Adult Laryngotracheal Stenosis

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Adult Laryngotracheal Stenosis

• Ric Leinbach MD

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Adult Laryngotracheal Stenosis

• One of the most difficult problems in the field
  of head and neck surgery
• Larynx is a semirigid tubular structure in which
  concentric scar contraction tends to narrow the
  lumen.

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Introduction

• Evaluation
• Etiology
• Histology
• Treatment Options
• 3 cases reports that illustrate differing natural
  history and treatment options

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Evaluation

• H and P (dyspnea, stridor)
• 1 DOE
• 2 Dyspnea is mild at rest
• 3 Stridor or wheeze
• 4 Severe distress, hypercapnia
• Flexible Laryngoscopy
• DL, Bronch
• CT scan
• Respiratory function tests

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Evaluation

• Flow Volume Loop

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Fixed Obstruction
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90mm2 or lt50 narrowing
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1.Cotton-Myer2.McCaffrey
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Treatment

• Endoscopic
• Dilation
• Laryngeal microsurgery
• Laser-assisted excision
• Endscopic stent placement
• External
• Spliting and stenting
• Resection with primary anastomosis
• Laryngotracheoplasty
• Tracheal transplantaion

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Treatment

• Endoscopic
• Lesion must have external cartilaginous support
• Usually small lesions (lt1cm in vertical length)
• Total cervical or subglottic stenosis does not
  respond well to endoscopic management
• External
• When conservative efforts to establish a
  satisfactory airway have failed or are
  inappropriate

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Treatment- primary anastomosis

• Grillo, Pearson, Laccoureye (1980s and 1990s)-
  97 decanulation rates
• Wolf (2001)- 95.6 decanulation rates
• Analyzed the effect of age and other
  comorbidities on the operative success rate and
  found advanced age was the only parameter
  correlating with surgical failure.

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Diameter of Stenosis
Length of Stenosis
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Case 1

• 60 YO white female initially seen 10/2002 with
  chief complaint I am having trouble breathing
• 4 month history of progressive SOB
• Witnessed apnea at night per husband
• Some dysphagia
• PMH
• Hiatal hernia?, GERD?, HTN
• T and A, cholecystectomy
• Denied tobacco or alcohol use

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Case 1

• PE
• 57, 297 pounds, respirations 16
• hot potato voice
• Large tongue, Friedman class IV palate position
• Neck thick, no adenopathy palpable
• Flexible laryngoscopy
• Omega shaped epiglottis, true cords could not be
  visualized, severe supraglottic inflammation and
  stenosis

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Case 1

• Local standby tracheotomy with DL and biopies
  10/2002
• Treated with Prilosec 40 mg bid
• EGD normal esophagus, normal stomach, normal
  duodenum 11/2002

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Case 1

• 24 hour pH dual probe study- no episodes where pH
  was less than 4, no episodes of reflux reported
  by the patient 6/2003
• Suspension microlaryngoscopy with CO2 laser
  supraglottic laryngectomy 9/2003
• CO2 laser resection supraglottic scar and
  restenosis 1/2004
• She has since been decanulated

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Idiopathic Progressive Subglottic Stenosis

• Series of 52 patients and all but one of the
  patients were female (Dedo, Ann Oto, 2001)
• Suggested a hormonal cause
• Laryngeal biopsy was negative for estrogen
  receptors in the eight patients who were tested
  with immunohistochemical analysis.

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Idiopathic Progressive Subglottic Stenosis

• GERD and IPSS
• Koufman created stenosis with acid application
• GERD is common and IPSS is rare
• Atypical Wegeners?
• In a series of 189 patients with Wegeners, 21
  patients showed subglottic stenosis as their only
  manifestation of the disease.
• Progressive

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Case 2

• 62 YO Vietnamese physician who presented to the
  ER in 9/2004 with CHF and florid pulmonary edema,
  ARF, evidence of pneumonia and sepsis and
  required ventilation for 4 days.
• After discharge he developed stridor and
  worsening respiratory status
• He was found to have a severe tracheal stenosis
  and in 11/2004 underwent tracheal dilatation and
  stent placement.
• Initial bronchoscopy revealed tracheal ring
  fracture.

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IntubationTrauma

• Stenosis occurs 4-12 weeks after prolonged
  intubation
• Oversized or overinflated cuff
• Necrosis of the subglottic mucosa
• Sepsis
• Hypotension
• Failure to secure the endotracheal tube

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27 mm2
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Long Term Safety and Tolerance.. Ann Thorac Surg
2000

• Compared 3 types of stents
• Self expandable Metallic and Polyester
• Silicone tube
• 12 Sheep, stents placed in right mainstem, killed
  at one year, postmortem exam
• All metallic stents showed full thickness
  ulcerations
• All polyester stents migrated
• 3 of 4 silicone stents showed squamous metaplasia

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Laryngopharygeal Reflux and Subglottic Stenosis
(Maronian, Ann Otol 2001)

• 9 cases of IPSS and 10 cases of SGS associated
  with concomitant disease states
• 12 of 14 patients tested demonstrated LPR with
  pharyngeal pH values less than 4.
• 5 of 7 patients with IPSS
• 7 of 7 patients with SGS and concomitant Dz.
• All patients with SGS should be tested and
  treated for reflux

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41 of patients needed Nissen due to
breakthrough (Koufman, The Otolaryngologic
Manifestations of GERD, Laryngoscope, 1991)
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Patterns of Cartilage Structural Protein Loss in
Human Tracheal Stenosis (Mankarious 2002)

• Resected specimens reveal loss of cartilage
  integrity and bulk
• Study sought to identify which structural
  proteins are most susceptible to inflammation and
  thereby degraded
• Hyaline cartilage in trachea and cricoid contain
  collagen I and aggrecan

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Patterns of Cartilage Structural Protein Loss in
Human Tracheal Stenosis (Mankarious 2002)

• Archival, paraffin-embedded tissue blocks were
  obtained (Mass General Hospital)
• Specimens were segments of human trachea excised
  for repair of stenosis due to intubation injury.
• Immunohistochemistry was performed

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Aggrecan loss at the fracture site
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Collagen I loss at the fracture site
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Case 3

• 36 YO AA male prisoner with a past medical
  history of prolonged intubation during the summer
  of 2003. Presented with DOE, no frank stridor
  but audible breathing.
• PSH 7 abdominal surgeries
• PE flex scope in clinic revealed greater than
  50 subglottic narrowing.
• Treatment Tracheal resection with end-to-end
  anastomosis 8/2004, uneventful post operative
  course

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Tracheal Resection with End-to-End Anastomosis
(Wynn, Ann Otol Laryngol, 2004)

• Series of 28 patients with 89 developing
  stenosis from postintubation(32),
  posttracheotomy(25), or both(32)
• 2-8 rings were resected (median 4)
• 22 patients extubated on the OR table and 6 were
  extubated after the first or second postoperative
  day

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Tracheal Resection with End-to-End Anastomosis

• No iatrogenic vocal cord paralysis
• 3 patients had failures with restenosis that all
  developed within 3 months after surgery
• Anastomotic success rate was 89, no deaths
• Conclusion- safe and reliable procedure in
  appropriately selected patients.

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Tracheal Resection with End-to-End Anastomosis

• Preoperative evaluation with predictors of
  failure
• Previous failed resection
• Higher level of stenosis
• Stenosis greater than 50 of the length of the
  trachea

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Tracheal Release Maneuvers

• Surgical techniques that permit low-tension
  end-to-end primary reconstruction after tracheal
  sleeve resection.
• 2 cm rule (Rob and Bateman 1949)
• Tracheal surgery has been late to develop due to
  belief that only short tracheal segments could
  safely be excised (Grillo 1989)

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Tracheal Release Maneuvers

• Dissection of the pretracheal plane
• Cervical flexion- allows resection of 4.5 cm
• Laryngeal release
• Hilar release

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Comfortable Flexion
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Suprahyoid laryngeal release
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Conclusion

• Rare and difficult problem that we will continue
  to encounter
• We are beginning to more fully understand the
  pathophysiology of the disease
• Various treatments options available
• Patients can have excellent outcomes

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Thank You