Secrets in Cricotracheal Resection for Benign Laryngotracheal Stenosis

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Thecauses of adult laryngeal and upper tracheal stenosis vary between traumatic, idiopathic, chronic inflammatory disease, collagen vascular disease, benign and malignant neoplasms. The most common cause is iatrogenic internal injury. Patients typically present with months to years of exertional dyspnea or cough, which has often been misdiagnosed as asthma. Others are diagnosed in intensive care with failure of weaning of endotracheal tube. An endotracheal cuff pressure greater than 30mm Hg exceeds the mucosal capillary perfusion pressure, causing mucosal ischemia, which may lead to ulceration and chondritis of the tracheal cartilages. These circumferential lesions heal with fibrosis, leading to a progressive tracheal stenosis.

In1994, Myer-Cotton System modified the original Cotton System in 1984. He classified the horizontal stenosis into 4 grades; depending on the percentage of narrowing of the lumen. McCaffrey designed another clinical staging depending on the vertical length and the location of the stenotic segment. Monnier et al. designed another staging system with considering the co-morbidities and glottis involvement that can affect the prognosis.

Surgicaloptions for laryngotracheal stenosis are closed or open techniques. In closed operation, dilatation, endoscopic laser ablation or laryngotracheal stents can be used. In the open approach, different procedures are used such as cricoid splitting procedures, Laryngotracheaplasty (LTP), vascularized myo-osseus flap, slide tracheoplasty, tracheal transplantation, Cricotracheal Resection (CTR). The standard technique used in the curative treatment of laryngotracheal stenosis is the segmental resection and anastomoses, by means of tracheotracheal anastomsis through the Küster operation and cricotracheal resection through the Pearson operation. The Rethi operation is reserved for cases of glottic and subglottic stenosis. During the 1980s and 1990s, it became apparent, notably through the work of Grillo, and Laccourreye, that resection of laryngotracheal stenosis with primary anastomotic reconstruction could achieve decannulation rates up to 97%.