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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