Non-intubation traumatic laryngotracheal stenosis - Metro Atlanta

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Lano CF Jr, Duncavage JA, Reinisch L, Ossoff RH, Courey. MS, Netterville JL ... Laryngoscope 111(5):765–768. 15. ... Laryngoscope 113(9):1494–1498. 636.
Eur Arch Otorhinolaryngol (2006) 263: 632–636 DOI 10.1007/s00405-006-0036-8

LARYNGOLOGY

Badr Eldin Mostafa Æ Lobna El Fiky Mohammed El Sharnoubi

Non-intubation traumatic laryngotracheal stenosis: management policies and results

Received: 30 June 2005 / Accepted: 6 December 2005 / Published online: 22 April 2006 Ó Springer-Verlag 2006

Abstract Traumatic laryngotracheal stenosis (LTS) is increasing in clinical practice. Causes include external trauma, post-intubation, and iatrogenic injuries. It is a complex problem and many patients undergo multiple procedures to achieve a stable and well-protected airway with adequate voice. We present our experience at AinShams University Hospitals on 15 patients followed-up for 7 years. All patients had traumatic LTS excluding post-intubation injuries. Patients were aged 4–58 years. Nine were the victims of road traffic accidents; five were occupational trauma victims; and one tried to commit suicide by strangulation. The patients underwent a total of 53 procedures (mean 3.5 per patient). A total of seven laryngotracheal reconstruction, six partial cricotracheal resection, and four laser recanalization with stenting were performed. Six patients have mean follow-up of 26.5 months (3–60 months). Six patients had normal speech (GRBAS 0–5), three had a moderate degree of voice disturbance (GRBAS 5–10), and five had severe dysphonia (GRBAS > 10). As regards tolerance for daily activities, we used a modification of the McMaster University asthma quality of life questionnaire [Rea et al. Eur J Cardiothorac Surg 22(3):352, 2002] (using the activities and emotional scores total 112). Four patients could perform above the 90th percentile; all the remaining patients were above the 50th percentile. No patient was totally handicapped as a result of their airway problem and they could tend for their basic activities. The aim of this work is to demonstrate that non-intubation traumatic LTS is a complex problem that usually needs a longer time for reconstruction and a different way of approach. However, most of the patients can be finally rehabilitated with a stable, protected airway and adequate voice albeit at the price of a prolonged series of interventions and a long follow-up.

B. E. Mostafa (&) Æ L. El Fiky Æ M. El Sharnoubi Otolaryngology, Head and Neck Surgery Department, Faculty of Medicine, Ain-Shams University, 48 Ibn el Nafees str, 11371 Nasr City, Cairo, Egypt E-mail: [email protected]

Keywords Laryngotracheal stenosis Æ Partial cricotracheal resection Æ Laryngotracheal reconstruction Æ Endoluminal stenting Æ Laser cordotomy Æ Laser resection

Introduction Laryngotracheal stenosis (LTS) is an increasing problem in clinical practice. Causes include external trauma, postintubation injury, and iatrogenic injuries [6, 17, 18]. In contradistinction to congenital LTS, traumatic cases present with different problems due to the unpredictability of the pattern and extent of trauma. Additional injuries may also compound the problem including vocal fold paralysis, mandibular fractures compromising the upper airway, chest injuries compromising the lower airways, and other pre-existing co-morbidities [14,19]. Most of these patients are primarily managed by an emergency trauma team, which aims at life maintenance at all costs. Forced intubations or traumatic tracheotomies may be sometimes performed urgently influencing the final outcome unfavorably. Patients are eventually referred for airway reconstruction and decannulation late after stabilization of other lesions. Many procedures are available for the management of these cases including endoscopic or open procedures without or with stenting [1, 9, 11, 12, 16]. The final outcome must include a patent stable airway, adequate voice, and proper airway protection [12, 20]. The choice of the technique is invariably influenced by the extent of trauma and the expertise and/or preference of the treating surgeon. Treatment is usually complex and prolonged [8, 10]. The aim of this study is to emphasize that most of the patients with traumatic LTS can eventually be decannulated but with the proviso that many of them will need multiple sessions with a combination of treatment modalities rather than sticking to a single technique. Similarly, we believe that final outcomes should be reported on a long time span so that a durable result can be achieved. This may relieve the intense frustration of both the patient and the treating surgeons.

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Patients and methods This study included 15 patients referred to the AinShams University Hospitals (a tertiary referral center). All cases were previously managed elsewhere and referred for definitive management and decannulation. There were three females and 12 males aged (at time of referral) 4–58 years. The final outcome measures were a stable patent well-protected airway without tracheostomy and a good voice (Table 1). Nine patients were victims of a road traffic accident, five were subjected to an occupational trauma, and one tried to commit suicide by hanging. This study did not include any patient with post-intubation injury. All patients underwent a high-resolution CT scan of the neck and chest, direct laryngobronchoscopy under GA, and telescopic examination, which was supplemented by antegrade and retrograde flexible endoscopy through the tracheostomy. Six patients had an MRI of the airway and four had CT virtual endoscopy as well. Emergency procedure Emergency management of the airway at the time of initial trauma was done in a primary or secondary care center. This consisted of tracheostomy in nine patients and endotracheal intubation in another four patients immediately after trauma. The last two patients needed no airway maintenance intervention and were admitted for observation and follow-up. Of the four patients who were intubated, three were tracheostomized 7 days after trauma due to failure of extubation and one was extubated. So a total of 12 patients presented to us with tracheostomy and three without tracheostomy.

trauma. In five, there was a direct blunt external trauma. In three, there was tracheal shearing due to high-speed thoracic trauma. Type of injury In five patients, there was a depressed fracture of the cricoid and upper tracheal rings. In three patients, there was a disruption of the trachea at the cervicothoracic level with loss of continuity and a circumferential stenosis. In three patients, there was a fracture of the thyroid ala, and in two patients a fracture involving the thyroid, cricoid, and upper tracheal rings with collapse of the airway. In two patients, there was subglottic stenosis at the level of the cricoid ring. Associated lesions Four patients had bilateral vocal fold paralysis and three had left vocal fold paralysis. One patient had an associated mandibular fracture and multiple rib fractures. One had a cervical spine injury resulting in bilateral paraparesis. Another patient had extensive lower limb injuries. Degree of stenosis [2] Eight patients had a grade three stenosis at the narrowest point whereas the seven remaining patients had a grade four stenosis. Five patients with grade four stenosis had multiple level lesions, two had grade two stenosis, and three had a grade three stenosis at another level. Surgical management

Type of trauma All cases were blunt closed injuries. In seven patients, the trauma was a compression strangulation type of

The time of presentation since initial injury till intervention in our center ranged from 6 weeks to 6 months. In all patients, the surrounding neck tissues were very

Table 1 Patient characteristics Patient

Age

Injury

Sites

Grade

Other injuries

VF palsy

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

23 25 31 56 18 10 18 5 4 16 58 16 28 7 19

Shearing Shearing Blunt Compression Blunt Blunt Compression Compression Blunt Compression Compression Shearing Compression Compression Blunt

Lower trachea Lower trachea Trachea Thyroid + cricoid + trachea Cricoid + trachea Trachea Trachea Thyroid + cricoid + trachea Cricoid Thyroid + cricoid + trachea Thyroid Lower trachea Cricoid Cricoid + trachea Trachea + cricoid

3 3 3 3 4 4 4 4 4 3 3 4 3 3 4

External wounds Multiple fractures Mandible + chest None Cervical spine None None None None None None Limb fractures + concussion None None Pc

None None Bilateral Bilateral Bilateral None None Bilateral None Left Left None None None Left

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badly scarred. There was extensive fibrous tissue especially in patients presenting late after initial trauma. Minimal dissection was carefully performed to prevent damage to the great vessels and the recurrent laryngeal nerves (Table 2).

A total of seven LTR, six PCTR, and four laser dilatation were done in this group of patients to achieve a good functional outcome. They had a total of 13 interventions. Additional procedures

Tracheostomized patients Twelve patients presented to our center with a tracheostomy. In four of these patients, the primary procedure was a laryngotracheal reconstruction (LTR) using costal cartilage. In two of them, we used anterior and posterior grafts. This was followed by laser dilatation. Five patients underwent partial cricotracheal resection (PCTR) with end to end thyro-tracheal anastomosis. One case had combined LTR and stenting as a primary management due to insufficient healthy anterior tracheal wall tissue. One case failed and underwent LTR and stenting. A third case needed laser dilatation of a post-anastomotic stricture. Two patients had a long tracheostomy tube placed to bypass a low tracheal stenosis. For these two patients, laser dilatation and endoluminal stenting were successfully done. The last patient, who presented with tracheostomy, needed only laser dilatation and stenting. A total of 40 interventions were performed for these 12 patients.

All patients undergoing LTR or PCTR had a temporary silastic stent for 3–18 weeks. Six patients had a permanent endoluminal stent (Ultraflex/Wallstent selfexpanding stent, Boston Scientific). All patients who underwent LTR required laser dilatation at various intervals for an average of three sessions until the airway became stable. Patients with bilateral vocal fold paralysis/fixation underwent an endoscopic laser cordotomy at some time before final decannulation.

Results The patients underwent a total number of 53 procedures with an average of 3.5 procedures (1–7 procedures). Not included are routine follow-up endoscopies or minimal clearance of granulation tissue on stents or around stomas (Table 3). Airway

Non-tracheostomized patients All three patients had grade three stenosis. One patient had an LTR followed by laser vaporization of granulations. The second patient had a PCTR, followed by laser dilatation of post-anastomotic stricture. The third patient underwent laser dilatation and endoluminal stenting. However, restenosis occurred at the distal end of the stent and an LTR with stenting was performed.

Thirteen of the fifteen patients (86.6%) were decannulated after an average of 1–60 weeks, with a mean follow-up of 26.5 months (3–60 months). Aspiration Only one patient had minimal occasional spill-over without chest problems and is under therapy with a speech pathologist.

Table 2 Management: LTR Laryngotracheal reconstruction; PCTR partial cricotracheal resection Patient

State of airway

Intervention

Additional treatment

Procedures

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Tracheostomy Tracheostomy Tracheostomy Tracheostomy Tracheostomy Tracheostomy Tracheostomy Tracheostomy Tracheostomy Tracheostomy None Tracheostomy None None Tracheostomy

Endoluminal stenting Endoluminal stenting Laser + stenting LTR PCTR + LTR + Stenting PCTR PCTR PCTR LTR LTR LTR Laser + stenting PCTR Laser + stenting PCTR

– – None Laser Laser Laser – LTR + laser Laser Laser Laser – Laser LTR + stenting –

2 5 2 4 6 4 1 6 3 3 3 2 3 7 2

635 Table 3 Outcomes

As regards tolerance for daily activities, we used a modification of the McMaster University asthma quality of life questionnaire [7] (using the activities and emotional scores total 112). Four patients could perform above the 90th percentile; all the remaining patients were above the 50th percentile. No patient was totally handicapped as a result of their airway problem and they could tend for their basic activities.

patients with such lesions present late as they might have other co-morbidities and are usually kept in intensive care units before being referred for evaluation of the laryngotracheal lesion. The time delay unfavorably influences the quality of surrounding tissues. Postoperative evaluation is also mandatory to prevent deterioration of results and manage complications early. Sticking to a single treatment strategy is not always possible in such cases and the treating physician must be able to modify management plans according to the patient’s progress [4, 5, 12, 13, 16, 17, 19]. We report on 15 patients with traumatic LTS treated over the past 7 years. The commonest cause of trauma was road traffic accidents. Most had complex injuries associated with scarring of the surrounding soft tissues. In our study, we could achieve good functional results on the long term and with a multistage approach tailored for each patient. Thirteen patients (86.6%) were eventually decannulated after an average of 3.5 procedures over a mean period of 20.8 months. Voice was functionally normal in 10 patients and poor in five (average GRBAS 6.9). Daily activity outcomes were satisfactory in most patients (mean 89/112). Unlike standardized therapeutic and surgical approaches in post-intubation LTS, these cases are complex and are preferably managed as early as possible by selected centers having both the expertise and the dedication to manage them. This might explain the increase in number of interventions and the prolonged time before extubation in comparison to other studies in the literature [4,5,8,12,15]. We would all be much better off if more prevention could spare originally healthy individuals such a burden and more and more emphasis should be directed toward better safety on the road and in the work areas [3, 5, 16]. Similarly, trauma teams should be instructed on the best way to evaluate the injured airway and manage it, to help rather than complicate further interventions [3, 12].

Discussion

Conclusion

LTS remains one of the most challenging problems facing the otolaryngologist. The final outcome should be a stable patent airway, a functionally acceptable voice, and proper protection of the lungs [16, 20]. Cases with post-traumatic stenosis should be considered separately from those with post-intubation stenosis. Each patient presents with a different and unpredictable problem. The patterns and extent of injuries and co-morbidities are unlimited and each patient should be evaluated individually. Thorough evaluation of the extent of injury is of utmost importance. Multiple levels in the larynx either in the supra- or subglottis and trachea may be affected. Vocal fold immobility, if present, represents an additional handicap. In many cases, there is loss of structural support due to traumatic loss of tissue and the vascularity of the remaining segments is usually precarious [1]. Moreover,

Traumatic LTS is a severe, unpredictable injury that affects multiple levels of the airway and its surrounding blood supply. This necessitates different and more versatile types of procedures dictated by the extent of injury. Neither the physician nor the patient should be frustrated by the problem of laryngotracheal trauma. Both must be prepared for a long-term contract and a multiplicity of judiciously planned steps in order to achieve a satisfactory result. The key words here are patience and perseverance.

Patient

Airway

Time (weeks)

Functional outcome

GRBAS score

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Decannulated Decannulated Decannulated Decannulated Not Not Decannulated Decannulated Decannulated Decannulated Decannulated Decannulated Decannulated Decannulated Decannulated

12 25 6 36 – – 3 32 10 52 12 3 1 60 2

105 70 89 79 66 83 100 85 80 93 89 102 101 98 95

1 2 8 10 5 12 0 11 9 10 14 4 2 9 5

Speech Speech was evaluated on the GRBAS scale. Six patients had normal speech (GRBAS 0–5), three had a moderate degree of voice disturbance (GRBAS 5–10), and five had severe dysphonia (GRBAS > 10). Daily activities

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