Chondronecrosis of the Larynx Treatment & Management

Treatment of radiation-induced laryngeal chondronecrosis can lead to total laryngectomy, preventing an attempt at organ preservation. Factors such as continued smoking, gastroesophageal reflux, diabetes mellitus, and arteriosclerosis have been implicated as etiologies that may exacerbate the condition. Initial management in Chandler grades I and II cases consists of inhaled steam, corticosteroids, antireflux medications and precautions, and antibiotics.

Ciprofloxacin 750 mg PO bid has been recommended because it produces excellent blood levels and covers organisms found in the upper aerodigestive tract, including Staphylococcus aureus, Pseudomonas species, and enterococcal bacilli. However, in early stage chondritis, initial medical management with culture-directed antibiotics and steroids is suggested. If no improvement is noted after 10 days, surgical exploration with debridement of the necrotic tissue is recommended.

A study has shown some encouraging results using adjuvant hyperbaric oxygen therapy for severe radionecrosis. Fibroblast and leukocyte function is impaired when tissue oxygen levels fall below reference range levels. An increase in oxygen tension in already hypoxic tissue is thought to stimulate (1) growth of functional capillaries, (2) fibroblast proliferation and collagen synthesis, and (3) leukocyte bactericidal activity. It also facilitates angiogenesis by acting as a stimulus for the release of growth factors from macrophages. Leukocyte killing has been noted to increase by 40% when the PO₂ is increased from 45 to 150 mm Hg.

Furthermore, angiogenesis in irradiated tissue has been shown to raise the oxygen tension to 75-80% of normal. No evidence indicates that hyperbaric oxygen stimulates tumor growth, although this continues to be a concern.

Chondronecrosis in relapsing polychondritis is secondary to inflammation from an autoimmune response. The cornerstone of therapy is corticosteroids. In the acute phase of the disease, a dosage of 0.75-1 mg/kg over 3-8 weeks with a slow taper is recommended. Most patients require long-term prednisone therapy at a dosage of 5-12 mg/d. In a 1998 report, Trentham and Le recommend combination therapy with methotrexate at an average dose of 17.5 mg per week. ^[17] This allows a prednisone reduction from 19 mg/d to 5 mg/d. In acute bouts of respiratory distress, symptoms typically are a result of edema. Racemic ephedrine is therefore suggested while initiating corticosteroid therapy. Patients with mild disease have been treated with dapsone, aspirin, other NSAIDs, and immunosuppression with agents such as azathioprine, cyclophosphamide, 6-mercaptopurine, penicillamine, and cyclosporin.

Patients with airway instability secondary to chondroradionecrosis may not be candidates for medical therapy. In such cases, tracheotomy is necessary. If the larynx is dysfunctional with life-threatening aspiration or functional with biopsy findings positive for recurrent carcinoma, laryngectomy is recommended. Persistent laryngeal edema for longer than 6 months is a clinical indication of persistent cancer and frequently leads to laryngectomy.

Several surgical approaches for laryngeal preservation following chondroradionecrosis have been described. In 1973, Theissing reported the use of a Y-shaped, tubed, pedicled flap from chest skin in a single patient with subtotal loss of cartilage. ^[18] In 1980, Draf described a composite deltopectoral skin and cartilage flap on 2 patients. ^[19] A unipedicled cervicothoracic flap and an osteomyocutaneous flap have also been reported. In 1993, Balm et al described the use of a pectoralis major muscle transposition with split-thickness skin coverage for repair of the defect. ^[2] Advantages include proximity, single-stage reconstruction, little functional deficit, independent blood supply, and ability to perform a salvage laryngectomy if needed without increasing morbidity.

Relapsing polychondritis is not typically localized to the larynx and usually involves the trachea. Montgomery T-tubes and intraluminal stents have been used to treat laryngotracheal involvement of relapsing polychondritis. Significant complications are possible, however, and include the following: (1) displacement of the stent, leading to asphyxia; (2) erosion through the anterior tracheal wall into the innominate artery; (3) mucosal irritation leading to ulceration and granulation tissue formation; and (4) vertical extension of the stent through the vocal cords, leading to aspiration pneumonia. Results of laryngotracheal reconstruction as a treatment in relapsing polychondritis are not good. Few reports and no large institutional or surgeon series exist.

In 1984, Eliachar used a sternohyoid myocutaneous rotary door flap in his laryngotracheal reconstructions, the advantage being a vascularized myocutaneous flap without the need for transfer of bone or cartilage for support. ^[20] In 1997, Spraggs described the use of a vascularized medial clavicular graft, in which he created a lumen in the clavicular flap and interposed it into the airway, maintaining the placement with a soft silastic stent. ^[21] Extensive tracheobronchial collapse in relapsing polychondritis is not within the confines of this article. However, external airway splinting is the treatment of choice, and the reader is referred to Spraggs' study for further information.

In the early stages (Chandler I-III), the airway cannot be protected, resulting in aspiration, pneumonia, and lung abscess. Furthermore, early stage chondronecrosis can progress to life threatening obstruction secondary to collapse, requiring emergent tracheotomy. Tracheal collapse resulting in sudden death has been reported in relapsing polychondritis. Other complications include dysphagia, odynophagia, and hoarseness.

With early recognition and medical intervention, the outcome and prognosis is good. In the case of chondroradionecrosis, frequent examination is recommended to detect an early manifestation of recurrent cancer.

A 10% mortality rate is reported in Michet's 1986 study on relapsing polychondritis. ^[22] Other studies have indicated anywhere from a 28-44% mortality rate. This, however, could be secondary to selective case reporting. No large series have been conducted on the outcome of patients who present with chondronecrosis secondary to other etiologies.