Thyroid alar cartilage graft in paediatric laryngotracheal reconstruction

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Summary

Objective

To evaluate the potential indications of thyroid alar cartilage (TAC) graft in the paediatric laryngotracheal reconstruction (LTR) population based on observations obtained in a case series of 27 consecutive infants referred to our tertiary care center.

Methods

Thyroid alar cartilage grafting was performed for limited Myer grade II and grade III subglottic stenosis requiring a single-stage laryngoplasty and for laryngeal enlargement after translaryngotracheal resection of endolaryngeal tumors. The evolution of the grafted area was evaluated prospectively during endoscopic follow-up.

Results

Twenty-five patients (92.5%) were successfully extubated after a mean of 5.1 days. No perioperative or postoperative complications were observed.

The mean duration of graft harvesting was 7.7 min.

Follow-up of the grafted area revealed one case of partial necrosis without prolapse into the lumen. The mean duration of graft epithelialization was 18.1 days (range: 12–30 days).

Development of granulation tissue was observed in eight patients (32%) with a mean duration of granulation tissue persistence of 61.5 days (range: 7–155 days).

Endoscopic follow-up did not demonstrate any pharyngolaryngeal asymmetry or feeding difficulties.

Conclusion

This study demonstrated that the use of thyroid alar cartilage grafting is feasible for pediatric laryngotracheal reconstruction. The indications of thyroid alar cartilage graft should be reserved for moderated subglottic stenosis. The use of TAC reduced the operative time and cosmetic sequelae significantly. The healing of the grafted area was similar to those obtained with other types of graft.

The TAC removal did not induce laryngeal deformation but longer follow-up is necessary to confirm this.

Introduction

Since 1970 there have been significant advances in the surgical management of pediatric laryngotracheal stenosis. Numerous external and endoscopic surgical techniques have been described. The single-stage laryngotracheal reconstruction (LTR) using cartilage graft insertion [1] is one of the best accepted techniques.

Different types of graft have been described including costal cartilage [2], [3], [4], hyoid bone [5], auricular cartilage [6], [7], [8], [9], [10] and thyroid cartilage [10], [11], [12]. The theoretical advantage [10], [11] of the thyroid alar cartilage (TAC) graft is its location in the same operative field therefore, potentially reducing operative time and reducing the morbidity of a second operative site. Moreover, its thickness is similar to that of the laryngotracheal cartilages decreasing the possibility of graft prolapse into the lumen. A better inclusion of the graft should decrease the formation of granulation tissue.

The purpose of this study was to analyse a series of 27 infants undergoing laryngotracheal reconstruction using TAC graft interposition, to evaluate the potential of this graft in paediatric laryngotracheal reconstruction.

Section snippets

Materials and methods

The study included all patients referred to our tertiary care institution from February 1999 to May 2003, with a laryngotracheal stenosis requiring a single-stage anterior laryngotracheal reconstruction or with an intralaryngeal tumor requiring a translaryngotracheal removal.

The TAC graft was systematically used in cases of:

  • -

    An anterior cricoid expansion for translaryngotracheal treatment of a subglottic lesion.

  • -

    A Myer–Cotton [13] grade II or grade III subglottic stenosis without extension to the

Results

Forty-five patients were referred to our centre with a laryngotracheal stenosis requiring a single-stage anterior laryngotracheal reconstruction or with an intralaryngeal tumor requiring a translaryngotracheal removal.

Twenty-seven patients (60%) matched the preoperative criteria for TAC graft use. One patient (no. 5) underwent a TAC graft without fulfilling the criteria because of a severe costal malformation contraindicating the use of costal cartilage graft.

One patient who initially fulfilled

Discussion

Some authors [4], [5], [11], [14] have advocated cartilage graft interposition in paediatric laryngotracheal reconstruction. Better results were obtained with a graft insertion than with a simple cricoid split [5], [14].

Numerous interposition materials have been proposed, including costal cartilage [2], [3], [4], auricular cartilage [5], [6], [7], [8], [9], [10], hyoid bone [3], thyroid alar cartilage [10], [11], [12].

Early ossification of hyoid bone limits its use in infants [3].

The

Conclusion

This study demonstrates that the successful use of TAC graft is possible in laryngotracheal reconstruction surgery in a pediatric population.

Graft stability and evolution are satisfactory and similar to results obtained with other types of graft.

TAC use can significantly reduce the length of the surgical procedure and reduce cosmetic sequelae.

TAC removal did not induce laryngeal deformation, but longer follow-up is necessary to confirm the absence of perturbation of laryngeal growth.

It is

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