Management of Postintubation Tracheal Stenosis: Appropriate Indications Make Outcome Differences

Abstract

Background: Laryngotracheal stenosis is difficult to treat and its etiologies are multiple; nowadays, the most common ones are postintubation or posttracheostomy stenoses. Objective: To provide an algorithm for the management of postintubation laryngotracheal stenoses (PILTS) based on the experience of a tertiary care referral center. Methods: A retrospective study was conducted on all patients treated for PILTS over a 10-year period. Patients were divided into a surgically and an endoscopically treated group according to predefined criteria. The characteristics of the two groups were analyzed and the outcomes compared. Results: Thirty-three consecutive patients were included in the study: 14 in the surgically treated group and 19 in the endoscopically treated group. Our candidates for airway surgery were healthy patients presenting with complex tracheal stenoses, subglottic involvement or associated tracheomalacia. The endoscopic candidates were chronically ill patients presenting with simple, strictly tracheal stenoses not exceeding 4 cm in length. Stents were placed if the stenosis was associated with tracheomalacia or exceeded 2 cm in total length. In the surgically treated group, 2/14 patients needed more than one procedure versus 8/19 patients in the endoscopically treated group. At the end of the intervention, 50% of the patients were decannulated in the surgically treated group versus 84.2% in the endoscopically treated group (p = 0.03). However, the decannulation rates at 6 months and the symptomatology at rest and on exertion on the last follow-up visit were comparable in the two groups. Conclusion: Our experience in the management of PILTS demonstrates that both surgery and endoscopy yield excellent functional outcomes if the treatment strategy is based on clear, predefined objective criteria.

Surgical management of airway stenosis by radiofrequency coblation

“…Prolonged endotracheal intubation, 'high' tracheostomy and airway instrumentation are associated with a higher risk of laryngotracheal stenosis. [9][10][11][12][13][14][15] The reported incidence of tracheal stenosis following tracheostomy ranges from 0.6 to 21 per cent, compared to 6 to 21 per cent following prolonged intubation. 10 Various treatment modalities have been used to manage laryngotracheal stenosis.…”

“…Since then, endoscopic techniques have subsequently evolved to include: controlled radial expansion balloon dilatation, microdebridement, cryotherapy and intraluminal stenting. [13][14][15] More recently, laryngotracheal stenosis has even been managed in the out-patient setting, using office-based laser surgery conducted under local anaesthetic only, with promising results. 18,19 Yet, despite technical and surgical advances, the management of laryngotracheal stenosis remains associated with high rates of re-stenosis.…”

Inhibitory Effect of Mitomycin C on Proliferation of Primary Cultured Fibroblasts from Human Airway Granulation Tissues

“…However, not all of the patients were candidates for this procedure due to their poor condition. Scarring and recurrent stricture at the surgical sites remain important issues in 4-14% of patients who undergo a lengthy resection or when there is tension at the sites of anastomosis or anastomotic infection [5,6,7]. Under these circumstances, endoluminal treatment is the only solution to maintain airway patency.…”

Iatrogenic Tracheal Stenosis Presenting as Persistent Asthma

“…17 Minimally invasive treatment, including neodymiumyttrium-aluminum-garnet laser (Nd:YAG) and CO 2 laser excision, dilatation, endoscopic stent placement, and topical application of mitomycin C, reduce airway surgical manipulation and post-surgical inflammatory response. 18 Still, for better outcome, endoscopic management requires early referral for stenotic lesions shorter than 10 mm, or shorter than 30 mm if stenting is considered, with no circumferential scarring and no loss of cartilagenous support. 15,16 Balloon dilatation has been well tolerated, but was often followed by recurrence requiring repeated dilatation or surgery.…”