tracheal stenosis - university of colorado denver trauma - high tracheostomy, cricothyroidotomy,...
TRANSCRIPT
![Page 1: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/1.jpg)
Ronald Durbin MD, UCHSC, Dept of Ronald Durbin MD, UCHSC, Dept of SurgerySurgery
Tracheal Tracheal StenosisStenosis
A CASE REPORTA CASE REPORT
![Page 2: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/2.jpg)
36 36 yoyo female with a history of head and neck female with a history of head and neck lymphoma (diagnosed 4/2004) creating lymphoma (diagnosed 4/2004) creating compression of the trachea requiring compression of the trachea requiring tracheostomytracheostomy after initial intubation to after initial intubation to protect her airway.protect her airway.
![Page 3: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/3.jpg)
Lymphoma was definitively treated with Lymphoma was definitively treated with chemoradiationchemoradiation but need for but need for tracheostomytracheostomycontinued and continued and tracheostomytracheostomy was was ultimately revised times oneultimately revised times one
![Page 4: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/4.jpg)
As of 3/2006 patient remained with a As of 3/2006 patient remained with a tracheostomytracheostomy and had been unable to and had been unable to phonate since its initial placement almost phonate since its initial placement almost two years beforetwo years before
![Page 5: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/5.jpg)
PMHxPMHx: lymphoma only: lymphoma onlyPSHxPSHx: : tracheostomytracheostomy with revisionwith revisionMeds: noneMeds: noneAllergies: NKDAAllergies: NKDASHxSHx: non: non--smoker, no ETOH/IVDAsmoker, no ETOH/IVDA
![Page 6: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/6.jpg)
Congenital Congenital MembranousMembranousCartilagenousCartilagenous
AcquiredAcquiredIntubation Intubation –– duration (5duration (5--10 days), size of ETT, 10 days), size of ETT, traumatic intubation, # of retraumatic intubation, # of re--intubationsintubationsLaryngeal trauma Laryngeal trauma -- high high tracheostomytracheostomy, ,
cricothyroidotomycricothyroidotomy, inhalational (thermal or caustic), , inhalational (thermal or caustic), trauma blunt or penetrating traumatrauma blunt or penetrating trauma
AutoimmuneAutoimmuneInfectionInfectionGERDGERDInflammatory diseases Inflammatory diseases –– sarcoidosissarcoidosis, SLE, SLENeoplasmsNeoplasms
![Page 7: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/7.jpg)
Combining principal in the acquired type of Combining principal in the acquired type of tracheal tracheal stenosisstenosis is that mucosal and/or is that mucosal and/or cartilaginous injury results in inflammatory cartilaginous injury results in inflammatory response and subsequent remodeling with response and subsequent remodeling with healing by secondary intention and, healing by secondary intention and, ultimately, scarring with narrowing of the ultimately, scarring with narrowing of the airway airway
![Page 8: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/8.jpg)
Three classification systems exist to help Three classification systems exist to help predict the chance of predict the chance of decannulationdecannulation after after treatment of tracheal treatment of tracheal stenosisstenosis
![Page 9: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/9.jpg)
Cotton et al, J Pediatric Surg 1984Cotton et al, J Pediatric Surg 1984
MyerMyer--Cotton staging system :Cotton staging system :Grade IGrade I -- less than 50% obstructionless than 50% obstructionGrade IIGrade II -- 51% to 70% obstruction51% to 70% obstructionGrade IIIGrade III -- 71% to 99% obstruction71% to 99% obstructionGrade IVGrade IV -- no detectable lumen or complete no detectable lumen or complete
stenosisstenosis. .
Most useful for mature, firm, circumferential Most useful for mature, firm, circumferential stenosisstenosis confined to the confined to the subglottissubglottis..
![Page 10: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/10.jpg)
McCaffrey, Laryngoscope 1992McCaffrey, Laryngoscope 1992
McCaffrey staging system : McCaffrey staging system : Stage IStage I -- confined to the confined to the subglottissubglottis or or
trachea and are less than 1cm longtrachea and are less than 1cm longStage IIStage II -- isolated to the isolated to the subglottissubglottis and are and are
greater then 1 cm longgreater then 1 cm longStage IIIStage III -- subglotticsubglottic/tracheal lesions not /tracheal lesions not
involving the glottisinvolving the glottisStage IV Stage IV -- lesions involve the glottis. lesions involve the glottis.
![Page 11: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/11.jpg)
Lano et al, Ann Otlo Rhinol Laryngol Lano et al, Ann Otlo Rhinol Laryngol 19981998
LanoLano et al. (1998) staging system: et al. (1998) staging system: Stage IStage I -- involve one involve one subsitesubsiteStage IIStage II -- involves two involves two subsitessubsitesStage III Stage III -- involves all three involves all three subsitessubsites
Based on the number of Based on the number of subsitessubsites of of involvement including the glottis, involvement including the glottis, subglottissubglottisand tracheaand trachea
![Page 12: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/12.jpg)
Surgical OptionsSurgical Options
TracheostomyTracheostomyEndoscopicEndoscopic –– Dilation (with or without Dilation (with or without stentingstenting))Open procedures Open procedures –– cricoidcricoid split split (pediatrics), tracheal resection(pediatrics), tracheal resection
![Page 13: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/13.jpg)
![Page 14: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/14.jpg)
![Page 15: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/15.jpg)
![Page 16: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/16.jpg)
Wright et al, J Thoracic Cardiovasc Wright et al, J Thoracic Cardiovasc Surg 2004Surg 2004
Risk factors for tracheal Risk factors for tracheal anastamoticanastamotic complicationscomplications
Wright et al 2004, retrospective trial of 901 Wright et al 2004, retrospective trial of 901 patients with complications in 9%patients with complications in 9%Risk factors identified as diabetes, Risk factors identified as diabetes, reoperationsreoperations, lengthy resections, young , lengthy resections, young age, age, laryngotracheallaryngotracheal resections, need for resections, need for tracheostomytracheostomy before resectionbefore resection
![Page 17: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/17.jpg)
For firstFor first--time resections greater than 4 cm the risk of time resections greater than 4 cm the risk of anastomoticanastomoticfailure doubledfailure doubled
![Page 18: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/18.jpg)
Outcomes after resection: Outcomes after resection: observational experiencesobservational experiences
Cotton (1984) Cotton (1984) –– rates of rates of decannulationdecannulation were 97%, were 97%, 97%, 91%, 72% based on his own staging 97%, 91%, 72% based on his own staging systemsystem
LanoLano (1998) (1998) –– rates of rates of decannulationdecannulation94%,78%,20% based on own staging system94%,78%,20% based on own staging system
Grillo(1992) Grillo(1992) –– overall rate of overall rate of decannulationdecannulation was was 97%, however, 77.5% had some degree of voice 97%, however, 77.5% had some degree of voice dysfunction (60% were mild)dysfunction (60% were mild)
![Page 19: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/19.jpg)
On 2/14/06 the patient underwent On 2/14/06 the patient underwent bronchoscopybronchoscopy –– From above this showed From above this showed complete occlusion of the tracheal lumen complete occlusion of the tracheal lumen approximately 2.5 cm beyond the vocal approximately 2.5 cm beyond the vocal cords, the airway proximal to the cords, the airway proximal to the cricoidcricoidwas normal, the airway distal as seen was normal, the airway distal as seen through the stoma was also normal.through the stoma was also normal.
Approximately 3.5 cm of trachea was Approximately 3.5 cm of trachea was involvedinvolved
![Page 20: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/20.jpg)
![Page 21: Tracheal Stenosis - University of Colorado Denver trauma - high tracheostomy, cricothyroidotomy, inhalational (thermal or caustic), trauma blunt or penetrating trauma](https://reader031.vdocuments.us/reader031/viewer/2022021822/5b21ced47f8b9aa97e8b45f0/html5/thumbnails/21.jpg)
On 3/22/06 pt underwent tracheal resection On 3/22/06 pt underwent tracheal resection with primary with primary anastamosisanastamosis, no , no complications intra or postcomplications intra or post--opop
Patient was discharged after 6 days able to Patient was discharged after 6 days able to speak with minimal hoarsenessspeak with minimal hoarseness
Recently pt seen in clinic and continues to Recently pt seen in clinic and continues to do well with eating/breathing/ and talkingdo well with eating/breathing/ and talking