Clin. Otolaryngol.

2000, 25, 342±349

REVIEW
Paediatric airway stenosis: laryngotracheal reconstruction
or cricotracheal resection?
B.E.J. HARTLEY & R.T. COTTON
The Children's Hospital Medical Center, Cincinnati, OH, USA

Accepted for publication 18 May 2000

HARTLEY B.E.J. & COTTON R.T.

(2000) Clin. Otolaryngol. 25, 342±349

Paediatric airway stenosis: laryngotracheal reconstruction or cricotracheal

resection?
Modern surgical management of paediatric laryngotracheal stenosis includes a wide variety of surgical
procedures. These can broadly be divided into two groups. First, laryngotracheal reconstruction (LTR)
procedures in which the cricoid cartilage is split and the framework is expanded with various
combinations of cartilage grafts and stents; and second, cricotracheal resection (CTR) where a
segmental excision of the stenotic segment is done and an end-to-end anastomosis is performed. In this
article we review the literature and our experience and discuss the relative indications for CTR and
LTR in children. High decannulation rates have been reported for CTR; however, it remains a more
extensive procedure than LTR involving extensive tracheal mobilization. If the tracheostomy site is
included in the resection then a signi®cant length of trachea is excised. Alternatively, LTR with
cartilage grafting can precisely correct a speci®c stenosis with minimum morbidity and high
decannulation rates for grade 2 and selected grade 3 stenosis. For the more severe stenosis treatment
with LTR has been less successful. Retrospective data from this institution suggests that the children
with grade 4 stenosis treated with LTR are more likely to require a subsequent open procedure to
achieve decannulation than those treated with CTR. LTR is a less extensive procedure and is preferred
for grade 2, selected grade 3 stenosis. CTR is the preferred option for grade 4 and severe grade 3
stenosis with a clear margin between the stenosis and the vocal cords.
Keywords paediatric laryngotracheal stenosis laryngotracheal reconstruction cricotracheal resection

Aetiology and incidence of laryngotracheal
stenosis
The introduction of prolonged endotracheal intubation for
premature neonates with immature lungs in the 1960s
caused a dramatic rise in the incidence of paediatric subglot-
tic stenosis. McDonald and Stocks1 reported a 20% tra-
cheostomy rate following prolonged intubation in 1965 and
Fearon et al.2 reported a 24% rate the following year. Since
that time many advances have been made in the manage-
Correspondence: Benjamin E.J. Hartley, The Royal National
Throat, Nose and Ear Hospital, Gray's Inn Road, London WC1X
8DA, UK.
ment of the neonatal airway on intensive care units and the
incidence of subglottic stenosis has decreased. Figures of
1%ÿ8% are often quoted3,4 but if the very low birth weight
infants (< 1.5 kg) are excluded the incidence is < 1%.5
This reduction has been achieved by a number of measures.
The replacement of red rubber endotracheal tubes with
polyvinylchloride tubes made a large impact. The length of
time of intubation is important but is only one factor. The
use of too large a tube quickly leads to ischaemia ulceration
and subsequent stenosis. Poor ®xation of the tube is likely
to increase the subglottic trauma and the chance of stenosis.
Nasotracheal intubation is preferred to orotracheal intuba-

# 2000 Blackwell Science Ltd 342


tion as the tube is more securely ®xed and less likely to
cause trauma to the subglottis.
Acquired subglottic stenosis due to endotracheal intuba-
tion is the predominant cause of subglottic stenosis that
requires surgery. Congenital subglottic stenosis is the second
commonest congenital laryngeal anomaly after laryngoma-
lacia.6 The diagnosis is suspected when subglottic stenosis is
diagnosed in a child who has not been previously intubated
and the cricoid is an abnormal shape, often elliptical.
In¯ammatory diseases such as Wegeners granulomatosis
may lead to subglottic stenosis although it is rare for this to
happen in children it may be seen in adolescents.
Classi®cation of subglottic stenosis
The original Cotton grading system for subglottic stenosis
was revised by Myer and Cotton7 to utilize endotracheal
tube size as a measure of airway size. The largest measured
size that can be admitted into the subglottis and still leak
with normal ventilation pressures (up to 25 cm water) is
compared to the age appropriate tube size for that child.
The percentage stenosis can be calculated. The Myer-Cotton
grading system is illustrated in Fig. 1.
Figure 1. The Myer±Cotton grading system for subglottic stenosis.
# 2000 Blackwell Science Ltd, Clinical Otolaryngology, 25, 342±349
Paediatric airway stenosis 343
Early adult procedures for laryngotracheal
stenosis
In 1938 Negus8 described the technique of laryngo®ssure
and dermal grafting for scar tissue formation in adults. Sub-
glottic stenosis at that time was principally due to high tra-
cheostomies performed as emergency procedures for
in¯ammatory disease, principally diphtheria. In 1953 Rethi9
in Budapest reported splitting the cricoid ring anteriorly
and posteriorly for cicatrical stenosis of the larynx in adults.
A long-term rubber stent was left in for several months
before the wound was closed. Rethi was working mainly
with adults who had sustained war injuries to the larynx.
Aboulker10 in 1966 introduced a stent which could be wired
into the tracheostomy tube and left in place for several
months.
Laryngotracheal reconstruction in children
With the increasing use of prolonged endotracheal intuba-
tion in children born prematurely in the 1960s came a new
wave of children with subglottic stenosis and tracheos-
tomies. Grahne11 in Helsinki in 1971 was the ®rst to
describe application of the Rethi procedure to children.
Grahne completely closed the incision using an Aboulker
stent wired to a metal tracheostomy tube. In 1972 Fearon
and Cotton12 in Toronto published a preliminary report of
an experimental surgical technique using a cartilage graft
positioned in an anterior cricoid split to maintain the expan-
sion of the cricoid ring. Included in this report were early
attempts at laryngotracheal reconstruction using auricular
cartilage (with skin attached) and rib cartilage lined with
buccal mucosa. Experimental work using the African green
monkey as a model was begun using a `trap±door' ¯ap
based on the thyroid cartilage. This was found to be suc-
cessful. In current practice all three of these cartilage grafts
are in use. It has been discovered that the lining of the graft
is better achieved by leaving the inner perichondrium on the
graft and skin and buccal mucosa are no longer used.
In 1974 Evans13 in London, who had visited Fearon and
Cotton in Toronto, described the laryngotracheoplasty.
This operation involved a di€erent approach. The cricoid
and trachea were split using a castellated incision and resu-
tured in an open fashion around a rolled silastic sheet. Suc-
cessful expansion of the cricoid was the result. The
laryngotracheoplasty (LTP) and the laryngotracheal recon-
struction (LTR) were the main surgical procedures
employed in the 1970s and 1980s. Gradually the laryngotra-
cheal reconstruction with cartilage grafting has become
more popular. In 1981 Cotton and Evans14 reported a 5-
year follow-up on laryngotracheal reconstruction in chil-
dren. In all, 103 children were reported: 55 from The Hospi-
tal for Sick Children (Great Ormond street, London, UK)
and 48 from The Children's Hospital Medical Center
344 B.E.J. Hartley & R.T. Cotton
(Cincinnati, OH, USA). Ninety-three of these children
(90%) had been decannulated. Sixty had been treated by
laryngotracheoplasty and the remainder by costal cartilage
grafts or the modi®ed Rethi principle (cricoid split and
stent). All these types of procedure were obtaining high suc-
cess rates in terms of decannulation. The next step was the
introduction of cartilage grafts into the posterior cricoid
lamina. This procedure also proved successful and a detailed
animal study demonstrated that posteriorly placed grafts
underwent signi®cantly less necrosis and absorption than
anteriorly placed grafts.3 The combination of anterior and
posterior grafts and even the addition of lateral cuts to form
the so-called four quadrant split15 meant that almost any
subglottic stenosis could be managed surgically although
not surprisingly surgery for the more severe stenosis was
less successful.16,17 High decannulation rates were being
achieved with a single procedure for grade 2 stenosis but
lower rates for grades 3 and 4 and often multiple procedures
were being required. The logical approach to those children
with total stenosis was some form of resection of the steno-
sis. Cricotracheal resection had become established in adults
at this time but had not been applied to children.
Neonates with failed extubation: the anterior
cricoid split procedure
Increasingly in the 1970s otolaryngologists were being
involved in the neonatal care of children developing sub-
glottic stenosis. The principle management was to perform a
tracheostomy and wait and see if the subglottic stenosis
improved as the child grew. It was becoming clear that the
majority of children did not grow out of this problem and
also there was a signi®cant morbidity and mortality asso-
ciated with paediatric tracheostomy which could potentially
be avoided by laryngotracheal surgery. While giving a pre-
sentation at a paediatric ground rounds about subglottic
stenosis a paediatrician suggested to Cotton that he split the
cricoid to facilitate extubation. It seemed the obvious solu-
tion but was against current opinion at the time because
splitting the cricoid during a high tracheostomy had been
the principle cause of subglottic stenosis for many years.
The operation was performed in 1977 and was successful.
This patient is now 22 years old with a normal airway. In
1980, Cotton18 published the anterior cricoid split procedure
as an alternative to tracheostomy in the neonate who could
not be successfully extubated. In 1988, 67 patients who had
undergone this procedure were reported and 47 (70%) had
been successfully extubated.19 Currently this operation is
performed to avoid a tracheostomy in the majority of chil-
dren with early subglottic stenosis who fail extubation and
have no baseline oxygen requirement due to pulmonary dis-
ease.
The single stage laryngotracheal
reconstruction
It became clear from the experience with the anterior cricoid
split that by using the endotracheal tube as a stent and as
an airway that laryngotracheal surgery could be performed
without a tracheostomy. This development gave rise to the
single stage laryngotracheal reconstruction.20,21 The tra-
cheostomy was removed at the time of surgery and the
patient kept intubated for a period of up to 2 weeks post-
operatively. A recent review of 200 cases has demonstrated
an overall decannulation rate of 96%. This should be quali-
®ed with the observation that 29% required re-intubation
and 15% required a postoperative tracheostomy which was
removed at a later stage in the majority of cases.22
Cricotracheal resection in children
In adults resection of subglottic stenosis and end-to-end
anastomosis was reported successfully by Conley in 1953.23
There was initial reluctance to introduce the procedure in
children based on concerns about the subglottic stenosis
commonly merging into the glottis or trachea3 and also con-
cerns about growth. In 1974 Gerwat and Bryce24 described
a modi®cation of Conley's operation performed on a 14-
year-old boy. Further descriptions of adult cricotracheal
resection followed and it is now a well-established procedure
in the management of adult subglottic stenosis.25,26 The ®rst
series of successful cricotracheal resection in children was
published by Monnier in Switzerland in 199327 and this was
followed by updates in 199828 and 1999.29 In this series 38
children have been treated and 36 of these are without tra-
cheostomy.
The early Cincinnati experience of 16 cases was published
in 1997, 15 of whom are without tracheostomy.30 In Cincin-
nati we now have performed cricotracheal resection on 53
children, 10 of whom are still with tracheostomy at the pre-
sent time. Decannulation is anticipated in the majority of
these patients. Some important lessons have been learned
from this experience and these are discussed under operative
technique.
Indications for cricotracheal resection and
laryngotracheal reconstruction in children
In Cincinnati over 1000 paediatric laryngotracheal recon-
structions have been performed and 53 cricotracheal resec-
tions in children. Our practice is to perform cricotracheal
resection on children who have severe laryngotracheal ste-
nosis (severe grade 3 and grade 4) where there is an ade-
quate margin of tissue between the stenosis and the vocal
cords. At least 3 mm is recommended.31 It is the authors'
experience that stenosis involving or close to the vocal cords
is preferably treated with laryngotracheal reconstruction
# 2000 Blackwell Science Ltd, Clinical Otolaryngology, 25, 342±349
 Paediatric airway stenosis 345

with cartilage grafts which can be placed higher than the
upper resection margin for CTR.
LTR with cartilage graft placement remains the mainstay
of the surgical management of subglottic stenosis at this
Institution for grade 2 and selected grade 3 stenosis. This is
a less extensive procedure than CTR as tracheal mobiliza-
tion is not required. In addition the placement of cartilage
grafts has a precision that is not present with CTR. Anterior
stenosis can be accurately corrected with anterior grafts.
Similarly posterior stenosis can be accurately corrected with
posterior grafts and slit shaped lateral stenosis can be
widened with anterior and posterior grafts.
Operative technique
The operative technique for laryngotracheal reconstruction
has been well described32 and will not be described here.
Here we describe the technique for cricotracheal resection as
used by the authors.
PREPARATION
Immediately before the procedure a repeat rigid endoscopy
is performed to con®rm the exact nature and position of the
stenosis. An oesophageal bougie is inserted to help de®ne
the position of the oesophagus during the later tracheal
mobilization. The neck is extended initially but when the
anastomosis is performed the neck is returned to the anato-
mical position to reduce tension. Usually a tracheostomy is
present and an oral RAE tube is cut short and placed in the
stoma to allow ventilation. A large size is chosen to reduce
the intraoperative air leak once the airway is opened. If a
single stage procedure is planned then an oral endotracheal
tube is placed initially. Local anaesthetic with adrenaline is
in®ltrated into the area around the tracheostomy.
incision is extended superiorly and inferiorly as required to
identify the lumen and de®ne the stenotic area. In the case
of grade 4 stenosis where no lumen is present a repeat endo-
scopy is performed and then a small pair of artery forceps is
used to break through the stenosis into the laryngeal lumen.
It is not usually necessary to divide the anterior commis-
sure.
UPPER RESECTION MARGIN
The upper resection margin is then de®ned. The incision is
extended laterally along the lower border of the thyroid car-
tilage towards the cricothyroid joint. Anterior to the joint
(and therefore clear of the recurrent laryngeal nerves) the
incision turns inferiorly and the cricoid cartilage is divide
vertically on both sides. Posteriorly the incision is continued
along the inferior border of the cricoid lamina to complete
the upper resection margin. The resulting superior end com-
prises the thyroid cartilage anteriorly and the cricoid lamina
posteriorly. The two being joined by the cricothyroid joints.
The inner surface of the cricoid lamina is covered with the
subglottic scar. This is excised leaving an edge of healthy
mucosa superiorly below the arytenoids. Later the posterior
¯ap of membranous trachea will be sutured to this. To
reduce the prominence of the cartilage posteriorly a drill is
used (4 mm cutting then diamond burr) to thin the cricoid
lamina. The thyroid cartilage is split anteriorly in the mid-
line. This will accept the V-shaped notch in the lower seg-
ment when the anastomosis is formed (Figs 2 and 3).

EXPOSURE

An elliptical incision is made around the tracheostomy

stoma. The tract of the tracheostomy is usually excised. A
superior subplatysmal ¯ap is elevated to above the level of
the hyoid bone. An inferior subplatysmal ¯ap is elevated
down to the sternal notch. The strap muscles are separated
in the midline to expose the airway with the overlying thyr-
oid isthmus if this has not been previously divided. Care is
taken to preserve the cricothyroid muscle which serves as a
useful landmark to identify the cricoid and therefore the
level of the subglottic stenosis.

DEFINING THE STENOSIS

The airway is opened with a blade by making a vertical

midline incision through the cricoid cartilage. This is held
open by retraction sutures and the stenosis is examined. The Figure 2. The margins of cricotracheal resection.

# 2000 Blackwell Science Ltd, Clinical Otolaryngology, 25, 342±349

346 B.E.J. Hartley & R.T. Cotton
Figure 3. The superior resection margin.
TRACHEAL MOBILIZATION
The trachea is mobilized anteriorly and laterally keeping as
close as possible to the trachea in the subperichondrial
plane to preserve the recurrent laryngeal nerves. In the
majority of cases there will have been previous surgery and
extensive scar tissue is present so time is not spent searching
for the nerves. By ensuring the dissection is close to the tra-
cheal wall in the subperichondrial plane the nerves can be
reliably preserved. Anteriorly the dissection is continued
deep to the innominate artery and down towards the carina.
This plane is extended laterally with sharp dissection. Two
2/0 prolene stay sutures are inserted into the tracheal wall
laterally and used to elevate the trachea. The posterior dis-
section is then performed starting at the lower border of the
cricoid. The oesphageal bougie can be palpated and helps to
identify the position of the oesophagus. The trachea is lifted
with the retraction sutures and dissected free of the oeso-
phagus (Fig. 4.). The posterior and lateral dissection planes
are then joined keeping close to the trachea and clear of the
recurrent laryngeal nerves (Fig. 4).
THE LOWER RESECTION MARGIN
The lower resection margin must contain a full sized healthy
tracheal ring to be con®dent of success.27 If the tracheal tis-
Figure 4. Tracheal mobilization.
sue at the stoma site is necrotic or there is evidence of sur-
rounding perichondritis then the stoma should be included
in the resection. Before this is done a new tracheostomy is
fashioned in the healthy lower trachea and the cut oral Rae
tube is transferred to the new tracheostomy to maintain
ventilation. The ®rst ring above the stoma is fashioned into
a V shape to insert into the thyroid cartilage anteriorly.27
The full size ring used for the anastomosis is usually there-
fore the second ring below the stoma site. (Consequently
approximately one-third of the trachea is resected in a CTR
that includes the stoma site.). The posterior membranous
trachea is fashioned into a tongue-shaped ¯ap that will lie
over the cricoid lamina (Figs 2 and 5).
THE LARYNGEAL RELEASE
This is an important factor in reducing tension in the ana-
stomosis. The hyoid is identi®ed and an incision is made
along its superior surface. Using a Freers elevator the supra-
hyoid muscles are dissected free of the hyoid bone in the
subperiosteal plane.
THE ANASTOMOSIS
Any shoulder support is removed and the neck returned to
the anatomical position. 2/0 prolene sutures are placed pos-
terolaterally in the trachea on either side and inserted into
the thyroid cartilage anterior to the cricothyroid joint.
These detensioning sutures approximate the ends while the
posterior mucosal anastomosis is completed. The tongue
shaped ¯ap of membranous trachea is sutured to the healthy
mucosa below the arytenoids and vocal cords using 4/0
vicryl sutures. At this point a T-tube or stent may be
inserted. Endoscopy is performed to con®rm that the upper
end of the T-tube or stent lies just above the level of the ary-
# 2000 Blackwell Science Ltd, Clinical Otolaryngology, 25, 342±349

Figure 5. The inferior resection margin
tenoids and the lower end of the T-tube is well clear of the
carina. The anastomosis is then completed anteriorly with
3/0 prolene. Additional anterior detensioning sutures may
be added. The V shaped notch is inserted into the midline
of the thyroid cartilage. It will be clear to the surgeon that
there is a mismatch in size between the lumen of the super-
ior and inferior segment with the superior lumen being
much smaller. The opening of the thyroid cartilage ante-
riorly and the placement of the V shaped notch opens the
superior end and reduces the size mismatch (Fig. 6).
CLOSURE
The strap muscles are closed over a Penrose drain. The sub-
platysmal layer is closed with interrupted vicryl sutures and
the skin is closed with a continuous subcuticular running
vicryl suture. In active children or extensive resections the
chin should be sutured to the chest for one week using 0
prolene to prevent neck extension which may lead to disrup-
tion of the anastomosis.
RESULTS OF SURGERY FOR
LARYNGOTRACHEAL STENOSIS
Traditionally the results of laryngotracheal surgery have
been expressed in terms of decannulation rates. As decannu-
# 2000 Blackwell Science Ltd, Clinical Otolaryngology, 25, 342±349
Paediatric airway stenosis 347
Figure 6. The complete anastomosis.
lation is the reason for the majority of patients seeking sur-
gery and remains an important outcome measure.
In 1989 before the introduction of CTR the senior author
(R.T.C.) published an update of the Cincinnati experience
of laryngotracheal reconstruction.16 Grade 1 patients mostly
did not require tracheostomies so decannulation rates are
not given. In all, 129 procedures were performed on 98
patients with grade 2 stenosis and 97% were ultimately
decannulated. Ninety-four procedures had been carried out
on 80 grade 3 patients and ultimately 91% were decannu-
lated. Twenty-eight procedures had been carried out on 25
grade 4 stenosis patients and ultimately 72% were decannu-
lated.
In 1992 a 10-year review from Great Ormond Street Hos-
pital in London17 published decannulation rates of 88% for
grade 1, 89% for grade 2, 78% for grade 3 and 50% for
grade 4 subglottic stenosis.
With the introduction of CTR it is natural to compare
outcomes with previous surgical techniques. In the compari-
son of di€erent surgical techniques for airway reconstruc-
tion the use of decannulation rates as principal outcome
measure has several limitations. First, most grade 1, some
grade 2 and even a few grade 3 patients did not have a tra-
cheostomy to begin with and therefore cannot be decannu-
lated. Second, patients may require a tracheostomy for
reasons other than subglottic stenosis. This is not uncom-
mon. Surgery may successfully correct the subglottic pro-
blem but the patient remains tracheostomy dependent due
to tracheomalacia, supraglottic collapse or suprastomal col-
lapse and granulation. The surgery for subglottic stenosis is
really a success although the patient is a decannulation fail-
ure. Third, patients may have had several procedures to
348 B.E.J. Hartley & R.T. Cotton
achieve decannulation and with enough time and a large
enough number of procedures high decannulation rates can
be achieved in the majority of cohorts of children.
Despite this, decannulation rates for patients with severe
(grade 3 and 4 subglottic stenosis) remains a broad and
easily understandable measure of success. Furthermore in
the published literature it is usually the only outcome mea-
sure available.
There is so far no published comparison of LTR and
CTR in matched patients. It has been suggested that CTR is
better than LTR based on published decannulation rates in
di€erent Institutions.29 Comparison of decannulation rates
in di€erent Institutions in a retrospective manner may be
misleading. The spectrum of disease at any given Institution
will vary enormously dependent on referral pattern. In addi-
tion the indications for surgery and surgical technique will
vary between Institutions.
GRADE 4 STENOSIS
In this institution airway reconstruction surgery has been
performed on 64 children with grade 4 stenosis.32 The surgi-
cal technique has evolved over three decades and a large
number of the early patients were treated with division of
the stenosis and stenting. The principle surgical options are
now between CTR and LTR with anterior and posterior
costal cartilage grafts. At the present time we have per-
formed CTR on 12 patients with grade 4 stenosis. Ten of
these have been decannulated (83%) and two have T-tubes
in situ. One is likely to be decannulated within the next 6
months. Two patients required further open surgery to
achieve decannulation (17%). LTR with anterior and pos-
terior grafts has been performed on 16 patients patients
with grade 4 stenosis, 13 of whom have been decannulated
(81%). Six patients (46%) required further surgery to obtain
this. Based on this retrospective data for patients with
matched stenosis grade at a single Institution at the current
time the decannulation rates for grade 4 subglottic stenosis
for CTR and LTR are equivalent, but the LTR patients are
more likely to require a second open procedure to achieve
decannulation.
GRADE 3 STENOSIS
Grade 3 subglottic stenosis includes a wide range of
patients. At one end of the spectrum some children with a
7% stenosis manage without a tracheostomy. Also included
in the category of grade 3 stenosis would be a child with
99% stenosis with a pinhole airway. The latter is clearly a
greater surgical challenge. The decannulation rate for grade
3 stenosis treated with CTR after one procedure at this
institution for patients with 1-year follow-up is 82% (28 of
34 patients).33 A second operation (anterior cartilage graft)
has been performed on one patient and decannulation is
imminent. Further surgery is planned on two of the others
who remain cannulated and one patient was lost to follow-
up but is presumed to still be tracheostomy dependent.
Although one might expect higher decannulation rates for
grade 3 than grade 4 patients undergoing CTR, the grade 3
stenosis patients include a number of patients where the ste-
nosis was close to the vocal cords or who had partial laryn-
geal atresia and these have done less well.
Conclusions
A surgeon facing the problem of a child with subglottic ste-
nosis now has a wide range of surgical options. The proce-
dure must be tailored to the anatomy of the stenosis. Both
LTR and CTR have achieved high decannulation rates.
There is no published data comparing di€erent surgical
techniques in matched patients. A retrospective review of
patients with grade 4 stenosis in this Institution suggests
that a similar proportion are decannulated with CTR and
LTR and the CTR patients are less likely to require a sec-
ond open procedure to achieve decannulation. CTR is the
preferred option for grade 4 and severe grade 3 stenosis that
are clear of the vocal cords. LTR as a less extensive proce-
dure is preferred for grade 2 and less severe grade 3 stenosis.
Stenosis close to the vocal cords remains a challenge.
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