Sutureless vs sutured posterior costal cartilage grafting in laryngotracheal reconstruction in children.

OBJECTIVE: To compare the postoperative course, complication rate, and decannulation rate in children who underwent either sutureless or sutured posterior costal cartilage grafting during laryngotracheal reconstruction (LTR). DESIGN: Retrospective chart review. SETTING: Tertiary care children's medical center. PATIENTS: The study included children who required posterior costal cartilage grafting when undergoing LTR for subglottic stenosis between the years of 2000 and 2009 by the senior author (J.E.M.) and who had adequate records for review. MAIN OUTCOME MEASURES: Postoperative complications, including the incidence of graft prolapse, restenosis or reobstruction requiring surgical intervention, and decannulation rate. RESULTS: Forty-nine children who underwent 52 procedures met the inclusion criteria for this study. All patients had grade III acquired subglottic stenosis and underwent double-staged LTR. Twenty procedures were performed with a sutureless posterior graft, and 32 were performed with suture placement. None of the 20 procedures that were performed with a sutureless graft had prolapse of the graft into the airway compared with 2 of 32 prolapsed posterior grafts (6%) that were sutured (P = .52). Eleven of 20 children (55%) with sutureless posterior grafts compared with 24 of 32 children (75%) who underwent sutured posterior grafts required endoscopic surgical intervention for restenosis or reobstruction (P = .22). Decannulation was achieved in 19 of 20 sutureless cases (95%) and in 28 of 30 cases (93%) in which sutures were placed (P = .56) after a single LTR and necessary endoscopic interventions occurring at 6.3 months and 4.9 months, respectfully (P = .42). CONCLUSION: Sutureless posterior costal cartilage grafting in children with acquired grade III subglottic stenosis is an equally effective and secure technique compared with sutured posterior grafting during double-staged LTR.

Three-dimensional conformation of the injected bolus in vocal fold injections in a cadaver model.

OBJECTIVE: To determine the 3-dimensional (3D) conformation of the injected bolus in the larynx in vocal fold injections, to understand how the bolus interacts spatially with elements of the laryngeal framework, and to relate the above to clinical observations in performing vocal fold injections. STUDY DESIGN: Excised cadaveric larynx study. SETTING: Laboratory. SUBJECTS AND METHODS: Vocal folds of 12 human excised cadaveric larynges were injected with calcium hydroxylapatite. High-resolution computed tomography scans were obtained of the injected larynges. Densities corresponding to the injected bolus and the laryngeal framework were extracted and processed with MATLAB routines to generate selective 3D reconstructions of the injected bolus within the laryngeal framework. Histology analysis was also performed to correlate with observations from the 3D reconstructions. RESULTS: Boluses injected into the lateral aspect of the thyroarytenoid muscle tended to be irregularly shaped, appeared to fill up the paraglottic space, and were associated with significant muscle compression. The vertical thickness of the injected boluses averaged 9.5 mm for lateral boluses and 7.6 mm for medial boluses, which were comparable to the vertical thickness of uninjected vocal folds. CONCLUSION: Laterally injected boluses are shaped by spatial constraints imposed by elements of the laryngeal framework. Compression of vocal fold muscle may be a mechanism accounting for stiffness from overinjection. The irregular shapes of some boluses may affect the outcome of subsequent medialization attempts. Injections may enhance the vocal fold contact height as a favorable effect beyond simple medialization.