Review

Authors: Delaney J Carpenter, Osama A Hamdi, Ariel M Finberg...

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Topics: Cicatrix; Constriction, Pathologic; Humans; Laryngostenosis; Tracheal Stenosis

PubMed: 35488503
DOI: 10.1002/hed.27079

Review

Authors: Efsun Gonca Uğur Chousein, Mehmet Akif Özgül

Postintubation tracheal stenosis (PITS) is an iatrogenic complication seen increasingly often as the number of intensive care unit (ICU) bed multiply, the indications for endotracheal intubation expand and disease awareness rises. PITS has a clinical severity spectrum ranging from asymptomatic cases to patients requiring urgent interventional procedures. It should therefore always be considered in the differential diagnosis in patients with a history of intubation who present with the complaint of difficult breathing. The golden standart for diagnosis is fiberoptic/rigid bronchoscopy. Even though tracheal resection and end-to-end anastomosis (TRA) is the preferred traetment, in some selected cases and in the patients who are not candidates for surgery, bronchoscopic interventions can be life saving, temporizing until surgery is possible and even be curative.

Topics: Adult; Bronchoscopy; Diagnosis, Differential; Dyspnea; Female; Humans; Intensive Care Units; Intubation, Intratracheal; Male; Severity of Illness Index; Tracheal Stenosis

PubMed: 30479232
DOI: 10.5578/tt.67108

Review

Authors: Alessandro Marchioni, Roberto Tonelli, Alessandro Andreani...

Laryngotracheal stenosis (LTS) is a complex and heterogeneous disease whose pathogenesis remains unclear. LTS is considered to be the result of aberrant wound-healing process that leads to fibrotic scarring, originating from different aetiology. Although iatrogenic aetiology is the main cause of subglottic or tracheal stenosis, also autoimmune and infectious diseases may be involved in causing LTS. Furthermore, fibrotic obstruction in the anatomic region under the glottis can also be diagnosed without apparent aetiology after a comprehensive workup; in this case, the pathological process is called idiopathic subglottic stenosis (iSGS). So far, the laryngotracheal scar resulting from airway injury due to different diseases was considered as inert tissue requiring surgical removal to restore airway patency. However, this assumption has recently been revised by regarding the tracheal scarring process as a fibroinflammatory event due to immunological alteration, similar to other fibrotic diseases. Recent acquisitions suggest that different factors, such as growth factors, cytokines, altered fibroblast function and genetic susceptibility, can all interact in a complex way leading to aberrant and fibrotic wound healing after an insult that acts as a trigger. However, also physiological derangement due to LTS could play a role in promoting dysregulated response to laryngo-tracheal mucosal injury, through biomechanical stress and mechanotransduction activation. The aim of this narrative review is to present the state-of-the-art knowledge regarding molecular mechanisms, as well as mechanical and physio-pathological features behind LTS.

Topics: Biomarkers; Biomechanical Phenomena; Cytokines; Genetic Predisposition to Disease; Humans; Intercellular Signaling Peptides and Proteins; Laryngostenosis; Mechanotransduction, Cellular; Tracheal Stenosis

PubMed: 35269565
DOI: 10.3390/ijms23052421

Authors: Andrew Yousef, Isaac Solomon, George Cheng...

OBJECTIVE

To characterize the preoperative and intraoperative findings of symptomatic tracheal stenosis associated with COVID-19 related respiratory failure requiring tracheal resection.

METHOD

We performed a retrospective review identifying all patients with a history of tracheal stenosis secondary to COVID-19 related respiratory failure who subsequently received a tracheal resection at our institution between January 2020 and June 2023. Clinical, radiological, pathological, and surgical characteristics were recorded to describe and characterize pre-operative and intraoperative findings associated with tracheal stenosis in the setting of a previous COVID-19 infection.

RESULTS

We retrospectively reviewed 11 patients with COVID-19 related tracheal stenosis that required open tracheal or cricotracheal resection. The mean age was 54.1. Patients were hospitalized for a mean of 49.5 days related to COVID-19 complications. Tracheotomy was completed in 10 patients (90.9%) during their initial hospitalization with COVID-19 related respiratory failure. Patients were intubated a mean of 18.6 days prior to tracheotomy completion. Ten patients (90.9%) underwent endoscopic operative interventions for their tracheal stenosis prior to open resection. Intraoperatively, the mean stenosis length was 3.33 cm. The mean tracheal resection length was 3.96 cm. Patients were hospitalized for a mean of 8.27 days post operatively with no significant post operative complications.

CONCLUSIONS

Symptomatic tracheal stenosis in the setting of prolonged intubation due to COVID-19 is an under-described etiology. This is one of the largest single institution retrospective reviews that identifies 11 patients with prolonged intubation who developed symptomatic tracheal stenosis refractory to conservative management and ultimately requiring tracheal resection.

Topics: Humans; Tracheal Stenosis; COVID-19; Middle Aged; Male; Retrospective Studies; Female; Tracheotomy; Aged; Adult; Trachea; Respiratory Insufficiency; SARS-CoV-2

PubMed: 39127881
DOI: 10.1177/00034894241266489

Meta-Analysis

Authors: Siqi Hong, Xiaobing Wu, Haihuan Feng...

OBJECTIVE

To systematically evaluate potential risk factors for tracheal stenosis and to provide a reference for the prevention and management of patients with this condition.

METHODS

Databases were searched to identify studies of the risk factors for tracheal stenosis, from their inception to October 2023, then a meta-analysis was performed. The study was registered with PROSPERO under the registration number CRD42023428906.

RESULTS

Ten studies of a total of 2525 patients were included. The meta-analysis showed that tracheotomy, diabetes, the duration of intubation, the duration of mechanical ventilation, respiratory tract infection, a high incision, and a ratio of intratracheal tube cuff diameter (C)/transverse diameter at the level of the clavicle (T) >150% were risk factors for the development of tracheal stenosis.

CONCLUSION

Measures such as shortening the duration of mechanical ventilation and intubation, reducing and avoiding tracheotomy after prolonged intubation, early tracheotomy in patients with obesity who require prolonged mechanical ventilation, appropriate choices of incision location and catheter, the maintenance of appropriate C/T, the prevention of respiratory infection, and the control of diabetes mellitus should limit the risk of tracheal stenosis.

Topics: Humans; Intubation, Intratracheal; Respiration, Artificial; Respiratory Tract Infections; Risk Factors; Tracheal Stenosis; Tracheotomy

PubMed: 39263927
DOI: 10.1177/03000605241275884

Authors: Abdulaziz Alrabiah, Shahad Almohanna, Abdullah Aljasser...

OBJECTIVES

Tracheal stenosis is defined as a narrowing of the airway distal to the lower edge of the cricoid cartilage. It is initially diagnosed based on clinical presentation and then confirmed using direct laryngobronchoscopy. Other adjunctive diagnostic methods, including spirometry, have been proposed. This study aimed to evaluate the relationship between tracheal stenosis severity and pre- and post-balloon dilatation spirometry parameters in order to assess for significant changes in spirometry values and to evaluate for the effects of stenosis-associated factors on post-dilation spirometry values, including vertical length and grade of the stenosis, as well as the role of wound-modifying agents.

METHODS

This retrospective study included adults (>18 years of age) with isolated tracheal stenosis who underwent endoscopic balloon dilations at King Saud University Medical City from June 2015 to May 2019, with detailed documentation of operative findings and valid spirometry measurements pre- and post-balloon dilation. Basic demographic data and operative note details, including information about the percentage of tracheal stenosis, distance of tracheal stenosis from vocal cords, vertical length of stenotic segment, and use of wound-modifying agents (topical mitomycin C or triamcinolone injections), were extracted.

RESULTS

Fourteen patients with spirometry measurements obtained on 50 occasions (25 pre-balloon dilation and 25 post-balloon dilation) were included. Each 1-unit increase in the vertical length of the stenosis showed a statistically significant negative relationship (-1.47 L/s) with pre-balloon dilation peak expiratory flow (PEF; = .034). Post-balloon dilation spirometric values showed statistically significant improvements for most variables.

CONCLUSIONS

The vertical length of an isolated tracheal stenosis can be predicted before surgical interventions using PEF values and may be a significant indicator of anticipated post-balloon dilation surgical success. Our study suggested that spirometry is a very useful technique for evaluating patients with tracheal stenosis due to its noninvasiveness, cost-effectiveness, with a good clinical value.

Topics: Adult; Dilatation; Female; Humans; Male; Retrospective Studies; Spirometry; Tracheal Stenosis

PubMed: 32692288
DOI: 10.1177/0145561320936968

Authors: Joana Ferreirinha, Claudio Caviezel, Walter Weder...

BACKGROUND

Tracheal or cricotracheal resection is the standard of care for definitive treatment of tracheal stenosis. However, the incidence is low, the management is complex, and only a few centres have reported their experience. Therefore, more clinical reports on this topic are needed.

METHODS

We performed a retrospective analysis of all patients who underwent tracheal or cricotracheal resection for malignant or benign tracheal stenosis in our institution between 2001 and 2016. Fisher’s exact test was used for analysis of complications and recurrence. P-value <0.05 was considered statistically significant.

RESULTS

37 patients, aged 19–74, underwent tracheal (n = 21, 56.8%) or cricotracheal (n = 16, 43.2%) resection for idiopathic (n = 15, 40.5%), neoplasm-related (n = 11, 29.7%), postintubation/-tracheotomy (n = 10, 27%), and congenital (n = 1, 2.7%) stenosis. Cervical incision was applied in 28 patients (75.7%), and an extended access (5 thoracotomy, 3 hemiclamshell, 1 partial-sternotomy) was required in 9 patients (24.3%). Mediastinal lymphadenectomy was done in 7 patients (18.9%), all with neoplasm-related stenosis. Median resection length was 2.8 cm (range 1.0–6.0), and longer than 4.0 cm in 6 cases (16.2%). Release manoeuvre was performed in 7 patients (18.9%). All patients were extubated immediately after surgery and median hospital stay was 5 days (range 3–15). Median follow-up was 6 months (range, 1-93). There was no 30-day mortality, and no dehiscence or fistula occurred at the suture line. Complications were seen in 11 patients (29.7%), significantly correlating to malignant stenosis (p = 0.011) and surgical procedure, meaning extended access (p = 0.011), mediastinal lymphadenectomy (p = 0.016), and release manoeuvres (p = 0.016). Temporary hoarseness was the most common complication (n = 5, 13.5%), but remained persistent in only one patient (n = 1, 2.7%). Recurrence was seen only in patients with idiopathic stenosis (n = 5, 13.5%).

CONCLUSIONS

Our results confirm good efficacy for surgical resection of tracheal stenosis. The complication rate is relatively low in comparison to the literature, suggesting the importance of managing tracheal stenosis in a tertiary referral centre.

Topics: Anastomosis, Surgical; Humans; Postoperative Complications; Retrospective Studies; Trachea; Tracheal Stenosis; Treatment Outcome

PubMed: 33378546
DOI: 10.4414/smw.2020.20383

Authors: Guoying Zhang, Jianming Wang, Yiming Zeng...

PURPOSE

To develop a simpler animal model for benign tracheal stenosis and introduce a low-cost household endoscope for postmodeling endotracheal evaluation.

METHODS

Twenty rabbits were randomly divided into a model group (15 rabbits, subjected to transoral nylon brush scraping of the trachea) and a mock group (5 rabbits, merely exempted from scraping), a household endoscope was then introduced for weekly endoscopic examination. Meanwhile, other 15 rabbits (modeling like the model group) underwent batch tracheal resection at different postintervention times for pathological analysis.

RESULTS

The model group presented a low mortality and few complications. The endoscope could obtain adequate images for stenosis assessment, which showed that the models presented homogeneous injury after scraping and developed a mature scar stricture at 28 days postoperatively with a mean stenosis degree of 65.9%, and 71.4% (10/14) above Myer-Cotton's grade II. The pathological findings were consistent with the clinicopathological process of human. No stenosis was found in mock group.

CONCLUSION

The modified model is simpler, minimally invasive and reliable, while the household endoscope is competent for model's follow-up, providing easily accessible and useful tools for facilitating more extensive studies of benign tracheal stenosis.

Topics: Animals; Disease Models, Animal; Endoscopes; Endoscopy; Rabbits; Trachea; Tracheal Stenosis

PubMed: 33331454
DOI: 10.1590/ACB351104

Review

Authors: Hao-Su Zhou, Yu-Xiang Wan, Hao Qin...

BACKGROUND

Severe tracheal stenosis is a life-threatening condition that often requires immediate intervention. Traditional surgical approaches may be challenging in critically ill patients, and bronchoscopic therapies have emerged as a less invasive alternative. However, maintaining adequate oxygenation and ventilation during these procedures can be challenging, especially in patients with near-complete airway obstruction. The manipulation of the already compromised airway during bronchoscopy can exacerbate respiratory insufficiency, leading to hypoxemia, hypercapnia, and even cardiac arrest. To address these challenges, extracorporeal membrane oxygenation (ECMO) has been increasingly utilized as a supportive measure during high-risk airway interventions. The use of ECMO in managing severe tracheal stenosis is a relatively recent development, with growing evidence supporting its role in facilitating complex airway interventions. By ensuring hemodynamic stability and adequate gas exchange, ECMO enables the safe and effective application of bronchoscopic techniques in critically ill patients who would otherwise be deemed unsuitable for such procedures. This approach can improve outcomes and expand treatment options for patients with severe tracheal stenosis.

CASE PRESENTATION

A 49-year-old woman, who underwent metal stent placement in her upper trachea 24 years ago due to tuberculous tracheal stenosis, was hospitalized due to worsening dyspnea. A thorough evaluation showed that the entire tracheal section was narrowed, with the smallest diameter measuring approximately 4-5 mm. Traditional respiratory support was inadequate for maintaining the patient's oxygen levels during bronchoscopy. We conducted bronchoscopic treatment with ECMO support, significantly alleviating the patient's dyspnea symptoms post-treatment. This is the first documented case of ECMO being utilized alongside bronchoscopy for patients with tracheal narrowing caused by tuberculosis.

CONCLUSION

The case study described a patient experiencing severe tracheal scar stenosis due to tuberculosis, who underwent successful treatment that included bronchoscopy supported by ECMO. Our effective handling of this case has provided crucial insights and strategies for managing similar situations in the future.

Topics: Humans; Extracorporeal Membrane Oxygenation; Tracheal Stenosis; Bronchoscopy; Middle Aged; Female; Stents; Severity of Illness Index

PubMed: 40165148
DOI: 10.1186/s12890-025-03612-1

Authors: Cesare Piazza, Davide Lancini, Marta Filauro...

OBJECTIVE

The COVID-19 pandemic was an extraordinary challenge for the global healthcare system not only for the number of patients affected by pulmonary disease, but also for the incidence of long-term sequalae. In this regard, laryngo-tracheal stenosis (LTS) represents one of the most common complications of invasive ventilation.

METHODS

A case series of patients who underwent tracheal resection and anastomosis (TRA) for post-COVID-19 LTS was collected from June 2020 to September 2021.

RESULTS

Among 14 patients included, 50% had diabetes and 64.3% were obese. During intensive care unit stay, mean duration of orotracheal intubation (OTI) was 15.2 days and 10 patients (71.4%) underwent tracheostomy, which was maintained in 7 for an average of 31 days. According to the European Laryngological Society classification, 13 patients (92.9%) had a grade IIIa LTS and one a grade IIIa+. All patients underwent Type A TRA, according to the authors' classification. No major perioperative complications were reported and at the last follow-up all patients were asymptomatic.

CONCLUSIONS

With the appropriate indications, TRA represents an effective treatment in post-COVID-19 LTS patients. Short OTI times and careful tracheostomy are required in order to reduce the incidence of airway injury.

Topics: Anastomosis, Surgical; COVID-19; Constriction, Pathologic; Humans; Intubation, Intratracheal; Pandemics; Retrospective Studies; Tracheal Stenosis; Tracheostomy; Treatment Outcome

PubMed: 35612502
DOI: 10.14639/0392-100X-N1952