Predictive Factors of Success or Failure in the Endoscopic Management of Laryngeal and Tracheal Stenosis

Abstract

Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

Management of laryngotracheal stenosis — our experience

“…This result in consistent with the result of Simpson et al [6] who opined that endoscopic methods are infrequently successful in major stenosis involving the suglottis either alone or in combination of laryngeal stenosis. Cases with limited stenosis involving the subglottis and without signifi cant associated loss of cartilage, not having circumferential cicatritial stenosis or scaring <1 cm in vertical width can be successful managed endoscopically.…”

“…Simpson et al [6] reported 80.6% (25 out of 31 patients) success rate of endoscopic treatment of subglottic stenosis by dilatation and using soft silastic stents. Shapshay et al [7] reported excellent results in 8 of 12 cases of total cervical tracheal stenosis using endoscopic laser excision, dilatation and prolonged stenting with a silicon T-tube.…”

Complications of Airway ManagementDiscussion

“…Historical success rates of endoscopic procedures range between 44 and 68%. [84][85][86] However, these procedures are usually most effective in the treatment of thin web-like lesions that are no longer than 2 cm. Mitomycin C, an antineoplastic agent that inhibits fibroblast proliferation, has been shown to be an effective adjuvant in preventing restenosis, 87 although many reports are anecdotal, and the literature lacks controlled studies.…”

Management of Post-traumatic Laryngotracheal Stenosis: Our Experience

“…In our study 8 patients underwent endoscopic dilatation with 6 cases being successfully decanulated (75 % success) in comparison to study of Simpson et al [25] with success rate of 80.6 % (Table 4).…”