Dexamethasone eluting polydopaminated polycaprolactone-poly (lactic-co-glycolic) acid for treatment of tracheal stenosis

Tracheal stenosis is commonly caused by injury, resulting in inflammation and fibrosis. Inhibiting inflammation and promoting epithelization can reduce recurrence after initial successful treatment of tracheal stenosis. Steroids play an important role in tracheal stenosis management. This study in vitro evaluated effectiveness of a polydopaminated polycaprolactone stent coated with dexamethasone-eluting poly(lactic-co-glycolic) acid microparticles (μPLGA) for tracheal stenosis management. Polydopamination was characterized by Raman spectroscopy and promoted epithelialization while dexamethasone delivery reduced macrophage activity, assessed by individual cell area measurements and immunofluorescent staining for inducible nitric oxide synthase (iNOS). Dexamethasone release was quantified by high-performance liquid chromatography over 30 days. Activation-related increase in cell area and iNOS production by RAW 264.7 were both reduced significantly (p < .05) through dexamethasone release. Epithelial cell spreading was higher on polydopaminated polycaprolactone (PCL) than PCL-alone (p < .05). Force required for stent migration was measured by pullout tests of PCL-μPLGA stents from cadaveric rabbit and porcine tracheas (0.425 ± 0.068 N and 1.082 ± 0.064 N, respectively) were above forces estimated to occur during forced respiration. Biomechanical support provided by stents to prevent airway collapse was assessed by comparing compressive circumferential stiffness, and stiffness of the stent was about 1/10th of the rabbit trachea (0.156 ± 0.023 N/mm vs. 1.420 ± 0.194 N/mm, respectively). A dexamethasone-loaded PCL-μPLGA stent platform can deliver dexamethasone and exhibits sufficient mechanical properties to anchor within the trachea and polydopamination of PCL is conducive to epithelial layer formation. Therefore, a polydopaminated PCL-μPLGA stent is a promising candidate for in vivo evaluation for treatment of tracheal restenosis.

New perspectives on tracheal resection for COVID-19-related stenosis: A propensity score matching analysis

OBJECTIVE

The large number of patients with COVID-19 subjected to prolonged invasive mechanical ventilation has been expected to result in a significant increase in tracheal stenosis in the next years. The aim of this study was to evaluate and compare postoperative outcomes of patients who survived COVID-19 critical illness and underwent tracheal resection for postintubation/posttracheostomy tracheal stenosis with those of non-COVID-19 patients.

METHODS

It was single-center, retrospective study. All consecutive patients with post-intubation/posttracheostomy tracheal stenosis who underwent tracheal resection from February 2020 to March 2022 were enrolled. A total of 147 tracheal resections were performed: 24 were in post-COVID-19 patients and 123 were in non-COVID-19 patients. A 1:1 propensity score matching analysis was performed, considering age, gender, body mass index, and length of stenosis. After matching, 2 groups of 24 patients each were identified: a post-COVID-19 group and a non-COVID group.

RESULTS

No mortality after surgery was registered. Posttracheostomy etiology of stenosis resulted more frequently in post-COVID-19 patients (n = 20 in the post-COVID-19 group vs n = 11 in the non-COVID-19 group; P = .03), as well as intensive care unit admissions during the postoperative period (16 vs 9 patients; P = .04). Need for postoperative reintubation for glottic edema and respiratory failure was higher in the post-COVID-19 group (7 vs 2 postoperative reintubation procedures; P = .04). Postoperative dysphonia was observed in 11 (46%) patients in the post-COVID-19 group versus 4 (16%) patients in the non-COVID-19 group (P = .03).

CONCLUSIONS

Tracheal resection continues to be safe and effective in COVID-19-related tracheal stenosis scenarios. Intensive care unit admission rates and postoperative complications seem to be higher in post-COVID-19 patients who underwent tracheal resection compared with non-COVID-19 patients.

Biodegradable polydioxanone stents: histologic and structural effects in an experimental model of tracheal stenosis

OBJECTIVES

To evaluate the biologic impact of polydioxanone (PDO) stenting in an animal model of inflammatory tracheal stenosis (TS). Additionally, to compare these results with those obtained in the same model without a stent and after placing one PDO stent in a healthy trachea.

METHODS

40 adult NZ rabbits were distributed into 3 groups: Group A, 8 animals with a healthy trachea and a PDO stent; group B, 17 rabbits with a TS and no stent; and group C, 15 animals with TS and a PDO stent. Histopathological studies included Masson's trichrome staining for submucosal fibrosis and Safranin O to assess structural integrity of cartilage. Morphometric analyses were performed in the 3 groups.

RESULTS

Stent placement was successful in every case. Histological studies did not show a significant increase in tracheal wall collagen area and cartilage structure was not modified in those rabbits with a PDO stent, even in a TS scenario. Stent implantation permitted recovery of normal tracheal lumen levels in the TS model.

CONCLUSIONS

PDO stenting in the normal trachea and in a model of TS neither caused increase in the collagen matrix nor modification of the cartilaginous support. Additionally, radial force exhibited by PDO stents was effective in restoring normal tracheal lumen when placed in a stenotic lesion. These findings suggest that they may be safe and useful in the setting of an acquired TS.

Airway necrosis and granulation tissue formation caused by Rhizopus oryzae leading to severe upper airway obstruction: a case report

Pulmonary Mucormycosis is a fatal infectious disease with high mortality rate. The occurrence of Mucormycosis is commonly related to the fungal virulence and the host's immunological defenses against pathogens. Mucormycosis infection and granulation tissue formation occurred in the upper airway was rarely reported. This patient was a 60-year-old male with diabetes mellitus, who was admitted to hospital due to progressive cough, sputum and dyspnea. High-resolution computed tomography (HRCT) and bronchoscopy revealed extensive tracheal mucosal necrosis, granulation tissue proliferation, and severe airway stenosis. The mucosal necrotic tissue was induced by the infection of Rhizopus Oryzae, confirmed by metagenomic next-generation sequencing (mNGS) in tissue biopsy. This patient was treated with the placement of a covered stent and local instillation of amphotericin B via bronchoscope. The tracheal mucosal necrosis was markedly alleviated, the symptoms of cough, shortness of breath, as well as exercise tolerance were significantly improved. The placement of airway stent and transbronchial microtube drip of amphotericin B could conduce to rapidly relieve the severe airway obstruction due to Mucormycosis infection.

Case Report: ECMO-assisted tracheal reconstruction in a 30-week-gestation preterm infant with tracheal stenosis

Tracheal stenosis is a rare but life-threatening disease in preterm infants. Misdiagnosis as congenital tracheal stenosis is common, making surgical management challenging. This report presents a case of a preterm infant with tracheal stenosis and congenital heart malformation treated with ECMO-assisted tracheal resection and end-to-end anastomosis. A male infant was born at 30 weeks of gestation with severe asphyxia, cardiac insufficiency, and pneumonia. Following failed medical treatment, fiberoptic bronchoscopy confirmed mid-tracheal to carinal stenosis. After a 2-week treatment course, ECMO-assisted tracheal resection and end-to-end anastomosis were performed successfully. This case confirms the feasibility of tracheal resection and end-to-end anastomosis in low-weight, preterm infants with tracheal stenosis born at 30 weeks gestation. The utilization of ECMO for oxygenation during surgery provides a clear surgical field and shorter operating time. Surgical intervention may be necessary for neonatal tracheal stenosis depending on the clinical presentation.

Timing of Complications in Open Airway Reconstruction

OBJECTIVE

Tracheal resection (TR) and cricotracheal resection (CTR) are performed for patients with airway stenosis, tracheal tumor, and tracheoesophageal fistula. Post-operative complications include airway edema requiring reintubation, hematoma, anastomotic dehiscence, restenosis, and death. Although these complications and associated risk factors have been well described, the time where clinical suspicion should be highest post operatively has not been characterized.

METHODS

Patients who underwent TR or CTR at a single center between 2015 and 2022 were reviewed. Variables including demographics and comorbidities were recorded. Rate, nature, and time in days of post-operative complications were evaluated.

RESULTS

Sixty-nine cases were reviewed. Average patient age was 46.8 years old and 63.8% were male. The average follow-up period was 625 ± 724 days. 19 (27.5%) patients experienced one or more major complications including four (5.8%) who died. Eight (11.6%) patients required reintubation and 4 (5.8%) patients underwent revision tracheostomy. Most complications occurred within 8 days of surgery. Restenosis was noted an average of 42.6 days after surgery, with no new restenosis occurring after 3 months.

CONCLUSIONS

In this single-center study, most post-operative complications after TR or CTR, including hematoma and anastomotic dehiscence, occurred within 8 days post-operatively. Restenosis was noted approximately 1-3 months after surgery. This may inform clinical decision-making regarding patient monitoring and surveillance after open airway surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Unveiling the Success of Awake Insertion of Supraglottic Airway Device for Ventilation in the Bronchoscopic Management of Tracheal Stenosis

Tracheal and subglottic stenoses are inflammatory conditions that can arise from a variety of potential etiologies, most commonly as a result of iatrogenic airway injury due to endotracheal intubation. Significant stenosis requires management by endoscopy or surgical resection. We describe a case of recurrent subglottic cuff stenosis with an episode of sudden desaturation in a 25-year-old female. The management involved balloon dilatation, laser ablation, and topical mitomycin C application through a flexible fiberoptic bronchoscope. Ensuring safe gas exchange during bronchoscopy was a priority, and this was achieved by maintaining ventilation with a supraglottic airway device, which was inserted in an awake patient after adequate tropicalization of the oral cavity. The intervention successfully helped in the management of stenosis and also addressed the complication of sudden complete airway collapse due to sedation.

Tracheopathia osteochondroplastica-A benign disorder with a daunting appearance

Tracheopathia osteochondroplastica (TO) is a rare and benign condition. It typically manifests as multiple osteocartilaginous nodules in the submucosa of the central airway. TO-related clinical symptoms and physical signs are nonspecific. The bronchoscopic examination is helpful in establishing the diagnosis. Treatment for TO is mostly conservative and symptom-oriented. The prognosis of TO is generally good, although cases of associated airway stenosis have been reported. In this case report, we describe the clinical, imaging, and histological features, and videoed bronchoscopic findings, of a middle-aged male patient with incidentally diagnosed TO.

Amyloid Light-Chain (AL) Amyloidosis of the Trachea Associated With an Indolent B-cell Neoplasm

We report the case of a 66-year-old woman who was diagnosed with localized tracheal amyloid light-chain (AL) amyloidosis caused by an underlying B-cell neoplasm. The diagnosis was confirmed through subsequent bronchoscopy and biopsies; however, she experienced a challenging episode of hypoxic respiratory failure that required intervention. Repeat bronchoscopies showed persistent subglottic stenosis and tracheobronchomalacia, which led to tracheal debulking surgery and additional interventions. The patient's treatment began with rituximab, zanubrutinib, and dexamethasone with outpatient follow-up. The rarity of tracheobronchial amyloidosis and its connection to B-cell malignancies are highlighted, emphasizing the challenges in diagnosis and the importance of tailored treatment strategies. The patient's clinical course, characterized by atypical respiratory symptoms, delayed diagnosis, and an evolving treatment approach, underscores the complexities of managing such a rare and intricate case.

Inhalation of Carboxymethyl Chitosan Alleviates Posttraumatic Tracheal Fibrosis

OBJECTIVES

The present study was performed to determine whether the inhalation of carboxymethyl (CM)-chitosan can alleviate tracheal fibrosis in a rabbit model.

METHODS

We designed a rabbit model of tracheal stenosis involving electrocoagulation with a spherical electrode. Twenty New Zealand white rabbits were randomly divided into experimental and control groups (10 animals each). Tracheal damage was successfully established by electrocoagulation in all animals. The experimental group was given CM-chitosan (inhalation for 28 days), while the control group inhaled saline. The effects of CM-chitosan inhalation on tracheal fibrosis were analyzed. Laryngoscopy was performed to evaluate and grade tracheal granulation, while tracheal fibrosis was evaluated by histological examination. The effects of CM-chitosan inhalation on the tracheal mucosa were examined by scanning electron microscopy (SEM), and hydroxyproline content in tracheal scar tissue was determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Laryngoscopy showed that the tracheal cross-sectional area was smaller in the experimental than control group. The amounts of loose connective tissue and damaged cartilage, as well as the severity of collagen and fibrosis, decreased following inhalation of CM-chitosan. According to the ELISA, the experimental group had low levels of hydroxyproline in the tracheal scar tissue.

CONCLUSION

The findings presented here showed that inhalation of CM-chitosan mitigated posttraumatic tracheal fibrosis in a rabbit model, thus suggesting a potential new treatment for tracheal stenosis.

Incidence of Tracheal Stenosis in ICU Hospitalized COVID-19 Patients: Results from a Prospective, Observational, Multicenter Study

Background: Tracheal stenosis represents a fearsome complication that substantially impairs quality of life. The recent SARS-CoV-2 pandemic increased the number of patients requiring invasive ventilation through prolonged intubation or tracheostomy, increasing the risk of tracheal stenosis. Study design and methods: In this prospective, observational, multicenter study performed in Lombardy (Italy), we have exanimated 281 patients who underwent prolonged intubation (more than 7 days) or tracheostomy for severe COVID-19. Patients underwent CT scan and spirometry 2 months after hospital discharge and a subsequent clinical follow-up after an additional 6 months (overall 8 months of follow-up duration) to detect any tracheal lumen reduction above 1%. The last follow-up evaluation was completed on 31 August 2022. Results: In the study period, 24 patients (8.5%, CI 5.6-12.4) developed tracheal stenosis in a median time of 112 days and within a period of 200 days from intubation. Compared to patients without tracheal stenosis, tracheostomy was performed more frequently in patients that developed stenosis (75% vs 54%, p = 0.034). Tracheostomy and alcohol consumption (1 unit of alcohol per day) increased risk of developing tracheal stenosis of 2.6-fold (p = 0.047; IC 0.99-6.8) and 5.4-fold (p = 0.002; CI 1.9-16), respectively. Conclusions: In a large cohort of patients, the incidence of tracheal stenosis increased during pandemic, probably related to the increased use of prolonged intubation. Patients with histories of prolonged intubation should be monitored for at least 200 days from invasive ventilation in order to detect tracheal stenosis at early stage. Alcohol use and tracheostomy are risk factors for developing tracheal stenosis.

[A case report of primary extubation by partial cricotracheal resection for severe subglottic stenosis]

This patient suffered from severe subglottic stenosis(grade Ⅳb). During partial cricotracheal resection, we cut through the cricothyroid membrane and the cricoid arch along the line from the lower edge of the thyroid cartilage to 5 mm of the inferior thyroid cartilage corner anteromedially. This can protect the cricothyroid joint, effectively protect the recurrent laryngeal nerve, and also support the airway. Strictly adhere to airway separation, avoid excessive separation of scars, and combine with reasonable postoperative management to achieve a safe extubation.

Analysis of Complications in (Crico-) Tracheal Resection Anastomosis in Adults: A Multicenter Study

OBJECTIVES

The gold standard treatments for advanced laryngotracheal stenosis (LTS) are represented by partial crico-tracheal (PCTRA) or tracheal resection and anastomosis (TRA). These procedures are potentially burdened by high postoperative complication rates. We investigated the impact of the most common stenosis and patient-related characteristics on the onset of complications in a multicentric cohort.

METHODS

We retrospectively analyzed patients who underwent PCTRA or TRA for LTS of different etiologies in three referral centers. We tested the effectiveness of these procedures, the impact of complications on the outcomes, and identified factors causing postoperative complications.

RESULTS

A total of 267 patients were included in the study (130 females; mean age, 51.46 ± 17.64 years). The overall decannulation rate was 96.4%. Altogether, 102 (38.2%) patients presented at least one complication, whereas 12 (4.5%) had two or more. The only independent predictor of post-surgical complications was the presence of systemic comorbidities (p = 0.043). Patients experiencing complications needed additional surgery more frequently (70.1% vs. 29.9%, p < 0.001), and had a longer duration of hospitalization (20 ± 10.9 vs. 11.3 ± 4.1 days, p < 0.001). Six of 102 (5.9%) patients with complications had restenosis, although this event did not occur among patients without complications.

CONCLUSION

PCTRA and TRA have an excellent success rate even when performed for high-grade LTS. However, a significant percentage of patients may experience complications associated with a longer duration of hospitalization or the need for additional surgeries. The presence of medical comorbidities was independently related to an increased risk of complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2910-2919, 2023.

Mapping Genetic Susceptibility to Stenosis in the Proximal Airway

OBJECTIVES

Recent translational scientific efforts in subglottic stenosis (SGS) support a disease model where epithelial alterations facilitate microbiome displacement, dysregulated immune activation, and localized fibrosis. Yet despite recent advances, the genetic basis of SGS remains poorly understood. We sought to identify candidate risk genes associated with an SGS phenotype, investigate their biological function, and identify the cell types enriched for their expression.

METHODS

The Online Mendelian Inheritance in Man (OMIM) database was queried for single gene variants associated with an SGS phenotype. The functional intersections and molecular roles of the identified genes were explored using pathway enrichment analysis (PEA) computational methods. Cellular localization of the candidate risk genes was measured via transcriptional quantification in an established single cell RNA sequencing (scRNA-seq) atlas of the proximal airway.

RESULTS

Twenty genes associated with SGS phenotype were identified. PEA resulted in 24 significantly enriched terms including "cellular response to TGF-β," "epithelial-to-mesenchymal transition," and "adherens junctions." Mapping the 20 candidate risk genes to the scRNA-seq atlas found 3 (15%) genes were enriched in epithelial cells, 3 (15%) in fibroblasts, and 3 (15%) in endothelial cells. 11 (55%) genes were expressed ubiquitously among tissue types. Interestingly, immune cells were not significantly enriched for candidate risk genes.

CONCLUSION

We identify and provide biologic context for 20 genes associated with fibrotic disease of the proximal airway and form the foundation for future detailed genetic study.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:3049-3056, 2023.

Temporary Stenting for Anastomotic Stenosis after Tracheal Resection of Adenoid Cystic Carcinoma: A Case Report

A 51-year-old man who noticed discomfort in the pharynx was found to have a tracheal tumor on physical examination. He was diagnosed as having adenoid cystic carcinoma by a transbronchial biopsy and underwent tracheal segmental resection via a collar incision. He was additionally treated with radiation therapy owing to a positive surgical margin, and he subsequently developed anastomotic tracheal stenosis. Silicon stent placement to open the airway was performed for the tracheal stenosis. One year after stent placement, the trachea was dilated, so the stent was removed, and he is still under follow-up without recurrence free 1.5 years after stent replacement.

Human Leukocyte Antigen Genotyping of Idiopathic Subglottic Stenosis

OBJECTIVE

Despite recent scientific inquiry, idiopathic subglottic stenosis (iSGS) remains an enigmatic disease. The consistent demographics of the affected population suggest genetic factors may contribute to disease susceptibility. Given the inflammation observed in the affected proximal airway mucosa, we interrogated disease association with human leukocyte antigen (HLA) polymorphisms. Polymorphisms in the HLA locus have previously been shown to influence individuals' susceptibility to distinct inflammatory diseases.

METHODS

High-resolution HLA typing of 37 iSGS patients was compared with 1,242,890 healthy Caucasian controls of European ancestry from the USA National Marrow Donor Program and 281 patients with granulomatosis with polyangiitis (GPA).

RESULTS

Complete HLA genotyping of an iSGS population showed no significant associations when compared to a North American Caucasian control population. Unlike GPA patients, iSGS was not associated with allele DPB1*04:01 nor did allele homozygosity correlate with disease severity.

CONCLUSIONS

There was not a detectable HLA association observed in iSGS. These results support the concept that iSGS possesses a distinct genetic architecture from GPA. If genetic susceptibility exists in iSGS, it likely lies outside the HLA locus.

LEVEL OF EVIDENCE

NA, basic science Laryngoscope, 133:2533-2539, 2023.

A Different Approach to the Treatment of Tracheal Stenosis

Tracheal stenosis can occur from several malignant and non-malignant conditions, including vascular ring/aneurysms, tracheomalacia, bronchomalacia, endotracheal tubes (ETT), tracheostomy tubes, mucus plug, burn, trauma, tuberculosis, etc. Significant tracheal stenosis typically requires management by bronchoscopy, dilatation, or surgical resection. Bronchoscopic balloon dilatation is a simple, inexpensive, safe, and minimally invasive method that can be used to dilate airway stenosis and restore adequate airflow. A Montgomery tracheostomy tube is often used as a combined tracheal stent and airway device. We describe a 68-year-old female with tracheal stenosis, which was managed with an unconventional approach, a non-compliant endovascular balloon, due to resource scarcity.

Airway management during unusual tracheal stenosis: A clinical feasibility trial

Objectives

Prolonged intubation is a known risk factor of LTS. LTS related to COVID-19 may result in a different phenotype: pronation affects the location of stenosis and COVID-19 pneumonia can decline lung mechanics. Therefore, airway management in these patients may carry unique challenges for both anesthesiologists and surgeons.This prospective observational feasibility trial aims to evaluate the use of a novel thin, cuffed, endotracheal tube (Tritube) in combination with flow-controlled ventilation (FCV) in the management of patients with COVID-19-related LTS undergoing laryngeal surgery.

Methods

20 patients suffering from COVID-19-related LTS, as diagnosed by CT, requiring endolaryngeal surgery, with or without CO2 laser, were included. Ultrathin endotracheal tube Tritube, together with FCV was used for airway management and ventilation. Feasibility, ventilation efficiency, and surgical exposure were evaluated.

Results

Median duration of mechanical ventilation during their ICU stay was 17 days, (range, 7-27), and all patients had been pronated. In 18/20 patients, endoscopic diagnosis confirmed the initial CT diagnosis: posterior subglottic stenosis. Surgeons' satisfaction on the view was rated 9 out of 10 (range 7-10), where 0 was the worst view and 10 was the best view. Hemodynamic and respiratory variables were within the normal clinical range during the surgical procedure. One patient that had a SpO2 of 90% before induction of anesthesia, a temporal drop to 89%, caused meeting the predefined requirement of "respiratory complication."

Conclusion

This study demonstrates the feasibility of using Tritube with FCV in patients with relatively unusual subglottic posterior location tracheal stenosis, undergoing laryngotracheal surgery. Tritube provides a good surgical field and FCV provides highly adequate ventilation especially in patients with compromised lung mechanics.

Level of Evidence

IV, non-comparitive prospective clinical trial with 20 patients.

Benign inoperable tracheal stenosis in COVID versus non-COVID patients at the pandemic epicenter: a case series

Background

The COVID-19 pandemic has exponentially expanded the number of patients requiring treatment for chronic respiratory failure. One consequence is an increase in the number of patients requiring intubation and mechanical ventilation. Benign inoperable tracheal stenosis presents a challenge, especially in COVID-19 patients.

Methods

We describe a case series of 15 patients with Benign inoperable tracheal stenosis treated with interventional bronchoscopy over a 15-month period. These patients were divided into two groups, COVID and non-COVID. We used an electrocautery snare as an electrocautery knife to cut the stenotic segment followed by four injections of 1 mg submucosal Decadron via a Wang needle. Patients were subsequently followed by the pulmonary clinic. Institutional review board approval was not required as per our institutional policy for a retrospective case series.

Results

There was a high degree of success with this intervention, with a low rate of recurrence. We also noticed the following differences between the two subgroups. COVID tracheal stenosis was longer in length, had a higher percentage of cartilage involvement, and was located more distal to cords than the non-COVID group. The median age was younger in the COVID group.

Conclusions

COVID pandemic an enormous number of intubations and tracheotomies have been performed. As a result, there will be an increased prevalence of tracheal stenosis. Most of these cases can be effectively treated with surgery. Dealing with complex inoperable cases remains a dilemma. Our case series/research article is an attempt to provide an easy technique with a high cure rate.

Our Clinical Experience With Patients Requiring Intensive Care for Tracheal Stenosis: A Retrospective Case-Control Study

Background and objective The clinical course in patients with tracheal stenosis (TS) ranges from being asymptomatic to respiratory failure requiring follow-up in the ICU. In this study, we aimed to assess the clinical characteristics, management, and outcome of TS patients who were admitted to the ICU. Materials and methods The data of patients hospitalized in the ICU due to TS between January 01, 2015, and January 01, 2016, were analyzed. The patients were classified into two groups: the post-intubation tracheal stenosis (PITS) group and the post-tracheostomy tracheal stenosis (PTTS) group. Demographic characteristics, body mass index (BMI), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment (SOFA) score of patients, factors that caused TS, management of TS, and ICU data of patients were compared. The outcome measures of our study were the ICU management of patients diagnosed with PITS or PTTS, their clinical characteristics, and differences in the treatment between patients diagnosed with PITS and those with PTTS in the ICU. Results Fifteen (75%) patients had PITS and five (25%) had PTTS. While BMI was significantly lower in patients in the PTTS group, the APACHE II and SOFA scores were significantly higher in PTTS patients (p<0.05). In most of the patients in the PITS group, the location of the stenosis was subglottic and at the 1/3 upper part of the trachea, while in the PTTS group, it was located only at the upper 1/3 of the trachea (p>0.05). Mechanical dilatation was performed in all patients in both groups. Mechanical dilatation and cryotherapy were performed in 10 (66.7%) patients in the PITS group (p>0.05), and a stent was applied in addition to this treatment in three (20%) patients in the PITS group and four (80%) patients in the PTTS group (p<0.05). Mechanical ventilation was not needed in 10 (66.7%) PITS patients and three (60.0%) PTTS patients after the interventional procedure. All patients were eventually discharged from the ICU after treatment. Conclusion While higher BMI was common in PITS patients, the PTTS patients were generally in worse condition. In this patient group, interventional pulmonology procedures in the ICU can be life-saving.

Tracheal Transection After Prolonged Intubation and Tracheostomy: A Case Report

Tracheal transection is a rare, life-threatening complication after tracheal injury. Most commonly, tracheal transection presents after blunt trauma, but iatrogenic tracheal transection after tracheotomy has not been well described. Here, we present a case without a history of trauma that presented with signs of symptoms of tracheal stenosis. She was taken to the operating room for tracheal resection and anastomosis and was incidentally found to have a complete tracheal transection intraoperatively.

Challenges and successful management of subglottic tracheal stenosis in a 2‑year‑old child: A case report and a mini‑review of the literature

Tracheal stenosis is a narrowing of the windpipe that can lead to shortness of breath, stridor and even suffocation. The present study reports the clinical course of a patient with this condition in an aim to help clinicians obtain more information about this rare condition and identify potential treatment options. A 2-year-old female child presented with progressive shortness of breath and stridor. She was initially managed with tracheostomy; however, this was unsuccessful in relieving the stenosis. Subsequent interventions, including rigid bronchoscopy and dilatation were successful in relieving the condition. A benign hypertrophy of the bronchial wall was identified through biopsy. The patient was treated with steroids and antibiotics, and she experienced a marked improvement in symptoms and remained asymptomatic after a 1-year follow-up. Tracheal stenosis is a rare, yet serious condition that may be life-threatening. Thus, the early diagnosis and treatment of this condition are essential in order to improve outcomes.

Concomitant Intubation with Minimal Cuffed Tube and Rigid Bronchoscopy for Severe Tracheo-Carinal Obstruction

BACKGROUND

Our aim was to report on the use of an innovative technique for airway management utilizing a small diameter, short-cuffed, long orotracheal tube for assisting operative rigid bronchoscopy in critical airway obstruction.

METHODS

We retrospectively reviewed the clinical data of 36 patients with life-threatening critical airway stenosis submitted for rigid bronchoscopy between January 2008 and July 2021. The supporting ventilatory tube, part of the Translaryngeal Tracheostomy KIT (Fantoni method), was utilized in tandem with the rigid bronchoscope during endoscopic airway reopening.

RESULTS

Indications for collateral intubation were either tumors of the trachea with near-total airway obstruction (13), or tumors of the main carina with total obstruction of one main bronchus and possible contralateral involvement (23). Preliminary dilation was necessary before tube placement in only 2/13 patients with tracheal-obstructing tumors (15.4%). No postoperative complications were reported. There was one case of an intraoperative cuff tear, with no further technical problems.

CONCLUSIONS

In our experience, this innovative method proved to be safe, allowing for continuous airway control. It enabled anesthesia inhalation, use of neuromuscular blockage and reliable end-tidal CO2 monitoring, along with protection of the distal airway from blood flooding. The shorter time of the procedure was due to the lack of need for pauses to ventilate the patient.

A Novel Use of Coblation in the Treatment of Tracheal Tumors

Radiofrequency coblation is a new method of electrosurgical intervention. Most recently, its use has been reported in the treatment of laryngotracheal pathology. However, studies on coblation for tracheal tumors have not been reported. In this article, we described a novel use of coblation technology, in which a new type of airway-specific wand was used to ablate tracheal benign or malignant tumors in 3 cases. The results suggest the possibility of usage of coablation in the treatment of tracheal tumors. More studies that are larger and have longer follow-up are needed to further evaluate the use of this technique in the treatment of tracheal tumors.

Tracheal stenosis in a yellow-crowned parrot (Amazona ochrocephala) due to diffuse ossification and osteopetrosis of tracheal rings

Tracheal luminal stenosis can cause clinical respiratory distress in wild birds. We describe a case of tracheal stenosis due to diffuse ossification with osteopetrosis of tracheal rings in a yellow-crowned parrot (Amazona ochrocephala) with a history of chronic respiratory distress and death after development of marked dyspnoea. An ante-mortem radiographic examination revealed that the tracheal rings were radiopaque and that there were multiple areas of osteopenic change in long bones. At necropsy, there was stenosis of the tracheal rings characterized by complete replacement of cartilage by thickened compact bone with osteopetrosis and bone necrosis. The clinical respiratory distress and death of the parrot were associated with tracheal luminal stenosis due to thickening of the tracheal rings by diffuse ossification with osteopetrosis.

Risk factors for developing subglottic and tracheal stenosis from the medical intensive care unit

Objective

Endotracheal intubation is a common procedure in the medical intensive care unit (MICU), but it carries risk of complications including, but not limited to, subglottic stenosis (SGS) and tracheal stenosis (TS). Current literature suggests identifiable risk factors for the development of airway complications. This study is a comprehensive evaluation of potential risk factors in patients who developed SGS and TS following endotracheal intubation in our MICU.

Methods

Patients intubated in our MICU were identified from 2013 to 2019. Diagnoses of SGS or TS within 1 year of MICU admission were identified. Data extracted included age, sex, body measurements, comorbidities, bronchoscopies, endotracheal tube size, tracheostomy, social history, and medications. Patients with prior diagnosis of airway complication, tracheostomy, or head and neck cancer were excluded. Univariate and multivariate logistic regressions were performed.

Results

A total of 136 patients with TS or SGS were identified out of a sample of 6603 patients intubated in the MICU. Cases were matched to controls who did not develop airway stenosis based on identical Charlson Comorbidity Index scores. Eighty six controls were identified with a complete record of endotracheal/tracheostomy tube size, airway procedures, sociodemographic data, and medical diagnosis. Regression analysis showed that SGS or TS were associated with tracheostomy, bronchoscopy, chronic obstructive pulmonary disease, current tobacco use, gastroesophageal reflux disease, systemic lupus erythematosus, pneumonia, bronchitis, and numerous medication classes.

Conclusion

Various conditions, procedures, and medications are associated with an increased risk of developing SGS or TS.

Level of evidence

4.

Morphologic classification of tracheobronchial arborization in children with congenital tracheobronchial stenosis and the associated cardiovascular defects

Background

We sought to classify patients with congenital tracheal stenosis (CTS) according to tracheobronchial morphology and determine anatomic features associated with tracheobronchial anomalies (TBAs) and concurrent cardiovascular defects (CVDs).

Methods

We enrolled 254 patients who underwent tracheoplasty between November 1, 2009 and December 30, 2018. The anatomic features of the tracheobronchial tree and cardiovascular system were abstracted from bronchoscopy, echocardiography, computerized tomography, and operative reports.

Results

Four types of tracheobronchial morphology were identified: Type-1, which included normal tracheobronchial arborization (Type-1A, n = 29) and tracheal bronchus (Type-1B, n = 22); Type-2 (tracheal trifurcation; n = 49), and Type-3 (typical bridging bronchus; n = 47). Type-4 (bronchus with an untypical bridging pattern) was divided into Type-4A (involving bronchial diverticulum; n = 52) and Type-4B (absent bronchus; n = 55). Carinal compression and tracheomalacia were significantly more frequent in Type-4 patients than in the other patients (P < 0.01). CVDs were common in patients with CTS, especially in patients with Type-3 and Type-4 (P < 0.01). Persistent left superior vena cava was most common among patients with Type-3 (P < 0.01), and pulmonary artery sling was most frequent among those with Type-4 (P < 0.01). Outflow tract defects were most likely to occur in Type-1B. Early mortality was detected in 12.2% of all patients, and young age (P = 0.02), operation in the early era (P < 0.01), and bronchial stenosis (P = 0.03) were proven to be risk factors.

Conclusions

We demonstrated a useful morphological classification for CTS. Bridging bronchus was most closely linked with vascular anomalies, while tracheal bronchus was frequently associated with outflow tract defects. These results may provide a clue to CTS pathogenesis.

Evaluation of Structural Viability of Porcine Tracheal Scaffolds after 3 and 6 Months of Storage under Three Different Protocols

Tracheal replacement with a bioengineered tracheal substitute has been developed for long-segment tracheal diseases. The decellularized tracheal scaffold is an alternative for cell seeding. It is not defined if the storage scaffold produces changes in the scaffold's biomechanical properties. We tested three protocols for porcine tracheal scaffold preservation immersed in PBS and alcohol 70%, in the fridge and under cryopreservation. Ninety-six porcine tracheas (12 in natura, 84 decellularized) were divided into three groups (PBS, alcohol, and cryopreservation). Twelve tracheas were analyzed after three and six months. The assessment included residual DNA, cytotoxicity, collagen contents, and mechanical properties. Decellularization increased the maximum load and stress in the longitudinal axis and decreased the maximum load in the transverse axis. The decellularization of the porcine trachea produced structurally viable scaffolds, with a preserved collagen matrix suitable for further bioengineering. Despite the cyclic washings, the scaffolds remained cytotoxic. The comparison of the storage protocols (PBS at 4 °C, alcohol at 4 °C, and slow cooling cryopreservation with cryoprotectants) showed no significant differences in the amount of collagen and in the biomechanical properties of the scaffolds. Storage in PBS solution at 4 °C for six months did not change the scaffold mechanics.

Point-of-care ultrasound-guided submucosal paclitaxel injection in tracheal stenosis model

Background and Objectives

Transcutaneous point-of-care ultrasound (POCUS) is a good tool to monitor the trachea in many clinical practices. The aim of our study is to verify the feasibility of POCUS-guided submucosal injection as a potential drug delivery method for the treatment of tracheal stenosis.

Materials and methods

The inner wall of the trachea was monitored via a bronchoscope during the POCUS-guided submucosal injection of methylene blue in fresh ex vivo porcine trachea to evaluate the distribution of methylene blue. The feasibility and eficacy of POCUS-guided submucosal injection were evaluated in a tracheal stenosis rabbit model. Animals were divided into sham group, tracheal stenosis group, and treatment group. Ten days after the scraping of the tracheal mucosa or sham operation, POCUS-guided submucosal injection of paclitaxel or saline was performed. Seven days after the submucosal injection, the trachea was assessed by cervical computed tomography (CT) scan and ultrasound.

Results

The distribution of methylene blue in trachea proved the technical feasibility of POCUS-guided submucosal injection. CT evaluation revealed that the tracheal stenosis index and the degree of tracheal stenosis increased significantly in the stenosis group, while POCUS-guided submucosal injection of paclitaxel partially reversed the tracheal stenosis. POCUS-guided submucosal injection of paclitaxel also decreased the lamina propria thickness and collagen deposition in the stenosed trachea.

Conclusion

POCUS-guided submucosal paclitaxel injection alleviated tracheal stenosis induced by scraping of the tracheal mucosa. POCUS-guided submucosal injection might be a potential method for the treatment of tracheal stenosis.

Analysis of Risk Factors for Tracheal Stenosis Managed during COVID-19 Pandemic: A Retrospective, Case-Control Study from Two European Referral Centre

INTRODUCTION

Benign subglottic/tracheal stenosis (SG/TS) is a life-threatening condition commonly caused by prolonged endotracheal intubation or tracheostomy. Invasive mechanical ventilation was frequently used to manage severe COVID-19, resulting in an increased number of patients with various degrees of residual stenosis following respiratory weaning. The aim of this study was to compare demographics, radiological characteristics, and surgical outcomes between COVID-19 and non-COVID patients treated for tracheal stenosis and investigate the potential differences between the groups.

MATERIALS AND METHODS

We retrospectively retrieved electronical medical records of patients managed at two referral centers for airways diseases (IRCCS Humanitas Research Hospital and Avicenne Hospital) with tracheal stenosis between March 2020 and May 2022 and grouped according to SAR-CoV-2 infection status. All patients underwent a radiological and endoscopic evaluation followed by multidisciplinary team consultation. Follow-up was performed through quarterly outpatient consultation. Clinical findings and outcomes were analyzed by using SPPS software. A significance level of 5% (p < 0.05) was adopted for comparisons.

RESULTS

A total of 59 patients with a mean age of 56.4 (±13.4) years were surgically managed. Tracheal stenosis was COVID related in 36 (61%) patients. Obesity was frequent in the COVID-19 group (29.7 ± 5.4 vs. 26.9 ± 3, p = 0.043) while no difference was found regarding age, sex, number, and types of comorbidities between the two groups. In the COVID-19 group, orotracheal intubation lasted longer (17.7 ± 14.5 vs. 9.7 ± 5.8 days, p = 0.001), tracheotomy (80%, p = 0.003) as well as re-tracheotomy (6% of cases, p = 0.025) were more frequent and tracheotomy maintenance was longer (21.5 ± 11.9 days, p = 0.006) when compared to the non-COVID group. COVID-19 stenosis was located more distal from vocal folds (3.0 ± 1.86 vs. 1.8 ± 2.03 cm) yet without evidence of a difference (p = 0.07). The number of tracheal rings involved was lower in the non-COVID group (1.7 ± 1 vs. 2.6 ± 0.8 p = 0.001) and stenosis were more frequently managed by rigid bronchoscopy (74% vs. 47%, p = 0.04) when compared to the COVID-19 group. Finally, no difference in recurrence rate was detected between the groups (35% vs. 15%, p = 0.18).

CONCLUSIONS

Obesity, a longer time of intubation, tracheostomy, re-tracheostomy, and longer decannulation time occurred more frequently in COVID-related tracheal stenosis. These events may explain the higher number of tracheal rings involved, although we cannot exclude the direct role of SARS-CoV-2 infection in the genesis of tracheal stenosis. Further studies with in vitro/in vivo models will be helpful to better understand the role of inflammatory status caused by SARS-CoV-2 in upper airways.

Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema With Resultant Airway Obstruction Following Endotracheal Intubation

Angiotensin-converting enzyme inhibitor (ACEi)-induced angioedema is a consequence of excessive levels of bradykinin and accounts for nearly a third of angioedema cases when patients present to emergency rooms. While rare, patients can present with swelling in the face, tongue, and airways making it a life-threatening emergency. To secure an airway, endotracheal intubation may be conducted; however, tracheal stenosis is a known complication. In this report, we present a 61-year-old female with a history of ACEi-induced angioedema care in which she was intubated with facial swelling. Upon a repeat hospitalization, the patient developed stridor with respiratory distress. Bronchoscopy revealed severe tracheal stenosis with multilevel damage to tracheal rings, warranting urgent tracheostomy. One month after discharge, the patient was seen by an ENT specialist who performed a transnasal laryngoscopy revealing near total subglottic and tracheal stenosis of 3 cm stenosis length, presumed secondary to traumatic intubation for prior angioedema management. This case highlights the importance of careful intubation practices in patients with suspected airway edema.

Diagnostic Dilemma: A Patient With Pulmonary Fibrosis Who Presented for Severe Tracheal Stenosis After COVID-19 Pneumonia

A 44-year-old man with pulmonary fibrosis presented to our pulmonary hypertension clinic with biphasic stridor and dyspnea. He was sent to the emergency department, where he was found to have 90% subglottic tracheal stenosis and was successfully treated with balloon dilation. Seven months prior to the presentation, he required intubation for coronavirus disease 2019 (COVID-19) pneumonia complicated by hemorrhagic stroke. He was discharged after percutaneous dilatational tracheostomy, which was decannulated after three months. Our patient possessed several risk factors for tracheal stenosis, including endotracheal intubation, tracheostomy, and airway infection. Furthermore, our case is of great importance given the developing literature on COVID-19 pneumonia and its subsequent complications. Additionally, his history of interstitial lung disease may have confounded his presentation. Therefore, it is important to understand stridor, as it is an important exam finding that clinically distinguishes upper and lower airway disease. Our patient's biphasic stridor is consistent with the diagnosis of severe tracheal stenosis.

Tracheostomy Outcomes on Trauma Patients

Objective

Tracheostomies are performed in trauma patients for multiple purposes. Approaches to the procedure are usually directed by individual expertise and local preferences. Though generally safe, a tracheostomy can cause serious complications. This study aims to identify complications associated with tracheostomies performed at the level I Trauma Center of the Puerto Rico Medical Center (PRMC) to have an advanced foundation to develop and implement guidelines to improve patient outcomes.

Study Design

A retrospective cross-sectional study.

Setting

Level I Trauma Center of the PRMC.

Methods

Medical charts of 113 trauma adult patients that underwent tracheostomy at the PRMC from 2018 to 2020 were reviewed. Data collected included patient demographics, surgical approach, initial tracheostomy tube size (ITTS), intubation period, and flexible laryngoscopic findings. Complications occurring during and after tracheostomy were documented. The unadjusted relationship of the independent variables and outcome measures was assessed using χ ² and Fisher's test for categorical variables and the Wilcoxon-Mann-Whitney rank-sum test for continuous ones.

Results

Abnormal airway findings detected on flexible laryngoscopic examination were reported in 30 patients in the open tracheostomy (OT) group and 43 patients in the percutaneous tracheostomy group (p = 0.007). Peristomal granulation tissue was reported in 10 patients with an ITTS 8, while in only 1 patient with an ITTS 6 (p = 0.026).

Conclusion

This study showed several key findings in our cohort. The OT surgical approach was associated with fewer long-term complications when compared to the percutaneous approach. Also, a statistically significant difference in peristomal granulation tissue findings was found between the ITTS, ITTS-6 and ITTS-8, the smaller size being associated with fewer abnormal findings.

Impact of Tracheal Arborization and Lung Hypoplasia in Repair of Pulmonary Artery Sling in Combination With Long-Segment Tracheal Stenosis

Background: Reimplantation of the left pulmonary artery (LPA) and slide tracheoplasty has been our standard approach of care for patients with pulmonary artery sling (PAS) and tracheal stenosis. We present our experience, with emphasis on tracheal arborization and hypoplastic lungs; and their impact on long-term outcome of children with PAS and tracheal stenosis. Methods: It is a retrospective comparative study. Data were classified and analyzed based on the type of tracheobronchial arborization and normal versus hypoplastic lungs. Results: Seventy-five children operated between January 1994 and December 2019 (67 with normal lungs and 8 with lung hypoplasia/agenesis) were included. Patients with hypoplastic lungs had higher rates of preoperative ventilation (87.5%), postoperative ventilation (10 vs 8 days, P = .621), and mortality (50% vs 9%, P = .009) compared with those with normal lungs. Nineteen patients had tracheal bronchus (TB) variety and 30 patients had congenital long-segment tracheal stenosis (CLSTS) variety of tracheobronchial arborization. Endoscopic intervention was needed in 47.4% of patients with TB type and 60% with CLSTS type. CLSTS patients had higher rates of preoperative ventilation (60% vs 47.4%, P = .386), longer periods of postoperative ventilation (13 vs 6.5 days, P = .006), and ICU stay (15 vs 11 days, P = .714) compared with TB type. Conclusion: Surgical repair of PAS with tracheal stenosis has good long-term outcomes. All variations of tracheal anatomy can be managed with slide tracheoplasty. Persistence of airway problems requires intervention during follow-up as tracheal stenosis continues to be the Achilles heel.

Interventions and Outcomes in Glottic Versus Multi-level Airway Stenosis: A Multi-institutional Review

OBJECTIVE

Airway stenosis-particularly multi-level-presents complex management challenges. This study assessed rates of tracheostomy, decannulation, and the number of surgeries required in patients with posterior glottic stenosis (PGS), multi-level airway stenosis (MLAS), and bilateral vocal fold paralysis (BVFP).

METHODS

Airway stenosis patients treated between 2016 and 2021 at three tertiary medical centers were identified. Demographics, etiology of stenosis, medical comorbidities, and patient-reported outcome measures (PROMs) were collected.

RESULTS

158 patients (84 women, mean age 56.98 ± 15.5 years) were identified (54 PGS, 38 MLAS, and 66 BVFP). 72.3% required tracheostomy, including 72.2%, 86.8%, and 63.6% in these groups, respectively. Decannulation rates were 43.6%, 21.2%, and 32.5% in these groups, respectively. Patients with MLAS had higher rates of tracheostomy than BVFP (p < 0.05). However, decannulation rates were not different between groups (p > 0.05). MLAS required more surgeries (mean 4.0 ± 3.9) than PGS (2.4 ± 2.2, p = 0.02) or BVFP (1.0 ± 1.8, p < 0.0001). Mean PROMs scores at the latest follow-up were abnormal: 15.4 ± 12.2 (Dyspnea Index), 19.9 ± 12.2 (Voice Handicap Index-10), and 9.67 ± 11.1 (Eating Assessment Tool-10). Co-morbidities present included body mass index >30 (41.4%), diabetes (31.8%), pulmonary disease (50.7%), gastroesophageal reflux disease (39.4%), autoimmune disease (22.9%), and tobacco use history (55.2%).

CONCLUSIONS

Airway stenosis is a challenging clinical problem that negatively impacts patients' quality of life and often requires numerous surgeries. PGS more frequently requires tracheostomy compared to BVFP, but patients can often decannulate successfully. Patients with multi-level stenosis have lower decannulation rates and require more surgeries than glottic stenosis alone; these patients may benefit from earlier and/or more aggressive intervention.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:528-534, 2023.

A Comparative Analysis of Conventional Tracheotomy Versus Bjork Flap Tracheotomy

Background and objective Tracheotomy is a surgical technique performed in the anterior neck in various circumstances, such as prolonged endotracheal intubation, acute or persistent upper airway blockage, for bronchopulmonary toilet, or in certain otolaryngologic surgical procedures. In this study, we aimed to compare conventional and Bjork flap tracheotomy in terms of operative duration, as well as intraoperative, immediate postoperative, and delayed postoperative complications. Materials and methods A prospective study was conducted at a tertiary care hospital. The selected patients undergoing tracheotomies were randomly classified into two groups: conventional (n=30) and Bjork flap (n=30). Results Our findings indicated no statistically significant difference (p≥0.05) in terms of demographic profile (age and gender) between conventional (mean age: 52.3 ±12.79 years, male-to-female ratio: 25:5) and Bjork flap (mean age: 56.4 ±12.24 years, male-to-female ratio: 24:6) groups. A similar trend was observed in patients with respect to the duration of time required to establish access to the airway in both groups (7.8 ±1.73 and 7.7 ±1.87 minutes respectively, p≥0.05). However, a marked difference (p≤0.05) was observed in visual analog scale (VAS) scores between conventional and Bjork flap patients for ease of tube change (5.8 ±1.02-7.2 ±1.13 and 2.4 ±0.51-2.9 ±0.12) and stomal care (5.6 ±1.14-7.0 ±1.12 and 2.0 ±0.16-2.6 ±0.11) on the second and seventh day respectively. The Bjork flap-treated tracheotomy patients showed significantly favorable outcomes (p≤0.05) in intraoperative (immediate bleeding: 43%), postoperative (primary hemorrhage: 0%, subcutaneous emphysema: 6.7%), and delayed postoperative complications (stomal granulation: 10%, stomal stenosis: 3%, tracheostomy tube blockage: 10%, stoma infection: 10%, and secondary hemorrhage: 0%) as compared to their counterparts who underwent conventional tracheotomy: immediate bleeding: 70%; primary hemorrhage: 26.7%, subcutaneous emphysema: 30%; stomal granulation: 70%, stomal stenosis: 10%, tracheostomy tube blockage: 70%, stoma infection: 73%, and secondary hemorrhage: 3%. There was no significant difference with regard to tracheal stenosis and decannulation (p≥0.05) between the groups. Of the 25 decannulated patients, 50% (n=15) were in the conventional group and 33.3% (n=10) belonged to the Bjork flap group. Conclusion Based on our findings, Bjork flap tracheotomy is associated with fewer complications than conventional tracheotomy and may be preferred over conventional tracheotomy for elective tracheotomy procedures in adults.

Pulmonary artery sling: An overview

Pulmonary artery sling is a rare childhood vascular tracheobronchial compression syndrome that is frequently associated with tracheal stenosis. Consequently, neonates or infants may present with critical airway obstruction if there is long segment airway narrowing and complete rings. Rapid diagnosis of this cardiac vascular malformation and evaluation of the extent and severity of airway involvement is essential to plan surgery, typically a slide tracheoplasty to relieve critical airway obstruction. Long term outcome can be excellent following surgical repair of the stenosed airway and reimplantation of the left pulmonary artery. In this review we focus on the embryology, diagnostic workup, airway investigations and management for this rare but challenging congenital condition.

Unsuspected severe tracheal stenosis and tracheomalacia after correction surgery for congenital scoliosis: A case report

Tracheal stenosis and tracheomalacia in patients with congenital scoliosis are serious and rare conditions caused by congenital dysplasia, postintubation injury, trauma, and tracheal tumor. Anesthesia of a child with tracheal stenosis is challenging for anesthesiologists. We describe an 8-year-old female patient developed severe tracheal stenosis and tracheomalacia after growing rod implantation for congenital scoliosis. Comprehensive assessment of preoperative pulmonary function and airway morphology, which can be neglected clinically, should be performed in congenital scoliosis patients.

Case series: Montgomery T-tube placement for subglottic tracheal stenosis: a report of 3 cases

RATIONALE

Subglottic tracheal stenosis is stenosis of the trachea between the vocal cords and the lower margin of the cricoid cartilage. The Montgomery T-tube is used as a tracheostomy tube and a combined tracheal stent to avoid postoperative tracheal stenosis.

PATIENT CONCERNS

Because the stenosis is close to the glottis, surgical treatment is complex, and many complications may arise.

DIAGNOSES

Subglottic tracheal stenosis.

INTERVENTIONS

The patients underwent endotracheal intubation or tracheotomy because of acute pancreatitis, laryngeal malignancy, or cerebral hemorrhage after endotracheal intubation or tracheotomy and presented with varying degrees of tracheal stenosis and dyspnea. We relieved airway stenosis and improved dyspnea in these 3 patients by placing a Montgomery T-tube.

OUTCOMES

None of the 3 patients had intraoperative complications. In 2 of the cases, airway secretions were stored after surgery.

LESSONS

Montgomery T-tube placement is safe and effective for patients with complex subglottic tracheal stenosis.

Idiopathic double tracheal stenosis mimicking asthma: a case report

Idiopathic tracheal stenosis (Idio-SS) is an extremely rare disease. Its diagnosis is of exclusion and could be misdiagnosed as asthma. Herein, we report the case of a 39-year-old woman who had been treated for asthma for several months. She has no history of endotracheal intubation or granulomatous disease. Flexible fiberoptic bronchoscopy and thoracic computed tomography revealed double tracheal stenosis. The patient had rigid bronchoscopy; the upper tracheal stenosis was dilated with insertion of a silicone airway stent at the level of the distal stenosis. The diagnosis of idiopathic stenoses was made according to the clinico-radiological features. Symptoms were completely relieved and no recurrence was observed after one year of follow-up. This case highlights the importance of clinical suspicion and early diagnosis of Idio-SS in patients with unexplained wheezing and dyspnea. It also illustrates the role of endoscopic procedures in this situation.

The impact of early surgical treatment of tracheal stenosis on neurorehabilitation outcome in patients with severe acquired brain injury

INTRODUCTION

Acquired tracheal stenosis (TS) is a potentially life-threatening condition following prolonged intubation and/or tracheostomy in adult patients with severe Acquired Brain Injury (sABI), requiring a tracheal resection and reconstruction.

METHODS

We included 38 sABI adult patients with TS, admitted at a post-acute Neurorehabilitation Hospital. Disability Rating Scale (DRS) and other functional assessment measures were recorded at admission (t₁), before TS surgical treatment (t₂), and at discharge (t₃). Patients were defined as 'improved' when they changed from a more severe to a less severe disability, between time t₂ and time t₃, and as "not improved" when they did not show any further improvement between t₂ and t₃, or they already exhibited a disability improvement since time interval t₁-t₂.

RESULTS

Time interval between the injury onset and TS surgical treatment (t₂-t₀) was associated with the patient's disability improvement, suggesting the t₂-t₀ time interval ≤ 115 days as a cutoff value for a possible functional recovery. A t₂-t₀ time interval ≤ 170 days is also associated to absence of persistent dysphagia.

CONCLUSIONS

Early TS surgical treatment within 115 days from the injury onset contributes to the improvement of the disability level in patients with sABI, optimizing their functional outcomes and recovery potential.

Fatal Asphyxia Potentially Caused by COVID-19-Induced Exacerbation of Pre-existing Tracheal Stenosis

We report a case of cardiac arrest due to asphyxia caused by coronavirus disease 2019 (COVID-19) in a patient with no history of tracheal intubation but with a history of subglottic stenosis. A 54-year-old man suffered a cardiac arrest at home. The patient had tracheal stenosis; therefore, it was difficult to intubate. The patient had COVID-19, which was presumed to have aggravated the existing tracheal stenosis and caused asphyxiation. The patient died seven days later. This is, to our knowledge, the first report of a patient with subglottic stenosis potentially aggravated by COVID-19, resulting in asphyxia-related cardiopulmonary arrest. The patient could not be saved, but emergency physicians should be aware that airway obstruction can be caused by viral infections, including severe acute respiratory syndrome coronavirus 2 infections. Physicians should consider the difficulty in performing oral intubation and cricothyrotomy and be aware of alternative methods to secure the airway.

Management of COVID-19 related tracheal stenosis: The state of art

Tracheal stenosis (TS) is a debilitating disease promoted by pathologic narrowing of the trachea. The acute respiratory distress syndrome caused by COVID-19 has been demonstrated to trigger enhanced inflammatory response and to require prolonged invasive mechanical ventilation as well as high frequency of re-intubation or emergency intubation, thus increasing the rate and complexity of TS. The standard-of-care of COVID-19-related tracheal complications has yet to be established and this is a matter of concern. This review aims at collecting latest evidence on this disease, providing an exhaustive overview on its distinctive features and open issues, and investigating different diagnostic and therapeutic strategies to handle COVID-19-induced TS, focusing on endoscopic versus open surgical approach. The former encompasses bronchoscopic procedures: electrocautery or laser-assisted incisions, ballooning dilation, submucosal steroid injection, endoluminal stenting. The latter consists of tracheal resection with end-to-end anastomosis. As a rule, traditionally, the endoscopic management is restricted to short, low-grade, and simple TS, whereas the open techniques are employed in long, high-grade, and complex TS. However, the critical conditions or extreme comorbidities of several COVID-19 patients, as well as the marked inflammation in tracheal mucosa, have led some authors to apply endoscopic management also in complex TS, recording acceptable results. Although severe COVID-19 seems to be an issue of the past, its long-term complications are still unknown and considering the increased rate and complexity of TS in these patients, we strongly believe that it is worth to focus on it, attempting to find the best management strategy for COVID-19-related TS.

Is prevention possible? A single-region experience]

OBJECTIVE

To develop the measures for prevention and treatment of tracheal stenosis in various phases of disease.

MATERIAL AND METHODS

We analyzed 290 patients who underwent long-term mechanical ventilation between 2006 and 2021. The main causes of previous intensive care with prolonged ventilation were combined trauma and stroke. All patients were divided into two groups. Group I included 149 people who underwent decannulation in a specialized department with further staged endoscopic follow-up. Group II included 141 patients with cicatricial tracheal stenosis and no follow-up. All patients underwent endoscopic treatment, tracheal resection and staged reconstructive plastic surgery.

RESULTS

In the 1^st group, tracheal stenosis occurred in 28 cases (18.8%). Of these, initial (edematous and granulation) stenoses were detected in 17 (60.7%), granulation-fibrous stenoses - in 11 (39.3%) cases. Endoscopic treatment was successful in 24 (85.7%) patients. Four patients with tracheomalacia underwent circular tracheal resections. In the 2^nd group, all patients required surgical interventions (circular resections - 71 cases, staged reconstructive plastic surgery - 70 patients). Among 70 patients after reconstructive surgery, 24 (34.2%) ones recovered, and 28 (40%) patients need for cannula. Seventeen (24.2%) patients are unavailable for follow-up, and 1 patient (1.42%) died from concomitant disease. Complications after circular resection occurred in 16 cases (24.6%), postoperative mortality was 2.7%.

CONCLUSION

Follow-up after prolonged mechanical ventilation and tracheotomy makes it possible to prevent severe forms of tracheal stenosis and carry out early endoscopic treatment.

Challenging Diagnosis of a Congenital Tracheal Malformation: Considerations From an Intensive Care Perspective

Congenital tracheal stenosis is a rare airway malformation. A high index of suspicion is fundamental. The authors report a case of congenital tracheal stenosis in a 13-month-old male infant, with a challenging diagnosis from the intensive care perspective. At birth, the patient presented an anorectal malformation with a recto-urethral fistula so a colostomy with mucous fistula was performed in the neonatal period. At the age of seven months, he was admitted due to a respiratory infection, treated with steroids and bronchodilators, and discharged after three days without any complications. He underwent complete repair of tetralogy of Fallot when he was 11 months old, which was performed without any reported perioperative complications. However, at the age of 13 months, due to another respiratory infection, he presented more severe symptoms and required admission to the pediatric intensive care unit (PICU) for invasive mechanical ventilation. He was intubated on the first attempt. While monitoring the difference between peak inspiratory and plateau pressures, we observed a sustained elevated difference between pressures suggestive of increased airway resistance, thus raising the possibility of an anatomical obstruction. Laryngotracheoscopy confirmed distal tracheal stenosis (grade II) with four complete tracheal rings. In our case, the absences of perioperative challenges or complications in previous respiratory infections were not suggestive of a tracheal malformation. Furthermore, no difficulties were encountered during intubation due to the distal location of the tracheal stenosis. A careful appreciation of respiratory mechanics on the ventilator at rest and during tracheal aspirations was essential to suspect an anatomical defect.

Association between surgical tracheostomy and chronic tracheal stenosis: A retrospective, single-center study

Background

Tracheal stenosis is a major complication of tracheostomy. Accordingly, anesthesiologists tend to select a smaller endotracheal tube (ETT) than usual for patients with a prior tracheostomy history, regardless of the presence or absence of respiratory symptoms. However, it likely comes from our trial and error, not scientific evidence. Therefore, in this study, we retrospectively examined the association between traditional surgical tracheostomy and tracheal stenosis as assessed by transverse computed tomography (CT).

Methods

Patients who underwent surgery for head and neck cancer from January 2010 to December 2013, with a temporary tracheostomy closed within a couple of months, were included. Exclusion criteria were tracheostoma before surgery, permanent tracheostomy, or insufficient CT follow-up. Transverse CT slices were measured 2 cm above and below the tracheostomy site (0.5 cm/slice for a total of 9 slices). The minimum cross-sectional tracheal area and horizontal and vertical diameters in transverse CT slices were compared before (baseline: BL), 6 months (6M) and 12 months (12M) after tracheostomy. Tracheal stenosis was defined as a decrease in the minimum cross-sectional tracheal area compared to BL.

Results

Of 112 patients, 77 were included. The minimum tracheal area was significantly decreased at 6M and 12M compared to BL (BL: mean 285 [SD 68] mm², 6M: 267 [70] mm², P < 0.01 vs. BL, 12M: 269 [68] mm², P < 0.01 vs. BL), and the localization was predominantly at or above the tracheostomy site at 6M and 12M. Tracheal stenosis was identified in 55 patients at 6M and in 49 patients at 12M without any respiratory symptoms. With regard to horizontal and vertical diameter, only horizontal diameter was significantly decreased at 6M and 12M compared to BL (BL: 16.8 [2.4] mm, 6M: 15.4 [2.7] mm, P < 0.01 vs. BL, 12M: 15.6 [2.8] mm, P < 0.01 vs. BL).

Conclusion

Conventional surgical tracheostomy was associated with a decreased horizontal diameter of the trachea. It resulted in a decreased cross-sectional tracheal area in more than one-half of the patients; however, no patient complained of any respiratory symptoms. Therefore, even without respiratory symptoms, prior tracheostomy causes an increased risk of tracheal stenosis, and using a smaller ETT than usual could be reasonable.