Estenosis traqueal postintubación después de neumonía grave por coronavirus / Postintubation Tracheal Stenosis after Severe Coronavirus Pneumonia

Introducción: La rápida propagación del SARS­CoV­2 ha provocado una pandemia mundial. Si bien puede salvar vidas, la intubación traqueal presenta el riesgo inherente de inducir daño en la mucosa traqueal con estenosis, con una incidencia estimada de 4,9 casos por millón cada año. Objetivo: Caracterizar la presentación de una estenosis traqueal por intubación prolongada en un paciente que sufrió neumonía grave por coronavirus. Presentación del caso: Se asiste a un paciente de 55 años que sufrió neumonía grave por coronavirus y necesitó intubación orotraqueal prolongada. Una vez recuperado comienza con disnea de empeoramiento progresivo. Se diagnostica una estenosis traqueal y se decide tratamiento quirúrgico donde se realiza resección y anastomosis. El paciente no presentó complicaciones y evolucionó satisfactoriamente. Conclusiones: La estenosis traqueal debe reconocerse como una complicación potencial, aun cuando los pacientes se recuperan de una neumonía grave por COVID-19. El diagnóstico definitivo de estenosis traqueal se realiza mediante fibrobroncoscopia. La resección traqueal con anastomosis entre tráquea y tráquea es el procedimiento más comúnmente realizado(AU)

Introduction: The rapid spread of SARS-CoV-2 has resulted in a global pandemic. Although tracheal intubation can save lives, it presents the inherent risk of inducing tracheal mucosal damage with stenosis, with an estimated annual incidence of 4.9 cases per million. Objective: To characterize a case of tracheal stenosis due to prolonged intubation in a patient with severe coronavirus pneumonia. Case presentation: A 55-year-old patient who suffered severe coronavirus pneumonia and required prolonged orotracheal intubation was attended. Once recovered, the patient began with progressively worsening dyspnea. Tracheal stenosis was diagnosed and surgical treatment was decided, in which resection and anastomosis were performed. The patient did not present any complications and evolved satisfactorily. Conclusions: Tracheal stenosis should be recognized as a potential complication, even when patients recover from severe COVID-19 pneumonia. A definitive diagnosis of tracheal stenosis is made by fibrobronchoscopy. Tracheal resection with anastomosis between trachea is the most commonly performed procedure(AU)

Mitomycin C in the Endoscopic Treatment of Laryngotracheal Stenosis: Systematic Review and Proportional Meta-Analysis

Abstract Introduction Mitomycin C is a natural antibiotic that has been used to inhibit the proliferation of fibroblasts in scar tissue. Objective To evaluate the effectiveness and safety of topical Mitomycin C as an adjuvant in the endoscopic treatment of laryngotracheal stenoses. Data synthesis A systematic review of experimental or observational studies that have evaluated the treatment of laryngotracheal stenoses with the use of topical Mitomycin C was performed. Databases researched: LILACS, PubMed, Embase, Cochrane and Web of Science. Outcomes: resolution (symptom-free time ≥ one year), number of procedures required, and complications resulting from the procedure. A total of 15 studies (involving 387 patients) were selected. Mitomycin C was administered to every patient in 11 studies, and in 4 other studies, the patients were separated into 2 groups, 1 receiving mitomycin C, and the other not. The resolution of the stenosis evaluated in 12 studies in which the patients received mitomycin C was of 69% (95% confidence interval [95%CI]: 61-76%; I2 = 17.3%). A total of 52% of the patients (95%CI: 39-64%, 11 studies; I2 = 64.7%) were submitted to a single endoscopic procedure, and 48% (95%CI: 36-61%, 11 studies; I2 = 64.7%) were submitted to more than 1 procedure. Complications (mediastinal and subcutaneous emphysema, dysphonia, laceration or vocal fold paralysis and acute light obstruction) were reported in 9% of the patients (95%CI: 3-18%, 9 studies; I2 = 79.8%). Conclusions The evidence suggests that mitomycin C is an effective and safe option in the endoscopic treatment of laryngotracheal stenosis.

Advanced laryngotracheal stenosis patients in a tertiary provincial government hospital: A prospective case series

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To describe the clinical profiles, interventions, and surgical outcomes of patients with advanced (grade III and IV) laryngotracheal stenosis prospectively seen over a 2-year period.  </p><p style="text-align: justify;"><strong>METHODS:</strong></p><p style="text-align: justify;">           <strong>Design:</strong>           Prospective Case Series</p><p style="text-align: justify;">          <strong>Setting:</strong>           Tertiary Provincial Government Hospital</p><p style="text-align: justify;"><strong>          Participants:</strong>  Five (5) patients with advanced laryngotracheal stenosis confirmed by laryngoscopy and/or tracheoscopy.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Five (5) patients (4 males, 1 female), aged 23 to 31years (mean 27-years-old) diagnosed with advanced laryngotracheal stenosis between June 2016 to June 2018 were included in this series. Four resulted from prolonged intubation (14 - 60 days) while one had a prolonged tracheotomy (13 years). Presentations of stenosis included dyspnea on extubation attempt (n=3), failure to extubate (n=1) and failure to decannulate tracheotomy (n=1). Stenosis length was 3 cm in two, and 1.5 cm in three. Of the five (5) patients, three had grade IV stenosis while two had grade III stenosis based on the Cotton-Myer Classification System. Two of those with grade IV stenosis and both patients with grade III stenosis had undergone prolonged intubation. The stenosis involved the subglottis in three, and combined subglottic and tracheal stenosis in two. Prolonged intubation was present in all three with subglottic stenosis, and in one of the two with combined subglottic and tracheal stenosis. Two patients underwent open surgical approaches while three underwent endoscopic dilatation procedures. Four patients were successfully decannulated while one is still on tracheostomy. None of them had post-operative complications.</p><p style="text-align: justify;"><strong>CONCLUSION:</strong>  Advanced laryngotracheal stenosis is a challenging entity that results from heterogenous causes. Categorizing stenosis and measuring stenosis length may help in treatment planning and predicting surgical outcome.</p><p style="text-align: justify;"> </p>

Laryngo Tracheal Stenosis : Management And Its Outcomes

Introduction: Laryngotracheal stenosis (LTS) implies a partial or complete narrowing of the larynx and/or trachea. Surgical management of it is technically challenging due to complex anatomy and delicate nature of airway structures. Ourstudy aims to study clinical profile, management, and surgical outcome of LTS. Materials and Methods: All patients with LTS treated between 2015 and 2018 were included in in our study.They underwent endoscopic assessment followed by definitive management which included endoscopic and external surgical techniques. The success of treatment was defined by decannulation Subjective assessment of voice quality.Results: A total of 30 patients with benign LTS were treated. Prolonged intubation was the single largest cause (56%). subglottic stenosis formed the largest group (74%) followed by Tracheal stenosis (14%).patiens were devided in four group depending upon surgical procedure they underwent:GROUP–I,endoscopic laser excision and dilatation(12cases),GROUP–II laryngo tracheoplasty and t–tube insertion(10 cases),GRUP–III tracheal stent insertion(3 cases),GROUPIV–Rection and anstomosis.Rate of decannalation following this surgical procedure in GROUP–I,GROUP–II,GROUP–III and GROUP–IV were 58%,60%,33% and80%.A total of 19 patients (63%) have been successfully decannulated. Conclusions: The use of appropriate size, low pressure cuffed tubes, and early tracheostomy will help in preventing LTS. The precise assessment of laryngotracheal complex is most useful in planning of management. Choice of treatment depends on location, severity, and length of stenosis, as well as on patient comorbidities an dhistory of previous interventions. Goal of our treatment modality is to achieve a patent airway and acceptable voice quality.

Prevention and treatment of laryngotracheal stenosis after tracheal intubation or tracheotomy in children / 国际儿科学杂志

In pediatric emergency,we often encounter laryngotracheal stenosis after tracheal intubation and tracheotomy. For acute cannulation injury,mitomycin C and other drugs can be tried. And for laryngotracheal stenosis with mature scar,surgery is the main treatment. Children with mild illness can be treated by endoscopic balloon dilatation and laser surgery,with less injury and faster recovery,but with a certain recurrence rate. Most of the children with severe stenosis need to be treated with open surgery such as laryngotracheal reconstruction, slideplasty,partial cricotracheal resection and so on. To prevent complications caused by tracheal intubation and tracheotomy,the appropriate size of tube should be selected,and intermittent discharging is required during intu-bation. If the tracheal intubation is needed for longer than 7 days,tracheotomy should be performed as soon as possible.

Airway reconstruction: review of an approach to the advanced-stage laryngotracheal stenosis / Reconstrução de via aérea: revisão de uma abordagem à estenose laringotraqueal em estágio avançado

Abstract Introduction: The management of laryngotracheal stenosis is complex and is influenced by multiple factors that can affect the ultimate outcome. Advanced lesions represent a special challenge to the treating surgeon to find the best remedying technique. Objective: To review the efficacy of our surgical reconstructive approach in managing advanced-stage laryngotracheal stenosis treated at a tertiary medical center. Methods: A retrospective review of all patients that underwent open laryngotracheal repair/reconstruction by the senior author between 2002 and 2014. Patients with mild/moderate stenosis (e.g. stage 1 or 2), or those who had an open reconstructive procedure prior to referral, were excluded. Patients who had only endoscopic treatment (e.g. laser, balloon dilatation) and were not subjected to an open reconstructive procedure at our institution, were not included in this study. Variables studied included patient demographics, clinical presentation, etiology of the laryngotracheal pathology, the location of stenosis, the stage of stenosis, the type of corrective or reconstructive procedure performed with the type of graft used (where applicable), the type and duration of stent used, the post-reconstruction complications, and the duration of follow-up. Outcome measures included decannulation rate, total number of reconstructive surgeries needed to achieve decannulation, and the number of post-operative endoscopies needed to reach a safe patent airway. Results: Twenty five patients were included, aged 0.5 months to 45 years (mean 13.5 years, median 15 years) with 16 males and 9 females. Seventeen patients (68%) were younger than 18 years. Most patients presented with stridor, failure of decannulation, or respiratory distress. Majority had acquired etiology for their stenosis with only 24% having a congenital pathology. Thirty-two reconstructive procedures were performed resulting in decannulating 24 patients (96%), with 15/17 (88%) pediatric patients and 5/8 (62.5%) adult patients requiring only a single reconstructive procedure. Cartilage grafts were mostly used in children (84% vs. 38%) and stents were mostly silicone made, followed by endotracheal tubes. The number of endoscopies required ranged from 1 to 7 (mean 3). More co-morbidities existed in young children, resulting in failure to decannulate one patient. Adult patients had more complex pathologies requiring multiple procedures to achieve decannulation, with grafting less efficacious than in younger patients. The pediatric patients had double the incidence of granulation tissue compared to adults. The decannulated patients remained asymptomatic at a mean follow-up of 50.5 months. Conclusion: The review of our approach to open airway repair/reconstruction showed its efficacy in advanced-stage laryngotracheal stenosis. Good knowledge of a variety of reconstructive techniques is important to achieve good results in a variety of age groups.

Resumo Introdução: A conduta da estenose laringotraqueal é complexa e é influenciada por vários fatores que podem afetar o resultado final. Lesões em estágio avançado representam um desafio especial para o cirurgião encontrar a melhor técnica de tratamento. Objetivo: Avaliar a eficácia de nossa abordagem de reconstrução cirúrgica no tratamento de estenose laringotraqueal em estágio avançado em um centro médico terciário. Método: Revisão retrospectiva de todos os pacientes submetidos a tratamento cirúrgico/reconstrução laringotraqueal aberta pelo autor principal, entre 2002 e 2014. Os pacientes com estenose leve (por exemplo, estágio 1 ou 2) ou aqueles submetidos a procedimento de reconstrução aberta antes da indicação foram excluídos. Pacientes que tinham sido submetidos somente a tratamento endoscópico (por exemplo, laser, dilatação por balão) e não haviam sido submetidos a procedimento de reconstrução aberta em nossa instituição não foram incluídos. As variáveis estudadas incluíram dados demográficos dos pacientes, apresentação clínica, etiologia da doença laringotraqueal, local da estenose, estágio da estenose, o tipo de procedimento corretivo ou reconstrutor feito com o tipo de enxerto usado (onde aplicável), tipo e duração do stent usado, complicações pós-reconstrução e duração do seguimento. Os resultados incluíram taxas de decanulação, número total de cirurgias reconstrutoras necessárias para possibilitar a decanulação e o número de endoscopias pós-operatórias necessárias para obter uma via aérea patente e segura. Resultados: Vinte e cinco pacientes foram incluídos, com 0,5 meses a 45 anos (média de 13,5, mediana de 15) com 16 homens e nove mulheres. Dezessete pacientes (68%) eram menores de 18 anos. A maioria dos pacientes apresentava estridor, falha de decanulação ou desconforto respiratório. A maioria das estenoses era adquirida, enquanto apenas 24% apresentavam causa congênita. Trinta e dois procedimentos reconstrutores foram feitos, resultaram em decanulação de 24 pacientes (96%), com 15/17 (88%) pacientes pediátricos e 5/8 pacientes (62,5%) adultos que necessitaram de apenas um único procedimento reconstrutor. Enxertos de cartilagem foram usados principalmente em crianças (84% vs. 38%) e a maioria dos stents era feita principalmente de silicone, seguido por tubo endotraqueal. O número de endoscopias necessárias variou de um a sete (média de três). Mais comorbidades foram observadas em crianças pequenas, o que resultou em falha de decanulação em um paciente. Pacientes adultos apresentavam doenças mais complexas que requereram vários procedimentos para decanulação, com enxertos menos eficazes do que em pacientes mais jovens. Os pacientes pediátricos apresentaram o dobro da incidência de tecido de granulação em comparação com os adultos. Os pacientes decanulados permaneceram assintomáticos em um seguimento médio de 50,5 meses. Conclusão: A revisão da nossa abordagem para tratamento cirúrgico/reconstrução aberta das vias aéreas demonstrou eficácia na estenose laringotraqueal em estágio avançado. O conhecimento de uma variedade de técnicas de reconstrução é importante para conseguir bons resultados em vários grupos etários.

Laryngotracheal stenosis in children / 中华耳鼻咽喉头颈外科杂志

Laryngotracheal stenosis includes congenital laryngotracheal stenosis and secondary laryngotracheal stenosis. Congenital laryngotracheal anomalies are rare, accounting for 0.3%-1.0% of all laryngotracheal stenosis(LTS). Despite the management of pediatric LTS over the past 30 years had been considerable improved, primary surgery still failed in a significant number of complex LTS cases. In some severe LTS cases combined with glottic stenosis, the primary surgery failed around 30%, even with the latest available techniques. Children with LTS usually need multiple operations, and need the tracheostomy tube for months or even years. Therefore, the etiology, clinical features, diagnosis and treatment of laryngotracheal stenosis are summarized in this paper.

Failed intubation of an unanticipated postintubation tracheal stenosis: a case report / 대한마취과학회지

Encountering a patient with unanticipated laryngotracheal stenosis (LTS) during anesthetic induction is challenging for an anesthesiologist. Because routine history taking and pre-anesthetic evaluation cannot rule out the possibility of LTS, other measures should be taken. Perioperative airway maintenance is considered crucial for avoiding complications such as airway edema, bleeding, obstruction, collapse, and ultimately respiratory failure and arrest. We report an unanticipated tracheal stenosis discovered during anesthetic induction that hindered endotracheal intubation. Because airway maintenance was difficult, we postponed surgery until determining the cause of the difficult entry, considered possible therapeutic approaches (both anesthetic and surgical), and provided successful surgery with a continuous epidural block.

Thyrotracheal Anastomosis for Combined Laryngotracheal Stenosis: Experience in 11 Cases / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The combined Laryngotracheal stenosis produces cripling complications of respiratory and phonation difficulty. The area between cricoid cartilage and first tracheal ring is the most common site of stenosis and is the most difficult area to manage, therefore, appropriate selection of surgical method is the important factor determining the success of treatment. The authors treated laryngotracheal stenosis with thyrotracheal anastomosis and here we report the results and problems of thyrotracheal anastomosis to provide aid in the management of laryngotracheal stenosis. MATERIALS AND METHODS: Authors retrospectively studied 11 cases of laryngotracheal resection with thyrotracheal anastomosis patients for clinical characteristics, site and degree of stenosis, operation technique such as granulation tissue removal under bronchoscopy, CO2 laser excision, insertion of T-tube, insertion of laryngeal stent, and its results. RESULTS: 1) Decannulation was possible in seven cases (63.6%). 2) The success rates of patients under the ages of 20years was 80%, patients with normal vocal cord movement was 85.7%. 3) The patients with residual neurologic symptom, or with decreased coughing reflex failed in decannulation. CONCLUSION: Treatment of combined laryngotracheal stenosis is very difficult and our study showed a success rate of 63.6%. Laryngotracheal resection and end to end thyrotracheal anastomosis showed to be the most effective treatment method and in general the patients under the ages of 20 years, or with normal vocal cord movement showed better prognosis. Therefore, a radical treatment planning with efforts to reduce complication at this group may produce satisfactory results in the management of laryngotracheal stenosis.