High Tracheal Resection With Intralaryngeal Extension for Treatment of Subglottic Stenosis

Subglottic stenosis is a fibrotic disease characterized by upper airway obstruction that causes shortness of breath and can severely impact quality of life. Initial surgical management typically includes endoscopic procedures with some combination of stenosis lysis, dilation, and corticosteroid injection. If open airway reconstruction is required, the current standard approach is cricotracheal resection where the anterior cricoid cartilage is removed and the cricothyroid muscles either transected or repositioned. However, cricotracheal resection is generally associated with worsened postoperative subjective and objective voice outcomes.¹⁻³

As an alternative to cricotracheal resection, the Head and Neck Institute has pioneered a novel technique. From a high tracheal resection approach, the subglottic stenotic tissue can be removed from below while sparing the cricoid cartilage itself. By leaving the cartilage intact, the cricothyroid muscles, which are important for voice pitch control, are also left undisturbed. The posterior anastomosis is traditionally accomplished by securing a flap of trachealis up to the residual laryngeal mucosa. These sutures are unreliable as this residual epithelium is diseased, thin, and weak. The key innovation for this new closure technique is a pair of sutures that travel circumferentially around the inferior half of the cricoid cartilage, which lends strength to the closure. Careful attention is paid not to entrap the posterior cricoarytenoid (PCA) muscles, which are on the back of the cricoid cartilage.

Between January 2016 and June 2021, 28 patients underwent surgery that included these posterior cricoid sutures. None of the patients had any injury to the PCA muscles. Fourteen of the patients had documented extension of the resection up into the cricoid. Twelve of those patients (86%) have had durable, patent airways, although some did require 1 or 2 minor endoscopic procedures after the tracheal resection to remove early scar tissue. No patients required a long-term tracheostomy. Thirteen patients (93%) had either transient or no postoperative dysphonia.

This novel approach to open resection of subglottic stenosis is made possible by 2 surgical innovations: (1) extension of resection into the cricoid lumen while sparing the cartilage structure and (2) posterior sutures that travel circumferentially around the cricoid cartilage. The results thus far are very promising in terms of both postoperative airway and voice.

Traditional technique for cricotracheal resection.The anterior portion of the cricoid is removed and a trachealis flap is sutured up to laryngeal mucosa.

In the new technique at Cleveland Clinic, none of the cricoid cartilage is removed. Resection is extended up into the lumen of the cricoid to remove stenotic posterior subglottic mucosa.

A trachealis flap is used to reline the denuded cricoid plate and secured with 2 sutures that travel circumferentially around the inferior half of the cricoid cartilage. Great care is taken not to injure the posterior cricoarytenoid muscles on the posterior surface of the cricoid.

Intraoperative view looking into the cricoid from below. The sutures travel through and around the cricoid cartilage. * = denuded cricoid plate



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  2. Houlton JJ, de Alarcon A, Johnson K, et al. Voice outcomes following adult cricotracheal resection. Laryngoscope. 2011 Sep;121(9):1910-1914.

  3. Smith ME, Roy N, Stoddard K, Barton M. How does cricotracheal resection affect the female voice? Ann Otol Rhinol Laryngol. 2008 Feb;117(2):85-89.

  4. Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg. 1982 Jan;33(1):3-18.