Tracheal stenosis (TS), a challenging problem, is a known complication of prolonged intubation and tracheostomy. The management involves a multidisciplinary approach with multiple complex procedures. In this study we discuss our experience with severe TS with regards to patient characteristics, cause and management. A retrospective analysis of 20 patients of severe TS treated at a tertiary care centre was evaluated. Inclusion criteria were all patients with severe TS who required surgical intervention. Exclusion criteria were patients with associated laryngeal stenosis and TS due to cancer. Demographic data was recorded and findings relating to aetiology, characteristics of stenosis and the various aspects of therapeutic procedures performed are discussed with review of literature. Descriptive analysis of data were performed SPSS 18. Results of the 20 patients, 17 patients (85 %) developed TS post tracheostomy, or post intubation and subsequent tracheostomy. 13 Patients (65 %) had true stenosis of which 7 patients (35 %) had simple web or circumferential fibrosis and 6 patients (30 %) had complex stenosis. Seven patients (35 %) had granulations causing severe TS which were mostly suprastomal (5 patients), stomal (5 patients) and combined stomal and suprastomal (3 patients). The average length of stenosis was 3.57 cm (0.5-8 cm). Montgomery t tube insertion was a common procedure in 18 patients (90 %) pre or post intervention. Each patient underwent an average of 3.4 procedures during their course of treatment which included rigid bronchoscopy and mechanical debulking, Nd YAG laser, KTP laser, balloon dilatation and use of stents. Among the 7 patients with granulations 100 % successful decanulation was noted with endoscopic management whereas in 13 patients with true stenosis, 10 patients (76.9 %) required open surgical management (8 tracheal resection and anastomosis and 2 tracheoplasty) with 80 % successful decanulation, 2 patients (15.4 %) were treated with endoscopy with 100 % successful decanulation and 1 patient (7.7 %) was a non surgical candidate on stent. Of the total 20 patients with severe TS in this series, 17 (85 %) of patients who were decanulated, asymptomatic on routine daily activities with normal FFB were considered cured. TS is a challenging condition requiring a highly skilled multidisciplinary team for adequate management. Prolonged intubation and tracheostomy are the common causes leading to tracheal stenosis. Simple tracheal stenosis is easier to manage than a complex stenosis which usually requires an open surgical procedure for successful management. Presence of conditions like tracheoesophageal fistula and long segment tracheomalacia are poor factors for successful management. In our cases successful decanulation was possible in 85 % of the patients following a systematic multidisciplinary approach.

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Malignant peripheral nerve sheath tumor (MPNST) refers to spindle cell sarcomas arising from or separating in the direction of cells of peripheral nerve sheath. The MPNST of the parotid gland is an extremely rare tumor, accounts for < 5% of all soft tissue sarcomas, and carries a poor prognosis. In this article, we report a case of MPNST of parotid gland in a 45-year-old male and review its diagnostic and therapeutic challenges. A 45-year-old male presented with right parotid swelling for 2 years with rapid increase in size over the last 3 months. He underwent right total conservative parotidectomy with selective neck dissection. Reconstruction was done with microvascular anterolateral thigh flap. On immunohistochemistry, the tumor cells expressed CD 56 diffusely and S 100 focally. Tumor was immunonegative for CK, Desmin, SOX -10, and SMA consistent with MPNST. The MPNSTs arising as parotid mass are very rare and aggressive tumors. The role of IHC is paramount in establishing the diagnosis. Multimodal management including wide surgical resection, neck dissection, and adjuvant chemoradiotherapy is the choice of treatment.