Rehabilitation of laryngeal scarring stenosis

Throat scarring is often caused by various traumas of the throat, such as blunt crushing, cutting of sharps such as knives and scissors, penetrating wounds of bullets, burns of chemicals such as strong acid and alkali, and accidental injuries (eg High tracheotomy, anesthesia intubation for a long time, etc. caused. Squeezing, cutting, and penetrating injuries can cause the laryngeal cartilage stent to collapse and become incomplete, causing severe stenosis or atresia. Chemical burns cause necrosis and ulceration of the mucous membranes and submucosal soft tissues in the larynx, causing scarring and narrowing of the larynx. High tracheotomy is mostly due to the cutting of the cartilage, and the foreign body stimulation of the tracheal cannula, secondary infection of the adjacent tissue of the fistula, forming a subglottic stenosis. Laryngeal stenosis is currently a difficult and complicated treatment problem, especially in cases with a wide range of stenosis or no effect after multiple operations. It is more difficult to treat, so attention should be paid to the prevention of laryngeal stenosis. For example, when the laryngeal trauma occurs, it should be repaired early, the infection should be controlled, and the mucosa and cartilage in the larynx should be preserved as much as possible to avoid high tracheotomy. If a tracheal cannula or other cannula is placed in the throat wound during first aid, it should be changed to a low tracheotomy as early as possible to avoid indwelling for too long, resulting in a narrow throat. Treating diseases: throat stenosis Indication According to the degree and location of scar stenosis in the laryngeal cavity, the stable condition of the laryngeal infection, and the general condition can support the surgery for a long period of time, the rectification of laryngeal scar stenosis can be considered, generally in the following cases: 1. The degree of scarring in the laryngeal cavity is relatively mild, the glottis is not locked, and there is still airflow that can be passed. It is feasible to perform direct laryngoscopy. 2. The scar in the laryngeal cavity is heavier, the gap is very small, or it is completely occluded, no airflow is passed, and the laryngeal fissure can be opened and rectified. 3. Lower than the glottic or cervical tracheal stenosis, feasible end-to-end anastomosis. 4. The upper glottic area is narrow, and it is feasible to perform sublingual incision. Contraindications 1, with systemic diseases, can not tolerate surgery. 2, local infection, not suitable for surgery. Preoperative preparation Because of the serious respiratory difficulties of the patients, tracheotomy is required. Surgical procedure According to the degree of laryngeal stenosis, there are four surgical methods: 1 through oral dilatation, 2 larynx rupture, 3 end suture, 4 sublingual incision. The description is as follows: (1) Oral dilatation is applied to less severe cases. The patient takes the supine position and, under the guidance of the direct laryngoscope, inserts the laryngeal dilator for expansion. The laryngeal dilator is a set of cylindrical metal heads of varying diameters that are stalked for easy insertion into the larynx. When expanding, the expander with a smaller diameter should be selected first, and then thickened and gradually enlarged. Once a week or 2 weeks. The advantage of this method is relatively simple, and has a certain effect on patients with less strictness; the disadvantage is that it needs to be repeated many times, the effect is not easy to consolidate, and there is no obvious effect on the more severe throat narrowing. (2) The laryngeal splitting can be performed in both horizontal and vertical incisions. After exposing the larynx, the median rupture, clear the scar area within the larynx, remove the scar tissue under the premise of retaining the mucosa as much as possible, and open the blocked airway, the wider the better. According to the size of the larynx after resection of the scar, a silicone tube of appropriate diameter is placed for expansion, and the wall is made of two small holes, which are pierced with stainless steel wire and ligated around a skin tube around the surface of the thyroid cartilage. The plastic tube is placed for at least 6-8 months to reduce the contractile force of the regenerated scar around the plastic tube. When taking out, first remove the fixed wire, take it out through the mouth with a laryngeal forceps under the direct laryngoscope peep, or take it out through the laryngeal opening. The silicone tube can be hollow or hollow, and each has its own advantages and disadvantages. Place the hollow dilatation tube, the patient can still breathe after blocking the tracheal tube, which is safer. If it falls off to the lower end of the trachea, there will be no suffocation. The disadvantage is that the stench is often accumulated in the dilatation tube, which is difficult to cough up and difficult. Smells the smell, and often because the glottis is stretched, it may cause food to break into the trachea. Solid tubes have no such disadvantages as hollow tubes, but if they are not securely fixed, there is a risk of suffocation falling into the lower end of the trachea. There is no opinion on whether skin grafting (or fascia, vein) is needed after resection of the scar. The purpose of skin grafting is to reduce or avoid the re-formation of scars. However, in practice, because the lumen is not flat, it is difficult to fix the compression, and it is difficult for the skin graft to survive, that is, to survive all, and the scar is still inevitable due to the thin skin. Therefore, skin grafting is generally not advocated, and silicone tube expansion is placed. (C) The end-to-end anastomosis is suitable for subglottic stenosis or cervical tracheal stenosis. The subglottic stenosis is often accompanied by a narrowing of the 1 to 4 ring of the cervical trachea. The cartilage and tracheal ring are often incomplete due to trauma, inflammation, etc., and can not function as a cartilage scaffold. If the stenosis length is within 2cm, it can be removed, and the lower part of the larynx is pulled up, and the lower end of the trachea is pulled up to enable the anastomosis. . In fact, there are often secondary infections after trauma, extensive local scars, difficulty in relaxing the laryngeal or trachea, and the risk of bilateral vocal cord paralysis due to injury of the recurrent laryngeal nerve. The recurrent laryngeal nerve is close to the posterior wall of the trachea. It is already very thin, and it is difficult to identify with local scarring. Therefore, the operation is mainly suitable for trauma. At the time, the local markers are clear, and the laryngeal and trachea are easier to relax. Case, or scar length of stenosis is shorter (about 1 cm), and the previous wall is predominant. The method is as follows: Make a transverse incision at the level of the stenosis, separate the skin and the underlying muscle layer, expose the anterior wall of the stenosis, and separate to the sides, so as not to excessively approach the posterior wall to avoid damage to the recurrent laryngeal nerve. Make a front wide and posterior narrow wedge resection (Fig. 4) and then anastomosis. When suturing, due to a certain tension, stainless steel wire can be used, usually 4 to 5 stitches can be sutured intermittently. If the anastomosis is good, it will heal quickly after the operation. There may be a small amount of granulation hyperplasia at the anastomosis (especially at the suture of the steel wire), but if the diameter of the cavity is large enough, it will not hinder the ventilation. (4) Sublingual resection is suitable for cases of glottic stenosis, which is more common in stenosis caused by burns of acid and alkali chemicals. The epiglottis often adheres to the posterior pharyngeal wall, and the cartilage of one or both sides is fixed. In severe cases, the upper end of the piriform esophagus is narrowed or blocked. Due to the higher stenosis position, the incision of the hyoid bone is a closer approach, as follows: A transverse incision of the sublingual skin was performed, separated layer by layer, and the lingual membrane and the loose connective tissue and the epiglottis mucosa were cut. Pull the wound open with a hook to see the epiglottic cartilage that adheres to the posterior wall of the hypopharynx. If necessary, cut off the adhesive part of the cartilage. If one side of the epiglottis wrinkles and the laryngeal wall is stuck, it should be separated and removed. In order to fully expose the throat and throat, the mucosa on both sides of the wound of the anatomical stump is sutured as much as possible. The wound surface of the posterior wall of the throat is generally not treated, because the posterior wall is supported by the cervical vertebrae. Transplantation of free skin pieces at this site is also difficult to fix due to difficulty in fixation. complication Postoperative bleeding.