Case report of a laryngotracheal reconstruction with anterior and posterior costal cartilage graft and stent placement – Surgical technique

OBJECTIVE: The purpose of this report is to examine a grade III subglottic stenosis case with double-stage laryngotracheal reconstruction using a costal cartilage graft and to explore the relevant literature regarding these topics. CONTEXT: In this report, the authors examine a severe grade III subglottic stenosis pediatric case and its subsequent laryngotracheal reconstruction with costal cartilage graft. This case demonstrates a surgical intervention which has become infrequently utilized since neonatologists began using noninvasive positive pressure airway support rather than intubation; thus, the incidence of acquired subglottic stenosis is decreasing. Features of the case and its surgical correction are discussed in detail. CASE REPORT SUMMARY: The patient is a 3-year-old African-American female born prematurely at 30 weeks by emergent cesarean section complicated by placenta previa, twin gestation and absent end diastolic flow. The patient has a past medical history significant for apnea of prematurity, necrotizing enterocolitis, bronchopulmonary dysplasia, hyaline membrane disease, pneumonia, abnormal electroencephalogram, cardiac arrest due to respiratory disorder, parainfluenza infection, chronic respiratory failure, laryngomalacia and grade III subglottic stenosis. The patient’s surgical history is significant for supraglottic laryngoplasty, tracheostomy placement, gastrostomy tube placement and laryngotracheal reconstruction with anterior and posterior costal cartilage graft and stent placement with subsequent stent removal. As of March 2019, the patient continues to have follow up laryngoscopy/bronchoscopy with dilation. Ultimately, the patient will maintain her own airway with tracheostomy tube removal. DATA SOURCES AND OVERALL COMPARISONS: A PubMed literature review of subglottic stenosis and laryngotracheal reconstruction with costal cartilage graft was performed. Twenty sources were reviewed leading to greater understanding of the evidence supporting the laryngotracheal reconstruction with graft treatment modality. CONCLUSION: Optimal management and correction of subglottic stenosis is possible via laryngotracheal reconstruction with cartilage graft. The reconstruction procedure, first utilized in the 1970’s, allows correction of severe (grades III and IV) subglottic stenosis. After healing is complete, the patient regains function of her own airway.