hyoid flap graft laryngotracheoplasty

Tongue flap transplantation for tracheal tracheal angioplasty is suitable for severe glottic, glottic and subglottic scar stenosis. Treatment of diseases: congenital subglottic stenosis Indication Tongue flap transplantation for tracheal tracheal angioplasty is suitable for severe glottic, glottic and subglottic scar stenosis. Contraindications Combined tracheal stenosis. Preoperative preparation 1. Learn more about the condition and conduct a comprehensive physical examination, including heart, lung, liver and kidney function tests. 2. Indirect laryngoscope, direct laryngoscope and fiber bronchoscopy to understand the location, extent, extent and cartilage defect of the scar in the laryngotracheal tube. 3. Take the X-ray or CT scan of the lateral position of the larynx to understand the location, extent, extent and cartilage defect of the scar. 4. Tracheotomy is generally a tracheotomy for chronic laryngeal stenosis. If not, a lower tracheotomy can be performed first, followed by an angioplasty. If the tracheotomy position is high, the cut opening should be moved to the 4th to 5th tracheal rings first. 5. Tracheal endocrine culture and bacterial drug sensitivity test. 6. Prepare the skin in the neck. Oral rinse with a 1:1000 nitrofurazone solution. 7. Prepare, fasting, and injecting atropine before general anesthesia. 8. Do a good job of explaining the work, so that patients can understand the treatment of scar stenosis is difficult, complications may occur, the quality of the sound is not good, postoperative swallowing, and may require surgery. Surgical procedure Incision Straight and U-shaped incisions: (1) Straight incision: In the middle of the neck, the lower edge of the hyoid bone is raised, and the upper sternal notch is 1 to 2 cm. The skin, subcutaneous tissue and platysma are vertically cut, and the skin is separated to both sides. (2) U-shaped incision: 2 cm from the upper sternal notch to make a U-shaped incision, both sides to the inner edge of the sternocleidomastoid, thyroid cartilage plane, incision of the skin, subcutaneous tissue to the platysma, from the platysma Separate the hyoid bone, cover the platysma with a sterile cotton pad, suture a few needles outside, and then attach it to the hyoid bone with the platysma. 2. Separation of the prethrombotic The flaps were separated, and the band muscles on both sides were separated from the midline, and pulled out to the sides with a hook to reveal thyroid cartilage and ring cartilage. 3. Cut thyroid cartilage and remove scar A transverse incision was made from the middle of the ring of the nail, and the thyroid cartilage was cut in the middle. Excision of the submucosal scar. One side of the sacral cartilage was excised from the submucosa, and the vocal folds were sutured outwardly to the ipsilateral thyroid cartilage with a nylon thread to move the vocal cords outward. 4. Preparation of the hyoid bone graft There are two types of hyoid bone grafts, one is a periosteum graft with a periosteum; the other is a graft flap with a sternohyoid muscle. 1 with periosteum flap: cut a 2cm long bone flap from the middle of the hyoid bone, separate the muscle attached to the upper and lower edges, and cut, retain the periosteum on the surface of the hyoid bone, peel off the bone coat on the inner side of the hyoid bone, then freely remove The periosteal flap is reserved. 2 lingual flap with sternohyoid muscle pedicle: cut the muscle attached to the upper edge of the middle part of the hyoid bone, cut one side of the sternohyoid muscle from the attachment end of the hyoid bone, and free the superficial and deep gluten of the other side of the sternum membrane. Cut a piece of hyoid bone flap with sternohyoid muscle from the middle part of the hyoid bone 5. Put the support Insert the nasogastric tube first. A silicone rubber T-tube or other material is placed into the laryngotracheal lumen. Pay attention to the following points: 1 If the combined glottis is narrow, the upper end of the support must be more than 1~2cm above the cartilage, and the upper mouth of the support must be sealed to prevent aspiration. The tube can be sealed with a penicillin cap or other stopper. The tracheal cannula can be inserted into a silicone T-tube or as a fixed support. If the silicone tube is not inserted into the tracheal tube, a thick thread or a wire can be used to penetrate the skin of the neck, the thyroid cartilage and the front wall of the support, and the skin on both sides of the neck is ligated to fix the support. 2 If the scar of the scar wound is large, a piece of the wound skin piece can be cut, and the skin is wrapped around the supporter, and the skin edges of both sides are sutured with a thin thread, and the skin is transplanted to the throat wound by the supporter. 6. Implanted hyoid flap The cut sternohyoid muscle flap was first moved between the thyroid cartilage plates on both sides, and the sternohyoid muscle flap was sutured with the anterior joint and the bilateral thyroid cartilage plates with a 4-0 gut. Two holes were drilled on both sides of the hyoid flap, and the periosteum or pedicled flap was grafted between the thyroid cartilage plates on both sides and the sternal musculoskeletal flap that had been sewed. The hyoid bone and the thyroid cartilage plate were sutured with nylon thread or silk thread. 7. Suture incision The incision was washed with physiological saline, the rubber drainage strip was placed, the banded muscles and the platysma were sutured with the gut, and the subcutaneous tissue and skin were sutured by thin wires. Aseptic dressing is applied. 8. Go to the supporter The support was taken 1 to 3 months after surgery. (1) Straight support method: Cut off the knot of the support on the neck skin and pull out the line. Insert the direct laryngoscope from the mouth and use a laryngeal forceps to remove the support. (2) Silicone rubber T-tube method: use 2 vascular clamps, 1 vascular clamp into the branch tube, push the T-tube up, and show a small gap under the branch tube. If there is no gap, use a knife to make a small hole from the branch tube. Incision, another vascular clamp is inserted from the space below the branch pipe, clamp the lower section of the main pipe, force the lower section of the main pipe, and the entire T-shaped pipe is pulled out. Place the tracheal cannula immediately. 9. Extract the tracheal tube and repair the tracheal fistula After the support was removed, the tracheal cannula was blocked for 2 to 4 weeks, and no dyspnea was observed. The tracheal cannula was removed and the tracheal fistula was repaired. complication 1. Patients with dyspnea and laryngotracheal angioplasty may have difficulty breathing after surgery. 2. Incision hemorrhage repeatedly sucked out blood after sucking, indicating that there is bleeding in the incision in the laryngotracheal tube. Common bleeding sites are stenosis of the glottic stenosis during surgery, and the blood of the incision mucosa or muscles is poor. The incision should be opened to find the bleeding point to stop bleeding. 3. Inadvertently see the surgical procedure 5. 4. Subcutaneous emphysema, laryngotracheal fistula, open incision, suture, puncture, poor airway or severe postoperative cough can cause subcutaneous emphysema. In the case of subcutaneous emphysema, it is advisable to remove the suture of the neck skin and make the respiratory tract unobstructed and give antitussives. 5. Laryngeal tracheal granulation in the laryngas tube can sometimes grow granulation at the suture. The top of the support is not smooth and can also wear out to grow granulation. Large granulation can block the respiratory tract and form new scar stenosis. Generally, the laryngoscope, bronchoscope or fiberoptic bronchoscopy should be performed after the support is removed. If granulation is found, it can be bitten with a bite. 6. Laryngeal tracheal restenosis Severe laryngotracheal scar stenosis is often not successful in one operation, such as anastomotic stenosis, graft infection necrosis, absorption, rejection, or displacement; the respiratory tract formed by surgery is not large enough; silicone rubber The T-shaped tube mouth is not smooth, damages the respiratory mucosa, forms a new scar stenosis, etc., and can be restenosis to make the operation fail. 7. Injury of the recurrent laryngeal nerve and paratracheal tissue is too deep, especially in the case of thyroid tracheal anastomosis and end-to-end anastomosis. If it is a fresh injury, nerve repair can be performed. 8. Pulmonary infection Anesthesia intubation air bag leaks, no gauze around the intubation, blood flow into the lower respiratory tract, and no adequate suction after surgery, can lead to lung infection. During the operation, attention should be paid to prevent blood from flowing downward, soaking in time after surgery, dropping medicine in the trachea and applying antibiotics throughout the body.