Eur J Cardiothorac Surg 2004;26:818-822
© 2004 Elsevier Science NL
Operative and non-operative treatment of benign subglottic laryngotracheal stenosis
Anna Maria Cicconea,*,
Tiziano De Giacomob,
Federico Venutab,
Mohsen Ibrahima,
Daniele Disob,
Giorgio Furio Colonib,
Erino A. Rendinaa
a University of Rome "La Sapienza", Division
of Thoracic Surgery, Sant'Andrea Hospital, Via Grottarossa, 1035-1039,
Rome 00189, Italy
b University of Rome
"La Sapienza", Division of Thoracic Surgery, Policlinico
Umberto I, Viale del Policlinico 150, Rome, Italy
Received 15 October 2003;
received in revised form 8 June 2004;
accepted 9 June 2004.
* Corresponding
author. Tel.: +39-06-80345-773; fax: +39-06-8034-5003. (E-mail:
amciccone{at}hotmail.com).
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Abstract
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Objective: Surgery is the first
line of treatment for laryngotracheal stenosis; Montgomery tube or
permanent tracheostomy have been so far the only alternatives. Nd-YAG laser
resection and indwelling endotracheal stents have rarely been used in
subglottic stenosis for anatomic and technical reasons. We have used the
latter approach to optimize the timing of surgery or to achieve palliation
without tracheostomy. Methods: Between 1991 and 2001 we have treated
18 patients with subglottic stenosis (10 males, 8 females; age range
14–78, mean 34). The upper margin of the stricture was 2mm to 1cm
below the vocal cords; the stenotic segment extended from 1.5 to 5cm. Three
patients had tracheostomy done elsewhere. Four patients (Group I) had laser
and stenting by a Dumon prosthesis as the only treatment; six had laser and
stenting (#4) followed after 1–6 months by laryngotracheal resection
(Group II); eight had surgery alone (Group III). Results: In Group
I, one patient required repositioning of the stent and in two the stent was
removed; two patients died of their underlying disease; at a follow-up of
2–9 years all living patients did well but required permanent
aerosolized therapy and periodical bronchoscopy. In Group II, we had two
wound infections due to airway colonization by staphylococcus aureus. In
Group III, two patients developed anastomotic postoperative stenosis,
treated by laser (#2) and stenting (#1), and one patient with previous
tracheostomy had a wound infection. Overall, in the 14 surgical patients
(Groups II and III) stenosis occurred in 14.2% and infection in 21.3%.
After a follow up of 15 months to 12 years, all surgical patients breathe
and speak well. Conclusions: Laser resection and endoluminal
stenting can be a viable alternative to surgery or optimize the timing of
operation in patients with subglottic
stenosis.
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1. Introduction
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Benign
stenosis involving the subglottic region represents a major therapeutic
challenge [1–3].
Surgery is the first line of treatment for laryngotracheal stenosis and
leads to high rate of success [4–8]. Although the preservation of the
recurrent laryngeal nerves remains one of the most vexing problems, a
number of reports show good results with respect to technical problems
[3–6,9–11].
Montgomery tube or permanent tracheostomy have been so far the only
alternatives to surgery. In recent years, the interest for endoscopic
treatment modalities, especially laser, has increased [12–14] in tracheal surgery; laser-assisted
endoscopy (with or without stenting) has however rarely been used in
subglottic stenosis for anatomical and technical reasons [15].
We have employed the
latter treatment modality in severely compromised patients or to allow
stabilization of the stenosis. Patients were either converted to surgery
when the stenosis was stabilized, or offered an acceptable palliation of
symptoms if surgery was not feasible for their compromised general
health.
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2. Methods
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Between 1991 and 2001,
we treated 18 patients with benign subglottic stenosis. Ten were males and
8 females with an age range of 14–78 years (median 34 years). The
cause of airway stenosis was iatrogenic in 16 patients who had undergone
intubation for cardiorespiratory resuscitation. The main causes of
intubation are reported in Table
1. Two stenoses were idiopathic. Preoperative assessment
included accurate laryngotracheal endoscopic examination to assess the
grade of inflammation and oedema of the trachea, especially at the margins
of the stenosis, the presence of tracheomalacia, the integrity of the vocal
cords, and the extention of tracheal involvement. Neck and chest CT scan
and, in the recent years, spiral CT scan were also performed to determine
the extention of stenosis; radiologic imaging also allowed to obtain more
information on the extraluminal region. The upper margin of the stricture
was 2mm to 1cm. below the vocal cords; the stenotic segment extended from
1.5 to 5cm. Three patients had tracheostomy done elsewhere. We subdivided
all patients in three groups. In Group I, 4 patients were managed by laser
and stenting by a silicon prosthesis as the only treatment. These were
patients with contraindications to open surgery because of poor general
status or pulmonary or cardiac disease. In Group II, 6 patients underwent
laryngotracheal resection after laser treatment (all 6 patients) and
positioning of a silicon stent (4 patients). This strategy was followed to
allow the stenosis to stabilize without tracheostomy or to improve
compromised general status. Surgery was performed after 1–6 months,
when the stenosis appared stabilized after endoscopic reevaluation. In
Group III, 8 patients with stabilized stenosis and good general health
underwent surgery as the only treatment. Three of these patients had
tracheostomy done elsewhere.
All the endoscopic procedures were
performed with the rigid bronchoscope (Efer-Dumon rigid bronchoscope; Efer
Medical, La Ciotat, Cedex, France) under deep sedation with short-acting
narcotics and local anesthesia (2% xylocaine).
The operative approach
was through a collar incision and the laryngotracheal resection was
performed on the base of the technique described by Pearson in 1975
[10]. The line of resection
began at the inferior border of the thyroid cartilage anteriorly and passed
below the cricothyroid joint behind, removing the anterior and lateral
aspects of the cricoid arch and leaving intact the posterior cricoid plate.
This manoeuvre allowed preservation of the recurrent laryngeal nerves. The
amount of trachea resected ranged from 1.5 to 5cm. No laryngeal release was
performed, as the technique of mobilization of the trachea was sufficient
to expose the stenotic lesion and to perform tracheal resection and
anastomosis. After resection, the distal airway was intubated with an
armoured endotracheal tube. The anastomoses were performed with interrupted
sutures (3-0 absorbable monofilament material) tied on the outside. With
the neck hyper extended to improve the exposure, all the sutures were
placed starting from the back and were left untied. The neck was then
flexed, the nasotracheal ventilation tube was readvanced distal to the
anastomosis and the two ends of the airway were allowed to reach applying
gentle traction simultaneously on all sutures. Sutures were then tied
starting from the front. The nasotracheal tube was left in place in the
awakened patient for 24h and then withdrawn after bronchoscopic check of
the anastomosis.
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3. Results
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There was
neither intraoperative nor perioperative mortality. None of the patients
was lost to follow-up. No patient required postoperative
tracheostomy.
In Group I (4 patients), no complications were observed
during and after endoscopic Nd:Yag laser treatment. The only complication
related to stent placement was dislocation in one patient who required
repositioning of the stent. In one patient the stent was removed after 2
years. Bronchoscopy demonstrated the absence of malacia and an airway
essentially normal in diameter. Two patients died of their
cardiorespiratory disease after 3.5 and 6 years with no signs of airway
stenosis. During a follow up ranging between 2 and 9 years, patients did
well but required permanent aerosolized and/or steroid therapy to avoid
plugging with secretions and airway oedema. These patients also require
periodical bronchoscopy to assess vocal cord integrity and function, the
correct position and the patency of the stent, and the status of the mucosa
of the remaining airway. All of these patients showed normal voice and
adequate breathing for normal activities.
In Group II, 6 patients
were treated before surgery with the laser and in four cases we placed an
endoluminal stent (Fig. 1). The goal of avoiding tracheostomy was achieved in all patients. We did not
report any complication related to laser therapy and stent positioning.
Surgery was performed 1 to 6 months after laser treatment when the stenosis
appeared stabilized and the stent could be removed. No intraoperative and
perioperative mortality occurred. Perioperative minor complications
occurred in two patients (33%) who had superficial wound infection due to
airway colonization by staphylococcus, and managed with drainage,
antibiotics and conservative therapy. No major complications occurred and
all patients breath and speak well after 2.5 to 10 years.
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Fig. 1. Sixty-nine year old lady with diabetes and chronic heart failure developing subglottic stenosis following intubation for myocardial ischemia. The stent was left in place for 3.5 years. The cricoid and the anterior commisure of the vocal cords can be seen.
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In Group
III (Fig. 2) we had no
intraoperative and perioperative mortality. Complications occurred in two
patients who developed postoperative stenosis (granuloma) at the
anastomotic level. Both stenoses were treated by laser vaporization and in
one patient we positioned a stent. The stent was removed after 1 year and
the calibre of the anastomosis was slightly inferior than the remaining
portion of the trachea, but yet above 90% of normal and without functional
impairment. One patient with preoperative tracheostomy had a wound
infection treated with drainage and conservative therapy. Overall in the 14
surgically treated patients we observed 2 (14.2%) major complications
(stenosis) and 3 (21.3%) minor complications (wound infection). After a
follow-up ranging from 15 months to 12 years all surgical patients present
voice and respiration completely
normal.
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Fig. 2. Seventy-two-year old gentleman with emphysema and chronic respiratory insufficiency. (A) Before surgery a fibrous stenosis associated with a granuloma is visible below the vocal cords at the cricoid level. (B) 1month after surgery. (C) 6 months after surgery.
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4. Discussion
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Surgical management
of benign tracheal and laryngotracheal stenosis is the treatment of choice
and may be done with high success rate [16,17]. However, primary surgery is not always
feasible. Contraindications to open surgery can be either general or local.
High-risk patients with severe associated systemic or cardiac diseases, or
a stenosis not yet stabilized with severe inflammatory signs of the
tracheal mucosa can contraindicate primary surgery. Temporary Montgomery
T-tube or permanent tracheostomy have been so far the only alternatives.
However, this solution in patients who require tracheostomy for surgical
contraindications has two disadvantages: the possible increase of the
length of stenosis and the development of airway bacterial colonization. In
order to avoid tracheostomy which would complicate surgical repair, we have
treated high risk patients and patients with benign subglottic stenosis not
yet stabilized, with Nd:YAG laser resection with or without indwelling
endotracheal stents. This necessarily heterogeneous group of patients shows
high variability in the outcomes. Some patients, whose compromised general
status did not improve and were thus not suitable for surgery, had good
results and quality of life after non-operative treatment, with a good
voice and adequate breathing for normal activities. Other patients,
endoscopically treated, required multiple laser treatments and frequent
bronchoscopy, which impaired their quality of life. While this less
aggressive, low risk approach is more acceptable for elderly patients,
definitive surgical treatment is more appropriate for younger patients who
are less likely to tolerate prolonged limitations in their lifestyle.
However, patients with severe inflammatory changes must be excluded from
surgery and treated only when the stenosis appears stabilized after a
suitable period of observation. In fact, restoration of a healthy mucosa is
mandatory to obtain good results. In this setting the endoscopic management
may be particularly valuable to provide time to reduce the damage due to
inflammation and oedema without tracheostomy, while awaiting definitive
surgical treatment. Furthermore, in our experience the use of laser with or
without stent positioning did not increase the morbidity rate and it was
used as a therapeutic option without increasing surgical complications and
postoperative mortality. On the other hand, patients who had wound
infection after surgery were as one would predict those who received
preoperative tracheostomy, thus suggesting that tracheostomy plays a role
in postoperative complications.
We also noticed that the fear of
dislocation of a subglottic, indwelling prosthesis is overestimated; in
fact, in our series, this occurred only in one patient. This was likeky due
to the characteristics of the fibrous stricture, which is usually stiff and
rigid and reduces tracheal calibre to that of the cricoid, thus providing
superior stability for the stent. This is demonstrated also by the fact
that none of the patients had vocal cord dysfunction due to prosthesis
dislocation.
Although open surgery is the treatment of choice for
benign subglottic laryngotracheal stenosis, the operation can not be
performed primarily in all patients. If local active inflammation or
compromised general health contraindicate surgery, laser assisted endoscopy
with stenting can represent a viable alternative. Also, the potentiality of
the combined approach should be considered to achieve good palliative and
definitive results without tracheostomy.
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Appendix A. Conference discussion
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Dr R. Santosham (India): We have had a fairly large experience of managing tracheal stenosis. We have done about 190 cases. But the thing you're talking about is laryngotracheal stenosis, and we understand that it's a difficult problem both surgically and with the use of laser. The only thing is that now the principles have been laid down and even higher strictures we are able to resect.
The only question that I would like to ask is, what stent did you use in these cases? We have found the expandable stents very useless in these situations and most of them give rise to problems in benign tracheal disease. That has been our observation.
Dr Rendina: We have used Dumon stents for a number of reasons. First of all, they can easily be removed at any time, they are reliable, they are cost-effective, and they do not cause the dreaded complication of granulation tissue on the upper and lower ends of the stent. As far as the laryngotracheal stenosis is concerned, maybe that would take too much time to comment, but the main difficulty is the anatomical location of the stenosis because the cricoid area is usually much more rigid than the rest of the trachea and the vicinity of the vocal cords makes a stent very unstable in that area.
Dr Santosham: How are you able to maintain the stent in the position? The problem is that they tend to slip, especially in benign disease, in high tracheal stenosis. Our problem has been that it tends to slip down because it doesn't hold on.
Dr Rendina: True.
Dr T. Orlowski (Warsaw, Poland): So could you explain how you fix the stent and how you position it according to the vocal cord level?
Dr Rendina: We place the stent with the normal stent deployer which has been designed and proposed by Dumon, and it's very easy to put the stent in. What is less easy and sometimes depends on the type of the stenosis, is to have the stent stay in place. Now, for laryngotracheal stenosis, there is a little trick. When you have a stenosis at the level of the upper rings of the trachea which makes the trachea rigid in that area, the rigidity of the trachea is comparable with the rigidity of the cricoid, and therefore the studs around the stent keep it in place. In other words, the more the stenosis is extended over the upper trachea, the more likely the stent is to stay in place.
Dr G. Stamatis (Essen, Germany): Can you give us more information about the role of comorbidity in your decision as to which patients are suitable for operation and which ones for conservative treatment?
Dr Rendina: Yes. I want to make this very clear. The nonoperative treatment in these patients is not an alternative to surgery. Sometimes the stenosis is fresh, with some degree of inflamation and edema and you do not want to operate; in these cases the alternative is to make a permanent tracheostomy, which we don't like to do for the risk of infection that it carries with it. Also, the patients in whom we have used nonoperative treatment were either very old or tetraplegic, because laryngo-tracheal problems usually occur in patients who have other comorbidities. The young patients in whom we have used this approach were patients with serious neurological problems or patients who were hospitalized and intubated for cardiopulmonary reasons.
Dr I. Poliakov (Krasnodar, Russian Federation): Did you observe any granulation tissue growth below or in the upper margin of the stent resulting in extension of the stenosis after you removed the stent?
Dr Rendina: We did not.
Dr Poliakov: How many patients did you convert to surgery after conservative treatment failed?
Dr Rendina: As I said, 4.
Dr P. Macchiarini (Hannover, Germany): I have a comment about group 3 where 8 patients were operated only and you have a 25% stenosis. Do you have any technical reasons for that or indications or what?
Dr Rendina: No. Two patients in the group you are referring to had restenosis after surgery. One was a 50-year-old patient with a congenital stenosis probably dating back to his early years of life, which was misconsidered for many years, and he had a restenosis which was treated by dilatation and stenting and healed after a year. Another patient had tracheostomy done elsewhere. He had some infection of the subcutaneous tissues and maybe that might have had an impact on restenosis.
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Footnotes
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Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.
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Top
Abstract
1. Introduction
