Airway Stenosis: Evaluation and Endoscopic Management Murtaza Ghadiali, M.D. UCLA Division of Head and Neck Surgery November 19 th, 2008

Airway Stenosis: Airway Stenosis: Evaluation and Evaluation and

Endoscopic Endoscopic ManagementManagement

Murtaza Ghadiali, M.D.Murtaza Ghadiali, M.D.UCLAUCLA

Division of Head and Neck Division of Head and Neck SurgerySurgery

November 19November 19thth, 2008, 2008

OutlineOutline IntroductionIntroduction EtiologyEtiology

Autoimmune Causes Autoimmune Causes Acquired CausesAcquired Causes Role of LPRRole of LPR IPSSIPSS

EvaluationEvaluation H&P, Grading, DL/BH&P, Grading, DL/B

Endoscopic ManagementEndoscopic Management MitomycinMitomycin TGF-TGF-ββ Lasers/Balloon DilationLasers/Balloon Dilation

IntroductionIntroduction

Airway Stenosis is both a Airway Stenosis is both a therapeutic and diagnostic challengetherapeutic and diagnostic challenge

Presents insidiously with progressive Presents insidiously with progressive SOB, brassy cough, SOB, brassy cough, wheezing/stridor, possible recurrent wheezing/stridor, possible recurrent pneumonitispneumonitis

Many times misdiagnosed as Many times misdiagnosed as asthma/bronchitis, COPD, CHFasthma/bronchitis, COPD, CHF

IntroductionIntroduction

Common etiology (beginning 1965)Common etiology (beginning 1965) either cuffed endotracheal or either cuffed endotracheal or

tracheotomy tubetracheotomy tube Less common: Less common:

external trauma/compressionexternal trauma/compression high tracheotomy incisionhigh tracheotomy incision benign tumors benign tumors ‘‘nontraumatic, nonneoplastic’ causesnontraumatic, nonneoplastic’ causes

Etiology of SGSEtiology of SGS I. Congenital SGSI. Congenital SGS

MembranousMembranous CartilaginousCartilaginous

II. Acquired SGSII. Acquired SGS IntubationIntubation Laryngeal traumaLaryngeal trauma AI (Wegener’s; Sarcoid; Amyloid; Relapsing AI (Wegener’s; Sarcoid; Amyloid; Relapsing

Polychondritis)Polychondritis) InfectionInfection IPSS (Idiopatic Subglottic Stenosis)IPSS (Idiopatic Subglottic Stenosis) GER/LPRGER/LPR Inflammatory diseasesInflammatory diseases NeoplasmsNeoplasms

Nonneoplastic, Nonneoplastic, nontraumatic Subglottic nontraumatic Subglottic

StenosisStenosis Wegener’s GranulomatosisWegener’s Granulomatosis AmyloidosisAmyloidosis

Can present with SG alone Can present with SG alone SarcoidosisSarcoidosis

Can present with SG aloneCan present with SG alone Relapsing PolychondritisRelapsing Polychondritis

SGS – Wegener’sSGS – Wegener’s

Systemic Systemic inflammatory inflammatory disorderdisorder

AutoimmuneAutoimmune ANCA C +ANCA C + 16-23% incidence 16-23% incidence

of SG stenosisof SG stenosis SGS can be the SGS can be the

lone manifestation lone manifestation of WGof WG

TreatmentTreatment Individualized Individualized

based on degree based on degree and acuity of and acuity of stenosisstenosis

No major surgery No major surgery during Wegener’s during Wegener’s flare upsflare ups

Wegener’s Wegener’s GranulomatosisGranulomatosis

Classic triad: necrotizing granulomas of Classic triad: necrotizing granulomas of the upper respiratory tract and lungs, the upper respiratory tract and lungs, focal glomerulitis, disseminating vasculitisfocal glomerulitis, disseminating vasculitis Treatment: Azathioprine, cyclophosphamide, Treatment: Azathioprine, cyclophosphamide,

steroidssteroids Laryngeal WGLaryngeal WG

Ulcerating lesions induce Ulcerating lesions induce subglottic stenosissubglottic stenosis Histopathology: Histopathology: coagulation necrosiscoagulation necrosis from vasculitis, from vasculitis,

multinucleated giant cells, palisading histiocytesmultinucleated giant cells, palisading histiocytes

AmyloidosisAmyloidosis Deposition of Deposition of extracellular fibrillar proteinsextracellular fibrillar proteins

in tissuesin tissues Primary (56%), secondary (8%), localized Primary (56%), secondary (8%), localized

(9%), myeloma associated (26%), familial (1%)(9%), myeloma associated (26%), familial (1%) Generalized amyloid evaluated by Generalized amyloid evaluated by rectal rectal

biopsybiopsy or FNA anterior or FNA anterior abdominal wall fatabdominal wall fat LocationsLocations

Tongue > orbit > larynxTongue > orbit > larynx Laryngeal amyloidosisLaryngeal amyloidosis

TVC > FVC > subglotticTVC > FVC > subglottic ManagementManagement

SurgicalSurgical

AmyloidosisAmyloidosis

DiagnosisDiagnosis Congo red staining and green Congo red staining and green

birefringence under polarized lightbirefringence under polarized light Fibrillar structure under electron Fibrillar structure under electron

microscopymicroscopy Beta-pleated sheet on x-ray Beta-pleated sheet on x-ray

crystallography and infrared crystallography and infrared spectroscopyspectroscopy

18 biochemical forms identified18 biochemical forms identified AL (plasma cells), AA (chronic AL (plasma cells), AA (chronic

inflammation), Ainflammation), A (cerebral lesions) (cerebral lesions)

Amyloidosis – Amyloidosis – ManagementManagement

Step 1 Biopsy the affected organStep 1 Biopsy the affected organ Step 2 Rule out generalized amyloidosisStep 2 Rule out generalized amyloidosis

Rectal bx, echocardiography, Rectal bx, echocardiography, bronchoscopy and PFTs, CT of bronchoscopy and PFTs, CT of neck/tracheaneck/trachea

Step 3 Rule out generalized Step 3 Rule out generalized plasmacytomaplasmacytoma Bone marrow biopsy, bone marrow Bone marrow biopsy, bone marrow

scintigraphy, serologic and immunologic scintigraphy, serologic and immunologic examininationsexamininations

Laryngeal AmyloidosisLaryngeal Amyloidosis

< 1% of benign laryngeal lesions< 1% of benign laryngeal lesions Most amyloid deposits are AL typeMost amyloid deposits are AL type Typically in men in the 5Typically in men in the 5thth decade of decade of

lifelife Sx depends on site (e.g. glottic Sx depends on site (e.g. glottic

amyloidosis amyloidosis hoarseness) hoarseness)

SarcoidosisSarcoidosis Idiopathic, non-caseating granulomasIdiopathic, non-caseating granulomas

Generalized adenopathy (25-50%), orbit (15-Generalized adenopathy (25-50%), orbit (15-25%), splenomegaly (10%), neural (4-6%)25%), splenomegaly (10%), neural (4-6%)

Symptoms: fever, weight loss, arthralgiasSymptoms: fever, weight loss, arthralgias Head and neck: cervical adenopathy > larynxHead and neck: cervical adenopathy > larynx Evaluation: CXR, PPD, skin test for anergy, Evaluation: CXR, PPD, skin test for anergy,

ACE levels (elevated in 80-90%)ACE levels (elevated in 80-90%) TreatmentTreatment

Oral steroidsOral steroids Laryngeal sarcoidosisLaryngeal sarcoidosis

Supraglottic involvementSupraglottic involvement Typical yellow subcutaneous nodules or polypsTypical yellow subcutaneous nodules or polyps Diffusely enlarged, pale pink, turban-like Diffusely enlarged, pale pink, turban-like

epiglottisepiglottis

Relapsing PolychondritisRelapsing Polychondritis

Inflammation of cartilage and other Inflammation of cartilage and other tissues with high concentration of tissues with high concentration of glycosaminoglycansglycosaminoglycans

Episodic and progressiveEpisodic and progressive Ear > nasal, ocular, respiratory tractEar > nasal, ocular, respiratory tract Treatment: symptomatic, steroidsTreatment: symptomatic, steroids

Laryngeal RPLaryngeal RP RareRare Inflammation can lead to laryngeal collapseInflammation can lead to laryngeal collapse Treatment usually tracheostomyTreatment usually tracheostomy

Acquired SGSAcquired SGS

95% of cases of SGS95% of cases of SGS Majority due to long-term or prior Majority due to long-term or prior

intubationintubation Duration of intubationDuration of intubation ETT sizeETT size Number of intubationsNumber of intubations Traumatic intubationsTraumatic intubations Movement of the ETTMovement of the ETT InfectionInfection

Poetker DM et al. Association of airway Poetker DM et al. Association of airway abnormalities and risk factors in 37 abnormalities and risk factors in 37 subglottic stenosis patients. Otolaryngol subglottic stenosis patients. Otolaryngol Head Neck Surg (2006) 135, 434-437Head Neck Surg (2006) 135, 434-437

Pathogenesis of acquired Pathogenesis of acquired SGSSGS

Initial injury – compression of mucosa by Initial injury – compression of mucosa by an ETT or cuffan ETT or cuff

IschemiaIschemia NecrosisNecrosis Decreased mucociliary flowDecreased mucociliary flow InfectionInfection Three stages of wound healingThree stages of wound healing

InflammatoryInflammatory Proliferative – granulation tissueProliferative – granulation tissue Scar formation – contraction and remodelingScar formation – contraction and remodeling

Pathogenesis SGSPathogenesis SGS Mankarious et al (2003):Mankarious et al (2003): Investigated Investigated

histopathologic features of 6 specimens from histopathologic features of 6 specimens from pts that underwent tracheal resectionpts that underwent tracheal resection Analyzed levels of hyaline cartilage components: Analyzed levels of hyaline cartilage components:

collagen type I and II & aggrecan (secreted by collagen type I and II & aggrecan (secreted by chondrocytes)chondrocytes)

Normal tracheal/cricoid: High ratio of type I to IINormal tracheal/cricoid: High ratio of type I to II Specimens: relative decrease in type I and Specimens: relative decrease in type I and

aggrecanaggrecan Regenerative cartilage: greatly increased amounts of Regenerative cartilage: greatly increased amounts of

type II collagen and aggrecantype II collagen and aggrecan Suggests Type I collagen and aggrecan responsibe for Suggests Type I collagen and aggrecan responsibe for

cartilage structural integritycartilage structural integrity Regenerative fibroblasts do not deposit type I collagenRegenerative fibroblasts do not deposit type I collagen

Acquired SGS and PDTAcquired SGS and PDT

Ciaglia 1985: Percutaneous Ciaglia 1985: Percutaneous dilational tracheotomy (PDT)dilational tracheotomy (PDT)

Bartels 2002: 108 PDT patients; 10 Bartels 2002: 108 PDT patients; 10 with 6 mo f/u; 1 patient with with 6 mo f/u; 1 patient with significant stenosis at f/u significant stenosis at f/u ? Selection Bias? Selection Bias Authors conclude 10% stenosis rate is Authors conclude 10% stenosis rate is

consistent with open tracheotomyconsistent with open tracheotomy


Klussman et al (2001): Reported case Klussman et al (2001): Reported case of complete suprastomal tracheal of complete suprastomal tracheal stenosis/atresia after second PDTstenosis/atresia after second PDT

? Initial infection leading to destruction ? Initial infection leading to destruction and cartilaginous necrosis/Tracheal and cartilaginous necrosis/Tracheal ring fracture leading to mucosal tears ring fracture leading to mucosal tears and cicatricial scarringand cicatricial scarring

Cautioned against use of PDT in Cautioned against use of PDT in secondary tracheotomysecondary tracheotomy


Hotchkiss & McCaffrey (2003): examined Hotchkiss & McCaffrey (2003): examined pathophysiology of PDT on 6 cadaverspathophysiology of PDT on 6 cadavers

3/6 Trachs were placed incorrectly (range: 3 3/6 Trachs were placed incorrectly (range: 3 tracheal rings away to just sub-cricoid)tracheal rings away to just sub-cricoid)

Anterior tracheal wallAnterior tracheal wall High degree of injuryHigh degree of injury Severe cartilage damage at site of insertionSevere cartilage damage at site of insertion Multiple, comminuted injuries in 2 or more Multiple, comminuted injuries in 2 or more

cartilaginous ringscartilaginous rings Findings suggest acute, severe mechanical injury Findings suggest acute, severe mechanical injury

in PDTin PDT

Acquired SGS & LPRAcquired SGS & LPR Gastroesophageal reflux Gastroesophageal reflux

(GER)/Laryngopharyngeal reflux (LPR)(GER)/Laryngopharyngeal reflux (LPR) 1985 – Little – applied gastric contents/H2O 1985 – Little – applied gastric contents/H2O

to subglottis of dogsto subglottis of dogs Delayed epithelialization and stenosis formation in Delayed epithelialization and stenosis formation in

lesions treated with gastric contentslesions treated with gastric contents 1991 – Koufman – applied acid and pepsin to 1991 – Koufman – applied acid and pepsin to

subglottis of dogs; control was H2Osubglottis of dogs; control was H2O 20 dogs with induced submucosal injury20 dogs with induced submucosal injury Increased level of granulation tissue and Increased level of granulation tissue and

inflammationinflammation 78% pts with LTS: abnormal acidic pH probes; 78% pts with LTS: abnormal acidic pH probes;

67% pharynx reflux67% pharynx reflux

GER/LPR and SGSGER/LPR and SGS

1998 Walner: 74 pediatric patients 1998 Walner: 74 pediatric patients with SGS had 3 times greater with SGS had 3 times greater incidence of GER than the general incidence of GER than the general pediatric populationpediatric population

2001 Maronian: 19 pts with SGS2001 Maronian: 19 pts with SGS 9 pts with IPSS; 10 with acquired SGS9 pts with IPSS; 10 with acquired SGS 14 pts with pH testing14 pts with pH testing

Abnormal (pH <4): 71% IPSS pts and 100% Abnormal (pH <4): 71% IPSS pts and 100% acquired ptsacquired pts

GER/LPR and SGSGER/LPR and SGS

Dedo (2001): Challenged association; Dedo (2001): Challenged association; largest review of 50 pts with IPSS; Only 7/38 largest review of 50 pts with IPSS; Only 7/38 patients had reflux symptomspatients had reflux symptoms

Ashiku (2004): 15/73 IPSS patients had Ashiku (2004): 15/73 IPSS patients had reflux symptoms; No patients had laryngeal reflux symptoms; No patients had laryngeal signs of refluxsigns of reflux

Both groups concluded no causal Both groups concluded no causal relationship between reflux and stenosis in relationship between reflux and stenosis in their groupstheir groups Only 2 patients in collective cohorts Only 2 patients in collective cohorts

underwent specific reflux testingunderwent specific reflux testing

Idiopathic Subglottic Idiopathic Subglottic StenosisStenosis

Rare condition of dense fibrous stenosis of Rare condition of dense fibrous stenosis of the proximal trachea in absence of inciting the proximal trachea in absence of inciting eventevent

Affects women; primarily involves subglottic Affects women; primarily involves subglottic larynx and proximal 2-4 cm of trachea larynx and proximal 2-4 cm of trachea circumferentiallycircumferentially

May be associated with certain autoimmune May be associated with certain autoimmune statesstates Wegener’s GranulomatosisWegener’s Granulomatosis Relapsing PolychondritisRelapsing Polychondritis Rheumatoid ArthritisRheumatoid Arthritis SLESLE

Ashiku SK et al. Idiopathic laryngotracheal stenosis. Ashiku SK et al. Idiopathic laryngotracheal stenosis. Chest Surg Clin North Am, Chest Surg Clin North Am, 2003; 13:2572003; 13:257

IPSS (Idiopathic Subglottic IPSS (Idiopathic Subglottic Stenosis)Stenosis)

Possible hormonal causePossible hormonal cause To date, presence of estrogen receptors To date, presence of estrogen receptors

in the affected airway has not been in the affected airway has not been conclusively shown in these patients conclusively shown in these patients ( Dedo 2001)( Dedo 2001)

? Possible link between female ? Possible link between female preponderance and LPRpreponderance and LPR Progesterone and its impact on LES pressureProgesterone and its impact on LES pressure Major contributing factor toward heartburn Major contributing factor toward heartburn

and reflux in pregnancyand reflux in pregnancy Cyclic hormonal variations in normal women Cyclic hormonal variations in normal women

found to impact LES pressure leading to found to impact LES pressure leading to possible refluxpossible reflux

SGS Initial presentationSGS Initial presentation

History of prior intubation andHistory of prior intubation and Progressive SOB and loud Progressive SOB and loud

breathingbreathing

Initial PresentationInitial Presentation

History History Review intubation recordsReview intubation records PmhxPmhx

DiabetesDiabetes Cardiopulmonary diseaseCardiopulmonary disease RefluxReflux Systemic steroid useSystemic steroid use

Initial presentationInitial presentation Physical exam – Complete H/N examPhysical exam – Complete H/N exam

ObserveObserve Stridor or labored breathingStridor or labored breathing RetractionsRetractions Breathing characteristics on exertionBreathing characteristics on exertion Voice quality Voice quality

Head/NeckHead/Neck Other abnormalities (congenital anomalies, Other abnormalities (congenital anomalies,

tumors, infection)tumors, infection)

DiagnosisDiagnosis

DifferentialDifferential CongenitalCongenital

LaryngeomalaciaLaryngeomalacia TracheomalciaTracheomalcia VC paralysisVC paralysis CystsCysts CleftsClefts Vascular compressionVascular compression MassMass

DiagnosisDiagnosis

DifferentialDifferential Infection/InflammationInfection/Inflammation

EpiglottitisEpiglottitis GERGER TracheitisTracheitis

NeoplasticNeoplastic MalignancyMalignancy Recurrent respiratory papillomas; benign Recurrent respiratory papillomas; benign

lesionslesions Foreign bodyForeign body

DiagnosisDiagnosis

RadiographsRadiographs Plain films – inspiratory and expiratory Plain films – inspiratory and expiratory

neck and chestneck and chest CTCT MRIMRI

DiagnosisDiagnosis Flexible nasopharyngolaryngoscopyFlexible nasopharyngolaryngoscopy

Nose/NasopharynxNose/Nasopharynx NP stenosisNP stenosis Masses, tumorMasses, tumor

SupraglottisSupraglottis Structure abnormalitiesStructure abnormalities LaryngomalaciaLaryngomalacia

GlottisGlottis VC mobilityVC mobility Webs/massesWebs/masses

Immediate subglottisImmediate subglottis

DiagnosisDiagnosis

Gold standard for diagnosis of SGSGold standard for diagnosis of SGS Rigid endoscopyRigid endoscopy

Properly equipped ORProperly equipped OR Experienced anesthesiologistExperienced anesthesiologist Preop discussion about possible need for Preop discussion about possible need for

trachtrach

Operative EvaluationOperative Evaluation EndoscopyEndoscopy

Fiberoptic endoscopic assisted intubation vs. Fiberoptic endoscopic assisted intubation vs. evaluation evaluation

LMALMA Spontaneous ventilation, Spontaneous ventilation, NO PARALYSISNO PARALYSIS !! Consider awake tracheotomyConsider awake tracheotomy

Perform Rigid DL, B, and EPerform Rigid DL, B, and E Closely evaluate the interarytenoid area for Closely evaluate the interarytenoid area for

stenosis/stricturestenosis/stricture Evaluate position of cordsEvaluate position of cords

Determine size, extent, and location of the Determine size, extent, and location of the stenotic lesionstenotic lesion Use an ETT/bronchoscope to measure the lumenUse an ETT/bronchoscope to measure the lumen Measure from undersurface of the cord to the lesionMeasure from undersurface of the cord to the lesion R/o other stenotic areasR/o other stenotic areas

Grading Systems for SGSGrading Systems for SGS

Cotton-Myer (1994)Cotton-Myer (1994) McCaffrey (1992)McCaffrey (1992)

Cotton-Myer Grading Cotton-Myer Grading SystemSystem

Classification From To

Grade I 0% 50%

Grade II 51% 70%

Grade III 71% 99%

Grade IV No DetectableLumen

Cotton-Cotton-Myer Myer grading grading system for system for subglottic subglottic stenosisstenosis

Grade II SGSGrade II SGS

Grade III SGSGrade III SGS

Grade IV SGSGrade IV SGS

Myer/Cotton Grading Myer/Cotton Grading SystemSystem

Multiple revision of original system Multiple revision of original system proposed by Cotton in 1984proposed by Cotton in 1984

First systems criticized for being First systems criticized for being based on subjective interpretation, based on subjective interpretation, although statistically proven to although statistically proven to relate grade with prognosis in relate grade with prognosis in childrenchildren

Myer 1994: used serial ETT Myer 1994: used serial ETT measurement to derive Cotton grademeasurement to derive Cotton grade


Cotton-MyerCotton-Myer Based on relative reduction of Based on relative reduction of

subglottic cross-sectional areasubglottic cross-sectional area Good for mature, firm, circumferential Good for mature, firm, circumferential

lesionslesions Does not take into account extension to Does not take into account extension to

other subsites or length of stenosisother subsites or length of stenosis Gold-Standard Staging in pediatric Gold-Standard Staging in pediatric

patientspatients

McCaffrey Grading McCaffrey Grading SystemSystem

McCaffrey McCaffrey (1991)(1991)

Relative reduction in cross sectional Relative reduction in cross sectional area not consistently reliable predictor area not consistently reliable predictor of decannulation in adultsof decannulation in adults

Reviewed 73 cases of LTS in adults Reviewed 73 cases of LTS in adults finding location of stenosis to be the finding location of stenosis to be the most significant factor in predicting most significant factor in predicting decannulationdecannulation


McCaffreyMcCaffrey Based on subsites (trachea, subglottis, Based on subsites (trachea, subglottis,

glottis) involved and length of stenosisglottis) involved and length of stenosis Does not include lumen diameterDoes not include lumen diameter

McCaffrey Clinical McCaffrey Clinical StagingStaging

Stage IStage I: confined to : confined to subglottis/tracheasubglottis/trachea

Stage IIStage II: SGS, : SGS, >1cm, confined to >1cm, confined to cricoidcricoid

Stage IIIStage III: SGS and : SGS and involving tracheainvolving trachea

Stage IVStage IV:involve :involve glottis with fixation glottis with fixation TVCTVC

Grading Systems for SGSGrading Systems for SGS McCaffreyMcCaffrey

McCaffrey ConclusionsMcCaffrey Conclusions

SiteSite: glottic, tracheal, subglottic: major : glottic, tracheal, subglottic: major factor factor in type of surgeryin type of surgery thin (<1cm) subglottic or tracheal thin (<1cm) subglottic or tracheal

lesions--Endoscopiclesions--Endoscopic thick(>1cm) any site or glottic lesions--thick(>1cm) any site or glottic lesions--

OpenOpen

StageStage: prognostic predictor: prognostic predictor 90% of Stage I and II successfully treated90% of Stage I and II successfully treated 70% of Stage III, 40% of Stage IV70% of Stage III, 40% of Stage IV

Management of SGSManagement of SGS

MedicalMedical ObservationObservation TracheotomyTracheotomy Endoscopic TreatmentEndoscopic Treatment

CO2 laser (with Mitomycin C/Steroid)CO2 laser (with Mitomycin C/Steroid) Rigid vs. Balloon Dilation (with Rigid vs. Balloon Dilation (with

Mitomycin)Mitomycin) Open Airway expansion procedureOpen Airway expansion procedure


MedicalMedical Diagnosis and treatment of GERDiagnosis and treatment of GER Pediatric – consultation with primary Pediatric – consultation with primary

physician and specialists (pulmonary, GI, physician and specialists (pulmonary, GI, cardiology etc.)cardiology etc.)

AdultAdult Assess general medical statusAssess general medical status Consultation with PCP and specialistsConsultation with PCP and specialists Optimize cardiac and pulmonary functionOptimize cardiac and pulmonary function Control diabetesControl diabetes Discontinue steroid use if possible before LTRDiscontinue steroid use if possible before LTR


ObservationObservation Reasonable in mild cases, esp. Reasonable in mild cases, esp.

congenital SGS (Cotton-Myer grade I congenital SGS (Cotton-Myer grade I and mild grade II)and mild grade II) If no retractions, feeding difficulties, or If no retractions, feeding difficulties, or

episodes of croup requiring hospitalizationepisodes of croup requiring hospitalization Follow growth curvesFollow growth curves Repeat endoscopy q 3-6 moRepeat endoscopy q 3-6 mo

Adults – depends on symptomsAdults – depends on symptoms

Surgery for SGSSurgery for SGS I. Endoscopic I. Endoscopic

Dilation +/- stentingDilation +/- stenting Rigid vs. balloon dilationRigid vs. balloon dilation

Laser +/- stentingLaser +/- stenting II. Open procedureII. Open procedure

Expansion procedure (with trach and Expansion procedure (with trach and stent or SS-LTR)stent or SS-LTR) Laryngotracheoplasty (Trough technique with Laryngotracheoplasty (Trough technique with

mucosal grafting +/- cartilage grafting)mucosal grafting +/- cartilage grafting) Laryngotracheal reconstructionLaryngotracheal reconstruction Tracheal Resection with primary anastamosisTracheal Resection with primary anastamosis

Management of SGSManagement of SGS How do you decide which procedure to How do you decide which procedure to

performperform Status of the patientStatus of the patient

Any contraindicationsAny contraindications AbsoluteAbsolute

Tracheotomy dependent (aspiration, severe Tracheotomy dependent (aspiration, severe BPD)BPD)

Severe GER refractive to surgical and Severe GER refractive to surgical and medical therapymedical therapy

RelativeRelative DiabetesDiabetes Steroid useSteroid use Cardiac, renal or pulmonary diseaseCardiac, renal or pulmonary disease


EndoscopicEndoscopic DilationDilation

Practiced frequently before advent Practiced frequently before advent of open LTP proceduresof open LTP procedures

Often requires multiple repeat Often requires multiple repeat proceduresprocedures

Potentially lower success rate but Potentially lower success rate but an option for patients who cannot an option for patients who cannot undergo open proceduresundergo open procedures

Treatment OptionsTreatment Options

GoalsGoals

1. Maintain patent airway1. Maintain patent airway

2. Maintain glottic competence to 2. Maintain glottic competence to

protect against aspirationprotect against aspiration

3. Maintain acceptable voice3. Maintain acceptable voice

Surgical ManagementSurgical Management

ApproachesApproaches Endoscopic: cryotherapy, Endoscopic: cryotherapy,

microcauterization, laser incision or microcauterization, laser incision or excision of scar tissue, dilatation, excision of scar tissue, dilatation, stentingstenting

Open surgical: tracheal resection and Open surgical: tracheal resection and reanastomosis, external tracheoplasty reanastomosis, external tracheoplasty with/without grafting and possible with/without grafting and possible stentingstenting

StentsStents

Indwelling expandable stentsIndwelling expandable stents Used in many organ systems: arteries, the Used in many organ systems: arteries, the

urethra, and biliary treeurethra, and biliary tree

Tracheobronchial system: Tracheobronchial system: Lower airways for either tumors, or Lower airways for either tumors, or

bronchial stenosis after lung bronchial stenosis after lung transplantationtransplantation

Upper airways (Montgomery T-tube, Upper airways (Montgomery T-tube, silicone, mesh stents): used alone or with silicone, mesh stents): used alone or with other modalities other modalities

StentsStents

StentingStenting Ensure adequate airway during wound Ensure adequate airway during wound

maturationmaturation While waiting for pt’s condition to While waiting for pt’s condition to

improve prior to definitive surgical improve prior to definitive surgical resection/treatmentresection/treatment

Silastic T-Tubes most commonly usedSilastic T-Tubes most commonly used Permit better hygienePermit better hygiene Not prone to obstructing granulationNot prone to obstructing granulation Stent removal possible after 1-2 years with Stent removal possible after 1-2 years with

good resultsgood results

Expandable StentExpandable Stent

Hanna Hanna 19971997 Canine model(6)Canine model(6)

Stenosis induced by resection of anterior Stenosis induced by resection of anterior cricoid arch/tracheal wall to reduce airway cricoid arch/tracheal wall to reduce airway diameter by 50%diameter by 50%

8 week stenosis maturation period8 week stenosis maturation period Tracheostomy performed, followed by Tracheostomy performed, followed by

introduction of titanium mesh stent (Group A), introduction of titanium mesh stent (Group A), +/- silicone covering (Group B)+/- silicone covering (Group B)

Euthanasia performed at 4 weeks with Euthanasia performed at 4 weeks with gross/histologic exam gross/histologic exam


HannaHanna (1997) (1997)

Stents well tolerated, minimal signs of Stents well tolerated, minimal signs of airway irritation, no infectionsairway irritation, no infections

Group A unable to be decannulated due Group A unable to be decannulated due to granulationto granulation

Group B all tolerated decannulation Group B all tolerated decannulation without complicationwithout complication


Silastic T-TubesSilastic T-Tubes

T-TubesT-Tubes

StentsStents

FroehlichFroehlich (1993) (1993)

Retrospective study of T-tubes in 12 Retrospective study of T-tubes in 12 pediatric patientspediatric patients

10 acquired after intubation, 2 10 acquired after intubation, 2 congenital, (4 extensive tracheomalacia)congenital, (4 extensive tracheomalacia)

10 with prior tracheotomy10 with prior tracheotomy

5 Cotton grade 2, 7 Cotton grade 3 (6 5 Cotton grade 2, 7 Cotton grade 3 (6 required anterior split to fit T-tube)required anterior split to fit T-tube)

StentsStents


mean time from insertion to final mean time from insertion to final removal 5.6 monthsremoval 5.6 months

9/12 successful tx (mean time from dx 9/12 successful tx (mean time from dx to end of tx 15.3 months)to end of tx 15.3 months)

Complications: tube migration, Complications: tube migration, accidental tube removal, tube accidental tube removal, tube occlusionocclusion

StentsStents


75% success rate of long term stenting 75% success rate of long term stenting comparable to either cricoid split or comparable to either cricoid split or LTR proceduresLTR procedures stenting takes longer, increased stenting takes longer, increased

complicationscomplications

T-tube stenting better reserved for T-tube stenting better reserved for cases not amenable to surgery, i.e. cases not amenable to surgery, i.e. tracheomalaciatracheomalacia

Endoscopic ApproachEndoscopic Approach

Benefits patients due to less Benefits patients due to less morbiditymorbidity

Shorter hospital stayShorter hospital stay Earlier return to workEarlier return to work Tolerance of repeated procedures, if Tolerance of repeated procedures, if

necessarynecessary

““Lasers”Lasers”

First medical use First medical use (December 1961)(December 1961)

Strong and Jako Strong and Jako (1972)(1972) First described CO2 First described CO2

laser for LTS laser for LTS managementmanagement

Types: Types: CO2CO2 KTPKTP Nd-YAGNd-YAG

LasersLasers Used as both definitive and as an Used as both definitive and as an

adjunct to open repairadjunct to open repair

Hall Hall (1971) delayed collagen (1971) delayed collagen synthesis in laser incisionssynthesis in laser incisions

Used in conjuncture with other Used in conjuncture with other epithelial preserving techniquesepithelial preserving techniques

Laser excision of subglottic Laser excision of subglottic stenosisstenosis

Laser excision of subglottic Laser excision of subglottic stenosisstenosis


Simpson, et alSimpson, et al (1982) (1982) Retrospective study of 60 patients: 49 Retrospective study of 60 patients: 49

laryngeal (supraglottic,glottic, subglottic), 6 laryngeal (supraglottic,glottic, subglottic), 6 tracheal, 5 combined stenosistracheal, 5 combined stenosis

Follow up: 1-8 yearsFollow up: 1-8 years Age: 2 months-72 years oldAge: 2 months-72 years old COCO22 laser used to vaporize scar tissue, laser used to vaporize scar tissue,

divide fibrotic bands, or excise redundant divide fibrotic bands, or excise redundant tissuetissue

+/- Silastic stenting, dilatation+/- Silastic stenting, dilatation


Simpson, et alSimpson, et al (1982) (1982) 39/60 had Silastic stents placed39/60 had Silastic stents placed

1/6 supraglottic1/6 supraglottic 2/12 glottic2/12 glottic 27/31 subglottic stenosis27/31 subglottic stenosis 4/6 tracheal4/6 tracheal 4/5 combined4/5 combined


Simpson, et alSimpson, et al (1982) (1982)

Dilatation employed 8/60Dilatation employed 8/60 0/49 laryngeal0/49 laryngeal 4/6 tracheal4/6 tracheal 4/5 combined4/5 combined


#CASES SUCCESS%

#PROCEDURESTO SUCCESS

Laryngeal 49 77.5 2.11

Tracheal 6 33.3 6

Combined 5 20.0 1


Simpson, et alSimpson, et al (1982): Conclusions (1982): Conclusions

Justified at all levelsJustified at all levels

Decreased success with ‘severe’, Decreased success with ‘severe’, combined, extensive (>1cm) or combined, extensive (>1cm) or circumferential stenosis; loss of circumferential stenosis; loss of cartilage, and preceding bacterial cartilage, and preceding bacterial infection associated with tracheostomyinfection associated with tracheostomy

Age not associated with failure rateAge not associated with failure rate

Management of SGSManagement of SGS EndoscopicEndoscopic

LaserLaser 66-80% success rate for Cotton-Myer grade I and 66-80% success rate for Cotton-Myer grade I and

II stenoses (pediatric cases)II stenoses (pediatric cases) Closer to 50% success rate in appropriately Closer to 50% success rate in appropriately

chosen adultschosen adults Factors associated with failureFactors associated with failure

Previous attempts Previous attempts Circumferential scarringCircumferential scarring Loss of cartilage supportLoss of cartilage support Exposure of cartilage Exposure of cartilage Arytenoid fixationArytenoid fixation Combined laryngotracheal stenosis with Combined laryngotracheal stenosis with

vertical length >1cmvertical length >1cm

Scar InhibitorsScar Inhibitors Mitomycin CMitomycin C

Antimetabolite of Antimetabolite of Streptomyces caespitosusStreptomyces caespitosus Possesses antineoplastic and Possesses antineoplastic and

antiproliferative propertiesantiproliferative properties Inhibits fibroblast proliferation Inhibits fibroblast proliferation in vivo in vivo and and

in vitroin vitro Mechanism may involve triggering of Mechanism may involve triggering of

fibroblast apoptosisfibroblast apoptosis 5-FU & B-aminopropionitrile5-FU & B-aminopropionitrile

Inhibit collagen cross-linking and scar Inhibit collagen cross-linking and scar formation in animal modelsformation in animal models

TGF-TGF-ββ

SGS Comparison StudySGS Comparison Study

Shapshay (2004)Shapshay (2004) Retrospective cohort studyRetrospective cohort study Compare efficacy of 3 endoscopic Compare efficacy of 3 endoscopic

techniquestechniques CO2 laser with rigid dilationCO2 laser with rigid dilation CO2 laser, rigid dilation, steroid CO2 laser, rigid dilation, steroid

injectioninjection CO2 laser, rigid dilation, topical CO2 laser, rigid dilation, topical

Mitomycin C applicationMitomycin C application

SGS Comparison StudySGS Comparison Study Endoscopic treatmentEndoscopic treatment

CO2 laser radial incision (Shapshay)CO2 laser radial incision (Shapshay) 15% success15% success

CO2 laser with steroid injectionCO2 laser with steroid injection 40 Kenalog in 3 quadrants40 Kenalog in 3 quadrants 18% success18% success

CO2 laser with mitomycin-C topical applicationCO2 laser with mitomycin-C topical application 0.4 mg/ml Mitomycin-C topically applied 4 minutes0.4 mg/ml Mitomycin-C topically applied 4 minutes 75% success75% success

Mitomycin C MetanalysisMitomycin C Metanalysis

Warner and Brietzke (2008)

Note: Lone human dissenting study was highest quality randomized clinical trial

TGF-TGF-ββ TGF-TGF-ββ: GF secreted by fibroblasts, : GF secreted by fibroblasts,

macrophages and plateletsmacrophages and platelets Implicated in scarring in many different Implicated in scarring in many different

organ systems and in animal modelsorgan systems and in animal models Biopsy specimens of IPSS and intubation Biopsy specimens of IPSS and intubation

related stenosis patients show high levels of related stenosis patients show high levels of TGF-TGF-ββ-2-2

IV and local injection of an antibody IV and local injection of an antibody availableavailable Used to treat fibrosis in skin, ureters, kidney Used to treat fibrosis in skin, ureters, kidney

and eyeand eye Recent study showed inhibition of scarring in rat Recent study showed inhibition of scarring in rat

trachea with continuous infusion of anti-TGFtrachea with continuous infusion of anti-TGFββ

TGF-TGF-ββSimpson CB et al (2008)

Pilot Study in Modified Canine Model

8 subjects underwent cautery injury to subglottis

4 treated with saline injection into injury site

4 treated with combination of IV and local injection of anti-TGFβ at day 0 and day 5

TGF-TGF-ββ Conclusions: Conclusions:

IV and local TGFIV and local TGFββ injection resulted in a injection resulted in a reduction in tracheal stenosis (p < .05) reduction in tracheal stenosis (p < .05) and an increase in survival time (p <.03) and an increase in survival time (p <.03) when compared to saline control subjectswhen compared to saline control subjects

Anti-TGFAnti-TGFββ appears to be useful adjunct in appears to be useful adjunct in treatment of LTStreatment of LTS

Further study needed to determine Further study needed to determine optimal dosing, route of administration optimal dosing, route of administration and timing of deliveryand timing of delivery

SGS Balloon DilationSGS Balloon Dilation Dilation of bronchtracheal stenoses with Dilation of bronchtracheal stenoses with

angioplasty balloons described previously angioplasty balloons described previously in adults and children +/- stentsin adults and children +/- stents

Advantage compared to rigid or bougie Advantage compared to rigid or bougie dilationdilation Balloons maximize the radial direction and Balloons maximize the radial direction and

pressure of dilationpressure of dilation Less damaging to tracheal wall mucosaLess damaging to tracheal wall mucosa Found to have good initial resultsFound to have good initial results

Often requires stenting of dilated portionOften requires stenting of dilated portion Repeated procedures necessary in active Repeated procedures necessary in active

processes, e.g. Autoimmune Statesprocesses, e.g. Autoimmune States

SGS Balloon DilationSGS Balloon Dilation Lee and Rutter (2008)Lee and Rutter (2008) 6 patients with IPSS (single discrete stenosis)6 patients with IPSS (single discrete stenosis) Underwent dilation with 10 to 14 mm balloon Underwent dilation with 10 to 14 mm balloon

in either single or 2 consecutive dilation (in 7 in either single or 2 consecutive dilation (in 7 days)days)

F/u between 10 and 30 months in 4 patientsF/u between 10 and 30 months in 4 patients No symptoms of recurrent airway stenosisNo symptoms of recurrent airway stenosis One patient required repeat dilation after 22 mosOne patient required repeat dilation after 22 mos No adverse effects or complicationsNo adverse effects or complications Recommended burst pressure (8 to 17 atm)Recommended burst pressure (8 to 17 atm) 4 cm long catheters, center of balloon positioned 4 cm long catheters, center of balloon positioned

at midpoint of stenosisat midpoint of stenosis Airway dilated from 2.0 to 3.5 ET size larger Airway dilated from 2.0 to 3.5 ET size larger

than initial sizethan initial size

Combined Laser & Balloon Combined Laser & Balloon DilationDilation

Andrews et al (2007)Andrews et al (2007) Performed flexible bronchoscopy for combined Performed flexible bronchoscopy for combined

Nd:YAG laser radial incision at site of stenosis Nd:YAG laser radial incision at site of stenosis and balloon dilation in awake, spontaneously and balloon dilation in awake, spontaneously breathing patientsbreathing patients

Total of 18 patients underwent 36 proceduresTotal of 18 patients underwent 36 procedures 8 pts required only 1 procedure; 5 pts required 2 8 pts required only 1 procedure; 5 pts required 2

procedures (72%)procedures (72%) 11/18 patients (60%) were obese or morbidly obese 11/18 patients (60%) were obese or morbidly obese Average f/u 22 mos; avg time b/w procedures 9 mosAverage f/u 22 mos; avg time b/w procedures 9 mos No complication in study groupNo complication in study group

Case ExampleCase Example

58-year-old female with several month 58-year-old female with several month history of hoarseness history of hoarseness Also has a history of asthmaAlso has a history of asthma Recent PFTs showed no evidence for Recent PFTs showed no evidence for

asthma. asthma. Also had a diagnosis of gastroesophageal Also had a diagnosis of gastroesophageal

reflux reflux disease and feels that her hoarseness has disease and feels that her hoarseness has been contributed by the reflux diseasebeen contributed by the reflux disease

Intermittent dysphagiaIntermittent dysphagia

Case ExampleCase Example

Laryngo video stroboscopic exam was Laryngo video stroboscopic exam was performed: shows normal vocal fold performed: shows normal vocal fold mobility bilaterallymobility bilaterally

Presence of mild nodular thickening of Presence of mild nodular thickening of the left anterior vocal cord surfacethe left anterior vocal cord surface

More significantly there is approximately More significantly there is approximately 50% stenoses of her subglottic airway at 50% stenoses of her subglottic airway at the level of the cricoid cartilage and the level of the cricoid cartilage and erythema of this areaerythema of this area

Endoscopic Balloon Endoscopic Balloon DilationDilation

Documents

Airway Stenosis: Evaluation and Endoscopic Management Murtaza Ghadiali, M.D. UCLA Division of Head and Neck Surgery November 19 th, 2008