Metallic (nitinol) stents epithialize 4-6 weeks following insertion or placement, hence almost impossible to remove after that
Adult laryngotracheal stenosis
7 th January 2011
Discuss management of a 19 year old patient with history of emergency intubation following acute organophosphate poisoning 2 months ago presenting with recurrent noisy breathing, dyspnoea and reduced effort tolerance.
Establishing diagnosis Laryngotracheal stenosis Noisy breathing Stridor Phases: inspiratory, expiratory, biphasic Wheezing Recurrent : precepitating factors and aggravating factors Infection, exercise History of emergency intubation Suggest higher possibility of intubation trauma due to repetition, stylet use and higher friction Duration of mechanical ventilation (2-5/7: 0-2%, 5-10/7: 5-10%, >10/7: 12- 14%)2,3, cuff pressure (laryngeal microcirculation critical P 30mmHg) 1 Tracheostomy (site, type of incision, tube biomechanics)4 Acute organophosphate poisoning: primary reason of intubation contributes to laryngotracheal stenosis Dysphagia, change in quality of voice 1. Nordin U, Lindholm CE. The trachea and cuff induced tracheal injury. Acta Otolaryngol 96 (Suppl345)1-71, 1977 2. Whited RE. A study of endotracheal tube injury to the subglottis. Laryngoscope 95: 1216-9,1985. 3. Bryce DP. The surgical management of laryngotracheal injury. J Laryngol Otol 86:547-87, 1972.4. Lulenski JC,Batsakis JG. Tracheal incision as a contributing factor to tracheal stenosis. An experimental study. Ann Otol 84: 781-6, 1975.
Infective (Tuberculosis of the larynx) Prolonged history of fever, unintentional weight loss, cough, hemoptysis, change in quality of voice, neck swelling. Contact with tuberculosis patients Immune mediated (Sarcoidosis, Rheumatoid arthritis, Pemphigus) Onset and progression is usually gradual Related symptoms: joint pain and deformity, skin lesions, Vocal fold immobility Change in quality of voice Aspiration symptoms
Establishing severity Dyspnoea and reduced effort tolerance At rest? Walking? Climbing stairs? Acute emergency visits to the hospital or clinic Progression Acute deterioration in airway symptoms Gradual worsening
Other related history Patient’s general medical condition Optimization for definitive surgical airway management Oxygen demand Prior surgical intervention to the larynx or trachea Patient dermographics Distance to hospital Education
General examination Concious level Stridor: inspiratory, expiratory, biphasic Cyanosis Tachypnoea Subcostal, intercostal recession Pulse Oxymetry Vital signs Focused examination Quality of voice Single breath counting5 1-10 in a single breath; correlates well with PEFR and FEV1 Neck scar +/- tracheostomy Examination of the larynx5. Joel MB. Bruce SU, Jonathan MR, Dylong K. Single breath counting in the Assessment of Pulmonary function. Annals of Emergency Medicine 24: 256-9, 1994.
Adhesion, granulation tissue Vocal cord Mobility7 Only significant risk factor for failure of decannulation following definitive airway reconstruction Vocal fold immobility: neuromuscular or joint fixation? Laryngeal electromyography Phonatory gap Laryngeal sensation Evidence of reflux6 Prophylactic antireflux medication following laryngeal injury Recalcitrant stenosis6. Gaynor EB. Gastroesophageal reflux as an etiologic factor in laryngeal complication of intubation. Laryngoscope 98: 972-9, 1988 7. White DR, Cotton RT, Bean JA et al. Pediatric cricotracheal resection. Arch Otolaryngol Head Neck Surg 131: 896-9, 2005
Arterial Blood Gases Usually shows Type 1 respiratory failure CO2 retention in decompensated cases hence require immediate establishment of airway
Direct Laryngo bronchoscopy Cotton Myer grading (1994) Grade 1 0-50% Grade 2 51-70% Grade 3 71-99% Grade 4 >99% Distance from vocal cord Measure using endoscope, take average of three readings Length of stenotic segment Consistency of stenosis (granulation tis or fibrous) Shape of stenosis (circumferential or not) Presence of tracheomalacia Mobility of vocal cord
Role of imaging To determine extent of stenosis especially in higher grade stenosis where length of stenosis cannot be ascertained endoscopically For planning of surgery especially when stenosis involve the lower trachea and requires combined approach through a median sternotomy or right thoracotomy or release procedures CT better ascertain the integrity of cartilaginous framework
Oxygen Establish airway Intubation Preoperative intubation in patients with thin segment stenosis amendable to endolaryngeal procedures Or intraoperative mask ventilation followed by quick dilatation to allow safe intubation Tracheostomy Preferably trachea incised at the level of stenosis to spare normal trachea from another injury
Endolaryngeal Dilatation LASER: Shapshay Cold instrumentation Open Laryngotracheal reconstruction Cricotracheal resection and anastomosis Tracheal resection and anastomosis Shian Lee Laryngofissure Slide tracheoplasty Adjunct Stents, Corticosteroids, Mitomycin C, Antibiotics
24/Indian lady Accidental organophosphate poisoning July 10 Presented with dysphagia to JBGH Intubated in the ED and then managed in ICU Tracheostomy D4 Assisted ventilation 11/7 Successful weaning off ventilation and decannulated after 3/52 Discharged home 4/7 later presented with dyspnoea and reduced effort tolerance Emergency intubation and mechanical ventilation Successful weaning off ventilation and discharged home Another similar presentation 1/12 after, managed similarly
In September 2010, acute onset noisy breathing, dyspnoea and reduced effort tolerance Tracheostomy and Dlscopy in KPJ JB Tracheal stenosis Subsequently managed in PPUKM Underwent emergency endolaryngeal dilatation 22nd Sept 2010 and was later decannulated in late November Presented with acute deterioration of symptoms two weeks later ,Cotton grade 3 tracheal stenosis of 2cm length 6cm from the vocal cord, Shapshay, dilatation was performed Just 10/7 after presented similarly , Shapshay, dilatation and application of mitomycin C performed 1/52 later presented again with upper airway obstruction hence tracheostomy was performed as patient opted for long term tracheostomy
No significant medical history No known allergies Completed studies in Diploma in Healthcare Management however is unemployed due to recurrent admissions Single and living with her parents in JB
CT thorax Tracheal stenosis measuring 2.35 cm in length, ends 2 cm above the carina, about 7 cm from the vocal cords
Endolaryngeal Dilatation LASER: Shapshay Open Tracheal resection and anastomosis Slide tracheoplasty Adjunct Stents, Corticosteroids, Mitomycin C, Antibiotics8. Chen Y, Wang WJ, Wang HF. Therapeutic effect of tracheal anastomosis versus interventional bronchoscopy in the treatment of airway stenosis. NaFang Yi Ke Da Xue Xue Bao. 2010 Jun;30(6):1359-62.9. Baugnee PE, Marquette CH, Ramon P, Darras J, Wurtz A. Endoscopic treatment of postintubation tracheal stenosis. Review of 58 cases. Rev Mal Respir. 1995;12 (6): 585-92.
Associated with recurrence rate of almost ¾ if used as a primary therapy10,11 Factors that improve success rate12: Thin segment of stenosis Soft or immature scars Used as adjunct to other endolaryngeal technique (ie. LASER Shapshay) Acquired stenosis resists dilatation due to hyalinization and collagen cross linking, hence incompressible.10. Clement P, Hans S, de Mones E, et al. Dilatation for assisted ventilation induced laryngotracheal stenosis. Laryngoscope 115: 1595-8, 2005 11. Herrington HC, Weber SM, Anderson PE. /modern management of laryngotracheal stenosis. Laryngoscope 116: 1553-7, 200612. Simpson GT, Strong MS, Healy GB, et al. Predictive factors for failure or success in the endoscopic management of laryngeal and tracheal stenosis. Ann Otol Rhinol Laryngol 91: 384-8, 1982
CO2 laser advantages: Precision and visual field not obscured by instruments, hence better preservation of normal tissue Hemostasis Early reepithelization and slow fibroblast proliferation and collagen formation13 Disadvantages Risk of fire or combustion Corneal burns Cost and availability The shapshay (radial incision and dilatation) technique popularized in 198714 13. Toohill RJ, Duncavage JA, Grossman TW: Wound healing in the larynx. Otolaryngol Clin North Am 17: 429-36, 1984.14. Shapshay SM, Hybels RL, Bohigian RK et al. Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation. Ann Otol Rhinol Laryngol 1987: 661-4.
Largest series in Italy; 209 patients with acquired tracheal stenosis over 10 yrs with 2 yrs follow up Endoscopic laser and mechanical dilatation gives success rate of 96% in simple stenosis (mean of 2.3 procedures per patient)15 Other smaller series show promising results with endoscopic treatment for length <3cm (success rate of 60-80%) 16,17 15. Galluccio G, Lucantoni G, Battistoni P et al. Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up. Eur J Cardiothorac Surg. 2009 Mar;35(3):429-3316. Cavaliere S, Bezzi M, Toninelli C, Foccoli P. Management of post-intubation tracheal stenoses using the endoscopic approach. Monaldi archives for chest disease 2007 67 (2) 71-2. 17. Reza SA, Khalid G, Anil P et al. Outcome of Endoscopic Treatment of Adult Postintubation Tracheal Stenosis. Laryngoscope 117 (6): 1073-9
In experienced hands, remains mainstay of treatment in symptomatic lower tracheal stenosis However, instances where it is not advisable Presence of severe inflammation Length of stenosis too long for resection and anastomosis Preceded with rigid bronchoscopy and serial dilatation through the stenosis to alleviate hypercarbia Remeasurement of length and site of stenosis, presence of inflammation
Supine, neck extended with expandable sandbag Collar incision +/- median upper sternotomy or right thoracotomy Subplatysmal flap sup (cricoid) and inf (sternum) Trachea dissected close to its wall to expose area of stenosis and not more than 1 cm normal trachea superiorly and inferiorly Not to injure vascular supply from inferior thyroid,bronchial, subclavian, right internal thoracic, and innominate arteries. Note that vascular supply comes from lateral then transverse intercartilaginous arterioles
Flexible scope thru ETT, tube pulled back till above the stenosis if area of stenosis can’t be ascertained externally Circumferential resection of stenotic airway with preservation of normal trachea as much as possible Use sterile anode tube cannulated to distal end Place traction sutures at lateral aspect 1cm from edge Place posterolateral sutures
Advance the proximal airway and place anterior sutures Oppose anastomosis and tighten traction sutures then anterior followed by posterior sutures with neck flexed Skin closure Chin stay sutures (submental to presternal) to keep neck in flexed position Extubate patient in the OT Bronchoscopy before discharge and 4/52 after
Indicated in tracheal resections of more than 3 cm. Allow resection of up to 6.4 cm without affecting anastomotic tension Involves: right hilar dissection and division of the right pulmonary ligament division of the left main bronchus freeing pulmonary vessels from the pericardium
901 patients over 28 yr period (2004) 165 pts with lower tracheal stenosis req partial median sternotomy , only 15 patients (18%) develop anastomotic complications Anastomotic complications lower in pts requiring release procedure via right thoracotomy (2.5%) Tracheal length resected 1-6.5cm 11 deaths, 6 from anastomotic dehiscence Anastomotic complications are uncommon, and important risk factors are reoperation, diabetes, lengthy resections (>4cm), young age (pediatric patients), and the need for tracheostomy before operation.18. Wright CD, Grillo HC, Wain JC, et al. Anastomotic complication after tracheal resection: prognostic factors and management. Jthorac.Cardiovasc.Surg 2004 128:731
Collar incision Site of stenosis exposed in the same manner Horizontal Slide the edges incision midway Vertical incision of trachea to Anastomosed of stenotic anteriorly and double its side by side segment posteriorly circumference Theoretical value in acquired stenosis, mostly used in congenital stenosis in the pediatric age group 19. Peter BM, Michael JR, Asher L, Resmi G, Bradley SM. One slide fits all: The versatility of slide tracheoplasty withcardiopulmonary bypass support for airway reconstruction in children J. Thorac. Cardiovasc. Surg., January 2011; 141: 155 - 161.
20. Braidy J, Breton G, Clement L. Effects of corticosteroids on post intubation tracheal stenosis. Thorax. 1989 44 (9) 753-55.21. Shapshay SM, Reza R, Healy GB. Mitomycin: Effects on Laryngeal and Tracheal Stenosis, benefits and complications. Ann Otol Rhinol Laryngol 2001
Evolved since Gianturco Ultraflex covered 1965 stainless steel expandable Montgomery: stent metallic stent Dumon silicone tracheal stent 22. Brendan P.M, Steven AS,Piers Mitchell M. Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation.Ann Thorac Surg 2000;70:1191-1193323. Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma coagulation and stents.ERJ 2006 6 1258-1271