Tracheal Stenosis

Etiology

  • Intubation-Related Injury
    • Anterior Commissural Stenosis:
    • Posterior Commissural Stenosis:
    • Vocal Cord Granuloma:
    • Subglottic stenosis:
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Etiology:
1) Following Trauma to Trachea (see above)
2) Post-XRT or Brachytherapy:
3) Post-Laser Bronch:
4) Congenital Tracheal Stenosis: usually presents soon after birth with circumferential O-rings of cartilage over long portions of trachea
5) Post-Infectious Tracheal Stenosis (see also infection above): Histoplasmosis/ TB/ Mucor/ Aspergillus/ Diphtheria/ Scleroma
6) Mucopolysaccharidoses: Hunter’s syndrome/ Hurler’s syndrome
7) IBD: subglottic stenosis is associated with UC
8) Idiopathic Tracheal Stenosis: predominantly females with short 2-3 cm circumferential tracheal stenosis (made of dense collagen)

1) Post-intubation tracheal stenosis:
a) Cuff tracheal stenosis (circumferential stenosis at site of ETT or tracheostomy tube cuff): most common type
b) Stomal tracheal stenosis (at site of former tracheostomy stoma):


Physiology

  • Post-Intubation: tracheal injury due to ETT cuff or tracheostomy cuff pressure on mucosa
    • High-volume/ low-pressure cuffs can be made to be high-pressure cuffs if inflated too much
    • Injury from ETT: tracheal injury is known to occur with high-pressure cuffs after about 3 weeks of intubation (amount of time with low-pressure cuffs is unknown)
  • Injury from Tracheostomy: due to traction by vent tubing/kyphoscoliosis

Diagnosis

  • CXR/Chest CT pattern: may reveal narrowing of tracheal air column
  • PFT’s
    • Flow-volume loop reveals
    • Flow-Volume Loop: flattening of inspiratory limb (variable extrathoracic obstruction)
  • FOB: diagnostic of site of narrowing (although may be missed if not carefully examined)
    • Stomal stenosis typically has triangular shape

Clinical

  • Symptoms/ signs of tracheal obstruction: inspiratory wheezing or stridor/ dyspnea/ cough
  • Hemoptysis: may occur in some cases
  • Recurrent post-obstructive pneumonia:

Treatment

Post-intubation tracheal stenosis (usually allow primary resection):

  • Urgent: rigid dilatation recommended until tracheal resection can be done
  • Non-urgent: primary tracheal resection (trach and other manipulations should be avoided pre-op as they may compromise future ability to resect)
  • Subglottic/high-tracheal lesions: less easily resected/ stenting (with or without laser) may be an option (need to be sutured in place)
  • Long or complex lesions: T-tube may be useful

Idiopatic Tracheal Stenosis (usually allow primary resection):
-Urgent: rigid dilatation recommended until tracheal resection can be done
-Non-urgent: primary tracheal resection (trach and other manipulations should be avoided pre-op as they may compromise future ability to resect)
-Subglottic/high-tracheal lesions: less easily resected/ stenting (with or without laser) may be an option (need to be sutured in place)

Long or complex lesions: T-tube may be useful Congenital tracheal stenosis: surgical resection often difficult, tracheoplasty is probably preferred (widens trachea, shortens length of stenosis)


References

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