Laryngotracheal stenosis refers to abnormal narrowing of the central air passageways. This can occur at the level of the
larynx
The larynx (), commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about ...
,
trachea
The trachea, also known as the windpipe, is a Cartilage, cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs. The trachea extends ...
,
carina
Carina may refer to:
Places
Australia
* Carina, Queensland, a suburb in Brisbane
* Carina Heights, Queensland, a suburb in Brisbane
* Carina, Victoria, a locality in Mildura
Serbia
* Carina, Osečina, a village in the Kolubara District
...
or
main bronchi
A bronchus is a passage or airway in the lower respiratory tract that conducts air into the lungs. The first or primary bronchi pronounced (BRAN-KAI) to branch from the trachea at the carina are the right main bronchus and the left main bronchus. ...
.
In a small number of patients narrowing may be present in more than one anatomical location.
Presentation
The most common symptom of laryngotracheal stenosis is gradually-worsening breathlessness (
dyspnea
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing di ...
) 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
A wheeze is a continuous, coarse, whistling sound produced in the respiratory airways during breathing. For wheezes to occur, some part of the respiratory tree must be narrowed or obstructed (for example narrowing of the lower respiratory tract ...
. This creates a diagnostic pitfall in which many patients with laryngotracheal stenosis are incorrectly diagnosed as having
asthma
Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, cou ...
and are treated for presumed lower airway disease.
This increases the likelihood of the patient eventually requiring major open surgery in benign disease
and can lead to tracheal cancer presenting too late for curative surgery to be performed.
Causes
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.
The main causes of adult laryngotracheal stenosis are:
Diagnosis
Patient history, CT scan of neck and chest, fiberoptic bronchoscopy, and spirometry are all several ways to assess for laryngotracheal stenosis and effectively develop preoperational approaches to treating the disease. In addition, a methodology called the Cotton-Myer system is commonly used to evaluate the degree of severity of the laryngotracheal stenosis based on the percentage of obstruction; other systems have also been proposed to fill potential shortcomings of the Cotton-Myer classification and help capture the full complexity of the illness.
Treatment
The optimal management of laryngotracheal stenosis is not well defined, depending mainly on the type of the stenosis.
General treatment options include
# Tracheal dilation using rigid
bronchoscope
# Laser surgery and endoluminal stenting
# Tracheal
resection and
laryngotracheal reconstruction
Tracheal
dilation
Dilation (or dilatation) may refer to:
Physiology or medicine
* Cervical dilation, the widening of the cervix in childbirth, miscarriage etc.
* Coronary dilation, or coronary reflex
* Dilation and curettage, the opening of the cervix and surgic ...
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%.
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).
There are differing opinions on treating with
laser surgery
Laser surgery is a type of surgery that uses a laser (in contrast to using a scalpel) to cut tissue.
Examples include the use of a laser scalpel in otherwise conventional surgery, and soft-tissue laser surgery, in which the laser beam vapor ...
.
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.
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
In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. A wide variety of stents are used for different purposes, from expandab ...
may be required to join the sections.
Late June or early July 2010, a new potential treatment was trialed 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 was hoped to prevent his immune system from rejecting the transplant,
but there remain doubts about the operation's success, and
several later attempts at similar surgery have been unsuccessful.
Nomenclature
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
The subglottis or subglottic region is the lower portion of the larynx, extending from just beneath the vocal cords down to the top of the trachea. 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.
See also
*
Hermes Grillo pioneer in tracheal resection surgery
*
Laryngospasm
Laryngospasm is an uncontrolled or involuntary muscular contraction (spasm) of the vocal folds. The condition typically lasts less than 60 seconds, but in cases partial blocking it may last 20 to 30 minutes and hinder inspiration, while exhala ...
References
;Bibliography
*
External links
{{Congenital malformations and deformations of respiratory system
Respiratory diseases
Gross pathology