Open Airway Cases

Hartnick CJ, Hansen MC, Gallagher TQ (eds): Pediatric Airway Surgery. Adv Otorhinolaryngol. Basel, Karger, 2012, vol 73, pp 39–41

Costal Cartilage Harvest

Thomas Q. Gallaghera � Christopher J. Hartnickb

aLCDR, MC, USN, Department of Otolaryngology, Naval Medical Center Portsmouth, Portsmouth, Va., bDepartment of Otology and

Laryngology, Massachusetts Eye & Ear Infirmary, Boston, Mass., USA

Abstract

Cartilage interposition grafting for treatment of sub-

glottic stenosis was pioneered by Fearon and Cot-

ton in 1972. Costal cartilage is the preferred source for

graft material in most cases. In this section, the authors

highlight the surgical technique for cartilage graft

harvest with discussion of surgical pearls necessary for

success.

Relevant Anatomy

• Structures divided during dissection (super-

ficial to deep):

– Skin and subcutaneous fat

– Muscle fibers of the pectoralis major muscle,

rectus abdominus muscle and external oblique

muscle

◆ Depending on which rib harvested and age/

muscle development of patient

– Perichondrium of cartilaginous rib

Indications

Subglottis stenosis requiring cartilage augmen-

tation.

Contraindications

• Age less than 1 year – rib cartilage may be too

small to carve adequately for an insert graft

• Osteogenesis imperfecta

Anesthesia Considerations

Communication with your anesthesia provider

regarding the chance of pneumothorax with this

procedure.

Preparation

• A 4- cm incision is marked out of the desired

rib. Injection with 1% lidocaine with 1:100,000

epinephrine is utilized.

• Rib selection is based on obtaining the most

flat and straight piece of cartilage that can be

obtained. This usually is the 5th or 6th rib.

• Gender is important to consider with making

incision. Placement of the incision in the

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Thomas Q. Gallagher is a military service member. This work was prepared as part of his official duties. Title 17 .S.C. 105 provides that ‘Copyright protection under this title is not avail-able for any work of the United States Government.’ Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.

40 Gallagher · Hartnick

mammary crease is considered for female

patients.

• If the need for autogenous cartilage is known

prior to surgery, the harvest is performed prior

to opening the airway in order to maintain

sterile technique for the chest wound

Procedure

• Sharp dissection through the skin is carried

into the subcutaneous fat

• Blunt dissection over the selected rib is

performed with a hemostat and electro-

cautery

• Palpation of the desired rib is done throughout

the procedure in order to avoid erroneous

dissection

• Muscle fibers are divided with electrocautery

(fig. 1; online suppl. video 1)

• The rib is exposed with the use of blunt

dissection from peanut sponges (fig. 2). Self-

retaining retractors are utilized.

• The rib is examined to ensure sufficient length

(>2 cm) and shape. The bony- cartilaginous

junctions are identified.

• The inferior and superior edges of the rib are

cauterized to help reduce bleeding

• Along the inferior and superior edges, the

perichondrium is sharply incised

• Subperichondrial dissection with a Cottle

elevator is initiated through these incisions.

The dissection is then continued with a Freer

elevator. Care is taken to make contact with the

undersurface of the rib the entire time.

• Once the inferior and superior subperi-

chondrial dissections are complete, the lateral

bony- cartilaginous junction (blue in color) is

identified (fig. 3)

• The lateral rib is incised sharply over the

Freer

• The remainder of the posterior rib dissection

is completed under direct vision. This is

accomplished with the surgeon in the seated

position.

• The medial incision is made once ensuring at

least 2 cm of cartilage is harvested

• Again, this is done over the Freer to avoid

injury to the structures below

• Once removed, the rib is placed on the back

table in saline solution

• The wound is filled with sterile saline solution,

and a Valsalva maneuver to 30 cm water

Fig. 1. Muscular layer is exposed. Fig. 2. Perichondrium of rib is exposed.

Costal Cartilage Harvest 41

pressure is performed to ensure the thoracic

cavity was not violated

• The wound is checked for hemostasis and

closed in a layered fashion over a rubber

band drain using absorbable braided suture.

Approximation of the muscular layer is

necessary.

Postoperative Care

• A portable chest X- ray is obtained in the

recovery room or intensive care unit to ensure

there is no pneumothorax

• The rubber band drain is usually removed on

postoperative day 1 or 2

Pearls

• The patient’s gender is kept in mind when

marking the incision

• The size and shape of the rib are more important

than which rib number

• Use of electrocautery on the inferior and

superior edges of the rib prior to sharply

incising will help reduce nuisance bleeding

• During subperichondrial dissection with the

Freer, contact with the posterior surface of the

rib is essential in order to prevent entry into

the thoracic cavity

• Identification of the ‘blue line’ laterally prior to

dividing the rib will help to obtain the largest

graft possible

• The surgeon in the seated position will facilitate

dissection of the posterior perichondrium of

the rib

Fig. 3. The rib is exposed and the ‘blue line’ is identified

with the needle. This is the bony- cartilaginous junction.

Christopher J. Hartnick, MD

Professor, Department of Otology and Laryngology

Chief, Division of Pediatric Otolaryngology

Director, Pediatric Airway, Voice and Swallowing Center

Chief Quality Officer

Massachusetts Eye and Ear Infirmary, Harvard Medical School

243 Charles Street

Boston, MA 02116 (USA)

E- Mail christopher_hartnick@meei.harvard.edu