Ronald Durbin MD, UCHSC, Dept of Ronald Durbin MD, UCHSC, Dept of SurgerySurgery

Tracheal Tracheal StenosisStenosis

A CASE REPORTA CASE REPORT

36 36 yoyo female with a history of head and neck female with a history of head and neck lymphoma (diagnosed 4/2004) creating lymphoma (diagnosed 4/2004) creating compression of the trachea requiring compression of the trachea requiring tracheostomytracheostomy after initial intubation to after initial intubation to protect her airway.protect her airway.

Lymphoma was definitively treated with Lymphoma was definitively treated with chemoradiationchemoradiation but need for but need for tracheostomytracheostomycontinued and continued and tracheostomytracheostomy was was ultimately revised times oneultimately revised times one

As of 3/2006 patient remained with a As of 3/2006 patient remained with a tracheostomytracheostomy and had been unable to and had been unable to phonate since its initial placement almost phonate since its initial placement almost two years beforetwo years before

PMHxPMHx: lymphoma only: lymphoma onlyPSHxPSHx: : tracheostomytracheostomy with revisionwith revisionMeds: noneMeds: noneAllergies: NKDAAllergies: NKDASHxSHx: non: non--smoker, no ETOH/IVDAsmoker, no ETOH/IVDA

Congenital Congenital MembranousMembranousCartilagenousCartilagenous

AcquiredAcquiredIntubation Intubation –– duration (5duration (5--10 days), size of ETT, 10 days), size of ETT, traumatic intubation, # of retraumatic intubation, # of re--intubationsintubationsLaryngeal trauma Laryngeal trauma -- high high tracheostomytracheostomy, ,

cricothyroidotomycricothyroidotomy, inhalational (thermal or caustic), , inhalational (thermal or caustic), trauma blunt or penetrating traumatrauma blunt or penetrating trauma

AutoimmuneAutoimmuneInfectionInfectionGERDGERDInflammatory diseases Inflammatory diseases –– sarcoidosissarcoidosis, SLE, SLENeoplasmsNeoplasms

Combining principal in the acquired type of Combining principal in the acquired type of tracheal tracheal stenosisstenosis is that mucosal and/or is that mucosal and/or cartilaginous injury results in inflammatory cartilaginous injury results in inflammatory response and subsequent remodeling with response and subsequent remodeling with healing by secondary intention and, healing by secondary intention and, ultimately, scarring with narrowing of the ultimately, scarring with narrowing of the airway airway

Three classification systems exist to help Three classification systems exist to help predict the chance of predict the chance of decannulationdecannulation after after treatment of tracheal treatment of tracheal stenosisstenosis

Cotton et al, J Pediatric Surg 1984Cotton et al, J Pediatric Surg 1984

MyerMyer--Cotton staging system :Cotton staging system :Grade IGrade I -- less than 50% obstructionless than 50% obstructionGrade IIGrade II -- 51% to 70% obstruction51% to 70% obstructionGrade IIIGrade III -- 71% to 99% obstruction71% to 99% obstructionGrade IVGrade IV -- no detectable lumen or complete no detectable lumen or complete

stenosisstenosis. .

Most useful for mature, firm, circumferential Most useful for mature, firm, circumferential stenosisstenosis confined to the confined to the subglottissubglottis..

McCaffrey, Laryngoscope 1992McCaffrey, Laryngoscope 1992

McCaffrey staging system : McCaffrey staging system : Stage IStage I -- confined to the confined to the subglottissubglottis or or

trachea and are less than 1cm longtrachea and are less than 1cm longStage IIStage II -- isolated to the isolated to the subglottissubglottis and are and are

greater then 1 cm longgreater then 1 cm longStage IIIStage III -- subglotticsubglottic/tracheal lesions not /tracheal lesions not

involving the glottisinvolving the glottisStage IV Stage IV -- lesions involve the glottis. lesions involve the glottis.

Lano et al, Ann Otlo Rhinol Laryngol Lano et al, Ann Otlo Rhinol Laryngol 19981998

LanoLano et al. (1998) staging system: et al. (1998) staging system: Stage IStage I -- involve one involve one subsitesubsiteStage IIStage II -- involves two involves two subsitessubsitesStage III Stage III -- involves all three involves all three subsitessubsites

Based on the number of Based on the number of subsitessubsites of of involvement including the glottis, involvement including the glottis, subglottissubglottisand tracheaand trachea

Surgical OptionsSurgical Options

TracheostomyTracheostomyEndoscopicEndoscopic –– Dilation (with or without Dilation (with or without stentingstenting))Open procedures Open procedures –– cricoidcricoid split split (pediatrics), tracheal resection(pediatrics), tracheal resection

Wright et al, J Thoracic Cardiovasc Wright et al, J Thoracic Cardiovasc Surg 2004Surg 2004

Risk factors for tracheal Risk factors for tracheal anastamoticanastamotic complicationscomplications

Wright et al 2004, retrospective trial of 901 Wright et al 2004, retrospective trial of 901 patients with complications in 9%patients with complications in 9%Risk factors identified as diabetes, Risk factors identified as diabetes, reoperationsreoperations, lengthy resections, young , lengthy resections, young age, age, laryngotracheallaryngotracheal resections, need for resections, need for tracheostomytracheostomy before resectionbefore resection

For firstFor first--time resections greater than 4 cm the risk of time resections greater than 4 cm the risk of anastomoticanastomoticfailure doubledfailure doubled

Outcomes after resection: Outcomes after resection: observational experiencesobservational experiences

Cotton (1984) Cotton (1984) –– rates of rates of decannulationdecannulation were 97%, were 97%, 97%, 91%, 72% based on his own staging 97%, 91%, 72% based on his own staging systemsystem

LanoLano (1998) (1998) –– rates of rates of decannulationdecannulation94%,78%,20% based on own staging system94%,78%,20% based on own staging system

Grillo(1992) Grillo(1992) –– overall rate of overall rate of decannulationdecannulation was was 97%, however, 77.5% had some degree of voice 97%, however, 77.5% had some degree of voice dysfunction (60% were mild)dysfunction (60% were mild)

On 2/14/06 the patient underwent On 2/14/06 the patient underwent bronchoscopybronchoscopy –– From above this showed From above this showed complete occlusion of the tracheal lumen complete occlusion of the tracheal lumen approximately 2.5 cm beyond the vocal approximately 2.5 cm beyond the vocal cords, the airway proximal to the cords, the airway proximal to the cricoidcricoidwas normal, the airway distal as seen was normal, the airway distal as seen through the stoma was also normal.through the stoma was also normal.

Approximately 3.5 cm of trachea was Approximately 3.5 cm of trachea was involvedinvolved

On 3/22/06 pt underwent tracheal resection On 3/22/06 pt underwent tracheal resection with primary with primary anastamosisanastamosis, no , no complications intra or postcomplications intra or post--opop

Patient was discharged after 6 days able to Patient was discharged after 6 days able to speak with minimal hoarsenessspeak with minimal hoarseness

Recently pt seen in clinic and continues to Recently pt seen in clinic and continues to do well with eating/breathing/ and talkingdo well with eating/breathing/ and talking