INTRODUCTION
Laryngotracheal reconstructive procedures have substantially advanced after Evans and Cotton introduced open laryngotracheal reconstruction (LTR) with an anterior costal cartilage graft in the 1970s, achieving a decannulation rate of over 90%. Moreover, in the 1980s, Cotton developed an open posterior cricoid division using a cartilage grafting technique combined with anterior grafting to expand the subglottic and posterior glottis.
Endoscopic airway surgeries were first reported in the 1960s, but their progress was limited until the development of new rigid laryngoscopes, endoscopic instruments, and high-definition telescopes in recent years. Posterior cricoid split with a rib graft was initially performed through an open partial laryngofissure, which could disrupt the laryngeal framework. Therefore, in 2003, Inglis introduced an endoscopic approach to this procedure involving the use of LASER or cold steel to endoscopically divide the posterior cricoid lamina. The designed rib cartilage graft is inserted into the divided cricoid to widen the posterior glottic aperture. This endoscopic technique offers several advantages, including shorter hospital stays, avoidance of extensive neck dissection, and minimal skin scarring.
Building upon advancements in endoscopic techniques, senior author Ahmed Alammar has led our institution in successfully planning and performing endoscopic anterior cricoid split and rib grafting in an animal model, demonstrating its feasibility in three goats (unpublished data presented at the American Society of Pediatric Otolaryngology [ASPO] 2022 Summer Meeting).
We hereby present our successful experience using this technique in humans, detailing the steps of the procedure and outcomes.
MATERIALS AND METHODS
This study presents a novel endoscopic anterior LTR with costal rib cartilage grafting performed in October 2023 at King Saud University Medical City. The study proposal was reviewed and approved by our Institutional Review Board under project number E-23-8317. Written informed consent of the legal guardian was obtained.
The child was an otherwise healthy two-year-old girl with acquired subglottic stenosis (SGS). She was intubated at birth due to meconium aspiration and underwent tracheostomy at another center at one month of age.
Pre-operative evaluations included flexible nasopharyngolaryngoscopy, 24-hour pH monitoring, methicillin-resistant Staphylococcus aureus (MRSA) colonization screening, swallowing evaluation, and direct laryngoscopy and bronchoscopy (DLB).
The selection criteria for this procedure were pediatric patients aged <18 years with grade II or III subglottic stenosis (SGS) that was unsuitable for or had failed endoscopic balloon dilation trials. Additionally, the patient’s legal guardian was willing to participate in the study. Because this was the first trial of its kind in a human model, a candidate with a tracheostomy was chosen to ensure airway safety below the graft. Our exclusion criteria were patients who were 18 years or older, had poor endoscopic laryngeal visualization, grade IV SGS, multiple levels of laryngotracheal stenosis, bilateral vocal cord immobility, or significant comorbidities.
Surgical Technique
Under general anesthesia, the larynx was visualized using a size 3 PARSONS laryngoscope (Karl Storz GmbH & Co KG, Tuttlingen, Germany) and inspected with a 4-mm, 0-degree Hopkins rod–lens telescope (Karl Storz GmbH & Co KG, Tuttlingen, Germany). The larynx was then anesthetized using 1% lidocaine (5 mg/kg). After obtaining the size and measurement of the stenosis, an endoscopic incision was made in the anterior midline of the cricoid cartilage (just above the start of the stenosis), extending to the first ring of the trachea (just below the stenosis) using a laryngeal round knife, but the incision length can be modified according to the extent of the stenosis. The cartilage incision was examined using alligator forceps to ensure that a full-thickness incision was made and to measure the length of the incision, after which the laryngoscope was removed.
A rib graft was harvested from the right fifth rib using a sterile technique and shaped into an elongated hexagon with grooves on both sides. Side grooves were positioned near the perichondrial surface of the graft. Two 26-mm needle taper points were inserted into the elongated side groove: one made of 2-O Prolene and the other made of 2-O Ethibond Excel suture (Johnson & Johnson International). The needles were inserted caudally and cranially at a right angle to the long axis of the graft—differently colored sutures were used to avoid suture tangling and to facilitate parachuting the graft into the airway. A safety suture was inserted into the graft to facilitate graft retrieval in cases of dislodgment before stent insertion.
The laryngoscope was reinserted, and balloon dilation was performed to distract the divided cartilaginous ends. A laryngeal needle holder was used to insert the first needle of the caudal suture into the divided tracheal cartilage 5 mm from its medial edge, and then retrieved externally from the neck skin. Another needle with the same sutures was inserted on the other side. This procedure was repeated for upper graft suturing along the divided cricoid cartilage in the same manner. Although the primary surgeon carefully maneuvered the graft into the anterior split, the assistant surgeon simultaneously pulled the caudal and cranial sutures. Then, balloon dilation of the airway was gradually performed to fully lock the rib graft into the anterior split (CRE Pulmonary, Pulmonary Balloon Dilation Catheter, Boston Scientific, Natick, Mass.). The balloon size was calculated by adding 2 mm to the outer diameter of an age-appropriate endotracheal tube. Correct graft position and alignment with the laryngeal lumen were visualized using a 4-mm, 30-degree Hopkins rod–lens telescope (Karl Storz GmbH & Co KG, Tuttlingen, Germany). The right upper and lower threads were tied together, and the left upper and lower threads were tied together simultaneously to achieve the highest possible graft suspension (one end of the Prolene suture was tied to one end of the Ethibond Excel suture on each side). The sutures were buried under the skin using approximately 4-mm incisions on both sides of the anterior neck.
After graft placement, an endoscopic laryngeal stent (Rutter’s stent), 7 mm in width, was placed. It was then fixed with an endoextralaryngeal 1-O prolene suture and tied to the neck over a silicone sheet. Finally, the safety sutures were removed.
Subsequent DLB and suprastomal stent removal were originally planned four weeks after surgery; however, because the patient developed an upper respiratory tract infection, the surgery was postponed for an additional two weeks.
RESULTS
The surgery was performed on a two-year-old child with a known case of acquired subglottic stenosis, for which she had undergone double-stage open laryngotracheal reconstruction with anterior and posterior costal cartilage grafting at the age of one year.
She had restenosis with suprastomal collapse and underwent four unsuccessful trials of endoscopic steroid injection and balloon dilation. Endoscopic anterior LTR was offered to parents to address restenosis, and they agreed to participate in the trial. Pre-expansion DLB revealed grade II SGS that began 7 mm from the level of the true vocal folds, accommodating a size 3.5 endotracheal tube. The procedure was performed uneventfully as described above for a total duration of four hours, and the patient was discharged 48 hours later.
In terms of her peri-operative medical management, she received prophylactic antibiotics: cefazolin administered intra-operatively, followed by oral cefuroxime for five days. Additionally, she was prescribed oral omeprazole for a one-month course.
Follow-up DLB with suprastomal stent removal was performed after six weeks, which showed that the graft was in a good position with no dehiscence or signs of infection, with a small granuloma at the end of the stent. The anterior neck was intact. A follow-up DLB was performed at three and six months to assess graft healing, which confirmed satisfactory graft positioning and adequate airway size, accommodating a 4.5 endotracheal tube. Therefore, a decannulation protocol was initiated, and she was successfully decannulated.