This document discusses the management of a 19-year-old patient with recurrent laryngotracheal stenosis following emergency intubation for acute organophosphate poisoning 2 months prior. It establishes the diagnosis of laryngotracheal stenosis through history and examination. It then discusses evaluating the severity and progression, as well as investigations including direct laryngoscopy. Finally, it outlines management approaches such as endolaryngeal procedures like dilation and LASER, open procedures like tracheal resection and anastomosis, as well as adjunct treatments and follow up.

1. 7 th January 2011

2. 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.

3.  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.

4.  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

5.  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

6.  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

7.  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 larynx
5. 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.

8.  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 stenosis
6. 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

9.  Respiratory system
 Rhonchi
 Exclude secondary lung infection

10.  Arterial Blood Gases
 Usually shows Type 1 respiratory failure
 CO2 retention in decompensated cases hence require
immediate establishment of airway

11.  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

12.  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

13.  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

14.  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

15.  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

16.  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

17.  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

18.  Biphasic stridor
 Saturation 97% under RA
 Tachypnoeic RR=26bpm
 Intercostal and subcostal recession
 Afebrile, hemodynamically stable
 Healed anterior neck scar

19.  Jet ventilation

20.  CT thorax
 Tracheal stenosis measuring 2.35 cm in length, ends 2
cm above the carina, about 7 cm from the vocal cords

21.  Endolaryngeal
 Dilatation
 LASER: Shapshay
 Open
 Tracheal resection and
anastomosis
 Slide tracheoplasty
 Adjunct
 Stents, Corticosteroids,
Mitomycin C, Antibiotics
8. 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.

22.  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, 2006
12. 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

23.  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.

24.  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):429-33
16. 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

25.  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

26.  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

27.  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

28.  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

29.  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

31.  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

32.  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 with
cardiopulmonary bypass support for airway reconstruction in children J. Thorac. Cardiovasc. Surg., January 2011; 141: 155 - 161.

33. 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

34. 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;70:1191-1193
323. Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma coagulation and stents.ERJ 2006 6 1258-1271

35.  Stent complications
 Failure of deployment
 Stent dislodged/ malposition
 Stent fracture
 Sputum retention
 Granulation tissue formation
 Recurrent respiratory infection
 Erosion