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PubMed1990

The role of infection in the pathogenesis of acquired tracheal stenosis.

A rabbit model was developed to study the role of infection in the development of postintubation acquired subglottic and tracheal stenosis. Following a surgically induced tracheal mucosal injury, rabbits were divided into three groups. Five animals underwent intratracheal bacterial inoculation using Staphylococcus aureus, six rabbits were given prophylactic antibiotics, and five control animals received neither bacteria nor antibiotics. After 10 days the rabbits were assessed for both tracheal stenosis and bacterial infection within the respiratory tree. Animals receiving antibiotic prophylaxis had a mean stenosis of 50.8%, similar to the 63.4% observed in controls. Rabbits inoculated with SA had a mean stenosis of 85.0%, greater than both the other groups (P = .001:ANOVA). Considering all animals, those with respiratory infection (including two control rabbits) had narrower stenoses than those that remained noninfected (82.1% versus 52.5%; P = .001). These data suggest that bacterial infection in the upper respiratory tract might increase the severity of airway stenosis following prolonged endotracheal intubation.

Animals↗

PubMed2000

[Anesthetic management of patients with tracheal stenosis for endoscopic treatment: usefulness of laryngeal mask airway].

We report two cases of tracheal stenosis for endoscopic treatment under general anesthesia with laryngeal mask airway. The tracheal stenosis of the two patients was so close to the glottis that endotracheal tube could not be inserted, and laryngeal mask airway was beneficial for maintaining airway and obtaining operating field. During the procedure, patients breathed spontaneously and we could support their ventilation easily and sufficiently. Endoscopic treatment of the airway obstruction by Nd-YAG laser associated with balloon dilatation and stent is an effective method of relieving the distressing symptom of asphylaxia, and laryngeal mask airway is considered to be useful for performing successful endoscopic procedure.

Aged↗

PubMed2002

Repair of congenital tracheal stenosis.

We have used six different techniques in 61 operations performed at Children's Memorial Hospital (Chicago, IL) between 1982 and 2001 on 54 infants with complete tracheal rings and primary or recurrent tracheal stenosis. Short-term and long-term outcomes are reviewed for all techniques including pericardial tracheoplasty, tracheal autograft, tracheal resection, cartilage tracheoplasty, slide tracheoplasty, and aortic homograft patch tracheoplasty. Patients' ages ranged from 7 days to 72 months; mean age at operation was 6 months. There were 33 boys and 21 girls. Associated pulmonary artery sling was present in 19 of 54 patients (35%). Significant associated intracardiac anomaly was present in 13 of 54 patients (24%). The number of complete tracheal rings involved ranged from two to 18 rings (mean, 14+/-5). All procedures were performed with the use of cardiopulmonary bypass. Simultaneous repair of pulmonary artery sling and cardiac abnormalities was undertaken. There were three early deaths, two after pericardial tracheoplasty and one after tracheal autograft. There were eight late deaths, five after pericardial tracheoplasty, one after tracheal autograft, one after slide tracheoplasty, and one after tracheal resection. Median length of hospital stay was 60 days for pericardial tracheoplasty, 28 days for tracheal autograft, 14 days for tracheal resection, and 18 days for the slide tracheoplasty. Follow-up is complete in all patients. Tracheal autograft is currently our procedure of choice for patients with long-segment tracheal stenosis because of its use of all-autologous material, technical ease of performance, already-present epithelial lining of the autograft, intrinsic maintenance of the cartilage contour, potential for growth, and ready availability. We limit the use of tracheal resections to patients with eight or less rings of tracheal stenosis.

Cardiopulmonary Bypass↗

PubMed1991

Pericardial patch tracheoplasty for severe tracheal stenosis in children: intermediate results.

Between 1982 and 1990, 15 children have undergone pericardial patch tracheoplasty, 13 for complete tracheal rings and 2 for acquired tracheal stenosis. Eleven had complete tracheal rings from the thoracic inlet or the cricoid to the carina. Diagnosis was by bronchoscopy (15), computed tomography (10), and magnetic resonance imaging (3). As first described by Idriss in 1984, the surgical technique uses a median sternotomy approach, extracorporeal circulation, bronchoscopic guidance, and the use of pericardium as a tracheal patch. There was one perioperative death of mediastinitis (operative survival, 93%). There were two late deaths caused by complications of tracheostomy (1) and direct laryngoscopy and bronchoscopy (DLB) (1). Follow-up is complete in 12 intermediate-term survivors and ranges from 0.4 to 8.2 years (mean, 4.2 +/- 2.9 years). Five children required multiple DLBs with dilation and excision of granulation tissue; one of these patients underwent tracheoplasty revision 5 months after the initial procedure for residual tracheal rings, and four of these children have had tracheostomies, two temporary and two currently (4 months, 7 years). Seven children had widely patent tracheas observed at follow-up DLB with little or no residual stenosis after tracheoplasty. All survivors are currently asymptomatic, except for the two children with tracheostomies. Pericardial patch tracheoplasty offers effective therapy with relatively low operative mortality for infants and children with severe long segment tracheal stenosis. On intermediate-term follow-up, nearly all survivors are essentially free of symptoms of residual tracheal stenosis.

Child, Preschool↗

PubMed2000

Endoluminal laser application under percutaneous cardiopulmonary support in severe tracheal stenosis.

Laser ablation under bronchoscopic guidance was conducted on 2 patients with severe tracheal stenosis. Case 1 was a 57-year-old man admitted to our emergency unit because asphyxia. Bronchoscopy showed the lumen occluded at the bifurcation by tracheal cancer. Case 2 was a 62-year-old woman who underwent tracheostomy elsewhere for respiratory failure caused by a brain contusion and was treated for 3 months. After transfer to our emergency unit, bronchoscopy showed severe tracheal stenosis. Tracheoplasty conducted under bronchoscopy used a noncontact Nd:YAG laser at an output of 10-40 W and irradiation time of 1 second per shot. Total irradiation energy was 1700-1900 J. Percutaneous cardiopulmonary support was used during the laser procedure due to asphyxia. All procedures were completed satisfactorily and clinical symptoms improved dramatically in both cases. Laser tracheoplasty under bronchoscopic guidance treated severe stenosis safely and completely. Percutaneous cardiopulmonary support was very useful in preventing severe respiratory failure or asphyxia during this procedure.

Asphyxia↗

PubMed2006

Development of acquired tracheal stenosis in premature infants due to prolonged endotracheal ventilation: etiological considerations and surgical management.

The aim of this study was to determine the etiology and appropriate surgical treatment for acquired tracheal stenosis that developed in patients who had undergone prolonged endotracheal mechanical ventilation as premature neonates. During the period 2000-2004, four patients aged 1-16 years were referred for tracheal stenosis characterized by stridor, choking, and recurrent pulmonary infection. All patients had undergone endotracheal mechanical ventilation for 2-5 months for respiratory distress related to prematurity (gestational age 25-29 weeks, birth weight 648-1,222 g). During this period, methicillin-resistant Staphylococcus aureus was predominantly cultured from the trachea. All patients exhibited a stenotic lesion encompassing 30-37% of the entire tracheal length on spiral CT. On palpation and inspection of the trachea during surgery, however, the stenotic segment appeared to encompass over 50% of the entire trachea. The carina was intact. Three patients underwent slide tracheoplasty with a tracheal resection and the other underwent resection and end-to-end anastomosis. Of the three patients treated by slide tracheoplasty, two are currently free of respiratory symptoms. However, one patient in this group required secondary resection of the remaining stenotic lesion with end-to-end anastomosis. This patient is currently asymptomatic. The remaining patient who underwent a resection and end-to-end anastomosis is doing well. The resected specimen showed fibrosis and degeneration of tracheal cartilage. A combination of prematurity, prolonged endotracheal mechanical ventilation and tracheal infection seem to be responsible for tracheal inflammation and stenosis. When considering surgical procedures for acquired tracheal stenosis, resection and end-to-end anastomosis are desirable. However, slide tracheoplasty with a partial tracheal resection is indicated for the treatment of stenosis involving a long tracheal segment.

Adolescent↗

PubMed1993

Congenital tracheal stenosis: a report of two cases.

Congenital tracheal stenosis (CTS) is a rare, potentially lethal condition. Two cases were diagnosed in this hospital between 1986 and 1992. Diagnosis was confirmed by endoscopy and radiography. These two cases were noted to have symptoms of airway obstruction after an infectious process. Their outcomes were quite different. The first patient, a victim of CTS diagnosed at two years old, still lives well and has been asymptomatic for subsequent six years, though he has received no surgical intervention. The second patient, a three-month-old female, exhibited an exacerbation after bronchoscopy and died in spite of intensive care. Prompt recognition of symptoms and a thorough evaluation of airway, as well as other anomalies, is essential for proper management of children with CTS. The diagnostic modalities, management and risk factors are discussed.

Child, Preschool↗

PubMed1991

Surgical management of tracheal stenosis in an infant with multiple congenital anomalies: when is baby inoperable?

Congenital tracheal stenosis is a rare disorder that carries a significant morbidity and mortality. It is an even greater challenge when present in combination with other life-threatening congenital anomalies. We present an infant with multiple congenital anomalies, including trisomy 21, who was diagnosed with congenital tracheal stenosis at 3 months of age. At age 5 months, the infant underwent tracheoplasty with costal cartilage graft and pulmonary artery banding. Bronchoscopy 3 weeks later revealed a patent airway. However, the patient died 2 months postoperatively of cardiac complications. At autopsy, whole organ and histologic specimens revealed excellent incorporation of the graft with no evidence of re-stenosis. Our documentation of graft incorporation in this patient is evidence that long segments of stenotic trachea can be successfully treated by tracheoplasty utilizing rib cartilage grafts.

Abnormalities, Multiple↗

PubMed2002

[Airway management in tracheal stenosis caused by malignant goiter].

We report a case of malignant goiter with severe tracheal stenosis. The patient was a 61-year-old female, who had orthopnea on admission. Radiological examinations revealed a tracheal stenosis extending from 4.5 cm to 8 cm below the glottis; the smallest caliber being 5 mm. On the seventh day after admission, the patient complained of dyspnea even while sitting. An emergency tracheotomy was scheduled. While the patient was awake in a sitting position, a fiberscope was inserted endotracheally to confirm the intact inner surface of the trachea, and then an armored endotracheal tube (outer diameter 9.2 mm, inner diameter 6.5 mm) was inserted. Unexpectedly, the tube could be advanced through the stenosis without resistance. After induction of general anesthesia, the patient was placed in a supine position, and a tracheotomy was performed. This case demonstrates that, while intubation of the trachea through a stenosis is sometimes dangerous, it may be indicated when the inner surface of the trachea is intact and a tube with an inner diameter greater than 5 mm can then be placed.

Anesthesia, General↗

PubMed2005

[The use of tracheostomy T-tube in the treatment of tracheal stenosis].

The aim of the study was evaluation of the use of tracheostomy T-tube in patients with tracheal stenosis. The advantages of closed T-tube over open tracheotomy are: 1/ normal breathing through the nose, 2/ normal speech without necessity to close the tube with a finger, 3/ no spitting during cough. Silicone tracheostomy T-tube was used in 12 patients with tracheal stenosis. The stenosis resulted in 7 patients from prolonged intubation, in 4 patients from defective tracheostomy and in one patient from failure of tracheal resection. In all the patients rigid tracheoscopy and/or flexible bronchoscopy revealed the length of the stenosis and the distance from vocal cords. T-tube was placed under local anesthesia. The patients used to wear closed T-tube from 1-12 years. The tube was exchanged every 2-4 years. The only adverse effect was recurrent granulation around tracheostomy in two patients. 7 of 12 patients were decannulated with good result in 3 months - 5 years follow up. In two decannulated patients stenosis recurred. One patient was retracheostomized and in another patient stenosis was resected with end to end anastomosis. Three patients were not decannulated. Tracheostomy T-tube can be used temporary in patients with tracheal stenosis before planned stenosis resection or as a sole treatment with good chances for successful decannulation. When stenosis resection is not possible, T-tube can be placed for long time.

Adult↗

PubMed2000

Efficacy of transoral intraluminal Wallstents for tracheal stenosis or tracheomalacia.

OBJECTIVES: The efficacy and safety of intraluminal Wallstent Endoprosthesis (Boston Scientific/ Medi-Tech, Quincy, MA) placement to restore airway patency in patients with tracheal stenosis or tracheomalacia are unknown. STUDY DESIGN: Retrospective review in setting of tertiary, referral, and academic center. METHODS: A retrospective review of 13 consecutive patients over a 2-year period who underwent transoral resection of tracheal stenosis and immediate transoral Wallstent placement. One patient had tracheomalacia. All of the patients were considered at high risk for transcervical surgery or had failed prior traditional open procedures. RESULTS: The average patient age was 54.2 years, with nine male and four female patients. All had Cotton/Myer stenoses (grades II to IV) with moderate to severe degrees of inspiratory stridor. Four patients were tracheotomy dependent. The length of stenosis varied from 1 to 4 cm. One patient had a 10-cm segment of tracheomalacia. At the time of writing, none of the patients has had a problem with significant migration or extrusion and most of the patients have incorporated the stent well without any short-term obstructive granulation tissue. After a mean follow-up of 15 months (range, 4-24 mo). 10 of the 12 patients with stenosis (83%) have remained free of any inspiratory noise during breathing. The one patient with tracheomalacia also has remained free of symptoms. CONCLUSIONS: Transoral Wallstents appear to be safe and may be a reasonable alternative in the restoration of airway patency in select patients with tracheal stenosis or tracheomalacia.

Adolescent↗

PubMed1984

Tracheal stenosis measured by the acoustic reflection technique.

We examined the usefulness of the acoustic reflection technique for measurement of airway area in 6 patients with tracheal stenosis. In each patient, we obtained airway area by acoustic reflections in the upright position, maximal expiratory and inspiratory flow-volume curve, and radiographs of the trachea. We identified acoustic and radiographic stenotic segments and compared their length, their distances from the glottis, and their cross-sectional areas. We found that (1) in all subjects except one, flow-volume curves did not suggest upper airway obstruction, (2) tracheal stenosis was confirmed by acoustic and radiographic measurements in all subjects, and (3) area of the stenotic segment showed less variation with lung volume than that of the nonstenotic segment. Length of the stenotic segment (mean +/- SE) was found to be 4.9 +/- 0.2 cm (acoustic versus 4.8 +/- 0.3 cm (radiographic); distance between the midglottis and maximal stenosis was 5.7 +/- 0.4 cm (acoustic) and 5.6 +/- 0.6 cm (radiographic); minimal acoustic cross-sectional area was 1.7 +/- 0.1 cm2 versus a radiographic circular cross-sectional area of 1.2 +/- 0.1 cm2. During slow expiration from total lung capacity to residual volume, average cross-sectional area of the stenotic segment decreased by 19.5 +/- 3.0% (mean +/- SE), whereas that of the distal nonstenotic segment decreased by 48.5 +/- 2.2% and that of the proximal nonstenotic segment by 43.6 +/- 5%. We conclude that the acoustic technique, which is rapid and noninvasive, is useful in confirming tracheal stenosis in patients with normal flow-volume curves, and in assessing elastic properties of the trachea.

Acoustics↗

PubMed1995

CO2 laser and Gianturco stent for endoscopic treatment of tracheal stenosis.

The self-expandable Gianturco stent was used in eleven cases of tracheal stenosis treated from September 92 to July 94. The stent is placed through a 9 mm outside diameter bronchoscope under optical control after cross-section and dilation of the stenosis with the CO2 laser according to the Shapshay technique. The follow-up varies from 3 to 22 months with a mean of 12 +/- 6 months. Pulmonary function tests (PFTs) show a mean improvement of the PEF (peak expiratory flow). Complications have been corrected in three patients with a second endoscopic procedure: the first case for malposition, the second for granuloma at the superior end of the prosthesis, and the third for the development of a mucous membrane webbing between the two loops of the stent. Owing to the lack of long-term follow-up, we reserve this technique for the treatment of severe tracheal stenosis with cartilage impairment in patients contraindicated when external reconstructive surgery is contraindicated.

Aged↗

PubMed1994

Self-expandable stents for tracheal stenosis: experience in two patients.

Two patients with cervical tracheal stenosis, following prolonged ventilatory support, underwent balloon dilatation and expandable stainless steel stent placement across the stenoses. Following the successful release of the stent, there was gradual widening of the stenosed trachea in one patient, while in the other re-stenosis occurred due to columns of tracheal tissue projecting between the limbs of the stent. In the chronically ill and debilitated, use of expandable stents provides a good alternative to complex reconstructive surgery.

Adult↗

PubMed2003

[Respiratory management in a patient with severe tracheal stenosis caused by compression from the ascending aortic arch aneurysm].

In cases of tracheal compression by a mediastinal mass or aortic aneurysm, muscle relaxant might induce fetal ventilatory failure. It is known to be valuable to keep spontaneous breathing in these cases. A 42-years-old woman complicated with Marfan syndrome had acute respiratory failure due to acute progression of tracheal stenosis caused by compression from the ascending and aortic pseudoaneurysm. After the induction of general anesthesia for video-assisted thoracic surgery (VATS) for high-pneumothorax, she was placed in lateral position. Suddenly it became difficult to ventilate her and her oxygenation saturation declined with bradycardia. We returned her to supine position and then could manage to ventilate her easier. But we could not maintain stable ventilation until her spontaneous breathing appeared. VATS was cancelled and she was brought in to the ICU after extubation. In the ICU she developed respiratory distress again soon and was reintubated under consciousness guided by bronchofiber scope. We managed successfully to keep spontaneous breathing intact under proper sedation by three sedative drugs; propofol, midazolam and morphine for 5 days until the next operation. We realized the importance of maintaining spontaneous breathing under proper sedation in a case of severe tracheal stenosis.

Acute Disease↗

PubMed2005

Nitinol stents in the treatment of benign proximal tracheal stenosis or tracheomalacia.

Nitinol stents have been used in the treatment of benign tracheal stenosis. A retrospective review of five patients treated at Stobhill Hospital over the last six and a half years is presented. Age at presentation ranged from 17 to 76 years. The minimum follow-up period was 23 months and the maximum was 78 months. All our patients were successfully decannulated, with none requiring recannulation. Four patients developed granulation tissue related to the stent at intervals ranging from three weeks to 41 months post stenting. Topical mitomycin C application has been useful after resection of granulations using the carbon dioxide (CO2) laser. Stent migration occurred in one patient three weeks after insertion. Nitinol stents are easy to insert and effective in the treatment of tracheal stenosis, but can have associated morbidity. Their use should be considered carefully, as insertion should be regarded as permanent. Publications reporting experience and outcome with the use of Nitinol stents in the trachea are reviewed.

Administration, Topical↗

PubMed2000

Perioperative extracorporeal membrane oxygenation for tracheal reconstruction in congenital tracheal stenosis.

The management of a critical airway in infants and toddlers with congenital tracheal stenosis (CTS) continues to be an enormous challenge to the surgeon. Until recently, this condition often proved fatal. Improvements in surgical techniques, anesthetic management, and postoperative critical care have resulted in successful outcomes in children not long ago considered untreatable. However, issues such as the best operative approach and the optimal perioperative management are still unresolved. The diagnosis of CTS, often delayed, must be considered in any infant with stridor, wheezing, cyanosis, or recurrent episodes of pneumonia. Associated anomalies are the rule, including frequently vascular rings and rarely pulmonary agenesis. These defects can be repaired with conventional ventilatory support under cardiopulmonary bypass, or using extracorporeal membrane oxygenation (ECMO). We report our experience in which ECMO was used to support two patients with CTS during the perioperative period. ECMO proved to be both safe and practical, allowing unrushed, precise repair of the tracheal stenosis and providing brief postoperative support. Perioperative outcomes were excellent, although one of our patients died months after the repair. A review of the literature and our experience in which ECMO was used to provide cardiopulmonary support during repair of CTS showed uniformly successful perioperative outcomes.

Extracorporeal Membrane Oxygenation↗

PubMed2000

Slide tracheoplasty for congenital tracheal stenosis: a case report.

BACKGROUND/PURPOSE: A variety of techniques have been used to manage pediatric congenital tracheal stenosis. The authors report the technique of slide tracheoplasty for a child with long congenital tracheal stenosis. METHODS: A 2-year-old male presented with a history of stridor with feeding. Bronchoscopy findings showed 50% stenosis from complete cartilaginous rings, extending from 2.5 cm below the vocal cords to 2 cm above the carina. Through a neck incision, the trachea was exposed from the cricoid to both bronchi and transected at the midpoint of the stenosis. The upper trachea was split anteriorly to the area of stenosis just below the cricoid. The lower trachea was split posteriorly in the midline. Posterior dissection allowed sliding and anastomosis of both tracheal segments while the lateral vascular supply was left intact. A brace was placed to maintain cervical flexion, and the patient underwent extubation in the operating room. RESULTS: He recovered without complication and was dis charged on postoperative day 4. CONCLUSION: Slide tracheoplasty offers several advantages for tracheal reconstruction because it is performed with the native tracheal tissues, can be accomplished through a transverse collar incision, and can repair long stenoses without significant tracheal shortening.

Child, Preschool↗