Laryngotracheal stenosis

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Laryngotracheal stenosis
Classification and external resources
Laryngotracheal stenosis 001.jpg
This condition can also be referred to as subglottic or tracheal stenosis.
ICD-10Q31.1, Q32.1, J38.6, J39.8, J95.5
ICD-9519.19, 748.3
MeSHD014135
 
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Laryngotracheal stenosis
Classification and external resources
Laryngotracheal stenosis 001.jpg
This condition can also be referred to as subglottic or tracheal stenosis.
ICD-10Q31.1, Q32.1, J38.6, J39.8, J95.5
ICD-9519.19, 748.3
MeSHD014135

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

Nomenclature[edit]

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.

Causes[edit]

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.[2] The main causes of adult laryngotracheal stenosis are:

Main causes of laryngotracheal stenosis
Benign causesMalignant causes
Extrinsic compression
Intrinsic narrowing

Presentation[edit]

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.[19][20] [21] [22] [23] .[24] This increases the likelihood of the patient eventually requiring major open surgery in benign disease [25] and can lead to tracheal cancer presenting too late for curative surgery to be performed. Recently a patient whose laryngotracheal stenosis, caused by Wegener's Granulomatosis was misdiagnosed for asthma was awarded almost £1,000,000 in damages.

Treatment[edit]

The optimal management of laryngotracheal stenosis is not well defined, depending mainly on the type of the stenosis.[26] General treatment options include

  1. Tracheal dilation using rigid bronchoscope
  2. Laser surgery and endoluminal stenting[27]
  3. Tracheal resection and reconstruction[16][28]

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%.[26] 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).[29][30][31]

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.[32]

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 pioneered 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 is hoped to prevent his immune system from rejecting the transplant.[33]

See also[edit]

References[edit]

  1. ^ Armstrong WB, Netterville JL (August 1995). "Anatomy of the larynx, trachea, and bronchi". Otolaryngol. Clin. North Am. 28 (4): 685–99. PMID 7478631. 
  2. ^ SAR Nouraei, E Ma, A Patel, DJ Howard, GS Sandhu. Estimating the population incidence of adult postintubation laryngotracheal stenosis. Clin Otolaryngol 2007; 32: 411-412.
  3. ^ a b Lu MS, Liu YH, Ko PJ, Wu YC, Hsieh MJ, Liu HP, Lin PJ (April 2003). "Preliminary experience with bronchotherapeutic procedures in central airway obstruction". Chang Gung Med J 26 (4): 240–9. PMID 12846523. 
  4. ^ Tsutsui H, Kubota M, Yamada M, Suzuki A, Usuda J, Shibuya H, Miyajima K, Sugino K, Ito K, Furukawa K, Kato H (September 2008). "Airway stenting for the treatment of laryngotracheal stenosis secondary to thyroid cancer". Respirology 13 (5): 632–8. doi:10.1111/j.1440-1843.2008.01309.x. PMID 18513246. Retrieved 2014-06-18. 
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  7. ^ Perkins JA, Inglis AF, Richardson MA (March 1998). "Iatrogenic airway stenosis with recurrent respiratory papillomatosis". Arch. Otolaryngol. Head Neck Surg. 124 (3): 281–7. doi:10.1001/archotol.124.3.281. PMID 9525512. Retrieved 2014-06-18. 
  8. ^ Wood DE, Mathisen DJ (September 1991). "Late complications of tracheotomy". Clin. Chest Med. 12 (3): 597–609. PMID 1934960. 
  9. ^ 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. Retrieved 2014-06-17. 
  10. ^ Lebovics RS, Hoffman GS, Leavitt RY, Kerr GS, Travis WD, Kammerer W, Hallahan C, Rottem M, Fauci AS (December 1992). "The management of subglottic stenosis in patients with Wegener's granulomatosis". Laryngoscope 102 (12 Pt 1): 1341–5. doi:10.1288/00005537-199212000-00005. PMID 1453838. Retrieved 2014-06-18. 
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  14. ^ Chang SJ, Lu CC, Chung YM, Lee SS, Chou CT, Huang DF (June 2005). "Laryngotracheal involvement as the initial manifestation of relapsing polychondritis". J Chin Med Assoc 68 (6): 279–82. doi:10.1016/S1726-4901(09)70151-0. PMID 15984823. Retrieved 2014-06-17. 
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  33. ^ "New throat surgery 'a success'". BBC News. 2010-08-06.