The "Hitch-Stitch" for Preventing High Tracheal Stent Migration: Expanding Indications and Extended Experience

BACKGROUND

Airway stenting is a standard treatment option for tracheo-bronchial obstruction and other conditions like tracheo-esophageal fistula (TEF).

METHODS

To prevent stent migration, a percutaneous fixation strategy called the "hitch-stitch" was described in 2016 as an efficient technique. We describe an extended experience of the "hitch-stitch" for silicone stents in high tracheal stenting situations and expanding indications to metal stents.

RESULTS

Seventy-four percutaneous stitches were placed in 54 patients (36 males and 18 females). The mean age of the patients was 42 (±19) years. The indication for stenting was tracheal stenosis in 63/74 (85%) cases and TEF in 11/74 (15%) cases. Silicone stents were used in 56/74 (75.5%) cases while self-expanding metal stents (SEMS) were used in 18/74 (24.5%) cases. The majority of the stents (62/74, 85%) were high tracheal stents. The "hitch-stitch" as an anti-migration strategy had a high success rate, with distal stent migration in only 2 cases (2.7%) as the stitch had given way-these were repositioned and hitched with double stitches. Minor complications included delayed skin healing (2.8%) and suture site infection (1.4%), which was successfully managed with oral antibiotics. Stitch removal was easy with no complications.

CONCLUSION

In this large series of percutaneous "hitch-stitch" as a stent migration prevention strategy, long-term data shows it is safe and effective in an expanded cohort of silicone stents. Its extended utility is the successful application to metal stents, especially in TEF, where the consequences can be deleterious. It is simple to do, with minimal extra requirements and not associated with any significant complications.

[The methods for the treatment and prevention of cicatrix stenoses of trachea]

The objective of the present study was to analyze the current literature concerning mechanisms underlying the development of tracheal stenosis, new methods for the treatment and prevention of this condition. The main cause behind the formation of cicatrical stenosis of trachea is believed to be long-term artificial lung ventilation whereas the principal factors responsible for the injury to the tracheal wall include the impact of the cuff and the free end of the endotracheal tube, reflux of duodenal and gastric contents, concomitant infection, and the involvement of the autoimmune component. These pathogenic factors produce morphological changes in all layers of the tracheal wall with the formation of the granulation tissue the appearance of which serves as a forerunner of irreversible changes leading to tracheal stenosis. The biomedical technologies including auto- and allo-transplantation, tissue engineering, gene and cell-based therapy are considered to be the most promising methods for the treatment and prevention of this condition likely to improve the outcome of the management of cicatrical tracheal stenosis.

[The pilot study of the effect of paclitaxel by local application on scar formation after airway injury in rabbits]

OBJECTIVE

To investigate the effect of local application of paclitaxel on airway scar formation after airway injury in rabbits.

METHODS

Forty New Zealand rabbits were randomly divided into four groups, negative control group (n = 10), saline control group (n = 10), group I (n = 10), group II (n = 10). All rabbits received tracheotomy. In negative control group, the specimens were harvested for histological examination and immunohistochemical analysis immediately after tracheotomy;in other three groups, rabbits received airway injury after tracheotomy. In group I and group II, 0.4 mg/ml and 1.0 mg/ml paclitaxel was applied locally in injured airway segment for 3 minutes after airway injury. The normal saline was used in control group for 3 minutes. The animals were killed in 21 days after operation. The specimens were harvested for histological examination and immunohistochemical analysis. Transmission electron microscopy was employed to observe the ultrastructure of paclitaxel-induced apoptotic cells.

RESULTS

The degree of stenosis in group I and group II were significantly decreased compared to those in saline control group [saline control group (59 ± 13)%, group I (27 ± 8)%, group II (22 ± 7)%]. Histological examination showed fibroblast cells and inflammatory cells in group I and group II were significantly fewer than in saline control group. The TGF-β1 positive cells and VEGF positive cells in group I and group II were significantly decreased compared to those in saline control group (P < 0.05). Paclitaxel-induced cell apoptosis and injured cell organs were observed by transmission electron microscopy.

CONCLUSIONS

Local application of paclitaxel inhibits airway scar formation after airway injury in rabbit model, and the inhibition is dose dependent. Paclitaxel may have a therapeutic potential for the treatment of airway stenosis caused by endotracheal intubation, tracheotomy or implantation of airway stents.

[The potential of prophylaxis and optimization of the treatment of rhinosinusitis in the children presenting with stenosing laryngotracheitis]

The objective of the present work was to estimate the clinical, prophylactic, and microbiological effectiveness of fusafungine applied for the treatment of acute rhinosinusitis (ARS) in the children that develops as a consequence of acute stenosing laryngotracheitis. The study included 61 children presenting with ARS and concomitant acute stenosing laryngotracheitis (ASLT) that were treated with fusafungine (Bioparox). Both tolerance and safety of this preparation were evaluated. Fusaferine was prescribed after reduction of pharyngeal stenosis. The children were divided into two groups. Group 1 was comprised of the patients with the respiratory symptoms and rhinosinusitis (n = 36), group 2 consisted of the children with the respiratory symptoms in the absence of rhinosinusitis (n = 25). Subgroups of the children treated with fusafungine and without it were distinguished to estimate the clinical, prophylactic, and microbiological effectiveness of fusafungide. Within the first days after hospitalization, 59% of the children with diagnosis ASLT developed bilateral rhinosinusitis, in all probability of viral etiology. Fusafungine produced the clinically apparent effect in the patients with ASLT regardless of the presence of ARS. Specifically, this preparation decreased the degree of hypertrophy of pharyngeal tonsils three times faster than standard therapy; moreover, it reduced the requirement for systemic antibiotics by 1.9 times. The treatment with fusaferine prevented the development of acute bilateral rhinosinusitis in the children with ASLT and promoted compete decontamination of the nasopharynx from M. catarrhalis, Str. pneumonia, Str. pyogenes, H. influenza, Cor. s the nasopharynx pecies, E. faecalis, and C. albicans. The frequency of adverse reactions of organoleptic character was estimated at 16.6%.

[Prophylaxis of complications at the surgery of postintubation and posttracheostomy tracheal stenoses]

Overall 42 patients aged 16 to 56 years with non-tumor stenosis of trachea were treated. Tracheostomia, endoscopic bougienage with endografting, circular resection of trachea with end-to-end anastomosis were performed. Original method of circular resection with allotransplantation was used at 4 patients with large tissues defect. There were no complications, the clinical results was good. The examination of trachea in 6 and 12 months after operation didn't revealed any pathological changes.

The Feasibility of Ultrasound to Assess Subglottic Diameter

BACKGROUND

In healthy patients, the narrowest diameter of the subglottic upper airway is the width of the air-column at the level of the cricoid cartilage. This diameter governs the selection of the endotracheal tube size, as excessive tube diameter may damage the tracheal mucosa leading to postextubation stridor or subglottic stenosis. Unfortunately, selecting endotracheal tube size based on height, weight, or age does not reliably lead to the proper tube. The knowledge of airway diameter, especially using a bedside noninvasive tool, could therefore be helpful in anesthesia and intensive care.

METHODS

We studied 19 healthy volunteers (27 +/- 3 yr, nine females) to compare the transverse diameter of the cricoid lumen assessed by ultrasonography and magnetic resonance imaging.

RESULTS

We found a strong correlation between the two techniques (r = 0.99, P < 0.05) confirmed by Bland-Altman analysis with a bias of 0.14 mm, a precision of 0.33 mm, and limits of agreement of -0.68 mm/0.96 mm.

CONCLUSION

In young healthy adults, ultrasonography appeared to be a reliable tool to assess the diameter of the subglottic upper airway.

[Some mechanisms of a recurrent course of stenosing laryngotracheitis in children]

Staged development of dysbiotic disturbance of the upper airways was revealed in children suffering from stenosing laryngotracheitis in the presence of viral infection. Chronic persistent virus-bacterial inflammation of respiratory tract mucosa and resultant hypersensitivity of the airways produce chronic defects in lung ventilation in patients with recurrent stenosing laryngotracheitis. High sensitivity of the airways to histamine is related to bioelectric activity of the brain characterized by dominant irritation of the mesencephalo-diencephalic structures. Typical features of the curve flow-volume and paradoxic result of the test with broncholytic drugs verified tracheobronchial dyskinesia in patients with stenosing laryngotracheitis. Such dyskinesia promoted the recurrent disease with transformation into bronchial asthma.

Complications of tracheotomy in patients with mucopolysaccharidoses type II (Hunter syndrome)

OBJECTIVE

To investigate the complication rate of tracheotomy in patients with mucopolysacchridoses (MPS) type II (Hunter syndrome).

MATERIALS AND METHODS

From 2004 to 2005, seven tracheotomy procedures were performed for the airway management in three patients with MPS type II. The complications for each procedure were analyzed, which included the stomal narrowing, granulation formation, infrastomal tracheal stenosis, and wound infection.

RESULTS

All tracheotomies in patients with MPS type II resulted in tracheotomy-related complications, though these procedures secured a safe airway. Infrastomal tracheal stenosis was the most frequent complication (85.7%) and stomal narrowing also occurred frequently (71.4%) after each tracheotomy. These complications caused cannula care to be difficult, with revision frequently required.

CONCLUSION

Of the complications observed after tracheotomy, infrastomal tracheal stenosis and stomal narrowing are frequent in patients with MPS type II. Therefore, tracheotomy procedures should be cautiously applied to the MPS type II patients, and the complications associated with tracheotomy should be discussed with caregivers preoperatively.

Accuracy of finger-tip palpated tracheostomy tube cuff pressure readings among otolaryngologists

The tracheal mucosa is very a delicate structure, and pressure–ischaemia problems following the use of cuffed tracheostomy tubes are well documented. Iatrogenic tracheal stenosis is one of the consequences of mucosal ischaemia and is very difficult to treat. In this study the accuracy of finger-tip tested tracheostomy tube cuff inflation pressure, as judged by consultants and non-consultants, was assessed by comparison with manometric pressure readings. The estimated pressure readings from the consultant group were more accurate than those from the non-consultant group, but a high standard deviation and very big difference between low and high readings in both these groups showed the real extent of the problem. Participants who performed 10 or more tracheostomies a year obtained more accurate results. No definite correlation was observed between the readings and the experience of the participants in otolaryngology or the size of the tube used. The authors recommend that instrumental monitoring of cuff pressure be considered good practice among junior otolaryngologists.

Comparison of Open Dilatational Tracheostomy with Conventional Pediatric Tracheostomy in a Growing Animal Model

OBJECTIVES

To compare the tracheal changes after applying a new open dilatational tracheostomy (ODT) technique with those from a conventional open tracheostomy (COT) with vertical cartilage incision in a growing animal model.

STUDY DESIGN

Prospective, experimental investigation in a rabbit model.

MATERIALS AND METHODS

Thirteen New Zealand white rabbits as a pediatric model were divided into three groups: six rabbits had COT (n = 6), another six underwent an ODT (n = 6), and one rabbit acted as a control. Each rabbit underwent tracheostomy by assigned procedures on the first day. On day 8, they were decannulated. On day 15, their tracheas were harvested. We examined the gross findings and histologic changes of each tracheal segment at the stomal level. In addition, we analyzed three parameters: the quotient of the stomal and nonstomal segment in sagittal diameter, coronal diameter, and cross-sectional area.

RESULTS

The framework of cartilages at the stomal level were more distorted in the COT group. Histologic examination also showed buckling of the anterior tracheal wall, loss of cartilage, infiltration by many polymorphonuclear neutrophils, and the marked ingrowth of fibrous tissue in the COT group. Sagittal and coronal diameters and cross-sectional areas were significantly affected more severely after a COT than after an ODT.

CONCLUSION

Our new modification of percutaneous dilatational tracheostomy, named "open dilatational tracheostomy," was successfully applied to a small, growing animal model and showed more favorable and consistent healing of trachea compared with COT. Therefore, the authors' new tracheostomy procedure could be applied to children who require short-term tracheostomy at any age in clinical settings.

[Laryngo-tracheal trauma. Problems in management]

It is presented the experience of Department of ENT&HNS from "Santa Maria Hospital" Bucharest in treating 85 patients with laryngo-tracheal trauma during a period of 10 years. The author presents the causes of these kind of trauma and insists on endoscopic and iatrogenic laryngotracheal trauma with an increasing number in the last years. Presenting the lot of patients the author insists on the therapeutic approach which is divided in 4 types of maneuvers depending on the etiology, the localisation and the extension of the lesions. An ancient controversy is debated--that of prolonged orotracheal intubation vs tracheostomy followed by tracheal intubation. The conclusion is that such types of laryngotracheal trauma require a team management (ENT, pneumology and thoracic surgeon) in order to prevent the stenotic and fibrous sequelae which are difficult to treat.

Late complications of tracheostomy

Tracheostomy may be associated with numerous acute, perioperative complications, some of which continue to be relevant well after the placement of the tracheostomy. A number of clinically important unique late complications have been recognized as well, including the formation of granulation tissue, tracheal stenosis, tracheomalacia, tracheoinnominate-artery fistula, tracheoesophageal fistula, ventilator-associated pneumonia, and aspiration. The clinical relevance of these complications is considerable, as their manifestations range from minimally symptomatic to failure to wean from the ventilator (tracheal stenosis) to life-threatening hemorrhage (tracheoinnominate fistula). Treatment modalities vary depending upon the nature of the complication. For the most frequent complication, tracheal stenosis, a multidisciplinary approach utilizing bronchoscopy, laser, airway stents, and tracheal surgery is most effective.

Anesthetic considerations for patients with Down syndrome

Patients with Down syndrome, or trisomy 21, present a unique set of anesthetic considerations to anesthesia providers. Down syndrome is the most prevalent genetic disorder worldwide and affects more than 1 in 800 live births. Patients with Down syndrome are afflicted with multiple congenital anomalies that affect almost all of their organ systems. Skillful management during the perioperative period is essential for a good outcome for patients with multiple congenital abnormalities in the cardiopulmonary and musculoskeletal systems. The purpose of this review is to describe clinically significant findings that are common to patients with Down syndrome. In addition to the presentation of clinical anomalies associated with trisomy 21, specific anesthetic considerations and interventions are reviewed.

Blunt external trauma to the trachea: report of two cases

We present two cases of blunt external trauma to the trachea. The first was a 19-year-old man who had suffered rupture of the first tracheal ring as a consequence of attempting suicide by hanging from a cable. The second was an 11-year-old boy who fell from a bicycle and struck his neck against the handlebars. Fracture of the second tracheal ring was found at surgery. Both cases were treated by primary repair. A surgical exploration is essential in the case of subcutaneous emphysema, even if no respiratory distress is present and a radiological evaluation is negative. Follow up, according to the extent and type of injury, is recommended to prevent post traumatic stenosis of the trachea.

The effects of mitomycin C and 5-fluorouracil/triamcinolone on fibrosis/scar tissue formation secondary to subglottic trauma (experimental study)

PURPOSE

The aim of the study was to compare the effects of mitomycin-C (MMC) and 5-fluorouracil/triamcinolone acetonide (5-FU/TA) on the development of fibrosis/scar tissue formation of rabbit subglottic area, which is injured acutely.

MATERIALS AND METHODS

After standardized trauma to subglottic area the rabbits were divided into those that received treatment and those that did not (controls). The subjects were treated with either topical 0.4 mg/mL MMC or 5 mg 5-FU/TA injection. Those groups were further divided into subgroups depending on the time of examination: at 2 or 6 weeks. Each subgroup had 4 rabbits. The specimens were examined histopathologically and the measurements were performed using a software.

RESULTS

The fibrosis indices (FIs) of the treated subgroups were significantly less than the FIs of their corresponding control subgroups (P<.05). The difference in FIs of the MMC-treated and 5-FU/TA-treated groups was not statistically significant (P>.05). MMC and 5-FU/TA did not interfere with regeneration of the epithelium although in 2 cases treated with 5-FU/TA the regenerated epithelium showed squamous metaplasia.

CONCLUSIONS

Both MMC and 5-FU/TA decrease fibrosis/scar tissue formation secondary to experimentally induced acute subglottic trauma. There is no significant difference between the effects of the 2 drugs.

[Prophylaxis of iatrogenic tracheostenosis after laryngeal extirpation]

Causes of such postoperative complication as cicatricial tracheostenosis after tracheotomy and laryngeal extirpation are considered. The author came to the conclusion that the leading cause of tracheostenosis is an invalid choice of tracheotomic tubes by diameter, length and angle. The experience with more than 3000 surgical interventions on the larynx and trachea allowed the author to recommend most effective treatments at each stage of cicatricial tracheostenosis.

Use of mitomycin C in the pediatric airway

PURPOSE OF REVIEW

Mitomycin C was not used in the field of otolaryngology before 1998. Currently it is commonly used by all pediatric otolaryngologists dealing with airway stenoses. Mitomycin C offers the surgeon a method of modifying healing and diminishing granulation tissue and cicatricial scar.

RECENT FINDINGS

There are numerous animal studies showing the beneficial effect of mitomycin C on wound healing in the airway. The human studies rarely have controls and in many cases are case reports. Human studies typically use dosages commonly used in ophthalmology, which are in the low range in relation to the animal airway studies.

SUMMARY

This article attempts to summarize the available research on mitomycin C, helping the clinical otolaryngologist choose the proper dosage, indications, and frequency of use.

Die knorpelerhaltende interkartilaginäre Visiertracheotomie. Mitteilung erster Erfahrungen mit einem alternativen, schonenden, konservativen Operationsverfahren

BACKGROUND

Most techniques of tracheostomy include a resection or at least incision of the cartilage himself. This may result in local tracheomalacia and chondritis.

METHODS/PATIENTS

We performed 48 tracheotomies (173 cases were totally performed in our in 2002 excluding laryngectomie patients) in with horizontal incision between 2 (nd) and 3 (rd) ring sparing all cartilage. The detailed technique is described and the (endoscopic controlled) follow-up data showed no complications. We called this techniques the visor-tracheostomy.

RESULTS

It is shown, that a modified concept of conservating cartilage while doing tracheostomy is easy to perform without any increasing in time and costs. The most important thing is to choose the right incision range.

CONCLUSIONS

It seems to us, that healing of these tracheotomies is better and secondary complications as stenosis of trachea should be less instead of the cases where Björk-flaps or simply local resection were performed.

Schwannoma of the trachea; a new resection technique

Tumors of the trachea are rare, especially schwannoma. We diagnosed a 27-year-old man with schwannoma of the trachea after he was admitted to our hospital with complaints of progressive dyspnea and wheezing. He was treated as having bronchial asthma initially, but his signs and symptoms did not improve with conventional therapy. Flexible fiberscopy revealed the presence of a submucosal tumor in the subglottic area. Tracheal tomography, computed tomography (CT) and magnetic resonance imaging (MRI) revealed the presence of a mass in the trachea that extended from the cricoid cartilage level to the second tracheal ring. After tracheostomy, we removed the tumor from a tracheostoma upwards to the larynx without a laryngofissure, using forceps and scissors usually used for laryngomicrosurgery and endoscopes usually used for sinus surgery. No complications developed during or after the procedure. To our knowledge, this is the first report of the removal of a tracheal schwannoma by this technique.

Endoluminal stenting for tracheal stenosis

This prospective clinical study evaluates the role of endoluminal stents in the maintenance of a tracheal lumen after management of stenosis. Tracheal stenosis may be due to a variety of causes, and it is a significant health problem. Most patients either remain tracheostomized for prolonged periods of time or undergo several major surgical interventions. The most common sequel is restenosis at the site of repair either after augmentation or resection anastomosis. In this study, 16 patients with different pathologies causing tracheal stenosis or collapse are presented. All patients had the tracheal lumen re-established either endoscopically or by an open procedure. The stent was then placed to support the site of repair and prevent restenosis. A patent well-epithelialized lumen was achieved in 11 cases with a follow-up of 3-24 months. Complications were encountered in five cases: three misplaced stents, one tracheal erosion with a Dumon stent and one granulomatous obstruction. The technique, complications and follow-up of these patients are described with recommendations for the management of such patients.

New design of a tracheostomy-cricothyroidostomy tube

In an attempt to minimize late airway stenosis, a new tube with an oval cross-section has been developed. Two to three tracheal cartilage arches are usually incised anteriorly, partially excised or inadvertently broken to fit a tracheostomy tube. The risk of post-tracheostomy stenosis seems to be greater when several cartilages have been involved. If an oval tube with the shortest diameter in its symmetry plane is used, the tissue defect along the longitudinal axis of the trachea will be shorter than that caused by a round tube. When such a stoma is healing, the adjacent intact tracheal cartilages, which are located fairly close to each other, will support the bridging scar tissue, thereby preventing collapse of the tracheal wall. The tubes come in three lengths to fit most neck sizes. An oval trial tube with the same length as the shortest one has been used for cricothyroidostomy--the aim being to spread the cricoid and thyroid cartilages apart as little as possible. A series of 23 patients were treated with this tube. At follow-up, no stenosis was found at flexible fiberoptic laryngo-tracheoscopy. Fifteen patients reported no voice change, and five, who were singers, experienced lower pitch, but four of them were still singing. None of these five patients had speech problems. The other three patients had voice problems when speaking. One of these had chronic bronchitis and another had had a stroke. The third one had a rough voice. The voice problems were milder than those reported from previous series.

[A study on the application of Nickle-Titanium alloys stent for prevention and treatment tracheostomal stenosis after total laryngectomy]

OBJECTIVE

To evaluate the effect of Nickle-Titanium alloys annular stent to prevent and treatment tracheostomal stenosis after total laryngectomy.

METHOD

The stent was used following total laryngectomy and after total laryngectomy.

RESULT

Long stent was implanted in 2 cases following total laryngectomy and in 1 cases after total laryngectomy, Which resulted in widening stenosis and relieving obstruction of airway. The tracheostomal diameter is 2 cm afterwards, but the patients have crusts, granuloma and stretch feeling in tracheostoma. Tracheostomaplasty was performed using short stent in 18 cases during laryngectomy. All the cases have no tracheostomal stenosis following over 6 months. The tracheostoma is smooth, enough larger and stable.

CONCLUSION

Nickle-Titanium alloys annular short stent is fixed outside the wall of trachea, its complication is less. It may prevent from tracheostomal stenosis. Nickle-Titanium alloys annular long stent is a better method to resolve dyspnea.

Regular tracheostomy tube changes to prevent formation of granulation tissue

OBJECTIVES/HYPOTHESIS

Tracheostomy is a commonly performed operative procedure that has been described since 2000 B.C. The early indications for tracheostomy were for upper airway obstruction, usually occurring in young people as a result of an infectious process. Recently, tracheostomies are more commonly performed in the critically ill patient to assist in long-term ventilatory support. Granulation tissue at the stoma and the trachea has been described as a late complication resulting in bleeding, drainage, and difficulty with maintaining mechanical ventilatory support.

STUDY DESIGN

The present report is of an observational study of a newly implemented policy that required regular changing of tracheostomy tubes. Comparable groups of patients were compared before and after this procedural change to document complications. Data collection consisted of chart reviews of all admissions for 1 year before the policy change and the subsequent 2 years. Complication rates were compared using standard statistical techniques.

METHODS

A policy change was instituted that required all tracheostomy tubes to be changed every 2 weeks in conjunction with a detailed evaluation of the tracheostomy stoma. Charts were reviewed the year before the change in policy and in the subsequent 2 years to determine the incidence of granulation tissue requiring operative intervention.

RESULTS

The number of patients requiring surgical intervention secondary to granulation tissue showed a statistically significant decrease (P =.02). A review of policies and procedures from the six largest hospitals in southeastern Michigan had no recommendations for routine tracheostomy tube changes.

CONCLUSIONS

A policy requiring a routine change of tracheostomy tubes results in fewer complications from granulation tissue. Tracheostomy tube changes to prevent granulation tissue and its complications.

Laryngotracheal injury after percutaneous dilational tracheostomy in cadaver specimens

OBJECTIVE

To evaluate the stoma and surrounding insertion site for common laryngotracheal injury patterns after percutaneous dilational tracheostomy that may contribute to clinically significant tracheal stenosis.

STUDY DESIGN

Preliminary prospective cadaver study.

METHODS

A preliminary prospective cadaver study was performed in which percutaneous dilational tracheostomy (Ciaglia Blue Rhino kit) was placed in six fixed cadaveric specimens. Laryngotracheal segments were harvested. Two independent evaluators graded cadaver features and characteristic injuries in laryngotracheal specimens the tracheal site of stoma placement was identified. Cadaver features evaluated included gender, obesity, and ease of landmark identification. Mucosal and cartilage injuries were evaluated on a scale of 0 to 4, with 4 representing severe comminuted injuries beyond the intended stoma site.

RESULTS

Accurate prediction of tracheal placement was achieved in only three (50%) of the specimens. In the remaining cadavers, one stoma site was placed higher than intended (16%) and two sites were lower than intended (33%). Mucosal injury was most severe at the anterior internal surface of the trachea with all specimens sustaining tears beyond one tracheal ring (mean mucosal injury score, 3.5). Cartilaginous injury was severe in five of six specimens (83%) that sustained multiple comminuted injuries to two or more adjacent rings (mean cartilage injury score, 3.34). Cricoid comminutions and a posterior membranous tracheal wall injury were each found in one specimen.

CONCLUSIONS

Laryngotracheal injuries found after percutaneous dilational tracheostomy in the study indicated that severe damage to mucosa and cartilage surrounding the intended stoma site occurs at the time of placement. These injuries may contribute to clinically significant tracheal stenosis preventing decannulation in patients undergoing percutaneous dilational tracheostomy. Two case studies that support this hypothesis are also presented.

[Control of the endotracheal cuff balloon pressure as a method of preventing laryngotracheal lesions in critically ill intubated patients]

OBJECTIVES

To study the development of tracheal stenosis after endotracheal intubation, percutaneous tracheotomy or both; to assess risk factors for tracheal stenosis and the relation of risk to endotracheal cuff pressure.

PATIENTS AND METHODS

A prospective study enrolling patients sustaining endotracheal intubation longer than 8 hours and/or undergoing percutaneous tracheotomy. Cuff pressure was recorded at the moment of intubation and every 8 hours thereafter; a ceiling of 25 mm Hg was targeted. The patients were examined 6 months after discharge.

RESULTS

Sixteen percutaneous tracheotomies were performed in the 95 patients enrolled (58 men, 37 women). The mean age was 54.1 +/- 19.7 years. The mean APACHE II score for all patients was 16.3 +/- 7.7 and the mean intubation time was 7.3 +/- 11 days, whereas the respective means for patients undergoing percutaneous tracheotomy were 18.4 +/- 7.6 and 20.5 +/- 19 days. Six months after discharge, 55 patients were examined for laryngotracheal lesions by fiberoptic endoscopy. Twenty-three of the remaining patients had died, 7 were lost to follow-up and 10 were only interviewed by telephone. Fiberoptic laryngotracheal endoscopy revealed minimal scarring and reduction of the endotracheal lumen. Reduction of the lumen was observed only in patients who had undergone percutaneous tracheotomy.

CONCLUSIONS

Monitoring cuff pressure three times per day seems to contribute to preventing ischemic lesions and tracheal stenosis.

Tracheal reconstruction under tension: an experimental study in sheep

AIMS

Invasion of the trachea by thyroid cancer is a difficult problem. Circumferential resection and end-to-end reconstruction is the treatment of choice. The objective of our study was to investigate the effect of tension on tracheal healing and stenosis formation, and to ascertain the maximum tolerable tension.

METHODS

Tracheal resections of 3, 6 and 9 cm with end-to-end anastomosis were performed on 25 sheep. The intraoperative force required for approximation of the tracheal stumps was measured. Luminal stenosis was determined with the aid of computerized planimetry 1, 2, 4, 8 and 24 weeks post-operatively.

RESULTS

A gradual increase of the stenosis rate occurred with increasing tension on the anastomosis. Acceptable results were achieved in the majority of cases without release techniques or tension suture.

CONCLUSIONS

Tracheal anastomosis under tension does not always lead to disruption or separation of the anastomosis. With the additional use of release manoeuvres and tension sutures, tracheal anastomosis under tension are possible without severe stenosis. The additional use of temporary stenting needs to be elucidated.

[Active tracheo-bronchial caseous tuberculosis. Ten patients]

BACKGROUND

We report 10 cases of active endobronchial tuberculosis in female patients.

PATIENTS AND METHODS

Diagnosis of endobronchial tuberculosis was established by demonstrating the presence of Koch bacilli in the bronchial washings or at pathology examination of a bronchial mucosa biopsy. Follow-up was available for 5 of the 10 cases.

RESULTS

These women were aged 19 to 756 years. Clinical signs included persistent cough (n=10), wheezing (n=10), dyspnea (n=5), dysphonia (n=4) and fever (n=8). Chest x-ray was normal in 4 cases but showed condensation in 4 others with infiltration of the superior lobe in 2 cases. Bronchoscopy findings were characteristic with a thick layer of white caseum on the mucosa. Koch bacilli were found in all bronchial wash specimens. Pathology examination confirmed the diagnosis of tuberculosis in 5 of the 10 cases.

Postintubation tracheal tear repair by cervicotomy and longitudinal tracheotomy

BACKGROUND

Membranous tracheal lacerations are a serious complication of endotracheal intubation. Smaller tears are often better managed with a conservative treatment. Larger ruptures, especially when associated with important manifestations, need an early surgical repair.

METHODS

In the last 3 years, three female patients with a posterior tracheal wall laceration, related to endotracheal intubation, underwent surgical procedure in our institution. All tracheal tears were repaired with a running suture through a small cervical collar incision and longitudinal tracheotomy.

RESULTS

All surgical procedures were effective and lasted less than 1 hour. Patients were discharged on average after 5 days. Endoscopic follow-up showed a perfect repair of the tear without signs of tracheal stenosis.

CONCLUSIONS

This is a reliable, quick, and safe approach to a rare but insidious complication of general anesthesia. It avoids lateral and posterior dissection of the trachea, reducing the risk of a recurrent laryngeal nerve injury.

Can topical mitomycin prevent laryngotracheal stenosis?

OBJECTIVES/HYPOTHESIS

Early topical application of mitomycin to a laryngotracheal lesion may prevent or reduce laryngotracheal stenosis (LTS).

STUDY DESIGN

Prospective controlled animal study.

METHODS

LTS was induced in 60 dogs randomly assigned to four groups. Controls received an immediate topical application of normal saline. The suction-control group received an immediate application of normal saline followed by suction of secretions on day 2. The mitomycin group received immediate application of 0.7 mL mitomycin (0.2 mg/mL). The repeat-mitomycin group received an immediate application of mitomycin and a second application on day 2, after secretions were suctioned. The laryngeal lumens were measured endoscopically at baseline, day 12, and day 21. Animals were euthanatized if stenosis approximated 95% or at day 21.

RESULTS

All dogs in the mitomycin groups survived to day 21, compared with 12 in the suction group and only 2 controls. No side effects of mitomycin were observed. At day 21, surviving controls had 85% and 95% stenosis. In the mitomycin group, median stenosis was 27% (interquartile range, 29% to 42%); in the repeat-mitomycin group, 30% (22% to 40%); and in the suction-control group, 84.5% (72.5% to 93.5%). The mitomycin group differed significantly from controls on day 12 (median difference = 85%, 95% CI = 80%-94%, P < .0001) and day 21 (difference = 63.9%, 95% CI = 58%-85%, P = .031).

CONCLUSION

A single topical application of mitomycin significantly reduces the severity of LTS in dogs. Reapplication after 2 days does not improve results. Prospective clinical studies are warranted to assess the efficacy in humans.

Mitomycin-C in the treatment of tracheal cicatrix after tracheal reconstruction

OBJECTIVE

To demonstrate the potential use of Mitomycin-C (MMC) in the treatment of difficult and recurrent tracheal stenosis.

DESIGN

Case series.

SETTING

Tertiary care setting.

PATIENTS

A retrospective chart review was performed on five pediatric patients with severe, recurrent tracheal granulation and cicatrix after tracheal reconstruction who were treated with topical MMC as an adjunct to bronchoscopy and laser treatment. MMC was applied intraoperatively on saturated pledgets at a dose of 0.1 mg/ml for 2 min to the area where the cicatrix had been lysed. The five patients were able to be decannulated.

DISCUSSION

Mitomycin-C is an anti metabolite known to inhibit fibroblast proliferation in vitro. This agent has been used with a high success rate in glaucoma filtration surgery to promote patency of the trabecula. The results of this preliminary application in the pediatric airway as well as the mechanism of action will be discussed.

Primary tuberculous tracheitis

We report a case of primary tuberculous tracheitis in an otherwise healthy woman who presented with cough and stridor due to diffuse tracheal narrowing by tuberculous pseudomembranous lesion, which resolved completely with antituberculosis chemotherapy.

A surgical technique to prevent tracheostomal stenosis after laryngectomy

Tracheostomal stenosis after total laryngectomy is a frequently occurring nuisance to both the patient and the surgeon. Although many causes may contribute to the development of tracheostomal stenosis, operative technique seems to play a major role. The authors describe and explain their method of stomal construction. Over a 10-year period they have used the described method on 260 patients undergoing a total laryngectomy, with an incidence of tracheostomal stenosis of 6%.

An experimental model for the prevention of postanastomotic tracheal stenosis

OBJECTIVE

The aim of the current study is to determine the efficiency of an external prosthesis made of expanded polytetrafluoroethylene reinforced with a continuous silicone spiral to prevent postanastomotic stenosis after surgical correction of extensive tracheal defects in rabbits.

METHODS

Forty-five rabbits were used, divided into three groups of 15 animals each. Group A was the control group. Group B animals underwent resection of six-ring segments of the cervical trachea and primary anastomosis. The procedure used in group C was similar to that used in group B, but the tracheal anastomosis was supported by an external expanded polytetrafluoroethylene prosthesis.

RESULTS

Direct anastomosis after resection of six tracheal rings caused anastomotic stenosis in 100% of the animals. We did not observe tracheal stenosis in any rabbit when we applied an expanded polytetrafluoroethylene tube as an external stent for the tracheotracheal suture.

CONCLUSION

We conclude that an external stent can be used to prevent tracheal stenosis resulting from the resection of six cervical tracheal rings in rabbits.

[Transient tracheal obstruction during surgical correction of scoliosis in a patient with Marfan's syndrome]

A 13-yr-old male with Marfan's syndrome underwent surgical correction of severe scoliosis. He had not manifested dyspnea previously in any position. Under anesthesia with thiamylal and vecuronium, his trachea was intubated with a reinforced endotracheal tube without any difficulty. Anesthesia was maintained with nitrous oxide and fentanyl, 8 micrograms.kg-1. The patient was placed in a prone position. Thirty min after the start of operation, when orthopedists compressed the thoracic vertebrae vertically, positive pressure ventilation became impossible abruptly, even with a high airway pressure. Three min later, ventilation became possible after cessation of compression and by mouth-to-tube insufflation. SpO2 monitored with a pulse oximeter recovered immediately from 61% to 99%. A capnogram showed a lengthy retardation of an inspiratory phase. Emergency fibreoptic bronchoscopy revealed that the trachea had been compressed vertically; the compression was reduced by moving the chest supporters laterally. After the apneic episode, the operation continued uneventfully, and he was discharged a month later. A severe deformity of the thorax due to severe scoliosis and weak tracheal tissue due to connective tissue defect caused partial tracheal compression before the surgery, and made his trachea susceptible to complete obstruction by vertical external compression on the thorax. Patients with Marfan's syndrome and scoliosis should have careful preoperative airway evaluation. The selection and positioning of endotracheal tubes should be done with care. During surgery, the patient's body position and the condition of the trachea should be checked frequently. Capnography and fiberoptic bronchoscopy seem to be mandatory for early detection of tracheal stenosis and prevention of tracheal obstruction.

Endobronchial tuberculosis: diagnostic features and therapeutic outcome

BACKGROUND

Endobronchial tuberculosis (EBTB) is not seen often in the adult population. In most cases it is associated with pulmonary tuberculosis. During its course significant tracheobronchial stenosis may develop. In this study we report our experience with patients with EBTB.

METHODS

The records of 38 patients in whom EBTB had been proved by fibre optic bronchoscopy, microbiology and histology studies were evaluated.

RESULTS

Symptoms were non-specific and represented mainly the co-existing pulmonary tuberculosis. Signs characteristic of airway obstruction were rare (localized wheezing in 6%). Indications for bronchoscopy were radiographic features (87%), microscopy smear negatives (8%), wheezing (3%), and blood stained sputum (3%). The lesions were more likely to be seen in the main and upper bronchi. In 5% of patients the lower trachea was involved. Most lesions looked inflamed (51%), followed by caseous (19%), granulomatous (17%), ulcerative (12%), and fibrotic appearance (1%). The degree of stenosis was nil (22%), minor (45%), significant (13%), subtotal (13%), or total (7%). The patients were treated with a combination of antituberculosis drugs. Four patients underwent surgical procedures. Dilatation techniques were used in two patients for a right and left main bronchus stenosis respectively, with significant improvement in one. Dilatation in combination with laser therapy of a right intermediate bronchus stenosis did not result in re-expansion of the dependent part of the lung due to pleural adhesions. Left pneumonectomy was performed in one patient for destroyed lung. Twenty-two patients agreed to follow up bronchoscopy. The macroscopic appearance of the mucosa had improved in most cases but the degree of stenoses was unchanged in a considerable proportion (58%). Bronchial stenosis in one patient subsided during therapy but developed again at a later stage.

CONCLUSIONS

Patients with pulmonary tuberculosis and radiographic evidence of volume loss are recommended to undergo bronchoscopy to rule out EBTB. Specific symptoms for EBTB are rare. Biopsy of inflamed areas of bronchial mucosa seems to be indicated. Despite adequate antituberculosis therapy tracheobronchial stenosis may develop. Long term follow up including bronchoscopy seems therefore advocated. Dilatational intervention may be indicated in selected cases.

Tracheal reconstruction using an epithelial equivalent

The application of a rapidly vascularized epithelial equivalent that inhibits wound contraction would have great potential in the prevention and repair of tracheal stenosis. An animal model was developed to simulate the effects of circumferential tracheal injury and an autologous epithelial equivalent was created from a fibroblast-collagen matrix and subsequently implanted in the traumatized site in an attempt to prevent stenosis. Postinjury physiologic and histologic evaluation revealed near-normal mucosal flow analysis in the treated sites and an area of less than 20% stenosis versus 95+% in controls. This study's findings indicate that tracheal stenosis can be limited by the use of an epithelial equivalent.

Microwave-cured tracheostoma vents

This article describes a technique of making custom flexible and combined flexible/rigid tracheostoma vents. The combined flexible rigid tracheostoma vent provides a flexible material that is nonirritating in the peristomial region and maintains a patent tracheostoma by the rigidity of the hard acrylic resin section. The flexible tracheostoma vent can be easily inserted and is more comfortable than the rigid commercially available tracheostomy tube. The use of microwave-cured materials permits fabrication during a single visit. The steps involved in the fabrication of the tracheostoma vents are simple and require no elaborate laboratory equipment.

Peristomal complications of paediatric tracheostomy

Failure of decannulation after paediatric tracheostomy, once the underlying disorder has resolved, is almost always due to peristomal complications. Granulation tissue formation in the raw tissue of the stoma and its subsequent fibrosis requires removal (50 of the 293 tracheostomies from the Red Cross War Memorial Children's Hospital). It is suggested that this can be avoided by creating a formal skin-to-trachea stoma at the time of tracheostomy. Suprastomal depression of the anterior wall of the trachea (52/293) appears to be unavoidable when using standard tracheostomy tubes. Localised stomal site tracheomalacia and stenosis (numbers of this complication are unknown) results from damage to cartilage of the trachea either by incision or by necrosis from pressure of the tracheostomy tube. Trauma to the cartilage needs to be minimised by careful design of the tracheal incision. It is suggested that consideration should be given to creating a formal tracheostomy stoma for any paediatric tracheostomy that is likely to be required for more than a short period of time.

[Respiratory maintenance of plastic maxillofacial surgeries in children]

Eighty nine children with the cleft lip and cleft palate underwent 95 surgical interventions under ketamine anesthesia. During 51.6% of interventions traditional AVL and during 48.4% of interventions high frequency AVL were used. It was demonstrated that central hemodynamics, systolic time intervals and metabolic parameters were similar in the case of traditional and high frequency AVL; however high frequency AVL proved more efficient in preventing complications during cleft lip and cleft palate surgery.