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Reconstruction of cervical trachea: Case report
R E C O N S T R U C T I O N OF CERVICAL T R A C H E A :
CASE R E P O R T
By RANDELLCHAMPION, M.B.E., F.R.C.S.
Wythenshawe Hospital, Manchester THE cervical part of the trachea occupies an exposed position, but is rarely injured. The limited number of cases seen are lacerations caused by fragmented glass in accidents, or the self-inflicted wounds of the attempted suicide, the treatment in these cases being primary suture, combined with a temporary tracheotomy. Nach and RothmaI1 (1943) report successful treatment of seventy such cases, with one death due to hmmorrhage and shock. Contusion, leading to stenosis, or actual destruction of the cervical trachea is extremely rare but has been observed in war injuries. Balakrishnan (1952) reports one such case where there was a tracheal stenosis of 1"5 cm. The reconstruction was performed by free grafting to reconstitute the posterior wall of the trachea and later with local flaps for anterior lining and skin covering. However, such injuries occurring in civilian life, from direct trauma, invariably cause a cervical spine injury resulting in death. This may account for the absence of such recorded cases in the medical literature. Serrano, in 1958, reports a case where the trachea was reconstructed by free grafting and local flaps, with the insertion of cartilage to form support to the trachea. The following case report is of interest as it illustrates the reconstruction of a portion of the cervical trachea following a severe contusion sustained ill a liftshaft accident. Case Report.--Male : aged 17 years. This youth became trapped in a lift shaft in such a manner that his neck was crushed against a steel girder causing severe injury to his trachea and oesophagus. When admitted to hospital there was gross swelling of his neck with some dyspnoea and cyanosis. He soon developed surgical emphysema of his neck. Within twenty-four hours a tracheotomy was performed, and at this operation it was noted that there was severe contusion of the trachea with destruction of the third, fourth, and fifth cartilaginous rings. A tracheooesophageal fistula was also observed and a gastrostomy was performed at the same time. The patient made a good recovery from the initial injury, the neck wound healing slowly. The gastrostomy was closed after two months. Six months after his injury he was transferred to the Plastic Unit. His general condition was satisfactory. He managed well with a permanent tracheotomy situated immediately above the manubrium sterni. The tracheo-oesophageal fistula had healed and the patient was able to take normal food, having no interference with swallowing. The external wound of the neck had healed well. Speech, however, was that of a soft whisper and practically inaudible. Direct laryngoscopy was carried out, and this examination showed the cords fixed in the position of semi-abduction, indicative of bilateral recurrent laryngeal nerve palsy. Attempts to penetrate the stricture of the trachea with the smallest dilator failed. It was apparent that about 2 in. of the trachea had been completely replaced by a mass of fibrous tissue, this stenosis of the trachea being 8 in. from the incisor teeth. After lengthy discussion it was decided to attempt reconstruction of the stenosed part of the trachea by using free grafts in the first instance, followed by 259
260
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
local neck flaps. About eight months after his injury this treatment was undertaken. The traumatised portion of the trachea was found to be replaced by a thick cord of fibrous tissue. This scar tissue was excised, leaving a raw surface of about 2½ by 2½ in., which was covered with a split-skin graft taken from the upper arm. Post-operatively, the patient developed a pulmonary infection, accompanied by much coughing. The graft failed to take. A second graft, one week later, also failed. No further attempts with free grafting were made.
FIG. I
Illustrating the construction of the tube pedicle after the first operation.
On further consideration it was decided to reconstruct the trachea by a tube pedicle moved up from the chest wall. About ten months after his original injury a tube pedicle 3 by 6 in. was constructed on the upper anterior chest wall. The pedicle was extended by further lengthening operations to the lateral sides .of the neck so that the final attachments were close to the site of the stenosed trachea, The tube pedicle then hung in a loop below the tracheotomy, measuring about Ii by 3 in. At a further operation the newly formed fibrous tissue in the region of the trachea was excised, creating a defect about 3 by 3 in. The tube pedicle was opened, thinned in its middle third, and then applied to the raw surface of the defect. The tube pedicle thus came to cover the raw surface anterior to the oesophagus. The upper margin of the pedicle was sutured to the posterior aspect of the distal end of the proximal part of the divided trachea. The lower border was sutured to the proximal opening of the distal portion of the divided trachea behind the manubrium sterni. In this way the posterior wall of the new trachea was fashioned, the epithelium of the tube pedicle forming the lining. Later, the
RECONSTRUCTION
OF
CERVICAL
TRACHEA
261
bilateral attachments of the tube pedicle were divided at intervals. When the pedicles were divided from the neck they were opened, thinned and folded on themselves to give double-lined flaps, lying at each side of the trachea in the central portion of the neck (Fig. 2). Finally, the folded flaps were incised at the ends and sutured so as to re-form the new trachea, giving both lining and skin covering. A small new tracheotomy opening was left.
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FIG. 2 Shows diagramaticallythe insertionof the tube pedicle before the finalrepair. At this stage it was considered inadvisable completely to close off the new trachea, as it was felt that without support the trachea would collapse, causing obstruction to the airway. Several methods of making the walls of the new trachea more rigid by inserting supports similar to tracheal rings were considered. The use of cartilage was discussed, but there appeared to be no satisfactory place from where such autogenous cartilaginous support could be obtained and constructed into rings. Finally, it was decided to use polythene. Two polythene tracheal rings were constructed, and inserted into the wall of the new trachea between the lining and skin covering. However, because of the constant movement of the trachea with deglutition these rings were slowly extruded by ulcerating through the skin covering and later had to be removed. A further attempt was made with smaller rings, but without success. The patient was then discharged home without support to the trachea, but with a tracheotomy. Some months later the patient was readmitted as he was very desirous of having the tracheotomy closed. The patient was observed in hospital whilst the tracheotomy opening was completely occluded, and he appeared to breathe satisfactorily with no dyspnoea on exertion. There was, however, some retraction of the anterior wall of the trachea on to its posterior wall on deep inspiration, but
262
BRITISH
JOURNAL
OF PLASTIC
SURGERY
this did not distress the patient. It was felt, therefore, that support was unnecessary because the new trachea was wider than normal, and although on inspiration the anterior wall of the trachea did retract there was apparently adequate airway on each side. Subsequently, the tracheotomy opening was closed by a small rotation flap (Fig. 3).
FIG. 3 Shows final result prior to closing small tracheotomy.
Since his discharge home the patient has returned to work and now performs clerical duties in a large office. He has no difficulty in breathing and is able to ride a bicycle long distances without dyspnoea. His voice is quite audible at an ordinary conversational distance, but he still has paralysis of both recurrent laryngeal nerves. SUMMARY This case demonstrates the reconstruction of 3 in. of the trachea by means of a thoracic tube pedicle. No support was inserted to make the new tracheal walls rigid. The patient has an adequate airway and is leading an active life.
I wish to thank the Department of Medical Illustration of Wythenshawe Hospital for the diagram and clinical photographs. REFERENCES BALAKRISHNAN, C. (1952). Personal communication. NACH, R. L., and ROTHMAN, M. (1943). Surg. Gynec. Obstet., 76, 614. SERRANO, A. (1958). Personal communication.
CASE R E P O R T
By RANDELLCHAMPION, M.B.E., F.R.C.S.
Wythenshawe Hospital, Manchester THE cervical part of the trachea occupies an exposed position, but is rarely injured. The limited number of cases seen are lacerations caused by fragmented glass in accidents, or the self-inflicted wounds of the attempted suicide, the treatment in these cases being primary suture, combined with a temporary tracheotomy. Nach and RothmaI1 (1943) report successful treatment of seventy such cases, with one death due to hmmorrhage and shock. Contusion, leading to stenosis, or actual destruction of the cervical trachea is extremely rare but has been observed in war injuries. Balakrishnan (1952) reports one such case where there was a tracheal stenosis of 1"5 cm. The reconstruction was performed by free grafting to reconstitute the posterior wall of the trachea and later with local flaps for anterior lining and skin covering. However, such injuries occurring in civilian life, from direct trauma, invariably cause a cervical spine injury resulting in death. This may account for the absence of such recorded cases in the medical literature. Serrano, in 1958, reports a case where the trachea was reconstructed by free grafting and local flaps, with the insertion of cartilage to form support to the trachea. The following case report is of interest as it illustrates the reconstruction of a portion of the cervical trachea following a severe contusion sustained ill a liftshaft accident. Case Report.--Male : aged 17 years. This youth became trapped in a lift shaft in such a manner that his neck was crushed against a steel girder causing severe injury to his trachea and oesophagus. When admitted to hospital there was gross swelling of his neck with some dyspnoea and cyanosis. He soon developed surgical emphysema of his neck. Within twenty-four hours a tracheotomy was performed, and at this operation it was noted that there was severe contusion of the trachea with destruction of the third, fourth, and fifth cartilaginous rings. A tracheooesophageal fistula was also observed and a gastrostomy was performed at the same time. The patient made a good recovery from the initial injury, the neck wound healing slowly. The gastrostomy was closed after two months. Six months after his injury he was transferred to the Plastic Unit. His general condition was satisfactory. He managed well with a permanent tracheotomy situated immediately above the manubrium sterni. The tracheo-oesophageal fistula had healed and the patient was able to take normal food, having no interference with swallowing. The external wound of the neck had healed well. Speech, however, was that of a soft whisper and practically inaudible. Direct laryngoscopy was carried out, and this examination showed the cords fixed in the position of semi-abduction, indicative of bilateral recurrent laryngeal nerve palsy. Attempts to penetrate the stricture of the trachea with the smallest dilator failed. It was apparent that about 2 in. of the trachea had been completely replaced by a mass of fibrous tissue, this stenosis of the trachea being 8 in. from the incisor teeth. After lengthy discussion it was decided to attempt reconstruction of the stenosed part of the trachea by using free grafts in the first instance, followed by 259
260
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
local neck flaps. About eight months after his injury this treatment was undertaken. The traumatised portion of the trachea was found to be replaced by a thick cord of fibrous tissue. This scar tissue was excised, leaving a raw surface of about 2½ by 2½ in., which was covered with a split-skin graft taken from the upper arm. Post-operatively, the patient developed a pulmonary infection, accompanied by much coughing. The graft failed to take. A second graft, one week later, also failed. No further attempts with free grafting were made.
FIG. I
Illustrating the construction of the tube pedicle after the first operation.
On further consideration it was decided to reconstruct the trachea by a tube pedicle moved up from the chest wall. About ten months after his original injury a tube pedicle 3 by 6 in. was constructed on the upper anterior chest wall. The pedicle was extended by further lengthening operations to the lateral sides .of the neck so that the final attachments were close to the site of the stenosed trachea, The tube pedicle then hung in a loop below the tracheotomy, measuring about Ii by 3 in. At a further operation the newly formed fibrous tissue in the region of the trachea was excised, creating a defect about 3 by 3 in. The tube pedicle was opened, thinned in its middle third, and then applied to the raw surface of the defect. The tube pedicle thus came to cover the raw surface anterior to the oesophagus. The upper margin of the pedicle was sutured to the posterior aspect of the distal end of the proximal part of the divided trachea. The lower border was sutured to the proximal opening of the distal portion of the divided trachea behind the manubrium sterni. In this way the posterior wall of the new trachea was fashioned, the epithelium of the tube pedicle forming the lining. Later, the
RECONSTRUCTION
OF
CERVICAL
TRACHEA
261
bilateral attachments of the tube pedicle were divided at intervals. When the pedicles were divided from the neck they were opened, thinned and folded on themselves to give double-lined flaps, lying at each side of the trachea in the central portion of the neck (Fig. 2). Finally, the folded flaps were incised at the ends and sutured so as to re-form the new trachea, giving both lining and skin covering. A small new tracheotomy opening was left.
t
,,
%,
%%%
%
I
\; s
ss ~
FIG. 2 Shows diagramaticallythe insertionof the tube pedicle before the finalrepair. At this stage it was considered inadvisable completely to close off the new trachea, as it was felt that without support the trachea would collapse, causing obstruction to the airway. Several methods of making the walls of the new trachea more rigid by inserting supports similar to tracheal rings were considered. The use of cartilage was discussed, but there appeared to be no satisfactory place from where such autogenous cartilaginous support could be obtained and constructed into rings. Finally, it was decided to use polythene. Two polythene tracheal rings were constructed, and inserted into the wall of the new trachea between the lining and skin covering. However, because of the constant movement of the trachea with deglutition these rings were slowly extruded by ulcerating through the skin covering and later had to be removed. A further attempt was made with smaller rings, but without success. The patient was then discharged home without support to the trachea, but with a tracheotomy. Some months later the patient was readmitted as he was very desirous of having the tracheotomy closed. The patient was observed in hospital whilst the tracheotomy opening was completely occluded, and he appeared to breathe satisfactorily with no dyspnoea on exertion. There was, however, some retraction of the anterior wall of the trachea on to its posterior wall on deep inspiration, but
262
BRITISH
JOURNAL
OF PLASTIC
SURGERY
this did not distress the patient. It was felt, therefore, that support was unnecessary because the new trachea was wider than normal, and although on inspiration the anterior wall of the trachea did retract there was apparently adequate airway on each side. Subsequently, the tracheotomy opening was closed by a small rotation flap (Fig. 3).
FIG. 3 Shows final result prior to closing small tracheotomy.
Since his discharge home the patient has returned to work and now performs clerical duties in a large office. He has no difficulty in breathing and is able to ride a bicycle long distances without dyspnoea. His voice is quite audible at an ordinary conversational distance, but he still has paralysis of both recurrent laryngeal nerves. SUMMARY This case demonstrates the reconstruction of 3 in. of the trachea by means of a thoracic tube pedicle. No support was inserted to make the new tracheal walls rigid. The patient has an adequate airway and is leading an active life.
I wish to thank the Department of Medical Illustration of Wythenshawe Hospital for the diagram and clinical photographs. REFERENCES BALAKRISHNAN, C. (1952). Personal communication. NACH, R. L., and ROTHMAN, M. (1943). Surg. Gynec. Obstet., 76, 614. SERRANO, A. (1958). Personal communication.