Caring for the patients with cervical spine injuries: what have we learned?

PURPOSE

Anesthesiologists are often involved in the early management and resuscitation of patients who have sustained cervical spine injuries (CSIs). The most crucial step in managing a patient with suspected CSI is the prevention of further insult to the cervical spine (C-spine). In this review, important factors related to initial management, diagnosis, airway and anesthetic management of patients with CSI are presented.

SOURCE

Medline search was performed to seek out the English-language literature using the following phrases and keywords: spine trauma; cervical spine; airway management after CSI.

PRINCIPAL FINDINGS

Cervical spine injury occurs in up to 3% to 6% of all patients with trauma. The initial management of a patient with potential spine injury requires a high degree of suspicion for CSI so that early stabilization of the spine can be used to prevent further neurological damage. Diagnostic radiology has a critical role to play; however, clinical evaluation is equally important in excluding CSI in a conscious and cooperative patient. Although in-line stabilization reduces the movement at C-spine, traction causes clinically significant distraction and should be avoided.

CONCLUSION

A high level of suspicion and anticipation are the major components of decision making and management in a patient with CSI. Endotracheal intubation using the Bullard laryngoscope may have some advantages over other techniques as it causes less head and C-spine extension than the conventional laryngoscope, and this results in a better view. However, the current opinion is that oral intubation using a Macintosh blade after intravenous induction of anesthesia and muscle relaxation along with inline stabilization is the safest and quickest way to achieve intubation in a patient with suspected CSI. In summation caution, close care and maintenance of spinal immobilization are more important factors in limiting the risk of secondary neurological injury than any particular technique.

Management of airway in patients with laryngeal tumors

STUDY OBJECTIVE

To describe our systematic approach to securing the airway in patients with laryngeal tumors, developed over a 10-year period.

DESIGN

Retrospective analysis.

SETTING

University-affiliated veterans administration medical center.

PATIENTS

Eight hundred one patients presenting for laryngeal tumor surgery in a 10-year period, 285 of whom underwent tracheostomy (25 with local anesthesia and 260 with general anesthesia).

INTERVENTIONS

Preoperative examination, including history, physical examination, computed axial tomography and/or magnetic resonance imaging, and ear, nose, and throat surgeons' evaluation via indirect laryngoscopy or fiberoptic bronchoscopy were performed before the anesthesiologist's interventions. Local (topical) anesthesia and mild sedation were used for laryngeal evaluation with fiberoptic bronchoscopy. Tumor grade was then established, which determined how the airway would be secured: general anesthesia induction, receive topical anesthesia for awake, direct laryngoscopy, and tracheal intubation, or undergo tracheostomy with local anesthesia.

MEASUREMENTS AND MAIN RESULTS

When the airway was secured, surgeons performed the biopsy, (any) tumor debulking, laser excision, or tracheostomy to establish both the airway and the diagnosis. Pulmonary function, including flow-volume loops and blood gas analysis were also useful in evaluating the degree of obstruction and gas exchange. In the event of respiratory distress, tracheostomy was performed after tracheal intubation or with local anesthesia, followed by direct laryngoscopy and biopsy. Depending on the diagnosis, further surgery and radiation treatment were planned next.

CONCLUSIONS

With these guidelines, we have reduced the frequency of emergencies because of a lost airway, bleeding, or dislodging of tumor.

Laryngoscopic detection of pharyngeal carcinoma in situ with narrowband imaging

OBJECTIVES

Narrowband imaging (NBI) is a novel optical technique that enhances the diagnostic capability of endoscopes in characterizing tissues by using narrow-bandwidth filters in a video endoscope system. The purposes of this study were to verify the effectiveness of the NBI system in conducting endoscopic screening at the oropharynx and the hypopharynx.

METHODS

This study was conducted between July 2005 and August 2005. During this period, 217 consecutive patients with esophageal cancer underwent endoscopic screening of the oropharynx and the hypopharynx with the NBI system at the Department of Otolaryngology, Keiyukai Sapporo Hospital.

RESULTS

Among 217 patients, 6 superficial lesions, at the oropharynx (n = 1) and at the hypopharynx (n = 5), were discovered with the NBI system. On conventional electroendoscopic view, four of six lesions could be hardly recognized because of its small diameter measuring 5 mm or less. The NBI view was more beneficial in recognizing the superficial lesions than conventional electroendoscopic view. Endoscopic mucosal resection was performed for all six patients under general anesthesia in the operation room. The histologic examination exhibited a histologically proven squamous cell carcinoma (SCC) in situ. In our series, the NBI system might improve the sensitivity by about twofold over the conventional method.

CONCLUSION

NBI may play an important role in the diagnosis of SCCs of the oropharynx and hypopharynx.

Virtual versus conventional laryngeal endoscopy

We have evaluated the capacity of virtual laryngoscopy and conventional laryngoscopy conducted with a rigid or flexible instrument to visualize laryngeal structures in 64 patients with normal endoluminal anatomy. Virtual laryngoscopy allowed total visualization of laryngeal structures, including those that could not be reached by a flexible instrument. There was good correlation between virtual laryngoscopy and "real" images, indicating satisfactory diagnostic accuracy (p < .05). Although virtual laryngoscopy does not provide histologic data, it is a fast and noninvasive technique that can be added to and integrated with conventional laryngoscopy, and it can be an alternative in cases in which conventional laryngoscopy is difficult, contraindicated, or impossible. It is particularly useful for the study of laryngeal narrow spaces and in the visualization of subglottic regions and of other more restricted areas (inferior tonsil region, posterior surface of the epiglottis, glossoepiglottic vallecula, Morgagni's ventricle, anterior commissure).

Subglottic Stenosis in Erdheim-Chester Disease: A Previously Unrecognized Site of Involvement

We describe a case of laryngeal stenosis secondary to an etiology not previously described. A patient with Erdheim-Chester disease presented with airway obstruction and was found to have subglottic stenosis. Biopsy results confirmed Erdheim-Chester nodules as the cause of the obstruction. This case illustrates the need for biopsy to rule out malignancy and less common etiologies of subglottic stenosis.

Endoscopic resection of laryngeal and tracheal lesions using the microdebrider

CONCLUSION

Endoscopic resection of laryngeal and tracheal lesions using the microdebrider is a safe, accurate and reliable method.

OBJECTIVE

The microdebrider is an important tool for endoscopic nasal and sinus surgery and over the last few years a powered blade with a long shaft has been developed for endoscopic laryngeal and tracheal surgery. The aim of this non-randomized prospective study was to determine the advantages and disadvantages of the microdebrider for treating patients with different laryngeal and tracheal pathologies.

MATERIAL AND METHODS

The laryngeal microdebrider was used under endoscopic control in 37 patients. In 29 cases a benign laryngeal lesion was removed endoscopically. In four patients debulking of a malignant obstructive endolaryngeal tumor was performed in order to avoid a tracheotomy. In four cases a bulky obstructing endotracheal lesion was removed.

RESULTS

All laryngotracheal lesions could be removed, and this was facilitated by the use of angled rigid telescopes and the laryngeal blade. No traumatic lesions to normal laryngeal tissue occurred as a result of use of the microdebrider and no postoperative endolaryngeal bleeding was observed. The histological diagnosis of the biopsies taken with the microdebrider was accurate in every case. In three of the four cases with obstructive laryngeal malignancies, a tracheotomy was avoided until definitive therapy was undertaken. Normal breathing was restored in all patients with endotracheal lesions.

Effects of Prolonged Loud Reading on Normal Adolescent Male Voices

Purpose

The purpose of this article was to test the effects of vocal loading in healthy, peripubescent teenage boys. It was hypothesized that select acoustic measures, ratings of physical appearance of the larynx, and self-ratings of physical effort and vocal quality in the experimental group would significantly change in response to 2 hr of prolonged loud reading.

Method

In this prospective, repeated measures study, 25 boys aged 13–16 years were randomly assigned to either an experimental group (2 hr of continuous loud reading) or a control group (silent reading with brief periods of conversation). Pre–post acoustic, videoendoscopic, and perceptual data including self-ratings were collected. Postreading recovery changes were tracked by monitoring average reading fundamental frequency (F0) and intensity for 20 min following cessation of the reading task.

Results

The experimental group demonstrated statistically significant differences before and after prolonged loud reading for three variables: F0 ( p < .01), self-ratings of vocal quality ( p < .01), and physical effort ( p < .01). No pre–post changes were evident in the control group. In the experimental group, posttest return of F0 to pretest levels occurred within 20 min. Self-ratings revealed that the boys felt that their voice quality worsened and physical effort increased during the experimental task. Expert ratings did not detect any significant differences in either the perceptual quality of the experimental group’s voices or their videoendoscopic images.

Implications

These findings demonstrate that prolonged loud reading can induce temporary but measurable changes in F0 and in self-perception of vocal function in adolescent males who are experiencing a period of rapid laryngeal growth. The underlying mechanism for these changes remains unclear and warrants continued investigation. Furthermore, the results suggest that in the pubescent male population, comparable vocal loading tasks encountered in daily use should not result in long-term negative effects.

Videolaryngoskopie zur modifizierten „Rapid-sequence-Narkoseeinleitung“

BACKGROUND

There is evidence that cricoid pressure, one of the key elements of rapid sequence induction (RSI) in patients at risk of aspiration, can distort the glottic view obtained by direct laryngoscopy (DL) and consequently impair or delay endotracheal intubation (ETI). The fact that cricoid pressure is applied by an assistant "blindly", i.e. without any visual feedback, is believed to be a contributing factor. Video laryngoscopy (VIL) offers the advantage that both the anaesthetist and the assistant can follow laryngoscopy. This could be useful for ETI during RSI.

METHODS

We used VIL for a simulated RSI in 170 adult patients randomised to either video laryngoscopy-guided application of cricoid pressure (group I) or conventional, i.e. "blind", application of cricoid pressure (group II). Time to ETI was compared between groups. The laryngoscopy view obtained by VIL was compared with the view of conventional DL obtained before, in all patients.

RESULTS

Time to ETI did not differ between groups (p=0.2): 25.1+/-14.2 s (group I) vs. 23.7+/-12.1 s (group II). Laryngoscopy scores were significantly better for VIL than conventional DL (p<0.001).

CONCLUSIONS

Visualisation of the larynx during RSI can be improved using VIL. Time to ETI is not decreased by use of video laryngoscopy-guided application of cricoid pressure.

Application of mitomycin C after endoscopic lysis of congenital laryngeal web combined with epiglottic hypoplasia in a middle-aged man

Laryngeal webs and epiglottic hypoplasias are uncommon congenital anomalies. Anterior glottic web combined with epiglottic hypoplasia was found in a middle-aged man presenting with hoarseness and dyspnea on exertion. This can be considered as a unique isolated defect of the larynx during early fetal development. The laryngeal web can be successfully treated in a single stage with endoscopic lysis and topical application of mitomycin C for prevention of anterior glottic restenosis. This case and prior reports suggest that the novel approach may be effective in the treatment of laryngeal webs.

Contact telescopy reveals blood vessel alterations of vocal fold mucosa in Reinke's edema

AIM

To evaluate contact telescopy findings for estimation of blood vessel changes in vocal fold mucosa in patients with Reinke's edema. Histological features significant for diagnosis of microvascular vocal fold alteration were correlated with clinical findings.

METHODS

In 80 patients with Reinke's edema, laryngoscopy and video-telescopy image analysis of vocal folds were performed. Vocal fold mucosa biopsies were histologically analyzed and compared with contact telescopy findings. An interesting aspect of vocal fold microcirculation found both by contact telescopy imiging and by histological specimens was described.

RESULTS

Contact telescopy in vivo revealed different forms of pathological blood vessel networks with unusual appearance of loops or branching. Some dilated varicose vascular channels had very thin walls, and within atypical capillaries, partial erythrocyte accumulation was found. Details of blood flow are also visible, showing multidirectional and discontinuous blood flow in neighboring vessels.

CONCLUSION

The noninvasive contact telescope technique is very useful as an additional diagnostic tool for defining a condition of a subepithelial Reinke's space in a very short period of time. The great advantage of contact telescopy is systematic in vivo and in situ observation of microvascular details in the vocal folds. The contact technique allows dynamic follow-up of the microcirculation in Reinke's edema as well as simultaneous consultation of a pathologist in the operating theater.

Continuous laryngoscopy exercise test: a method for visualizing laryngeal dysfunction during exercise

OBJECTIVES/HYPOTHESIS

To assess the diagnostic feasibility and patient acceptance of a new developed diagnostic test for exercise induced upper airway flow limitation.

STUDY DESIGN

Clinical case control study including evaluation of contemporary ergo-spirometry and laryngoscopy continuously performed during exercise.

METHODS

Twelve nonsymptomatic controls and four young females with documented dyspnea and noisy breathing during exercise were studied. All subjects exercised to exhaustion on a treadmill while attached to a fully equipped ergo-spirometry unit and a fiberoptic laryngoscope linked to a video camera and a sound recorder.

RESULTS

The test situation was well tolerated. Two control subjects had a minor inspiratory synchronous medial motion of the aryepiglottic folds without limitation of laryngeal airflow. In the four symptomatic subjects, exercise induced inspiratory synchronous medial motion of the dorsal part of the aryepiglottic folds as well as vocal cord adduction and inspiratory stridor was demonstrated.

CONCLUSION

The continuous laryngoscopy exercise test was easy to perform, well tolerated, and can be implemented in future diagnostic work-up programs of laryngeal dysfunction.

Objective sizing of upper airway stenosis: a quantitative endoscopic approach

OBJECTIVE

In patients with airway stenosis, anatomy of the lesion determines the magnitude of the biomechanical ventilatory disturbance and thus the nature and severity of symptoms. It also gives information about biology, likelihood of response to treatment, and prognosis of laryngotracheal lesions. Accurate airway sizing throughout treatment is therefore central to managing this condition. We developed a method for objective assessment of airway lesions during endoscopy.

METHODS

We used airway simulations to investigate the effects of endoscope tilt and lens distortions on measurement accuracy, devising and validating clinical rules for quantitative airway endoscopy. A calibrator was designed to assess lesion length, location, and cross-section during tracheoscopy.

RESULTS

It proved possible to calculate the length and location of the stenosis using simple mathematics. Cross-section measurements were more than 95% accurate, independent of endoscope tilt and without making assumptions about endoscope optics and visuospatial distortion, for both pediatric and adult airway dimensions. The technique was used to characterize airway lesions in 10 adult patients with an average age of 48 years undergoing therapeutic laryngotracheoscopy. Lesions occurred on average 36 mm below the glottis (range, 21-54 mm) and were 9.3 mm long (5-17 mm). The average pretreatment airway cross-section was 48.3 mm, increasing to 141.1 mm after laser therapy. Two independent observers calculated airway cross-sections, achieving an interobserver concordance of 0.98.

CONCLUSIONS

This method can be used to objectively and precisely determine the anatomy of airway lesions, allowing accurate documentation of lesion characteristics and surgical results, serial monitoring throughout treatment, and comparison of outcomes between different centers.

Thyroid surgery and recurrent laryngeal nerve monitoring

Recurrent laryngeal nerve paralysis is a much-dreaded complication of thyroid surgery.

Objective: To study the feasibility and the reliability of a recurrent laryngeal nerve monitoring technique.

Materials and methods: This was a prospective study including 36 patients proposed for thyroid surgery with recurrent laryngeal nerve monitoring. They underwent post-operative fibre-optic laryngeal examination and speech therapist consultation.

Results: Our technique of nerve monitoring showed a 98 per cent sensitivity and 86 per cent specificity.

Conclusions: Recurrent laryngeal nerve monitoring is a feasible and reliable technique. It can be used to avoid bilateral nerve injury and to increase the surgeon's confidence but not to replace a systematic nerve identification and a careful dissection.

Seeing is believing: the importance of video laryngoscopy in teaching and in managing the difficult airway

Of the several million patients who undergo surgery in North America annually, a large proportion undergo intubation of the trachea. In approximately 90% of these patients, the endotracheal tube is introduced using a traditional laryngoscope with a battery in the handle and a small bulb near the tip of the blade. This bulb provides a limited and often dim view of the glottic structures. In about 10% of cases, the patient is intubated using a flexible fiberoptic intubating scope. The authors have developed a video laryngoscope that preserves the standard blade configuration with a modified handle. A 3-mm image light guide is built into the blade, replacing the bulb. A small TV camera with an incorporated light bundle is inserted into the handle. A wide-angle panoramic view of the upper airway anatomy is displayed on a TV screen, which can be positioned at a convenient working distance. The use of a TV monitor is a well-accepted standard during minimally invasive surgical procedures.

Operating videoscope for microlaryngeal surgery

For operative laryngoscopy, a laryngoscope is introduced into the anesthetized patient's mouth for exploration of the larynx and vocal cords. To improve the vision, a binocular microscope is positioned between the operator and the laryngoscope. This interferes, to some degree, with the introduction of instruments, particularly if the surgeon is using bimanual manipulation. In the case of lengthy operations, a fatigue or stress factor can be troublesome to the operator. The authors developed a video laryngoscope using standard blades. An angulated telescope attached to a TV camera was introduced in the top portion of the blade. An enlarged image from the anatomy was produced and viewed from a convenient distance. The manipulations are unobstructed, and simultaneous records can be obtained. It is the method of choice for teaching. The operative laryngoscope is less cumbersome and supersedes the microscope for viewing the endolarynx. This new technique was used successfully in 532 cases.

Modified endoscopic swallowing test for improved diagnosis and prevention of aspiration

Laryngopharyngeal sensation is important in the normal process of swallowing, it is often impaired after neurological events and it has been common practice in such an occurrence to order non-oral tube feeding to prevent aspiration. This study assesses a novel approach to the evaluation of the laryngopharyngeal sensation that allows for improved triage of aspiration risk and more lenience towards oral feeding. This is a case series with follow-up period ranging from 6 to 24 months. Forty patients with neurological deficiencies were tested by a modified laryngopharyngeal sensation study that included evaluation of both supra and infra-glottis. All patients had impaired supra glottic sensation but had good infra glottic sensation that enabled cough protection. All had received oral feeding. Main outcome measure is incident aspiration pneumonia. Twenty-two patients maintained oral feeding without any evidence of aspiration. Eighteen patients had some aspirations associated with cough, and were maintained on modified oral feeding. Out of these 18 patients, four patients (10% of the entire group) developed aspiration pneumonia. The presented procedure identified patients with impaired supraglottic sensation but preserved good infra glottic sensation. This observation enables safe oral feeding in most patients and therefore offers a better quality of life for these individuals.

Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy

STUDY OBJECTIVE

External cricoid and thyroid cartilage manipulations are commonly taught to facilitate laryngeal view during intubation. We compare the laryngeal views during laryngoscopy with 4 manipulations (no manipulation, cricoid pressure, backward-upward-rightward pressure [BURP], and bimanual laryngoscopy) to determine the method that optimizes laryngeal view.

METHODS

This was a randomized intervention study involving emergency physicians participating in airway training courses from December 2003 to November 2004. Direct laryngoscopies were performed with curved blades on fresh, non-fixed cadavers by using each of the 4 methods. The percentage of glottic opening (POGO), a validated scoring scale, was recorded for each laryngoscopy. Scores for bimanual laryngoscopy were recorded before the assistant applied external pressure.

RESULTS

A total of 1,530 sets of comparative laryngoscopies were performed by 104 participants. One thousand one hundred eighteen of 1,530 sets (73%) had POGO scores less than 100 with no manipulation. Compared to no manipulation, mean POGO scores with bimanual laryngoscopy improved by 25 (95% confidence interval [CI] 23 to 27); mean POGO score improvement with cricoid pressure and BURP were 5 (95% CI 3 to 8) and 4 (95% CI 1 to 7), respectively. POGO scores with bimanual laryngoscopy were higher compared to cricoid pressure (mean difference 20, 95% CI 17 to 22) and BURP (mean difference 21, 95% CI 19 to 24). Among laryngoscopies with no manipulation in which the POGO score greater than 0 (n=1,434), laryngeal view worsened in 60 cases (4%, 95% CI 3% to 5%) with bimanual laryngoscopy, in 409 cases (29%, 95% CI 26% to 31%) with cricoid pressure, and in 504 cases (35%, 95% CI 33% to 38%) with BURP.

CONCLUSION

Using a cadaver model, we found pressing on the neck during curved blade laryngoscopy greatly affects laryngeal view. Overall, bimanual laryngoscopy improved the view compared to cricoid pressure, BURP, and no manipulation. Cricoid pressure and BURP frequently worsen laryngoscopy. These data suggest bimanual laryngoscopy should be considered when teaching emergency airway management.

Endoscopic radiosurgical posterior transverse cordotomy for bilateral median vocal fold immobility

The objectives in treatment of bilateral vocal fold immobility (BVFI) are to achieve adequate airway, preservation of voice quality and laryngeal competence. The present prospective study was designed to evaluate precisely the efficiency and long-term clinical outcome in a series of 13 patients with irreversible BVFI, consecutively managed with endoscopic radiosurgical posterior transverse cordotomy (ERPTC). The operation was performed endoscopically using an Ellman Radiosurgical Instrument and a specially designed electrode. Pre- and post-operative inspiratory function measurements and acoustical vocal analysis were conducted on the patients and were tested for potential statistical relation to successful rehabilitation of the airway. One-step, successful restoration of the airway was achieved in all patients. The post-operative improvement of spirometric values was statistically significant (p < 0.0001), and during the follow-up period of (six to 30) months, airway stability was demonstrated in all patients. In terms of acoustic analysis a non-significant difference was found between pre- and post-operative vocal functions (p > 0.05). This management approach offers an alternative to laser procedures, it provides a ’one-stage’ solution for permanent bilateral vocal fold immobility, and avoids terminal loss of voice quality. The authors’ data confirm the safety, ease of performance, and efficiency of ERPTC in patients with bilateral immobile vocal folds.

Role of margin status in recurrence after CO2 laser endoscopic resection of early glottic cancer

CONCLUSION

In patients with early glottic squamous cell carcinoma (SCC) submitted to CO2 laser endoscopic resection, local disease recurrence was significantly correlated with the presence of positive additional surgical margins on permanent sections.

OBJECTIVES

To evaluate the rate of cancer recurrence in patients with early glottic SCC submitted to CO2 laser endoscopic resection according to margin status after resection, stage of disease and postoperative radiotherapy. The rate of larynx preservation and the length of hospital stay were also evaluated.

MATERIAL AND METHODS

Forty consecutive patients with early glottic cancer were subjected to laser endoscopic resection surgery of glottic cancer followed by frozen-section control of margins, with intraoperative enlargement of margins when positive. Adjuvant radiation therapy or enlargement of previous margins was indicated in the case of positive additional surgical margins on permanent section.

RESULTS

Local recurrence occurred in three patients (7.5%), all with positive additional surgical margins on permanent section. Positive additional surgical margins on permanent section were related to 37.5% of recurrences and negative additional surgical margins with 0% of recurrences (p=0.006). All patients spent at most 1 day at the hospital.

The clinical observation of difficult laryngoscopy and difficult intubation in infants with cleft lip and palate

BACKGROUND

The aims of this study were to evaluate the incidence of difficult laryngoscopy in infants with cleft lip and palate and to observe its relationships with age, sites, and degrees of deformities.

METHODS

A total of 985 infants aged 1 month to 3 years, undergoing repair of cleft lip and palate were included in this study. The infants suffering from unilateral cleft lip, simple cleft palate, and combined bilateral cleft lip and palate were 465, 421, and 79 respectively. They were divided into three groups according to age; 1-6 months group, 6-12 months group and 1-3 years group.

RESULTS

The total incidence of difficult laryngoscopy was 4.77%. The incidence of difficult laryngoscopy was closely related to age, sites and degrees of deformities, and micrognathia. The incidence of difficult laryngoscopy was 7.06% in 1-6 months group, 2.90% in 6-12 months group, and 3.13% in 1-3 years group, and was greatest for infants with combined bilateral cleft lip and palate, less for those with left cleft lip and least for those with right cleft lip and simple cleft palate. The incidences of difficult laryngoscopy in infants with and without micrognathia were 50% and 3.83% respectively. The incidences of moderately difficult, difficult, and failed intubations were 1.02%, 0.91%, and 0.102% respectively.

CONCLUSIONS

Infants with cleft lip and palate, left cleft lip and alveolus, combined bilateral cleft lip and palate, micrognathia, and age <6 months were the important risk factors for difficult laryngoscopy. Difficult intubation occurred mainly in infants with laryngoscopic views of grade III and IV.

Endoscopic treatment of severe tracheal stenosis

OBJECTIVES

Endoscopic treatment of subglottic and tracheal stenosis has traditionally been reserved for short-segment and web-like stenoses with normal cartilage. This retrospective case series review was undertaken to examine my experience with definitive endoscopic treatment for circumferential and complete tracheal stenosis with loss of cartilaginous support.

METHODS

Patients who presented with tracheostomy dependence or dyspnea as a result of clinically significant tracheal stenosis over a 2-year period were treated endoscopically. Mitomycin C was applied after dilation in 19 patients. Three patients with complete stenosis and cartilage collapse underwent endoscopic placement of a silicone elastic stent, which was in place for less than 23 days.

RESULTS

Twenty patients were treated for tracheal stenosis over a 2-year period. No surgical complications were observed after operation in the endoscopic treatment group. Three of 6 patients with complete stenoses and 8 of 10 patients with circumferential stenoses with cartilage involvement gained airways that remained patent. Nine patients' stenoses resolved after the initial treatment. Three patients (15%) eventually required tracheal resection. The follow-up periods ranged from 5 to 25 months.

CONCLUSIONS

Although some limitations apply, severe and complete tracheal stenoses may be successfully treated endoscopically with the techniques described. Definitive endoscopic treatment may be considered before tracheal resection in select cases. Endoscopic treatment is associated with few complications, low morbidity, a short operative time, and a short length of hospitalization.