Concurrent glottic and tracheal stenoses: restoration of airway continuity in end-stage malignant disease

Thoracic oesophageal cancer as a cause of stridor: a literature review

An 83-year-old woman, with a background of treated squamous cell oesophageal cancer, presented with a 3-week history of stridor. Of note, the patient had no risk factors for oesophageal cancer other than age. Clinical examination was unremarkable apart from stridor. Laboratory investigations, including arterial blood gas on room air, were unremarkable. Radiological examination revealed a 4.5×3.5×3.6 cm mass involving the posterior trachea and invading the tracheal orifice. Oesophagogastroduodenoscopy and rigid bronchoscopy confirmed an extensive tumour arising from the lower oesophagus and invading the trachea, causing 90% airway obstruction for a 6 mm length ending 1.5 cm above the carina. Biopsy revealed a poorly differentiated carcinoma with foci of squamous cell carcinoma. Unfortunately, the patient passed away 2 months after palliative tracheal stent placement.

[The diagnostics and treatment of bilateral paralysis of the larynx]

The objective of the present study was to consider the currently available methods for the diagnostics and treatment of the patients presenting with bilateral paralysis of the larynx of various etiologies. We undertook the analysis of the publications in the domestic and foreign scientific literature concerning diagnosis and treatment of bilateral paralysis of the larynx. It was found that despite the existing modern high-tech diagnostic technologies and the variety of surgical methods for the treatment of this condition, the problem of diagnostics, management, and rehabilitation of the patients suffering from bilateral paralysis of the larynx remains a serious challenge for the researchers and clinicians that requires further investigation of this pathology. For the correct and timely diagnosis of bilateral paralysis of the larynx, the comprehensive evaluation of the functional state of the neuromuscular apparatus of the larynx is necessary. The key prerequisites for the success of the surgical intervention are its timeliness and the choice of the optimal surgical modalities.

Current Treatment Options for Bilateral Vocal Fold Paralysis: A State-of-the-Art Review

Vocal fold paralysis (VFP) refers to neurological causes of reduced or absent movement of one or both vocal folds. Bilateral VFP (BVFP) is characterized by inspiratory dyspnea due to narrowing of the airway at the glottic level with both vocal folds assuming a paramedian position. The primary objective of intervention for BVFP is to relieve patients’ dyspnea. Common clinical options for management include tracheostomy, arytenoidectomy and cordotomy. Other options that have been used with varying success include reinnervation techniques and botulinum toxin (Botox) injections into the vocal fold adductors. More recently, research has focused on neuromodulation, laryngeal pacing, gene therapy, and stem cell therapy. These newer approaches have the potential advantage of avoiding damage to the voicing mechanism of the larynx with an added goal of restoring some physiologic movement of the affected vocal folds. However, clinical data are scarce for these new treatment options (i.e., reinnervation and pacing), so more investigative work is needed. These areas of research are expected to provide dramatic improvements in the treatment of BVFP.

Polyflex stenting of tracheomalacia after surgery for congenital tracheal stenosis

Polyflex self-expanding stents (Rüsch, Germany) were used in three young children who had presented with life-threatening long-segment tracheal stenosis with bronchial stenosis in two cases. Two children had slide tracheoplasties and subsequently aortic homografts and another tracheal resection and autotracheoplasty. However, in all cases persistent lower tracheal malacia necessitated stenting. Complications of granuloma, stent migration or dislodgement occurred in all cases. A fatal tracheo-aortic fistula occurred in one child. Granuloma in one was treated successfully with steroids. One child survives.

Prevalência de achados pulmonares em 55 pacientes com neoplasias esofagianas

OBJETIVO: Identificar alterações pulmonares em pacientes com neoplasia esofágica. Comparar os dados obtidos, além de mostrar sua relação com o tabagismo. MATERIAIS E MÉTODOS: Estudo transversal tipo série de casos. Foram analisados prontuários e exames de imagem (tomografias computadorizadas e radiografias) de 55 pacientes com câncer de esôfago, diagnosticados entre 1998 e 2001, no Hospital de Base de São José do Rio Preto. Comparou-se a freqüência dos tumores encontrados e outras alterações pulmonares em dois grupos de pacientes: tabagistas e não tabagistas. RESULTADOS: Quarenta e seis (83%) pacientes apresentaram carcinomas espinocelulares, sete (13%) adenocarcinomas, um (2%) carcinoma de pequenas células e um (2%) linfoma não-Hodgkin. Quarenta e oito (87%) pacientes eram tabagistas e sete (13%) eram não tabagistas. Entre os tabagistas, 89% possuíam carcinoma espinocelular, 9% adenocarcinoma e 2% carcinoma de pequenas células. Entre os não tabagistas, 57% apresentaram adenocarcinoma, 28% carcinoma espinocelular e 15% linfoma não-Hodgkin. Houve metástases em quatro tabagistas e em dois não tabagistas. A prevalência das alterações pulmonares (infiltrado intersticial, enfisema e pneumonia) foi maior nos tabagistas (73%) do que nos não tabagistas (27%) (p = 0,03). CONCLUSÃO: Este fato reforça a importância da avaliação pulmonar nos pacientes com neoplasia esofágica.

Management of bilateral arytenoid cartilage fixation versus recurrent laryngeal nerve paralysis

Bilateral arytenoid cartilage fixation (ACF) closely resembles vocal cord immobility due to recurrent laryngeal nerve paralysis (RLNP). This study sought to determine the etiologic differences between these two entities and to derive conclusions about treatment. The charts of 218 consecutive adult patients with immobility of both vocal cords requiring surgery for airway restoration were reviewed. The results of laryngeal electromyography and laryngotracheoscopy were used to distinguish ACF from RLNP. In 186 patients (85.3%), RLNP was identified. Of these, 154 paralyses (82.8%) were caused by surgical interventions, 5 (2.7%) were caused by previous intubation, 16 (8.6%) were caused by various malignancies, and 7 (3.8%) were neurogenic. In 4 patients (2.2%), the cause remained unclear. We identified ACF in 32 patients. The etiologic factors included previous long-term intubation in 22 patients (68.8%), short-term intubation in 3 patients (9.4%), Wegener's granulomatosis in 3 patients (9.4%), rheumatoid arthritis in 2 patients (6.3%), previous laryngeal surgery in 1 patient (3.1%), and caustic ingestion in 1 patient (3.1%). Additional second-site airway stenosis was found in 10 of the RLNP patients (5.4%) and in 15 of the ACF patients (46.9%). All RLNP patients had endoscopic surgery without temporary tracheotomy. Eighteen ACF patients required open surgery, and 4 were managed endoscopically but required temporary tracheotomy. The etiologic factors were significantly different for the two entities under study. Additional sites of stenosis were more frequent in ACF patients. Stenosis due to RLNP could be managed endoscopically without preliminary tracheotomy, while ACF frequently required open surgery and temporary tracheotomy.

Suspension laryngoscopy for endotracheal stenting

OBJECTIVES/HYPOTHESIS

Airway stents have recently been used to establish and maintain patent airways in patients with malignant central airway obstruction, but insertion modalities remain controversial to date. The study seeks to determine the role of suspension laryngoscopy in interdisciplinary airway stenting.

STUDY DESIGN

Retrospective, single-institution analysis of a case series treated by a multidisciplinary airway team.

METHODS

Ninety-three consecutive patients with malignant obstruction of the trachea and/or tracheobronchial bifurcation underwent endotracheal stenting through a suspension laryngoscopy approach for the relief of impending respiratory distress. Feasibility, mortality, survival, and complications were analyzed as main outcome measures.

RESULTS

Stenting through a suspension laryngoscopy approach was feasible 91 of 93 patients (97.8%). Fifteen patients needed repeated stenting, and in all, 121 stents were implanted during the observation period. This approach allowed for the repeated insertion of rigid bronchoscopes of graded sizes to establish an airway and for precise stent positioning. Optical instruments and stent introducer systems could easily be used while adequate ventilation was continuously maintained. Silicone stents of maximal size were inserted without injury of the vocal cords during intubation. Median survival for all patients was 8 months. No intraoperative airway complications were observed, and no patient died secondary to stenting.

CONCLUSIONS

Suspension laryngoscopy and jet ventilation provide an ideal setting for the precise placement of tracheal and bifurcation airway stents. Laryngologists should actively participate in interdisciplinary airway stenting programs.