Endoscopic posterior cricoid split with costal cartilage graft placement in patients under one year of age.

Endoscopic posterior cricoid split and costal rib graft placement (EPCSCG) is an important tool in enlarging the glottic and subglottic airway, both of which can be disproportionally affected in the small airways of neonates and early infants. We present a series of 8 patients under the age of one who successfully underwent EPCSCG, with 7/8 patients avoiding tracheostomy entirely. Of these patients, the indication for EPCSCG was isolated bilateral vocal fold immobility (6/8), bilateral vocal fold immobility with subglottic stenosis (1/8), and isolated subglottic stenosis (1/8). EPCSCG can be safely applied to select patients less than one year of age.

Early preclinical evaluation of a novel, computer aided designed, 3D printed, bioresorbable posterior cricoid scaffold.

OBJECTIVES: The posterior cricoid split with rib graft is a procedure that elegantly corrects pediatric posterior glottic stenosis and subglottic stenosis. Currently, the procedure requires harvesting of rib cartilage which leaves room for optimization. With use of three dimensional printing technology, our objective was to design a device that would negate the need for costal cartilage harvesting in this procedure. METHODS: An optimized, novel polycaprolactone scaffold was designed using computer aided design software and three dimensional printing. A pilot proof of concept study was conducted with implantation of the device in three porcine animal subjects. Device was evaluated by post-procedural clinical course, endoscopic exams, post-mortem exam, and histological evaluation. RESULTS: A series of variably sized scaffolds were created. The scaffolds showed structural integrity and successfully expanded the cricoid cartilage in the porcine model study. Post-operative endoscopy and clinical exams demonstrated no signs of implant instability or failure. Gross and histologic exams showed successful mucosalization over the scaffold and cartilage ingrowth by six weeks. CONCLUSION: This porcine animal pilot study demonstrated early success of a computer-aided designed, 3D printed, bioresorbable PCL posterior graft scaffold. The scaffolds eliminate the need for costal cartilage harvesting and had excellent surgical usability. The scaffolds functioned as designed, offering proof of concept and grounds for further evaluation to expand on this small pilot study with larger animal studies and continued design refinement.

Split cricoídeo posterior endoscópico con injerto de cartílago costal / Endoscopic posterior cricoid split with costal cartilage graft

RESUMEN A pesar de los avances en cirugía de vía aérea, tanto abierta como endoscópica, la inmovilidad bilateral de cuerdas vocales continúa representando un desafio significativo para los cirujanos de vía aérea. Entre las alternativas quirúrgicas existen tanto abordajes endoscópicos como transcervicales, no obstante, la mayoría de estas técnicas modifican estructuralmente regiones de la cuerda vocal y/o aritenoides de manera permanente. La traqueostomía ha sido el tratamiento de elección en niños con inmovilidad bilateral de cuerdas vocales severamente sintomática, sin embargo, el procedimiento ideal debiese establecer una vía aérea adecuada evitando la necesidad de realizar una traqueostomía, y a la vez no generar un deterioro de la función fonatoria. La capacidad de expandir el aspecto glótico posterior sin modificación estructural de aritenoides y/o ligamento vocal ha convertido a la sección cricoidea posterior endoscópica con injerto de cartílago costal en una alternativa quirúrgica atractiva para estos casos. En este trabajo se realiza una revisión de la literatura y presenta un caso tratado mediante esta técnica en el Hospital Guillermo Grant Benavente de Concepción, Chile.

ABSTRACT Despite advances in both open and endoscopic airway surgery, bilateral vocal cord immobility still poses a significant challenge for airway surgeons. Among the surgical alternatives there are both endoscopic and transcervical approaches. However, most of these techniques structurally modify certain regions of the vocal cord and/or arytenoids permanently. Tracheostomy has been the treatment of choice in severely symptomatic children with bilateral immobility of vocal cords. Nevertheless, the ideal procedure should establish an adequate airway, avoiding the need to perform a tracheostomy, and at the same time not causing a deterioration of the phonatory function. The ability to expand the posterior glottis without structural modification of the arytenoids and/or vocal ligament has converted the posterior endoscopic cricoid split with costal cartilage graft into an attractive surgical alternative for these cases. In this article we review the literature and present a case treated by this technique in the Guillermo Grant Benavente Hospital in Concepción, Chile.

Endoscopic Posterior Cricoid Split With Graft in an Adult With Posterior Cricoid Fracture.

A 45-year-old man presented with bilateral vocal fold immobility (BVFI) following a remote history of assault. He was found to have a comminuted, telescoped, and ossified posterior cricoid fracture on imaging. Electromyography revealed normal cricothyroid and thyroarytenoid muscle function, but moderate chronic denervation of bilateral posterior cricoarytenoid muscles. The patient underwent endoscopic posterior cricoid split with rib graft (EPCS/RG), and he regained moderate vocal abduction and full vocal adduction, resolution of dysphonia, and was decannulated. This report describes the only case of an adult with BVFI due to a posterior cricoid fracture that was successfully treated with EPCS/RG. Laryngoscope, 128:2864-2866, 2018.

Endoscopic posterior cricoid split with costal cartilage graft: A fifteen-year experience.

OBJECTIVE: To evaluate outcomes of the endoscopic posterior cricoid split with rib graft (EPCS/RG) procedure in the treatment of subglottic stenosis (SGS), posterior glottic stenosis (PGS), and bilateral vocal fold immobility (BVFI). STUDY DESIGN: Retrospective chart review. METHODS: Chart review of all patients who underwent EPCS/RG at a single tertiary-care facility between 1999 and 2014. Patients were grouped based on the primary indication for the procedure. Decannulation was the primary endpoint. Secondary endpoints were the number of subsequent airway procedures and length of hospitalization. RESULTS: Thirty-three patients were identified; 32 had tracheotomy. Overall decannulation rate was 65.6%. Subgroup analysis demonstrated the following decannulation rates: 53.8% for SGS, 100% for PGS, and 28.6% for BVFI. Fisher exact test found a significant difference in overall decannulation rates between groups (P = 0.002). Operation-specific decannulation rates for patients who never required an open procedure were 23% for SGS, 91.6% for PGS, and 28.6% for BVFI. This difference was also statistically significant (P = 0.001). Multivariate logistic regression analysis found prematurity had a positive correlation with decannulation that approached statistical significance (P < 0.051; odds ratio 6.1; 95% confidence interval 0.99, 37.6). The percentage of patients who underwent repeat airway procedures for the groups was 61.5% for SGS, 16.6 % for PGS, and 14.3% for BVFI. The median length of hospitalization after EPCS/RG was 3 days. CONCLUSION: This represents the largest series of patients who have undergone EPCS/RG and demonstrates that the majority of patients can be decannulated after this procedure. Patients with PGS had the highest operation-specific decannulation rates. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:252-257, 2017.