Management of tracheal stenosis with a titanium ring and nasal septal cartilage

Abstract

Surgical management of subglottic laryngeal and upper tracheal stenosis remains a formidable challenge. The significant number of proposed techniques only highlights the difficulties associated with effectively managing this problem. Between 1996 and 1999, seven patients with stenosis of the upper trachea were treated. The stenosis resulted from long-term intubation during intensive-care hospitalization in five patients and from tracheotomy complications in the other two. Six patients were male and one female, their ages ranging between 13 and 60 years. The mean postoperative observation period was 3 years (1.5-4.5 years). In all patients, the stenosis exclusively involved the upper tracheal segment, measuring from 2 to 5 cm in length. The stenotic area of the trachea is exposed, and the local application of a solution of mitomicin C for a duration of 4 min is performed. A graft consisting of cartilage and mucosa is harvested from the nasal septum and is fixed with sutures to a titanium semiring. After the fixation of the graft on the ring, the entire construct is placed on the stenosed segment of the exposed trachea. The graft must cover the anterior exposed face of the trachea with the lateral members of the semicircular titanium ring adjacent to the lateral walls of the trachea, externally. The lateral tracheal walls are attracted laterally with sutures and are attached on the edges of the semicircular titanium ring. Four of the patients in whom no tracheotomy had been performed preoperatively needed none at all intraoperatively, and they were decannulated normally at the end of the procedure. Tracheotomy was deemed necessary for one patient's safety and was maintained for 7 days. In one patient with a pre-operative tracheotomy, the point of the tracheotomy was displaced lower on the trachea and was maintained there for 7 days. The course of management described here and employed on seven patients involves a safe surgical procedure with excellent results. The placement of the titanium ring offers very good support for the graft and maintains the patency of the tracheal lumen. The main reasons for the failure of techniques using only cartilage grafts are therefore avoided. The number of cases presented here is certainly too small to establish definite conclusions; however, the initial results are extremely satisfying and urge us to suggest the use of this method in indicated cases.

Tracheal Reconstruction

“…To improve reconstruction of the trachea, several experimental approaches have been followed in animal models. As mentioned in our introduction, autologous cartilage with laryngotracheal frameworks from solid titanium, Medpor, or hydroxyapatite 5,7 ; tissue engineered cartilage with chondrocytes seeded in polypropylene or polyglycolic acid with or without mucosal lining [8][9][10] ; and prefabricated tubes with cartilage strips and a vascularized muscle or fascia 21 have all been used. They all had the same problem, that is, the restoration of the mucosal lining through reepithelialization.…”

“…Because of the limitations of prefabrication using autologous tissues such as the combination of cartilage and mucosa, the use of various biomaterials has been attempted. Solid titanium, Medpor (Porex Surgical GmBH, Munich, Germany), hydroxyapatite, [5][6][7] or tissue engineered cartilage with chondrocytes seeded in polypropylene or polyglycolic acid with or without mucosal lining [8][9][10] have been used in experimental settings. The main problem in all of these studies is the regeneration of the mucosal lining, as mentioned in a review by Tan et al 11 In cases of minor defects, reepithelialization from the wound edges occurred, but for larger defects this process of reepithelialization proved to be insufficient.…”

Tracheal inflammatory response to bacterial cellulose dressing after surgical scarification in rabbits

“…Resected tissue replacement prevents the formation of an opening and the consequent formation and growth of granulation tissue, known to be a key prognostic factor in the treatment of this condition. However, surgical techniques whose aim is to cover the opening with skin or mucosal grafts end up extending surgery time and patient morbidity, as there is the additional step of having to collect the graft from another site and place it on the stenotic site 13 , 14 .…”