Single-Staged Laryngotracheal Reconstruction for Idiopathic Tracheal Stenosis Alfonso Morcillo, PhD, Richard Wins, MD, Abel Gómez-Caro, PhD, Marina Paradela,

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 Etiology  External trauma (MVA, surf board, assault, etc.)  Internal trauma (Endotracheal intubation, tracheostomy)  Other ▪ Systemic diseases (vasculitis,

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Single-Staged Laryngotracheal Reconstruction for Idiopathic Tracheal Stenosis Alfonso Morcillo, PhD, Richard Wins, MD, Abel Gómez-Caro, PhD, Marina Paradela, MD, Laureano Molins, PhD, Vicente Tarrazona, PhD The Annals of Thoracic Surgery Volume 95, Issue 2, Pages 433-439 (February 2013) DOI: 10.1016/j.athoracsur.2012.09.093 Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Idiopathic laryngotracheal stenosis schemes are shown. (A) Typical lesion, which can be corrected by the Pearson operation. Lesion is at cricoid ring level. (B) Lesion amenable to Grillo-type operation, > 0.5 to 1 cm below the vocal cords. A tailored flap is needed for cricoid plate resurfacing. (C) Maddaus-type lesion: stenosis is closer to the vocal cords, with little space for anastomosis. A laryngofissure is needed for total removal of affected mucosa and a more accurate thyroid-tracheal anastomosis. (D) Couraud techniques for typical stenosis. Impaired mobility or fixed vocal cords, most often with cricoid or upper trachea cartilage damage. Midline cricoid incision and temporary T tube is mandatory. The Annals of Thoracic Surgery 2013 95, 433-439DOI: (10.1016/j.athoracsur.2012.09.093) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Schema of the Grillo technique is shown. In stenosis affecting the mucosa at the cricoid ring level, the removal of the anterior cricoid ring is performed extraperichondrically, allowing preservation of a healthy layer for anastomotic coverage. The anterior ring is removed, completing the lateral excision with a fine rongeurs forceps. Posterior mucosa that is circumferentially affected is replaced using a Grillo flap tailored from the remnant trachea. Thyroid–trachea anastomosis is performed using absorbable running sutures in the membranous face anchored by 2 stitches placed in the corners. The posterior stitches, picking up all the cricoids, layer (perichondrium and cartilage) to achieve a solid anastomosis. Covering the cricoids plate with healthy mucosa allows a proper confrontation with superior edge for healing. The anterior face is completed using interrupted concentric stitches in the cartilaginous face. The Annals of Thoracic Surgery 2013 95, 433-439DOI: (10.1016/j.athoracsur.2012.09.093) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A) Initial Maddaus technique: Laryngofissure and posterior face of the anastomosis. An optimal exposure of affected mucosa and the lower limits of the vocal cords make consistent anastomosis easier to achieve. At least 4 stitches, picking up all the tracheal layers, are placed in the posterior face. These stitches give the real strength of the posterior part of the anastomosis. The Grillo flap resurfaces the cricoids plate, approaching both healthy mucosa edges by a running suture anchored with the corner stitches. (B) The Couraud technique: A midline cricoids plate split using a scalpel is the best option to widen the subglottic space. This preserves the recurrent laryngeal nerves and opens the larynx to achieve a normal airway caliber at this level. Sometimes free grafts (clavicle or ribs bone) are interposed into the cricoids edges or, very infrequently, between the split thyroids cartilage. These grafts are also covered with the membranous flap and with buccal or cheek mucosa in the anterior face. (C) Laryngofissure and cricoids division requires an endoluminal stent (T tube) for larynx modeling and vocal cords edema. The superior branch is placed immediately above the vocal cords and is tamponaded for correct feeding. The tracheotomy for the anterior branch is usually done 2 rings below the thyroid–tracheal anastomosis and comes out to the skin through a contraincision. The Annals of Thoracic Surgery 2013 95, 433-439DOI: (10.1016/j.athoracsur.2012.09.093) Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions