Endoscopic Posterior Cricoid Split with Rib Grafting for Posterior Glottic Stenosis

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Author: Vikash Modi
Published:
Specialties: Otolaryngology
Schools: Weill Cornell Medical College
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Basic Info

Endoscopic posterior cricoid split with rib grafting can be used in children with Bilateral Vocal Fold Immobility due to bilateral vocal fold paralysis or cricoarytenoid joint fixation with posterior glottic stenosis. It is preferred to open laryngotracheal reconstruction because it does not disrupt the anteior cricoid ring therby preserving the "spring" of the cricoid.

DOI#: http://dx.doi.org/10.17797/5w4hsqmgnq

Advanced

Procedure

1. Size airway
2. Insert metal tracheostomy tube
3. Spontaneous Ventilation
4. Insert and suspend Lindholm laryngoscope. Spray vocal folds with 2% lidocaine.
5. Insert Lindholm laryngeal spreader in an inverted fashion to distract false vocal folds. Suspend with rubber bands to suspension apparatus
6. Attach suction to lindholm laryngoscope
7. Use straight alligator, curved alligator, and/or straight suction to move interarytenoid muscles posteriorly and to palpate the superior margin of the cricoid and push it inferiorly so it tilts anteriorly.
8. Use Carbon dioxide laser to divide cricoid (smallest spot size on 5 watts in pulsed mode) to divide posterior cricoid. (May use Lumenis scanning laser if desired.)
9. May use sickle knife to get tactile feedback when dividing the most posterior aspect of the cricoid to ensure the posterior cricoid perichondrium is not divided. (Do not undermine posterior cricoid perichondrium)
10. Measure length of cricoid split with the suction
11. Harvest rib graft
12. Carve rib graft in an inverted "T-shape" with perichondrium on the luminal surface. Place rescue stitch on graft
13. Use stout laryngeal forcep with ratooth to place graft in posterior glottic region
14. User right angle probe to move graft and ensure flanges are tucked in under posterior edges of the cricoid.
15. Divide rescue suture
16. Remove Laryngeal spreader, replace endotracheal tube with age appropriate tracheostomy tube, and remove laryngoscope.

Indications

Age over 12 months
Bilateral Vocal Fold Immobility
Bilateral Vocal Fold Paralysis
Cricoarytenoid Joint Fixation with posterior glottic stenosis
Subglottic Stenosis Grade 3 or less

Contraindications

Poor endoscopic exposure of the larynx (i.e. micrognathia, retrognathia)
Grade 4 subglottic stenosis
Severe transglottic stenosis
Tracheal Stenosis
Under 12 months of age

Instrumentation

Setup

1. Insert metal tracheostomy tube
2. Spontaneous Ventilation
3. Insert and suspend Lindholm laryngoscope. Spray vocal folds with 2% lidocaine.
4. Insert Lindholm laryngeal spreader in an inverted fashion to distract false vocal folds. Suspend with rubber bands to suspension apparatus

Preoperative Workup

1. Awake Flexible fiberoptic laryngoscopy
2. Direct Laryngoscopy and bronchoscopy
3. Palpate cricoarytenoid fixation
4. Laryngeal EMG

Anatomy and Landmarks

1. True and False Vocal Folds
2. Interarytenoid muscles
3. Cricoid cartilage

Advantages/Disadvantages

Advantages:
- Less destabilization of the cricoid, faster recovery, less affect on voice, less morbidity, and no need for stenting when compared to the open approach
- Non-destructive procedure
Disadvantages:
- Need good endoscopic exposure

Complications/Risks

- Graft extrusion
- Restenosis

Disclosure of Conflicts

- None

Acknowledgements

References

1. Modi VK. Endoscopic posterior cricoid split with rib grafting. Adv Otorhinolaryngol. 2012; 73:116-22
2. Gerber ME, Modi VK, Ward RF, Gower VM, Thomsen J. Endoscopic posterior cricoid split and costal cartilage graft placement in children. Otol Head Neck 2013 Mar; 148:494-502
3. Inglis AF, Perkins JA, Manning SC, Mouzakis J. Endoscopic posterior cricoid split and rib grafting in 10 children. Laryngoscope. 2003; 113:2004-2009

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