AATS: Tailored Cricoplasty - An Improved Modification for Reconstruction in Subglottic Tracheal Stenosis

Tailored Cricoplasty - An Improved Modification for Reconstruction in Subglottic Tracheal Stenosis

Moishe Liberman, Douglas J. Mathisen; Thoracic Surgery, Massachusetts General Hospital, Boston, MA

Objective: Stenosis of the subglottic larynx is the most challenging part of the airway to reconstruct. When the laryngeal ventricle is adequate, chance for success is good. When the ventricle is small and especially narrowed from side to side, success is limited and not thought to be achievable in many patients.
Methods: A modification of the standard technique of anterior cricoid resection was developed. Once the anterior cricoid is removed, a submucosal resection of thickened tissue is performed. The inner third to half of the cricoid cartilage is carefully excised. The exposed cricoid cartilage is resurfaced by advancing the preserved mucosa over the cricoid with interrupted 5-0 chromic sutures. This results in an additional horizontal enlargement of the luminal diameter of the airway of 4-5mm.
This study consists of a retrospective chart review and telephone questionnaire follow-up of consecutive patients with subglottic stenosis at a single institution. Follow-up study questionnaires used Likert Scales (ratings: 1-10) to describe pre- and post-operative symptomatology, satisfaction, and perceived effectiveness. A score of zero signified extreme dissatisfaction/therapy ineffective, and a score of ten signified extreme satisfaction/effectiveness. Results are reported as means, ranges and standard deviations. The Paired Sample T-test was used to compare means prior to surgery and at follow-up.
Results: Eighteen patients (17 females) underwent tailored cricoplasty over a 15 month period. Three resections were performed for post-intubation tracheal stenosis and 15 for idiopathic subglottic stenosis. Mean age was 51 (range=20-75), average number of tracheal rings resected (excluding cricoid) was 2.5 (range=1-4), and mean follow-up was 9.1±1.2 (range=2-17) months. All patients were extubated in the operating room and mean duration of hospital stay was 8.3±1.6 days. There were six complications in five patients.
Table 1 compares symptoms before and after tailored cricoplasty. All patients reported that they were satisfied and would undergo surgery again. Overall satisfaction was rated at 9.5±1.0 and satisfaction with resting and exertional dyspnea were 9.7±0.5 and 9.5±1.0, respectively. Symptoms of recurrence at follow-up were rated as 0.6±1.4 out of 10.
Conclusion: Tailored cricoplasty is an effective technique to improve the outcome of reconstructive subglottic stenosis. It offers reconstructive possibilities for patients previously excluded from surgical reconstruction.

Table 1 - Symptoms Pre- and Post-Cricoplasty

Symptom	Pre-Operative	Post-Operative	P-Value
Dyspnea at rest	6.1 ± 2.4	0.5 ± 0.8	<0.001
Dyspnea with activity	8.6 ± 1.3	1.0 ± 2.0	<0.001
Wheezing severity	7.3 ± 2.2	0.4 ± 1.2	<0.001
Coughing severity	6.8 ± 2.1	1.0 ± 1.4	<0.001
Noisy breathing	7.8 ± 2.2	0.5 ±1.1	<0.001
Stridor severity	2.9 ± 4.2	0	0.010
Inability to clear secretions	3.0 ± 4.0	0.1 ± 0.2	0.007
Difficulty swallowing / lump in throat	1.8 ± 3.3	1.1 ± 2.4	0.226
Impact of disability on day-to-day Activity	7.6 ± 2.4	1.5 ± 2.5	<0.001
Impact of disability on profession activity	7.0 ± 3.0	0.6 ± 1.3	<0.001
Impact of disability on social activity	5.9 ± 3.4	0.6 ± 1.1	<0.001
Number of blocks patient can walk without dyspnea	1.2 ± 2.0	23.9 ± 17.6	<0.001
Number of stairs patient can climb without dyspnea	1.6 ± 2.4	85.1 ± 192.7	0.102

Back to 88th Annual Meeting
Back to Program Outline