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Subglottic stenosis is usually due to either endotracheal tube ischemic necrosis or idiopathic larygotracheal stenosis. The ischemic area involves varying depths of injury, causing a spectrum of injury from mucosal to full thickness, including the cartilage. The narrowest portion of the airway is the cricoid in the lower larynx. Selection of an endotracheal tube that is too large relative to the size of the cricoid can lead to circumferential injury to the cricoid mucosa, which may lead to subglottic stenosis. Idiopathic laryngotracheal stenosis is an unusual disease that almost always just affects women with a peculiar nonspecific scarring that only affects the lower larynx and upper few tracheal rings. Autoimmune disease and Wegner’s granulomatosis must be eliminated in the differential diagnosis by appropriate blood tests. Stenosis involving the larynx is more complex to repair and the results are less certain than simple tracheal resection. Stenosis also may involve the glottis from endotracheal tube damage to the vocal cords and arytenoids. An abnormal glottis must be corrected before correction of any tracheal problem as the glottis must provide an adequate airway at the conclusion of a laryngotracheal resection.
Resection should be deferred until the patient fully recovers from the original illness that precipitated mechanical ventilation. All necessary operations that require general anesthesia (ie, burn patients that require multiple excisions and scar releases) should be completed before embarking on tracheal resection. Often steroids are mistakenly administered to treat new-onset “asthma” after prolonged intubation. Steroids should be rapidly weaned off as they play no role in ameliorating postintubation stenosis and interfere with healing of the anastomosis. Glottic pathologic problems should be corrected before treating the tracheal pathologic problem. Mucosal inflammation identified by bronchoscopy should be allowed to resolve before resection to reduce the chance of an anastomotic problem. If the patient is in otherwise good shape, definitive treatment by resection may be performed. The airway can be temporarily opened by rigid bronchoscopic dilation if only a short period (ie, weeks) of time is needed before definitive treatment. Laser bronchoscopy further injures the airway and should be avoided when one wishes to temporize before proceeding to definitive resection. Self-expanding metallic stents should not be used as they effectively lengthen the airway injury and often convert a simple short resection to a very long resection, which has a much greater failure rate.
In general, any patient with obstructive airway symptoms and airway stenosis after ventilation should have definitive laryngotracheal resection and reconstruction if they have favorable anatomy. Patients with idiopathic stenosis often have significant inflammation and scarring coming very close to the vocal cords, leading to an inadequate subglottic vestibule to perform an anastomosis (Figure 1, Figure 2). These patients must be selected with care as there is little margin for error. Absolute contraindications are few and include a nonreconstructable airway (usually due to excessive length of the damaged airway), severe comorbidities, and a continued need for ventilation. Relative contraindications include a history of radiation to the trachea, continued mucosal inflammation beyond the area of resection, and active steroid use.
Although everyone has a trachea, anatomic and demographic factors influence how much trachea can be safely resected and reconstructed. Probably the most important factor is body habitus; young, tall, thin patients with long necks have an abundance of trachea and are the most straightforward candidates for surgery. Alternatively, elderly, kyphotic, short, obese patients with bull necks and a cricoid that is at the sternal notch are the most challenging patients. Recent high-dose steroid use and insulin-dependent diabetes seem to be risk factors for anastomotic problems, so special attention needs to be paid to the details and amount of tension on the anastomosis. Pediatric patients tolerate anastomotic tension less well than adults; ideally resections only under 30% should be done in children, whereas some adults can tolerate resections up to 50% of the length of the trachea. Previous tracheal surgery causes relative fixation of the remaining trachea and thus limits any possible re-resection to less than normal. Previous radiation therapy to the trachea limits tracheal mobility and impairs microvascular blood supply, both of which place constraints on how much trachea can be safely removed.
Patients who present with critical airway obstruction almost always can be managed with bronchoscopic dilation. It is very rare that a tracheostomy is needed to establish an airway in postintubation tracheal stenosis or idiopathic laryngotracheal stenosis. Patients should be promptly taken to the operating room for urgent brochoscopic dilation. If the airway is judged to be critical, muscle relaxants are avoided and induction of anesthesia is done by an inhalational technique, which allows the patient to breathe spontaneously until the airway is secured by bronchoscopy. The surgeon must be present during induction of anesthesia with all equipment immediately available and absolute competence to establish an airway. When the patient is deep enough to allow airway manipulation, rigid bronchoscopy is commenced with an adult no. 7 or 8 rigid bronchoscope to visualize the airway and stenosis. Dilation is begun with plastic small-diameter Jackson dilators through the bronchoscope until the maximal size is reached (about 6 mm). At this point, the airway is open enough to allow suctioning of retained distal secretions and to allow the anesthesiologist to ventilate the patient enough to return the end-tidal CO2 to normal. The airway can be further dilated by passage of serial-sized rigid bronchoscopes from a pediatric no. 3 up to an adult no. 9. The surgeon can appreciate the degree of resistance with the passage of each size scope to decide exactly how far to dilate so as to avoid tearing the airway. The surgeon should select the proper sized bronchoscope that is just a little too small to fit through the stenosis to begin with dilation. This allows for a graded stretching of the stenosis. If too large a size is selected, the lip of the bronchoscope can instead tear the mucosa, leading to development of a flap, which can occlude the end of the bronchoscope and lead to loss of the airway. If dilation is planned as a temporizing measure, in general, the dilation should be to the largest size possible so it will last for as long as possible. An alternate technique is to use the new noncompliant balloon dilators with either a rigid or a flexible bronchoscope to achieve the same result. If dilation is being done just before a resection, usually one dilates just enough to accept a no. 6 endotracheal tube.
In a recent series review of idiopathic laryngotracheal stenosis, we reported 91% of patients had good to excellent results with only 1% needing long-term dilation.
In our unit’s most recent series of patients with postintubation stenosis, 82% had a good result, 8% had a satisfactory result, and 8% had a failed result after laryngotracheal resection and reconstruction.