Laryngotracheal stenosis: Resection and primary reconstruction

Estenosis laringotraqueales: Resección y reconstrucción primaria

A review is made of patients with stenosis involving the larynx and trachea, treated in the thoracic surgery service of the Hospital de San José with resection and reconstruction techniques with primary anastomosis, during the period between 1996 and 2005. The histories were reviewed Clinical data and the information collected retrospectively were recorded in a database with: sex, age, origin, cause of the stenosis, location, severity, length, previous interventions related to the current problem, history of intubation, cause and duration of the same, time elapsed between extubation and the appearance of stenosis, stay in the ICU, history of tracheostomy, symptoms, management of acute airway obstruction, diagnostic images, endoscopic findings, surgical procedure performed, mortality, complications, time of hospitalization and functional results. Thirty patients, 16 men and 14 women were intervened. The age range varied between 12 and 80 years, with an average of 44. Twenty-seven patients had stenosis after intubation (25 orotracheal and 2 tracheostomy). The symptoms of obstruction occurred between 30 and 90 days after the procedure and the duration ranged between 3 and 45 days. In one patient an idiopathic stenosis was diagnosed, in another an inflammatory pseudotumor of the body of the trachea and in a third after trauma by firearm. In eight the narrowness compromised the laryngotracheal region, four in the subglottic space and four in the glottic in the posterior commissure. Seven of them secondary to orotracheal intubation and one idiopathic. In 22 patients it was located in the body of the trachea. The length of the narrow segment varied between 2 and 6 cm. The severity of the obstruction ranged between 70% and 90%. In two cases there was a combination of stenosis and tracheomalacia. The symptoms consisted of dyspnea of ​​effort and laryngeal stridor. There was acute obstruction of the airway in 18 and it was treated with tracheostomy in 16 and dilatations in two. Twelve patients had a tracheostomy tube when they visited the hospital. Three patients had undergone different procedures of resection and reconstruction in other institutions. In all cases, laryngeal and trachea CT and fibrobronchoscopy were performed. Three brought magnetic nuclear resonance at the time they were first evaluated in our service. Two patients were assessed in other institutions with linear tomography. In 14 patients with a clinical picture of airway obstruction, a volume flow curve was performed that showed a pattern of fixed obstruction of the upper airway. They were studied with arterial gases that showed mild to severe hypoxemia in ten and retention of CO in five. All the patients underwent resection and reconstruction by end-to-end anastomosis of the airway. In 26, a cervical approach was made and four required a combined cervical and sternal approach. In four patients with subglottic stenosis, resections were made of the anterior plate of the cartilage and the diseased mucosa, covering the defect with a membranous tracheal flap and anastomosis between the thyroid cartilage and the trachea. In one a tracheostomy cannula was left; in another, a plastic T tube was placed as a mold, which was maintained for seven months. The others were extubated at the end of the procedure. Four patients who presented lesions that compromised the glottis required a complex reconstruction consisting of a laryngofisura and resection of the entire anterior portion of the cricoid cartilage. In two, one T-tube was left for six months and in another a temporary tracheostomy cannula was placed. Twenty-two with stenosis of the body of the trachea were treated with resection and primary anastomosis of trachea segments whose length varied between 3 and 6 cm. Fifteen with resections larger than 3 cm required laryngeal release maneuvers. Three with stenosis greater than 5 cm required a median sternotomy for mobilization of the pulmonary hilum. In a patient with stenosis and tracheomalacia caused by compression by a goiter, the procedure was combined with a total thyroidectomy. One patient presented a new obstruction after the resection of a subglottic stenosis and was reoperated at six months. Hospitalization time varied between 8 and 20 days with an average of 9. There were two deaths due to tracheal fistulas with massive hemorrhage and seven complications in 30 resection and reconstruction procedures. The results obtained in 26 patients were excellent, with restoration of patency of the airway and recovery of the normal voice. To the extent that surgical reconstruction techniques have been perfected and experience with them is greater, We are increasingly convinced that resection and early reconstruction of these lesions is widely justified and that conservative treatment does not represent an appropriate alternative. Abbreviations: ICU, intensive care unit; CT scan, computerized axial tomography.

1. Hopkinson DN, Keshavjee S: Inflammatory conditions. En: Pearson FG, Cooper JD, Deslauriers J, editors. Thoracic Surgery. 2ND. ed. Churchill Livingstone; 2002. p 325.

2. Grillo HC, Donahue DM. Postintubation tracheal stenosis. Chest Surg Clin N Am. 1996 Nov;6(4):725-31.

3. Pearson FG, Goldberg M, da Silva A.T. A prospective study of tracheal injury complicating tracheostomy with a cuffed tube. Ann Otol Rhinol Laryngol. 1968 Oct;77(5):867-82.

4. Pearson FG, Andrews MJ. Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg. 1971 Oct;12(4):359-74.

5. Grillo HC. Surgery of the trachea. En: Ravitch MM, editors. Current problems in Surgery. Chicago: Year Book Medical Publishers, 1970.

6. Dedo HH, Fishman NH. Laryngeal release and sleeve resection for tracheal stenosis. Ann Otol Rhinol Laryngol. 1969 Apr;78(2):285-96.

7. Montgomery WW. Suprahyoid release for tracheal anastomosis. Arch Otolaryngol. 1974 Apr;99(4):255-60.

8. Ogura JH, Powers WE. Functional restitution of traumatic stenosis of the larynx and pharynx. Laryngoscope. 1964 aug;74:1081-110.

9. Pearson FG, Cooper JD, Nelems JM, Van Nostrand AW. Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg. 1975 Nov;70(5):806-16.

10. Monnier P, Savary M, Chapuis G. Partial cricoid resection with primary tracheal anastomosis for subglottic stenosis in infants and children. Laryngoscope. 1993 Nov;103(11 Pt 1):1273-83.

11 Couraud L, Hafez A. Acquired and non-neoplastic subglotic stenosis. En: Grillo HC, Eschapasse H, editors. International trends in general thoracic surgery: major challenges. Vol 2. Philadelphia : WB Saunders; 1987. p. 91-110.

12. Grillo HC, Mathisen DJ, Wain JC. Laryngotracheal resection and reconstruction for subglottic stenosis. Ann Thorac Surg. 1992 Jan;53(1):54-63.

13. Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg. 1982 Jan;33(1):3-18.

14. Maddaus MA, Toth JL, Gullane PJ, Pearson FG. Subglottic tracheal resection and synchronous laryngeal reconstruction. J Thorac Cardiovasc Surg. 1992 Nov;104(5):1443-50.

15. Pearson FG: Technique and management of subglotic stenosis. Chest Surg Clin N Am. 1996 Nov;6(4):683- 92.

16. Grillo HC. Management of idiopathic tracheal stenosis. Chest Surg Clin N Am. 1996 Nov;6(4):811-8.

17. Grillo HC. Postintubation estenosis. En: Grilo HC, editores. Surgery of the trachea and bronchi. London : BC Decker Inc. Hamilton; 2004.