Laryngotracheal stenosis


Laryngotracheal stenosis refers to abnormal narrowing of the central air passageways1 This can occur at the level of the larynx, trachea, carina or main bronchi2 In a small number of patients narrowing may be present in more than one anatomical location

Contents

  • 1 Nomenclature
  • 2 Causes
  • 3 Presentation
  • 4 Treatment
  • 5 See also
  • 6 References

Nomenclatureedit

Laryngotracheal stenosis Laryngo-: Glottic Stenosis; Subglottic Stenosis; Tracheal: narrowings at different levels of the windpipe is a more accurate description for this condition when compared, for example to subglottic stenosis which technically only refers to narrowing just below vocal folds or tracheal stenosis In babies and young children however, the subglottis is the narrowest part of the airway and most stenoses do in fact occur at this level Subglottic stenosis is often therefore used to describe central airway narrowing in children, and laryngotracheal stenosis is more often used in adults

Causesedit

Laryngotracheal stenosis is an umbrella term for a wide and heterogeneous group of very rare conditions The population incidence of adult post-intubation laryngotracheal stenosis which is the commonest benign sub-type of this condition is approximately 1 in 200,000 adults per year3 The main causes of adult laryngotracheal stenosis are:

Main causes of laryngotracheal stenosis
Benign causes Malignant causes
Extrinsic compression
  • Thyroid goitre
  • Thymoma
  • Mediastinal lymphadenopathy eg TB4
  • Vascular anomalies
  • Thyroid cancer5
  • Lung cancer/lymphomas-related mediastinal lymphadenopathy
Intrinsic narrowing
  • At the level of the larynx glottis
    • Bilateral vocal fold paralysis
    • Blunt/sharp laryngeal trauma
    • Foreign body inhalation
    • Sarcoidosis
    • Amyloidosis6
    • Bilateral vocal fold mobility impairment
      • Crico-arytenoid joint fixation
        • Rheumatoid arthritis
        • Intubation-related joint fixation
      • Inter-arytenoid scarring
        • Intubation-related
    • Infections eg Diphtheria, epiglottitis
    • Respiratory papillomatosis78
    • Large ball-valving vocal polyps
    • Congenital laryngeal stenosis
      • Laryngeal atresia
      • Congenital laryngeal webs
  • At the level of subglottis/trachea
    • Intubation/tracheostomy-related most common cause910
    • Granulomatosis with polyangiitis<11al involvement of relapsing polychondritis in a Korean girl |journal=Pediatr Pulmonol |volume=35 |issue=4 |pages=314–7 |date= April 2003 |pmid=12629631 |doi=101002/ppul10247 |url=http://dxdoiorg/101002/ppul10247%7Ctype=Review</ref>
    • Idiopathic Progressive Subglottic Stenosis
    • Amyloidosis
    • Tracheopathia osteoplastica
    • Tracheomalacia
      • Expiratory Dynamic Airway Collapse EDAC
      • Tracheobronchomalacia
        • Relapsing polychondritis1213
        • Tracheal ring damage due to COPD
        • Tracheal ring weakness
    • Benign tumors eg Carcinoid
    • Tracheal trauma / rupture14
    • Congenital subglottic/tracheal anomalies
      • Complete tracheal rings
      • Congenital subglottic/tracheal webs
      • Subglottic haemangioma
      • Subglottic / tracheal cysts15
  • At the level of carina or main bronchi
    • Granulomatosis with polyangiitis
    • Foreign body inhalation
    • Tuberculosis
    • Following Photodynamic Therapy
  • Head and neck especially laryngeal or supraglottic cancers
  • Primary tracheal cancers
  • Erosive thyroid cancer
  • Erosive esophageal cancer16
  • Lung cancer causing central airway obstruction4

Presentationedit

The most common symptom of laryngotracheal stenosis is gradually-worsening breathlessness dyspnea particularly when undertaking physical activities exertional dyspnea The patient may also experience added respiratory sounds which in the more severe cases can be identified as stridor but in many cases can be readily mistaken for wheeze This creates a diagnostic pitfall in which many patients with laryngotracheal stenosis are incorrectly diagnosed as having asthma and are treated for presumed lower airway disease1718 19 20 21 22 This increases the likelihood of the patient eventually requiring major open surgery in benign disease 23 and can lead to tracheal cancer presenting too late for curative surgery to be performed

Treatmentedit

The optimal management of laryngotracheal stenosis is not well defined, depending mainly on the type of the stenosis24 General treatment options include

  1. Tracheal dilation using rigid bronchoscope
  2. Laser surgery and endoluminal stenting25
  3. Tracheal resection and laryngotracheal reconstructionr1426

Tracheal dilation is used to temporarily enlarge the airway The effect of dilation typically lasts from a few days to 6 months Several studies have shown that as a result of mechanical dilation used alone may occur a high mortality rate and a rate of recurrence of stenosis higher than 90%24 Thus, many authors treat the stenosis by endoscopic excision with laser commonly either the carbon dioxide or the neodymium: yttrium aluminum garnet laser and then by using bronchoscopic dilatation and prolonged stenting with a T-tube generally in silicone272829

There are differing opinions on treating with laser surgery

In very experienced surgery centers, tracheal resection and reconstruction anastomosis complete end-to-end with or without laryngotracheal temporary stent to prevent airway collapse is currently the best alternative to completely cure the stenosis and allows to obtain good results Therefore, it can be considered the gold standard treatment and is suitable for almost all patients30

The narrowed part of the trachea will be cut off and the cut ends of the trachea sewn together with sutures For stenosis of length greater than 5 cm a stent may be required to join the sections

Late June or early July 2010, a new potential treatment was trialed at Great Ormond Street Hospital in London, where Ciaran Finn-Lynch aged 11 received a transplanted trachea which had been injected with stem cells harvested from his own bone marrow The use of Ciaran's stem cells was hoped to prevent his immune system from rejecting the transplant,31 but there remain doubts about the operation's success, and several later attempts at similar surgery have been unsuccessful

See alsoedit

  • Hermes Grillo pioneer in tracheal resection surgery

Referencesedit

  1. ^ Gelbard, A 2014 "Causes and Consequences of Laryngotracheal Stenosis" The Laryngoscope doi:101002/lary24956 
  2. ^ Armstrong WB, Netterville JL August 1995 "Anatomy of the larynx, trachea, and bronchi" Otolaryngol Clin North Am 28 4: 685–99 PMID 7478631 
  3. ^ Nouraei SA, Ma E, Patel A, Howard DJ, Sandhu GS 2007 "Estimating the population incidence of adult postintubation laryngotracheal stenosis" Clin Otolaryngol 32: 411–412 doi:101111/j1749-4486200701484x 
  4. ^ a b Lu MS, Liu YH, Ko PJ, Wu YC, Hsieh MJ, Liu HP, Lin PJ April 2003 "Preliminary experience with bronchotherapeutic procedures in central airway obstruction" Chang Gung Med J 26 4: 240–9 PMID 12846523 
  5. ^ Tsutsui H, Kubota M, Yamada M, Suzuki A, Usuda J, Shibuya H, Miyajima K, Sugino K, Ito K, Furukawa K, Kato H September 2008 "Airway stenting for the treatment of laryngotracheal stenosis secondary to thyroid cancer" Respirology 13 5: 632–8 PMID 18513246 doi:101111/j1440-1843200801309x 
  6. ^ Peña J, Cicero R, Marín J, Ramírez M, Cruz S, Navarro F October 2001 "Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present" Otolaryngol Head Neck Surg 125 4: 397–400 PMID 11593179 doi:101067/mhn2001117372 
  7. ^ Bent J July 2006 "Pediatric laryngotracheal obstruction: current perspectives on stridor" Laryngoscope 116 7: 1059–70 PMID 16826038 doi:101097/01mlg000022220488653c6 
  8. ^ Perkins JA, Inglis AF, Richardson MA March 1998 "Iatrogenic airway stenosis with recurrent respiratory papillomatosis" Arch Otolaryngol Head Neck Surg 124 3: 281–7 PMID 9525512 doi:101001/archotol1243281 
  9. ^ Wood DE, Mathisen DJ September 1991 "Late complications of tracheotomy" Clin Chest Med 12 3: 597–609 PMID 1934960 
  10. ^ Lorenz RR December 2003 "Adult laryngotracheal stenosis: etiology and surgical management" Curr Opin Otolaryngol Head Neck Surg 11 6: 467–72 PMID 14631181 doi:101097/00020840-200312000-00011 
  11. ^ Lee, PY; Adil, EA; Irace, AL; Neff, L; Son, MB; Lee, EY; Perez-Atayde, A; Rahbar, R January 2017 "The presentation and management of granulomatosis with polyangiitis Wegener's Granulomatosis in the pediatric airway" Laryngoscope 127 1: 233-40 PMID 27113905 doi:101002/lary26013 
  12. ^ Chang SJ, Lu CC, Chung YM, Lee SS, Chou CT, Huang DF June 2005 "Laryngotracheal involvement as the initial manifestation of relapsing polychondritis" J Chin Med Assoc 68 6: 279–82 PMID 15984823 doi:101016/S1726-49010970151-0 
  13. ^ Kim CM, Kim BS, Cho KJ, Hong SJ April 2003 "Laryngotracheal involvement of relapsing polychondritis in a Korean girl" Pediatr Pulmonol 35 4: 314–7 PMID 12629631 doi:101002/ppul10247 
  14. ^ a b Mostafa BE, El Fiky L, El Sharnoubi M July 2006 "Non-intubation traumatic laryngotracheal stenosis: management policies and results" Eur Arch Otorhinolaryngol 263 7: 632–6 PMID 16633824 doi:101007/s00405-006-0036-8 
  15. ^ Kokturk N, Demircan S, Kurul C, Turktas H October 2004 "Tracheal adenoid cystic carcinoma masquerading asthma: a case report" BMC Pulm Med 4: 10 PMC 526771  PMID 15494074 doi:101186/1471-2466-4-10 
  16. ^ Wassermann K, Mathen F, Edmund Eckel H October 2000 "Malignant laryngotracheal obstruction: a way to treat serial stenoses of the upper airways" Ann Thorac Surg 70 4: 1197–201 PMID 11081870 doi:101016/s0003-49750001614-3 
  17. ^ Catenacci MH July 2006 "A case of laryngotracheal stenosis masquerading as asthma" South Med J 99 7: 762–4 PMID 16866062 doi:101097/01smj00002174987096777 
  18. ^ Ricketti PA, Ricketti AJ, Cleri DJ, Seelagy M, Unkle DW, Vernaleo JR 2010 "A 41-year-old male with cough, wheeze, and dyspnea poorly responsive to asthma therapy" Allerg Asthma Proc 31: 355–8 doi:102500/aap2010313344 
  19. ^ Scott PM, Glover GW 1995 "All that wheezes is not asthma" Br J Clin Pract 49: 43–4 
  20. ^ Kokturk N, Demircan S, Kurul C, Turktas H 2004 "Tracheal adenoid cystic carcinoma masquerading asthma: a case report" BMC Pulm Med 4: 10 
  21. ^ Parrish RW, Banks J, Fennerty AG 1983 "Tracheal obstruction presenting as asthma" Postgrad Med J 59: 775–6 doi:101136/pgmj59698775 
  22. ^ Galvin IF, Shepherd DR, Gibbons JR 1990 "Tracheal stenosis caused by congenital vascular ring anomaly misinterpreted as asthma for 45 years" Thorac Cardiovasc Surg 38: 42–4 doi:101055/s-2007-1013990 
  23. ^ Nouraei SA, Singh A, Patel A, Ferguson C, Howard DJ, Sandhu GS 2006 "Early endoscopic treatment of acute inflammatory airway lesions improves the outcome of postintubation airway stenosis" Laryngoscope 116 8: 1417–21 doi:101097/01mlg00002253773394514 
  24. ^ a b Brichet A, Verkindre C, Dupont J, Carlier ML, Darras J, Wurtz A, Ramon P, Marquette CH April 1999 "Multidisciplinary approach to management of postintubation tracheal stenoses" Eur Respir J 13 4: 888–93 PMID 10362058 doi:101034/j1399-3003199913d32x 
  25. ^ Ciccone AM, De Giacomo T, Venuta F, Ibrahim M, Diso D, Coloni GF, Rendina EA October 2004 "Operative and non-operative treatment of benign subglottic laryngotracheal stenosis" Eur J Cardiothorac Surg 26 4: 818–22 PMID 15450579 doi:101016/jejcts200406020 
  26. ^ Duncavage JA, Koriwchak MJ August 1995 "Open surgical techniques for laryngotracheal stenosis" Otolaryngol Clin North Am 28 4: 785–95 PMID 7478638 
  27. ^ Shapshay SM, Beamis JF, Hybels RL, Bohigian RK 1987 "Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation" Ann Otol Rhinol Laryngol 96 6: 661–4 PMID 3688753 doi:101177/000348948709600609 
  28. ^ Shapshay SM, Beamis JF, Dumon JF November 1989 "Total cervical tracheal stenosis: treatment by laser, dilation, and stenting" Ann Otol Rhinol Laryngol 98 11: 890–5 PMID 2817681 doi:101177/000348948909801110 
  29. ^ Mehta AC, Lee FY, Cordasco EM, Kirby T, Eliachar I, De Boer G September 1993 "Concentric tracheal and subglottic stenosis Management using the Nd-YAG laser for mucosal sparing followed by gentle dilatation" Chest 104 3: 673–7 PMID 8365273 doi:101378/chest1043673 
  30. ^ Gómez-Caro A, Morcillo A, Wins R, Molins L, Galan G, Tarrazona V January 2011 "Surgical management of benign tracheal stenosis" Multimed Man Cardiothorac Surg 2011 1111: mmcts2010004945 PMID 24413853 doi:101510/mmcts2010004945 
  31. ^ "New throat surgery 'a success'" BBC News 2010-08-06 
Bibliography
  • Ongkasuwan, Julina 2006-02-09 "Tracheal Stenosis" Baylor College of Medicine Archived from the original on 2007-02-20 Retrieved 2007-03-17 


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