Anterior and posterior cricothyrotomy laryngotracheoplasty

Severe laryngotracheal stenosis is difficult to achieve with simple laryngotracheal incision. For example, the anterior wall of the annular cartilage plate and the laryngotracheal tube are cut open, the larynx lumen is widened, and a graft is added between the annular cartilage plate and the anterior wall of the laryngotracheal tube to widen the laryngotracheal tube. The cavity can be solved. Treatment of diseases: laryngotracheal esophageal hiatus tracheal scarring stenosis Indication Anterior and posterior ring cartilage incision laryngotracheal angioplasty is indicated for severe laryngotracheal 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. If the cartilage is prepared, the chest should be prepared. 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 1. Incision and exposure of the anterior wall of the larynx 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. Cut the anterior wall of the larynx Use a slotted probe to insert upward from the tracheal incision opening and use a knife to cut the anterior wall of the laryngeal trachea upward along the slotted probe. The laryngotracheal cavity was opened with an automatic retractor, and the scar tissue was removed from the mucosa. 3. Cut the annular cartilage plate and post-join The scar and the cartilage plate were cut from the annular cartilage plate with an orthopedic knife and extended upward to the posterior median. Separate the annular cartilage plate to both sides, taking care not to damage the anterior wall of the esophagus, causing esophageal tracheal fistula. Stop bleeding completely. 4. According to the degree and length of the stenosis, cut one piece of the costal cartilage with the perichondrium as needed. 5. The cartilage of the annular cartilage plate is transplanted A piece of perichondrug-shaped rhomboid cartilage was trimmed according to the area of the cleft cartilage plate. The perichondrium was placed in the rupture of the larynx bronchial cavity between the annular cartilage plates, and the gut was sutured intermittently with the annular cartilage plate. If the cartilage is not transplanted, a piece of perichondrug or myofascial fascia can be sutured to the ring of the cartilage plate to reduce granulation. 6. Place the nasogastric tube and supporter A nasogastric tube is inserted from the nasal cavity. Place the silicone rubber T-tube with the upper end not exceeding the braided bulge. Pull the larynx trachea together, block the T-shaped tube branch, observe that it can breathe from the nose and mouth, indicating that the support is placed properly. 7. Repair the anterior wall of the larynx The anterior wall rupture of the laryngotracheal can be treated in three ways: (1) The thyroid cartilage and the annular cartilage arch were sutured with the gut, the trachea was not sewed, and the anterior wall sulcus was covered with the sternohyoid muscle suture. (2) The thyroid cartilage and the annular cartilage arch were sutured with the gut, and the tracheal wall was cut into a fence, and the anterior wall of the trachea was sutured with the gut. (3) Transplantation of costal cartilage, sutured with cartilage rib cartilage in a fusiform shape between the two sides of thyroid cartilage, annular cartilage and tracheal cleft, suture the costal cartilage with thyroid cartilage, annular cartilage and tracheal cartilage. Generally, the latter two methods work well. 8. Suture incision The band muscles on both sides were sutured with the gut, the incision was washed with saline, and the flow strip was placed. The platysma, subcutaneous tissue and skin are layered. Aseptic dressing is applied. 9. Remove the support The trachea was ruptured before and after, and the stent was removed from the transplanted cartilage six months to one year after surgery. The transplanted cartilage can be taken out from the supporter 1 to 3 months after surgery. complication 1. Difficulty breathing laryngotracheal surgery with silicone rubber T-tube may cause breathing difficulties after surgery. The reasons are: (1) It may be blocked due to obstruction of the branch tube. (2) The silicone rubber T-shaped tube placed under the glottis is too close to the glottis (generally about 2cm away from the glottis), causing edema under the glottis and long granulation, which causes difficulty in breathing. The prevention method is as follows: if the scar under the glottis is less than 2cm away from the glottis, when placing the silicone T-shaped tube, the main pipe should be extended above the plane of the false sound belt. If it has been placed under the glottis and edema and dyspnea have occurred, and the support tube can be taken out in a short period of time, take a tracheal incision sleeve slightly smaller than the branch tube, and insert it into the trachea from the T-tube branch tube. To relieve breathing difficulties. If the T-tube cannot be removed in a short period of time, the T-tube must be replaced, otherwise a new scar will be formed under the glottis. (3) In a few cases, due to the poor quality of the T-shaped tube, or the tube wearing time is too long, the branch tube is broken, the main tube falls off into the trachea, causing respiratory obstruction and breathing difficulties, which can be taken out by bronchoscopy. 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 the stenosis of the posterior scar of the glottis after surgery. The posterior combined and annular cartilage incision is used, and the incision mucosa or muscles are poorly hemostasis. The incision should be opened to find the bleeding point to stop bleeding. 3. The upper end of the misdiagnosed silicone rubber T-shaped tube is too long, beyond the plane of the sacral cartilage or the patient does not adapt to the silicone rubber T-shaped tube. It may cause a swallowing when the diet is taken. If it is not treated in time, aspiration pneumonia may occur. Therefore, the distance between the tracheal incision and the braided bulge should be measured repeatedly, and then the length of the T-tube should be trimmed to avoid postoperative swallowing. If a swallow has occurred, use a snare to cut a long T-tube head through a straight laryngoscope. If the patient is not adapted, the diet training method is adopted first, that is, the patient is allowed to eat dry food first, and then drink water after adaptation. Or take a small plastic tube and wire it into the small finger sleeve of the cut rubber glove to make the airbag. When eating, insert the airbag from the T-shaped tube branch, put it on the upper end of the T-shaped tube and inflate it, and put the T-shaped tube on the tube. If the mouth is blocked, the food will not fall into the trachea. After the diet, remove the balloon. 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. If it is a fresh injury, nerve repair can be performed. 8. In the tracheal esophagus, laryngotracheal tracheal angioplasty, the scar tissue on the posterior wall of the trachea is removed too deep, resulting in tracheoesophageal fistula. Intraoperative scarring of the posterior wall was performed as little as possible. 9. Pulmonary infection Anesthesia intubation air bag leaks, there is no gauze around the intubation, blood flows into the lower respiratory tract, and there is no adequate suction after surgery, which can lead to pulmonary 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. 10. In a few cases of mediastinal inflammation, excessive paratracheal tissue, especially laryngotracheal anastomosis or end-to-end anastomosis, intraoperative aseptic operation is not strict, no antibiotics are used after surgery, and patients have low resistance. With mediastinal inflammation. If it has already occurred, the wound should be circulated smoothly and the dose of antibiotics should be increased.