Tracheal stenosis and airway complications in the Coronavirus Disease-19 era

BACKGROUND

Severe Coronavirus Disease 2019 (COVID-19) infection is associated with prolonged intubation and its complications. Tracheal stenosis is one such complication that may require specialized surgical management. We aimed to describe the surgical management of post-COVID-19 tracheal stenosis.

METHODS

This case series describes consecutive patients with tracheal stenosis from intubation for severe COVID-19 infection at our single, tertiary academic medical center between January 1^st, 2021, and December 31^st, 2021. Patients were included if they underwent surgical management with tracheal resection and reconstruction, or bronchoscopic intervention. Operative through six-month, symptom-free survival and histopathological analysis of resected trachea were reviewed.

RESULTS

Eight patients are included in this case series. All patients are female, and most (87.5%) are obese. Five patients (62.5%) underwent tracheal resection and reconstruction (TRR), while three patients (38.5%) underwent non-resection-based management. Among patients who underwent TRR, six-month symptom free survival is 80%; one patient (20%) required tracheostomy after TRR due to recurrent symptoms. Two of the three (66.7%) of patients who underwent non-resection-based management experienced durable relief from symptoms of tracheal stenosis with tracheal balloon dilation, and the remaining patient required laser excision of tracheal tissue prior to experiencing symptomatic relief.

CONCLUSIONS

The incidence of tracheal stenosis may increase as patients recover from severe COVID-19 infection requiring intubation. Management of tracheal stenosis with TRR is safe and effective, with comparable rates of success to TRR for non-COVID-19 tracheal stenosis. Non-resection-based management is an option to manage tracheal stenosis in patients with less severe stenosis or in poor surgical candidates.

How we do it: endoscopic tracheal dilatation technique using a supraglottic airway device and non-occlusive balloon

BACKGROUND

Tracheal stenosis can be difficult to manage. Dilatation can relieve acute symptoms, avoid emergency tracheostomy and may be curative, but traditional dilators risk injury and obstruction in an already critical airway. This paper describes a novel technique for conducting tracheobronchial dilatation with a non-occlusive balloon through a supraglottic airway device, performed under endoscopic guidance.

TECHNICAL DESCRIPTION

A supraglottic airway device is placed whilst the patient is under total intravenous anaesthesia with mechanical ventilation. Using a multiport airway adaptor, inspection is performed by flexible endoscopy and a guidewire is placed through the stenosis. A non-occlusive balloon is advanced over the guidewire and positioned using the endoscope reinserted through the second adaptor port. Ventilation can thus be continued throughout dilatation under vision.

CONCLUSION

This technique has revolutionised our approach to tracheal dilatation in our institution. It avoids tracheostomy, and can be safely and reliably performed by junior staff in the emergency setting after adequate training.

Transnasal Humidified Rapid Insufflation Ventilatory Exchange in Laryngotracheal Resection and Reconstruction: A Report of Two Pregnant Cases

Introduction

The incidence of tracheal stenosis is progressively increasing. A risk factor for developing this clinical condition is a history of prolonged endotracheal intubation. A transnasal humidified rapid insufflation ventilatory exchange, known as THRIVE, has gained importance in tracheal resection surgeries.

Case Presentation

Herein, we describe the anesthetic management of two obstetric patients, a 19-year-old and 29-year-old, with a history of prolonged endotracheal intubation and a diagnosis of tracheal stenosis. The patients required the resection of the tracheal segment and end-to-end anastomosis. The anesthetic management focused on THRIVE using a high-flow nasal cannula.

Conclusions

This system proved to be a safe anesthetic technique for pregnant women and the fetus. Furthermore, it allowed surgeons to better visualize the surgical field without the risk of accidental injury to the endotracheal tube.

An Incidental Finding of a Double-Lumen Trachea

The aim of this case report is to present an incidental finding of a firm tracheal septum in a 61-year-old woman. The patient was admitted to the hospital with mild dyspnea and a preliminary diagnosis of a tracheal subglottic stenosis. During microlaryngoscopy, just below the subglottic stenosis, a firm, vertical symphysis (septum), forming a double-lumen trachea was found. There was no record of any previous difficulties with intubation. A computed tomography scan performed after the microlaryngoscopy revealed an airway branch arising from the trachea at the level of thyroid gland and joining its lumen below. The radiological and endoscopic findings in the presented case hardly resemble the conditions described in the literature, as the discovered septum does not have a pseudomembranous nature, nor does it form a tracheal bronchus. Therefore, the finding is thought to be an unusual complication of multiple intubations in the past. This is an extremely rare finding and it is important to share our experience in managing a patient with the aforementioned post-intubation complications.

Anomalous innominate artery complicating tracheal surgical procedures

OBJECTIVE

To highlight the importance of imaging in reducing an accidental injury to the anomalous brachiocephalic trunk and its branches during tracheal surgery.

CASE REPORT

This paper reports two cases of accidental injury to the great vessels in the neck during tracheal surgery. The first incident occurred during a repeat tracheostomy, when the right common carotid artery was injured. On reviewing the computed tomography images, the bifurcation of the brachiocephalic artery was seen to the left of the midline, and the right common carotid artery was adherent just below the tracheostomy site. The second incident happened during surgery for tracheal stenosis, when there was an inadvertent injury to the main brachiocephalic trunk, which was adherent to the trachea in the lower neck region.

CONCLUSION

For airway surgeons, radiological assessment of vascular structures in relation to the trachea prior to surgery is as important as the endoluminal airway assessment for the best outcome.

Upper Airway Nerve Block for Rigid Bronchoscopy in the Patients with Tracheal Stenosis: A Case Serie

Background

Rigid bronchoscopy is often used to diagnose and treat the location of resection of the tracheal stenosis. It is a selective procedure for the dilatation of tracheal stenosis, especially when accompanied by respiratory distress.

Objectives

We introduced patients who were diagnosed with tracheal stenosis and candidate for rigid bronchoscopy dilatation by the upper airway nerve blocks.

Methods

This prospective observational study was conducted on 17 patients who underwent dilatation with rigid bronchoscopy in tracheal stenosis at Hospitals affiliated with Babol University of Medical Sciences from 2002 to 2017. The patients were given three nerve blocks, 6 bilateral superior laryngeal nerve block, bilateral glossopharyngeal nerve block, and recurrent laryngeal nerve block (transtracheal) before awake rigid bronchoscopy using 2% lidocaine. We evaluated the demographic data, the cause of tracheal stenosis, the quality of the airway nerve block (Intubation score), patients’ satisfaction from bronchoscopy and thoracic surgeons’ satisfaction. Complications of nerve blocks were recorded.

Results

From 2002 to 2017, 17 patients (14 were male and 3 were) female with tracheal stenosis who were candidates for dilatation with bronchoscopy and accepted the upper nerve block were included. The quality of the block was acceptable in 16 (94%) patients. 15 patients received fentanyl, and only two patients did not need to intravenous sedation. The mean age of patients was 29.59 ± 11.59. The average satisfaction of the surgeon was 8.82 ± 1.13 and the satisfaction of patients with anesthesia was 8.89 ± 1.16. There was one serious complication (laryngospasm) in one patient.

Conclusions

The upper airway nerve block method is a suitable anesthesia technique for patients with tracheal stenosis who are candidates for the tracheal dilatation with rigid bronoscopy, especially when the patient has respiratory distress and has not been evaluated before surgery.

[Effect of partial cricotracheal resection and extended cricotracheal resection for severe laryngotracheal stenosis]

Objective: To assess the outcomes of partial cricotracheal resection (CTR) and extended cricotracheal resection (ECTR) for severe laryngotracheal stenosis. Methods: From November 2009 to September 2017, 18 patients underwent CTR and ECTR at the Department of Otorhinolaryngology Head and Neck Surgery, Tangdu Hospital, Air Force Medical University for severe laryngotracheal stenosis were reviewed retrospectively. There were 12-male and 6-female patients, with the age ranged from 4 to 56 years (median 25 years). The causes were postintubation in 11 cases, cervical trauma in 4, idiopathic in 3. The stenosis located in subglottic and tracheal (n=12), glottic and subglottic and tracheal (n=3), subglottic (n=2), and glottic and subglottic (n=1). Two patients had concurrent unilateral vocal cord palsy.One patient had undergone previous endoscopic balloon dilation and 8 patients had previous laryngotracheal reconstruction. The stenosis was graded according to modified Myer-Cotton classification as follows: Ⅲb (n=1), Ⅲc(n=1), Ⅳa (n=2), Ⅳb (n=12), Ⅳc (n=2). The surgical outcomes and complications were recorded. Results: Among 18 patients,11 of the 12 patients undergoing CTR were decannulated. Five of the 6 patients undergoing ECTR were decannulated. Resected airway length ranged from 1.5 to 4.0 cm (median 2.8 cm). Surgical complications included infection of incision wound in 2 cases, anastomotic granulation in 2, cervical subcutaneous emphysema in 1, aspiration in 1, and unilateral arytenoid prolapse in 1. No recurrent laryngeal nerve injury or tracheoesophageal fistula occurred. The median follow up was 11 months. Conclusions: CTR is efficient for severe subglottic and upper tracheal stenosis while ECTR is efficient for subglottic stenosis extended to the glottis. Both procedures also provide a salvage therapy for patients with previous failed treatments.

Obstructive sleep apnoea as a late complication after tracheostomy

BACKGROUND

Obstructive sleep apnoea occurs consequent to partial or complete upper airway obstruction, caused mostly by the collapse of upper airway musculature. Drug-induced sleep endoscopy represents the 'gold standard' in identifying the obstruction site, from the palatal level to laryngeal entry. Breathing impairment in sleep caused by the collapse of cervical trachea after previous tracheostomy has not yet been described in the literature.

METHODS

This report presents two patients with severe obstructive sleep apnoea, in whom pre-operative drug-induced sleep endoscopy revealed upper airway and cervical trachea collapse at the level of previous tracheostomy.

RESULTS

The female patient was successfully treated with resection of hypertrophic tissue of the tongue base via lateral pharyngectomy, and resection of the collapsed segment of the trachea with primary reconstruction of the trachea by end-to-end anastomosis. The male patient was recommended continuous positive airway pressure therapy because of serious co-morbidities and high operative risk.

CONCLUSION

Drug-induced sleep endoscopy should always be used for visualisation of anatomical structures below the vocal folds in patients with a history of cervical trachea surgery. These two cases demonstrate the importance of drug-induced sleep endoscopy in planning conservative and surgical treatments, contributing significantly to operative success.

Tracheal stenosis due to endotracheal tube cuff hyperinflation: a preventable complication

Endotracheal intubation injuries are rare, but may be devastating-mostly among the pediatric patients or when these occur in the distal trachea. Such complications typify a therapeutic challenge, which, besides requiring intellectual and technical resources, takes a long time to reach a resolution. The authors present the case of a 15-year-old girl admitted with an abnormal state of consciousness due to diabetic ketoacidosis. She was submitted to endotracheal intubation with hyperinflation of the tube cuff, which rendered tracheal necrosis and detachment of the tracheal mucosa, and consequent obstruction. Later, she developed scarring retraction and stenosis. The patient was successfully treated with an endotracheal prosthesis insertion. The aim of this report is to illustrate a preventable complication.

Preoperative planning and tracheal stent design in thoracic surgery: a primer for the 2017 Radiological Society of North America (RSNA) hands-on course in 3D printing

In this work, we provide specific clinical examples to demonstrate basic practical techniques involved in image segmentation, computer-aided design, and 3D printing. A step-by-step approach using United States Food and Drug Administration cleared software is provided to enhance surgical intervention in a patient with a complex superior sulcus tumor. Furthermore, patient-specific device creation is demonstrated using dedicated computer-aided design software. Relevant anatomy for these tasks is obtained from CT Digital Imaging and Communications in Medicine images, leading to the generation of 3D printable files and delivery of these files to a 3D printer.

End-to-end anastomosis in the management of laryngotracheal defects

OBJECTIVE

To present clinical experience and surgical outcomes of end-to-end anastomosis in the management of laryngotracheal stenosis and tracheal defects following invasive thyroid malignancy resection.

METHODS

A retrospective analysis was performed of 14 patients with laryngotracheal stenosis and tracheal invasive thyroid malignancy. All patients underwent tracheal or cricotracheal resection and primary end-to-end anastomosis.

RESULTS

Length of stenosis was 1.7-4 cm. Stenosis was classified as Myer and Cotton grade II in 4 patients, grade III in 6 and grade IV in 2. Surgical procedures included tracheotracheal end-to-end anastomosis (n = 4), cricotracheal anastomosis (n = 2) and thyrotracheal anastomosis (n = 6). Patients with invasive thyroid malignancy underwent segmental resection of the involved segment with tumour-free margins, and tracheal or cricotracheal end-to-end anastomosis. Successful decannulation was achieved in 13 patients (93 per cent). Post-operative complications were: wound infection (n = 1), subcutaneous emphysema (n = 1), temporary unilateral vocal fold palsy (n = 1), granulation tissue development (n = 1), and restenosis (n = 2).

CONCLUSION

End-to-end anastomosis can be used safely and successfully in the management of advanced laryngotracheal stenosis and wide laryngotracheal defects. Greater success can be achieved using previously described surgical rules and laryngotracheal release manoeuvres.

Effectiveness of Palatal Mucosa Graft in Surgical Treatment of Sub-Glottic Stenosis

OBJECTIVES

Mucosal free grafts may be successfully applied in many surgical interventions. This study aims at investigating the feasibility of palatal mucosa graft in sub-glottic field in an animal model.

METHODS

This randomized prospective controlled study was conducted with an animal model. Sub-glottic inflammation was created in 15 adult rabbits in each group and sub-glottic stenosis surgery was applied thereafter. The rabbits in group 1 (control group) underwent segmental resection, partial cricoidectomy, and trachea-thyroid cartilage anastomosis; the rabbits in group 2 underwent segmental resection, cricoplasty, and crico-tracheal anastomosis using free buccal mucosa graft; and the rabbits in group 3 underwent segmental resection, cricoplasty, and crico-tracheal anastomosis using free palatal mucosa graft. Re-stenosis was evaluated after 42 days.

RESULTS

The percentages of stenosis were 27%±20%, 40%±20%, and 34%±23% for group 1, 2, and 3, respectively and the difference was not statistically significant (P=0.29). Intensive and tight fibrosis was observed in 2 rabbits (13%) in group 1, in 5 rabbits (33%) in group 2, and in 3 rabbits (20%) in group 3. There was not a statistically significant difference between groups (P=0.41). Excessive inflammation was observed in 3 rabbits (20%) in group 1, in 7 rabbits (47%) in group 2, and 3 rabbits (20%) in group 3. There was no a statistically significant difference between groups although inflammation rate was higher in the rabbits which underwent buccal mucosa graft (P=0.18).

CONCLUSION

The surgical treatments applied with free mucosa graft reduced anastomosis tension through enabling anastomosis to the distal of cricoid instead of thyroid cartilage. Free palatal mucosa grafts may be used in sub-glottic field, one of the most challenging fields of trachea surgery, due to ease of application and rapid vascularization.

A Safe Method of Tracheal Polyflex Stent Placement: A Review of 20 Patients

Background:

Surgery is an appropriate therapeutic approach for tracheal stenosis due to various benign and malignant conditions. When surgery is postponed for certain reasons, other options are chosen for airway patency. One alternative is using airway stents.

Objectives:

We aimed to introduce a safe method of tracheal polyflex stent placement in patients with tracheal stenoses.

Patients and Methods:

During a 7-year period (2002 - 2008), polyflex stents were used 29 times among 20 patients for various indications. After encountering many difficulties in earlier cases, we gradually developed our new method and used it in most of our patients. In this method, without using large rigid bronchoscopes, the introducer tube could be used as a bronchoscope with the aid of a zero-degree lens and ventilating apparatus. In this method, the rate of possible trauma to the airway can be minimized by avoiding the use of thick rigid bronchoscopies and the stent can be placed faster and more accurately.

Results:

Polyflex stents were used in 11 men (55%) and 9 women with a mean age of 38.5 years. Stents were removed and changed in 12 cases and replaced with another type of stent in 3 patients. Indications were recurrence of tracheal stenosis (7), multisegmental tracheal stenosis (3), anesthesia limitations (3), tracheal tumors (2), dehiscence of tracheal anastomosis (1), severe inflammation of the tracheal mucosa (1), esophagobronchial fistula (1), and external pressure on the left main bronchus (1). In one patient, a stent was used to open a kinked Dumon stent as a temporary life-saving procedure. We found 6 cases of stent migration, 3 cases of granulation tissue formation, 1 case of infection, and 1 case of surgical site dehiscence.

Conclusions:

Stents would be regarded as a temporary means of reaching the ideal condition for resection and reconstruction in most patients with tracheal stenoses. Although an optimal stent has not been introduced yet, we used polyflex stents in most of our patients with tracheal stenosis due to its availability and ease of use. We suggest that this method is safe and less time consuming than its traditional method of placement.

Traumatic Aneurysm of Innominate Artery Resulting in Tracheal Stenosis and Rapidly Progressive Respiratory Failure; A Case Report and Literature Review

Traumatic injuries to great vessels are relative common in trauma practice. Blunt thoracic trauma may result in dissection injury to aorta and innominate artery. We herein present a late presentation of traumatic innominate artery aneurysm. A29-year-old woman presented with dyspnea to our emergency department. She had previous motor-vehicle accident a month before presentation for which had undergone chest tube insertion. She was diagnosed to have traumatic aneurysm of innominate artery resulting in tracheal stenosis resulting in acute life threatening respiratory failure. She underwent simultaneous aneurysm resection and tracheal reconstruction. She was uneventfully discharged from hospital. Any post-traumatic respiratory and cardiovascular symptoms may propound an undiagnosed serious injury to the great vessels. Extra and repetitive imaging studies may help us in better evaluation of traumatized patients with high energy mechanisms and sharp injuries to chest and neck.

Tracheal stenosis after tracheostomy treated successfully with papillotome electrocautery

A 39-year-old woman presented with symptoms of dyspnea. Ten years previously, she had received a tracheostomy because of the decision to not continue taking an anticonvulsant drug. Presently, chest computed tomography showed diffuse stenosis and focal web at the cervical trachea. We performed bronchoscopy and found a two-thirds reduction of the upper trachea due to the web-like fibrotic stenosis. Papillotome electrocautery removed the stenotic lesion. Endobronchial electrocautery is a valuable tool with potential for therapy of an endobronchial obstructing airway lesion. We report this case to introduce the successful treatment with papillotome electrocautery.

Clinical experience of rigid bronchoscopy in single center

Background

The aim of this study was to analyze clinical situations requiring rigid bronchoscopy and evaluate usefulness of rigid bronchoscopic intervention in benign or malignant airway disorders.

Methods

We retrospectively reviewed 29 patients who underwent rigid bronchoscopy from November 2007 to February 2011 at St. Paul's Hospital, The Catholic University of Korea School of Medicine.

Results

Of the 29 patients, the most frequent underlying etiology was benign stenosis of trachea (n=20). Of those 20 patients, 16 had post-intubation tracheal stenosis (PITS), 2 had tracheal stenosis due to inhalation burn (IBTS) and other 2 had obstructive fibrinous tracheal pseudomembrane (OFTP). Other etiologies were airway malignancy (n=6), endobronchial stenosis due to tuberculosis (n=2), and foreign body (n=1). For treatment, silicone stent insertion was done in 16 cases of PITS and IBTS and mechanical removal was performed in 2 cases of OFTP. In 6 cases of malignant airway obstruction mechanical debulking was performed and silicone stents were inserted additionally in 2 cases. Balloon dilatation and electrocautery were used in 2 cases of endobronchial stenosis due to tuberculosis. In all cases of stent, airway obstructive symptom improved immediately. Granulation tissue formation was the most common complication.

Conclusion

Tracheal stenosis was most common indication and silicone stenting was most common procedure of rigid bronchoscopy in our center. Rigid bronchoscopic procedures, at least tracheal silicone stenting, should be included in pulmonary medicine fellowship programs because it is a very effective and indispensable method to relieve critical airway obstruction which needs training to learn.