Annals of Otology. Rhinology & Laryngology 122(7):445-449.
© 2013 Annals Publishing Company. All rights reserved.
Novel Method for Laryngotracheal Reconstruction:
Combining Single- and Double-Stage Techniques
Jennifer Setlur, MD; Stephen Maturo, MD; Christopher J. Hartnick, MD
Objectives: Traditional open techniques for laryngotracheal reconstruction are either single- or double-stage procedures.
Some patients may benefit from the presence of a long, single-tube stent, such as an endotracheal tube, but their predicted
need for a 2-stage procedure and a persistent tracheostomy is high. We describe a novel technique for airway reconstruction that combines the methods of both single- and double-stage procedures.
Methods: We present a retrospective review of 4 patients. All patients underwent laryngotracheal reconstruction by a
single surgeon. After the operation, the airway was stented with nasotracheal intubation. A small stent, fashioned from an
endotracheal tube, was placed in the tracheostoma to keep it patent. The patients subsequently underwent extubation and
replacement of the tracheostomy tube.
Results: The study included 1 patient with grade 4 subglottic stenosis, 2 patients with grade 3 subglottic stenosis, and 1
patient with a posterior glottic scar. All were tracheostomy tube-dependent. Serial bronchoscopy was used to follow the
patients for a minimum of 9 months after the operation. All 4 patients have since met the criteria for decannulation.
Conclusions: This hybrid reconstruction merges the advantages of both the single- and double-stage procedures. It adds
versatility to the surgical toolbox for airway reconstruction.
Key Words: airway surgery, laryngotracheal reconstruction, pediatrics, subglottic stenosis, tracheostomy.
INTRODUCTION
onto the airway mucosa itself. Also, there is the risk
of either aspiration or supraglottic granulation tissue
or stenosis if the top limb of the stent is fashioned
either too long or too short."*
The problem of laryngotracheal stenosis remains
a significant burden on the pédiatrie population.
Numerous methods have been attempted to treat
stenosis, but open techniques endure as a mainstay
of therapy despite the development of endoscopie techniques.''2 Laryngotracheal reconstruction
(LTR) with cartilage grafting was initially described
as double-stage LTR (dsLTR).^ As such, it allows
the tracheostomy tube to remain in place throughout the duration of the reconstruction and recovery, with decannulation planned at a later date. This
technique may be useful in patients with high-grade
stenosis, for combined glottic and subglottic stenosis, or when there are significant comorbidities that
prevent immediate decannulation. Nevertheless, by
definition, it necessitates postoperative continued
tracheostomy dependence. Additional problems inherent to this technique are the need for an abovestoma stent that rests immediately adjacent and superior to the tracheostomy tube in the airway lumen.
There are significant risks of suprastomal granulation tissue development and, at times, frank stenosis
development due to rubbing of the inferior edge of
the stent onto the top of the tracheostomy tube and
Single-stage LTR (ssLTR) was developed as
means of reconstructing the airway without a tracheostomy tube, and therefore allows for decannulation at the time of reconstruction or avoidance of
a tracheostomy altogether.^ Although this may seem
more advantageous, it also comes with a risk of having to rely solely on the reconstructed airway after
the operation. For younger children, when muscle
relaxants and sedatives are used while the child remains intubated, there may be a prolonged recovery resulting from withdrawal of sedation, as well
as the need for physical therapy to help with the ensuing hypotonia. A single-stage reconstruction poses the additional risk that a child may need emergent reintubation and replacement of the tracheostomy tube after the operation. Such airway crises
may be dangerous for children and psychologically
traumatic for their families. In spite of their limitations, both dsLTR and ssLTR have been developed
and refined over time to allow for excellent patient
outcomes.^"^
From the Department of Otolaryngology, Massachusetts Eye and Ear Infirmary (all authors), and the Department of Otology and Laryngology, Harvard Medical School (Setlur, Hartnick), Boston, Massachusetts.
Correspondence: Christopher J. Hartnick, MD, Dept of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114.
445
Setlur et al. Hybrid Laryngotracheal Reconstruction
446
Fig 1. Measurement of size 3.0 endotracheal tube to
match length of tracheostomy tube.
Surgical management of the stenotic airway relies not only on the surgeon's technique, but also
on careful patient selection and preoperative planning.'O-" Consequently, once it has been determined
that a patient requires an open procedure, it can be
difficult to choose between dsLTR and ssLTR, as the
benefits and risks of each may for that patient not
be clear-cut. We have developed a novel technique
that allows the surgeon to combine the advantages
of both dsLTR and ssLTR. The hybridization of LTR
can continue to improve patient outcomes after open
airway surgery for laryngotracheal stenosis.
METHODS
Institutional Review Board approval was obtained
to perform a retrospective medical record review of
all patients who underwent LTR with cartilage grafting at a tertiary care children's hospital. All procedures were performed by a single surgeon. The patients underwent anesthetic induction via their existing tracheostomy tubes. Once they were asleep, diagnostic rigid bronchoscopy was performed. Next,
the tracheostomy tube was removed and replaced
with an endotracheal tube (ETT) secured to the
chest. A transverse skin incision was made to expose
the superior portion of the trachea and the cricothy-
Fig 2. Suture closure of one end of endotracheal tube
stent.
Fig 3. Cloth ties sutured to stent.
roid cartilage complex. This incision was kept separate from the tracheostomy site. The specifics of
reconstruction were tailored according to the bronchoscopy findings.
After reconstruction, the patients were then nasotracheally intubated and the reconstructed airway
was closed over the ETT. The ETT was then removed from the tracheostoma. The length of the patient's preexisting tracheostomy tube was measured,
and a size 3.0 ETT was cut to match (Fig 1). The
external portion of this tube was sutured closed with
3-0 Prolene (Ethicon, Somerville, New Jersey; Fig
2). This was placed into the tracheostoma and secured to the neck with cloth ties (Figs 3 and 4). The
Fig 4. Stent secured to patient's neck and seated in former tracheostoma.
Setlur et al. Hybrid Laryngotracheal Reconstruction
AAl
SUMMARY OF CASES
Age
(y)
Sex
1
5
M
2
14
M
Bilateral vocal fold paralysis
posterior glottic scar
Grade 4 stenosis
3
4
1.5
5
M
M
Grade 3 stenosis
Grade 3 stenosis
Patient
Diagnosis
Procedure
Decannulated
Anterior laryngofissure, posterior graft
No
Anterior and posterior laryngofissure, open removal of
scar tissue
Anterior laryngofissure, posterior graft
Anterior laryngofissure, posterior graft
No
Yes (at 4 mo)
Yes (at 3 mo)
transverse neck incision was then closed in a layered
fashion over a rubber-band drain.
all were approved for a regular diet without restriction or risk of aspiration.
At the conclusion of the procedure, the patients
were taken to the pédiatrie intensive care unit, in
which a chest radiograph confirmed the placement
of both the ETT itself and the fashioned stent. The
neck was dressed in such a way as to prevent significant air leak from the tracheostoma. The children
remained intubated and sedated until postoperative
day 7, at which time they returned to the operating
room. The ETT was removed, and diagnostic rigid
bronchoscopy was performed. Once bronchoscopy was completed, the tracheostomal stent was removed and replaced with the patient's tracheostomy
tube.
The patients were followed for a minimum of 9
months after the operation with serial bronchoscopy. One patient required balloon dilation to maintain the reconstructed airway lumen at 1 month after the operation (patient 4). The remaining patients
did not require airway manipulation. Two of the patients have been successfully decannulated. Another
patient is ready for decannulation, but his parents
have not opted for this yet. This patient could have
been a candidate for either ssLTR or dsLTR, but the
family had reservations about a single-stage procedure because of concern for recannulation. They remain too fearful to consider decannulation despite a
stable airway. During the follow-up period, no patients had evidence of supraglottic or suprastomal
granulation tissue.
RESULTS
A total of 4 patients underwent the hybrid LTR
procedure (see Table). All patients were tracheostomy tube-dependent at the time of reconstruction.
All patients were male, and the mean age was 6.3
years (range, 1.5 to 14 years). Two patients carried a
diagnosis of grade 3 subglottic stenosis with glottal
involvement, 1 patient had grade 4 stenosis, and 1
patient had bilateral vocal fold paralysis and a posterior glottic scar. The degree of stenosis was graded
according to the Cotton-Myer system for subglottic
stenosis. 12 Three of the 4 patients underwent anterior laryngofissure and placement of a posterior graft,
and 1 patient underwent anterior and posterior laryngofissures with debridement and excision of scar
tissue from the airway lumen.
Three patients were deemed candidates for this
procedure because of high-grade glottic or subglottic stenosis and the need to rely on the tracheostomy
for postoperative airway support. The fourth patient
was truly a candidate for T-tube placement, but was
too young for this. Each of the families was educated as to the risks and benefits of each technique, and
they opted for the novel technique. None of the patients experienced accidental extubation, alar necrosis, or postoperative infection or pneumonia. Each
patient was placed on a narcotics weaning schedule
after extubation. All underwent a modified barium
swallow study to assess for possible aspiration, and
DISCUSSION
Surgical management of the patient with laryngotracheal stenosis requires the surgeon to possess
an extensive toolbox that offers versatility to the patient. A combination of dsLTR and ssLTR can prove
very useful when applied to the correct patient population. Because the plan is to leave the patient with
the tracheostomy after the reconstruction, patients
who undergo hybrid LTR should be those who the
surgeon predicts will be tracheostomy-dependent.
According to dsLTR selection criteria, this includes
patients with high-grade stenosis, multilevel stenoses, or other comorbidities that prevent successful
decannulation.^ With the tracheostomy tube in place,
the airway remains secure in the critical postoperative period. Additionally, this method is useful when
emergent postoperative access to the airway may be
difficult or impossible, as may be the case for patients with craniofacial or vertebral anomalies.
Typically, patients who are candidates for a hybrid, or one-and-a-half-stage, reconstruction are
those who would benefit from the placement of a
long-segment but short-term stent in the airway, as
described for the ssLTR.^^ This allows the reconstructed airway to heal and grafts to take. Where-
448
Setlur et al. Hybrid Laryngotracheal Reconstruction
as strict single-stage procedures make the postoperative management of the airway difficult and are
best for patients with lower-grade stenosis requiring a single graft, the presence of a stent in the tracheostoma in the hybrid LTR allows for emergent
airway access, thereby allowing ssLTR to become
applicable to patients with higher-grade or complex
In performing airway surgery on children with
complex stenoses, safety in the perioperative period
is of the utmost importance, particularly during single-stage procedures. The success rates are affected
not only by careful preoperative planning and patient selection, but also by events that may not be directly under the surgeon's control."''^ Events such
as plugging of the ETT or unplanned extubation may
occur. Although it is convenient to have pédiatrie intensivists on hand to aid in the management of these
events, we recognize that this is not always a possibility. In instances in which staffing of the intensive
care unit may be limited, we advocate the use of the
hybrid reconstruction, as the tracheostomal stent offers the team emergent access to the airway, while
treating underlying sedation or ventilation issues.
Experience with ssLTR has shown that not only
is it important to formulate a plan in case of airway
loss, but that it is also important to use nasotracheal
intubation.'^ This has been incorporated into the hybrid LTR in an effort to improve patient outcomes.
Prior studies have shown that nasotracheal intubation can be well tolerated in children, and can lead
to reduced requirements of sedatives and paralytics.'^-'^ As such, the incidence of adverse sequelae
such as atelectasis, sedation withdrawal syndrome,
and neuromuscular weakness can be reduced.'^ Of
particular interest is the applicability of this technique to patients with glottic or subglottic stenosis
who may be best served by T-tube placement but
are too young for such treatment. The period of intubation allows the glottic airway to be stented after
reconstruction, but offers the tracheostomy as additional support once the stent is removed. The glottic
airway can then be monitored for patency while the
tracheostomy is in place for airway protection.
This combined technique may be of particular
benefit to children whose parents are apprehensive
about sudden airway compromise after ssLTR and
have a significant fear of emergent recannulation.
In our study, we had one set of parents who felt that
neither they nor their child was ready for decannulation simultaneous with airway reconstruction (patient 1). The child had an underlying autistic condition, and his parents were concerned that the child
would find it hard to cope with a complex surgery
and removal of the tracheostomy tube. Our hybrid
technique allows time not only for the reconstructed airway to heal and be monitored for patency, but
also for the family to prepare themselves for subsequent decannulation.
Eurthermore, performing a hybrid LTR offers the
advantage of repairing anterior trachéal collapse.
Erequently, a component of suprastomal trachéal
collapse is a sequela of tracheostomy dependence,
and may hinder decannulation.'^ In instances in
which the tracheostomy tube is replaced immediately after reconstruction, the repair of the anterior trachéal wall may be put at risk of failure. The hybrid
technique allows for adequate manipulation of the
anterior trachéal wall, followed by a period of immobility to allow for healing.
The hybrid LTR method combines the advantages of dsLTR and ssLTR and results in a novel approach that is highly versatile. However, we do acknowledge that there are limitations. Consultation
with a pédiatrie intensivist is essential for postoperative ventilation management. If the neck and peristomal area are not dressed appropriately to minimize air leak, determining adequate ventilator settings can be a significant challenge. Consequently,
it may be hard to calculate the patient's true ventilation requirements and weaning needs. As a last resort, the tracheostomal stent has the option of being
removed. We have found that careful attention to the
neck dressing with daily changes is the best management option for a peristomal air leak and have
not yet had to remove the stent.
The one-and-a-half-stage technique combines
many of the advantages of the 1- and 2-stage procedures together. One of the drawbacks of ssLTR that
we know of is the relatively high rate of reintubation
after planned extubation, due to subglottic swelling,
oversedation, or withdrawal issues. The hybrid procedure allows the child to recover from being sedated without the need for sudden, semi-urgent or
urgent reintubation that may result in laryngeal trauma. It has been our experience that many parents are
more comfortable with hybrid reconstruction than
with ssLTR, in which there is a sudden transition of
the airway that can affect the child, the parents, and
general family life. That is, children who have been
living with their tracheostomy tubes for a long time
either succeed or need revision tracheostomy, which
may be psychologically traumatizing. The hybrid
procedure provides a smoother transition.
As compared to dsLTR, hybrid reconstruction offers the distinct advantage of a single smooth stent
(the ETT) without the granuloma formation possible
at the junction of the tracheostomy tube and a su-
Setlur et al. Hybrid Laryngotracheal Reconstruction
prastomal stent. The relative disadvantage of a hybrid procedure as compared to dsLTR is that in children too young to tolerate awake nasotracheal intubation (generally those younger than 3 years of age),
there may be problems related to long-term sedation
or muscle relaxation. Therefore, a one-and-a-halfstage procedure is the best option for children who
otherwise might be candidates for a possible single-
449
stage procedure.
We have offered a small case series, but hope
to expand this in the future. Our goal was to focus
on the hybrid technique as one that allows quicker postoperative weaning from ventilatory support,
reduced anesthesia needs, and an overall reduced
length of stay.
REFERENCES
1. Santos D, Mitchell R. The history of pédiatrie airway reconstruction. Laryngoscope 2010;120;815-20.
11. Choi SS, Zalzal GH. Pitfalls in laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg 1999;125;650-3.
2. Herrington HC, Weber SM, Anderson PE. Modem management of laryngotracheal stenosis. Laryngoscope 2006;1161553-7.
12. Myer CM III, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube
sizes. Ann Otol Rhinol Laryngol 1994;103;319-23.
3. Fearon B, Cotton R. Surgical correction of subglottic
stenosis of the larynx in infants and children. Progress report.
Ann Otol Rhinol Laryngol 1974;83;428-31.
13. Lusk RP, Gray S, Muntz HR. Single-stage laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg 1991;
4. Zalzal GH. Stenting for pédiatrie laryngotracheal stenosis . Ann Otol Rhinol Laryngol 1992 ; 101 ; 651 -5.
5. Prescott CA. Protocol for management of the interposition cartilage graft laryngotracheoplasty. Ann Otol Rhinol Laryngol 1988;97;239-42.
6. Smith LP, Zur KB, Jacobs IN. Single- vs double-stage
laryngotracheal reconstruction. Arch Otolaryngol Head Neck
Surg2010;136;60-5.
7. Agrawal N, Black M, Morrison G. Ten-year review of
laryngotracheal reconstruction for paediatric airway stenosis.
Int J Pediatr Otorhinolaryngol 2007;71;699-703.
8. Liew L, Blaney SPA, Morrison GAJ. Surgical selection
and outcomes in laryngotracheal reconstruction for subglottic
stenosis. Int Congr Ser 2003; 1254; 147-50.
9. Gustafson LM, Hartley BEJ, Liu JH, et al. Single-stage
laryngotracheal reconstruction in children; a review of 200 cases. Otolaryngol Head Neck Surg 2000;123;430-4.
10. Myer CM III, Hartley BEJ. Pédiatrie laryngotracheal surgery. Laryngoscope 2000; 110; 1875-83.
14. Saunders MW, Thirlwall A, Jacob A, Albert DM. Single-or-two-stage laryngotracheal reconstruction; comparison of
outcomes. Int J Pediatr Otorhinolaryngol 1999;50;51-4.
15. Schmidt RJ, Shah G, Sobin L, Reilly JS. Laryngotracheal
reconstruction in infants and children; are single-stage anterior
and posterior grafts a reliable intervention at all pédiatrie hospitals? Int J Pediatr Otorhinolaryngol 2011 ;75; 1585-8.
16. Rothschild MA, Cotcamp D, Cotton RT. Postoperative
medical management in single-stage laryngotracheoplasty. Arch
Otolaryngol Head Neck Surg 1995;121;1175-9.
17. Jacobs BR, Salman BA, Cotton RT, Lyons K, Brilli RJ.
Postoperative management of children after single-stage laryngotracheal reconstruction. Crit Care Med 2001 ;29; 164-8.
18. Bauman NM, Oyos TL, Murray DJ, Kao SC, Biavati MJ,
Smith RJ. Postoperative care following single-stage laryngotracheoplasty. Ann Otol Rhinol Laryngol 1996;105;317-22.
19. Willis R, Myer C, Miller R, Cotton RT. Tracheotomy decannulation in the pédiatrie patient. Laryngoscope 1987;97;7645.
Copyright of Annals of Otology, Rhinology & Laryngology is the property of Annals
Publishing Company and its content may not be copied or emailed to multiple sites or posted
to a listserv without the copyright holder's express written permission. However, users may
print, download, or email articles for individual use.