Skip to main content Accessibility help
×
Hostname: page-component-7c8c6479df-nwzlb Total loading time: 0 Render date: 2024-03-28T16:00:24.010Z Has data issue: false hasContentIssue false

6 - Tracheal stenosis, masses and tracheoesophageal fistula

from Section II - Upper airway

Published online by Cambridge University Press:  05 September 2016

Timothy M. Millington
Affiliation:
Division of Thoracic Surgery, Dartmouth Geisel School of Medicine, Lebanon, NH, USA
Douglas J. Mathisen
Affiliation:
Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
Marco Scarci
Affiliation:
University College London Hospital
Aman Coonar
Affiliation:
Papworth Hospital
Tom Routledge
Affiliation:
Guy’s Hospital
Get access

Summary

Like any hollow viscus in the face of untreated pathology, the trachea can over time develop either symptomatic obstruction or fistula into an adjacent space. Tracheal lesions can be divided according to these two mechanisms.

Obstructive lesions of the trachea (stenosis and masses)

A narrowing of greater than 50% of the cross-sectional area of the trachea by a mass or stricture is necessary before a patient experiences dyspnea at rest. The typical presentation of chronic or subacute tracheal obstruction is the insidious onset of wheezing and shortness of breath that may evolve to stridor and respiratory distress. The finding of tracheal narrowing may not be seen on chest radiographs. Many patients initially receive incorrect diagnoses of asthma or chronic obstructive pulmonary disease and are often treated unsuccessfully with bronchodilators or steroids. Patients with malignant tracheal tumours may report associated hemoptysis and hoarseness, often with a more rapid onset of symptoms.

Axial imaging by computed tomography has superseded linear tracheal tomograms as the imaging study of choice. Three-dimensional reconstruction of images obtained by CT allows virtual bronchoscopy to identify and localize tracheal lesions. Inspiratory and expiratory CT scans are useful to demonstrate tracheomalacia. Pulmonary function testing demonstrating an obstructive pattern may help to suggest the diagnosis but is of limited use in operative planning. Patients with a central airway obstruction will benefit from treatment regardless of pre-operative pulmonary function tests (PFTs).

Bronchoscopy is the mainstay of diagnosis. Relative to flexible bronchoscopy, rigid bronchoscopy with general anaesthesia provides better visualization and control of the airway, precise measurement of laryngotracheal pathology and improved access for biopsy. Rigid bronchoscopy also permits debulking of tracheal lesions and improves tracheal dilatation. Flexible bronchoscopy without the availability of rigid bronchoscopy should be undertaken with caution because of the risk that endoscopic manipulation may lead to abrupt worsening of critical airway stenosis.

Obstructive lesions

Obstructive lesions of the trachea may be extrinsic, intramural or intraluminal. Extrinsic lesions causing tracheal compression include thyroid masses, congenital vascular rings and mediastinal masses. Inflammatory diseases of the mediastinum including tuberculosis, histoplasmosis, sarcoidosis and Wegener's granulomatosis may also lead to extrinsic tracheal obstruction due to lymphadenopathy and fibrosis. Treatment of the underlying cause of extrinsic compression is necessary and usually sufficient to relieve symptoms.

Type
Chapter
Information
Publisher: Cambridge University Press
Print publication year: 2016

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Minnich, D, Mathisen, D. Anatomy of the Trachea, Carina and Bronchi. Thor Surg Clin 2007; 17:571–85. Summary of tracheobronchial anatomy and relationships to adjacent structures and their role in the advancement of airway surgery.Google Scholar
Ashiku, S, Kuzucu, A, Grillo, H, et al. Idiopathic laryngotracheal stenosis: effective definitive treatment by laryngotracheal resection. J Thorac Cardiovasc Surg 2004; 127:99–107. Reports on the outcome of 73 patients treated for undergoing laryngotracheal resection at the Massachusetts General Hospital between 1971 and 2002, with no perioperative mortality and excellent long-term results in 91%.Google Scholar
Donahue, D, Grillo, H, Wain, J, et al. Reoperative tracheal resection and reconstruction for failed repair of postintubation stenosis. J Thorac Cardiovasc Surg 1997; 1114:934–9. Discussion of 75 patients operated on at the Massachusetts General Hospital between 1966 and 1997 after initially failed repairs with further resection ranging from 1 to 5.5 cm, with good or satisfactory outcomes in 82%.Google Scholar
Gaissert, H, Grillo, H, Shadmehr, B, et al. Laryngotracheoplastic resection for primary tumors of the proximal airway. J Thorac Cardiovasc Surg 2005; 129:1006–9. Reports on the results of 25 patients undergoing laryngotracheal resection for primary airway tumours close to the vocal cords with median follow-up of 101 months and overall 5- and 10-year survival of 79% and 64%.Google Scholar
Gaissert, H, Grillo, H, Shadmehr, B, et al. Uncommon primary tracheal tumors. Ann Thorac Surg 2006; 82:268–73. Retrospective analysis of treatment and outcomes of 360 benign and malignant tracheal tumours other than squamous cell and adenoid cystic carcinoma over a 40-year period.Google Scholar
Gaisssert, H, Grillo, H, Shadmehr, M,et al. Long-term survival after resection of primary adenoid cystic and squamous cell carcinoma of the trachea and carina. Ann Thor Surg 2004; 78:1889–997. Retrospective analysis of 270 patients with adenoid cystic or squamous cell carcinoma treated between 1962 and 2002 comparing 5- and 10-year survival in resected and unresected patients by histology.Google Scholar
Gaissert, H, Honings, J, Grillo, H, et al. Segmental laryngotracheal and tracheal resection for invasive thyroid Carcinoma. Ann Thorac Surg 2007; 83:1952–9. Retrospective study of 82 patients demonstrating that thyroid cancer invading the airway can be safely and effective managed by segmental airway resection.Google Scholar
Muniappan, A, Wain, J, Wright, C, et al Surgical treatment of nonmalignant tracheoesophageal fistula: a thirty-five year experience. Ann Thorac Surg 2013 Apr; 95(4):1141–6. doi: 10.1016/j.athoracsur.2012.07.041. Epub 2012 Sep 20. Retrospective study of 36 patients undergoing various surgical repairs of tracheoesophageal fistula between 1992 and 2010, reporting successful fistula closure in 94%.CrossRefGoogle Scholar
Wright, C, Grillo, H, Wain, J, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004; 128:731–9. Describes anastomotic complications in 9% of 901 patients with reoperation, diabetes, resection > 4 cm, age < 17 years, and pre-operative tracheostomy as independent risk factors.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×