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One case of isolated type IV posterior glottic stenosis successfully treated with CO2 laser posterior transverse cordotomy is presented. This report emphasized the value of the CO2 laser posterior transverse cordotomy in this situation. A review of the various therapeutic options advocated in the medical literature to treat isolated posterior glottic stenosis is also presented.
A patient with Wegener's granulomatosis is reported. The diagnosis was confirmed by parotid gland biopsy. The patient responded to treatment with cyclophosphamide and prednisone. After many years, urethral stricture and subglottic stenosis developed and responded satisfactorily to surgery.
Cricothyrostomy is the procedure of choice for emergency airway control when nasotracheal and endotracheal intubation are not possible or contraindicated. A vertical skin incision followed by a horizontal incision in the cricothyroid membrane are used. A number 6 tracheostomy tube should be used due to the anatomic size of the cricothyroid space. Using this technique, complications are rare.
Cicatricial pemphigoid can no longer be considered a "benign" bullous disorder. The most critical lesions are those involving the larynx and esophagus. Endoscopy, biopsy, and culture are essential as early in the patient's course as possible. Surgical intervention might include tracheostomy or gastrostomy and possibly surgical rehabilitation of the airway.
The CT findings of a patient with relapsing polychondritis involving the larynx, tracheobronchial tree, and nasal cartilage are described. In the proper clinical setting, a characteristic constellation of findings when noted on CT can aid in differentiating this rare inflammatory disease from other causes of airway compromise. CT is the most useful imaging modality, because cartilage and soft tissue components are well visualized. If diagnosed early, appropriate treatment may prevent life-threatening airway obstruction.
Seventy-two patients with laryngeal or laryngo-tracheal stenotic lesions resulting from tracheal intubation or laryngo-tracheal injuries are reported. Prior to 1978, the method of surgical treatment consisted mainly of laryngoplasty supported by laryngeal stenting. Twenty-six patients were treated by this method with 2 mortalities. Twenty-one long term results were good and 3 were fair. After 1978, laryngo-tracheal resection was performed in 46 patients. Twenty-seven had a Pearson-type operation, 13 underwent total or subtotal cricoid plate resection and modelling, and the remaining 6 had modelling alone. Perfect results after resection depend on the treatment of infection and inflammation of the airway before surgery. Our preferred method is resection and end-to-end anastomosis whenever possible. In addition to the anatomical site of the lesion, the glottic opening has to be considered in planning the surgical operation since impairment necessitates enlargement of the glottis as part of the procedure.
Of 43 tracheo-bronchial ruptures, 19 patients presented with disruption of the laryngo-tracheal junction which would appear to be a very specific anatomical lesion. The disruptions were secondary to blunt cervical trauma in 11 cases and strangulation in 8 cases. The disruption was complete in 14 cases and incomplete in 5. The lesion is very complex and involved the retraction of the lower part of the trachea into the mediastinum (14 cases), fracture of the cricoid ring (9 cases), bilateral recurrent nerve tears (14 cases), unilateral (4 cases) and retraction of the laryngeal mucosa with exposure of the cricoid cartilage in all cases. According to the complexity of the lesion, the treatment was: laryngo-tracheal resection and end-to-end anastomosis with treatment of the vocal cord palsy in 13 patients; simple end-to-end anastomosis in 4 patients who had an unilateral vocal cord palsy; 2 patients with a partial disruption were treated medically with endoscopic stenting and laser photocoagulation. All had restoration of airway patency and recovery of voice. The results contrast with the failures and reoperations reported in the literature and underline the necessity of complete evaluation and treatment of these complex lesions.
The factors affecting the development and prognosis of scarred airways in children are presented from a long-term follow-up study of 14 cases of tracheobronchial lesions following either injury or operation. Four children managed by endoluminal treatment developed severe stenosis and required treatment, later as adults, by laser resection in 2 cases and by laryngotracheal plastic enlargement and resection with anastomosis in 1 case each. The follow-up of 7 children managed by plastic procedures showed inconsistent results: they were good or excellent in 3 cases but with a decrease in the laryngotracheal diameter of 36%, 28% and 7% respectively. The laryngotracheal calibre decreased in 2 patients to 45% due to partial fibrous stenosis. Resection and anastomosis was required in the remaining 2 patients after 11 and 12 years for severe re-stenosis. The 3 patients who underwent immediate surgical resection all had an excellent clinical and morphological result, with a decrease in the laryngotracheal diameter of only 7%, 13% and 19% after a follow-up of 18, 20 and 15 years, respectively. These results show that the growth capacity of scars in children's airways is closely related to residual sclerosis following the initial treatment. It is thus suggested that primary resection and anastomosis should be performed in as many cases as possible. In the performance of plastic procedures, special attention should be paid to complete resection of the fibrotic tissues. Finally, a very long postoperative follow-up is always required in children in order to assess the development of the airway.
Between 1981 and June 1992, 26 consecutive patients with a postintubation subglottic stenosis (21 circumferential, 2 anterolateral) underwent the Pearson operation. Subglottic stenosis resulted from a complication of mechanical ventilation with endotracheal intubation with (n = 14) or without (n = 12) tracheostomy (median placement: 25 days). One patient had an associated laryngopharyngeal and tracheoesophageal fistula. Overall, the upper limit of the stenoses lay 1.8 +/- 0.3 cm below the vocal cords, falling in the range of 1 to 2 cm in 88% of patients; they measured 2.9 +/- 0.8 cm in length and the diameter at the level of the maximum stenotic process was 0.5 +/- 0.1 cm. Operations were performed without dissection of the recurrent nerves and plicature of the membranous trachea. Because of scarred mucosa at a higher level, one vertical section of the posterior cricoid plate with interposition of autogenous costal cartilage and 2 subtotal cricoid plate resections with stenting were necessary. The mean length of resection was 3.6 +/- 0.8 cm (range: 2-5 cm) and 88% of them ranged within 2.8 and 5 cm. Twelve thyrohyoid and 3 supralaryngeal releases were performed. Six patients required postoperative tracheostomy, but all were extubated within 24 h. Good results were obtained in 24 (96%) surviving patients; 1 failure and 1 postoperative death (sudden myocardial infarction) occurred. The results confirm that the Pearson operation is an adequate treatment for subglottic stenosis extending up to 1 cm below the vocal cords and measuring up to 6 cm in length. Dissection of both the recurrent nerves, plicature of the membranous trachea, postoperative decompressive tracheostomy and stenting are not necessary.
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PURPOSE: The aim of the study was to compare the effects of mitomycin-C (MMC) and 5-fluorouracil/triamcinolone acetonide (5-FU/TA) on the development of fibrosis/scar tissue formation of rabbit subglottic area, which is injured acutely. MATERIALS AND METHODS: After standardized trauma to subglottic area the rabbits were divided into those that received treatment and those that did not (controls). The subjects were treated with either topical 0.4 mg/mL MMC or 5 mg 5-FU/TA injection. Those groups were further divided into subgroups depending on the time of examination: at 2 or 6 weeks. Each subgroup had 4 rabbits. The specimens were examined histopathologically and the measurements were performed using a software. RESULTS: The fibrosis indices (FIs) of the treated subgroups were significantly less than the FIs of their corresponding control subgroups (P<.05). The difference in FIs of the MMC-treated and 5-FU/TA-treated groups was not statistically significant (P>.05). MMC and 5-FU/TA did not interfere with regeneration of the epithelium although in 2 cases treated with 5-FU/TA the regenerated epithelium showed squamous metaplasia. CONCLUSIONS: Both MMC and 5-FU/TA decrease fibrosis/scar tissue formation secondary to experimentally induced acute subglottic trauma. There is no significant difference between the effects of the 2 drugs.
Isolated supraglottic stenosis in adults without a history of laryngeal injury is a rare and poorly described clinical entity. We report a case of a 61-year-old woman who presented with near total airway obstruction and a diagnosis of an epiglottic mass. She required a tracheotomy for definitive airway control. Initial diagnostic laryngoscopy and biopsies revealed isolated supraglottic stenosis due to fibrosis with acute and chronic inflammation. The patient had a medical history of gastroesophageal reflux disease and hiatal hernia and no history of laryngeal trauma. Transoral supraglottic laryngectomy was required for definitive treatment. Isolated supraglottic stenosis may be seen in children with congenital laryngotracheal anomalies, as a sequelae of prolonged orotracheal intubation or after laryngeal trauma or tumor surgery. Other causes may include autoimmune and inflammatory disorders. Gastroesophageal reflux disease may also contribute to the disease process of isolated supraglottic stenosis. Supraglottic laryngectomy is a feasible treatment option for isolated supraglottic stenosis and may allow for tracheostomy decannulation.
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The aim of this study is to determine, from the data available in the literature, the indications of tracheostomy in brain injured patients, the incidence and risk factors for complications and the follow-up required until decannulation. The incidence of tracheostomy is 10% in TBI and 50 to 70% in subpopulations with a Glasgow Coma Scale (GCS) below 9. Early complications are not specific. The most frequent late complication is laryngotracheal stenosis, which occurs in 15% and is more frequently observed in the most severe patients with major hypertonia. It is likely that tracheostomy, if needed, should be performed early and the prognosis as to whether it will be required, can be made at the end of the first week. The follow-up of these patients includes surveillance of multiresistant colonisations and systematic performance of fibroscopy before decannulation. Cuffless, small diameters, soft tracheostomy tubes, are preferred on the long-term unless the risk of aspiration remains high.
The ex utero intrapartum treatment (EXIT) procedure is a surgical procedure maintaining utero-placental circulation during caesarean section. Anaesthetic implications are described: foetal transplacental anaesthesia to avoid first breathing and to permit surgical procedure on obstructed foetal airway, deep maternal haemodynamically stable anaesthesia to relax uterine smooth muscle during a long caesarean procedure but avoiding post-partum haemorrhage. Volatile anaesthesia with sevoflurane seems to be adequate for these aims. Two cases are described.
OBJECTIVE: Surgery is the first line of treatment for laryngotracheal stenosis; Montgomery tube or permanent tracheostomy have been so far the only alternatives. Nd-YAG laser resection and indwelling endotracheal stents have rarely been used in subglottic stenosis for anatomic and technical reasons. We have used the latter approach to optimize the timing of surgery or to achieve palliation without tracheostomy. METHODS: Between 1991 and 2001 we have treated 18 patients with subglottic stenosis (10 males, 8 females; age range 14-78, mean 34). The upper margin of the stricture was 2mm to 1cm below the vocal cords; the stenotic segment extended from 1.5 to 5 cm. Three patients had tracheostomy done elsewhere. Four patients (Group I) had laser and stenting by a Dumon prosthesis as the only treatment; six had laser and stenting (#4) followed after 1-6 months by laryngotracheal resection (Group II); eight had surgery alone (Group III). RESULTS: In Group I, one patient required repositioning of the stent and in two the stent was removed; two patients died of their underlying disease; at a follow-up of 2-9 years all living patients did well but required permanent aerosolized therapy and periodical bronchoscopy. In Group II, we had two wound infections due to airway colonization by staphylococcus aureus. In Group III, two patients developed anastomotic postoperative stenosis, treated by laser (#2) and stenting (#1), and one patient with previous tracheostomy had a wound infection. Overall, in the 14 surgical patients (Groups II and III) stenosis occurred in 14.2% and infection in 21.3%. After a follow up of 15 months to 12 years, all surgical patients breathe and speak well. CONCLUSIONS: Laser resection and endoluminal stenting can be a viable alternative to surgery or optimize the timing of operation in patients with subglottic stenosis.
OBJECTIVE: Partial tracheal resection (Küster operation (KO)) and cricotracheal resection (Pearson operation (PO)) are currently the standard operative techniques in the curative treatment of tracheal and cricotracheal stenosis, respectively. This study aims to analyze the outcomes of tracheal and cricotracheal resection when a specific protocol is applied. METHODS: Between 1990 and 2004 we treated 54 patients with laryngotracheal stenosis. The mean age was 44.9 years with a sex ratio of 1:1. All patients were treated according to the random protocol "Lesions of the main airway (MA) protocol," which considers the following stenosis variables: stage of development (S), caliber (C), and length (L). We performed 38 Küster operations, 14 Pearson operations, and 2 combined Pearson-Küster-Rethi operations (ROs). RESULTS: Overall mortality of the series was 1.85%, with a specific morbidity of 27.7%. A total of 96.2% of patients were cured (85.6% of Pearson operation and 100% of Küster operation). We performed 3.7% re-interventions (14.2% of Pearson operation and 0% of Küster operation), and the failure rate was 3.7% (14.4% of Pearson operation and 0% of Küster operation). We had 27.5% who had postoperative complications (28.5% of Pearson operation and 26.3% of Küster operation). The most frequent complications were restenosis (14.2%), granulation tissue (13.1%), edema (10.5%), anastomotic dehiscence (7.1%), and tracheoesophageal fistula (7.1%). In terms of the SCL variables, significant differences were only observed with respect to morbidity between the S4 group and the other cases without tracheoesophageal fistula in the Küster operation group; we found no differences in Pearson operation. CONCLUSIONS: Application of the Main Airway protocol allowed development of a strategy for the surgical treatment of main airway stenosis. This, in turn, enabled a strict selection of cases and meticulous preoperative preparation that, coupled with a highly effective surgical technique, led to excellent outcomes with minimal sequel. The presence of tracheoesophageal fistula could increase the complications.
Stent placement may induce granulation tissue, occlude the stent lumen, and exacerbate respiratory symptoms. Microdebrider was designed to treat laryngeal papillomas and airway stenosis. However, little research exists on the management of airway stenosis following airway stenting with microdebrider. This study describes two cases of glottic stenosis caused by airway stenting successfully treated with mibrodebrider.