Upper airway compromise after inhalation injury. Complex strictures of the larynx and trachea and their management.

OBJECTIVE: Strictures of the upper airway caused by burns have features distinct from other benign stenoses. The authors reviewed their experience with burn-related stenoses to define the principles of treatment. SUMMARY BACKGROUND DATA: The combined effects of inhaled gases and heat in burn victims produce an intense, often transmural, inflammation of the airway, further complicated by intubation. The incidence of laryngotracheal strictures in survivors of inhalation injury is high, but the reported experience with their treatment is limited and often unduly separated into injuries of larynx and trachea. METHODS: Presentation, treatment, and long-term follow-up are reviewed in 9 women and 9 men age 9 to 63 years, who were evaluated over a 22 year period for chronic airway compromise after inhalation injury. There were 18 tracheal stenoses, 14 subglottic strictures, and 2 main bronchial stenoses. Laryngotracheal strictures stenosis. T-tubes were placed in 15 patients, in low subglottic or tracheal stenosis below the vocal cords, in high subglottic stenosis through the vocal cords, and as a stent after resection of subglottic stenosis. RESULTS: There were two deaths during follow-up, one from respiratory failure and one from an unrelated cause. Two patients underwent evaluation only. Early in this series, one tracheal and one laryngotracheal resection resulted in prompt restenosis. Of the remaining 14 patients, 9 are without airway support from 2 to 20 years later. Four have permanent tracheal tubes. One patient required tracheostomy 8 years after successful subglottic reconstruction. CONCLUSIONS: Strictures of the upper airway related to inhalation injury are associated with prolonged inflammation and involve larynx and trachea in a majority of patients. These complex injuries respond to prolonged tracheal stenting (mean, 28 months) and resection or stenting of subglottic stenoses with recovery of a functional airway and voice in most patients. Early tracheal resection should be avoided.

Spontaneous retropharyngeal and cervical subcutaneous emphysema in adults.

The presence of air in the retropharyngeal and cervical subcutaneous spaces of the neck in association with the acute onset of severe odynophagia and dysphagia is an uncommonly recognized initial feature of pneumomediastinum. Free air in the mediastinum extends into the neck via fascial planes. Spontaneous pneumomediastinum is a self-limited disorder that can be confused with Boerhaave's syndrome (spontaneous esophageal perforation), which is potentially fatal. The diagnosis is established radiologically.