Editing Tracheal stenosis


== Aetiology ==

* Tracheotomy
** Severity of stenosis depends on extension of the defect, necrosis and infection
** Symptoms can occur immediately after decannulation or years later
* Ventilation
* Trauma
* Malignancy

== Presentation ==

* Dyspnoea on exertion is the main symptom
* Wheeze, stridor, cough, difficulty clearing secretions, recurrent URTI, hoarseness
* 50% reduction in cross-sectional area of trachea results in dyspnoea only with significant exertion, whereas narrowing of the lumen to <25% usually produces dyspnoea and stridor at rest
* A 5-6mm lumen reduces peak expiratory flow rate to 30%
* Usually have stridor or wheezing if they have significant airway obstruction

== Workup ==

* Spirometry and flow volume loops are not helpful in diagnosis
* If no respiratory distress, CT is best
* Bronchoscopic evaluation will give diagnosis most of the time
** Flexible bronchoscopy is ok for diagnosis, but rigid bronchoscopy is needed for intervention, especially in an emergency (dilation/core out of tumour/laser/stenting)
** Look for anatomic location, proximal and distal extent, and diameter of stenosis

== Indications for tracheal resection ==

* Post-intubation or post-tracheostomy stenosis
** Prolonged cuff pressure causes full-thickness necrosis of the tracheal cartilage, causing symptoms from circumferential scar contracture 3-6 weeks after extubation
** Stomal stenosis from tracheostomy occurs with scarring at the anterior tracheal defect (anterior narrowing with normal posterior membranous wall)
** Post-intubation stenosis is amenable to dilation, whereas post-tracheostomy is not
* Trauma
* Inflammatory
** Tracheal infections
** Collagen vascular diseases
* Idiopathic tracheal stenosis
** Occurs most commonly in 20-50yo women, focused at the level of the cricoid cartilage with varying degrees of subglottic involvement
* Primary tracheal tumours
** Consider these for resection if they can be removed with less than half of the longitudinal length of the trachea, and do not have unresectable local extension
** SCC
** Adenoid cystic carcinoma
** Carcinoid
** Mucoepidermoid
* Local tumours with airway invasion
** Almost never an indication for tracheal resection, but locally advanced thyroid cancer may be considered, even in the presence of metastatic disease (because prognosis is still pretty good)

== Anaesthesia/airway management ==

* Stomal stenosis can nearly always be intubated without difficulty, whereas post-intubation stenosis might be harder
* Anaesthesia for tracheal resection is normally given as mixed inhalational/IV, while maintaining spontaneous ventilation until airway is established
* Aim to extubate in OT

== Surgical technique ==

* Tracheal resection now thought to be safe up to 5-6cm
* Most benign stenoses approached through neck incision - thoracotomy rarely required
*

== Post-op support ==

* Manually support neck flexion to prevent hyper-extension and associated strain on anastomosis
* Laryngeal oedema manifests within 24-72 hours and typically resolves without any intervention
* Subcutaneous emphysema post-op likely represents anastomotic dehiscence - surgical emergency - needs airway secured - bronchoscopy to evaluate anastomosis

[[Category:Thoracics]]