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196 THE LARYNX, BRONCHI AND OESOPHAGUS
Not all patients with tracheal avulsion or tears in the cricotracheal
membrane die. If they survive long enough to get to hospital then it is possible
to replace the trachea and to suture the first ring to the cricoid cartilage. There
is no need to use a stent mould since this may result hi infection and a
breakdown of the anastomosis.
CHRONIC LARYNGOTRACHEAL STENOSIS
This is said to be established if the patient has not got a satisfactory airway
4 weeks after an injury. Apart from trauma other causes include: (a) Tracheo-
tomy: If the tracheotomy is placed too high then the cricoid cartilage will
collapse. Recently it has been shown, however, that some stenosis is common
after all tracheostomies both at the site of the tracheotomy and at the site of the
inflatable cuff on the tracheostomy tube. Post-tracheostomy stenosis, however,
seldom gives rise to stridor but most commonly causes difficulty in clearing
sputum. (£) Partial laryngectomy. If hemilaryngectomy includes more than
one and one-fifth vocal cords then a McNaught keel must be used in re-
construction. Failure to do this will result in laryngotracheal stenosis,
(c) Granulomatous disease. Stenosis may be the late result of tuberculosis or
widespread aphthous ulceration. (d) Tumours. Subglottic and tracheal
tumours are dealt with in Chapter 37 (p. 184).
DIAGNOSIS. There will be difficulty hi breathing, speaking and clearing
secretions from the lower respiratory tract, to a greater or lesser degree,
depending upon the severity of the stenosis.
On mirror examination, narrowing, web formation, granulations or oedema
may be seen. The arytenoids may also be seen to bs fixed. This is better
assessed at direct laryngoscopy, however, because the fixation may be due to
cordal scarring or fixation of the crico-arytenoid joint. These two possibilities
may be assessed by moving the arytenoid at direct laryngoscopy. The extent
of the stenosis, especially if it is severe, is not always possible to assess at
laryngoscopy. It is in these cases that laryngography is of greatest benefit
because without it no adequate preoperative planning can be done, and to
operate on a tracheal stenosis without knowing its exact extent is both foolish
Supraglottic Stenosis. This may be managed by doing a modified supra-
glottic laryngectomy, excising only the scarred area and leaving the normal
functioning vocal cords. The long-term results of the procedure are not as
good as one would expect from this simple explanation of the procedure, but
apart from wearing a permanent tracheostomy tube there is little else to offer
the patient. If the stenosis is limited to the false cord region the scar may be
pulled laterally by wiring it to the thyroid cartilage.
Glottic Stenosis. If stenosis is limited to the glottis it is due either to
fixation of the arytenoids or to an anterior web of the cords. In the case of
arytenoid fixation the arytenoid may be removed and the cord stitched in the
desired fixed position, or the vocal process may be wked laterally.
A web is best dealt with by a laryngofissure approach, excising the web and
closing the larynx over a McNaught keel.
If the whole glottis is stenosed and disorganized then it should be explored,
the scar exised, the remainder refashioned as well as possible and fixed