Postintubation tracheal stenosis

Postintubation tracheal stenosis is a clinical problem caused by regional ischemic necrosis of the airway. The incidence of postintubation tracheal stenosis has decreased with recognition of its etiology and modifications in the design and management endotracheal and tracheostomy tubes; however, it remains the most common indication for tracheal resection and reconstruction. Single-stage resection and reconstruction by a competent tracheal surgeon results in good or satisfactory results in 93.7% of patients, with a failure rate of 3.9% and a mortality rate of 2.4%. The intellect and skill of Dr. Grillo has made the etiology and management of postintubation stenosis obvious to us all.     

Postintubation tracheal stenosis; problems associated with choice of management

We experienced a case with tracheal stenosis due to postintubation damage, or so-called cuff stenosis. A 50-year-old man who attempted suicide by pounding nails into his head and chest using carpenter's tools was treated by endotracheal intubation and immediately underwent emergency surgery in July 2000. The patient was placed on artificial ventilation with oral endotracheal intubation, and a tracheostomy was performed 4 days after the operation. After that, his respiration recovered and he was weaned from the respirator. He was discharged 22 days after surgery with no respiratory symptoms. Two days after discharge, he complained of wheezing and dyspnea. Medical examination revealed that the cervical trachea had a severe circumferential stenosis 2.5 cm from the second tracheal cartilage. On retrospective inspection, the region of stenosis was compatible with the cuff site of the endotracheal tube used for the emergency operation. At first we tried nonoperative treatment, considering his mental state. However, we found that surgical treatment was ultimately necessary. A 2.5 cm sleeve resection of the trachea (5 tracheal cartilage rings) was performed, followed by end-to-end suture using 21 stitches with 4-0 MEDIFIT C thread. Pathologically, the surgical specimen showed degeneration and necrosis of tracheal cartilage with excessive growth of granulation tissue. These findings revealed that the etiologic basis of the tracheal stenosis was attributed to pressure necrosis by the cuff. The postoperative course was uneventful. Sixteen months after the surgery, the granulation tissue had not recurred, and problematic stenosis was not visible in the trachea. In this report, we discussed a reasonable management of postintubation tracheal stenosis. Tracheoplasty has been proposed as the most reliable method for treating tracheal stenosis. However, the best treatment in each case is still somewhat controversial because various nonoperative treatment methods are recently available, including laser phototherapy, argon plasma coagulation, mechanical dilatation, stent replacement, and drug treatment. Therefore, it is very important to judge properly the absolute indication for surgical treatment. If granulations are removed successfully by the above-described nonoperative methods, attempts at repair lead only to regrowth of granulation tissue as long as there is necrotic tracheal cartilage. Thus, the determinant of treatment methods is whether postintubation damage extends to tracheal cartilage or not. For now, there is no accurate diagnostic study for viability of cartilage preoperatively. In the literature, symptoms due to airway stenosis occurred rapidly within one month in the case of patients with necrosis of tracheal cartilage. We concluded that the period between extubation and development of symptoms is very informative in the management of postintubation tracheal stenosis. Surgical approaches should be selected for a patient with a rapid and progressive course after extubation when the patient can tolerate it.     

Total tracheal resection for long-segment benign tracheal stenosis

Tracheal resection for long benign tracheal stenosis is challenging because of the lack of a suitable replacement to facilitate tension-free anastomosis. We describe a patient with a 6-cm post-tuberculous tracheal stricture, severely debilitated post-recurrent bronchoscopic intervention. Staged resection facilitated near-total tracheal resection with primary anastomosis and complete symptom resolution.     

Postintubation tracheal stenosis in an 11-year-old boy: a surgical and anaesthetic challenge

We present a case of postintubation tracheal stenosis in an 11-year-old boy occurring after a relatively short period of intubation. He had been intubated and ventilated in a paediatric intensive care unit after a road traffic accident. Clinical symptoms manifested by oxygen desaturation and wheeziness, finally leading to deterioration of the level of consciousness, occurred a few hours after the first attempt at extubation after 48 h requiring reintubation. Endoscopic examination performed a few weeks later revealed a tracheal stenosis. Consequently, he underwent an initial period of conservative treatment consisting of balloon dilatation and intralesional injection of steroids, followed by a tracheal resection and reconstruction. The anaesthetic management of patients with tracheal stenosis presenting for laryngo-tracheobronchoscopy and balloon dilatation is discussed.     

Benign tracheal and laryngotracheal stenosis: surgical treatment and results.

OBJECTIVES: Benign tracheal stenoses remain the most common indications for tracheal resection. We report lessons learned with surgical management of tracheal stenoses in a consecutive series of 65 patients from the beginning of our experience to date. METHODS: From December 1991 to January 2001 65 patients underwent primary tracheal and laryngotracheal resection and reconstruction for non-neoplastic stenoses. There were 39 males and 26 females with a median age of 33 years (range 14-74 years). There were 58 cases of postintubation and seven of idiopathic stenosis. A cervical approach was used in 60 patients, and a cervical incision with sternal split in four and with sternotomy in one. We performed 45 (69.2%) tracheal resections and 20 (30.8%) laryngotracheal resections. The length of resection ranged between 1.5 and 4 cm (median 2.5 cm). The range of resected rings was two to eight (median five). RESULTS: Fifty-four patients received a preoperative treatment. Preoperative procedures consisted of laser therapy (37), tracheostomy (38) and endotracheal prosthesis (16). We had major complications in eight patients (12.3%) and minor complications in 15 patients (23%). The most frequent complications were: temporary vocal cord dysfunction (eight patients), wound infection (five patients), anastomotic dehiscence (four patients), vocal cord paralysis (two patients), granulation tissue (two patients), deglutition dysfunction (one patient) and restenosis (one patient). Perioperative mortality was 1.5% (one patient). In classifying final results obtained, 54 patients achieved an excellent result, eight a good result and two satisfactory. CONCLUSIONS: The strategy for treatment of airway stenoses is now well established and leads to a high level of success with minimal or no sequelae. Meticulous preoperative assessment and preparation associated with a perfect surgical technique is mandatory to obtain good results. Preoperative treatments (laser and/or endotracheal prosthesis) could increase the extent of injury and the length of stenosis.     

Idiopathic tracheal and bronchial stenosis in two pediatric patients

Idiopathic tracheal stenosis, a rare benign chronic inflammatory and fibrotic entity, has previously been reported in the literature in adults, but never in children. Here we report two pediatric cases, one with the rarer condition of idiopathic bronchial stenosis, and we discuss the management and histopathologic findings.     

Idiopathic tracheal stenosis: successful outcome with antigastroesophageal reflux disease therapy

There is controversial evidence that gastroesophageal reflux disease (GERD) is an etiologic factor for idiopathic laryngotracheal stenosis. We present the case of a 44-year-old woman with symptomatic tracheal stenosis managed as idiopathic stenosis. She underwent six endoscopic dilations during 1 year, and before surgery she underwent 24-hour esophageal pH monitoring that documented GERD. Anti-GERD treatment was started, which was confirmed as effective with 24-hour esophageal pH monitoring 3 months later. At 2-year follow-up the patient remained free of symptoms and no additional airway procedure was necessary. A close relationship between anti-GERD therapy and clinical outcome was noted.     

Long-segment tracheal stenosis treated with vascularized mucosa and short-term stenting

A free, vascularized radial forearm fascia flap lined with two full-thickness buccal mucosa grafts can be used in cases of acquired, long-segment tracheal stenosis. To compensate for the absence of supportive tissue, the reconstructive tissue has to be supported by a stent for a period of 4 weeks. A case with an airway stenosis with a length greater than 5 cm is presented. The vascularized mucosa allowed for primary healing of the augmented airway. The tracheostomy could be closed shortly after stent removal.     

Modified sliding tracheal plasty using the bridging bronchus for repair of long-segment tracheal stenosis

A child with severe respiratory distress, previously operated on at age 4 months for pulmonary sling and atrial septal defect, underwent reoperation at age 4 years because of long-segment congenital tracheal stenosis complicated by an abnormal branching of the trachea-bridging bronchus. We review the anatomy of that rare pathomorphology and describe a slide tracheoplasty that uses the bridging bronchus for treatment of this complex anomaly.     

Primary tracheal tumors: treatment and results

One hundred ninety-eight patients with primary tracheal tumors were evaluated in 26 years. One hundred forty-seven tumors were excised (74%): 132 (66%) by resection and primary reconstruction, seven by laryngotracheal resection or cervicomediastinal exenteration, and eight by staged procedures. Eleven more were explored. Forty-four squamous cell carcinomas were resected, 60 adenoid cystic, and 43 assorted tumors, benign and malignant. Eighty-two patients underwent tracheal resection with primary reconstruction, and 50 had carinal resection and reconstruction. Surgical mortality for resection with primary reconstruction was 5%, with one death after tracheal and six after carinal repair. Six patients had stenosis after tracheal or carinal resection; all underwent reresection successfully. Nearly all patients with squamous or adenoid cystic carcinoma were irradiated postoperatively. Twenty of 41 survivors of resection of squamous cell carcinoma are living free of disease (some for more than 25 years), 39 of 52 with adenoid cystic carcinoma (up to nearly 19 years), and 35 of 42 with other lesions (5 lost to follow-up). Comparison of length of survival of patients with squamous cell carcinoma and adenoid cystic carcinoma who are alive without disease with those who died with carcinoma supports surgical treatment (usually followed by irradiation). Positive lymph nodes or invasive disease at resection margins appear to have an adverse effect on cure of squamous cell carcinoma; such an effect is not demonstrable with adenoid cystic carcinoma.