic
probably related to a localized, chronic, low-grade powder, and closed in layers with an incorporated
infection in the tissues of the larynx and upper tra­ corrugated rubber drain. A nasogastric feeding tube
chea despite the use of perioperative and post­ is passed and the anesthetic discontinued.
operative antibiotics. This appeared to b e exacer­
bated by the presence of the foreign body that the Postoperatively, the child is nursed in the pedi­
stent represented. Almost certainly, the source of atric respiratory unit. Intravenous antibiotics

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 Prescott, Interposition Cartilage Graft Laryngotracheoplasty 241

RESULTS OF NEW MANAGEMENT PROTOCOL (continued)

Patient at Duration Duration
Admission to First to Second
Age Change Change Duration to
Sex (mo) Complications
Μ 14 5 4 1 yr. No stridor, good voice despite one
episode of respiratory tract infection and
one episode of bleach ingestion. Dis­
charged.
Μ 24 8 4 1 yr. No stridor, good voice despite two
episodes of respiratory tract infection.
Discharged.
F 5 5 5 2 1 yr. No stridor, good voice despite one
episode of respiratory tract infection.
Discharged.
Μ 3 6 3 4 Pneumonia. Intubated for 7 9 mo. No stridor, good voice despite three
days for aspiration of secretions. episodes of respiratory tract infection.
Discharged.
Μ 9 4 Partial prolapse of graft 5 days 9 mo. No stridor, good voice despite con­
after extubation. Intubated for tracting pulmonary TB, for which he re­
further 13 days. mains on treatment.

(cephalosporin) started preoperatively are contin­ quires the support offered by the endotracheal tube
ued until after removal of the drain on the second for about 10 days before its perichondrium will
postoperative day. T h e antibiotic thereafter is given have become vascularized from the adjacent mu­
via the nasogastric tube. cosa and its cartilage firmly adheres to the adjacent
trachea.
One week postoperatively, the nasoendotracheal
tube is changed under anesthetic for a tube one
whole size smaller (usually from 4 mm to 3 m m in­
DISCUSSION
ternal diameter). TTiis step is necessary because the
larger tube excites considerable e d e m a of the tissues Failure of uniformly successful, early postopera­
about the glottis. Three days later, extubation is at­ tive decannulation after laryngotracheoplasty can
tempted under general anesthesia. If it is successful, b e attributed to inflammation and induration in the
the child is returned to the respiratory unit, where submucosid tissues of the larynx and upper trachea.
any stridor that m a y develop is m a n a g e d with nebu­ T h e stent, necessary for support of the graft until it
lized adrenaline inhalations. Should there b e no re­ has become firmly adherent to the laryngeal and
sponse to these, direct laryngoscopy under general tracheal cartilages, acts as a foreign body and exac­
anesthesia is performed with reintubation. E x t u b a ­ erbates the inflammatory reaction. T h e tracheosto-
tion is attempted again 3 days later. m a invariably is colonized by bacteria, and in some
cases spread of organisms into the inflamed tissues
RESULTS occurs before healing can take place and predis­
poses the site to a state of low-grade, chronic infec­
This protocol has been followed with five infants tion. This exacerbates the induration, and granula­
(Table). T w o were successfully extubated on the tion tissue appears in ulcerated areas. It is a basic
first attempt. T w o required a second period of in­ surgical principle that infection around a foreign
tubation. One of these, 3 days after extubation, body is unlikely to resolve until the foreign body is
developed bronchopneumonia with copious secre­ removed. This would explain the exuberant growth
tions and required a period of reintubation for of granulation tissue seen at times around the stent
aspiration of the secretions. With the last child, after laryngotracheoplasty.
primary extubation w a s attempted on the fourth
postoperative day (when it was noted that the Therefore, it would a p p e a r reasonable in such
perichondrium of the cartilage graft h a d not begun surgery to aim at closure of the tracheotomy with
vascularization). Persistent stridor developed 5 days excision of its colonized stoma at surgery in order to
later, and laryngoscopy revealed that the cartilage remove this site of potential complications. Al­
graft had prolapsed partially into the subglottic though it can be expected that the expanded sub­
lumen. Reintubation was required for a further 13 glottic area would provide an a d e q u a t e postopera­
days before successful extubation. Laryngoscopy tive air p a s s a g e , the possibility exists that this m a y
performed at extubation revealed that the perichon­ be rendered inadequate should e d e m a develop.
drium of the cartilage graft had become vascular­ Further, the negative pressure that develops within
ized. In all children it was noted that the trache­ the upper trachea during inspiration could predis­
ostome had healed by the time of extubation. There pose to inward prolapse of the graft before it has be­
was no significant formation of granulation tissue come firmly adherent. A period of postoperative en­
around the cartilage graft. F r o m the last case it has dotracheal intubation would serve to prevent these
been concluded that the cartilage graft probably re­ potential complications. T h e tube would still be

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242 Prescott, Interposition Cartilage Graff Laryngotracheoplasty

acting as a foreign body, but because it is only in a protocol that has demonstrated its effectiveness in
situ for a short period of time, any infection that reducing the period of postoperative intubation to
develops around it can be controlled with systemic between 10 and 20 days. This is an a d v a n c e in
antibiotics. laryngotracheoplasty surgery, a n d it is hoped that
its presentation will be of interest to others working
This small series of patients has been m a n a g e d by in this field.

REFERENCES
1. Fearon B, Ellis D. The management of long term airway 4. Fearon B, Gotton R. Surgical correction of subglottic ste­
problems in infants and children. Ann Otol Rhinol Laryngol nosis of the larynx in infants and children. Progress report. Ann
1971;80:669-77. Otol Rhinol Laryngol 1974;83:428-31.
5. Evans JNG, Todd GB. Laryngotracheoplasty. J Laryngol
2. Holinger PH, Kutnick S L , Schild JA, Holinger L D . Sub­ Otol 1974;88:589-97.
glottic stenosis in infants and children. Ann Otol Rhinol Laryngol
1976;85:591-9. 6. Cotton R. Management of subglottic stenosis in infancy
and childhood. Review of a consecutive series of cases managed
3. Andersen HC, Elbrond O, Greison O. Treatment of tra­ by surgical reconstruction. Ann Otol Rhinol Laryngol 1978;87:
cheal stenosis. J Laryngol Otol 1974;88:615-24. 649-57.

NINCDS NOTES ^

RESEARCH GRANTS AVAILABLE

Grant applications to study dysphagia associated with neurologic disorders and to study progressive hearing impairment are currently
being sought by the Division of Communicative and Neurosensory Disorders of the National Institute of Neurological and Communicative
Disorders and Stroke (NINCDS).
For the dysphagia research initiative, both basic and clinical investigators of the oral, pharyngeal, and laryngeal aspects of swallowing
disorders (in patients with neurologic diseases) are encouraged to submit grant proposals.
Hearing loss proposals may include studies of 1) the pathophysiological bases of progressive hearing impairment, including the in­
teraction of time, severity, and noise; 2) changes in auditory system neurotransmitters; and 3) animal model studies of disordered cochlear
blood flow related to such factors as exposure to ototoxic agents and to noise.
For further information on dysphagia applications, contact Dr Judith Cooper, Division of Communicative and Neurosensory
Disorders, NINCDS, Federal Building, Rm lC-06, 7550 Wisconsin Ave, Bethesda, MD 20892; (301) 496-5061. For further information of
progressive hearing loss proposals, contact Dr Ralph Naunton in Rm IC-Il at the above address; (301) 496-1804.

•This information is prepared monthly by the Office of Scientific and Health Reports, NINCDS, NIH, Bldg 31, Rm 8A-06. Bethesda, MD 20892; (301)
496-5924.

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