Idiopathic subglottic stenosis: diagnosis and endoscopic laser treatment

Endoscopic treatment of benign tracheal stenosis: a single-centre study

BACKGROUND

Benign tracheal stenosis is relatively rare but remains a significant chronic disease due to its drastic symptoms including dyspnoea and inspiratory stridor, and consequent negative effect on quality of life. Traditionally, the surgical approach by resection of the stenotic tracheal segment has been the therapy of choice. However, endoscopic techniques have arisen and may offer a safe and less invasive alternative.

OBJECTIVES

The aim of the retrospective study was to evaluate procedure-related safety and outcome of endoscopic treatment of benign tracheal stenosis at a single centre.

METHODS

The study included all patients at our institution who between 2013 and 2022 had received endoscopic treatment of benign tracheal stenosis by rigid tracheoscopy, radial incision by electric papillotomy needle and dilation (endoscopic tracheoplasty) followed by triamcinolone acetonide as a local submucosal injection and additionally, from 2020, budesonide inhalation.

RESULTS

A total of 22 patients were treated in a total of 38 interventions, each resulting in immediate improvement of symptoms. There were no peri-interventional complications or mortality. Of the 38 interventions, 11 received no triamcinolone acetonide administration, resulting in a 54.5% recurrence rate after an average of 21.1 (±18.0) months, while 27 had local triamcinolone acetonide, with a 37% recurrence rate. Since 2020, we additionally initiated post-interventional budesonide inhalation as recurrence prophylaxis for newly admitted patients and patients with recurrences(n = 8), of whom only one (12.5%) has to date experienced a recurrence.

CONCLUSION

Our results indicate that endoscopic tracheoplasty offers a safe and successful, minimally invasive alternative to open surgery for patients with benign tracheal stenosis. We recommend local administration of triamcinolone into the mucosa as an additional treatment to decrease the risk of recurrence. However, given the uncontrolled study design and low sample size, safety and effectiveness cannot be conclusively demonstrated. Nonetheless, our findings suggest promising avenues for further investigation. Further studies on the additional benefit of inhaled corticosteroids are warranted.

Idiopathic subglottic stenosis in Saskatchewan Hutterite population

Background

By studying the odds of developing idiopathic subglottic stenosis in the isolated and genetically unique Hutterite population, this study sought to strengthen the hypothesis that an underlying genetic predisposition may exist for its development.

Methods

A retrospective chart review examined the medical records of all adult patients treated for idiopathic subglottic stenosis in Saskatchewan between 2008 and 2018. Cases were segregated into Hutterite and non-Hutterite.

Results

Four out of 36 cases of idiopathic subglottic stenosis occurred among Hutterites. The odds of a Hutterite developing idiopathic subglottic stenosis are 21.89 times higher than for non-Hutterites. Positive family history was only observed in the Hutterite population.

Conclusion

The study strengthens the hypothesis that genetics may play a role in the aetiology of idiopathic subglottic stenosis by demonstrating that the genetically and socially unique Hutterites are more likely to develop this rare disease. This study is the first to demonstrate that a specific subpopulation is at a higher risk for developing idiopathic subglottic stenosis.

Laryngotracheal stenosis: Mechanistic review

Background

The purpose of this review article is to summarize the existing literature surrounding wound healing mechanisms in laryngotracheal stenosis.

Methods

A review of general wound healing pathophysiology, followed by a focused review of iatrogenic laryngotracheal stenosis (iLTS) and idiopathic subglottic stenosis (iSGS) as conditions of aberrant wound healing.

Results

iLTS is the scarring of the laryngotracheal complex, coming secondary to injury from prolonged intubation. iSGS is a chronic fibroinflammatory scarring and narrowing of the subglottic airway in the absence of any obvious preceding injury or trauma. They are both thought to result from a prolonged and dysregulated wound healing response that promotes the deposition of pathologic scar in the airway.

Conclusions

Understanding the mechanisms that underlie wound healing will help identify and intervene on the process early in its development and discover future therapies that target individual wound healing mechanisms limiting the incidence of this recalcitrant disease process.

Idiopathic Subglottic Stenosis: An Institutional Review of Outcomes With a Multimodality Surgical Approach

OBJECTIVES

This article reports on a unique cohort of patients with idiopathic subglottic stenosis spilt fairly equally between endoscopic and open surgical approaches. Patients' sequence of operations and reinterventions over time are outlined, offering insight to improve surgical counseling and allow for informative, autonomous patient decision making.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic center.

METHODS

Cases of consecutive adults with idiopathic subglottic stenosis managed surgically over a 12-year period (January 2006-December 2017) were retrospectively reviewed. Surgical workflow, complications, and outcomes, including reinterventions and tracheotomy dependence, are reported.

RESULTS

Seventy-two patients (71 women; mean age, 50.4 years) with idiopathic subglottic stenosis requiring surgical airway intervention were identified. Six patients underwent tracheotomy prior to attempt at airway stenosis surgery. Initial surgical approach thereafter included endoscopic (73.5%, n = 53) and open (26.4%, n = 19) procedures. Thirty-one patients underwent cricotracheal resection; the reintervention rate was 22.5%. Sixty patients underwent 147 endoscopic procedures; the reintervention rate was 75.5%, and the mean time between dilations was 83 weeks (range, 5-402). Two (2.8%) patients remain tracheotomy dependent. Adverse events were significantly higher in the cricotracheal group, especially with respect to dysphonia and temporary gastrostomy tube placement (P < .01).

CONCLUSIONS

Endoscopic and open surgical airway intervention can be employed successfully to avoid tracheotomy dependence and maintain airway patency; however, multiple procedures are usually required, regardless of surgical approach. Cricotracheal reintervention rates are lower than endoscopic dilation but with increased morbidity. Quality-of-life outcomes should be clearly discussed with patients before deciding on a surgical management strategy.

Proteomic and Genomic Methylation Signatures of Idiopathic Subglottic Stenosis

OBJECTIVE

Idiopathic subglottic stenosis (iSGS) is a chronic inflammatory condition that causes dyspnea and affects middle-aged women of White race and non-Latino or Hispanic ethnicity. To better characterize its phenotype and pathogenesis, we assessed the proteomic and genomic methylation signatures of subglottic tissue collected from iSGS patients compared to controls.

STUDY DESIGN

Molecular analysis of clinical biospecimens.

METHODS

We collected subglottic tissue biopsies from 12 patients during direct laryngoscopy, immediately prior to surgical treatment of iSGS; as well as from 4 age-, sex-, and race/ethnicity-matched control patients undergoing other direct laryngoscopic procedures. We isolated protein and genomic DNA, acquired proteomic data using label-free quantitative mass spectrometry techniques, and acquired genome-wide methylation data using bisulfite conversion and a microarray platform. We compared molecular profiles across the iSGS and control groups, and with respect to clinical course in the iSGS group. Eight of the 12 iSGS patients underwent subsequent blood collection and plasma isolation for further assessment.

RESULTS

Proteomic analysis revealed 42 differentially abundant proteins in the iSGS biopsies compared to controls, inferring enrichment of biological pathways associated with early wound healing, innate immunity, matrix remodeling, and metabolism. Proteome-based hierarchical clustering organized patients into two iSGS and one control subgroups. Methylation analysis revealed five hypermethylated genes in the iSGS biopsies compared to controls, including the biotin recycling enzyme biotinidase (BTD). Follow-up analysis showed elevated plasma BTD activity in iSGS patients compared to both controls and published normative data.

CONCLUSION

iSGS exhibits distinct proteomic and genomic methylation signatures. These signatures expand current understanding of the iSGS phenotype, support the possibility of disease subgroups, and should inform the direction of future experimental studies.

LEVEL OF EVIDENCE

Not applicable Laryngoscope, 131:E540-E546, 2021.

Idiopathic cervical tracheal stenosis in an 11-year-old male

Idiopathic laryngotracheal stenosis is a fibroinflammatory stenosis in persons without alternative explanation such as trauma, intubation, or autoimmune disease. Patients are usually females of child-bearing age. We report on an 11-year-old male who developed progressive dyspnea and stridor. Bronchoscopy revealed 90% stenosis of the cervical trachea. He underwent serial balloon dilation with steroid injection; stenosis decreased to 20%. He had no history of intubation or trauma. Histologic and laboratory workup for autoimmune disease was negative. This report highlights occurrence of a well-known disease in an uncommon population, and alerts providers to consider this when seeing new pediatric patients with symptoms of progressive airway restriction.

Role of Balloon Dilation in the Management of Adult Idiopathic Subglottic Stenosis

Objectives

We evaluated the efficacy of balloon dilation for adjunctive and symptomatic management of isolated idiopathic subglottic stenosis in adults.

Methods

Adults with airway obstruction symptoms classified as idiopathic subglottic stenosis based on history and findings of a single discrete stenotic area on microlaryngoscopy and bronchoscopy were included in this series. Patients who met these criteria underwent dilation with a 10- to 14-mm balloon in a single procedure or in 2 consecutive dilations within 7 days. The patients were followed for up to 30 months after dilation.

Results

Six patients met the criteria. One of the 6 had prior laser treatments and a cricotracheal resection. One patient had a previous scar band lysis procedure. The remaining 4 patients had no prior procedures. The airway sizes prior to dilation ranged from a 2.5 endotracheal tube to a 5.0 endotracheal tube. In all cases the airway was dilated to 2.0 to 3.5 endotracheal tube sizes larger than the initial size. To date, 4 patients have been followed for 10 to 30 months without symptoms of recurrent airway stenosis. One patient was symptom-free for 22 months, then presented with progressive airway difficulty following an upper respiratory tract infection, and has undergone a repeat dilation. No patients had adverse effects or complications from the procedure.

Conclusions

Balloon dilation of idiopathic subglottic stenosis in adults is a relatively safe and effective method to manage this disease entity for cases of isolated and discrete lesions. Patients who underwent a single procedure have remained symptom-free for up to 30 months after balloon dilation.

Idiopathic subglottic stenosis: an epidemiological single-center study

A retrospective epidemiological study of patients treated for idiopathic subglottic stenosis (ISS) during 2003-2013 at Oslo University Hospital, Rikshospitalet, was undertaken to assess its incidence, management and treatment outcomes. Out of a total of 123 patients with subglottic stenosis (84 female, 39 men), 38 patients were diagnosed with ISS, all of whom were female. Of these, 23 lived in the South-Eastern Norway Regional Health Authority, representing an incidence of 0.2 per 100,000 (95% CI 0.13-0.3) in this region of 2.9 million inhabitants. Mean age at diagnosis was 54 years (range 20-85 years), and the mean interval between symptom onset and diagnosis was 3.1 years. The 38 patients with ISS underwent a total of 132 operations between 2003 and 2013. All patients were managed endoscopically using laser surgery, with or without corticosteroids and Mitomycin C, with dilatation by balloon or bougie. Eight patients (21.1%) required only one procedure, while 30 patients (78.9%) had multiple operations. The median follow-up for all patients from the first operation was 5.3 years. The mean interval between procedures was 1 year for patients aged 20-48 years, 1.3 years for patients aged 49-61 years and 3.0 years for patients aged 62-85 years. No clinically significant complications were observed. In conclusion, the symptoms of ISS can be treated effectively with laser surgery and dilatation but the recurrence rate remains high and the time interval between operations does not increase with time, making ISS a continuing challenge.

Risk Factors for Adult Laryngotracheal Stenosis: A Review of 74 Cases

Objectives:

We sought to identify risk factors for and review our experience in the management of adult acquired laryngotracheal stenosis (LTS) at an academic urban medical center.

Methods:

A retrospective review of all patients given a diagnosis of acquired LTS between 1997 and 2005 was performed. Seventy-four patients with LTS were identified. Demographic information, medical and surgical history, surgical procedures performed, and outcomes were collected. A control group of 106 patients admitted over the same time period with respiratory distress but without LTS was identified. The data collected for both groups were analyzed by Fisher's exact test and logistic regression analysis.

Results:

Demographically, the control group was not significantly different from the LTS group. Patients who had a previous tracheostomy were 10.99 times more likely to develop LTS than control patients (95% confidence interval [CI], 4.68 to 25.80). Patients irradiated for carcinomas of the oropharynx and larynx were 5.95 times more likely to develop LTS than control patients (95% CI, 1.87 to 18.91). Those previously intubated for more than 48 hours were 3.91 times more likely to develop LTS than control patients (95% CI, 1.91 to 8.02). Finally, patients who were intubated for any non-airway surgery were found to be 2.07 times more likely to develop LTS (95% CI, 1.09 to 3.93).

Conclusions:

Prolonged intubation, tracheostomy, previous non-airway surgery, and irradiation for oropharyngeal and laryngeal tumors are risk factors for LTS. Multiple surgical procedures are often required for treatment. Mitomycin C did not significantly improve decannulation rates.

Effects of Balloon Dilation for Idiopathic Laryngotracheal Stenosis on Voice Production

OBJECTIVE

To evaluate the effects of balloon dilation for idiopathic laryngotracheal stenosis on voice production.

METHODS

Retrospective review of 10 female patients with idiopathic laryngotracheal stenosis undergoing balloon dilation. Voice outcomes were evaluated by comparing pre- and posttreatment patient-reported, perceptual, aerodynamic, and acoustic parameters. Complete data sets were not available for all subjects; sample size for each parameter is reported with the corresponding result.

RESULTS

Total Voice Handicap Index (VHI) decreased significantly (22.9 ± 13.5 to 6.8 ± 6.5; n = 8; p = .015), as did glottal function index (7.2 ± 4.9 to 1.5 ± 2.0; n = 6; p = .022). No changes were observed in the GRBAS (grade, roughness, breathiness, asthenia, strain) scale. Changes in aerodynamic parameters were not statistically significant. Percent jitter decreased (1.32 ± 1.37 to 0.60 ± 0.29; n = 7; P = .078), and fundamental frequency range was preserved (507 ± 325 to 612 ± 281; n = 7; P = .309).

CONCLUSIONS

Our sample of patients with idiopathic laryngotracheal stenosis had a mild-moderate dysphonia that improved with balloon dilation. Importantly, adverse effects on voice that can occur with open procedures were not observed. Patient perception of dysphonia improved while fundamental frequency range was maintained and aerodynamic parameters remained within or moved toward the normal range. Larger prospective studies are warranted to further evaluate changes in voice production associated with balloon dilation.

Idiopathic Subglottic and Tracheal Stenosis

Objectives:

To report and compare patients’ experiences with acquired subglottic stenosis (AS) versus idiopathic subglottic and tracheal stenosis (ISTS).

Methods:

A survey was made available to patients with AS and ISTS. Results were analyzed for inter- and intragroup differences using a 2-tailed t test.

Results:

The study included 160 survey participants (AS n = 28; ISTS n = 132), with a predominance of female participants (82% AS, 98% ISTS). Acid reflux was the most prevalent comorbidity across groups (42%-43%). A significant difference in time to diagnosis was found between groups, with 32% of AS patients diagnosed within 3 months of symptom onset, compared to 2% with ISTS. A diagnosis delay greater than 18 months occurred for 58% of ISTS patients. There was no difference in treatment approach, with the most common treatment being balloon dilation, followed by laser dilation. Tracheal resection was performed in 36% of patients in both groups. Patient satisfaction with surgical outcomes was significantly higher after tracheal resection (76%) compared to other treatment modalities (39%).

Conclusions:

ISTS remains a diagnostic challenge as highlighted by the delay in diagnosis compared to AS. There appears to be no historical or symptomatic factors specific to ISTS. Additionally, patients report increased satisfaction and symptom resolution after tracheal resection.

[Subglottic tracheal stenosis]

OBJECTIVES

To assess the results of endoscopic CO(2) laser resections combined with mitomycin-C and/or triamcinolone acetonide therapy in the treatment of patients with symptomatic subglottic tracheal stenosis.

MATERIALS AND METHODS

Eleven patients (all female) with subglottic tracheal stenosis were divided into two groups: six patients with idiopathic subglottic tracheal stenosis and five with subglottic tracheal stenosis of known etiology (four with Wegener's disease and one with polychondritis of the trachea). Three patients showed signs of reflux. The primary outcome measure was improvement of the clinical symptoms and the secondary the postoperative reduction of airway resistance.

RESULTS

All patients were treated with CO(2) laser resections combined with mitomycin-C and/or triamcinolone acetonide therapy. Postoperative examinations during a period of 7 to 72 months demonstrated a reduction of symptoms and of airway resistance in all patients.

CONCLUSIONS

One or more endoscopic CO(2) laser resections combined with mitomycin-C and/or triamcinolone acetonide therapy are effective in the treatment of subglottic tracheal stenoses. Long-term oral steroid and immunosuppressive therapy as well as the use of proton pump inhibitors positively influences the postoperative outcome.

Endoscopic management of idiopathic tracheal stenosis

BACKGROUND

Idiopathic tracheal stenosis (ITS) is a rare condition representing a difficult therapeutic challenge. Endoscopic management is a therapeutic option but long-term results are not established. The aim of this retrospective multicenter study was to analyze long-term outcome after endoscopic management of ITS.

METHODS

Nine institutions involved in interventional bronchoscopy were contacted and asked to identify ITS endoscopically treated. A standard form was used to report the main characteristics and long-term outcome after endoscopic management.

RESULTS

Twenty-three patients, 96% women, aged 45±16 years, were endoscopically treated for ITS. Time between first symptoms and diagnosis was 19±18 months. Bronchoscopy showed a weblike (61%) or complex (39%) stenosis, located in the upper part of the trachea, mainly in the cricoid area. Endoscopic treatment included mechanical dilation only (52%) or associated with laser or electrocoagulation (30%) and stent placement (18%). All procedures were efficient. The follow-up after endoscopic management was 41±34 months. The ITS recurrence occurred in 30% at 6 months, 59% at 2 years, and 87% at 5 years, with a delay of 14±16 months. The treatment of recurrence (n=13) included endoscopic management in 12 cases.

CONCLUSIONS

Endoscopic management of ITS provides a safe and efficient therapeutic option but late recurrences are frequent and require long-term follow-up.

Treatment of idiopathic laryngotracheal stenosis with laryngotracheal reconstruction

OBJECTIVES

We evaluated the efficacy of laryngotracheal reconstruction with costal cartilage grafting for the treatment of idiopathic laryngotracheal stenosis.

METHODS

From January 2001 to December 2005, 129 patients with laryngotracheal stenosis were treated at our hospital. Of these patients, five (4 per cent) female patients whose ages ranged from 14 to 34 years were identified as having idiopathic laryngotracheal stenosis. These patients were treated with a modified laryngotracheal reconstruction with anterior costal cartilage grafting. A Montgomery T-tube remained in place for 12 to 22 months.

RESULTS

Three patients presented with grade three and two with grade two stenosis. Three patients were decannulated after one procedure, with normal respiratory function and good exercise tolerance; one patient was decannulated after two procedures. One patient failed decannulation. The mean time to decannulation was 13 months.

CONCLUSIONS

Laryngotracheal reconstruction with anterior costal cartilage grafting is a safe and effective method, and provides an alternative treatment for idiopathic laryngotracheal stenosis.

Tailored cricoplasty: an improved modification for reconstruction in subglottic tracheal stenosis

OBJECTIVE

Subglottic laryngotracheal stenosis with side-to-side narrowing poses a challenge for successful reconstruction. The standard technique of anterior cricoid resection was modified to address a small ventricle with lateral narrowing.

METHODS

This study was a retrospective chart review and telephone questionnaire follow-up of consecutive patients with subglottic stenosis at a single institution. Follow-up questionnaires used Likert scales (ratings 1-10) to describe preoperative and postoperative symptoms, satisfaction, and perceived effectiveness. Once the anterior cricoid is removed, resection of thickened submucosal tissue is performed. The inner third to half of the lateral wall of the remaining cricoid cartilage is carefully excised. Advancing the preserved mucosa over the cricoid resurfaces the exposed cartilage. This results in additional horizontal enlargement of the luminal diameter of the airway of 3 to 5 mm.

RESULTS

Eighteen patients with subglottic stenosis, small laryngeal ventricle, and lateral narrowing underwent tailored cricoplasty during a 15-month period. Mean age was 51 years (range 20-75 years), and mean follow-up was 9.1 +/- 1.2 months (range 2-17 months). There were 2 self-limited airway complications. All patients reported that they were satisfied and would undergo surgery again. Overall satisfaction was rated at 9.5 +/- 1.0, and satisfactions with resting and exertional dyspnea were 9.7 +/- 0.5 and 9.5 +/- 1.0, respectively. Symptoms of recurrence at follow-up were rated as 0.6 +/- 1.4.

CONCLUSION

Tailored cricoplasty is an effective technique to improve the outcome of reconstructive subglottic stenosis. It offers reconstructive possibilities for patients with diminished side-to-side dimensions in the subglottic airway.

[ANCA-negative subglottic laryngeal stenosis in childhood]

A 15-year-old female, having developed recurrent infections of the upper airway, hoarseness, dyspnea, and nasal congestion, was referred to our department. There was no history of trauma or intubation. The subglottic space was circularly narrowed. The test for c-ANCA was negative. Chest X-ray and renal function were normal. A tracheotomy was performed; the histology showed infiltrating plasma cells, but no signs of vasculitis or granulomatous inflammation. One year later the patient developed acute renal failure. Biopsy of the kidney confirmed Wegener's disease. The laryngeal stenosis completely resolved after therapy with cyclophosphamide. Juvenile Wegener's granulomatosis is extremely rare; the larynx and trachea seem to be involved more frequently in children than in adults. The positive testing of c-ANCA can support the diagnosis; however, even when c-ANCA do not test positive, the disease can never be excluded. Surgical interventions within the larynx or trachea might only be considered after ineffective therapy with immunosuppressive drugs.

Association of airway abnormalities and risk factors in 37 subglottic stenosis patients

OBJECTIVES

The study objective is to characterize the airway abnormalities in a series of patients with subglottic stenosis (SGS) as they relate to etiology and risk factors.

STUDY DESIGN AND SETTING

Retrospective review, academic medical center. Airway characteristics, patient demographics, and suspected risk factors were recorded from a database of SGS cases from 2001 to 2004.

RESULTS

Thirty-seven patients with SGS were identified; 22 of 37 had isolated SGS (59%). Intubation (10 of 37, 27%), high tracheotomy (4 of 37, 11%), and reflux (5 of 37, 14%) comprised the bulk of cases; 13 of 37 (35%) were considered idiopathic. Of 22 patients with isolated SGS, the majority 18 of 22 (P = 0.06) were women, 59% of which were idiopathic. Multiple-level cases (0 of 15) were idiopathic (P < 0.001). Intubation was the most common cause of multiple site stenosis (6 of 15, 40%).

CONCLUSIONS

The majority of patients in this study had isolated lesions. These patients tend to have no apparent risk factors. Multi-level cases are associated with prolonged intubation and known injuries. The nature of "idiopathic" stenoses is discussed.

SIGNIFICANCE

Clinical examination of SGS may be meaningful in understanding the etiology of the stenosis.

Surgical management of laryngotracheal stenosis in adults

The purpose was to evaluate the outcome following the surgical management of a consecutive series of 26 adult patients with laryngotracheal stenosis of varied etiologies in a tertiary care center. Of the 83 patients who underwent surgery for laryngotracheal stenosis in the Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital of Lausanne, Switzerland, between 1995 and 2003, 26 patients were adults (> or = 16 years) and formed the group that was the focus of this study. The stenosis involved the trachea (20), subglottis (1), subglottis and trachea (2), glottis and subglottis (1) and glottis, subglottis and trachea (2). The etiology of the stenosis was post-intubation injury ( n = 20), infiltration of the trachea by thyroid tumor ( n = 3), seeding from a laryngeal tumor at the site of the tracheostoma ( n = 1), idiopathic progressive subglottic stenosis ( n = 1) and external laryngeal trauma ( n = 1). Of the patients, 20 underwent tracheal resection and end-to-end anastomosis, and 5 patients had partial cricotracheal resection and thyrotracheal anastomosis. The length of resection varied from 1.5 to 6 cm, with a median length of 3.4 cm. Eighteen patients were extubated in the operating room, and six patients were extubated during a period of 12 to 72 h after surgery. Two patients were decannulated at 12 and 18 months, respectively. One patient, who developed anastomotic dehiscence 10 days after surgery, underwent revision surgery with a good outcome. On long-term outcome assessment, 15 patients achieved excellent results, 7 patients had a good result and 4 patients died of causes unrelated to surgery (mean follow-up period of 3.6 years). No patient showed evidence of restenosis. The excellent functional results of cricotracheal/tracheal resection and primary anastomosis in this series confirm the efficacy and reliability of this approach towards the management of laryngotracheal stenosis of varied etiologies. Similar to data in the literature, post-intubation injury was the leading cause of stenosis in our series. A resection length of up to 6 cm with laryngeal release procedures (when necessary) was found to be technically feasible.

A case of idiopathic tracheal stenosis

Idiopathic tracheal stenosis (ITS) is an extremely rare disease. We report the case of a 32-year-old woman with ITS. She had no history of previous surgery, endotracheal intubation, neck trauma, granulomatous disease, or any other severe respiratory tract infections. She presented with progressive dyspnea on effort and had been treated for bronchial asthma for 3 years. Chest radiography and laboratory examinations revealed no abnormalities. Bronchoscopy demonstrated almost circumferential tracheal stenosis extending for 10 mm from about 20 mm below the vocal cords. Luminal diameter was about 4 mm at the narrowest. Bronchoscopic biopsy revealed increased fibrous tissue and chronic inflammatory cell infiltration (nonspecific inflammatory tissue). These finding are compatible with idiopathic stenosis as reported by Grillo et al. After tracheostomy, the patient was treated by tracheal segmental resection (two rings) with end-to-end anastomosis of the cartilaginous trachea. Symptoms of tracheal stenosis were completely relieved and no recurrence has been observed as of 3 years postoperatively.

Idiopathic laryngotracheal stenosis: effective definitive treatment with laryngotracheal resection

OBJECTIVE

Little was known about idiopathic laryngotracheal stenosis when it was first described. We have operated on 73 patients with idiopathic laryngotracheal stenosis, have confirmed its mode of presentation and response to surgical therapy, and have established long-term follow-up.

METHODS

Charts of 73 patients treated surgically for idiopathic laryngotracheal stenosis between 1971 and 2002 were retrospectively reviewed.

RESULTS

All patients were treated with a single-staged laryngotracheal resection, with (36/73) and without (37/73) a posterior membranous tracheal wall flap. Nearly all were women (71/73), with a mean age of 46 years (range, 13-74 years). Twenty-eight (38%) of 73 had undergone a previous procedure with laser, dilation, tracheostomy, T-tube, or laryngotracheal operations. After laryngotracheal resection, the majority of patients (67/73) were extubated in the operating room, and 7 required temporary tracheostomies, only 1 of whom was among the last 30 patients. All were successfully decannulated. There was no perioperative mortality. Principal morbidity was alteration of voice quality, which was mild and tended to improve with time. Sixty-seven (91%) of 73 patients had good to excellent long-term results with voice and breathing quality and do not require further intervention for their idiopathic laryngotracheal stenosis.

CONCLUSION

Idiopathic laryngotracheal stenosis is an entity that occurs almost exclusively in women and is without a known cause. It is not a progressive process, but the timing of the operation is crucial. Single-staged laryngotracheal resection is successful in restoring the airway while preserving voice quality in more than 90% of patients. Protective tracheostomy is now rarely required (1/30). Long-term follow-up shows a stable airway and improvement in voice quality.

Idiopathic laryngotracheal stenosis

ILTS is a rare inflammatory disease that results in a cicatricial stenosis of the cricoid and upper trachea. It occurs almost exclusively in women and is without known cause. Patients present with dyspnea on exertion that progresses to dyspnea at rest, often with stridor. The diagnosis is usually made on the basis of patient history, physical examination, and radiography. Rigid bronchoscopy is usually reserved for the day of proposed surgery to confirm diagnosis and to plan the operative strategy. On occasion, the presence of active inflammation extending into the immediate subglottis or the patient's use of corticosteroids requires that surgery be postponed. In these cases, a patent airway is temporarily restored with careful bronchoscopic dilation. Single-staged laryngotracheal resection is successful in more than 90% of patients and is the most effective treatment when performed by experienced hands. Long-term follow-up shows stable airway and improvement in voice quality. Palliative procedures such as repeated airway dilations should be reserved for poor surgical candidates. Protective tracheostomy is rarely required.

Idiopathic subglottic stenosis revisited

Idiopathic subglottic stenosis (ISS) is a rare inflammatory process of unknown cause, usually limited to the subglottic region and the first 2 tracheal rings. We performed a retrospective analysis of our experience with a series of patients with this condition. The study involved retrospective review of the records of patients with ISS. A series of criteria that included patient clinical history, laboratory tests, flexible nasolaryngoscopic examination, and biopsies were used to establish a diagnosis. Symptoms, treatment, and outcome were examined. A total of 16 patients were identified; 14 were female (87.5%), and 2 were male. The mean follow-up time was 75.5 months. Fourteen patients required surgical treatment for respiratory compromise. Nine of these cases have been controlled effectively with endoscopic laser techniques. Endoscopic management failed in 5 patients, and 2 patients underwent laryngotracheal resection and reconstruction. Mitomycin-C was used in 6 patients as an adjuvant to endoscopic laser surgery. Patients in whom endoscopic treatment failed were noted to have thicker (>1 cm) and more complex stenoses. The diagnosis of ISS is a diagnosis of exclusion. A complete workup of the patient must be performed to rule out other causes of stenosis. Endoscopic laser surgery is a valid initial approach for thinner, noncomplicated lesions. Patients with thicker, complex lesions in whom endoscopic treatment fails are best managed with laryngotracheal resection and reconstruction. However, adjuvant use of mitomycin-C may prove beneficial in the treatment of these patients. Estrogen may play a role in the pathogenesis of ISS by altering the wound healing response.

Bronchoscopic dilatation in the management of benign (non-transplant) tracheobronchial stenosis

BACKGROUND

Tracheobronchial stenosis in the adult patient is a recognized postoperative complication of sleeve resection or lung transplantation, but also occurs in medical conditions such as sarcoidosis, tuberculosis, postintubation/tracheostomy or post-radiation.

AIMS

To assess the response of bronchoscopic dilatation in the management of benign (non-transplant) tracheobronchial stenosis and the longevity of symptomatic relief.

METHODS

Eight patients underwent bronchoscopic dilatation for benign (non-transplant) tracheobronchial stenosis. The indications were post-tuberculous bronchostenosis (n = 3), post-tracheostomy/endotracheal intubation strictures (n = 3), postradiation bronchostenosis (n = 1) and narrowing of the tracheal lumen following a muscle flap surgery for tracheoesophageal fistula (n = 1).

RESULTS

Dilatation alone was effective in the management of four patients (50%). Two patients had stent placement postdilatation, one patient had tracheal resection and primary anastomosis and one patient had laser ablation for restenosis followed by balloon dilatation. All patients had clinical improvement. One patient was successfully weaned off mechanical ventilation and extubated. There was no procedure-related mortality and all patients were alive and well at the time of reporting, with a mean duration since procedure of 123 +/- 105 (range 8-340) weeks. The complications observed were granuloma formation at the site of laser excision and restenosis, each in one patient.

CONCLUSIONS

Bronchoscopic dilatation is a safe and effective modality in the initial assessment and management of benign tracheobronchial stenosis. Stent placement and Nd:YAG laser therapy complement a dilatation procedure in the combined bronchoscopic treatment of benign tracheobronchial stenosis.

Idiopathic progressive subglottic stenosis: findings and treatment in 52 patients

Rarely, patients develop severe idiopathic subglottic stenosis. In 34 years, we have observed this disorder in 52 patients. All but 1 of the patients were female--a finding that suggests a hormonal cause. Without treatment, the airway progressively narrows--in some cases, until the patient requires tracheotomy. Laser submucosal resection and rotation mucosal flaps open and stabilize the airway and provide effective palliation. However, unlike traumatic subglottic stenosis, which has been cured with this technique, the idiopathic form causes submucosal fibrosis that regenerates spontaneously. Thus, treatment helps, but does not cure, the patient. The characteristic pathological finding is of submucosal dense fibrotic tissue with evidence of chronic inflammation. The clinical findings and treatment are here discussed.

Evaluation of gastroesophageal reflux in patients with laryngotracheal stenosis

To report the incidence of pharyngeal acid reflux events in patients with laryngotracheal stenosis (LTS), we studied 12 patients with LTS and 34 healthy volunteers. All patients and controls underwent ambulatory 24-hour 3-site pH monitoring. In ambulatory pH monitoring, pH was recorded at manometrically determined sites of the pharynx, proximal esophagus, and distal esophagus. For all 3 sites, a pH value below 4 that was not related to the time of oral intake or belching was considered an acid reflux event. Eight of the 12 LTS patients exhibited pharyngeal acid reflux events. In the control group, pharyngeal acid reflux events were documented in 7 subjects. In between-group comparison, the number of reflux episodes and the percent acid exposure time in the pharynx were greater in LTS patients than in controls. Reflux parameters of the proximal and distal esophagus in LTS patients were similar to those of controls. The incidence of pharyngeal acid reflux events in LTS patients was higher than that in controls. It is suggested that identification and treatment of gastroesophageal reflux in patients will significantly simplify and improve the results of treatment for LTS.