Successful Treatment of Tracheal Stenosis with Slide Tracheoplasty after the Failure of Resection with End-to-End Anastomosis

The combined effects of inhaled irritant gases and heat in burn patients can result in the development of laryngotracheal strictures. Several factors could adversely affect the development of tracheal stenosis and cause the growth of granulation tissue. Yet the current treatment options for this condition are limited because of the paucity of case reports. We report here on a case of a patient who experienced recurrent upper tracheal stenosis after an inhalation injury. She displayed repetitive symptoms of stenosis even after several laryngomicrosurgeries and resection with end-to-end anastomosis. Finally, 5 yr after the burn injury, slide tracheoplasty was successfully performed and the postoperative check-up findings and the increased airway volume seen on imaging were all satisfactory.     

Endoscopic Treatment of Tracheal Stenosis Using the Carbon Dioxide Laser and the Gianturco Stent: Indications and Results

The self-expandable Gianturco stent was used in 11 patients with tracheal stenosis who were treated from September 1992 through July 1994. Under optical control, the stent was placed through a bronchoscope with an outside diameter of 9 mm after cross-section and dilation of the stenosis were performed with the carbon dioxide laser according to the Shapshay technique. The follow-up period varied from 3 to 22 months, with a mean of 12±6 months. Pulmonary function tests showed a mean improvement of the peak expiratory flow (50%), from 0.95±0.45 L/sec before the operation to 2.13±0.86 L/sec after the procedure. Radiologic and fibroscopic controls showed prosthesis stability. Three patients needed a second endoscopic procedure because of malposition of the stent, the formation of granuloma at the superior end of the prosthesis, and the development of a mucous membrane webbing between the two loops of a stent. Due to the lack of long-term follow-up, this technique is reserved for the treatment of severe tracheal stenosis with cartilage impairment in patients who have contraindications for external reconstructive surgery.     

镍钛记忆合金支架治疗兔外耳道狭窄的实验研究

目的比较镍钛记忆合金支架与硅胶管治疗兔外耳道瘢痕狭窄的疗效。方法将16只外耳道瘢痕狭窄的新西兰大白兔,随机分为植皮组和不植皮组各8只,各组在兔的双侧外耳道分别植人镍钛记忆合金支架和硅胶管,在植入后5、15、30、60天时,植皮组测量两侧的外耳道直径变化;不植皮组分别取双侧外耳道瘢痕组织HE染色观察瘢痕中成纤维细胞变化、RT—PCR检测转化生长因子β1mRNA（TGFβ1）表达,比较两种材料抑制瘢痕增生的效果。结果植皮组使用镍钛记忆合金支架侧各时间点兔外耳道直径明显大于硅胶管侧;不植皮组植人镍钛记忆合金支架侧外耳道瘢痕组织中成纤维细胞数明显少于植入硅胶管侧（P〈0．05）,TGFβ1mRNA表达亦明显较硅胶管侧降低（P〈0．05）。结论镍钛记忆合金支架在治疗兔外耳道狭窄方面疗效显著优于传统的硅胶管。     

Long-Term Results of Endoscopic Dilatation for Tracheal and Subglottic Stenosis

Objectives

The purpose of this study was to assess the long-term results of endoscopic dilatation of airway stenosis and to evaluate predictive factors for favorable results.

Methods

Fifty-four patients with tracheal and subglottic stenosis who underwent endoscopic dilatation with at least 12 months follow-up were enrolled in this study. We evaluated predictive factors for final treatment outcome such as stenosis length, location, characteristics, procedure type, and the severity of stenosis.

Results

The final outcome of endoscopic dilatation showed a cure rate of 40.7%, improvement rate of 46.3%, and failure rate of 13.0%. Patients with mild stenosis or a shorter stenotic segment and those who underwent a touch-up procedure following tracheal resection with end-to-end anastomosis showed better outcomes. The cure rate of endoscopic dilatation for patients with shorter mild stenosis was 72.2%.

Conclusion

Endoscopic dilatation may be a primary treatment modality for patients with airway stenosis characterized by mild severity and a short stenotic segment.     

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.     

不同术式治疗喉气管狭窄的疗效观察

目的：总结不同手术方法治疗喉气管狭窄的临床疗效。方法回顾性分析2006年7月～2014年7月手术治疗的56例喉气管狭窄患者（儿童7例,成人49例）的临床资料,其中9例行支撑喉镜下CO2激光瘢痕切除术,5例行支撑喉镜下低温等离子射频瘢痕组织消融术,5例行支撑喉镜下硅胶片或导尿管喉模置入术,6例行喉裂开聚丙烯支架置入术,23例行喉气管成型加T管植入术,8例行气管环形切除端端吻合术,术后随访6个月～2年,观察不同手术方式患者的治疗效果。结果单次手术治愈39例,多次手术治愈10例,复查无再次气道狭窄;无效5例,长期带管生存;失访2例,无死亡及并发症发生的病例。其中,5例喉模置入患者和8例气管端端吻合患者均一次手术治愈;9例行CO2激光瘢痕切除术的患者中1次手术治愈5例,2次手术治愈3例,1例喉癌复发;5例低温等离子射频消融术治疗患者中3例一次手术治愈,1例2次手术治愈,1例无效;6例聚丙烯支架置入的患者中1次手术治愈4例,2次手术治愈1例,1例无效;23例T管置入术的患者中1次手术治愈14例,2次及2次以上手术治愈5例,2例无效,2例失访。结论治疗喉气管狭窄需要依据狭窄程度、狭窄部位及喉气管支架缺损情况等采取个体化治疗方法,才能取得满意效果。     

镍钛合金在豚鼠听泡的生物相容性观察

目的 探讨镍钛形状记忆合金(nitinol,NiTi)植人体在豚鼠听泡的生物相容性.方法 健康、听觉灵敏的纯白红目豚鼠50只,一耳为实验组(NiTi植入组,50耳),其中25只对侧耳为对照组I[纯钛(Ti)植入组],另25只对侧耳为对照组II(空白组).分别于术后7、14、28、56、112 d随机处死含对照组I和对照组II的豚鼠各5只,观察听泡内有无肉芽生长等炎性反应、材料外观有无蚀斑和颜色改变,以Sirion 200场发射扫描电镜(FEI公司,美国)观察材料表面新生组织,GENESIS 60S EDAX能谱仪(EDAX 公司,美国)能谱分析新生组织的元素构成.结果NiTi及Ti植入体表面均有新生骨骼样组织生长,有纤维状物与听泡壁及听小骨相连,周围无明显肉芽组织,植入材料表面无蚀斑和颜色改变,有新生骨骼样组织形成,从术后7 d的零星点状或条索状逐渐增多交织成网状到112天时形成板状,能谱分析证实为骨组织,但NiTi植入组新生组织中含有极微量的镍(Ni).结论 NiTi在豚鼠听泡有很好的生物相容性,但有微量的Ni释放,其生物毒性需进一步观察.     

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.     

Insulin-like growth factor 1 promotes the extension of Tracheal Epithelium in an in Vitro Tracheal organ culture model

ObjectiveRapid epithelialization is crucial to maintain tracheal patency and prevent potential graft failure in tracheal reconstruction after tracheal resection for cancer with tracheal infiltration or tracheal stenosis. Insulin-like growth factor 1 is a liver-secreted endocrine molecule that controls cell proliferation, differentiation, and apoptosis and has been reported to promote epithelialization in several organs. Here, we utilized mouse tracheal organ cultures to examine the effect of insulin-like growth factor 1 on tracheal epithelialization.MethodsThe trachea was resected from thirteen-week-old female ICR mice, and cut into small plate-shaped tracheal sections. First, the expression of insulin-like growth factor 1 receptor was assessed by immunohistochemistry. Secondly, the tracheal sections were cultured for seven days in the culture medium, and the morphological change during the seven-day culture was assessed by immunohistochemistry, hematoxylin and eosin staining, and scanning electron microscopy. Moreover, the tracheal sections were cultured for 48 h with different concentration of insulin-like growth factor 1 (0, 0.1, 1 and 10 µg/mL) in the culture medium, and the extension length of the tracheal epithelium during culture was measured in order to assess the effect of topical IGF1 on tracheal epithelialization.ResultsImmunohistochemistry showed that insulin-like growth factor 1 receptor was expressed in tracheal epithelium. Immunohistochemistry, hematoxylin and eosin staining, and scanning electron microscopy showed that the tracheal organ cultures were stable for at least seven days without apparent morphological damage. The effect of insulin-like growth factor 1 on tracheal epithelialization was examined in plate-shaped tracheal sections cultured in medium supplemented with or without insulin-like growth factor 1 for 48 h. We also found that the epithelial edge of plate-shaped tracheal sections extended further along the surface of the tracheal section in culture medium containing insulin-like growth factor 1 compared with that in culture medium without insulin-like growth factor 1.ConclusionThe current study using an in vitro mouse tracheal organ culture model demonstrated that topical insulin-like growth factor 1 treatment promoted the extension of tracheal epithelium, suggesting the potential utility of insulin-like growth factor 1 in aiding rapid tracheal epithelialization in patients requiring tracheal reconstruction using tissue-engineered tracheas.     

Endoscopically Applied Biodegradable Stent in a Rabbit Model of Pediatric Tracheomalacia

ObjectivesA polydioxanone (PDO) stent was developed to treat tracheomalacia in pediatric patients. However, its safety and efficacy need to be verified in animal studies before clinical trials in patients can be conducted. This study evaluated the safety and efficacy of a PDO stent in normal and tracheomalacia-model rabbits.MethodsIn total, 29 New Zealand white rabbits were used: 13 for evaluating the biocompatibility of the PDO stent in normal rabbits and 16 for the creation of a tracheomalacia model. The tracheomalacia model was successfully established in 12 rabbits, and PDO stents were placed in eight of those rabbits.ResultsThe PDO stent was successfully positioned in the trachea of the normal rabbits using an endoscopic approach, and its degradation was observed 10 weeks later. The stent fragments did not induce distal airway obstruction or damage, and the mucosal changes that occurred after stent placement were reversed after degradation. The same procedure was performed on the tracheomalacia-model rabbits. The survival duration of the tracheomalacia rabbits with and without stents was 49.0±6.8 and 1.0±0.8 days, respectively. Thus, the PDO stent yielded a significant survival gain (P=0.001). In the tracheomalacia rabbits, stent degradation and granulation tissue were observed 7 weeks after placement, leading to airway collapse and death.ConclusionWe successfully developed a PDO stent and an endoscopic guide placement system. The degradation time of the stent was around 10 weeks in normal rabbits, and its degradation was accelerated in the tracheomalacia model. The mucosal changes associated with PDO stent placement were reversible. Placement of the PDO stent prolonged survival in tracheomalacia-model rabbits.     

镍钛合金支架在预防喉全切除术后气管造口狭窄的应用

目的探讨镍钛形状记忆合金(NT-smA)支架在喉全切除术后预防气管造口狭窄的作用。方法对15例喉癌患者行喉全切除术后I期安装NT-smA支架,其中5例同期安装Blom-Singer发音管,观察其气管造口情况及术后发声功能情况。结果除1例因术后5天时造口感染引起支架暴露而取出外,余14例术后14天拆线时气管造口平均直径约16.1±1.4mm,横截面积约200.5±9.2mm2,能满足呼吸需要,免戴气管套管;随访1~3年,造口形状和大小稳定,气管造口平均直径为15.6±1.1mm,横载面积约为198±8.4mm2。经统计学检验,拆线时气管造口大小与末次随访时气管造口大小差异无统计学意义。5例I期安装Blom-Singer发音管的患者,发声效果良好,发声时音质较好,平均声强达58.8dB,平均最长声时为7.52s。结论镍钛形状记忆合金支架是一种理想的喉全切除术后预防气管造口狭窄的材料,值得临床推广应用。     

Changes in the Flow-Volume Curve According to the Degree of Stenosis in Patients With Unilateral Main Bronchial Stenosis

Objectives

The shape of the flow-volume (F-V) curve is known to change to showing a prominent plateau as stenosis progresses in patients with tracheal stenosis. However, no study has evaluated changes in the F-V curve according to the degree of bronchial stenosis in patients with unilateral main bronchial stenosis.

Methods

We performed an analysis of F-V curves in 29 patients with unilateral bronchial stenosis with the aid of a graphic digitizer between January 2005 and December 2011.

Results

The primary diseases causing unilateral main bronchial stenosis were endobronchial tuberculosis (86%), followed by benign bronchial tumor (10%), and carcinoid (3%). All unilateral main bronchial stenoses were classified into one of five grades (I, ≤25%; II, 26%-50%; III, 51%-75%; IV, 76%-90%; V, >90% to near-complete obstruction without ipsilateral lung collapse). A monophasic F-V curve was observed in patients with grade I stenosis and biphasic curves were observed for grade II-IV stenosis. Both monophasic (81%) and biphasic shapes (18%) were observed in grade V stenosis. After standardization of the biphasic shape of the F-V curve, the breakpoints of the biphasic curve moved in the direction of high volume (x-axis) and low flow (y-axis) according to the progression of stenosis.

Conclusion

In unilateral bronchial stenosis, a biphasic F-V curve appeared when bronchial stenosis was >25% and disappeared when obstruction was near complete. In addition, the breakpoint moved in the direction of high volume and low flow with the progression of stenosis.     

Use of the Round Window Microcatheter in the Treatment of Meniere's Disease

Objectives/Hypothesis Transtympanic gentamicin is an increasingly popular treatment for Meniere's disease. The present report examines the 2‐year follow‐up of our first 27 patients with Meniere's disease treated with the use of microdose gentamicin through the Round Window Microcatheter. We applied the 1995 American Academy of Otolaryngology—Head and Neck Surgery criteria to this patient group to analyze the results of treatment. Study Design This study is an evaluation of consecutive patients with predetermined data collection on each patient. Methods Patients with confirmed Meniere's disease underwent placement of the Round Window Microcatheter, which was filled with 10 mg/mL gentamicin, after placement into the round window niche was confirmed. Ten milligrams per milliliter of gentamicin was injected into the catheter by hand on two occasions after device placement in the first several patients. The remaining patients had continuous infusion of 10 mg/mL gentamicin at 1μL/h for the next 10 days. The catheter was removed 10 days after placement. All patients underwent an extensive set of hearing and vestibular tests on several occasions before, during, and after treatment. Results In the patients in the study, vertigo was eliminated in 92.6%, with 3.7% of patients (1/27) demonstrating a mild permanent threshold shift in hearing. Tinnitus and pressure were significantly reduced in more than 65% of patients. Only one patient demonstrated a reduction of vestibular function after treatment. Conclusions Results of this study on this group of patients indicate that vertigo can be controlled in the long term using microdose gentamicin without a significant reduction in cochlear or vestibular function in most of the patients in our series. Our results are compared with the published literature examining transtympanic injection. In addition, the underlying science supporting this type of treatment is examined.     

Endoscopically placed expandable metal tracheal stents for the management of complicated tracheal stenosis

BACKGROUND: Metal stents have been advocated to manage complicated tracheal stenosis. OBJECTIVE: The purpose of this investigation is to review the effectiveness of endoscopic placement of tracheal expandable metal stents for complicated tracheal stenosis. METHODS: The charts of 6 patients who have undergone placement of metal expandable stents between 1998 and 2000 were reviewed. RESULTS: Initially, all patients enjoyed immediate palliation of symptomatic tracheal stenosis. Eventually, 4 patients developed significant granulation tissue and/or recurrent stenosis, requiring intervention within 6 months after placement of the stent. One patient required the removal of the stent and placement of a T-tube silicone stent. CONCLUSIONS: Metal stents provide temporary palliation for tracheal stenosis. Metal stents, however, are associated with a high incidence of obstruction with granulation tissue. Their use should be limited to a select group of patients with a short life expectancy (because of other comorbidities) or patients who are not good candidates for reconstructive surgery and/or who refuse or cannot tolerate a tracheotomy.