Tracheal Stenosis: Our Experience at a Tertiary Care Centre in India with Special Regard to Cause and Management

Abstract

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.

Does duration of mechanical ventilation affect the resection length in benign tracheal stenosis?

“…[10] Ischemic injury due to cuff pressure is the main etiological factor in this benign condition. Stenosis might be seen after a series of consecutive processes: local infection may be superimposed on the damaged endotracheal surface and perichondritis may occur in tracheal cartilage, then fibroblastic activity accelerates in this area, and finally scar tissues and stenosis occur in traumatic area.…”

“…Stenosis might be seen after a series of consecutive processes: local infection may be superimposed on the damaged endotracheal surface and perichondritis may occur in tracheal cartilage, then fibroblastic activity accelerates in this area, and finally scar tissues and stenosis occur in traumatic area. [10] Steroids and antibiotics are helpful in reducing granulation and fibrosis. [10] The gold standard in diagnosis of tracheal stenosis is bronchoscopy.…”

“…[10] Steroids and antibiotics are helpful in reducing granulation and fibrosis. [10] The gold standard in diagnosis of tracheal stenosis is bronchoscopy. [11,12] Fiberoptic bronchoscopy may be the first option in elective patients but rigid bronchoscopy should be preferred in cases with respiratory distress.…”

“…[3] Other treatment modalities are surgical resection, balloon dilatation, tracheal T-tube, various lasers, and stents. [10,[15][16][17] Although several techniques, such as mentioned above, have been described in the management of tracheal stenosis related to intubation, principal approach is resection of affected tracheal segment and end-to-end anastomosis. Success rate of resection was reported to be between 74% and 96% in the literature.…”

Use of Conchal Cartilages for Laryngotracheal Stenosis: Experiences at a Tertiary Care Hospital of Eastern India

“…Despite the availability of different surgical options, management of laryngotracheal stenosis is still remains an enigma. LTS is a challenging problem, a known complication of prolonged intubation and tracheostomy [2]. Despite good quality of endotracheal tube used nowadays, its incidence is rising because of the large number of patients requiring intubation in the intensive care unit.…”