Airway Stenosis: Airway Stenosis: Evaluation and Evaluation and
Endoscopic Endoscopic ManagementManagement
Murtaza Ghadiali, M.D.Murtaza Ghadiali, M.D.UCLAUCLA
Division of Head and Neck Division of Head and Neck SurgerySurgery
November 19November 19thth, 2008, 2008
OutlineOutline IntroductionIntroduction EtiologyEtiology
Autoimmune Causes Autoimmune Causes Acquired CausesAcquired Causes Role of LPRRole of LPR IPSSIPSS
EvaluationEvaluation H&P, Grading, DL/BH&P, Grading, DL/B
Endoscopic ManagementEndoscopic Management MitomycinMitomycin TGF-TGF-ββ Lasers/Balloon DilationLasers/Balloon Dilation
IntroductionIntroduction
Airway Stenosis is both a Airway Stenosis is both a therapeutic and diagnostic challengetherapeutic and diagnostic challenge
Presents insidiously with progressive Presents insidiously with progressive SOB, brassy cough, SOB, brassy cough, wheezing/stridor, possible recurrent wheezing/stridor, possible recurrent pneumonitispneumonitis
Many times misdiagnosed as Many times misdiagnosed as asthma/bronchitis, COPD, CHFasthma/bronchitis, COPD, CHF
IntroductionIntroduction
Common etiology (beginning 1965)Common etiology (beginning 1965) either cuffed endotracheal or either cuffed endotracheal or
tracheotomy tubetracheotomy tube Less common: Less common:
external trauma/compressionexternal trauma/compression high tracheotomy incisionhigh tracheotomy incision benign tumors benign tumors ‘‘nontraumatic, nonneoplastic’ causesnontraumatic, nonneoplastic’ causes
Etiology of SGSEtiology of SGS I. Congenital SGSI. Congenital SGS
MembranousMembranous CartilaginousCartilaginous
II. Acquired SGSII. Acquired SGS IntubationIntubation Laryngeal traumaLaryngeal trauma AI (Wegener’s; Sarcoid; Amyloid; Relapsing AI (Wegener’s; Sarcoid; Amyloid; Relapsing
Polychondritis)Polychondritis) InfectionInfection IPSS (Idiopatic Subglottic Stenosis)IPSS (Idiopatic Subglottic Stenosis) GER/LPRGER/LPR Inflammatory diseasesInflammatory diseases NeoplasmsNeoplasms
Nonneoplastic, Nonneoplastic, nontraumatic Subglottic nontraumatic Subglottic
StenosisStenosis Wegener’s GranulomatosisWegener’s Granulomatosis AmyloidosisAmyloidosis
Can present with SG alone Can present with SG alone SarcoidosisSarcoidosis
Can present with SG aloneCan present with SG alone Relapsing PolychondritisRelapsing Polychondritis
SGS – Wegener’sSGS – Wegener’s
Systemic Systemic inflammatory inflammatory disorderdisorder
AutoimmuneAutoimmune ANCA C +ANCA C + 16-23% incidence 16-23% incidence
of SG stenosisof SG stenosis SGS can be the SGS can be the
lone manifestation lone manifestation of WGof WG
TreatmentTreatment Individualized Individualized
based on degree based on degree and acuity of and acuity of stenosisstenosis
No major surgery No major surgery during Wegener’s during Wegener’s flare upsflare ups
Wegener’s Wegener’s GranulomatosisGranulomatosis
Classic triad: necrotizing granulomas of Classic triad: necrotizing granulomas of the upper respiratory tract and lungs, the upper respiratory tract and lungs, focal glomerulitis, disseminating vasculitisfocal glomerulitis, disseminating vasculitis Treatment: Azathioprine, cyclophosphamide, Treatment: Azathioprine, cyclophosphamide,
steroidssteroids Laryngeal WGLaryngeal WG
Ulcerating lesions induce Ulcerating lesions induce subglottic stenosissubglottic stenosis Histopathology: Histopathology: coagulation necrosiscoagulation necrosis from vasculitis, from vasculitis,
multinucleated giant cells, palisading histiocytesmultinucleated giant cells, palisading histiocytes
AmyloidosisAmyloidosis Deposition of Deposition of extracellular fibrillar proteinsextracellular fibrillar proteins
in tissuesin tissues Primary (56%), secondary (8%), localized Primary (56%), secondary (8%), localized
(9%), myeloma associated (26%), familial (1%)(9%), myeloma associated (26%), familial (1%) Generalized amyloid evaluated by Generalized amyloid evaluated by rectal rectal
biopsybiopsy or FNA anterior or FNA anterior abdominal wall fatabdominal wall fat LocationsLocations
Tongue > orbit > larynxTongue > orbit > larynx Laryngeal amyloidosisLaryngeal amyloidosis
TVC > FVC > subglotticTVC > FVC > subglottic ManagementManagement
SurgicalSurgical
AmyloidosisAmyloidosis
DiagnosisDiagnosis Congo red staining and green Congo red staining and green
birefringence under polarized lightbirefringence under polarized light Fibrillar structure under electron Fibrillar structure under electron
microscopymicroscopy Beta-pleated sheet on x-ray Beta-pleated sheet on x-ray
crystallography and infrared crystallography and infrared spectroscopyspectroscopy
18 biochemical forms identified18 biochemical forms identified AL (plasma cells), AA (chronic AL (plasma cells), AA (chronic
inflammation), Ainflammation), A (cerebral lesions) (cerebral lesions)
Amyloidosis – Amyloidosis – ManagementManagement
Step 1 Biopsy the affected organStep 1 Biopsy the affected organ Step 2 Rule out generalized amyloidosisStep 2 Rule out generalized amyloidosis
Rectal bx, echocardiography, Rectal bx, echocardiography, bronchoscopy and PFTs, CT of bronchoscopy and PFTs, CT of neck/tracheaneck/trachea
Step 3 Rule out generalized Step 3 Rule out generalized plasmacytomaplasmacytoma Bone marrow biopsy, bone marrow Bone marrow biopsy, bone marrow
scintigraphy, serologic and immunologic scintigraphy, serologic and immunologic examininationsexamininations
Laryngeal AmyloidosisLaryngeal Amyloidosis
< 1% of benign laryngeal lesions< 1% of benign laryngeal lesions Most amyloid deposits are AL typeMost amyloid deposits are AL type Typically in men in the 5Typically in men in the 5thth decade of decade of
lifelife Sx depends on site (e.g. glottic Sx depends on site (e.g. glottic
amyloidosis amyloidosis hoarseness) hoarseness)
SarcoidosisSarcoidosis Idiopathic, non-caseating granulomasIdiopathic, non-caseating granulomas
Generalized adenopathy (25-50%), orbit (15-Generalized adenopathy (25-50%), orbit (15-25%), splenomegaly (10%), neural (4-6%)25%), splenomegaly (10%), neural (4-6%)
Symptoms: fever, weight loss, arthralgiasSymptoms: fever, weight loss, arthralgias Head and neck: cervical adenopathy > larynxHead and neck: cervical adenopathy > larynx Evaluation: CXR, PPD, skin test for anergy, Evaluation: CXR, PPD, skin test for anergy,
ACE levels (elevated in 80-90%)ACE levels (elevated in 80-90%) TreatmentTreatment
Oral steroidsOral steroids Laryngeal sarcoidosisLaryngeal sarcoidosis
Supraglottic involvementSupraglottic involvement Typical yellow subcutaneous nodules or polypsTypical yellow subcutaneous nodules or polyps Diffusely enlarged, pale pink, turban-like Diffusely enlarged, pale pink, turban-like
epiglottisepiglottis
Relapsing PolychondritisRelapsing Polychondritis
Inflammation of cartilage and other Inflammation of cartilage and other tissues with high concentration of tissues with high concentration of glycosaminoglycansglycosaminoglycans
Episodic and progressiveEpisodic and progressive Ear > nasal, ocular, respiratory tractEar > nasal, ocular, respiratory tract Treatment: symptomatic, steroidsTreatment: symptomatic, steroids
Laryngeal RPLaryngeal RP RareRare Inflammation can lead to laryngeal collapseInflammation can lead to laryngeal collapse Treatment usually tracheostomyTreatment usually tracheostomy
Acquired SGSAcquired SGS
95% of cases of SGS95% of cases of SGS Majority due to long-term or prior Majority due to long-term or prior
intubationintubation Duration of intubationDuration of intubation ETT sizeETT size Number of intubationsNumber of intubations Traumatic intubationsTraumatic intubations Movement of the ETTMovement of the ETT InfectionInfection
Poetker DM et al. Association of airway Poetker DM et al. Association of airway abnormalities and risk factors in 37 abnormalities and risk factors in 37 subglottic stenosis patients. Otolaryngol subglottic stenosis patients. Otolaryngol Head Neck Surg (2006) 135, 434-437Head Neck Surg (2006) 135, 434-437
Pathogenesis of acquired Pathogenesis of acquired SGSSGS
Initial injury – compression of mucosa by Initial injury – compression of mucosa by an ETT or cuffan ETT or cuff
IschemiaIschemia NecrosisNecrosis Decreased mucociliary flowDecreased mucociliary flow InfectionInfection Three stages of wound healingThree stages of wound healing
InflammatoryInflammatory Proliferative – granulation tissueProliferative – granulation tissue Scar formation – contraction and remodelingScar formation – contraction and remodeling
Pathogenesis SGSPathogenesis SGS Mankarious et al (2003):Mankarious et al (2003): Investigated Investigated
histopathologic features of 6 specimens from histopathologic features of 6 specimens from pts that underwent tracheal resectionpts that underwent tracheal resection Analyzed levels of hyaline cartilage components: Analyzed levels of hyaline cartilage components:
collagen type I and II & aggrecan (secreted by collagen type I and II & aggrecan (secreted by chondrocytes)chondrocytes)
Normal tracheal/cricoid: High ratio of type I to IINormal tracheal/cricoid: High ratio of type I to II Specimens: relative decrease in type I and Specimens: relative decrease in type I and
aggrecanaggrecan Regenerative cartilage: greatly increased amounts of Regenerative cartilage: greatly increased amounts of
type II collagen and aggrecantype II collagen and aggrecan Suggests Type I collagen and aggrecan responsibe for Suggests Type I collagen and aggrecan responsibe for
cartilage structural integritycartilage structural integrity Regenerative fibroblasts do not deposit type I collagenRegenerative fibroblasts do not deposit type I collagen
Acquired SGS and PDTAcquired SGS and PDT
Ciaglia 1985: Percutaneous Ciaglia 1985: Percutaneous dilational tracheotomy (PDT)dilational tracheotomy (PDT)
Bartels 2002: 108 PDT patients; 10 Bartels 2002: 108 PDT patients; 10 with 6 mo f/u; 1 patient with with 6 mo f/u; 1 patient with significant stenosis at f/u significant stenosis at f/u ? Selection Bias? Selection Bias Authors conclude 10% stenosis rate is Authors conclude 10% stenosis rate is
consistent with open tracheotomyconsistent with open tracheotomy
Acquired SGS and PDTAcquired SGS and PDT
Klussman et al (2001): Reported case Klussman et al (2001): Reported case of complete suprastomal tracheal of complete suprastomal tracheal stenosis/atresia after second PDTstenosis/atresia after second PDT
? Initial infection leading to destruction ? Initial infection leading to destruction and cartilaginous necrosis/Tracheal and cartilaginous necrosis/Tracheal ring fracture leading to mucosal tears ring fracture leading to mucosal tears and cicatricial scarringand cicatricial scarring
Cautioned against use of PDT in Cautioned against use of PDT in secondary tracheotomysecondary tracheotomy
Acquired SGS and PDTAcquired SGS and PDT
Hotchkiss & McCaffrey (2003): examined Hotchkiss & McCaffrey (2003): examined pathophysiology of PDT on 6 cadaverspathophysiology of PDT on 6 cadavers
3/6 Trachs were placed incorrectly (range: 3 3/6 Trachs were placed incorrectly (range: 3 tracheal rings away to just sub-cricoid)tracheal rings away to just sub-cricoid)
Anterior tracheal wallAnterior tracheal wall High degree of injuryHigh degree of injury Severe cartilage damage at site of insertionSevere cartilage damage at site of insertion Multiple, comminuted injuries in 2 or more Multiple, comminuted injuries in 2 or more
cartilaginous ringscartilaginous rings Findings suggest acute, severe mechanical injury Findings suggest acute, severe mechanical injury
in PDTin PDT
Acquired SGS & LPRAcquired SGS & LPR Gastroesophageal reflux Gastroesophageal reflux
(GER)/Laryngopharyngeal reflux (LPR)(GER)/Laryngopharyngeal reflux (LPR) 1985 – Little – applied gastric contents/H2O 1985 – Little – applied gastric contents/H2O
to subglottis of dogsto subglottis of dogs Delayed epithelialization and stenosis formation in Delayed epithelialization and stenosis formation in
lesions treated with gastric contentslesions treated with gastric contents 1991 – Koufman – applied acid and pepsin to 1991 – Koufman – applied acid and pepsin to
subglottis of dogs; control was H2Osubglottis of dogs; control was H2O 20 dogs with induced submucosal injury20 dogs with induced submucosal injury Increased level of granulation tissue and Increased level of granulation tissue and
inflammationinflammation 78% pts with LTS: abnormal acidic pH probes; 78% pts with LTS: abnormal acidic pH probes;
67% pharynx reflux67% pharynx reflux
GER/LPR and SGSGER/LPR and SGS
1998 Walner: 74 pediatric patients 1998 Walner: 74 pediatric patients with SGS had 3 times greater with SGS had 3 times greater incidence of GER than the general incidence of GER than the general pediatric populationpediatric population
2001 Maronian: 19 pts with SGS2001 Maronian: 19 pts with SGS 9 pts with IPSS; 10 with acquired SGS9 pts with IPSS; 10 with acquired SGS 14 pts with pH testing14 pts with pH testing
Abnormal (pH <4): 71% IPSS pts and 100% Abnormal (pH <4): 71% IPSS pts and 100% acquired ptsacquired pts
GER/LPR and SGSGER/LPR and SGS
Dedo (2001): Challenged association; Dedo (2001): Challenged association; largest review of 50 pts with IPSS; Only 7/38 largest review of 50 pts with IPSS; Only 7/38 patients had reflux symptomspatients had reflux symptoms
Ashiku (2004): 15/73 IPSS patients had Ashiku (2004): 15/73 IPSS patients had reflux symptoms; No patients had laryngeal reflux symptoms; No patients had laryngeal signs of refluxsigns of reflux
Both groups concluded no causal Both groups concluded no causal relationship between reflux and stenosis in relationship between reflux and stenosis in their groupstheir groups Only 2 patients in collective cohorts Only 2 patients in collective cohorts
underwent specific reflux testingunderwent specific reflux testing
Idiopathic Subglottic Idiopathic Subglottic StenosisStenosis
Rare condition of dense fibrous stenosis of Rare condition of dense fibrous stenosis of the proximal trachea in absence of inciting the proximal trachea in absence of inciting eventevent
Affects women; primarily involves subglottic Affects women; primarily involves subglottic larynx and proximal 2-4 cm of trachea larynx and proximal 2-4 cm of trachea circumferentiallycircumferentially
May be associated with certain autoimmune May be associated with certain autoimmune statesstates Wegener’s GranulomatosisWegener’s Granulomatosis Relapsing PolychondritisRelapsing Polychondritis Rheumatoid ArthritisRheumatoid Arthritis SLESLE
Ashiku SK et al. Idiopathic laryngotracheal stenosis. Ashiku SK et al. Idiopathic laryngotracheal stenosis. Chest Surg Clin North Am, Chest Surg Clin North Am, 2003; 13:2572003; 13:257
IPSS (Idiopathic Subglottic IPSS (Idiopathic Subglottic Stenosis)Stenosis)
Possible hormonal causePossible hormonal cause To date, presence of estrogen receptors To date, presence of estrogen receptors
in the affected airway has not been in the affected airway has not been conclusively shown in these patients conclusively shown in these patients ( Dedo 2001)( Dedo 2001)
? Possible link between female ? Possible link between female preponderance and LPRpreponderance and LPR Progesterone and its impact on LES pressureProgesterone and its impact on LES pressure Major contributing factor toward heartburn Major contributing factor toward heartburn
and reflux in pregnancyand reflux in pregnancy Cyclic hormonal variations in normal women Cyclic hormonal variations in normal women
found to impact LES pressure leading to found to impact LES pressure leading to possible refluxpossible reflux
SGS Initial presentationSGS Initial presentation
History of prior intubation andHistory of prior intubation and Progressive SOB and loud Progressive SOB and loud
breathingbreathing
Initial PresentationInitial Presentation
History History Review intubation recordsReview intubation records PmhxPmhx
DiabetesDiabetes Cardiopulmonary diseaseCardiopulmonary disease RefluxReflux Systemic steroid useSystemic steroid use
Initial presentationInitial presentation Physical exam – Complete H/N examPhysical exam – Complete H/N exam
ObserveObserve Stridor or labored breathingStridor or labored breathing RetractionsRetractions Breathing characteristics on exertionBreathing characteristics on exertion Voice quality Voice quality
Head/NeckHead/Neck Other abnormalities (congenital anomalies, Other abnormalities (congenital anomalies,
tumors, infection)tumors, infection)
DiagnosisDiagnosis
DifferentialDifferential CongenitalCongenital
LaryngeomalaciaLaryngeomalacia TracheomalciaTracheomalcia VC paralysisVC paralysis CystsCysts CleftsClefts Vascular compressionVascular compression MassMass
DiagnosisDiagnosis
DifferentialDifferential Infection/InflammationInfection/Inflammation
EpiglottitisEpiglottitis GERGER TracheitisTracheitis
NeoplasticNeoplastic MalignancyMalignancy Recurrent respiratory papillomas; benign Recurrent respiratory papillomas; benign
lesionslesions Foreign bodyForeign body
DiagnosisDiagnosis
RadiographsRadiographs Plain films – inspiratory and expiratory Plain films – inspiratory and expiratory
neck and chestneck and chest CTCT MRIMRI
DiagnosisDiagnosis Flexible nasopharyngolaryngoscopyFlexible nasopharyngolaryngoscopy
Nose/NasopharynxNose/Nasopharynx NP stenosisNP stenosis Masses, tumorMasses, tumor
SupraglottisSupraglottis Structure abnormalitiesStructure abnormalities LaryngomalaciaLaryngomalacia
GlottisGlottis VC mobilityVC mobility Webs/massesWebs/masses
Immediate subglottisImmediate subglottis
DiagnosisDiagnosis
Gold standard for diagnosis of SGSGold standard for diagnosis of SGS Rigid endoscopyRigid endoscopy
Properly equipped ORProperly equipped OR Experienced anesthesiologistExperienced anesthesiologist Preop discussion about possible need for Preop discussion about possible need for
trachtrach
Operative EvaluationOperative Evaluation EndoscopyEndoscopy
Fiberoptic endoscopic assisted intubation vs. Fiberoptic endoscopic assisted intubation vs. evaluation evaluation
LMALMA Spontaneous ventilation, Spontaneous ventilation, NO PARALYSISNO PARALYSIS !! Consider awake tracheotomyConsider awake tracheotomy
Perform Rigid DL, B, and EPerform Rigid DL, B, and E Closely evaluate the interarytenoid area for Closely evaluate the interarytenoid area for
stenosis/stricturestenosis/stricture Evaluate position of cordsEvaluate position of cords
Determine size, extent, and location of the Determine size, extent, and location of the stenotic lesionstenotic lesion Use an ETT/bronchoscope to measure the lumenUse an ETT/bronchoscope to measure the lumen Measure from undersurface of the cord to the lesionMeasure from undersurface of the cord to the lesion R/o other stenotic areasR/o other stenotic areas
Grading Systems for SGSGrading Systems for SGS
Cotton-Myer (1994)Cotton-Myer (1994) McCaffrey (1992)McCaffrey (1992)
Cotton-Myer Grading Cotton-Myer Grading SystemSystem
Classification From To
Grade I 0% 50%
Grade II 51% 70%
Grade III 71% 99%
Grade IV No DetectableLumen
Cotton-Cotton-Myer Myer grading grading system for system for subglottic subglottic stenosisstenosis
Grade II SGSGrade II SGS
Grade III SGSGrade III SGS
Grade IV SGSGrade IV SGS
Myer/Cotton Grading Myer/Cotton Grading SystemSystem
Multiple revision of original system Multiple revision of original system proposed by Cotton in 1984proposed by Cotton in 1984
First systems criticized for being First systems criticized for being based on subjective interpretation, based on subjective interpretation, although statistically proven to although statistically proven to relate grade with prognosis in relate grade with prognosis in childrenchildren
Myer 1994: used serial ETT Myer 1994: used serial ETT measurement to derive Cotton grademeasurement to derive Cotton grade
Grading Systems for SGSGrading Systems for SGS
Cotton-MyerCotton-Myer Based on relative reduction of Based on relative reduction of
subglottic cross-sectional areasubglottic cross-sectional area Good for mature, firm, circumferential Good for mature, firm, circumferential
lesionslesions Does not take into account extension to Does not take into account extension to
other subsites or length of stenosisother subsites or length of stenosis Gold-Standard Staging in pediatric Gold-Standard Staging in pediatric
patientspatients
McCaffrey Grading McCaffrey Grading SystemSystem
McCaffrey McCaffrey (1991)(1991)
Relative reduction in cross sectional Relative reduction in cross sectional area not consistently reliable predictor area not consistently reliable predictor of decannulation in adultsof decannulation in adults
Reviewed 73 cases of LTS in adults Reviewed 73 cases of LTS in adults finding location of stenosis to be the finding location of stenosis to be the most significant factor in predicting most significant factor in predicting decannulationdecannulation
Grading Systems for SGSGrading Systems for SGS
McCaffreyMcCaffrey Based on subsites (trachea, subglottis, Based on subsites (trachea, subglottis,
glottis) involved and length of stenosisglottis) involved and length of stenosis Does not include lumen diameterDoes not include lumen diameter
McCaffrey Clinical McCaffrey Clinical StagingStaging
Stage IStage I: confined to : confined to subglottis/tracheasubglottis/trachea
Stage IIStage II: SGS, : SGS, >1cm, confined to >1cm, confined to cricoidcricoid
Stage IIIStage III: SGS and : SGS and involving tracheainvolving trachea
Stage IVStage IV:involve :involve glottis with fixation glottis with fixation TVCTVC
Grading Systems for SGSGrading Systems for SGS McCaffreyMcCaffrey
McCaffrey ConclusionsMcCaffrey Conclusions
SiteSite: glottic, tracheal, subglottic: major : glottic, tracheal, subglottic: major factor factor in type of surgeryin type of surgery thin (<1cm) subglottic or tracheal thin (<1cm) subglottic or tracheal
lesions--Endoscopiclesions--Endoscopic thick(>1cm) any site or glottic lesions--thick(>1cm) any site or glottic lesions--
OpenOpen
StageStage: prognostic predictor: prognostic predictor 90% of Stage I and II successfully treated90% of Stage I and II successfully treated 70% of Stage III, 40% of Stage IV70% of Stage III, 40% of Stage IV
Management of SGSManagement of SGS
MedicalMedical ObservationObservation TracheotomyTracheotomy Endoscopic TreatmentEndoscopic Treatment
CO2 laser (with Mitomycin C/Steroid)CO2 laser (with Mitomycin C/Steroid) Rigid vs. Balloon Dilation (with Rigid vs. Balloon Dilation (with
Mitomycin)Mitomycin) Open Airway expansion procedureOpen Airway expansion procedure
Management of SGSManagement of SGS
MedicalMedical Diagnosis and treatment of GERDiagnosis and treatment of GER Pediatric – consultation with primary Pediatric – consultation with primary
physician and specialists (pulmonary, GI, physician and specialists (pulmonary, GI, cardiology etc.)cardiology etc.)
AdultAdult Assess general medical statusAssess general medical status Consultation with PCP and specialistsConsultation with PCP and specialists Optimize cardiac and pulmonary functionOptimize cardiac and pulmonary function Control diabetesControl diabetes Discontinue steroid use if possible before LTRDiscontinue steroid use if possible before LTR
Management of SGSManagement of SGS
ObservationObservation Reasonable in mild cases, esp. Reasonable in mild cases, esp.
congenital SGS (Cotton-Myer grade I congenital SGS (Cotton-Myer grade I and mild grade II)and mild grade II) If no retractions, feeding difficulties, or If no retractions, feeding difficulties, or
episodes of croup requiring hospitalizationepisodes of croup requiring hospitalization Follow growth curvesFollow growth curves Repeat endoscopy q 3-6 moRepeat endoscopy q 3-6 mo
Adults – depends on symptomsAdults – depends on symptoms
Surgery for SGSSurgery for SGS I. Endoscopic I. Endoscopic
Dilation +/- stentingDilation +/- stenting Rigid vs. balloon dilationRigid vs. balloon dilation
Laser +/- stentingLaser +/- stenting II. Open procedureII. Open procedure
Expansion procedure (with trach and Expansion procedure (with trach and stent or SS-LTR)stent or SS-LTR) Laryngotracheoplasty (Trough technique with Laryngotracheoplasty (Trough technique with
mucosal grafting +/- cartilage grafting)mucosal grafting +/- cartilage grafting) Laryngotracheal reconstructionLaryngotracheal reconstruction Tracheal Resection with primary anastamosisTracheal Resection with primary anastamosis
Management of SGSManagement of SGS How do you decide which procedure to How do you decide which procedure to
performperform Status of the patientStatus of the patient
Any contraindicationsAny contraindications AbsoluteAbsolute
Tracheotomy dependent (aspiration, severe Tracheotomy dependent (aspiration, severe BPD)BPD)
Severe GER refractive to surgical and Severe GER refractive to surgical and medical therapymedical therapy
RelativeRelative DiabetesDiabetes Steroid useSteroid use Cardiac, renal or pulmonary diseaseCardiac, renal or pulmonary disease
Management of SGSManagement of SGS
EndoscopicEndoscopic DilationDilation
Practiced frequently before advent Practiced frequently before advent of open LTP proceduresof open LTP procedures
Often requires multiple repeat Often requires multiple repeat proceduresprocedures
Potentially lower success rate but Potentially lower success rate but an option for patients who cannot an option for patients who cannot undergo open proceduresundergo open procedures
Treatment OptionsTreatment Options
GoalsGoals
1. Maintain patent airway1. Maintain patent airway
2. Maintain glottic competence to 2. Maintain glottic competence to
protect against aspirationprotect against aspiration
3. Maintain acceptable voice3. Maintain acceptable voice
Surgical ManagementSurgical Management
ApproachesApproaches Endoscopic: cryotherapy, Endoscopic: cryotherapy,
microcauterization, laser incision or microcauterization, laser incision or excision of scar tissue, dilatation, excision of scar tissue, dilatation, stentingstenting
Open surgical: tracheal resection and Open surgical: tracheal resection and reanastomosis, external tracheoplasty reanastomosis, external tracheoplasty with/without grafting and possible with/without grafting and possible stentingstenting
StentsStents
Indwelling expandable stentsIndwelling expandable stents Used in many organ systems: arteries, the Used in many organ systems: arteries, the
urethra, and biliary treeurethra, and biliary tree
Tracheobronchial system: Tracheobronchial system: Lower airways for either tumors, or Lower airways for either tumors, or
bronchial stenosis after lung bronchial stenosis after lung transplantationtransplantation
Upper airways (Montgomery T-tube, Upper airways (Montgomery T-tube, silicone, mesh stents): used alone or with silicone, mesh stents): used alone or with other modalities other modalities
StentsStents
StentingStenting Ensure adequate airway during wound Ensure adequate airway during wound
maturationmaturation While waiting for pt’s condition to While waiting for pt’s condition to
improve prior to definitive surgical improve prior to definitive surgical resection/treatmentresection/treatment
Silastic T-Tubes most commonly usedSilastic T-Tubes most commonly used Permit better hygienePermit better hygiene Not prone to obstructing granulationNot prone to obstructing granulation Stent removal possible after 1-2 years with Stent removal possible after 1-2 years with
good resultsgood results
Expandable StentExpandable Stent
Hanna Hanna 19971997 Canine model(6)Canine model(6)
Stenosis induced by resection of anterior Stenosis induced by resection of anterior cricoid arch/tracheal wall to reduce airway cricoid arch/tracheal wall to reduce airway diameter by 50%diameter by 50%
8 week stenosis maturation period8 week stenosis maturation period Tracheostomy performed, followed by Tracheostomy performed, followed by
introduction of titanium mesh stent (Group A), introduction of titanium mesh stent (Group A), +/- silicone covering (Group B)+/- silicone covering (Group B)
Euthanasia performed at 4 weeks with Euthanasia performed at 4 weeks with gross/histologic exam gross/histologic exam
Expandable StentExpandable Stent
HannaHanna (1997) (1997)
Stents well tolerated, minimal signs of Stents well tolerated, minimal signs of airway irritation, no infectionsairway irritation, no infections
Group A unable to be decannulated due Group A unable to be decannulated due to granulationto granulation
Group B all tolerated decannulation Group B all tolerated decannulation without complicationwithout complication
Expandable StentExpandable Stent
Silastic T-TubesSilastic T-Tubes
T-TubesT-Tubes
StentsStents
FroehlichFroehlich (1993) (1993)
Retrospective study of T-tubes in 12 Retrospective study of T-tubes in 12 pediatric patientspediatric patients
10 acquired after intubation, 2 10 acquired after intubation, 2 congenital, (4 extensive tracheomalacia)congenital, (4 extensive tracheomalacia)
10 with prior tracheotomy10 with prior tracheotomy
5 Cotton grade 2, 7 Cotton grade 3 (6 5 Cotton grade 2, 7 Cotton grade 3 (6 required anterior split to fit T-tube)required anterior split to fit T-tube)
StentsStents
FroehlichFroehlich (1993) (1993)
mean time from insertion to final mean time from insertion to final removal 5.6 monthsremoval 5.6 months
9/12 successful tx (mean time from dx 9/12 successful tx (mean time from dx to end of tx 15.3 months)to end of tx 15.3 months)
Complications: tube migration, Complications: tube migration, accidental tube removal, tube accidental tube removal, tube occlusionocclusion
StentsStents
FroehlichFroehlich (1993) (1993)
75% success rate of long term stenting 75% success rate of long term stenting comparable to either cricoid split or comparable to either cricoid split or LTR proceduresLTR procedures stenting takes longer, increased stenting takes longer, increased
complicationscomplications
T-tube stenting better reserved for T-tube stenting better reserved for cases not amenable to surgery, i.e. cases not amenable to surgery, i.e. tracheomalaciatracheomalacia
Endoscopic ApproachEndoscopic Approach
Benefits patients due to less Benefits patients due to less morbiditymorbidity
Shorter hospital stayShorter hospital stay Earlier return to workEarlier return to work Tolerance of repeated procedures, if Tolerance of repeated procedures, if
necessarynecessary
““Lasers”Lasers”
First medical use First medical use (December 1961)(December 1961)
Strong and Jako Strong and Jako (1972)(1972) First described CO2 First described CO2
laser for LTS laser for LTS managementmanagement
Types: Types: CO2CO2 KTPKTP Nd-YAGNd-YAG
LasersLasers Used as both definitive and as an Used as both definitive and as an
adjunct to open repairadjunct to open repair
Hall Hall (1971) delayed collagen (1971) delayed collagen synthesis in laser incisionssynthesis in laser incisions
Used in conjuncture with other Used in conjuncture with other epithelial preserving techniquesepithelial preserving techniques
Laser excision of subglottic Laser excision of subglottic stenosisstenosis
Laser excision of subglottic Laser excision of subglottic stenosisstenosis
Endoscopic ApproachEndoscopic Approach
Simpson, et alSimpson, et al (1982) (1982) Retrospective study of 60 patients: 49 Retrospective study of 60 patients: 49
laryngeal (supraglottic,glottic, subglottic), 6 laryngeal (supraglottic,glottic, subglottic), 6 tracheal, 5 combined stenosistracheal, 5 combined stenosis
Follow up: 1-8 yearsFollow up: 1-8 years Age: 2 months-72 years oldAge: 2 months-72 years old COCO22 laser used to vaporize scar tissue, laser used to vaporize scar tissue,
divide fibrotic bands, or excise redundant divide fibrotic bands, or excise redundant tissuetissue
+/- Silastic stenting, dilatation+/- Silastic stenting, dilatation
Endoscopic ApproachEndoscopic Approach
Simpson, et alSimpson, et al (1982) (1982) 39/60 had Silastic stents placed39/60 had Silastic stents placed
1/6 supraglottic1/6 supraglottic 2/12 glottic2/12 glottic 27/31 subglottic stenosis27/31 subglottic stenosis 4/6 tracheal4/6 tracheal 4/5 combined4/5 combined
Endoscopic ApproachEndoscopic Approach
Simpson, et alSimpson, et al (1982) (1982)
Dilatation employed 8/60Dilatation employed 8/60 0/49 laryngeal0/49 laryngeal 4/6 tracheal4/6 tracheal 4/5 combined4/5 combined
Endoscopic ApproachEndoscopic Approach
#CASES SUCCESS%
#PROCEDURESTO SUCCESS
Laryngeal 49 77.5 2.11
Tracheal 6 33.3 6
Combined 5 20.0 1
Endoscopic ApproachEndoscopic Approach
Simpson, et alSimpson, et al (1982): Conclusions (1982): Conclusions
Justified at all levelsJustified at all levels
Decreased success with ‘severe’, Decreased success with ‘severe’, combined, extensive (>1cm) or combined, extensive (>1cm) or circumferential stenosis; loss of circumferential stenosis; loss of cartilage, and preceding bacterial cartilage, and preceding bacterial infection associated with tracheostomyinfection associated with tracheostomy
Age not associated with failure rateAge not associated with failure rate
Management of SGSManagement of SGS EndoscopicEndoscopic
LaserLaser 66-80% success rate for Cotton-Myer grade I and 66-80% success rate for Cotton-Myer grade I and
II stenoses (pediatric cases)II stenoses (pediatric cases) Closer to 50% success rate in appropriately Closer to 50% success rate in appropriately
chosen adultschosen adults Factors associated with failureFactors associated with failure
Previous attempts Previous attempts Circumferential scarringCircumferential scarring Loss of cartilage supportLoss of cartilage support Exposure of cartilage Exposure of cartilage Arytenoid fixationArytenoid fixation Combined laryngotracheal stenosis with Combined laryngotracheal stenosis with
vertical length >1cmvertical length >1cm
Scar InhibitorsScar Inhibitors Mitomycin CMitomycin C
Antimetabolite of Antimetabolite of Streptomyces caespitosusStreptomyces caespitosus Possesses antineoplastic and Possesses antineoplastic and
antiproliferative propertiesantiproliferative properties Inhibits fibroblast proliferation Inhibits fibroblast proliferation in vivo in vivo and and
in vitroin vitro Mechanism may involve triggering of Mechanism may involve triggering of
fibroblast apoptosisfibroblast apoptosis 5-FU & B-aminopropionitrile5-FU & B-aminopropionitrile
Inhibit collagen cross-linking and scar Inhibit collagen cross-linking and scar formation in animal modelsformation in animal models
TGF-TGF-ββ
SGS Comparison StudySGS Comparison Study
Shapshay (2004)Shapshay (2004) Retrospective cohort studyRetrospective cohort study Compare efficacy of 3 endoscopic Compare efficacy of 3 endoscopic
techniquestechniques CO2 laser with rigid dilationCO2 laser with rigid dilation CO2 laser, rigid dilation, steroid CO2 laser, rigid dilation, steroid
injectioninjection CO2 laser, rigid dilation, topical CO2 laser, rigid dilation, topical
Mitomycin C applicationMitomycin C application
SGS Comparison StudySGS Comparison Study Endoscopic treatmentEndoscopic treatment
CO2 laser radial incision (Shapshay)CO2 laser radial incision (Shapshay) 15% success15% success
CO2 laser with steroid injectionCO2 laser with steroid injection 40 Kenalog in 3 quadrants40 Kenalog in 3 quadrants 18% success18% success
CO2 laser with mitomycin-C topical applicationCO2 laser with mitomycin-C topical application 0.4 mg/ml Mitomycin-C topically applied 4 minutes0.4 mg/ml Mitomycin-C topically applied 4 minutes 75% success75% success
Mitomycin C MetanalysisMitomycin C Metanalysis
Warner and Brietzke (2008)
Note: Lone human dissenting study was highest quality randomized clinical trial
TGF-TGF-ββ TGF-TGF-ββ: GF secreted by fibroblasts, : GF secreted by fibroblasts,
macrophages and plateletsmacrophages and platelets Implicated in scarring in many different Implicated in scarring in many different
organ systems and in animal modelsorgan systems and in animal models Biopsy specimens of IPSS and intubation Biopsy specimens of IPSS and intubation
related stenosis patients show high levels of related stenosis patients show high levels of TGF-TGF-ββ-2-2
IV and local injection of an antibody IV and local injection of an antibody availableavailable Used to treat fibrosis in skin, ureters, kidney Used to treat fibrosis in skin, ureters, kidney
and eyeand eye Recent study showed inhibition of scarring in rat Recent study showed inhibition of scarring in rat
trachea with continuous infusion of anti-TGFtrachea with continuous infusion of anti-TGFββ
TGF-TGF-ββSimpson CB et al (2008)
Pilot Study in Modified Canine Model
8 subjects underwent cautery injury to subglottis
4 treated with saline injection into injury site
4 treated with combination of IV and local injection of anti-TGFβ at day 0 and day 5
TGF-TGF-ββ Conclusions: Conclusions:
IV and local TGFIV and local TGFββ injection resulted in a injection resulted in a reduction in tracheal stenosis (p < .05) reduction in tracheal stenosis (p < .05) and an increase in survival time (p <.03) and an increase in survival time (p <.03) when compared to saline control subjectswhen compared to saline control subjects
Anti-TGFAnti-TGFββ appears to be useful adjunct in appears to be useful adjunct in treatment of LTStreatment of LTS
Further study needed to determine Further study needed to determine optimal dosing, route of administration optimal dosing, route of administration and timing of deliveryand timing of delivery
SGS Balloon DilationSGS Balloon Dilation Dilation of bronchtracheal stenoses with Dilation of bronchtracheal stenoses with
angioplasty balloons described previously angioplasty balloons described previously in adults and children +/- stentsin adults and children +/- stents
Advantage compared to rigid or bougie Advantage compared to rigid or bougie dilationdilation Balloons maximize the radial direction and Balloons maximize the radial direction and
pressure of dilationpressure of dilation Less damaging to tracheal wall mucosaLess damaging to tracheal wall mucosa Found to have good initial resultsFound to have good initial results
Often requires stenting of dilated portionOften requires stenting of dilated portion Repeated procedures necessary in active Repeated procedures necessary in active
processes, e.g. Autoimmune Statesprocesses, e.g. Autoimmune States
SGS Balloon DilationSGS Balloon Dilation Lee and Rutter (2008)Lee and Rutter (2008) 6 patients with IPSS (single discrete stenosis)6 patients with IPSS (single discrete stenosis) Underwent dilation with 10 to 14 mm balloon Underwent dilation with 10 to 14 mm balloon
in either single or 2 consecutive dilation (in 7 in either single or 2 consecutive dilation (in 7 days)days)
F/u between 10 and 30 months in 4 patientsF/u between 10 and 30 months in 4 patients No symptoms of recurrent airway stenosisNo symptoms of recurrent airway stenosis One patient required repeat dilation after 22 mosOne patient required repeat dilation after 22 mos No adverse effects or complicationsNo adverse effects or complications Recommended burst pressure (8 to 17 atm)Recommended burst pressure (8 to 17 atm) 4 cm long catheters, center of balloon positioned 4 cm long catheters, center of balloon positioned
at midpoint of stenosisat midpoint of stenosis Airway dilated from 2.0 to 3.5 ET size larger Airway dilated from 2.0 to 3.5 ET size larger
than initial sizethan initial size
Combined Laser & Balloon Combined Laser & Balloon DilationDilation
Andrews et al (2007)Andrews et al (2007) Performed flexible bronchoscopy for combined Performed flexible bronchoscopy for combined
Nd:YAG laser radial incision at site of stenosis Nd:YAG laser radial incision at site of stenosis and balloon dilation in awake, spontaneously and balloon dilation in awake, spontaneously breathing patientsbreathing patients
Total of 18 patients underwent 36 proceduresTotal of 18 patients underwent 36 procedures 8 pts required only 1 procedure; 5 pts required 2 8 pts required only 1 procedure; 5 pts required 2
procedures (72%)procedures (72%) 11/18 patients (60%) were obese or morbidly obese 11/18 patients (60%) were obese or morbidly obese Average f/u 22 mos; avg time b/w procedures 9 mosAverage f/u 22 mos; avg time b/w procedures 9 mos No complication in study groupNo complication in study group
Case ExampleCase Example
58-year-old female with several month 58-year-old female with several month history of hoarseness history of hoarseness Also has a history of asthmaAlso has a history of asthma Recent PFTs showed no evidence for Recent PFTs showed no evidence for
asthma. asthma. Also had a diagnosis of gastroesophageal Also had a diagnosis of gastroesophageal
reflux reflux disease and feels that her hoarseness has disease and feels that her hoarseness has been contributed by the reflux diseasebeen contributed by the reflux disease
Intermittent dysphagiaIntermittent dysphagia
Case ExampleCase Example
Laryngo video stroboscopic exam was Laryngo video stroboscopic exam was performed: shows normal vocal fold performed: shows normal vocal fold mobility bilaterallymobility bilaterally
Presence of mild nodular thickening of Presence of mild nodular thickening of the left anterior vocal cord surfacethe left anterior vocal cord surface
More significantly there is approximately More significantly there is approximately 50% stenoses of her subglottic airway at 50% stenoses of her subglottic airway at the level of the cricoid cartilage and the level of the cricoid cartilage and erythema of this areaerythema of this area
Endoscopic Balloon Endoscopic Balloon DilationDilation