外伤性喉气管狭窄63例临床分析

Analysis of traumatic laryngotracheal stenosis in 63 cases

目的探讨外伤喉气管狭窄的手术方式与选择原则。方法回顾性分析解放军总医院耳鼻咽喉头颈外科1993至2006年共收治外伤性喉气管狭窄患者63例的手术方法与治疗效果。结果63例患者在该院共行99次针对喉气管狭窄治疗的手术（不包括气管切开、拔管及拔管后的气管造口封闭手术），每例患者平均经历1．9次手术；经1次手术者40例（占63．5％），经2次手术者15例（23．8％），3次手术者5例（7．9％），4次手术者2例（3．2％），经历6次手术者1例（1．6％）。对首次入院时判断为喉软骨支架完整而行支撑喉镜手术15例，11例1次手术成功。软骨支架骨折、狭窄严重者，首次单纯喉气管裂开T管置入36例，经单次手术成功拔管者20例（55．6％）；喉气管裂开、腔内植皮＋T管置入术10例，拔管7例（70％）；喉气管裂开T管置入、带蒂舌骨喉气管软骨缺损修复共6例，拔管4例（4／6）。声门下及气管的局限性狭窄采用狭窄部气管或环状软骨部分切除、端端吻合术9例，7例单次手术拔管（7／9）。2例声门下狭窄并气管食管瘘修补均一次成功，拔除气管套管。患者随访6个月～5年，57例拔管后均呼吸通畅，无误吸，无再狭窄，但嗓音沙哑；6例拔管失败，拔管率为90．5％。结论外伤性喉气管狭窄治疗比较困难，需根据术前全面检查，准确评估喉气管支架缺损情况、狭窄的程度和受累的范围，选择恰当的手术方式。

Objective To explore the surgical treatment and the principle of selecting approaches in traumatic laryngotracheal stenosis. Methods Sixty three cases of traumatic laryngotracheal stenosis treated in the Department of Otolaryngology, Head and Neck Surgery, Chinese People＇s Liberation Arauy General Hospital from 1993 - 2006 were reviewed. The surgical treatment and the effects were analyzed. Results Among the 63 eases, 99 operations were accomplished in total, excluding tracheotomy and the closure operation for the fistula. Forty patients had experienced one operation （63.5%）, 15 cases （23.8%） had 2 operations, 5 cases had 3 operations, 2 cases had 4 operations, and one case had 6 operations. Fifteen initially estimated as laryngotracheal stenosis with intact framework had supporting laryngoscopic surgery, 11 cases decannulated successfully after single operation. Primary laryngotracheal split and plasticity with T tube implantation were accomplished in 36 cases, with 20 cases decannulated. Among 10 cases experienced laryngotraeheal split, skin graft in laryngotracheal cavity with T tube implantation, 7 decannulated. Among 6 cases of laryngotracheal split, pedicled hyoid flap transfer for reconstruction of the laryngotracheal framework defect, 4 cases decannulated. Tracheal and cricotraeheal resection and end-end anastomosis were performed in 9 cases, 7 cases decannulated after single procedure. Two cases of suhglottic stenosis with traehoesophageal fistula were repaired with laryngotracheal plasticity in single procedure successfully. Fifty seven patients were decannulated after different procedures with variable hoarseness, within 6 months to 5 years follow-up. Six cases failed in decannulation. The decannulation rate was 90. 5%. Conclusions Traumatic laryngotracheal stenosis is a complex problem that usually needs a longer time for reconstruction and a different ways of approaches. It is necessary to evaluate the laryngotracheal framework defect, the degree and extension of stenosis systematically before operation for surgical planning.