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Ann Thorac Surg 1995;60:250-259
© 1995 The Society of Thoracic Surgeons
Thoracic Surgery Unit, Xavier Arnozan Hospital, Pessac (Bordeaux), France
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsTreatment and ResultsCommentReferences |
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Methods. A series of 217 nontumoral stenoses of the upper airway were treated following the same therapeutic principles in the period 1978 to 1992. Two hundred one of them were iatrogenic postintubation strictures (92%); the others were posttraumatic (7), idiopathic (5), and various (4).
Results. One hundred twenty (55%) were tracheal stenoses and treated by resection and primary end-to-end anastomosis with 117 excellent or good results and three deaths. Length of the stenosis, old age, neuropsychological sequelae, and overall poor respiratory status of the patients made up the remaining difficulties in the treatment. Ninety-seven (45%) were laryngotracheal stenoses with much more complex surgical indications: 57 patients underwent tracheal and subglottic resection and anastomosis with 56 successes and one death, 7 had laryngotracheal resection and anastomosis with total cricoidectomy and consequently laryngeal stenting for 3 to 6 months (six successes, one death), 3 had supraglottic resection and anastomosis (three successes), 12 patients with glottic opening difficulties and short laryngeal stenosis underwent a laryngeal enlargement over a T tube without resection (11 successes, one death), and 18 were subjected to a complex combination of resection and modeling with 16 successes, 2 failures, and 1 death. Final results were successful in 208 cases (96%) with seven deaths and two failures. Mild phonetic sequelae were observed after laryngeal modeling. A minimal follow-up of 1 year has shown long-term stability of most repairs.
Conclusions. Despite acceptable results, the therapeutic approach remains difficult for laryngotracheal stenoses involving the glottic and the supraglottic level as well as for those that have not responded to previous attempts at repair. In a few cases, despite a meticulous preoperative assessment, the surgical strategy can only be adopted intraoperatively. The key to surgical success is undoubtedly a careful preoperative treatment of infection and inflammation as well as a meticulous muco-mucosal approximation of healthy margins at the anastomosis.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsTreatment and ResultsCommentReferences |
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After 1965 the number of nontumoral stenoses of the upper airway requiring surgical treatment has increased dramatically due to the increasing number of patients receiving respiratory support by tracheostomy or laryngotracheal intubation, now the leading cause of such stenoses. Less commonly they follow external laryngotracheal trauma, chemical burns, mismanaged cervicomediastinal radiotherapy, or idiopathic causes.
The first attempts at surgical repair proposed various surgical approaches dependent on the speciality of the surgeon: mainly laryngotracheal enlargement with ear, nose, and throat surgeons, skin or cartilage plasties with plastic surgeons, and as often as possible resection anastomosis in the hands of thoracic surgeons. After that pioneers such as Grillo and Pearson [1–3] described the indications and technique for safe tracheal resection followed by end-to-end reanastomosis, and it was generally accepted that tracheal stenosis should be treated through resection and anastomosis whereas laryngeal stenosis should be treated through laryngoplasty.
After our first 15 cases (Feb 1967 to Oct 1968) we described the conditions and the local preparation necessary for good healing of the tracheal anastomosis avoiding leakages or restenosis [4]. We emphasized the necessity of palliative clearing of the obstruction of the airway through endoscopic electrocoagulation of obstructive granulomata and the importance of preoperative antibiotic and antiinflammatory therapy, delaying the surgical procedure to allow the tracheal resection anastomosis in healthy margins.
After 1970 the widespread use of nasotracheal intubation avoided tracheostomy and its pitfalls, but resulted in more frequent laryngeal or laryngotracheal stenoses requiring long and multistaged procedures for their treatment. Since Gerwat and Bryce [5] and Pearson and colleagues [6] demonstrated that resection anastomosis could be extended to the subglottic larynx, surgery of laryngotracheal stenoses evolved into more aggressive and effective techniques for single-stage procedures up to the subglottic area and later up to the upper larynx [7].
After 1978 our philosophy was well established with a consistant protocol for investigations, preoperative assessment, preparation, and therapeutic options. The object of this article is to report our experience of treatment of upper airway stenoses in 217 patients in the period 1978 to 1992 and a minimal follow-up of 1 year. We excluded from the series patients in whom surgical treatment was unnecessary (eg, patients with inflammatory and noncircumferential obstructive lesions such as granuloma and partially stenosing fibrous arches, which were cured by antiinflammatory drugs and endoscopic laser photocoagulation). We also excluded patients with contraindications to operation who underwent endoluminal stenting (Gianturco or Dumont) [8], T tubes, or permanent tracheostomy. Furthermore, we excluded long-segment congenital tracheal stenoses with O rings as well as tracheomalacia, the treatment of the latter with expanding wire stents being nowadays well established [8].
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsTreatment and ResultsCommentReferences |
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The cause of airway stenosis was iatrogenic in 201, who had undergone an intubation for respiratory resuscitation. That was indicated for one of the diseases that can result in respiratory failure: the main causes were trauma, frequently of brain, chest, or polytrauma, medical diseases including metabolic and neurologic problems, acute failure in chronic respiratory insufficiency, and, finally resuscitation after operation followed by metabolic or postinfective multiorgan failure. The other causes were external cervical trauma with mismanaged total laryngotracheal separation in 7 patients and various in 4 including chemical burn in 1, postinfectious fibrous scar in 1, and irradiation in 2. Five stenoses were idiopathic, always affecting the subglottic area with alteration of the cricoid cartilage.
Lesions
Because the location of the lesions will have an important influence on the surgical options, two types of stenotic lesions are defined depending on the presence or absence of concomitant laryngeal damage.
Tracheal stenoses were present in 120 patients. They make up 55% of our series and by definition are located below the cricoid ring. The lesions were located at the cervical level in 78 patients (65%), at the cervicothoracic junction level in 22 patients (18%), and intrathoracically in 12 patients (10%). Eight patients had distant multifocal lesions at different levels (7%).
Laryngeal or laryngotracheal stenoses were present in 97 patients (45%): 91 were secondary to nasotracheal intubation, 1 to chemical burn, and 5 to idiopathic causes. Additional contributing factors were prolonged intubation followed by tracheostomy, improper siting of a tracheostomy involving the cricoid cartilage, traumatic laryngeal intubation, and failed previous attempts at surgical repair (9 cases). The laryngeal lesions were located at the subglottic level in 93 patients, reached the glottis in 34, and went up to the supraglottic level in 4. Most were multifocal at the laryngeal level, and they were associated with varying degrees of tracheal lesions or stenosis in 69 patients (71%). Therapeutic options varied accordingly.
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Treatment and Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsTreatment and ResultsCommentReferences |
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The phonetic results were more difficult to classify because we did not assess these results systematically with physiologic testing of laryngeal function. Therefore, we report a subjective classification considering the result as good when the patient was able to speak aloud, to shout, and to sing; as fair when the patient could speak aloud and shout but with an altered voice; and as acceptable when the patient could speak aloud but with an evident weakness. We never observed a voiceless patient at the 1-year follow-up.
Tracheal Stenosis
All 120 patients underwent tracheal resection anastomosis after the above-mentioned preparation. Incision was cervical in 91 patients (76%), which allows resection at the level of the cervical trachea and the cervicothoracic junction. The cervical approach was combined with a sternotomy in 28 patients (23%), and the route was a right thoracotomy in 1. The results were excellent to good in 117 patients (97%) with reestablishment of a normal respiratory function and an airway patency from 90% to 100% (excellent) to 80% (good) without clinical consequences. The phonation was equally restored, with good to fair results allowing normal professional and social communication. Nevertheless, the recovery of a normal voice sometimes was impaired by some laryngeal sequelae such as hemilaryngeal palsy or fibrotic arches anchoring the vocal cords, the result of brain trauma consequences or of a long and traumatic transglottic intubation, respectively.
There were three deaths, one of total anastomotic dehiscence with fatal hemorrhage, one cerebrovascular accident in an 80-year-old patient, and one respiratory failure in a patient with chronically impaired respiratory function.
Tracheal resection and anastomosis therefore can achieve good vital and functional results provided the above-mentioned principles are respected.
Laryngeal and Laryngotracheal Stenosis
Therapeutic strategy varied according to the site and the length of the lesions, the length of tracheal involvement, and the result of a meticulous evaluation of glottic opening and vocal cord mobility. Thereafter treatment of these complex lesions required various types of surgical procedures, which are as follows:
Late Results at Follow-up
Overall results are successful in 208 cases (96%); there were seven deaths and two failures. Follow-up from 1 to 10 years has demonstrated long-term stability of the results acquired at 3 months after tracheal resection and acquired at 1 year after complex repairs in laryngotracheal stenoses.
Indeed, in few cases with total or subtotal resection of the cricoid, we observed at 3 to 6 months postoperatively some degree of instability of the posterior supraglottic structures resulting in prolapse of the arytenoid or supraarytenoid cartilages and mucosa into the glottic lumen with subsequent stridor on exertion or night-time snoring and dyspnea. Laser photocoagulation of these structures and of any redundant mucosa universally has been easy to achieve and successful in relieving the symptoms.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsTreatment and ResultsCommentReferences |
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Clinical Course and Emergency Treatment
Airway stenosis usually becomes symptomatic soon after extubation. Nevertheless, in a previous study we found that 22 of 74 stenoses occurred later than the first month after extubation and caused severe difficulties when occurring in nonspecialized medical environment. Systematic endoscopic examination of all patients who underwent respiratory resuscitation reduced the necessity of emergency treatment. However, the ability to provide such care without pitfalls or inappropriate measures remains important. Acute distress from such a lesion not responding to antibiotic and steroid therapy requires immediate rigid bronchoscopy. This allows ventilation and oxygenation of the patient, dilation of the stenosis, and distal toilet of the airway. Laser coagulation of granuloma and endoluminal scars immediately reestablishes adequate tracheal caliber, allows comfortable breathing, and gives time for preoperative assessment and convenient preparation for definitive operation. If rigid endoscopy is not available, we recommend forceful orotracheal intubation using a small-caliber tube, which will permit adequate oxygenation and ventilation and should allow distal bronchial toilet, that being one of the most important steps in palliative treatment. A few hours later, the small tube can be replaced by a larger one in the molded bed of the stenosis and then the stabilized patient may be transferred to a specialized center for further treatment. Two pitfalls must be avoided at this moment: first, the creation of a tracheostomy below the stenotic segment, which augments the length of the tracheal injury and renders the final surgical treatment much more difficult, and second, an emergency surgical resection anastomosis in an infected, inflamed, and unprepared field, which significantly increases the risk of failure of any type of surgical correction.
Limits and Contraindications to Operation
Important difficulties may arise from the general status of the patient and from the local aspect of the lesions. Each of these difficulties is by itself a large field of discussion, where our answer was not always the best one.
Old age, per se, is not a contraindication to tracheal resection. On the contrary, the aged should have as good oxygenation as anyone through a good airway and they suffer more than anyone from multiple manipulations and the problems that can result from permanent intubation and prosthesis. Three patients were more than 80 years old in our series, the oldest being 88 years. One of them died of a cerebral accident, underlining that old age is certainly a risk factor.
After brain trauma, residual neuropsychological sequelae may be a problem when considering the patient for tracheal resection and closing tracheostomy. We require that the patient at least be able to swallow without aspirating cough and expectorate on command. These requirements will facilitate the postoperative course and avoid too frequent tracheobronchial suctions.
The timing of resection should be coordinated with the rehabilitation physician. It should be remembered that the reestablishment of normal airway and voice in these patients often will be followed by a rapid improvement in their neurologic status.
Another difficult decision is whether to resect or permanently tracheotomize patients with severe chronic respiratory insufficiency. It is difficult to predict which patients will be at risk for early relapse of acute respiratory failure. One patient in our series died in the postoperative period with pyocyanic reinfection, and 2 others with an excellent surgical result were retracheotomized in the following months for a recurrent postinfectious respiratory failure episode. When that can be anticipated these patients are best managed with endoluminal stents or permanent tracheostomy, which allows night-time oxygenation or ventilation when necessary.
Another very difficult problem may arise with very long stenoses or bifocal stenoses. These raise the question of the maximal length of trachea that can be resected and reanastomosed safely. Because the tension at the anastomotic level appears to be an important prognostic factor after tracheal anastomosis, Mulliken and Grillo [9] have meticulously measured the average amount of trachea that can be resected and the resulting tension required for reapproximation of the tracheal ends as well as the effect of the right hilar dissection and carinal mobilization. The maximal length of resection generally is taken to be 5 to 6 cm or nine to ten tracheal rings. We find these indications of limited practical value because fibrotic stenosis may retract the trachea and ``telescope'' or completely destroy the rings. Moreover, the resectable length varies with patient morphology and age. A longer resection is possible in taller patients with a long neck because the neck flexion permits lowering of the tension at reaproximation of the tracheal ends more than in shorter patients. Furthermore, the elasticity of the trachea in younger patients permits easier tension-free approximation than the corresponding airway in older patients with fibrous and sometimes calcified tracheal structure. Prior attempts at repair also render reapproximation more difficult and dangerous. All the above factors must be taken into account when the feasibility of resection and anastomosis is evaluated. After Mulliken and Grillo we proposed that half of the trachea could represent the length of trachea that is safely resectable. Appropriate allowance to do a little less or more depends on circumstances. In some cases, lengthening the time of preparation permits increasing fibrosis and retraction of the stenosed segment, which brings it within the limits of resectability.
Various lengthening procedures are available to allow extended resections and tension-free repair. Laryngeal releases proposed by Dedo and Fishman [10] and by Montgomery [11] give 2 to 3 cm of additional length for end to end approximation. However, both techniques may cause significant problems of aspiration, and whenever a sternotomy is necessary we prefer hilar and carinal mobilization, which may give 2 to 4 cm (Fig 1
).
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Technical Strategy and Indications
Tracheal resection and end-to-end anastomosis is now a well-established technique under well-codified indications, which requires no commentary.
Laryngotracheal surgery is much more difficult. Indications for various techniques may vary from millimeter to millimeter according to the extension of the lesions, and the technical execution must pay attention to both anatomic and functional results. Two factors must be considered in the preoperative assessment to define the surgical procedure. First, the precise topography of the injury must be defined with exact location and length of the stenosis, the length of the tracheal involvement, and the amount of cricoid destruction. Second, functional evaluation of the glottis is of capital importance, with reference to glottis patency as well as mobility of the vocal cords that may be affected by scarring, recurrent nerve injury, or ankylosis of the cricoarytenoid joints. To define the lesions, preoperative assessment should include awake-flexible as well as anesthetized-rigid endoscopic evaluation, laryngotracheal tomography, and fine-cut computed tomography of the larynx. Despite all the information obtained from these investigations the extent of involvement of the various structures may sometimes only be fully assessed during operation, so the planned interventions often have to be modified intraoperatively.
These considerations are the basis of our policy in regard to treatment modalities.
1. Tracheal and laryngeal sublottic senoses with open and mobile glottis are best managed by resection of the involved trachea and of the cricoid ring according to the technique described by Gerwat and Bryce [5] and Pearson and associates [6] (Fig 2). More or less of the cricoid plate can be excised until the resection reaches the margin of healthy mucosa. A posterior tracheal mucosal flap may be fashioned as described by Grillo [12] to cover with mucosa the anterior part of the cricoid plate up to the basis of the vocal cords if it is bared after resection of fibrous and inflammatory tissues. Our technique of subglottic laryngotracheal resection has evolved to appreciable modifications of the original technique. We avoid identification of the recurrent nerves, plication of the posterior membranous trachea, and subanastomotic tracheostomy. We find that subperichondrial cricoid resection by curette protects the laryngeal nerves from injury and obviates the need for dissection in fibrotic scar tissue, which may itself compromise the nerves either directly or by interference with their blood supply. Furthermore, the perichondrium left in place provides a strong support to the tracheal reimplantation. We avoid tracheostomy to prevent further tracheal injury and possible tracheal ischemia between the stoma and the anastomosis. Early postoperative extubation is possible in most patients without subsequent respiratory problems provided laryngeal edema is prevented by the administration of corticosteroids (methylprednisolome, 40 to 60 mg/day for 5 to 7 days). If at extubation there is concern about the degree of laryngeal edema or vocal cord dysfunction we opt to leave a silicone nasotracheal tube with a noninflated cuff in situ for 2 to 4 days. In general, when a tracheal tube has to be left in place a short time for general or local indications after tracheal resection and anastomosis we recommend a deflated cuff to avoid mucosal and submucosal ischemia and necrosis.
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). Total circoid resection generally is not undertaken deliberately; the aim should be to preserve a rim or bridge of superior cricoid cartilage that will serve to support the arytenoids and thus the glottic opening. However, previous chondritis or cartilage necrosis may result in the entire rigid structure being removed during the curettage. When this happens the perichondrium is preserved and cleaned carefully, a periostial or a perichondrial graft is inserted in the bed of the cricoid plate, and the laryngotracheal anastomosis with mucomucosal apposition is carried out as previously mentioned. The graft is taken from the anterior extremity of the fifth rib, which is easy to reach in the large operative field including the neck and the thorax that we prepare for tracheal operations. The graft can be slightly fixed with three to four thin knots or not because the cricoid resection is fashioned subperichondrally, leaving good tissue ahead of the graft, covering it and allowing a strong and reinforced muco-mucosal anastomosis. For lack of covering with mucosa, a posterior tracheal flap such as Grillo's can provide a good substitute. The laryngeal collapse is prevented by the insertion of a Montgomery T tube arising just above the level of the vocal cords. This will be removed after 3 to 6 months according to the importance of the perichondrial structures left in place and consequently of the estimated delay required to achieve competent rigidity of the laryngeal posterior wall (Fig 4). When removing the tube at 3 months, the findings of a residual laryngeal softness and collapse led us to put in a new T tube for 3 further months in 2 patients; the insertion is easy to do endoscopically.
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).
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). The separation of the edges is widened to 3 to 5 mm and a thin slice of periostial free graft is inserted between them in the bed of the posterior cricoidotomy. The vocal cord abduction and the adequacy of the glottic passage are checked and, if they are inadequate, similar insertion between the margins of the anterior section can be achieved giving a complementary enlargement. The section of a fibrous scar between the anterior part of the vocal cords enlarging the glottic slot may be necessary also. There is a balance to find between breathing and speaking because a restricted laryngeal enlargement leaves the patient dyspneic on exertion and too wide a glottic opening makes speech rehabilitation more difficult. The posterior graft is fixed with some thin knots to the edges of the cricoidotomy until T tube stent positioning maintains it in place with an appropriate shape. The anterior graft, when necessary, is similarly sewn to the anterior slot over the tube.
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). Large fibrotic scars must be resected as completely as possible and the wound must be covered with mucosa as fully as possible, especially in children, in whom conservation of an important block of fibrosis may be the cause of impaired laryngeal growth [13].
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5. Traumatic total laryngotracheal break of continuity after blunt trauma on the anterior aspect of the neck results in stenosis of the laryngotracheal junction when mismanaged in the acute period [16]. Later the patients have either a nasotracheal tube, which is impossible to remove without causing asphyxia, or an evident total obstruction of the airway above a tracheostomy. The diagnosis of total laryngotracheal separation can be based on the previous history, confirmed by plain or computed tomography, or at the operative findings as a discontinuity of the laryngeal and tracheal structures and a retraction of the lower part of the trachea into the mediastinum. The treatment has to take into account that a disruption of one or both recurrent nerves generally is associated with large laryngotracheal separations. A previously nonevident functional glottic closure therefore may compromise the success of a simple subjacent anatomic restoration of the airway continuity. Consequently, the resection of the stenosed laryngotracheal segment must be complemented by glottic enlargement. In general, the laryngotracheal approximation is relatively easy after mobilization and elevation of the trachea. At the laryngeal level, the retraction of the torn mucosa into the subglottic lumen makes it necessary partially to resect the cricoid ring subperichondrally to permit a convenient muco-mucosal apposition at the laryngotracheal anastomosis.
The glottic enlargement can be achieved through a vertical posterior section of the cricoid plate according to Rethi's fashion, then the vocal cord abduction and the laryngeal molding are stented with a nasotracheal or T tube for 1 to 3 months (Fig 8). When the vocal cord abduction is slightly insufficient at extubation, laser cord resection may secondarily complete the operation as performed once in our experience. In our hands that combined technique provided good respiratory and fair phonetic primary successes, in contrast with many disappointing results and reoperations reported elsewere after such trauma (Fig 9).
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). Covering the molding bed with mucosa as completely as possible is important, and resorting to every trick for that must be advised. In some cases one or two paralized vocal cords were fixed to the lateral wall of the thyroid cartilage or sutured into the laryngotracheal anastomosis to palliate a definitive vocal cord adduction. The high level of laryngeal alterations often necessitates very high stenting with the upper arm of the T tube open up to the laryngeal structures. Consequently, the patient is exposed to permanent saliva aspiration and impossibility of feeding orally. The closing of the upper end of the tube obviates these complications. The patient can breathe through the external branch, which has to be left open. Because meticulous cleaning of the lower branch, ultrasonic nebulizations maintaining humidity in the airways, and avoiding obstructive fibrinous scabs can be kept up, the technique may be used with acceptable comfort and security.
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Fortunately the most frequently associated stenoses are laryngeal and tracheal. In our initial experience, before 1978, we did multistaged procedures, the upper stenosis generally being cured first. We have modified our policy in the present series. In such cases combining tracheal resection and laryngeal enlargement and molding in a single-stage procedure was achieved frequently. The method is safe because the laryngeal stenting tube is cuffless and therefore does not threaten the vascular supply of the lower tracheal segment through compressive mucosal ischemia.
Conclusion
The strategy for treatment of airway stenoses is now well established and leads to a high level of success with minimal or no sequelae [17]. Tracheal stenoses often are very easy to cure. The treatment of laryngotracheal stenoses is less simple, but the most difficult cases arise from failure of previous surgical attempts. These add extensive destruction and sometimes sequelae to the original iatrogenic lesions. Although a solution usually could be found with an acceptable morbidity, as seen in this series, where surgical efforts were rewarded in most patients by restoration of breathing and speaking through the normal route, the necessity of a per primam recovery must be emphasized. In our opinion, meticulous preoperative assessment and preparation are as important as appropriate surgical options and a good surgical technique.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsTreatment and ResultsCommentReferences |
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Address reprint requests to Dr Couraud, Xavier Arnozan Hospital, 33604 Pessac, France.
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TopFootnotesAbstractIntroductionMaterial and MethodsTreatment and ResultsCommentReferences |
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