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Cricotracheal Resection - A Surgical Intervention For Clearing Vocal Cords

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Cricotracheal resection is a procedure that is used to clear the vocal cords. Read the article below to know more.

Medically reviewed by

Dr. Oliyath Ali

Published At May 18, 2023
Reviewed AtMay 18, 2023

Introduction

Cricotracheal resection (CTR) is a surgical option for subglottic stenosis. It is considered the best option in severe grade III and grade IV stenosis that is clear of the vocal cords. Over the last 30 years, pediatric airway construction has been fast-growing, and there has been an increase in cases of subglottic stenosis. CTR is an alternative subglottic stenosis technique used for adults.

CTR is a technique that involves resection of the anterior cricoid arch and thinning of the posterior cricoid plate, along with preserving the posterior mucosal flap. The resected normal trachea is telescoped into the posterior cricoid plate. Then joined with a mucosal flap and thyroid cartilage. CTR is more challenging than the expansion laryngotracheal reconstruction ( LTR). This procedure is done to remove the stenotic portion. Care should be taken to avoid any injury to the recurrent laryngeal nerve during the procedure. Conley first reported CTR for the treatment of SGS in an adult in 1953.

What Are the Indications for Cricotracheal Resection?

Many clinical situations need to be treated with CTR. Indications include the following:

  • Individuals with severe and high-grade SGS.

  • Individuals with less grade SGS where the cartilage of the affected area has less structural integrity.

  • When there is an airway obstruction due to the collapse of the subglottic and proximal walls of the trachea.

  • When lateral subglottic and tracheal walls are not sturdy enough to support the graft placed during the procedure called LTR.

  • When an area of SGS is attached to the area of the supra-stomal collapse of the anterior tracheal wall, this weakens the cartilage strength and affects the anteroposterior lumen dimension.

  • When there is a failure of LTR, CTR is indicated.

What Are the Contraindications for Cricotracheal Resection?

The position and length of stenosis are important to be considered in conducting the procedure called CTR. The selection of an individual for CTR depends on the proximity of the stenosis to the vocal folds and the risk of resecting the stenosis without causing injury to the vocal cords.

A distance of two to three mm from stenosis to vocal cords must be present for CTR.

Contraindications include the presence of:

  • When SGS extends into the anterior two-thirds of the vocal cords.

  • When lengthy stenosis of almost 40 % to 50 % is present in the trachea.

  • When uncontrolled gastroesophageal reflux is present.

  • When uncontrolled eosinophilic esophagitis is present.

  • When Down syndrome is present.

  • When untreated methicillin-resistant staphylococcus aureus colonization is present.

  • Individuals with a history of previous distal tracheal surgery.

When the scar is present in the posterior glottis and CTR, posterior cricoid split and cartilage graft may be used. LTR is used as a preferred procedure when CTR is contraindicated.

How Is Cricotracheal Resection Performed?

Stenosis is a challenging problem even today. CTR is a newer option with minimal complications after the procedure and provides long-term results. This procedure is performed under the following steps.

1. Preoperative Planning or Surgical Planning: To decide whether CTR will be conducted at a single or two-stage procedure. Single-stage procedure: In this procedure, the individual is decannulated intraoperatively without tracheostomy. Two-stage procedure: Reconstruction is done over a supra-stomal stent or around a T tube. The single-stage procedure is preferred over the two-stage procedure. In case of multiple airway obstructions, individuals with poor cardiopulmonary status, and those undergoing another airway procedure along with CTR, a two-stage procedure is done and also called extended CTR.

2. Technique: CTR is a surgery to remove a narrow part of the trachea (windpipe) just below the voice box ( larynx). CTR is done to remove a stenotic portion of the trachea.

  • Directly cutting into the stenosis is done to open the airway, thereby minimizing the amount of trachea resected.

  • At the distal end of the divided trachea, stenosis is removed. Stay sutures are placed on both sides at the membranous and cartilaginous portions.

  • The anterior third cricoid cartilage is resected at the other end (proximal). Then the stenotic portion of the trachea is removed. The posterior wall of the cricoid cartilage is thinned up to 40 % of its thickness.

  • The stay suture is given from the distal to the proximal aspect of the trachea through the mucosa and cricoid cartilage.

  • The posterior wall is anastomosed using a running suture.

  • The stay sutures should be given before the posterior wall anastomosis ( joining).

  • Edges of the trachea are brought together, and tightening is done with posterior wall anastomosis.

  • Interrupted sutures are placed at the anterior wall anastomosis. The T-tube is placed for airway support.

  • The upper limb of the T-tube is placed above the vocal cords.

  • For the sidearm of the T-tube, tracheostomy is done in the distal trachea.

Two weeks are required to recover after surgery. This is a very successful treatment and has excellent long-term results.

What Are the Complications of Cricotracheal Resection?

Complications of Cricotracheal resection are:

  • Post-operative Laryngeal Edema: It is generally seen after one to two weeks of the procedure.

  • Occurrence of Restenosis: Generally seen among 10 % of individuals who underwent the procedure. Early restenosis is treated with an endoscopically placed balloon dilation.

  • The Recurrent Laryngeal Nerve May Get Injured With Vocal Cord Paralysis: This occurs in two percent of individuals who underwent the procedure. It occurs during the posterolateral dissection of the airway.

  • Bursting Open of Anastomosis: It is rare but a serious complication that needs immediate diagnosis. Intubation with a cuffed endotracheal tube is used to treat this condition.

Conclusion

In a nutshell, an alternative method for treating SGS is Cricotracheal resection, which involves removing a stenotic section of the trachea near the larynx and understanding its indications, contraindications, and complications can facilitate seeking prompt medical attention. Early detection is crucial for successful treatment, and while CTR is a more complex technique compared to Expansion LTR, it can also yield outstanding long-term outcomes when used for severe cases of SGS.

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Dr. Oliyath Ali
Dr. Oliyath Ali

Otolaryngology (E.N.T)

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