Tracheal Stenosis Diagnosis and treatment
Abstract
Tracheal stenosis is one of the most challenging problems facing a variety of medical specialists. Although post-intubation stenoses are the commonest many other causes can lead to tracheal stenosis. Various lesions can occur singly or in combination. Proper diagnosis and evaluation are essential for tailoring the most suitable management policy for each patient. This is a tedious process and requires a strong commitment from both patient and physician
The aim of this publication is to summarize the relevant aspects in the diagnosis and treatment of this complex affection.
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Objective:
This study aimed to evaluate complications and success rates of tracheal resection and anastomosis (TRA) and cricotracheal resection and anastomosis (CTRA) in patients treated in 2 academic institutions.
Methods:
Retrospective charts review of 137 patients submitted to TRA/CTRA. Fifty (36.5%) had neoplastic (group A) and 87 (63.5%) benign (group B) stenoses. Using univariate analysis, age, medical comorbidities, previous radiotherapy, type of TRA/CTRA, association with neck dissection and thyroidectomy, length of resected airway, and preoperative tracheotomy were evaluated to identify factors predictive of complications and outcomes.
Results:
The mean length of resected airway was 2.7 and 3 cm in groups A and B, respectively. Overall decannulation and complication rates for group A were 96% and 36%, and 99% and 46% for group B, respectively. Length of airway resected and presence of preoperative tracheotomy had a statistically significant effect on major surgical complications. Age older than 70 and cardiovascular and pulmonary comorbidities were significantly associated with the incidence of major medical complications. No statistically significant difference was found considering the complication rates of group A versus group B.
Conclusion:
Even though the overall success rate of TRA/CTRA is high, it should always be regarded as a major surgical procedure with a non-negligible incidence of complications.
After suffering an inhalation burn, a 22-year-old male was intubated for seven days. Full-length massive scar formation in
the upper airway necessitated tracheostomy five months later. After this, the stenosis became complete in the cricoid region,
and a long cannula was needed to maintain the severely damaged middle–distal trachea. After unsuccessful laser dilatation,
the more stenotic 3 cm distal tracheal segment was resected, but two months later the stenosis recurred. As resection was
ineffective, tracheoplasty was performed via a right-sided thoracotomy; the re-stenotized trachea was incised in length and
successfully extended with 5 cm long, oval-shaped rib cartilage. Three months later, the complete cricotracheal stenosis was
fixed by combined laryngofissure and cricoid laminotomy with two 6 cm×2.5 cm cartilage pieces sutured into the incisions.
The middle portion of the trachea was expanded with a similar graft inserted into the anterior wall below the tracheostomy.
The fixing T-tube was removed three months later, and the patient had an adequate airway two years after the last procedure.
We conclude that multiple cartilage graft reconstruction can be successful even after the development of an extremely long
airway stenosis following inhalation burn injury.
Tracheobronchial stenosis, a serious problem in adults and children, has multiple causes and has been treated in many ways. While developing an international multicentre study to evaluate efficacy of airway stents, it was realised that no adequate description of central airway stenosis regarding type, location and degree has been published. Thus, comparing results of different treatment modalities in different centres has been difficult due to a lack of uniformity of classification. Reports are typically descriptive and precise classification schemes have not adequately addressed either for the trachea or the main bronchi.
A standardised classification scheme was proposed with descriptive images and diagrams for rapid and uniform classification of central airway stenosis. The present authors’ system divides stenosis into structural and dynamic types and further classifies the disease by degree of stenosis, location and transition zone.
Multiple sites can be described and each is transformed into a simple numerical scoring system prompted by a diagram, which can be easily captured for subsequent uniform analysis across sites.
A pilot validation of the system, with 18 pulmonologists of varying training background, showed strong precision and agreement between observers. Such a system will enhance the ability to study the effectiveness of treatment modalities for central airway stenosis.
Abstract
Background
Management of benign tracheal stenosis (BTS) varies with the type and extent of the disease and influenced by the patient's age and general health status, hence we sought to investigate the long-term outcome of patients with BTS that underwent minimally invasive bronchoscopic treatment.
Methods
Patients with symptomatic BTS were treated with flexible bronchoscopy therapeutic modalities that included the following: balloon dilatation, laser photo-resection, self-expanding metal stent placement, and High-dose rate endobronchial brachytherapy used in cases of refractory stent-related granulation tissue formation.
Results
A total of 115 patients with BTS and various cardiac and respiratory co-morbidities with a mean age of 61 (range 40-88) were treated between January 2001 and January 2009. The underlining etiologies for BTS were post - endotracheal intubation (N = 76) post-tracheostomy (N = 30), Wegener's granulomatosis (N = 2), sarcoidosis (N = 2), amyloidosis (N = 2) and idiopathic BTS (N = 3). The modalities used were: balloon dilatation and laser treatment (N = 98). Stent was placed in 33 patients of whom 28 also underwent brachytherapy. Complications were minor and mostly included granulation tissue formation. The overall success rate was 87%. Over a median follow-up of 51 months (range 10-100 months), 30 patients (26%) died, mostly due to exacerbation of their underlying conditions.
Conclusions
BTS in elderly patients with co-morbidities can be safely and effectively treated by flexible bronchoscopic treatment modalities. The use of HDR brachytherapy to treat granulation tissue formation following successful airway restoration is promising.
The report is a retrospective review of 238 benign tracheal stenoses of various etiologies treated between 1995 and 2008. To show that urgent segmental resection has complication rates similar to elective resection and, therefore, preoperative dilation is not necessary, we analysed records of patients who underwent either standard segmental resections with anterolateral mediastinal tracheal mobilization, single-suture anastomosis and neck flexion; or insertion of T-tube with oval-shaped horizontal arm. Primary segmental resection was performed in 164 patients (68.9%), including 14 cases with concomitant tracheo-esophageal fistula (TEF). T-tube as an initial treatment suited 74 (31.1%) patients. We encountered two partial and one complete anastomotic disruptions following subglottic resections treated by T-tube insertion and costal cartilage tracheoplasty or permanent tracheostomy. Restenosis rate in segmental resection was 3.1%. No difference in complication rate between urgent and elective segmental resections was experienced. We treated a small number of patients by endotracheal stent insertion but the results were discouraging. Urgent segmental resection without prior rigid bronchoscopy dilation is our strategy of choice whenever possible. As an alternative to dilation we prefer temporary insertion of modified T-tube. Stand-alone endoluminal dilation and stenting has yet to prove its safety and long-term efficacy.
Bronchoscopic balloon dilatation (BBD) using angioplasty balloon catheters has been employed successfully in the treatment of tracheobronchial stenoses in children and has worked with variable success in adults with bronchial stenosis. In adults with tracheal stenosis, BBD only has been reported anecdotally. In this study, experience with BBD using a valvuloplasty balloon catheter in the combined treatment (with Nd-YAG laser photoresection and stenting) of severe benign postintubation tracheal stenoses in three adults is delineated. BBD was particularly successful in establishing tracheal patency when laser photoresection was contraindicated or was too dangerous; BBD allowed easy insertion of tracheal stents and the "opening" of folded silicone stents. BBD is a simple, inexpensive, safe, and efficient adjunct in the combined treatment of severe postintubation rigid tracheal stenosis in selected adults.
To evaluate the treatment, perioperative management, and outcome of infants who underwent repair of congenital tracheal stenosis. We hypothesized that early resection and tracheoplasty with early weaning of ventilatory support results in less mucosal injury, and thus better outcome.
Retrospective study from 1986 to 1996.
Tertiary care children's hospital.
Seventeen consecutive infants with congenital tracheal stenosis, aged from birth to 16 months. Fifteen patients had complete tracheal rings, 6 of whom also had a left pulmonary artery sling. Fourteen patients underwent either tracheoplasty or resection and reanastomosis of the trachea, both facilitated by cardiopulmonary bypass.
Six patients underwent resection and reanastomosis; 4 patients were extubated within 2 to 5 days without sequelae. There was 1 unrelated perioperative death. Two patients required reintubation. Eight patients required tracheoplasty due to severe tracheal stenosis and had variable postoperative courses. Seven of 14 patients required 0 to 1 postoperative bronchoscopies. Seven of 14 patients required 2 to 7 bronchoscopies for granulation tissue formation, cicatrix, graft collapse, and tracheitis. One patient required numerous procedures and revision tracheoplasty for cicatrix and stenosis.
Correction of short-segment (<5 rings) tracheal stenosis by resection and reanastomosis of the trachea with the aid of cardiopulmonary bypass and early weaning of ventilatory support is recommended. Tracheoplasty using either the castellation technique or slide tracheoplasty is recommended in the treatment of infants with severe (long segment) tracheal stenosis.
Background: Postintubation stenosis remains the most frequent indication for tracheal surgery. Rigid bron-choscopy has traditionally been considered the technique of choice for the preoperative diagnostic assessment. However, this technique is not routinely available, and new techniques such as flexible video-bronchoscopy and spiral computed tomography (CT) scan with multiplanar reconstructions have been proposed as alternatives to rigid bronchoscopy. The aim of this study was to compare these techniques in the diagnostic assessment of patients with tracheal stenosis submitted to surgical treatment. Methods: Twelve patients who underwent airway resection and reconstruction for postintubation tracheal and laryngotracheal stenosis were preoperatively evaluated with rigid and flexible bronchoscopy and with spiral CT scan with multiplanar reconstructions. The following parameters were examined: involvement of subglottic larynx, length of the stenosis, and associated lesions. The results were compared with the intraoper-ative findings. Results: The accuracy of rigid bronchoscopy, flexible bronchoscopy, and CT scan in the evaluation of the involvement of subglottic larynx was, respectively, 92%, 83%, and 83%. The evaluation of the length of the ste-nosis was correct in 83%, 92%, and 25% of the patients, respectively, with rigid bronchoscopy, flexible bron-choscopy, and CT scan. A significant correlation was observed between the length of the stenosis measured intraoperatively and preoperatively with rigid (p < 0.001) and flexible bronchoscopy (p < 0.05) but not with CT scan (p = 0.08). The three techniques correctly showed the presence of an associated tra-cheoesophageal fistula in two patients, but CT scan did not correctly show the exact location of the fistula in relation to the airway. Flexible bronchoscopy was the only effective technique in the assessment of laryngeal function. Conclusions: Rigid bronchoscopy remains the procedure of choice in the evaluation of candidates for tracheal resection and reconstruction for postintubation stenosis, and it should be available in centers that perform surgery of the airway. Flexible bronchoscopy and CT scan have to be considered complementary techniques in the evaluation of laryngeal function and during follow-up.
Tracheal resection and reconstruction (TRR) and laryngotracheal resection and reconstruction (LTRR) is commonly performed for post-intubation tracheal stenosis, tracheal tumor, idiopathic laryngotracheal stenosis (ILTS), and tracheoesophageal fistula (TEF). Ninety-five percent of patients have a good result from surgery. Complications occur in ~20% of patients, of which half are anastomotic complications. Complications include granulation tissue formation, restenosis of the trachea, anastomotic separation, TEF and tracheoinnominate fistula (TIF), wound infection, laryngeal edema, and glottic dysfunction. Risk factors for anastomotic complication include diabetes, reoperation, previous tracheal appliance, and long-segment tracheal resection. Bronchoscopy should be part of the diagnostic workup when a complication is suspected. Anastomotic separation-the most feared complication of tracheal surgery-may present subtly with stridor and wound infection, or with respiratory distress and extremis. Prompt management is required to prevent devastating consequences. The airway should be secured, bronchoscopy should be performed to address the degree of separation, and the anastomosis should be revised if needed, usually with the addition of t-tube or tracheostomy. Anastomotic complications that are managed aggressively typically yield good results. More than half of such patients will eventually have a satisfactory airway. However, an anastomotic complication is associated with a thirteen-fold increase in the risk of death following tracheal resection.
The intent of this study is to examine the diagnostic contribution of MDCT and its role, in comparison with traditional endoscopy, in the evaluation of pathologies which obstruct the central respiratory tract, thanks to virtual bronchoscopy, a non-invasive, reproducible and objective technique compared to flexible bronchoscopy. The technique could represent a valuable alternative for patients of advanced age or those presenting pathologies which obstruct the central respiratory tract, or also in cases in which traditional bronchoscophy doesn't provide sufficient information, e.g. lesions totally obstructing one bronchus, or copious bleeding due to attempted biopsy. Results of some cases in which the technique was applied are presented, compared with the traditional methodologies.
Introduction: Acquired tracheal stenosis can be created by various malignant or benign causes. The most common cause of acquired non-malignant tracheal stenosis is endotracheal intubation, even for a short period. Argon plasma coagulation is a non-contact method of thermal hemostasis. Argon plasma coagulation can be used easily and fast and has low depth of penetration. Methods: This study is single blinded. Subjects are patients with tracheal stenosis after endotracheal intubation who were selected by non-probability sampling and were studied from March 2007 to November 2009 in bronchoscopy and laser center of Masih Daneshvari Hospital, Tehran. First, for each patient, a diagnostic flexible bronchoscopy was performed to identify the type, location, and severity of the stenosis. Then, under general anesthesia, patients underwent rigid bronchoscopy. Then, with Argon plasma coagulation device (ERBE VIO 200D) the stenosis was removed as possible. After two weeks, a new PFT (pulmonary function test) was done for checking the obstructive signs. Results: Of these 34 patients, 24 were asymptomatic for more than 1 year and responded to treatment(70/6%), 5 were asymptomatic for more than 10 months and less than 12 months (14/7%) and 5 did not have asymptomatic periods more than 10 months, and did not respond to treatment. In PFT follow-ups, FEV1 in all patients who were asymptomatic for more than 10 months had a significant progress; therefore, in 27 out of 29 patients at the end of the study, FEV1 was more than 90% and 2 patients had FEV1 of 70-90%. Conclusion: In fact, although the surgical treatment remains the main treatment of tracheal stenosis after intubation (PITS), if this method is not possible for any reason, APC is very useful as a safe and effective method.
Adult and pediatric laryngotracheal stenoses (LTS) comprise a wide array of various conditions that require precise preoperative assessment and classification to improve comparison of different therapeutic modalities in a matched series of patients. This consensus paper of the European Laryngological Society proposes a five-step endoscopic airway assessment and a standardized reporting system to better differentiate fresh, incipient from mature, cicatricial LTSs, simple one-level from complex multilevel LTSs and finally "healthy" from "severely morbid" patients. The proposed scoring system, which integrates all of these parameters, may be used to help define different groups of LTS patients, choose the best treatment modality for each individual patient and assess distinct post-treatment outcomes accordingly.
Despite the availability of various surgical options, management of laryngotracheal stenosis (LTS) still remains an enigma. Proper selection of surgical technique in each clinical setting is the key for successful outcome. The purpose of this article is to guide one in selection of appropriate surgical procedures depending upon various stenosis parameters. Aim To record the clinical profile of cases with LTS. To assess the outcome following various surgical interventions based on site, severity, cause of stenosis and to derive conclusions regarding treatment options in various stenosis. Materials and Methods It is a study of 60 cases with chronic LTS. It includes retrospective study of 30 cases treated from 2004 and prospective study of 30 cases from Jan 2007 to Dec 2009. A total of 60 cases with LTS were enrolled in the study. Patients were assessed clinically by eliciting detailed history and analyzing previous records. After assessment of extent of stenosis, they were subjected to surgical interventions (endoscopic/open approach). Outcome after surgical interventions was assessed. Results 60 patients were included in the study, in the age group of 2.5–50 years. There were 46 (77%) male patients and 14 (23%) female patients. Intrinsic trauma, secondary to prolonged intubation was the most common cause of LTS, seen in 23 (38%) cases followed by post traumatic stenosis (strangulation-18 (30%), blunt injury-15 (25%), penetrating neck injury-4 (7%)). Stenosis was divided into 6 types based on subsite involvement. Of which, cervical trachea was the commonest site of involvement (25/60 cases). Majority of cases had fixed vocal cords at presentation (55%), more commonly due to post traumatic injury. 60 cases had undergone a total of 110 surgical procedures (endoscopic-56,open approach-54). In the end, overall decannulation rate is 93.3%. In site wise tracheal stenosis, isolated subglottis, combined glottis and subglottic stenosis had decannulation rate of 100% each and with mobile vocal cords, the success rate is 96%. Conclusions Post traumatic stenosis with fixed vocal cords is more common in our practice. Categorizing stenosis into various subtypes helps in treatment planning and predicts surgical outcome. Tracheal or subglottic stenosis with mobile vocal cords has better success rate.
Objectives
Retrospective survey (over 13 years) of the surgical treatment of 46 acquired tracheal stenosis, in adult patients. Our goals were to study their epidemiology, changes in the surgical technique with the cervical or endoscopic approach, and the recent contribution of endoprotheses.
Materials and methods
Sixty-six therapeutic procedures were performed for 46 tracheal stenoses. Most of stenoses were post-intubation and/or post-tracheotomy and were fixed in 50% of the cases. We used 21 sleeve resections with end-to-end anastomoses, 9 tracheal stents, 27 dilations, 6 calibrations, and 3 electro-coagulations.
Results
The sleeve resection gave 91% success (1 failure and 1 death). The endoscopic treatments were less efficient: 79% for tracheal stents (2 mobilizations), 50% success for iterative dilations. The respiratory tests were meaningfully improved with a mean follow-up of 18 months.
Conclusion
Sleeve resection remains the gold standard treatment. For all temporary or definitive contraindications to open surgery, tracheal stents would be an excellent alternative to avoid often inefficient iterative dilations.
Purpose:
To assess airway measurements, endobronchial ultrasonography (EBUS) and multidetector, row computed tomography (MDCT) images were compared in patients with tracheal stenosis.
Methods:
Airway stenting was performed on 31 patients, 25 malignant and 6 benign. EBUS and MDCT images were compared before intervention to assess the degree of airway narrowing at 212 sites. Of these, 130 sites were considered normal and 82 abnormal. For malignant stenosis, airway measurements were taken at 160 sites including 112 normal and 48 abnormal. For benign stenosis, airway measurements were taken at 52 sites including 18 normal and 34 abnormal. This technique enables the EBUS probe to measure the distal end to the proximal end of the stenosis whereby the inflated balloon size changes according to the degree of stenosis.
Results:
The diameter and length of the stenotic sites measured by EBUS and MDCT were nearly equal in all patients. Significant correlation was seen at all 212 sites (r=0.805, P<0.0001), 130 normal (r=0.758, P<0.0001) and 82 abnormal (r=0.654, P<0.0001). For malignant cases, there was significant correlation in a total of 160 sites (r=0.810, P<0.0001), 112 normal (r=0.782, P<0.0001) and 48 abnormal (r=0.564, P<0.0001). Benign cases showed significant correlations in total 52 sites (r=0.780, P<0.0001), 18 normal (r=0.778, P<0.0001) and 34 abnormal (r=0.731, P<0.0001).
Conclusion:
This EBUS technique was successful in establishing accurate airway measurements for suitable airway stent sizes in interventional procedures, especially in cases with tracheobronchial malacia.
Sixteen cases of Chronic laryngotracheal stensis were included in the study. They underwent endoscopic CO(2) laser excision of the stenotic segment. Three patients were decannulated. giving a success rate of 18.75%.
We evaluated the usefulness and accuracy of spiral CT in detection and assessment of post-intubation tracheal stenosis. Fourteen
patients with post intubation stenosis underwent evaluation of their airway by spiral CT scan with multiplanar reformatting
(MPR) and virtual endoscopy (VE) and conventional rigid bronchoscopy, and telescopy (RB). The following parameters were assessed:
involvement of the subglottic larynx, site, number, and degree of the stenosis. The results were compared with the intra-operative
findings. The detection rate for tracheal stenotic lesions was 94% by CT and 88% by rigid bronchoscopy. The sensitivity and
specificity of both CT scan and bronchoscopy in the detection of subglottic stenosis was 100%. The preoperative assessment
of the length of stenosis was accurate in 14 (87%) of the 16 stenotic segments detected by CT and in 11 (73%) of the 15 segments
detected by bronchoscopy. The length of stenosis as assessed intra-operatively significantly correlated with the data obtained
with CT scan (r=0.98, p<0.001) and RB (r=0.94, p<0.001). The grade of stenosis was correctly assessed by bronchoscopy in 13/15 lesions (86%). CT measurements correctly
estimated 15/16 (93.75%) lesions and allowed accurate measurements of the stenotic segment as well as the proximal and distal
airway segments. Spiral CT scan with MPR and VE may be considered as a substitute to direct endoscopic examination and the
additional information on laryngeal function can be easily obtained during flexible nasolaryngoscopic examination of the awake
patient. This policy can minimize patient morbidity and spare them an extra anaesthetic for evaluation.
Experience with surgical treatment of 164 patients with various diseases of the trachea at the All-Union Institute of Clinical and Experimental Surgery in Moscow since 1963 is summarized. The main diagnostic methods used in tracheal diseases were tracheography and tracheoscopy with biopsy. Operations were performed for malformation, trauma, exflammatory disease, benign and malignant tumors, nontumoral stenoses, and esophagotracheal fistula. A bypass respiration system was used in the majority of patients after tracheal transection. Hyperbaric oxygenation added to the bypass respiration system made it possible to interrupt lung ventilation during operations on the trachea for long periods.
The best operative approach to the thoracic trachea was a partial sternotomy and posterior thoracotomy. The standard approach to the tracheal bifurcation was a posterior right thoracotomy.
The various operations performed on the trachea included sleeve resection with end-to-end anastomosis, resection of the tracheal bifurcation, window resection, tumoral incision in the opened trachea, plastic repair of esophagotracheal fistula, and strengthening of the membranous trachea. Six variations of resection of the tracheal bifurcation were performed. In cases of sleeve resection, operative risk was minimized by suturing the left main bronchial stump closed, leaving the left lung in a state of atelectasis.
Of the 164 patients who underwent operation, 138 were discharged from the hospital and 26 (16%) died in the postoperative period. Bleeding from the brachiocephalic artery, pneumonia, thromboembolism of the pulmonary artery, and anastomotic leak were the causes of death. Operations on the trachea and its bifurcation require special anesthesia and surgical expertise in tracheobronchial procedures.
Major surgery on the trachea and airway is an anaesthetic challenge which necessitates the simultaneous control of the airway, maintenance of gas exchange and good surgical exposure. Advance planning, good communication and teamwork among surgeon, anaesthetist and theatre nurses are never more important. This is one of the few areas of surgery where the management of the airway is shared at times between the anaesthetist and surgeon. A major indication for laryngeal and tracheal surgery is laryngotracheal stenosis, a rare condition which can cause significant morbidity and life-threatening airway obstruction. In the era of modern medicine, post-intubation injury has superseded infection and external trauma as the commonest aetiology. The incidence of post-intubation stenosis has been estimated at 4.9 cases per million per year. Definitive surgery is usually carried out in tertiary specialist centres; the surgical technique depends on the site and pathological process. Segmental resection of the trachea with primary end-to-end anastomotic reconstruction has demonstrated a high level of successful decannulation and is usually the technique of choice for tracheal stenosis.
This article discusses the anaesthetic management of adult and paediatric patients undergoing bronchoscopy for diagnostic and therapeutic procedures. Particular emphasis is place on the techniques of ventilation and the controversy regarding the relative merits of intravenous and inhalational induction for foreign body removal by bronchoscopy. A brief introduction to the management of the patient for tracheal surgery follows and the importance of diverse ventilatory strategies is discussed.
Postintubation tracheal stenosis is caused by either cuff-induced ischemic damage to the trachea, stomal injury from a tracheostomy, or a combination of the two. Patients who present with stridor or unexplained dyspnea after a period of mechanical ventilation should be investigated for postintubation tracheal stenosis. Most patients with such an injury are candidates for tracheal resection and reconstruction. The length of the anticipated resection is the most important determinant of resectability. Tracheal resection is now a standardized operation with predictable, reliable, good results. The principles of operative repair include precise bronchoscopic assessment, complete tracheal mobilization, dissection close to the trachea to avoid recurrent nerve injury, and precise anastomotic technique.
To assess forced expiratory tracheal collapsibility in healthy volunteers by using multidetector computed tomography and to compare the results with the current diagnostic criterion for tracheomalacia.
An institutional review board approved this HIPAA-compliant study. After informed consent was obtained, 51 healthy volunteers (age range, 25-75 years) with normal spirometry results and no history of smoking or risk factors for tracheomalacia were prospectively studied. Volunteers were imaged with a 64-detector row scanner, with spirometric monitoring at total lung capacity and during forced exhalation, with 40 mAs, 120 kVp, and 0.625-mm detector collimation. Cross-sectional area and sagittal and coronal diameters of the trachea were measured 1 cm above the aortic arch and 1 cm above the carina. The percentage of expiratory collapse, the reduction in sagittal and coronal diameters, and the number of participants exceeding the current diagnostic criterion (>50% expiratory reduction in cross-sectional area) for tracheomalacia were calculated.
The final study population included 25 men and 26 women (mean age, 50 years). The mean percentage of expiratory reduction in tracheal lumen cross-sectional area was 54.34% +/- 18.6 (standard deviation) in the upper trachea and 56.14% +/- 19.3 in the lower trachea. Forty (78%) participants exceeded the current diagnostic criterion for tracheomalacia in the upper and/or lower trachea. Decreases in cross-sectional area of the upper and lower trachea correlated well with decreases in sagittal (r = 0.807 and 0.688, respectively) and coronal (r = 0.779 and 0.751, respectively) diameters (P < .001 for each correlation).
Healthy volunteers demonstrate a wide range of forced expiratory tracheal collapse, frequently exceeding the current diagnostic criterion for tracheomalacia.
Interventional bronchoscopy is one of the modalities for palliation and definitive treatment of benign tracheal stenosis. There is however no general agreement on the management of this disease. Aim of this work is to define, in the largest group of patients presented in the literature, what types of tracheal stenosis are amenable to definitive treatment by interventional endoscopy.
From January 1996 to June 2006 209 consecutive patients (105 men, 104 women) with benign tracheal stenosis were referred to our center. Etiology included 167 post-intubation and 34 cases of post-tracheostomy stenoses, 8 cases of other diseases. The lesions were classified into two groups: simple and complex. All but nine patients underwent interventional procedures (mechanical dilatation, laser photoresection and placement of a silicone stent). Two years follow-up was complete for all patients.
Simple stenoses (n=167) were treated by 346 endoscopic procedures (mean of 2.07 per patient), 16 stents and 1 end-to-end anastomosis. Thirty-eight granulomas were treated by 59 procedures (1.56 per patient), 97 concentrical stenoses by 228 procedures (2.35 per patient) and 32 web-like lesions with 59 operative endoscopies (1.84 per patient). Overall success rate was 96%. Among the 42 complex stenoses, 9 were immediately treated by surgical resection and the remaining 33 lesions underwent 123 endoscopic procedures (3.27 per patient), with 34 stents and 1 end-to-end anastomosis subsequent to recurrence after stent removal. In this group the success rate was 69%.
Our study shows that, after a correct classification and stratification, interventional endoscopy may have a crucial role in the treatment of tracheal stenoses. In particular, endoscopy should be considered the first choice for simple stenoses, whereas complex stenoses need a multidisciplinary approach and often require surgery.
The loss of a normal airway is devastating. Attempts to replace large airways have met with serious problems. Prerequisites for a tissue-engineered replacement are a suitable matrix, cells, ideal mechanical properties, and the absence of antigenicity. We aimed to bioengineer tubular tracheal matrices, using a tissue-engineering protocol, and to assess the application of this technology in a patient with end-stage airway disease.
We removed cells and MHC antigens from a human donor trachea, which was then readily colonised by epithelial cells and mesenchymal stem-cell-derived chondrocytes that had been cultured from cells taken from the recipient (a 30-year old woman with end-stage bronchomalacia). This graft was then used to replace the recipient's left main bronchus.
The graft immediately provided the recipient with a functional airway, improved her quality of life, and had a normal appearance and mechanical properties at 4 months. The patient had no anti-donor antibodies and was not on immunosuppressive drugs.
The results show that we can produce a cellular, tissue-engineered airway with mechanical properties that allow normal functioning, and which is free from the risks of rejection. The findings suggest that autologous cells combined with appropriate biomaterials might provide successful treatment for patients with serious clinical disorders.
To assess the efficacy of endoscopic laser radial incisions with mitomycin-C application (ELRM) in managing adult subglottic stenosis (SGS).
Retrospective case series review.
Fifteen consecutive cases of adult SGS treated with ELRM at a single tertiary referral center over three years were reviewed. Subjects with SGS secondary to Wegener's granulomatosis (WG) and idiopathic SGS were included. Patients with cartilaginous SGS were excluded. The primary outcome measure was postoperative reduction in symptoms. Secondary outcome measures included total number of procedures required to relieve symptoms, interval between procedures, and improvement in pulmonary function tests when available. In addition to surgery, 14 of 15 patients were treated medically for reflux.
Ten women and five men with average age 48 years were identified. Ten patients had idiopathic SGS and five had WG. The predominant presenting symptom was dyspnea on exertion in all patients. All subjects reported at least a temporary postoperative reduction in symptoms. Six patients (40%) required only one ELRM and nine patients (60%) required repeat ELRM at an average interval of 9 months. The average interval for the six patients with idiopathic etiology requiring a second procedure was 9 months. One subject with WG required four procedures. His interval improved from 2.5 to 7 months between procedures. Evidence of extrathoracic airway obstruction resolved in three of four patients with pre and postoperative pulmonary function tests.
ELRM is an effective method of managing SGS associated with idiopathic causes. In patients with WG, ELRM reduced airway associated symptoms and avoided need for tracheotomy.
Twenty-one human tracheal specimens were perfused and dissected, 10 with conventional techniques and 11 with clearing and microdissection techniques. The lateral pedicles of the trachea and esophagus induct vessels from the inferior thyroid, subclavian, supreme intercostal, internal thoracic, innominate, and superior and middle bronchial arteries. These vessels are interconnected along the lateral surface of the trachea by an important longitudinal vascular anstomosis. From the 2 lateral longitudinal anastomoses the lateral and anterior tracheal walls receive their blood supply through transverse segmental vessels that run in the soft tissues between the cartilages. These transverse vessels interconnect the longitudinal anastomoses across the midline and feed the submucosal capillary network that arborizes richly beneath the endotracheal mucosa. The tracheal cartilages receive nourishment from the capillary bed applied to their internal surface. The esophageal arteries and their subdivisions that supply the posterior membranous wall of the trachea contribute almost nothing to the circulation of the cartilaginous walls.
Seventy-two cases of laryngotracheal stenosis treated from 1981 through 1991 were reviewed to develop a system of classification which would be useful in predicting the outcome of treatment. Decannulation and absence of dyspnea after exertion were the criteria of successful management. The probability of decannulation over time was computed using the Kaplan-Meier technique. Cox multiple regression analysis was used to determine the effects of independent variables (age, sex, etiology, site of stenosis, length of stenosis, diameter of stenosis, and surgical technique) on treatment success. The only factors with a significant effect on the outcome were site of stenosis and diameter of stenosis. A classification into four clinical stages of stenosis based on site of lesion was shown to effectively predict the likelihood of successful decannulation.
Acquired tracheal stenosis in childhood is frequently difficult to manage because of poor healing, infection, and scarring. In a 10-year period, 62 patients (4 weeks to 14 years of age) were treated for acquired tracheal stenosis. The causes of stenosis were endotracheal intubation (44 patients), caustic aspiration (6 patients), recurrent infection (5 patients), bronchoscopic perforation (4 patients), and gastric aspiration (3 patients). The subglottic or upper trachea was involved in 47 patients, mid portion in 8, and distal or carinal area in 7. Fifty children underwent tracheostomy as part of the therapy, and 12 were managed without tracheostomy. Therapy was individualized, frequently sequentially, utilizing rigid or balloon dilatation (20 patients), bronchoscopic electrocoagulation resection (44 patients), steroid injection (48 patients), T tube stent (8 patients), resection with anastomosis (12 patients), cricoid split (3 patients), and rib cartilage graft (12 patients). Most patients required several techniques and repeated procedures to eventually achieve decannulation. Seven patients (11%) died of unrelated causes. Forty-four of 55 surviving patients (80%) are without tracheostomy, although 14 have required continued endotracheal treatment after tracheostomy removal (dilatation, endotracheal resection). This series demonstrates that acquired tracheal stenosis in childhood is a common, difficult problem, but manageable with the use of a variety of techniques. Resection and grafting procedures should be reserved for cases in which less complex modalities fail.
This project was undertaken to develop models of acute and chronic laryngeal intubation as a format for testing a newly designed endotracheal tube. The tube has a specially created laryngeal cuff designed to reduce pressure exerted against the laryngeal soft tissues. The laryngeal foam cuff was shown to prevent the injurious sequence of mucosal ischemia, ulceration, and cartilage damage.
A laryngeal foam cuff has the potential to significantly reduce laryngeal injury from prolonged endotracheal intubation. A prospective randomized clinical trial has been initiated and will be reported subsequently.
An operation for obtaining additional length in order to achieve end to end anastomosis of cervical trachea without excessive suture line tension is accomplished by sectioning of suprahyoid musculature in order to obtain release from above. The technique is described, illustrated, and compared to other methods for release of tension on cervical trachea.
Direct tracheoscopy was employed to assess tracheal damage following prolonged intubation. Comparison of conventional and
low-pressure cuffs showed that there was less trauma from the low-pressure cuff. Comparison of tube sizes showed a reduction
in injury with 8-mm diameter tubes compared with larger ones.
We have now used the procedure in 19 patients with high and mid-tracheal stenosis which measured up to 3-4 cm in length. Only one recurrent nerve was paralyzed by the surgery. Two patients with severe lung disease expired after surgery from respiratory failure. Three patients restenosed and required replacement of a tracheotomy. The remaining 14 patients have had no evidence of recurrent tracheal stenoses.
The classification of airway stenoses has been a problem for many years. As a result, both intradepartmental and interdepartmental comparisons of airway sizes remain difficult. It follows that comparisons of therapeutic maneuvers are even more difficult. A system is proposed that is simple, reproducible, and based on a readily available reference standard. Endotracheal tubes, which are manufactured to high standards of precision and accuracy, can be used to determine the size of an obstructed airway at its smallest point. The endotracheal tube that will pass through the lumen, if one exists, and tolerate normal leak pressures (10 to 25 cm H2O), can be compared to the expected age-appropriate endotracheal tube size. By using the outside diameters of the endotracheal tubes, the maximum percentage of airway obstruction can be determined. We present a conversion of tube size to the proposed grading scale: grade I up to 50% obstruction, grade II from 51% to 70%, and grade III above 70% with any detectable lumen. An airway with no lumen is assigned to grade IV.
Tracheal resection and primary anastomosis can be performed for the management of congenital, traumatic, iatrogenic, and neoplastic etiologies of tracheal stenosis. During a 19-year period, we performed 45 tracheal resections on 38 patients with low operative mortality (7.9%) and morbidity. One patients had congenital tracheal stenosis (group 1); 4 patients had stenosis resulting from traumatic lesions (group 2); 18 patients had stenosis caused by tracheostomy or endotracheal tubes (group 3); and 15 patients had stenosis caused by a variety of neoplastic lesions (nine primary and six secondary) (group 4). Preoperative evaluation and surgical and anesthesia management are described. Eight tracheal stents were used (three Neville prostheses and five Montgomery T tubes). Disastrous results occurred with the Neville prosthesis, but acceptable results were obtained when the Montgomery T tube was used. There were several "lessons learned" during the evolution of this series. Chest roentgenograms are not useful. Tracheal tomography and computed tomography are extremely informative in evaluation of iatrogenic and neoplastic lesions. Proper mobilization allows primary anastomosis after almost all resections. Excellent results were obtained with iatrogenic lesions. Increased mortality and morbidity occur in patients undergoing resection for neoplastic lesions; however, 5-year survival is good, and results are gratifying.
To evaluate the potential of MRI in the assessment of tracheal stenosis due to tracheal or vascular malformations, 45 children with severe respiratory distress were examined prospectively during a period of 1 year. Five of these children had tracheal stenosis due to a sling left pulmonary artery (SLPA).
Magnetic resonance examinations of the anesthetized children were performed with a 1.5 T Siemens MR imager using electrocardiographically gated T1-weighted SE sequences in transverse and sagittal slice orientations. Slice thickness was 3 mm and each sequence was repeated after shifting the slice position by 1 mm. Monitoring during the examinations included ECG, oscillatory blood pressure, respiratory rate, and oxygen concentration. Magnetic resonance findings were compared with esophagography, selective pulmonary angiography, bronchoscopy, Doppler sonography, and surgery. All examinations were repeated after surgical therapy to assess the improvement in tracheal stenoses and the patency of the ligated and reimplanted left pulmonary arteries.
Magnetic resonance imaging clearly revealed the course of the SLPA and its topographic relationship to the trachea as well as the coexistence of cardiovascular and tracheobronchial or esophageal malformations. The degree and length of tracheal stenoses, which were measured in the pre- and postoperative axial slices and graphically displayed, as well as the angles of the right and left main stem bronchi, could be accurately determined.
Magnetic resonance imaging in combination with bronchoscopy yielded the necessary and sufficient information for diagnosis and aided the surgeon in planning operative strategy and in postoperative follow-up.
Since 1974, nearly 800 open pediatric airway reconstruction procedures have been performed. Data on these procedures and patients are being systematically recorded as part of an airway procedures database. When complete, the database will facilitate the tracking and description of reconstructive techniques and their success as they evolve. This preliminary look at twenty years' experience with paediatric airway reconstruction is an overview of the changes that have occurred in the etiology of airway stenosis and the surgical procedures used to correct it.
Although several techniques for the treatment of long-segment stenosis of the trachea have been reported, including slide tracheoplasty, rib grafting, and use of a pericardial patch, the optimal repair remains controversial because of a lack of midterm to long-term follow-up data.
To assess the intermediate and long-term outcomes of patients having repair with anterior pericardial tracheoplasty, we reviewed case histories of 12 patients (1984 to present). The median age was 6.7 months (range, 1 to 98 months), and the median weight was 6.0 kg (range, 0.97 to 42 kg). All patients underwent anterior pericardial tracheoplasty through a median sternotomy during partial normothermic cardiopulmonary bypass. An average of 13 tracheal rings (range, five to 23) were divided anteriorly, and a patch of fresh autologous pericardium was used to enlarge the trachea by 1.5 times the predicted diameter for patient age and weight.
There was one hospital death, and all but 2 patients are long-term survivors. All but 1 current survivor remain asymptomatic, with no bronchoscopic evidence of airway obstruction or granulation on the pericardial patch. All survivors examined have normal tracheal growth and development, with a median follow-up of 5.5 years (range, 1 to 11 years).
Anterior pericardial tracheoplasty for congenital tracheal stenosis provides excellent results at intermediate to long-term follow-up.
Complications of tracheal surgery are best managed by avoiding them. This entails proper patient selection through evaluation; careful coordination between anesthesia, otolaryngology, and thoracic surgery; meticulous attention to the technical details of operation; and postoperative care. There must be a firm understanding of airway management in the postoperative period ranging from edema, anastomotic granulations, fistula, separation, or recurrent stenosis. Successful management can be accomplished with preservation of the airway.
Tracheal stenosis can be a life-threatening problem in children. Long-segment tracheal stenosis and recurrent tracheal stenosis are especially problematic. Tracheal homograft reconstruction represents a novel therapeutic modality for these patients.
Cadaveric trachea is harvested, fixed in formalin, washed in thimerosal (Methiolate), and stored in acetone. The stenosed tracheal segment is opened to widely patent segments proximally and distally. The anterior cartilage is excised and the posterior trachealis muscle or tracheal wall remains. A temporary silicone rubber intraluminal stent is placed and absorbable sutures secure the homograft. Regular postoperative bronchoscopic treatment clears granulation tissue. The stent is removed endoscopically after epithelialization over the homograft. Twenty-four children with severe tracheal stenosis (age 5 months to 18 years, mean +/- standard error of the mean = 8.18 +/- 1.21 years) underwent tracheal homograft reconstruction. All but one had had previous unsuccessful reconstructive attempts. Ten lesions were congenital, nine were posttraumatic, and five were due to prolonged intubation.
Follow-up ranged from 5 months to 10 years (3.79 +/- 0.70 years). Twenty patients survive (20/24 = 83%), 16 without any airway problems. Four patients are still undergoing treatment. One patient requiring emergency extracorporeal membrane oxygenator support before the operation died 10 days after tracheal homograft reconstruction. Another patient with severe preoperative mediastinal sepsis died 3.5 months after tracheal homograft reconstruction. Two patients with functional airways died late of unrelated problems.
Tracheal homograft reconstruction demonstrates encouraging short-term to medium-term results for children with severe recurrent tracheal stenosis. Postoperative bronchoscopic and histologic studies provide evidence of epithelialization and support the expectation of good long-term results.
The incidence of tracheal stenosis following conventional tracheostomy has been reported as lying between one and 30 per cent. Methods used to assess the degree of stenosis include CT scanning, fibreoptic visualization and plain X-ray tomographs. The aim of this study was to assess the degree of stenosis in patients following percutaneous dilatational tracheostomy (PDT) using MRI scanning. This method has not been reported in the literature previously. Nine patients without symptoms of tracheal stenosis were studied for at least six months following PDT performed in the intensive therapy unit. The tracheas were assessed for scarring and stenosis using a three dimensional volume scanning MRI technique. Although scarring could be detected in the wall of the trachea and subcutaneous tissues of all patients, tracheal stenosis was not demonstrated at the insertion site or at the site of the cuff (p > 0.05). MRI scanning provides an excellent non-invasive method of assessing the tracheal lumen. Our patients who had undergone PDT do not appear to have any degree of post-operative stenosis.
The purpose of this study is to retrospectively analyze our experience with airway reconstruction, to outline a new staging system for laryngotracheal (LT) stenosis, and to identify preoperatively those patients likely to fail reconstruction. We reviewed 41 patients who underwent 46 LT reconstructions over the past 10 years. Success was judged by the ability to decannulate patients within 1 year postoperatively. Of our patients, 63% were treated successfully, and an additional 17% had intermediate success. The techniques used for laryngotracheoplasty with augmentation grafting and tracheal resection are reviewed. Major complications, thoracic complications, and wound complications are presented. Each patient was staged by the McCaffrey staging system and Cotton grades. We propose a new staging system based on the extent of the stenosis throughout the glottis, subglottis, and trachea. It is logical and easy to use. Applied to our cases of LT stenosis retrospectively, the new system predicts clinical success (chi2, p = .05). Using contingency tables and chi2 testing for statistical evaluation, we found that diabetics have a significantly higher failure rate (chi2, p = .0002). Further, we identified a group of patients who in addition to the airway stenosis also had comorbid medical conditions that frequently necessitate a tracheostomy. These patients have a significantly higher failure rate (chi2, p = .009). Using this information and applying the staging system prior to reconstruction, we can identify patients likely to fail.
To report the incidence of pharyngeal acid reflux events in patients with laryngotracheal stenosis (LTS), we studied 12 patients with LTS and 34 healthy volunteers. All patients and controls underwent ambulatory 24-hour 3-site pH monitoring. In ambulatory pH monitoring, pH was recorded at manometrically determined sites of the pharynx, proximal esophagus, and distal esophagus. For all 3 sites, a pH value below 4 that was not related to the time of oral intake or belching was considered an acid reflux event. Eight of the 12 LTS patients exhibited pharyngeal acid reflux events. In the control group, pharyngeal acid reflux events were documented in 7 subjects. In between-group comparison, the number of reflux episodes and the percent acid exposure time in the pharynx were greater in LTS patients than in controls. Reflux parameters of the proximal and distal esophagus in LTS patients were similar to those of controls. The incidence of pharyngeal acid reflux events in LTS patients was higher than that in controls. It is suggested that identification and treatment of gastroesophageal reflux in patients will significantly simplify and improve the results of treatment for LTS.
The optimal management of postintubation tracheal stenosis is not well defined. A therapeutic algorithm was designed by thoracic surgeons, ear, nose and throat (ENT) surgeons, anaesthetists and pulmonologists. Rigid bronchoscopy with neodymium-yttrium aluminium garnet (Nd-YAG) laser resection or stent implantation (removable stent) was proposed as first-line treatment, depending on the type of stenosis (web-like versus complex stenosis). In patients with web-like stenoses, sleeve resection was proposed when laser treatment (up to three sessions) failed. In patients with complex stenoses, operability was assessed 6 months after stent implantation. If the patient was judged operable, the stent was removed and the patient underwent surgery if the stenosis recurred. This algorithm was validated prospectively in a series of 32 consecutive patients. Three patients died from severe coexistent illness shortly after the first bronchoscopy. Of the 15 patients with web-like stenosis, laser resection was curative in 10 (66%). Among the 17 patients with complex stenoses, three remained symptom-free after stent removal. Bronchoscopy alone was thus curative in more than one-third of the patients. Six patients underwent surgery, two after failure of laser resection and four after failure of temporary stenting. Surgery was always performed with the patient in good operative condition. Palliative stenting was the definitive treatment in nine cases. Tracheostomy was the definitive solution in two cases. This approach, including an initial conservative treatment, depending on the type of the stenosis, appears to be applicable to almost all patients and allows secondary surgery to be performed with the patient in good condition.