Laryngotracheal reconstruction with a muscle-pedicle hyoid bone flap: a series of 23 patients.

Abstract

We conducted a study to evaluate the effectiveness of muscle-pedicle hyoid bone flaps in the repair and reconstruction of the larynx and trachea in 23 patients who had undergone extended partial laryngectomy. Of this group, 17 patients had undergone surgery to correct laryngotracheal stenosis and 6 to remove laryngeal carcinoma. Intervention resulted in successful decannulation in 20 of the 23 patients (8 7.0%). Of the 3 patients who did not experience a successful outcome initially, 2 were successfully decannulated following a second intervention; the other patient required a total laryngectomy because of cancer recurrence. In light o four follow-up results, we conclude that hyoid bone appears to be an effective autograft in such cases.

Introduction

Recent improvements in the management of laryngotracheal stenosis and laryngeal cancer have made it possible to achieve nasal respiration without tracheotomy, swallowing without aspiration, and sufficient voice to communicate for patients who were previously consigned to life-long tracheotomy. Many materials have been used to expand and support the lumen in patients with advanced stenosis and to correct defects created by extended partial laryngectomy.

The first use of hyoid bone as a graft to treat laryngotracheal stenosis was reported by Looper in 1938. (1) Long after his study, Bennett in 1960 reported partial success in the treatment of chronic subglottic stenosis by using an autologous hyoid bone graft. (2) Alonso et al used hyoid bone in their experimental study of dogs published in 1975.3 That same year, Finnegan et al were the first to report the use of hyoid bone with a muscle pedicle in dogs. (4) Following that interesting report, Ward et al published their study of the use of muscle-pedicle hyoid bone in the treatment of laryngotracheal stenosis in 1977. (5) In 1983, Sekercioglu et al used the same material to reconstruct defects following tumor resection in the larynx. (6) In this article, we discuss the results of laryngotracheal reconstruction procedures that involved the use of muscle-pedicle hyoid bone as a grafting material.

Patients and methods

Between 1980 and 2000, we used hyoid bone with a muscle pedicle in 23 patients--12 males and 11 females, aged 5 to 62 years (mean: 37--who had laryngotracheal stenosis or laryngeal carcinoma. Of this group, 17 patients had undergone surgery to correct laryngotracheal stenosis and 6 to remove laryngeal carcinoma. In the latter group, 5 patients had had a stage T3 transglottic tumor and 1 had had a stage T1b tumor.

Prior to grafting, all patients provided a detailed history and underwent complete ENT and systemic examinations. To assess the anatomic location of their detects, indirect and direct laryngoscopic examinations were carried out in all patients. Most also underwent radiologic examination by magnetic resonance imaging or computed tomography.

The postoperative evaluation involved assessment of parameters such as the quality of respiration and speech and the ability to swallow. For those patients who had had a laryngeal tumor, surveillance and recurrence data were also recorded. Patients who experienced normal or near-normal respiration postoperatively were regarded as having a successful outcome, patients who were dyspneic on minimal exercise were classified as having an intermediate outcome, and those who could not be decannulated were classified as having an unsuccessful outcome. Normal swallowing was regarded as successful, swallowing with minimal aspiration as intermediate, and swallowing with aspiration as unsuccessful.

Patients who had not undergone preoperative tracheotomy were tracheotomized before or during the surgical intervention. After each patient was prepared and draped with the neck extended, a horizontal skin incision was made approximately 2 to 3 cm caudal to the stenotic or resected area. The upper skin flap, including the platysma, was elevated slightly above the hyoid bone. During dissection, care was taken not to injure the blood vessels and innervations in the infra- and suprahyoid muscles. The superior portion of the hyoid bone was freed from the suprahyoid muscle attachments. The posterior portion of the hyoid bone was dissected along with its overlying periosteum. (The sternohyoid and omohyoid muscles can also be dissected; the length of the dissection depends on the distance from the hyoid bone to the area to be reconstructed.) We dissected only enough tissue to allow for the free movement and interposition of the hyoid bone muscle pedicle to the reconstructed area. A sufficient length of hyoid bone was dissected to fit the stenotic segment. The bone flap was constructed subperiosteally with the aid of a drill. This flap was positioned either horizontally or vertically and fixed to the reconstructed area (figure 1). (The bone areas facing the lumen must be lined with a skin graft or a mucosal graft obtained from the pyriform sinus.) For extended partial laryngectomies, the thyroid cartilage and the cephalic portion of the cricoid cartilage were resected, and the arytenoid cartilage was removed (figure 2). Hyoid bone with a muscle pedicle was then used to create a bulge where the arytenoid cartilage had been. The part of the hyoid bone that faced the lumen was covered with mucosa obtained from the pyriform sinus.

[FIGURES 1-2 OMITTED]

Results

For most of these patients, hyoid bone reconstruction was performed to supply rigid support against a mobile arytenoid cartilage or vocal fold following extended surgical resection. In the patient with the T1b tumor, we used hyoid bone to reconstract the anterior commissure alter an extended resection. However, this patient could not be decannulated because the airway was insufficient. He subsequently underwent a total laryngectomy following a peristomal recurrence of laryngeal cancer.

Of the 5 patients who had had a stage T3 tumor, 4 were successfully decannulated in an average of 41 days. Decannulation of the other patient was postponed until she had completed radiotherapy because we were concerned about the possibility of severe laryngeal edema. After radiotherapy, she could still not be decannulated, and she underwent revision surgery using the greater cornu of the thyroid cartilage. She was successfully decannulated on postoperative day 14. After a mean follow-up of 6 years, all 5 patients showed no evidence of recurrence.

Of the 17 patients who had had laryngotracheal stenosis, 7 had glottic-subglottic stenosis, 5 had glottic-subglottictracheal stenosis, 2 had glottic stenosis, 2 had subglottic-tracheal stenosis, and I had supraglottic-glottic-subglottic stenosis. The two most common etiologic factors in their stenosis were (1) a long period of intubation and (2) an unsuccessful surgical intervention for treatment of post-thyroidectomy bilateral vocal fold paralysis. Of these 17 patients, 14 were successfully decannulated in an average of 21.4 days. Of the remaining 3 patients, 2 could not be decannulated because they had previously undergone reconstruction with another graft material. We eventually achieved decannulation in 1 of these patients by using the greater cornu of the thyroid cartilage. The other patient was decannulated with the help of an auricular cartilage graft. Both were successfully decannulated in an average of 10 days following these additional operations. In 3 of our patients, we used additional reconstruction material--nasal septal cartilage with mucosa and hyoid bone--for external support (figure 3).

[FIGURE 3 OMITTED]

Only 1 of our patients exhibited graft necrosis, and his lesion was reconstructed with epithelialized retroauricular cartilage.

We placed a stent in 4 patients; the mean duration of stent placement was 12.75 days.

Of the 23 patients in our series, 20 (87.0%) were successfully decannulated, and their respiration, speech quality, and swallowing ability were adequate.

Discussion

The primary aim of laryngotracheal reconstruction is to establish an adequate airway by creating a wide lumen with an epithelial lining and a flexible structure that does not collapse during respiration. Many flaps and grafts have been used to achieve this goal; among them are nasal septal (7) and auricular cartilage, (8) epiglottic tissue, (9) thyroid cartilage, (10) costal cartilage, (11) sternocleidomastoid myoperiosteal flaps, (12) and hyoid bone. (4,13)

As mentioned earlier, Alonso et al (3) and Finnegan et al (4) published early reports on the use of hyoid bone with a muscle pedicle for the repair of subglottic stenosis in dogs. Alonso et al noted several advantages of this method, and they reported histologic evidence of graft survival. Finnegan et al used hyoid bone with a muscle pedicle rather than a free graft to ensure a more reliable blood supply. The next year, Alonso et al reported that this technique resulted in the successful repair of laryngotracheal stenosis in 5 of 6 humans. (13)

Ward et al achieved satisfactory results in 3 of 4 patients by using hyoid bone with a muscle pedicle. (5) They noted that when they used a graft with a vascular supply, the rate of reabsorption and the rate of remodeling were gradual. When they altered their replacement process in favor of maintaining continuous structural support, the continuous blood supply helped facilitate healing and prevention of infection and the attached muscles helped establish the stabilization and fixation of the graft.

McGuirt et al reported a prospective analysis of 20 infants who had undergone an anterior cricoid split with hyoid interposition grafting for the repair of subglottic stenosis, (14) They reported satisfactory results and concluded that readily available hyoid bone is a reliable grafting material for interposition grafting during the anterior cricoid split procedure.

We based our work on the successful results reported by these authors, noting that composite muscle bone grafts provide for both structural support and a wide lumen. The vascular supply of the immediately available autologous material ensures its viability, as has been confirmed experimentally. The probability of encountering necrosis of the reconstruction materials when using a graft without a vascular pedicle is higher, and the superiority of flaps over grafts in the reconstruction process of stenosis is well established.

A hyoid bone flap with a muscle pedicle can be used to correct both glottic and subglottic stenosis. Another indication for hyoid bone reconstruction is the presence of bilateral abductor vocal fold paralysis that has failed to respond to arytenoidectomy.

There are three circumstances in which the hyoid bone can be used safely to close a defect and restore glottic closure by providing rigid support against the contralateral arytenoid and vocal fold:

* after extended partial laryngectomy in which unilateral cordectomy and arytenoidectomy are performed

* when the resection is extended to the contralateral side or to the subglottic region

* when resection of a large portion of the thyroid cartilage is performed

Special attention must be given to lining the lumen that faces the endolarynx with epithelium; the mucosa of the skin or pyriform sinus can be used for this purpose. Because extended partial laryngectomy involves subglottic resection, the risk of local recurrence is diminished. According to Kirchner and Sore, surgical failures are usually the result of an inadequate margin at the inferior edge of the resection. (15) For this reason, the resection of a part of the cricoid cartilage may be required; however, because this extension increases the probability of aspiration, reconstruction is necessary. Biller and Lawson described a method of reconstruction that involves the use of the posterior portion of the thyroid cartilage lamina when available. (10)

Nasal septal cartilage and auricular cartilage with epithelium are used widely for reconstruction. However, in some cases--especially in children these cartilages are too delicate to provide adequate support. We used our reconstruction method to repair defects with epithelialized cartilage followed by external hyoid bone support in 3 of our patients. With this method, the placement of a stent is unnecessary, decannulation is rapid, repeat surgery is unnecessary, and a rigid framework that avoids collapse is provided.

When a stent is necessary, it is important to use materials that are rigid enough to prevent constriction secondary to scar tissue and flexible enough to adapt to intraluminal volume changes in the larynx. Wrapping the stent with skin is important in order to line the bone portions with epithelium and to prevent rejection. We prefer not to use stents, but when we do, we limit the duration of stent placement to 10-15 days.

In conclusion, we believe that reconstruction with muscle-pedicle hyoid bone is an effective means of repairing laryngotracheal stenosis. The advantages of this technique are that:

* it provides much more reliable and stronger support than do other grafts

* it allows for better vascularization of the muscle pedicle

* it is associated with rapid wound healing facilitated by stabilizing the mobile laryngotracheal structure

* it can be performed close to the stenotic or reconstructed segment

* it can be performed easily in one stage

* it is associated with a low complication rate

* it may require sacrifice of less tissue

References

(1.) Looper EA. Use of hyoid bone as a stent in laryngeal stenosis. Arch Otolaryngol 1938;28:106-11.

(2.) Bennett T. Laryngeal strictures. South Med J 1960;53:1101-4.

(3.) Alonso WA, Druck NS, Griffiths CM, et al. Cricoid arch replacement in dogs. Further studies. Arch Otolaryngol 1975;101:42-5.

(4.) Finnegan DA, Wong ML, Kashima HK. Hyoid autograft repair of chronic subglottic stenosis. Ann Otol Rhinol Laryngol 1975;84: 643-9.

(5.) Ward PH, Canalis R, Fee W, Smith G. Composite hyoid sternohyoid muscle grafts in humans. Its use in reconstruction of subglottic stenosis and the anterior tracheal wall. Arch Otolaryngol 1977;103: 5314.

(6.) Sekercioglu N, Gokcel A, Irez T. Extended partial laryngectomy. Presented at the 17th National Congress of the Turkish Otorhinolaryngology Society; Oct. 9-12, 1983; Adana, Turkey.

(7.) Laurian N, Zohar Y. Laryngeal reconstruction by composite nasal mucoseptal graft after partial laryngectomy. Three years follow-up. Laryngoscope 1981;91:609-16.

(8.) Caputo V, Consiglio V. The use of patient's own auricular cartilage to repair deficiency of the tracheal wall. J Thorac Cardiovase Surg 1961;41:594-6.

(9.) Tucker HM, Wood BG, Levine H, Katz R. Glottic reconstruction after near total laryngectomy. Laryngoscope 1979;89:609-18.

(10.) Biller HF, Lawson W. Partial laryngectomy for vocal cord cancer with marked limitation or fixation of the vocal cord. Laryngoscope 1986;96:61-4.

(11.) Zalzal GH, Cotton RT, McAdams AJ. The survival of costal cartilage graft in laryngotracheal reconstruction. Otolaryngol Head Neck Surg 1986;94:204-11.

(12.) Friedman M, Toriumi DM, Owens R, Grybauskas VT. Experience with the sternocleidomastoid myoperiosteal flap for reconstruction of subglottic and tracheal defects: Modification of technique and report of long-term results. Laryngoscope 1988;98:1003-11.

(13.) Alonso WA, Druck NS, Ogura JH. Clinical experiences in hyoid arch transposition. Laryngoscope 1976;86:617-24.

(14.) McGuirt WF, Jr., Little JP, Healy GB. Anterior cricoid split. Use of hyoid as autologous grafting material. Arch Otolaryngol Head Neck Surg 1997;123:1277-80.

(15.) Kirchner JA, Som ML. The anterior commissure technique of partial laryngectomy: Clinical and laboratory observations. Laryngoscope 1975;85:1308-17.

From the Department of Otolaryngology-Head and Neck Surgery, Cerrahpasa Faculty of Medicine, University of Istanbul (Dr. Cansiz, Dr. Yener, and Dr. Sekereioglu), and the Department of Otolaryngology, Side Government Hospital, Antalya, Turkey (Dr. Gunes).

Reprint requests: Harun Cansiz, MD, Nato Yolu, Caprazli Alt Sok., 12/7 Cengelkoy/Uskfudar 81220, Istanbul, Turkey. Phone: [phone]; fax: [phone]; e-mail: [e-mail]