NEW POSSIBILITIES FOR TRACHEOSTOMY REVERSAL

May 19, 2017

Surgical technique restores normal breathing, talking in 12-year-old

INNOVATIONS IN OTOLARYNGOLOGY – HEAD & NECK SURGERY - Winter 2017 - View Full PDF

MARK WEIDENBECHER, MD

Otolaryngologist, UH Ear, Nose & Throat Institute; Assistant Professor of Otolaryngology,Case Western Reserve University School of Medicine

Illustration

Prolonged intubation can cause posterior glottic stenosis with respiratory distress, presenting patients with an undesirable choice: either (1) a permanent tracheotomy to restore adequate airflow but maintain a good voice, or (2) removal of part of the vocal cords to establish an adequate glottic airway, which causes permanent hoarseness.

“Both of these procedures obviously have a significantly negative impact on quality of life,” says otolaryngologist Mark Weidenbecher, MD, of University Hospitals Ear, Nose & Throat Institute. He recently introduced a third surgical option that has allowed for the reversal of a tracheotomy and restoration of normal breathing, swallowing and phonation in an adolescent boy.

The boy was born at 25 weeks’ gestation with mild cerebral palsy. Physicians intubated him for approximately four months due to respiratory insufficiency. After extubation, he developed chronic stridor due to a posterior glottic stenosis. He was ultimately unable to maintain adequate respiration and had to undergo a tracheotomy.

As he grew, the boy could not engage in typical childhood activities such as swimming or playing outside with friends. He and his parents had seen several physicians, who gave no hope of removing the tracheostomy because of his severe posterior glottic stenosis with cricoarytenoid joint ankylosis. When the boy reached age 12, his parents brought him to Dr. Weidenbecher for another opinion. Dr. Weidenbecher proposed a procedure to establish normal vocal cord mobility with a normal glottic airway.

CRICOARYTENOID JOINT RELEASE WITH INTERPOSITIONAL PIRIFORM SINUS MUCOSAL FLAP RECONSTRUCTION

Dr. Weidenbecher has used a novel vocal cord joint release technique with great success in nearly a dozen cases. He endoscopically removed the interarytenoid scar with a laser, while using microlaryngeal instruments to carefully incise and release the fibrotic cricoarytenoid joint capsule circumferentially, which, according to Dr. Weidenbecher, is key in establishing full vocal cord mobility.

To prevent the formation of new scar tissue that would pull the vocal cords back together, he endoscopically raised a pedicled flap from the piriform sinus, which he sutured into the posterior commissure to prevent restenosis and to maintain arytenoid mobility.

“Because it’s fresh mucosal tissue that’s not scarred or exposed to any trauma, scar tissue is less likely to form,” Dr. Weidenbecher explains.

He continues, “Patients with posterior glottic stenosis and fairly intact cricoarytenoid joint facets without bony remodeling of facet joints tend to do very well and benefit from this procedure. We are often able to establish normal vocal cord function.”

Dr. Weidenbecher performs the procedure on both adults and children. Flap procedures have been described in the past, but as Dr. Weidenbecher explains, releasing the joints from their scar and mobilizing them is an important step in this novel procedure.

A SUCCESSFUL OUTCOME

Dr. Weidenbecher’s 12-year-old patient underwent surgery without complication. He kept the tracheostomy for a few weeks while his surgical site healed, and then physicians removed the tracheostomy cannula. 

“In my opinion, there are no major drawbacks to this procedure. The advantage compared to previous procedures, such as a posterior cordotomy, is that the membranous vocal cord is not affected from the surgery and patients are, therefore, not expected to be hoarse. Restoring laryngeal function and allowing patients – particularly pediatric patients – to live a normal life is very gratifying.

“Since surgery, my 12-year-old patient has been able to talk, swallow and breathe normally,” Dr. Weidenbecher says. “He is able to go swimming and play in the backyard. We were essentially able to give him back a normal life.”

Dr. Weidenbecher, Otolaryngologist, UH Ear, Nose & Throat Institute, specializes in larynx disorders and airway management. If you have a patient who may benefit from cricoarytenoid joint release with interpositional piriform sinus mucosal flap reconstruction, please contact Dr. Weidenbecher at 216-844-5470 for a consult.

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