tracheal stenosis Dr.muthukumar dr.semmanaselvan

A CASE SERIES STUDY OF TRACHEAL STENOSIS

1. “ A LIFELINE TO THE LIFE’S CONDUIT ” -A CASE SERIES ANALYSIS ON TRACHEAL STENOSIS & ITS MANAGEMENT AUTHORS : PROF. DR .R.MUTHUKUMAR,MS,DLO,DNB PROF.DR.K.SEMMANASELVAN,MS,DLO

2. INTRODUCTION Management of tracheal stenosis is an enigma for the ENT surgeons U ntil recently s urgery for tracheal stenosis was under the realm of the cardiothoracic surgeon. Presently, cervical tracheal stenosis is increasingly managed by ENT surgeons, avoiding unnecessary midline sternotomy. MAIN GOAL – To reduce the morbidity of the patient and to provide a Normal Functioning Airway

3. STUDY METHODOLOGY: STUDY DESIGN: - A Case Series analysis from 2011-2021 ,10 year study period STUDY SUBJECTS: - 25 patients AGE GROUP NUMBER PERCENTAGE % <25 Years 18 72 26 – 45 Years 7 28 >45 Years - - TOTAL 25 RANGE 19- 36 YEARS AGE DISTRIBUTION: GENDER DISTRIBUTION:

4. 25 Cases done in a period of 10 years - 3 cases done along with CTS - 22 cases done independently In 4 cases cricotracheal anastamosis , rest were tracheotracheal anastomosis Suprahyoid Laryngeal drop was done in 21 cases In 23 of our cases the cause was a postintubation stenosis and 2 cases - post traumatic In 20 cases prior tracheostomy done- hence anaesthetized via the tracheostomy site In 2 cases – no tracheostomy –ET tube kept proximal to the stenotic site In 3 cases – Intra Operative tracheostomy done & proceeded

5. MATERIALS & METHODS STENOTIC SEGMENT NUMBER OF PATIENTS 1-2 tracheal rings 3 3-4 tracheal rings 8 4-5 tracheal rings 13 6-7 tracheal rings 1 1.Flexible bronchoscopy - Flexible fibreoptic bronchoscopy is the best investigation for exact site & size . 2. CT scan with reconstruction Helical CT with high resolution and 3 dimensional reconstruction - Site,length,surrounding anatomy 3.VLS & Direct laryngoscopy 4.Lung function tests

6. RADIOLOGICAL FINDINGS :

7. PRE OPERATIVE VIDEO LARYNGOSCOPY COMPLETE OBSTRUCTION PARTIAL OBSTRUCTION

8. FLEXO – METALLIC TUBE INSERTION & FIXATION SURGICAL STEPS INCISION MADE & SUBPLATYSMAL PLANE FLAP ELEVATED

9. STRAP MUSCLES SEPARATED ON EITHER SIDE ,THYROID ISTHMUS DIVIDED ,TRACHEA SEPARATED POST FROM ESOPHAGUS, taking care not to injure RLN

10. LOWER SEGMENT ANCHORING & STENOTIC SEGMENT DELINEATED,TRACHEAL ENTRY BELOW THE STENOTIC SEGMENT

11. SUPRAHYOID LARYNGEAL DROP 3mm CIRCUMFERENTIAL INTERMITTENT SUTURING OF POSTERIOR ,LATERAL WALL –OROTRACHEAL INTUBATION MADE , ANTERIOR WALL ANASTOMOSIS

12. COMPLETE ANASTOMOSIS DONE,ANASTOMATIC LEAKAGE TESTED ,II TIER THYROTRACHEAL SUTURING DONE

13. WOUND CLOSURE IN LAYERS THIRD TIER TENSION RELIEVING SUTURE-CHIN TO CHEST MADE

14. POST OP CARE 1 . Patient is maintained in chin flexed position with adequate back support for 7 days. 2. Patient allowed to converse but with minimal necktwisting movements . 3. Sympathetic counselling to the patients. 4 . Steam nebulisation 5 . Adequate hydration 6 . Antibiotics, Mucolytics 7 . Supplementation steroids 8 . RT feeding for 3 days, followed by straw feeding 9.Physiotherapy-not possible GRILLO’S STITCHES /GUARDIAN SUTURE

15. POST OPERATIVE POSITION

16. PRE OP-POST OP VDL

17. PATHOPHYSIOLOGY OF LTS : LTS is the end result of inflammation/trauma to larynx - This is further compounded by hypoxia which coexists with the condition DISCUSSION

18. FACTORS FAVOURING DEVELOPMENT OF LARYNGOTRACHEAL STENOSIS IN POST INTUBATION PATIENTS Pressure necrosis Tracheal mucosal blood flow Pressure and volume of cuff Duration of intubation Head and neck position Systemic hypotension Local infection

19. MEYER – COTTON STAGING SYSTEMS UPPER AIRWAY STENOSIS ( GRILLO TYPES) TYPE A – High tracheal stenosis (easily treated by segmental resection and tracheotracheal anastomosis .) TYPE B – Stenosis reaching lower border of cricoid - Cricotracheal anastomosis TYPE C – Stenosis of lower subglottic larynx and upper trachea -involves anterior portion of cricoid cartilage(LTR/PCTR) TYPE D – Stenosis that reaches to glottis No subglottic space for an effective anastomosis . - LTR/PCTR/ Glottic reconstruction All types require Cervical approach without sternotomy CLINICAL FEATURES : Ineffective cough Stridor ( Insp / Exp ) Dyspnoea - Clinical signs of stenosis appear when lumen obliterated >50%

20. PEARLS & PITFALLS To use LOW PRESSURE HIGH VOLUME Endo tracheal & Tracheostomy tubes When a stenotic patient presents with stridor –Tracheostomy should be done at or just below the stenotic site, So that cartilage is not wasted and trachea can be saved for future anastomosis Laryngeal drop-aids in additional 2-3cm tracheal mobilisation MONTGOMERY DROP /SUPRAHYOID RELEASE

21. POST OP COMPLICATIONS Granulation Separation – excessive anastamotic tension Air leakage Cord dysfunction Aspiration Hypoxemia Quadriplegia

22. RESULTS In 1 case – revision surgery done and patient is doing well. In another case – post traumatic stenosis with long stenotic segment. Hence Shian -Lee procedure done, resulted in failure . Patient underwent revision anastomosis successfully .

23. CONCLUSION Tracheal resection and reconstruction can be challenging and should be undertaken by centres with experience. St a ndard treatment consists of resection of pathologic segment of trachea with end to end anastomosis ( > 95% success rate ). Careful attention to matching the geometry of the ends to be anastomosed is important to avoid gaps or weak points and for air tight seal anastomosis. ( However some amount telescoping of the anastomosis ends is permitted ) Adequate planning of ENT surgeon & anaesthesia support is essential for ventilation, haemostasis and better visualisation. Second and third tier reinforcement suturing is essential to relieve the tension at the anastomotic site for successful wound healing .

24. REFERENCES Surgery of the trachea and bronchi,Hermes c.Grillo,MD,2004 Laryngeal and tracheobronchial stenosis,Guri s.sandhu MD,FRCS,2016 D'Andrilli , Antonio et al. “Subglottic tracheal stenosis.”  Journal of thoracic disease  vol. 8,Suppl 2 (2016): S140-7. Melkane AE, Matar NE, Haddad AC, Nassar MN, Almoutran HG, Management of postintubation tracheal stenosis: appropriate indications make outcome differences. Respiration. 2010;79(5):395-401. doi : 10.1159/000279225. Epub 2010 Jan 26. PMID: 20110646.