Primary reconstructive method for tracheal defect from invasion by differentiated thyroid carcinoma

Differentiated thyroid carcinoma is not highly malignant, and thus surgical resection is the most common treatment even if the carcinoma has invaded the trachea. Although some cases exist in which the carcinoma invades the trachea, using the tracheal window resection method allows complete resection of the carcinoma. Yet these patients must often control a large tracheocutaneous wound until reconstructive surgery is performed because such surgery occurs secondarily. Our hospital admitted three patients for which tracheally invasive, differentiated thyroid carcinoma was surgically resected. Tracheal defects of 1/2 to 2/3 of the tracheal circumference were reconstructed primarily using the free forearm flap and costal cartilage during carcinoma resection. Following surgery, only a small tracheocutaneous fistula remained open, which was closed at about three months post-operation. The reconstructed tracheal space and transferred costal cartilage thickness were monitored by CT scan imaging at about 12 months post-operation. Details of the reconstructive method and postoperative changes in the reconstructed trachea and thickness of the costal cartilage are described in this report.     

Pediatric laryngeal trauma: a case series at a tertiary children's hospital

Background

Pediatric blunt or sharp laryngotracheal injuries are infrequent because of the softer cartilages and the protection of the prominent mandible. These injuries usually occur secondary to striking furniture or via the “clothesline” injury.

Methods

We present five cases of pediatric laryngotracheal injury (thyroid cartilage, true vocal cords, cricoid cartilage, cricotracheal junction, and posterior tracheal wall).

Results

We examined the need for intubation, need for tracheostomy, length of intubation, length of hospital stay, interval until direct laryngoscopy, use of steroids, post-injury swallowing, and post-injury phonation.

Discussion

Three of the five patients were intubated either prior to arrival or upon arrival to the emergency department. Two of the patients underwent direct laryngoscopy on the day of arrival. Three patients received steroids. CT (computed tomography) was not helpful in diagnosis or decision regarding treatment. The patients with thyroid cartilage fracture, cricoid cartilage fracture, cricotracheal separation, and posterior tracheal wall tear required open repair. The tracheal wall injury, cricoid fracture, and cricotracheal separation were repaired with sutures and the thyroid cartilage fracture with a plate and screws. One tracheal stent was placed. Two open repairs were performed within 24 h of injury. The patient with posterior tracheal wall injury experienced persistent dysphagia and dysphonia, which may have been secondary to intraoperative dissection.

Conclusion

Dyspnea was not necessarily indicative of the severity of injury in our patients. CT added little information about the integrity of the larynx not already known by physical examination. Open repair was usually indicated for the blunt neck injuries in our series. Oral intubation proved less difficult than tracheostomy in our patient with cricoid cartilage fracture.     

甲状腺癌侵犯颈段气管的气管缺损与修复

目的总结甲状腺癌侵犯颈段气管的气管缺损修复经验,提高术中气管缺损修复的治疗效果。方法收集2011年8月—2019年2月诊治的32例甲状腺癌侵犯颈段气管患者资料,其中6例术中采用锐性削除受侵气管外壁,8例气管袖式切除+端端吻合,6例胸锁乳突肌锁骨骨膜瓣,8例胸锁乳突肌锁骨骨膜瓣联合生物膜,2例前臂皮瓣+自体软骨移植,2例气管造瘘+Ⅱ期修复。结果6例锐性削除气管外壁患者中,有1例患者术后第6天出现气管瘘,予以换药后出院;余26例患者中,24例于术后6个月内恢复正常呼吸功能,1例前臂皮瓣+自体软骨移植患者术后出现局部气管狭窄,黏痰堵塞,带管生存,1例带蒂胸锁乳突肌骨膜瓣+生物膜患者术后气管局部塌陷伴双侧声带麻痹,带管生存。结论对于侵犯气管的甲状腺癌患者,根据不同的侵犯范围,选取合适的气管切除和缺损气管的修复方式,才能取得较高的手术成功率和较好的治疗效果。     

Safe reconstruction of a large cervico-mediastinal tracheal defect with a pectoralis major myocutaneous flap and free costal cartilage grafts

A large cervico-mediastinal tracheal defect in a 72-year-old man as a result of surgery for thyroid carcinoma with tracheal invasion and mediastinal lymph node metastasis was reconstructed using a pectoralis major myocutaneous flap and free costal cartilage grafts. The tracheal defect (55 mm x 30 mm) was located at the thoracic inlet adjacent to the major mediastinal vessels. Our reconstructive procedure was a two-staged surgery. In the first stage, a pectoralis major myocutaneous flap was transferred to the neck to provide a well-vascularized recipient bed for free costal cartilage grafts and to cover large vessels. Two pieces of free costal cartilage were grafted on the pectoralis major myocutaneous flap, one for the lateral wall reconstruction and the other prefabricated for the anterior wall of the trachea. In the second stage, the re-vascularized cartilage graft for the anterior wall of the trachea with overlying skin was rotated onto the trough of the remaining trachea and the closure of the tracheal defect was completed. We conclude that free cartilage grafts for the reconstruction of a large cervico-mediastinal tracheal defect can be safely used when they are combined with well-vascularized pectoralis major myocutaneous flaps.     

The pathogenesis of tracheal stenosis following thyroidectomy (author's transl)

The frequency of trachealmalacia or stenoses following operations for struma or recurrent struma initiated our study of the pathogenesis of such changes. This study revealed that mechanical factors, such as compression of the trachea and the like, had been reported in the literature as the causative factors. The present paper investigates to what extent disturbances in the blood supply of the trachea, particularly after ligature of the inferior thyroid artery during thyroidectomy, influence changes in the tracheal mucosa, the connective tissue, and the adjacent cartilage. In twelve experiments on domestic pigs, the blood supply of the cervical trachea was interrupted. After varying periods of survival time, the animals were sacrificed and the tracheas histologically examined. In all cases, ischemic changes in the tracheal mucosa and cartilage could be found in addition to inflammatory reactions with scar formation. It seems justified to conclude that both mechanical factors and disturbances in local blood supply can cause tracheal tissue changes after thyroidectomy. The inferior thyroid artery and its branches also seem to play a central role in the success or failure of tracheal reconstructions following end-to-end anastomoses after stenosis resections. As a consequence, this paper also deals comprehensively with the detailed anatomy of this vessel.     

Anatomy of the cricothyroid articulation: differences between men and women

A greater difficulty in exposing the arytenoid cartilage during rotation surgeries has been observed for men. The objective of the present study was to describe the position of the cricothyroid articulation and the distance between the right and left articulations, and to compare these findings between genders. The following measurements were obtained for 16 cadavers (9 men and 7 women): angulation of the cricothyroid articulation in the cricoid ring, dimensions of the thyroid articular surface of the cricoid cartilage, and distance between the cricothyroid and cricoarytenoid articulations. The cricothyroid articulation angle was narrower in men than in women (p = .04). The major diameter of the articular facet of the thyroid cartilage was wider in men (p = .001). The longer lamina of the thyroid cartilage, as well as the more posterior position of the cricothyroid articulation, in men might explain the greater difficulty in exposing the arytenoid cartilage during laryngeal framework surgeries observed for this group of patients.     

Phonatory effects of thyroid cartilage fractures

Blunt trauma can cause a wide range of injuries to the cartilaginous framework of the larynx. The severity of injury that is required to cause a permanent disorder of vocal function if left untreated has not been defined. A study using excised canine and human larynges was undertaken to identify the effects of minimal displacement or malalignment in simulated thyroid cartilage fractures on selected voice production measurements. These fractures were found to cause changes in glottal configuration sufficient to affect glottal resistance as well as amplitude and noise content of the voice signal produced by each larynx. Therefore, relatively minor injuries of the thyroid cartilage may cause potentially serious disorders of phonation.     

Surgical treatment of laryngeal tumors with subglottic extension and tracheal tumors with composite nasal septal cartilage graft: technique and outcome

OBJECTIVE: Composite nasal septal cartilage grafts (CNSCG) are effective grafting materials in laryngeal and tracheal reconstruction following tumor resection. METHODS: Between 1985 and 2005, we used CNSCG for the reconstruction of defects following resection of laryngeal tumors with subglottic extension (20 cases), subglottic mesenchymal tumors (2 cases), invasive thyroid carcinoma (4 cases), tracheal tumors (3 cases) and esophagus carcinoma with tracheal invasion (1 case) in total of 30 patients. RESULTS: The patients with subglottic tumors were decanulated within 5-7 days except one case. We achieved satisfactory voice and swallowing without any sign of recurrence. Overall complications consisted of subglottic stenosis in one case, and unilateral paralysis of recurrent laryngeal nerve in two cases. One patient with subglottic laryngeal carcinoma died due to neck and distant metastases 4 years after the operation. All patients are well with a mean follow-up period 9 years. Three patients with tracheal tumors underwent lateral resection and reconstructed with CNSCG. Satisfactory healing of the grafts was seen in all cases without local recurrence or complication with a mean follow-up period of 62 months. One of the patients had distant metastases 3 years after the operation. The patient with esophagus carcinoma and tracheal invasion was treated by total esophagectomy, gastric pull-up, tracheal resection and CNSCG reconstruction. He died at postoperative 5th day due to mediastinitis as a complication of gastric pull-up. CONCLUSION: Free composite cartilage graft is a reliable material in the reconstruction of defects after surgery of laryngeal tumors with subglottic extension, invasive thyroid and esophagus tumors and well-selected tracheal tumors.     

Management of injuries to the larynx and trachea

The past decade has witnessed an accelerated number of laryngeal and tracheal injuries. The present decade may see a rapid decline due to more safety devices on automobiles and a cessation of the military conflict. A format has been recognized and accepted for the management of these injuries by many who have been interested and contributed to this subject. Open repair, internal splinting with a soft stent fixed to the thyroid cartilage, and often a split-thickness skin graft to cover the raw areas is the choice of most. In automobile accidents the type of injury usually falls into one of five categories: a. supraglottic tears and fractures; b. transglottic injuries; c. cricoid fractures; d. evulsion of the trachea from the cricoid; and e. lacerations or tears of the trachea. Laceration by knives and small caliber gun shot wounds usually requires a laryngofissure for exposure and repair of the defect. Schrapnel wounds and blunt missile injuries with loss of skin and cartilage should be repaired immediately with a transfer of bone or cartilage in a pedicle skin flap.     

Releasing tension on a tracheal anastomosis: an ex vivo study on a sheep model

OBJECTIVES: Tension is the limiting factor in long tracheal resection with end-to-end anastomosis. Complications such as dehiscence and restenosis are well correlated with the degree of anastomotic tension. The objective of our study was to investigate the effects of patches of auricular cartilage glued craniocaudally along a tracheal anastomosis. METHODS: Rupture tests were performed on sheep tracheas collected from a slaughterhouse. In group A (n = 5), 3 patches of auricular cartilage of 0.5 x 5 cm were glued with albumin-glutaraldehyde tissue adhesive (BioGlue) craniocaudally along the left, right, and anterior borders of the transected tracheas. In group B (n = 10), the patches were fixed with 2 transparietal intercartilaginous stitches without adhesive. In group C (n = 10), adhesive and stitches were used. RESULTS: Three patches of cartilage glued along the tracheal anastomosis held tension as high as 11.1 N. Adhesive maintained the tracheal extremities in closer contact than did stitches alone. It increased the anastomotic resistance strength (50.8 N in group C versus 29.6 N in group B). This increase was statistically significant. CONCLUSIONS: Gluing auricular cartilage patches along ex vivo tracheal anastomoses strengthened them and helped diminish tension on the suture line.     

Clinical application of in situ tissue engineering using a scaffolding technique for reconstruction of the larynx and trachea

OBJECTIVES: The objective of the present study was to demonstrate the efficacy of the clinical application of in situ tissue engineering using a scaffolding technique for laryngeal and tracheal tissue. METHODS: We have developed a tissue scaffold made from a Marlex mesh tube covered by collagen sponge. Based on successful animal experimental studies, in situ tissue engineering with a scaffold implant was applied to repair the larynx and trachea in 4 patients. RESULTS: In 1 patient with subglottic stenosis, the thyroid cartilage, cricoid cartilage, and cervical trachea with scarring and granulation were resected and reconstructed by use of the scaffold. In 3 patients with thyroid cancer, the trachea and cricoid cartilage with tumor invasion were resected and the scaffold was implanted into the defect. Postoperative endoscopy during the observation period of 8 to 34 months showed a well-epithelialized airway lumen without any obstruction. CONCLUSIONS: Our current technique of in situ tissue engineering using a scaffold shows great potential for use in the regeneration of airway defects.     

Structural airway anomalies in patients with DiGeorge syndrome: a current review

DiGeorge Syndrome is a genetic disorder characterized by either absence or hypoplasia of the thymus and the parathyroid glands. Patients with this syndrome also have a high incidence of cardiovascular malformations and facial dysmorphism. Structural airway anomalies have also been described, albeit infrequently. Tracheoesophageal fistula, short trachea with reduced numbers of tracheal rings, abnormal thyroid cartilage, laryngomalacia, tracheomalacia, and bronchomalacia have been recognized in these patients. We review all previously reported patients with DiGeorge syndrome and lower airway anomalies. In addition, we present 2 patients with DiGeorge syndrome who were each found to have an aberrant right tracheal bronchus. Structural airway anomalies can be a cause of morbidity and mortality in patients with DiGeorge syndrome. Prompt, thorough evaluation of the upper and lower airway in these patients is essential.     

Conservative surgical management of invasive differentiated thyroid cancer

The majority of well differentiated thyroid carcinoma are tumours of low grade malignancy. Laryngotracheal invasion by well differentiated thyroid carcinoma is an uncommon occurrence. The surgical management of patients with thyroid cancer invading the upper airway has primarily been by total laryngectomy. Other surgeons recommend in selected cases partial laryngeal and/or tracheal resection. A total of 122 patients with thyroid carcinoma were treated in our department between 1967 and 1982. Only seven patients with well differentiated tumours had airway invasion. In these seven patients we used a partial laryngeal and/or tracheal resection. In three of the patients with tracheal invasion a myoperichondrial flap was used for closing the tracheal defect. A partial resection of the larynx and trachea, and end to end anastomosis between the trachea and the remaining part of the larynx was performed in another four patients. The techniques used and a long-term follow-up are presented (Table I).     

同种异体软骨修复甲状软骨缺损的实验研究

OBJECTIVE: To study the effect of laryngeal cartilage defect repair with differently preserved allogeneic cartilage grafts. METHODS: 16 New Zealand white rabbits were used and divided into two groups. A 6 mm x 3 mm x 1 mm whole thickness cartilage defect was made in each side of the thyroid cartilage of each rabbit. In group one, the tissue-cultured cartilage grafts, preserved in RPMI-1640 medium for 30 days, were implanted in the left defects and the 4% formaldehyde preserved cartilage grafts for 30 days were implanted in the right defects. Fresh autogenous and allogeneic grafts were seprately transplanted into the right and left thyroid cartilage defects of the other group. Thyroid cartilages were taken out at 7, 30, 180 and 360 days after implantation. Samples were observed by macroscopy and prepared for hematoxylin and eosin (H&E) staining and immunohistochemical examination. RESULTS: No marked changes in form and volume were found in the fresh allografts and RPMI-1640 cultured cartilage grafts. The same as the autogenous cartilages, the defects of thyroid cartilage were successfully repaired by the fresh allografts and RPMI-1640 cultured cartilages. Whereas 4% formaldehyde preserved cartilage grafts were completely absorbed and replaced by cicatricial tissues in the thyroid cartilage defects. Histological observation showed that severe inflammatory cellular infiltration in the formaldehyde preserved cartilages at 7 and 30 days. The cartilage matrixes were resorpted and the chondrocytes showed degenerative change. Finally they were replaced by fibrous connective tissue at 360 days. In the RPMI-1640 cultured and fresh allogeneic cartilages only a little inflammatory cellular infiltration was observed and the cartilage matrixes were almost normal from 7 to 360 days. CONCLUSION: It is clinically feasible to use allogeneic grafts stored in RPMI-1640 medium or fresh allogeneic cartilage grafts for repairing laryngeal cartilage defects.     

Vascularized hemitracheal autograft for laryngotracheal reconstruction: a new surgical technique based on the thyroid gland as a vascular carrier

BACKGROUND: The management of extensive laryngotracheal stenosis has been a challenge confronting head and neck surgeons for over a century. The key to the successful restoration of a stable airway is providing a cartilaginous infrastructure to provide support to withstand both the negative and positive lumenal pressures produced during normal respiration and deglutition. We introduce a novel technique for restoration of such defects. METHODS: The blood supply to the thyroid gland by way of the inferior thyroid artery and the superior thyroid artery and vein are mobilized for transfer. One half to two thirds of the circumference of the adjacent tracheal rings are mobilized on the basis of the requirements of the stenotic segment. This mucochondrial composite tracheal flap is advanced superiorly to the ipsilateral "laryngeal" region where insetting of the cartilage and the mucosa is performed. Primary reconstruction or, more likely, a staged repair of the secondary tracheal defect is performed. RESULTS: Three case reports are presented. The patients were successfully decannulated postoperatively, continue to have an adequate voice, and are tolerating a diet (3-27 months postreconstruction). CONCLUSION: A new surgical technique for reconstruction of benign laryngotracheal stenoses is introduced to restore phonatory capability and a stable airway. The composite thyroid-tracheal graft based on the inferior and superior thyroid arterial pedicles allows a single-staged, primary reconstruction of the hemilarynx with a well-vascularized composite thyrotracheal flap that allows resurfacing as well as replacement of the infrastructure of the glottis and subglottis. This technique would be an excellent method to restore the cricoid ring following partial resection for primary cartilaginous tumors.     

Vocal fold medialization using autologous cartilage in a canine model: A preliminary study

Unilateral vocal fold paralysis can alter phonation. Medialization of the vocal fold using cartilage augmentation dates to the early 1950s. Improved phonation after cartilage chordal augmentation has been reported, but no study has as yet documented cartilage viability or size in this setting over time. The authors of this study evaluated thyroid alar cartilage as a medializing material in three mongrel dogs. Grafts were inserted lateral to the inner thyroid perichondrium at the vocal fold level via a window in the thyroid cartilage. Changes in weight, size, and volume were assessed 6 months after implantation. The average graft weight declined by 15%, and the average square area declined by 3%. Importantly, the average volume maintained was 87%. The grafts remained rigidly fixed to the thyroid cartilage in their placement positions. Histologic examination documented minimal resorption. The data suggest that thyroid alar cartilage is a viable filler in type I thyroplasty procedures.     

Prefabricated composite free flaps for tracheal reconstruction: a new technique

OBJECTIVES: Successful laryngotracheal reconstruction requires both structurally supported tissue that withstands airway pressure changes and well-vascularized epithelial lining to prevent granulation and stricture formation. For circumferential defects, end-to-end anastomosis achieves favorable results, but for long-segment or large noncircumferential defects, no proven methods have emerged. Several animal studies describe prefabricated soft tissue flaps wrapped around synthetic materials or cartilage. However, prefabricated flaps have had very little use in human airway reconstruction. We present a patient with laryngeal stenosis and tracheostomy dependence following chemoradiotherapy for hypopharyngeal carcinoma. METHODS: In an attempt to widen the patient's laryngeal airway, a thyrotracheal autograft procedure, previously described by our institution, was performed. We transferred a segment of hemitrachea cephalad using the thyroid gland as a "vascular carrier," thus creating an 8-cm-long trough inferiorly that involved a 40% defect of the anterior tracheal circumference. Severe radiation damage to the cervical skin precluded use of traditional tracheoplasty methods. We used a technique whereby costal cartilage strips were implanted into a radial forearm free flap, designed to replicate the anterior tracheal wall. RESULTS: Four weeks later, we harvested the prefabricated composite flap and placed it into the defect, using forearm skin as tracheal lining. The cervical skin defect was closed with an island deltopectoral flap. A soft stent was kept in the neotrachea for 3 weeks, and a tracheostomy tube was left beneath it. The tracheostomy was subsequently closed with local advancement flaps, and the patient currently maintains an excellent airway. CONCLUSIONS: Prefabricated composite free flaps are an attractive option for certain challenging cases of airway reconstruction.     

New design of a tracheostomy-cricothyroidostomy tube

In an attempt to minimize late airway stenosis, a new tube with an oval cross-section has been developed. Two to three tracheal cartilage arches are usually incised anteriorly, partially excised or inadvertently broken to fit a tracheostomy tube. The risk of post-tracheostomy stenosis seems to be greater when several cartilages have been involved. If an oval tube with the shortest diameter in its symmetry plane is used, the tissue defect along the longitudinal axis of the trachea will be shorter than that caused by a round tube. When such a stoma is healing, the adjacent intact tracheal cartilages, which are located fairly close to each other, will support the bridging scar tissue, thereby preventing collapse of the tracheal wall. The tubes come in three lengths to fit most neck sizes. An oval trial tube with the same length as the shortest one has been used for cricothyroidostomy--the aim being to spread the cricoid and thyroid cartilages apart as little as possible. A series of 23 patients were treated with this tube. At follow-up, no stenosis was found at flexible fiberoptic laryngo-tracheoscopy. Fifteen patients reported no voice change, and five, who were singers, experienced lower pitch, but four of them were still singing. None of these five patients had speech problems. The other three patients had voice problems when speaking. One of these had chronic bronchitis and another had had a stroke. The third one had a rough voice. The voice problems were milder than those reported from previous series.     

甲状腺乳头状腺癌侵犯气管的治疗与预后

目的探讨甲状腺乳头状腺癌（papillary thyroid carcinoma，PTC）侵犯气管的治疗方式及其预后。方法回顾性分析1980-1995年间45例PTC侵犯气管患者的临床资料。根据肿瘤侵犯气管的范围和程度不同分为气管局限性受侵组（A组）行肿瘤切除术28例，肿瘤侵及气管腔内组（B组）行根治性切除术10例和肿瘤区域广泛受侵组（C组）行姑息性切除术7例。39例行颈淋巴清扫术。术后切缘病理检查有肿瘤细胞或术中肉眼观察肿瘤切除不干净的部分患者给予术后放疗，共17例。Kaplan-Meier法计算累积生存率，组问差异采用Log．Rank法检验。结果①A组5年和10年生存率分别为85．0％和62．6％。7例术后放疗，21例术后未放疗。术后放疗与术后未放疗比较，5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。②B组5年和10年生存率分别为80．0％和58．3％。术后放疗6例，未放疗4例。术后放疗与否，5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。③C组5年和10年生存率分别为42．9％和28．6％。4例术后放疗患者，5年和10年生存率分别为50．0％和50．0％。3例术后未放疗患者，5年生存率为33．3％，无10年生存。术后放疗与否，其5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。结论PTC气管受侵尚未侵及腔内黏膜层者可采用肿瘤切除术得以根治，穿透气管腔内黏膜层者行肿瘤根治性切除可延长患者的生存。术后放疗有可能提高姑息性切除患者的生存率。     

Recidived medullary thyroid carcinoma with neck metastases and tracheal invasion

Medullary carcinoma represents about 5% of all malignant tumors located in thyroid gland and it can appear as sporadic or hereditary form. We report the case of a 58-year-old female who was initially operated by General Surgery Department of an infiltrating medullary carcinoma with cervical metastasic nodes having its origin on left thyroid lobe (LTL). The patient did not want any kind of control and 5 years later she suffered dyspnea due to the tumoral recurrence with invasion of the trachea and recurrential left palsy. Our ENT Service only performed a tracheostomy on fourth tracheal ring because the woman did not accept another surgical intervention. For 6 years she has been followed and reviewed in our consults beeing on alive up to now.