Medicine:Laryngotracheal stenosis

From HandWiki
Laryngotracheal stenosis
Laryngotracheal stenosis 001.jpg
This condition can also be referred to as subglottic or tracheal stenosis.
Diagnostic methodPatient history, CT scan of neck and chest, fibre-optic bronchoscopy

Laryngotracheal stenosis refers to abnormal narrowing of the central air passageways.[1] This can occur at the level of the larynx, trachea, carina or main bronchi.[2] In a small number of patients narrowing may be present in more than one anatomical location.

Presentation

The most common symptom of laryngotracheal stenosis is gradually-worsening breathlessness (dyspnea) particularly when undertaking physical activities (exertional dyspnea). The patient may also experience added respiratory sounds which in the more severe cases can be identified as stridor but in many cases can be readily mistaken for wheeze. This creates a diagnostic pitfall in which many patients with laryngotracheal stenosis are incorrectly diagnosed as having asthma and are treated for presumed lower airway disease.[3][4][5][6][7][8] This increases the likelihood of the patient eventually requiring major open surgery for benign disease[9] and can lead to tracheal cancer presenting too late for curative surgery to be performed.

Causes

Laryngotracheal stenosis is an umbrella term for a wide and heterogeneous group of very rare conditions. The population incidence of adult post-intubation laryngotracheal stenosis which is the commonest benign sub-type of this condition is approximately 1 in 200,000 adults per year.[10] The main causes of adult laryngotracheal stenosis are:

Main causes of laryngotracheal stenosis
Benign causes Malignant causes
Extrinsic compression
  • Thyroid goitre
  • Thymoma
  • Mediastinal lymphadenopathy (e.g. TB)[11]
  • Vascular anomalies
  • Thyroid cancer[12]
  • Lung cancer/lymphomas-related mediastinal lymphadenopathy
Intrinsic narrowing

Diagnosis

Patient history, CT scan of neck and chest, fiberoptic bronchoscopy, and spirometry are all several ways to assess for laryngotracheal stenosis and effectively develop preoperational approaches to treating the disease. In addition, a methodology called the Cotton-Myer system is commonly used to evaluate the degree of severity of the laryngotracheal stenosis based on the percentage of obstruction; other systems have also been proposed to fill potential shortcomings of the Cotton-Myer classification and help capture the full complexity of the illness.[23]

Treatment

The optimal management of laryngotracheal stenosis is not well defined, depending mainly on the type of the stenosis.[24] General treatment options include

  1. Tracheal dilation using rigid bronchoscope
  2. Laser surgery and endoluminal stenting[25]
  3. Tracheal resection and laryngotracheal reconstruction[21][26]

Tracheal dilation is used to temporarily enlarge the airway. The effect of dilation typically lasts from a few days to 6 months. Several studies have shown that as a result of mechanical dilation (used alone) may occur a high mortality rate and a rate of recurrence of stenosis higher than 90%.[24] Thus, many authors treat the stenosis by endoscopic excision with laser (commonly either the carbon dioxide or the neodymium: yttrium aluminum garnet laser) and then by using bronchoscopic dilatation and prolonged stenting with a T-tube (generally in silicone).[27][28][29]

There are differing opinions on treating with laser surgery.

In very experienced surgery centers, tracheal resection and reconstruction (anastomosis complete end-to-end with or without laryngotracheal temporary stent to prevent airway collapse) is currently the best alternative to completely cure the stenosis and allows to obtain good results. Therefore, it can be considered the gold standard treatment and is suitable for almost all patients.[30]

The narrowed part of the trachea will be cut off and the cut ends of the trachea sewn together with sutures. For stenosis of length greater than 5 cm a stent may be required to join the sections.

Late June or early July 2010, a new potential treatment was trialed at Great Ormond Street Hospital in London, where Ciaran Finn-Lynch (aged 11) received a transplanted trachea which had been injected with stem cells harvested from his own bone marrow. The use of Ciaran's stem cells was hoped to prevent his immune system from rejecting the transplant,[31] but there remain doubts about the operation's success, and several later attempts at similar surgery have been unsuccessful.

Nomenclature

Laryngotracheal stenosis (Laryngo-: Glottic Stenosis; Subglottic Stenosis; Tracheal: narrowings at different levels of the windpipe) is a more accurate description for this condition when compared, for example to subglottic stenosis which technically only refers to narrowing just below vocal folds or tracheal stenosis. In babies and young children however, the subglottis is the narrowest part of the airway and most stenoses do in fact occur at this level. Subglottic stenosis is often therefore used to describe central airway narrowing in children, and laryngotracheal stenosis is more often used in adults.

See also

  • Hermes Grillo pioneer in tracheal resection surgery
  • Laryngospasm

References

  1. ↑ Gelbard, A (2014). "Causes and Consequences of Laryngotracheal Stenosis". The Laryngoscope 125 (5): 1137–1143. doi:10.1002/lary.24956. PMID 25290987. 
  2. ↑ "Anatomy of the larynx, trachea, and bronchi". Otolaryngol. Clin. North Am. 28 (4): 685–99. August 1995. doi:10.1016/S0030-6665(20)30488-6. PMID 7478631. 
  3. ↑ Catenacci MH (July 2006). "A case of laryngotracheal stenosis masquerading as asthma". South. Med. J. 99 (7): 762–4. doi:10.1097/01.smj.0000217498.70967.77. PMID 16866062. 
  4. ↑ "A 41-year-old male with cough, wheeze, and dyspnea poorly responsive to asthma therapy". Allerg Asthma Proc. 31 (4): 355–8. 2010. doi:10.2500/aap.2010.31.3344. PMID 20819328. 
  5. ↑ "All that wheezes is not asthma". Br J Clin Pract 49 (1): 43–4. 1995. doi:10.1111/j.1742-1241.1995.tb09878.x. PMID 7742187. 
  6. ↑ 6.0 6.1 "Tracheal adenoid cystic carcinoma masquerading asthma: a case report". BMC Pulm Med 4: 10. October 2004. doi:10.1186/1471-2466-4-10. PMID 15494074. 
  7. ↑ "Tracheal obstruction presenting as asthma". Postgrad Med J 59 (698): 775–6. December 1983. doi:10.1136/pgmj.59.698.775. PMID 6318209. 
  8. ↑ "Tracheal stenosis caused by congenital vascular ring anomaly misinterpreted as asthma for 45 years". Thorac Cardiovasc Surg 38 (1): 42–4. 1990. doi:10.1055/s-2007-1013990. PMID 2309228. 
  9. ↑ "Early endoscopic treatment of acute inflammatory airway lesions improves the outcome of postintubation airway stenosis". Laryngoscope 116 (8): 1417–21. August 2006. doi:10.1097/01.mlg.0000225377.33945.14. PMID 16885746. 
  10. ↑ "Estimating the population incidence of adult post-intubation laryngotracheal stenosis". Clin Otolaryngol 32 (5): 411–2. October 2007. doi:10.1111/j.1749-4486.2007.01484.x. PMID 17883582. 
  11. ↑ 11.0 11.1 "Preliminary experience with bronchotherapeutic procedures in central airway obstruction". Chang Gung Med J 26 (4): 240–9. April 2003. PMID 12846523. 
  12. ↑ "Airway stenting for the treatment of laryngotracheal stenosis secondary to thyroid cancer". Respirology 13 (5): 632–8. September 2008. doi:10.1111/j.1440-1843.2008.01309.x. PMID 18513246. 
  13. ↑ "Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present". Otolaryngol Head Neck Surg 125 (4): 397–400. October 2001. doi:10.1067/mhn.2001.117372. PMID 11593179. 
  14. ↑ Bent J (July 2006). "Pediatric laryngotracheal obstruction: current perspectives on stridor". Laryngoscope 116 (7): 1059–70. doi:10.1097/01.mlg.0000222204.88653.c6. PMID 16826038. 
  15. ↑ "Iatrogenic airway stenosis with recurrent respiratory papillomatosis". Arch. Otolaryngol. Head Neck Surg. 124 (3): 281–7. March 1998. doi:10.1001/archotol.124.3.281. PMID 9525512. 
  16. ↑ "Late complications of tracheotomy". Clin. Chest Med. 12 (3): 597–609. September 1991. doi:10.1016/S0272-5231(21)00806-6. PMID 1934960. 
  17. ↑ Lorenz RR (December 2003). "Adult laryngotracheal stenosis: etiology and surgical management". Curr Opin Otolaryngol Head Neck Surg 11 (6): 467–72. doi:10.1097/00020840-200312000-00011. PMID 14631181. 
  18. ↑ Filocamo, G; Torreggiani, S; Agostoni, C; Esposito, S (April 2017). "Lung involvement in childhood onset granulomatosis with polyangiitis.". Pediatric Rheumatology Online Journal 15 (1): 28. doi:10.1186/s12969-017-0150-8. PMID 28410589. 
  19. ↑ "Laryngotracheal involvement as the initial manifestation of relapsing polychondritis". J Chin Med Assoc 68 (6): 279–82. June 2005. doi:10.1016/S1726-4901(09)70151-0. PMID 15984823. 
  20. ↑ "Laryngotracheal involvement of relapsing polychondritis in a Korean girl". Pediatr. Pulmonol. 35 (4): 314–7. April 2003. doi:10.1002/ppul.10247. PMID 12629631. 
  21. ↑ 21.0 21.1 "Non-intubation traumatic laryngotracheal stenosis: management policies and results". Eur Arch Otorhinolaryngol 263 (7): 632–6. July 2006. doi:10.1007/s00405-006-0036-8. PMID 16633824. 
  22. ↑ "Malignant laryngotracheal obstruction: a way to treat serial stenoses of the upper airways". Ann. Thorac. Surg. 70 (4): 1197–201. October 2000. doi:10.1016/s0003-4975(00)01614-3. PMID 11081870. 
  23. ↑ Rosow, David E.; Barbarite, Eric (December 2016). "Review of Adult Laryngotracheal Stenosis: Pathogenesis, Management, and Outcomes". Current Opinion in Otolaryngology & Head and Neck Surgery (Current Opinion in Otolaryngology & Head and Neck Surgery) 24 (6): 489–493. doi:10.1097/MOO.0000000000000305. PMID 27585080. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovftr&NEWS=N&AN=00020840-201612000-00007. Retrieved 2020-12-05. 
  24. ↑ 24.0 24.1 "Multidisciplinary approach to management of postintubation tracheal stenoses". Eur. Respir. J. 13 (4): 888–93. April 1999. doi:10.1034/j.1399-3003.1999.13d32.x. PMID 10362058. 
  25. ↑ "Operative and non-operative treatment of benign subglottic laryngotracheal stenosis". Eur J Cardiothorac Surg 26 (4): 818–22. October 2004. doi:10.1016/j.ejcts.2004.06.020. PMID 15450579. 
  26. ↑ "Open surgical techniques for laryngotracheal stenosis". Otolaryngol. Clin. North Am. 28 (4): 785–95. August 1995. doi:10.1016/S0030-6665(20)30495-3. PMID 7478638. 
  27. ↑ "Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation". Ann. Otol. Rhinol. Laryngol. 96 (6): 661–4. 1987. doi:10.1177/000348948709600609. PMID 3688753. 
  28. ↑ "Total cervical tracheal stenosis: treatment by laser, dilation, and stenting". Ann. Otol. Rhinol. Laryngol. 98 (11): 890–5. November 1989. doi:10.1177/000348948909801110. PMID 2817681. 
  29. ↑ "Concentric tracheal and subglottic stenosis. Management using the Nd-YAG laser for mucosal sparing followed by gentle dilatation". Chest 104 (3): 673–7. September 1993. doi:10.1378/chest.104.3.673. PMID 8365273. http://journal.publications.chestnet.org/article.aspx?volume=104&page=673. 
  30. ↑ "Surgical management of benign tracheal stenosis". Multimedia Manual of Cardio-Thoracic Surgery 2011 (1111): mmcts.2010.004945. January 2011. doi:10.1510/mmcts.2010.004945. PMID 24413853. 
  31. ↑ "New throat surgery 'a success'". BBC News. 2010-08-06. https://www.bbc.co.uk/news/uk-northern-ireland-10882931. 
Bibliography

External links

Classification



Retrieved from "https://handwiki.org/wiki/index.php?title=Medicine:Laryngotracheal_stenosis&oldid=3273097"