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Laryngeal and tracheal stenosis: an adapted speaking aid tracheostomy tube.

A 41-year-old male patient with post-diphtheritic laryngeal deformity and an extensive upper tracheal stenosis is presented. Previous surgical attempts at repair of the tracheal stenosis had been unsuccessful and further surgery is not contemplated at the present time. A permanent speaking-aid tracheostomy tube must therefore be worn at all times and an adaptation to this tube to allow some expiratory escape past the valve is described.

Adolescent↗

Tracheal stenosis and congenital heart disease in patients with Down syndrome: diagnostic approach and surgical options.

Upper airway obstruction is a prevalent feature in patients with Down syndrome. However, these patients may be completely asymptomatic in the early months of life. The recognition of a problem within the airway quite often occurs when these children present for cardiac surgery, diagnostic radiography with sedation, or during the induction and intubation for anesthesia. Tracheal stenosis is rare in the general population, but is seen somewhat more frequently in patients with Down syndrome. The incidence of tracheal stenosis in children with congenital heart disease, which is seen in 40% of patients with Down syndrome, has been reported to be 1.2%. Patients with Down syndrome also tend to have other upper airway obstructive pathology such as nasopharyngeal, oropharyngeal, and subglottic compromise. These entities, combined with the high incidence of cardiac disease, put these children at risk for acute and chronic cardiopulmonary compromise. We present two patients with Down syndrome and congenital heart disease who were found to have significant tracheal stenosis at the time of their cardiac surgery. The perioperative management of their airway defects including diagnostic evaluation and treatment modalities are discussed.

Cardiac Surgical Procedures↗

Preoperative assessment in patients with postintubation tracheal stenosis : Rigid and flexible bronchoscopy versus spiral CT scan with multiplanar reconstructions.

BACKGROUND: Postintubation stenosis remains the most frequent indication for tracheal surgery. Rigid bronchoscopy 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 videobronchoscopy 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 intraoperative 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 stenosis was correct in 83%, 92%, and 25% of the patients, respectively, with rigid bronchoscopy, flexible bronchoscopy, 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 tracheoesophageal 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.

Adult↗

Tracheal stenosis or agenesis in association with tracheo-oesophageal fistula and oesophageal atresia.

Two babies are described with oesophageal atresia, a tracheo-oesophageal fistula and severe subglottic tracheal stenosis. A third baby, who did not survive, had a tracheal agenesis associated with bronchi arising from the oesophagus. A review of the types of tracheal stenosis and agenesis associated with various forms of tracheo-oesophageal fistula is included.

Abnormalities, Multiple↗

[Functional diagnosis of tracheal stenosis and tracheoplasty in non-neoplastic disease].

Over the past ten years we have performed 47 tracheoplasty for non-neoplastic disease. Of the 47 patients, 17 had post-tracheostomy stenosis and 17 tracheobronchial tuberculosis. Non-neoplastic disease causes stenosis in the trachea to various degrees. Provided the lung function of these patients is not reduced, tracheoplasty may not be necessary. Functional diagnosis of the tracheal stenosis is therefore important in determining the indications for tracheoplasty in this condition. Clinically, evaluation of the flow plateau of the flow-volume curve has been utilized as a method for detection of fixed upper airway obstruction and the ratio of FEV1.0 to PEFR is helpful for an assessment of the degree of stenosis. But it has not been explained why the ratio correlates with the degree of stenosis. In this study, fixed-type tracheal stenosis was simulated in seven normal subjects by the use of a mouthpiece with an orifice of variable diameter. We derived the experimental formulae of FEV1.0/PEFR as follows. FEV1.0/Qp = FVC/Qp-e2(FVC/Qp-1.5)/2 Qp = 48.7 alpha 1.12 (1-1.1 alpha) (Qp; the plateau flow of the flow-volume curve) (alpha; the ratio of the cross-sectional area of the stenotic portion to that of normal trachea) The values of FEV1.0/Qp calculated from FVC and alpha using these formulae were equal to or in the neighborhood of the experimental values. On the basis of these calculations we concluded that the ratio FEV1.0/PEFR is helpful in the assessment of the degree of stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗

Tracheoplasty with pericardial patch for extensive tracheal stenosis in infants and children.

Five infants with long tracheal stenosis were operated upon by means of a pericardial patch tracheoplasty. The approach was through a median sternotomy with extracorporeal circulation for respiratory support. In four, the obstruction was due to complete rings; in the other, there was an associated tracheal trauma which had occurred during resuscitation. This patient requires prolonged stenting with a tracheostomy tube. All others are asymptomatic postoperatively, with the longest follow-up being 22 months. There were no deaths or infections. We conclude from this experience that median sternotomy provides an excellent approach to the trachea, that autogenous pericardium is advantageous, and that there is no need for prolonged tracheal stenting in most patients.

Child, Preschool↗

[Contact allergy-induced tracheal stenosis caused by vulcanization accelerators in the endotracheal tube?].

Tracheal stenoses occur mainly under iatrogenic conditions: they develop specially after long-term intubation, but also after tracheotomy. Etiological-pathogenic relevant factors include the mechanical irritation of mucosa, perichondrium and cartilage in addition to infected tracheal secretions. An allergic cell-mediated reaction in the respiratory tract has been already described. It is seldom recognized. The possibility of such a hyperergic, allergic, delayed reaction (Type IV Coombs-Gell response) with subsequent tracheal stenosis caused by rubber chemicals (accelerators) found in endotracheal tubes is presented in the following case report.

Dermatitis, Allergic Contact↗

[Therapeutic approach and results in the treatment of subglottic tracheal stenosis].

INTRODUCTION: We had the opportunity to treat upper respiratory tract stenosis, so the aim of this paper was to present results of treatment of subglottic and upper tracheal stenosis in our clinical material. MATERIAL AND METHODS: Retrospective study included a period of 5 years (1990-1995), and evaluated results of treating 11 patients with subglottic laryngeal stenosis--with stenosis of proximal tracheal part. There were 6 females and 5 males ranging from 2-65 years of age. Nine patients had postintubational stenosis, one patient had corrosive injury, and one had congenital stenosis which occurred in older age. Apart from two patients, the rest were already treated in other institutions in our country (1-6 times) where they underwent laser (6 patients) or open surgical resection (3 patients). Diagnosis of stenosis was based on laryngotracheoscopy, laryngotracheal tomography, and CT. RESULTS: The patient with congenital subglottic stenosis underwent resection with laryngomicroscopy. Two weeks later, she was decannulated, having good breathing and voice. Two youngest patients, aged 2 and 10 years, underwent dilatation of upper tracheal part and subglottic stenosis, followed by Montgomery T tube placement. The two-years-old boy had the tube for 26 months. During that period, his tube was once replaced with wider one, and after that, he was decannulated. He has a good voice with preserved mobility of vocal cords, but he still has stenosed subglottic level, which partly narrows the lumen, so his tracheotomy is still present. We successfully decannulated a 10-year-old boy, who had the tube for 18 months after stenosis dilatation. In eight patients stenosis of proximal tracheal part and subglottic part of larynx was diagnosed. It was 2.5 to 4 cm long. In three patients we diagnosed tracheal malacia, and in one of them also cricoid malacia with luxation of one arytenoid and ankylosis of the other. In all patients we performed resection of proximal tracheal part with excision of half of cricoid ring. What was left of laryngeal stenosis was cut out and covered with distal tracheal mucosa or Thiersch grafting. In two patients after resection of proximal part of the trachea and part of cricoid ring, end-to-end anastomosis was performed without tube placing, with excellent results. In six patients Montgomery T tube was placed, and in four of them it stayed for 6 to 12 months. These four patients were later decannulated with good functional results. In the rest of two patients, we did not resolve the stenosis of proximal part of trachea and subglottic space of the larynx. DISCUSSION: In etiology of chronic subglottic stenosis postintubational stenoses are dominate. Methods we used were successful in solving high tracheal and subglottic stenosis if the stenotic part was at cricoid level. In higher subglottic stenosis, other techniques are to be used. CONCLUSION: We presented cases of 11 patients with high tracheal and/or subglottic laryngeal stenosis. In one patient stenosis was solved by laryngomicroscopy, in two with subglottic stenosis dilatation. Eight patients were operated using segmental resection of proximal tracheal part and part of cricoid ring, using end-to-end method. In our opinion this method gives good results in stenosis which does not spread higher than upper cricoid cartilage. Some patients can be operated without tracheotomy. For higher stenoses, this method is not recommended.

Adolescent↗

Tracheal stenosis treated with self-expanding nitinol stent.

A self-expanding nitinol stent was used in 2 patients with inoperable tracheal stenosis due to invasive malignant tumor of the trachea. One was a 70-year-old man with recurrent tumor from adenocarcinoma of the left lung, and the other was a 63-year-old man with recurrent tumor in mediastinal lymph nodes from esophageal cancer. The self-expanding nitinol stent is very useful and effective in inoperable tracheal stenosis due to intraluminal tumor invasion.

Adenocarcinoma↗

Microtrapdoor flap repair of laryngeal and tracheal stenosis.

Twenty patients have undergone repair of laryngeal and tracheal stenosis by microtrapdoor accessing of scar or soft tissue and removal with the carbon dioxide laser. A total of 34 flap procedures were performed in the 20 patients. Follow-up ranged from 8 months to 4 years, and 30 of these flaps were considered successful on the basis of improvement of the airway. The only complications were postoperative granulation tissue in 2 patients that responded to endoscopic removal.

Adult↗

Tracheal stenosis complicated with tracheoesophageal fistula.

OBJECTIVE: The aim of the present study was to evaluate the results of surgical treatment in patients with simultaneous occurrence of postintubation tracheal stenosis (TS) and tracheoesophageal fistula (TEF). METHODS: In the group of 51 patients with postcannulation tracheal stenosis who underwent segmental resection, TEF was identified simultaneously in five (10%) of them. The mean age of the TS-TEF patients was 43 years (range 35-60 years). The patients underwent a single-stage operation during which TEF was sealed and resection of the stenotic tracheal segment was performed. RESULTS: The cause of TEF and of TS was artificial pulmonary ventilation by tracheostomy tube (n=4) or by endotracheal tube (n=1) with a simultaneous insertion of nasogastric tube. In one of the patients with tracheostomy the fistula resulted from an injury to the pars membranacea tracheae and the esophageal wall during tracheostomy. All the patients were respiring spontaneously before the surgical treatment. The mean length of the fistula was 24.0 mm (range 15-30 mm), the fistulae were located at the junction of the upper and middle third of the trachea. The mean length of the resected tracheal segment was 29.6 mm (range 26-32 mm). Postoperative complications were not observed in the group of the TS-TEF patients, none of them died. CONCLUSIONS: The method of choice of the surgical treatment of TEF associated with TS is a single-stage procedure in the patient who respires spontaneously.

Adult↗

[Surgical management of congenital tracheal stenosis].

A six month old infant with dextrocardia, butterfly vertebrae and oesophageal atresia type I is reported. After surgical repair, she developed respiratory distress, needing ventilatory support. The bronchoscopy and bronchography demonstrated segmental tracheal stenosis. A resection of the stenotic segment was performed, and tracheal reconstruction with terminoterminal anastomosis. After a period of clinical improvement, respiratory distress came back and reestenosis was ascertained locating its level on the anastomosis. Three sessions of balloon dilation were ineffective and because that it's decided the introduction of a metallic self-expandable stent. After a transient relief, the patient had a bilateral pneumonia ending with the dead of the patient. In spite of the treatment used, it was not possible to accomplish solution in a middle or a large place. This constitutes a clear exponent of the complexity in the management of the congenital tracheal stenosis.

Anastomosis, Surgical↗

Functional evaluation of tracheal stenosis before and after surgical management.

14 patients affected by tracheal stenosis resulting from assisted ventilation underwent a tracheal resection (n = 12) or dilatation (n = 2). Lung function tests were performed before and after surgical treatment. Prior to surgery, we observed a significant increase in airway resistance (Raw) in all subjects and a negative exponential relationship between Raw and FEV1/VC. Expiratory flows were also reduced with an increase in FEV1/PEFR ratios. After surgical correction of the stenosis, Raw normalized in 10 out of 14 subjects. The observed changes were more significant than for the other functional tests. After surgery, the patient's follow-up with Raw allowed the diagnosis of recurrent stenosis in 4 subjects lacking significant clinical symptoms. We conclude that measurement of Raw helps the clinical diagnosis and the appreciation of the possible changes in airway permeability after the surgical procedure.

Forced Expiratory Volume↗

An experimental model for the prevention of postanastomotic tracheal stenosis.

OBJECTIVE: The aim of the current study is to determine the efficiency of an external prosthesis made of expanded polytetrafluoroethylene reinforced with a continuous silicone spiral to prevent postanastomotic stenosis after surgical correction of extensive tracheal defects in rabbits. METHODS: Forty-five rabbits were used, divided into three groups of 15 animals each. Group A was the control group. Group B animals underwent resection of six-ring segments of the cervical trachea and primary anastomosis. The procedure used in group C was similar to that used in group B, but the tracheal anastomosis was supported by an external expanded polytetrafluoroethylene prosthesis. RESULTS: Direct anastomosis after resection of six tracheal rings caused anastomotic stenosis in 100% of the animals. We did not observe tracheal stenosis in any rabbit when we applied an expanded polytetrafluoroethylene tube as an external stent for the tracheotracheal suture. CONCLUSION: We conclude that an external stent can be used to prevent tracheal stenosis resulting from the resection of six cervical tracheal rings in rabbits.

Anastomosis, Surgical↗

[A case report of relapsed esophageal cancer with tracheal stenosis treated with expandable metallic stent placement].

A 63-year-old male who suffered from relapsed esophageal cancer in the thoracic lymphonode causing severe tracheal stenosis, was treated by expandable metallic stent (EMS) placement. Dyspnea has disappeared immediately after EMS placement and the patient has been free from dyspnea until his death. EMS has been very effective for the therapy of tracheal stenosis by esophageal cancer.

Combined Modality Therapy↗

The treatment of low retrosternal tracheal stenosis in the neonate and small children.

In the years 1979 to 1983, 8 infants or small children under 2 years of age were treated for severe low retrosternal (carinal) tracheal stenosis. The etiology was iatrogenic (postintubation) in 7 cases and congenital in one. Low tracheal stenosis was seen in 0.4% of all intubated (1607 patients) neonates during the same time period. In 6 cases of acute obstruction, diagnostic bronchoscopy was used to relieve the stenosis by forcefully dilating the trachea. One patient died and all had severe complications, but 3 children are living and doing well without further treatment. Only short granular retrosternal stenoses appeared to be suitable for violent dilatation, which is indicated if the patient is otherwise facing death due to suffocation. All other operative facilities must be at hand. Resection of low retrosternal trachea under cardiopulmonary bypass was performed in 4 patients - 2 of them had had earlier unsuccessful dilatations. One patient, aged 1.5 months, died. In this case the obstruction extended into both bronchi. Another patient was re-resected with success. The follow-up time of the 3 living patients with resection is already 2.4, 4.5 and 4.7 years respectively. The patients are living a normal life and the anastomoses are growing normally.

Bronchoscopy↗

Beclomethasone diproprionate inhalation as a treatment for post-intubation tracheal stenosis.

A 67-year-old man was intubated for one week and suffered from wheeze and dyspnoea three months after the extubation. Bronchoscopy revealed tracheal stenosis by a web, which subsequent biopsy showed to be granulation tissue. The stenosis was removed by laser therapy but the stenosis soon returned. As cardiac function was poor, beclomethasone diproprionate (BDP) inhalation therapy (1200 micrograms daily) was started and proved successful. Discontinuation of inhalation therapy resulted in restenosis. Steroid inhalation therapy may be able to control post-intubation tracheal stenosis caused by granulation tissue.

Administration, Inhalation↗