Laryngotracheal stenosis

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Laryngotracheal stenosis
Laryngotracheal stenosis 001.jpg
This condition can also be referred to as subglottic or tracheal stenosis.
Specialty Otorhinolaryngology   OOjs UI icon edit-ltr-progressive.svg
Diagnostic method Patient history, CT scan of neck and chest, fibre-optic bronchoscopy

Laryngotracheal stenosis refers to abnormal narrowing of the central air passageways. [1] This can occur at the level of the larynx, trachea, carina or main bronchi. [2] In a small number of patients narrowing may be present in more than one anatomical location.

Contents

Presentation

The most common symptom of laryngotracheal stenosis is gradually-worsening breathlessness (dyspnea) particularly when undertaking physical activities (exertional dyspnea). The patient may also experience added respiratory sounds which in the more severe cases can be identified as stridor but in many cases can be readily mistaken for wheeze. This creates a diagnostic pitfall in which many patients with laryngotracheal stenosis are incorrectly diagnosed as having asthma and are treated for presumed lower airway disease. [3] [4] [5] [6] [7] [8] This increases the likelihood of the patient eventually requiring major open surgery for benign disease [9] and can lead to tracheal cancer presenting too late for curative surgery to be performed.

Causes

Laryngotracheal stenosis is an umbrella term for a wide and heterogeneous group of very rare conditions. The population incidence of adult post-intubation laryngotracheal stenosis which is the commonest benign sub-type of this condition is approximately 1 in 200,000 adults per year. [10] The main causes of adult laryngotracheal stenosis are:

Main causes of laryngotracheal stenosis
Benign causesMalignant causes
Extrinsic compression
Intrinsic narrowing

Diagnosis

Patient history, CT scan of neck and chest, fiberoptic bronchoscopy, and spirometry are all several ways to assess for laryngotracheal stenosis and effectively develop preoperational approaches to treating the disease. In addition, a methodology called the Cotton-Myer system is commonly used to evaluate the degree of severity of the laryngotracheal stenosis based on the percentage of obstruction; other systems have also been proposed to fill potential shortcomings of the Cotton-Myer classification and help capture the full complexity of the illness. [23]

Treatment

The optimal management of laryngotracheal stenosis is not well defined, depending mainly on the type of the stenosis. [24] General treatment options include

  1. Tracheal dilation using rigid bronchoscope
  2. Laser surgery and endoluminal stenting [25]
  3. Tracheal resection and laryngotracheal reconstruction [21] [26]

Tracheal dilation is used to temporarily enlarge the airway. The effect of dilation typically lasts from a few days to 6 months. Several studies have shown that as a result of mechanical dilation (used alone) may occur a high mortality rate and a rate of recurrence of stenosis higher than 90%. [24] Thus, many authors treat the stenosis by endoscopic excision with laser (commonly either the carbon dioxide or the neodymium: yttrium aluminum garnet laser) and then by using bronchoscopic dilatation and prolonged stenting with a T-tube (generally in silicone). [27] [28] [29]

There are differing opinions on treating with laser surgery.

In very experienced surgery centers, tracheal resection and reconstruction (anastomosis complete end-to-end with or without laryngotracheal temporary stent to prevent airway collapse) is currently the best alternative to completely cure the stenosis and allows to obtain good results. Therefore, it can be considered the gold standard treatment and is suitable for almost all patients. [30]

The narrowed part of the trachea will be cut off and the cut ends of the trachea sewn together with sutures. For stenosis of length greater than 5 cm a stent may be required to join the sections.

Late June or early July 2010, a new potential treatment was trialed at Great Ormond Street Hospital in London, where Ciaran Finn-Lynch (aged 11) received a transplanted trachea which had been injected with stem cells harvested from his own bone marrow. The use of Ciaran's stem cells was hoped to prevent his immune system from rejecting the transplant, [31] but there remain doubts about the operation's success, and several later attempts at similar surgery have been unsuccessful.

Nomenclature

Laryngotracheal stenosis (Laryngo-: Glottic Stenosis; Subglottic Stenosis; Tracheal: narrowings at different levels of the windpipe) is a more accurate description for this condition when compared, for example to subglottic stenosis which technically only refers to narrowing just below vocal folds or tracheal stenosis. In babies and young children however, the subglottis is the narrowest part of the airway and most stenoses do in fact occur at this level. Subglottic stenosis is often therefore used to describe central airway narrowing in children, and laryngotracheal stenosis is more often used in adults.

See also

Related Research Articles

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<span class="mw-page-title-main">Trachea</span> Cartilaginous tube that connects the pharynx and larynx to the lungs

The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all animals with lungs. The trachea extends from the larynx and branches into the two primary bronchi. At the top of the trachea the cricoid cartilage attaches it to the larynx. The trachea is formed by a number of horseshoe-shaped rings, joined together vertically by overlying ligaments, and by the trachealis muscle at their ends. The epiglottis closes the opening to the larynx during swallowing.

<span class="mw-page-title-main">Tracheal intubation</span> Placement of a tube into the trachea

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.

<span class="mw-page-title-main">Esophageal atresia</span> Congenital discontinuity of the oesophagus

Esophageal atresia is a congenital medical condition that affects the alimentary tract. It causes the esophagus to end in a blind-ended pouch rather than connecting normally to the stomach. It comprises a variety of congenital anatomic defects that are caused by an abnormal embryological development of the esophagus. It is characterized anatomically by a congenital obstruction of the esophagus with interruption of the continuity of the esophageal wall.

<span class="mw-page-title-main">Tracheotomy</span> Temporary surgical incision to create an airway into the trachea

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<span class="mw-page-title-main">Airway management</span> Medical procedure ensuring an unobstructed airway

Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration).

<span class="mw-page-title-main">Stenosis</span> Abnormal narrowing of a blood vessel or other tubular organ or structure

Stenosis is the abnormal narrowing of a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture.

<span class="mw-page-title-main">Laryngectomy</span> Surgical procedure

Laryngectomy is the removal of the larynx and separation of the airway from the mouth, nose and esophagus. In a total laryngectomy, the entire larynx is removed. In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a stoma. This procedure is usually performed by an ENT surgeon in cases of laryngeal cancer. Many cases of laryngeal cancer are treated with more conservative methods. A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of head and neck cancer. Less invasive partial laryngectomies, including tracheal shaves and Feminization Laryngoplasty may also be performed on transgender women and other female or non-binary identified individuals to feminize the larynx and/or voice. Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be affected post-surgery.

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<span class="mw-page-title-main">Laryngeal papillomatosis</span> Medical condition

Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis (RRP) or glottal papillomatosis, is a rare medical condition in which benign tumors (papilloma) form along the aerodigestive tract. There are two variants based on the age of onset: juvenile and adult laryngeal papillomatosis. The tumors are caused by human papillomavirus (HPV) infection of the throat. The tumors may lead to narrowing of the airway, which may cause vocal changes or airway obstruction. Laryngeal papillomatosis is initially diagnosed through indirect laryngoscopy upon observation of growths on the larynx and can be confirmed through a biopsy. Treatment for laryngeal papillomatosis aims to remove the papillomas and limit their recurrence. Due to the recurrent nature of the virus, repeated treatments usually are needed. Laryngeal papillomatosis is primarily treated surgically, though supplemental nonsurgical and/or medical treatments may be considered in some cases. The evolution of laryngeal papillomatosis is highly variable. Though total recovery may be observed, it is often persistent despite treatment. The number of new cases of laryngeal papillomatosis cases is approximately 4.3 cases per 100,000 children and 1.8 cases per 100,000 adults annually.

<span class="mw-page-title-main">Laryngospasm</span> Involuntary contraction of the vocal folds restricting inhalation

Laryngospasm is an uncontrolled or involuntary muscular contraction (spasm) of the vocal folds. It may be triggered when the vocal cords or the area of the trachea below the vocal folds detects the entry of water, mucus, blood, or other substance. It may be associated with stridor or retractions.

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<span class="mw-page-title-main">Subglottic stenosis</span> Medical condition

Subglottic stenosis is a congenital or acquired narrowing of the subglottic airway. It can be congenital, acquired, iatrogenic, or very rarely, idiopathic. It is defined as the narrowing of the portion of the airway that lies between the vocal cords and the lower part of the cricoid cartilage. In a normal infant, the subglottic airway is 4.5-5.5 millimeters wide, while in a premature infant, the normal width is 3.5 millimeters. Subglottic stenosis is defined as a diameter of under 4 millimeters in an infant. Acquired cases are more common than congenital cases due to prolonged intubation being introduced in the 1960s. It is most frequently caused by certain medical procedures or external trauma, although infections and systemic diseases can also cause it.

<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.

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Endoscopic laser cordectomy, also known as Kashima operation, is an endoscopic laser surgical procedure performed for treating the respiratory difficulty caused as a result of bilateral abductor vocal fold paralysis. Bilateral vocal fold paralysis is basically a result of abnormal nerve input to the laryngeal muscles, resulting in weak or total loss of movement of the laryngeal muscles. Most commonly associated nerve is the vagus nerve or in some cases its distal branch, the recurrent laryngeal nerve. Paralysis of the vocal fold may also result from mechanical breakdown of the cricoarytenoid joint. It was first described in by Kashima in 1989.

Laryngotracheal reconstruction is a surgical procedure that involves expanding or removing parts of the airway to widen a narrowing within it, called laryngotracheal stenosis or subglottic stenosis.

Eustachian tube dysfunction (ETD) is a disorder where pressure abnormalities in the middle ear result in symptoms.

<span class="mw-page-title-main">Intubation granuloma</span> Medical condition

Intubation granuloma is a benign growth of granulation tissue in the larynx or trachea, which arises from tissue trauma due to endotracheal intubation. This medical condition is described as a common late complication of tracheal intubation, specifically caused by irritation to the mucosal tissue of the airway during insertion or removal of the patient's intubation tube.

References

  1. ↑ Gelbard, A (2014). "Causes and Consequences of Laryngotracheal Stenosis". The Laryngoscope. 125 (5): 1137–1143. doi:10.1002/lary.24956. PMC   4562418 . PMID   25290987.
  2. ↑ Armstrong WB, Netterville JL (August 1995). "Anatomy of the larynx, trachea, and bronchi". Otolaryngol. Clin. North Am. 28 (4): 685–99. doi:10.1016/S0030-6665(20)30488-6. PMID   7478631.
  3. ↑ Catenacci MH (July 2006). "A case of laryngotracheal stenosis masquerading as asthma". South. Med. J. 99 (7): 762–4. doi:10.1097/01.smj.0000217498.70967.77. PMID   16866062. S2CID   34396984.
  4. ↑ Ricketti PA, Ricketti AJ, Cleri DJ, Seelagy M, Unkle DW, Vernaleo JR (2010). "A 41-year-old male with cough, wheeze, and dyspnea poorly responsive to asthma therapy". Allerg Asthma Proc. 31 (4): 355–8. doi:10.2500/aap.2010.31.3344. PMID   20819328.
  5. ↑ Scott PM, Glover GW (1995). "All that wheezes is not asthma". Br J Clin Pract. 49 (1): 43–4. doi:10.1111/j.1742-1241.1995.tb09878.x. PMID   7742187. S2CID   3262759.
  6. 1 2 Kokturk N, Demircan S, Kurul C, Turktas H (October 2004). "Tracheal adenoid cystic carcinoma masquerading asthma: a case report". BMC Pulm Med. 4: 10. doi: 10.1186/1471-2466-4-10 . PMC   526771 . PMID   15494074.
  7. ↑ Parrish RW, Banks J, Fennerty AG (December 1983). "Tracheal obstruction presenting as asthma". Postgrad Med J. 59 (698): 775–6. doi:10.1136/pgmj.59.698.775. PMC   2417814 . PMID   6318209.
  8. ↑ Galvin IF, Shepherd DR, Gibbons JR (1990). "Tracheal stenosis caused by congenital vascular ring anomaly misinterpreted as asthma for 45 years". Thorac Cardiovasc Surg. 38 (1): 42–4. doi:10.1055/s-2007-1013990. PMID   2309228. S2CID   46374081.
  9. ↑ Nouraei SA, Singh A, Patel A, Ferguson C, Howard DJ, Sandhu GS (August 2006). "Early endoscopic treatment of acute inflammatory airway lesions improves the outcome of postintubation airway stenosis". Laryngoscope. 116 (8): 1417–21. doi:10.1097/01.mlg.0000225377.33945.14. PMID   16885746. S2CID   1951308.
  10. ↑ Nouraei SA, Ma E, Patel A, Howard DJ, Sandhu GS (October 2007). "Estimating the population incidence of adult post-intubation laryngotracheal stenosis". Clin Otolaryngol. 32 (5): 411–2. doi:10.1111/j.1749-4486.2007.01484.x. PMID   17883582. S2CID   9866769.
  11. 1 2 Lu MS, Liu YH, Ko PJ, Wu YC, Hsieh MJ, Liu HP, Lin PJ (April 2003). "Preliminary experience with bronchotherapeutic procedures in central airway obstruction". Chang Gung Med J. 26 (4): 240–9. PMID   12846523.
  12. ↑ Tsutsui H, Kubota M, Yamada M, Suzuki A, Usuda J, Shibuya H, Miyajima K, Sugino K, Ito K, Furukawa K, Kato H (September 2008). "Airway stenting for the treatment of laryngotracheal stenosis secondary to thyroid cancer". Respirology. 13 (5): 632–8. doi:10.1111/j.1440-1843.2008.01309.x. PMID   18513246. S2CID   24855053.
  13. ↑ Peña J, Cicero R, Marín J, Ramírez M, Cruz S, Navarro F (October 2001). "Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present". Otolaryngol Head Neck Surg. 125 (4): 397–400. doi:10.1067/mhn.2001.117372. PMID   11593179. S2CID   27872003.
  14. ↑ Bent J (July 2006). "Pediatric laryngotracheal obstruction: current perspectives on stridor". Laryngoscope. 116 (7): 1059–70. doi:10.1097/01.mlg.0000222204.88653.c6. PMID   16826038. S2CID   46380408.
  15. ↑ Perkins JA, Inglis AF, Richardson MA (March 1998). "Iatrogenic airway stenosis with recurrent respiratory papillomatosis". Arch. Otolaryngol. Head Neck Surg. 124 (3): 281–7. doi:10.1001/archotol.124.3.281. PMID   9525512.
  16. ↑ Wood DE, Mathisen DJ (September 1991). "Late complications of tracheotomy". Clin. Chest Med. 12 (3): 597–609. doi:10.1016/S0272-5231(21)00806-6. PMID   1934960.
  17. ↑ Lorenz RR (December 2003). "Adult laryngotracheal stenosis: etiology and surgical management". Curr Opin Otolaryngol Head Neck Surg. 11 (6): 467–72. doi:10.1097/00020840-200312000-00011. PMID   14631181. S2CID   32700438.
  18. ↑ Filocamo, G; Torreggiani, S; Agostoni, C; Esposito, S (April 2017). "Lung involvement in childhood onset granulomatosis with polyangiitis". Pediatric Rheumatology Online Journal. 15 (1): 28. doi: 10.1186/s12969-017-0150-8 . PMC   5391594 . PMID   28410589.
  19. ↑ Chang SJ, Lu CC, Chung YM, Lee SS, Chou CT, Huang DF (June 2005). "Laryngotracheal involvement as the initial manifestation of relapsing polychondritis". J Chin Med Assoc. 68 (6): 279–82. doi: 10.1016/S1726-4901(09)70151-0 . PMID   15984823.
  20. ↑ Kim CM, Kim BS, Cho KJ, Hong SJ (April 2003). "Laryngotracheal involvement of relapsing polychondritis in a Korean girl". Pediatr. Pulmonol. 35 (4): 314–7. doi:10.1002/ppul.10247. PMID   12629631. S2CID   7537380.
  21. 1 2 Mostafa BE, El Fiky L, El Sharnoubi M (July 2006). "Non-intubation traumatic laryngotracheal stenosis: management policies and results". Eur Arch Otorhinolaryngol. 263 (7): 632–6. doi:10.1007/s00405-006-0036-8. PMID   16633824. S2CID   19560207.
  22. ↑ Wassermann K, Mathen F, Edmund Eckel H (October 2000). "Malignant laryngotracheal obstruction: a way to treat serial stenoses of the upper airways". Ann. Thorac. Surg. 70 (4): 1197–201. doi:10.1016/s0003-4975(00)01614-3. PMID   11081870.
  23. ↑ Rosow, David E.; Barbarite, Eric (December 2016). "Review of Adult Laryngotracheal Stenosis: Pathogenesis, Management, and Outcomes". Current Opinion in Otolaryngology & Head and Neck Surgery. Current Opinion in Otolaryngology & Head and Neck Surgery. 24 (6): 489–493. doi:10.1097/MOO.0000000000000305. PMID   27585080. S2CID   46797890 . Retrieved 2020-12-05.
  24. 1 2 Brichet A, Verkindre C, Dupont J, Carlier ML, Darras J, Wurtz A, Ramon P, Marquette CH (April 1999). "Multidisciplinary approach to management of postintubation tracheal stenoses". Eur. Respir. J. 13 (4): 888–93. doi: 10.1034/j.1399-3003.1999.13d32.x . PMID   10362058.
  25. ↑ Ciccone AM, De Giacomo T, Venuta F, Ibrahim M, Diso D, Coloni GF, Rendina EA (October 2004). "Operative and non-operative treatment of benign subglottic laryngotracheal stenosis". Eur J Cardiothorac Surg. 26 (4): 818–22. doi: 10.1016/j.ejcts.2004.06.020 . PMID   15450579.
  26. ↑ Duncavage JA, Koriwchak MJ (August 1995). "Open surgical techniques for laryngotracheal stenosis". Otolaryngol. Clin. North Am. 28 (4): 785–95. doi:10.1016/S0030-6665(20)30495-3. PMID   7478638.
  27. ↑ Shapshay SM, Beamis JF, Hybels RL, Bohigian RK (1987). "Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation". Ann. Otol. Rhinol. Laryngol. 96 (6): 661–4. doi:10.1177/000348948709600609. PMID   3688753. S2CID   7789067.
  28. ↑ Shapshay SM, Beamis JF, Dumon JF (November 1989). "Total cervical tracheal stenosis: treatment by laser, dilation, and stenting". Ann. Otol. Rhinol. Laryngol. 98 (11): 890–5. doi:10.1177/000348948909801110. PMID   2817681. S2CID   3183178.
  29. ↑ Mehta AC, Lee FY, Cordasco EM, Kirby T, Eliachar I, De Boer G (September 1993). "Concentric tracheal and subglottic stenosis. Management using the Nd-YAG laser for mucosal sparing followed by gentle dilatation". Chest. 104 (3): 673–7. doi:10.1378/chest.104.3.673. PMID   8365273. Archived from the original on 2014-06-18.
  30. ↑ Gómez-Caro A, Morcillo A, Wins R, Molins L, Galan G, Tarrazona V (January 2011). "Surgical management of benign tracheal stenosis". Multimedia Manual of Cardio-Thoracic Surgery. 2011 (1111): mmcts.2010.004945. doi:10.1510/mmcts.2010.004945. PMID   24413853.
  31. ↑ "New throat surgery 'a success'". BBC News. 2010-08-06.
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