Jvf

Later in life (reported from age 9 to 83 years) but 25 of cases present before age 17. These fistulas connect to the middle or lower esophagus, from right upper lobe, from left lower lobe, from bronchus intermedius, from right middle or lower lobe, and from left upper lobe. The fistula usually slopes downward from the bronchus to esophagus, perhaps accounting in part for the lack of earlier symptoms, but it may also connect from a small diverticulum of esophagus, or on the pulmonary side, to a...

T

Tabulae Anatomicae, 2 Talking tracheostomy tubes, 740-741, 740f Technique failure of, 487-488 complications from, 492-495 TEF. See Tracheoesophageal fistula (TEF) Teflon injection, 705 TES, 106 from median sternotomy, 513 Thermovent T, 746 Thoracentesis, 820 Thoracic aorta aneurysm, 414, 415f injuries of, 272-274 Thoracic trachea, 639-641 injuries of, 272-274 laceration of, 276 Thoracic trachea and bronchi injuries results of, 283 Thoracotomy bilateral, 11, 513 incision, 515f foreign body...

Exploration

The cervical incision is made first to determine whether the lesion can be removed and reconstruction accomplished. The initial incision is transverse and follows the line of the clavicles at the base of the neck (Figure 34-1). If resection is to be performed, the incision is extended laterally and turned downward slightly at either end as the shoulder is reached in order to allow the flap to be moved caudad and into the mediastinum more easily. The upper skin flap is elevated superiorly, with...

Lak

Figure 18-1 Ventilation for tracheal resection. A, The endotracheal tube (ET) is passed beyond the obstructing lesion. In this case a tight stenosis provides a seal without inflating the cuff. B, The tube is retracted and the trachea is divided below the lesion. Cross-field intubation is performed. If there is insufficient distal trachea, the cuff is seated in the left main bronchus. C, After all sutures are placed, the proximal ET is passed distally and the cuff is inflated while the...

B5

Reprinted with permission from Grillo HC et al.32 TEF tracheoesophageal fistula. Reprinted with permission from Grillo HC et al.32 TEF tracheoesophageal fistula. good results, 3 satisfactory, whereas 1 required reoperation and 2 required permanent tracheostomy. The placement of a complementary tracheostomy and its compartmentalization from the fresh anastomosis and from the innominate artery are detailed in Chapter 25, Laryngotracheal Reconstruction. Complications of operations are summarized...

Types of Stents Silicone Stents

The most commonly used silicone stents are the Dumon and Hood stents (Figure 40-1A). These are both manufactured from molded silicone. Both of these stents come in a variety of diameters (6 to 18 mm) and lengths (20 to 80 mm). Both also have regularly placed external studs to engage the airway wall and prevent migration. The Hood stents also come in a version that has proximal and distal flanges in the smaller bronchial sizes to prevent proximal or distal migration in an area of stricture. Both...

High Dose Radiation Therapy for Unresectable and Medically Inoperable Tracheal Cancers

The relationship between radiation dose and tumor control has been described in nonsmall cell carcinoma of the bronchus.15,16 Limited data from studies of tracheal tumors also suggest that a radiation dose higher than 60 Gy 30 fractions 6 weeks is necessary to achieve local tumor control in squamous cell carcinoma of the trachea.3,17-25 If we assume that squamous cell carcinoma of the trachea and carina does respond to radiation in a similar fashion to primary squamous cell carcinoma of the...

Normal Anatomy

The larynx is divided into supraglottis glottic, and subglottic parts, whereas the trachea is composed of the cervical extrathoracic trachea and the mid and lower intrathoracic trachea.1,2 The supraglottic portion of the larynx is constituted by the epiglottis, aryepiglottic folds, arytenoids, and false cords. The glottic portion of the larynx is made up of the laryngeal ventricles and both vocal cords. The crescent-shaped laryngeal ventricles are situated between the false and true cords as...

Eey

By pulling together the paired traction sutures of the trachea and left main bronchus on both sides. In general, anastomosis of the trachea to the left main bronchus may be safely accomplished in the adult without dangerous tension, if the initial gap is no greater than 4 cm. This varies with individual patients. If tension seems too great, the technique described in the next section should be employed instead. The end-to-end anastomosis between the trachea and left main bronchus is...

Autogenous Tube Construction

The cervical trachea has been reconstructed experimentally by formation of a cutaneous trough, variously supported by cartilage or plastic rings, with staged closure of the trough.4,125,126 Edgerton and Zovickian reviewed early attempts at creation of skin flaps, including tubed pedicles, variously supported with rib or costal cartilage and sometimes lined with split grafts.4 In 1964, Grillo and colleagues proposed a staged repair of the cervical trachea to replace a cervical tracheal segment...

Altered Fractionation Schedules

Accelerated or hyperfractionated radiation therapy may exploit the radiobiologic advantages of both a reduced fraction size for late-reacting tissues (lung, spinal cord, connective tissue) and a shortened overall treatment time against rapidly proliferating tumors such as squamous cell carcinoma of the trachea.37,38 Repair of sublethal radiation damage in aerobic mammalian cells is essentially complete within 2 to 4 hours.39,40 When a rapidly proliferating tumor cell population such as squamous...

Complications from Failure of Technique

The problem of granulation tissue at the suture line has been almost eliminated by the use of 4-0 Vicryl for anastomosis. All nonabsorbable sutures often produced granulomas. On two occasions, when a single reinforcing suture of Tevdek was placed anteriorly, a granuloma appeared at that site only Since then, 3-0 Vicryl sutures have been used in circumstances that require reinforcement. Granulations are removed with biopsy forceps through a rigid bronchoscope. An offending suture at the base of...

Other Complications

Laryngeal edema, which may follow laryngotracheal procedures especially, is treated immediately with Decadron systemically for a short period of time (24 to 48 hours). This brief treatment will not adversely affect healing. Racemic epinephrine is also administered by nebulization. If the airway is severely obstructed, an uncuffed small-bore endotracheal tube is placed. After a few days, the tube is removed in the operating room. If the airway is still unsatisfactory, the tube is replaced and a...

Upper Tracheal Lesions

Most benign stenoses can and should be resected through an anterior approach, even when located at the supracarinal level. Stenosis involving the uppermost trachea, or the lower larynx and upper trachea, will almost uniformly be resectable and reparable through a low collar incision alone (Figure 23-1A). A low incision results in more cosmetic scar than in one placed higher across the neck. The length of incision will depend upon the vertical spread of incision needed in each patient, usually...

Incision and Management of an Existing Stoma

The initial incision for the anterior approach is a low collar incision. This is usually relatively short since the lateral extent need only be sufficient to permit elevation of skin flaps to the level of the cricoid cartilage above and to the sternal notch below. If a previous cervical incision does not lie too high, it is reopened. As much as possible, unsightly scars from a prior surgery or tracheostomy are excised with the incision. Most often, an existing stoma is circumcised by the...

Inflammatory Subglottic Stenosis

Combined subglottic laryngeal and upper tracheal stenosis following intubation may result from tissue damage by an endotracheal tube, from cricothyroidostomy, or from a high stoma which was misplaced or eroded superiorly (see Chapter 11, Postintubation Stenosis). If the tracheal stenosis abuts the cricoid cartilage without intralaryngeal extension, circumferential tracheal resection is performed just below the cricoid (Figure 25-1 A). If, however, there is a small atrium or space immediately...

Closure of a Fistula without Tracheal Resection

In the case where there is no tracheal injury except at the site of a fistula to the esophagus, repair does not require tracheal resection.6 Dissection differs at critical points from that just described. A collar incision will provide as good exposure as an oblique incision anterior to the sternocleidomastoid muscle and a better cosmetic result. The collar approach also facilitates bilateral dissection should this become necessary. This can be important if prior attempt at closure has been...

Cervicomediastinothoracic Resection

A cervicomediastinothoracic incision allows wide access to the entire upper airway from the hyoid bone to the carina, if necessary.3 This consists of a collar incision and a vertical sternotomy which angles into the right fourth interspace (see Chapter 23, Surgical Approaches). The cutaneous component sweeps beneath the breast, but the breast and the underlying pectoralis muscle are elevated as a single flap up to the fourth interspace. The interspace is entered over the top of the fifth rib...

Postpneumonectomy Syndrome

The keys to successful surgical treatment of postpneumonectomy syndrome are 1) restoration of the mediastinum to a normal central position 2) implantation of filler to prevent recurrence of mediastinal displacement and 3) correction of severe residual malacia, when present. Herniated lung is also reduced (see Chapter 15, Tracheobronchial Malacia and Compression, and Figure 40 Color Plate 16 ). The prior thoracotomy incision is carefully reopened since there may be essentially no residual...

Laser Applications in the Subglottic Larynx and Cervical Trachea

The CO2 laser has remained the laser of choice for precise excision of scar tissue and treatment of benign tumors in the subglottic area. However, this laser possesses poor hemostatic properties and is unable to deliver focused energy through a flexible fiber, resulting in severe limitations for treatment of hyper-vascular tumors and lesions located in the distal airway. The Nd YAG laser has become the laser of choice for vascular tumors such as venous malformations and obstructing tumors of...

Hermes C Grillo MD

The T Tube and Its Placement Immediate Care Modifications of Tubes and Placement Tube Management Experience with T Tubes Conclusions Critical stenosis of the upper airway not amenable to surgical resection often requires a tracheostomy, either as a temporary measure or for long-term relief. Transient airway obstruction after operative reconstruction may also require temporary intubation. Although tracheostomy tubes have the virtue of simplicity in insertion, management, and change, they divert...

Bronchoscopic Evaluation

Bronchoscopy is essential in the evaluation of the patient with central airway obstruction who may be a candidate for airway stenting. Bronchoscopy is also useful for delivery and adjustment of an endoluminal stent and is preferred for refining the accuracy of stent delivery by a majority of pulmonary physicians and thoracic surgeons. Although stents may also be placed under fluoroscopic guidance without bronchoscopy, initial evaluation of the airway by bronchoscopy is critical to assess the...

Treatment of Chronic Postpneumonectomy Bronchopleural Fistula

An anterior approach to closure of a postpneumonectomy bronchopleural fistula was reported by Padhi and Lynn in 1960, using an anterior thoracotomy, and was modified by Abruzzini in 1961, using a median sternotomy.26,27 This approach was originally advocated for patients with long bronchial stumps and was thought to be an advantage since the operation was largely carried out through an undisturbed field. After a median sternotomy is performed, the anterior...

Anastomotic Complications and Their Management

Complications involving the airway anastomosis in lung transplant patients occur infrequently when appropriate surgical techniques are employed. The majority of pulmonary transplant recipients can be expected to have acceptable healing of the airway anastomosis. However, a consistent subpopulation of patients does develop airway complications in spite of meticulous surgical methods. These complications usually require some form of operative intervention for their resolution. The etiology of...

Implantation of Nonviable Tissues

Cadaver trachea and other tissues, fixed chemically, frozen, or lyophilized, have been used both experimentally and clinically as tracheal replacements. Such implantation has mistakenly been called transplantation or described as a tracheal allograft, despite its nonviable and denatured status. Bioprosthesis may be a better term, since a fixed tissue is more akin to tanned leather than it is to transplanted tissue in the usual sense. Preserved or lyophilized tissues are usually replaced in time...

Concurrent Chemotherapy

Assuming that the biological characteristics of squamous cell carcinoma of the trachea and carina and their response to radiation and chemotherapy are very similar to those of primary carcinoma of the bronchus and lung, it is recommended that radiation therapy be combined with chemotherapy for patients with unresectable or gross residual squamous cell carcinoma. Dillman and colleagues compared radiation therapy alone (60 Gy 30 fractions 6 weeks) with sequential chemoradiotherapy, in which two...

Bronchoesophageal Fistula

Benign bronchoesophageal fistula is quite rare.13 Types of congenital fistulae are described in Chapter 12, Acquired Tracheoesophageal and Bronchoesophageal Fistula (see Figures 12-9,12-10). The fistula is dissected out via a thoracotomy, and both esophageal and bronchial ends are carefully closed by suture. Even where there is sufficient pulmonary infection to require a lobectomy, dissection of a congenital fistula is not difficult. Healthy tissue is sutured over the esophageal closure. A...

Diagnosis

The patient with differentiated thyroid cancer involving the airway may present with classical symptoms and signs of airway neoplasm, namely, hemoptysis, wheezing, dyspnea on exertion, and, additionally, hoarseness. More often, airway involvement produces no symptoms, since the tumor has not yet penetrated the mucous membrane or projected any distance into the lumen. A firm mass may be palpated, which is not freely movable over the trachea. Often, tracheal and laryngeal involvement are...

Clinical Experience

In 1967, I saw a 54-year-old patient who 6 years earlier had undergone a thyroid lobectomy and radical neck dissection for differentiated carcinoma of the thyroid, and who subsequently received 4,800 cGy of radiotherapy because of invasion of the tracheal wall by tumor. She presented with severe airway obstruction due to recurrent cancer. The invaded tracheal segment was resected and an end-to-end anastomosis was performed. The trachea failed to heal, turned grayish-green, and necrosed, and the...

Talking Tracheostomy Tubes

Talking tracheostomy tubes permit vocalization with the cuff inflated (Figure 38-1).14-16 Positive airway pressure and airway protection are maintained. Examples are Bivona's tracheostomy tube with talk attachment, Portex's Trach-Talk tracheostomy tube, and Implant Technologies' Communi-Trach I. These have a cuff inflation line and speaking port. The speaking port is a small bore tube, set into the curvature of the tracheostomy tube and stopping just above the cuff. The external end has a...

Subglottic Hemangioma and Other Vascular Lesions

The CO2 laser has been the laser and treatment of choice for over 15 years for hemangiomas with limited involvement of the subglottic airway.24,25 The CO2 laser provides an excellent choice of treatment because of its soft tissue interaction and the ability to achieve microhemostasis for capillary sized blood vessels. Most importantly, it offers the advantage of avoiding tracheostomy during the proliferative phase of the hemangioma. Approximately 80 of subglottic hemangiomas can be eradicated...

Info

Figure 25-3 (continued) C, The larynx and trachea are prepared for anastomosis. The bared inner surface of the cricoid will be covered by advancement of the posterior tracheal flap. The curved tracheal cartilage will repair the anterior cricoid gap. D, The reconstituted upper airway. For clarity, only two posterior mucosal sutures are shown. Their knots lie behind the mucosa. One fixing suture is also shown between the outer layer of the base of the membranous wall flap and the inferior margin...

Other Lasers Diode Holmium 585 nm Pulsed

The near infrared wavelength (810 nm) of the diode laser allows a relatively deep penetration of soft tissue. Its soft tissue effects are somewhat similar to those of the Nd YAG. We have used this diode laser for mucosal graft soldering in the treatment of posterior glottic stenosis, combining indocyanine dye with fibrin glue.9 Ongoing research is focused on creating a higher power diode laser, which may be a cheaper, more portable laser alternative in the future. Holmium YAG...

Hairpin Aorta

Division of the more often-identified vascular rings that cause airway obstruction has been described elsewhere, often and in detail. These anomalies are listed in Chapter 6, Congenital and Acquired Tracheal Lesions in Children. Also noted there is the less-common occurrence of circumflex aorta. Brief technical note will be made here, however, of the highly unusual compression, described in Chapter 6, Congenital and Acquired Tracheal Lesions in Children, which is due to right aortic arch, right...

Benign Strictures

Inflammatory strictures requiring resection of the lung and adjacent main bronchus are rare and are almost always caused by tuberculosis (TB). Resection cannot be recommended in the presence of active TB or when active disease remains after resection. The adverse outcome under such circumstances is illustrated by Price Thomas's first patient to undergo a bronchoplastic procedure for benign disease.3 This patient, who had a stricture of the distal mainstem bronchus and diffuse lobar disease,...

Speaking Valves

Placement of a cuffed tracheostomy tube generally causes dysphagia, aphonia, and reduces the ability of the patient to taste and smell. Patients who are stable on mechanical ventilation, or those capable of maintaining spontaneous ventilation for a few hours, are candidates for a one-way speaking valve to restore voice communication. There are suitable valves for the ventilator-dependent and nonventilated patient.21-23 The one-way valve is placed on the tip of the tracheostomy tube with the...

Vedic Hymns For Peripheral Neuropathy

Radiation therapy postoperative, 797-799 resected tracheal cancer, 792-793 tracheal cancer, 791-801 Radiography, 106-107 of benign fistula, 343 of cervical injury, 276 for thyroid carcinoma, 251 of tracheal lesions, 446 Reanastomosis, 5-6 Recent tracheostomy delaying resection, 447 Recipient airway blood supply optimizing, 833t Recurrent laryngeal carcinoma, 17 Recurrent laryngeal nerves, 46, 611f, 633f following reconstruction, 495 injury of, 272, 274, 280f, 526, 695 papillary thyroid...

Lipomatous Tumors

Lipoma is a benign mesenchymal neoplasm of fat and is most common in the subcutis. In the usual type, it resembles mature fat, surrounded by a delicate capsule. It is exceedingly rare in the trachea, with only approximately 10 cases reported in the literature. Lipomas produce a polypoid mass covered by respiratory epithelium. One of the reported cases did not produce any symptoms and was found on autopsy,23 whereas 2 other cases caused airway obstruction.23-25 Microscopically, tracheal lipomas...

Post Tracheostomy Fistula

Two types of tracheoarterial fistulae occur from tracheostomy. The first is due to erosion of the artery lying immediately beneath the curve of the tracheostomy tube. The second is caused by erosion of the anterior tracheal wall into the artery by either the cuff or the tip of the tracheostomy tube. The two lesions must be kept clearly in mind, since the emergency and definitive management of each is different (see Figures 27-1 through 27-3 in Chapter 27, Repair of Tracheobrachiocephalic Artery...

Modifications of Tubes and Placement

Modifications of the silicone tracheal T tube are useful for special circumstances. Westaby and colleagues fashioned a T-Y tube for lesions involving the carina and main bronchi (Figure 39-6).8 The T-Y tube may be inserted over two ureteral catheters, which pass through the tube and its right and left bronchial limbs into the tracheal stoma, and by bronchoscopic placement, into right and left main bronchi. A simpler alternative is to squeeze the right and left limbs together, with a...

Benign Intrathoracic Fistula

Benign acquired fistula is not often seen in the thorax, but inflammatory diseases, including tuberculosis, histoplasmosis, and silicosis, produce tracheoesophageal fistulae just above the carina or broncho- figure 26-5 Closure of tracheoesophageal fistula in the absence of a circumferential tracheal lesion. A, A small fistula may be approached initially laterally at esophageal depth with the trachea drawn anteriorly. The left recurrent nerve can remain with the trachea, depending on the size...

Gib

Figure 24-8 Division of the trachea and dissection of the stenosis. Note the traction sutures. A, In most cases, the trachea is circumferentially dissected below the stenosis, and the trachea divided and intubated distally. Traction on the lower end of the specimen facilitates posterior and lateral dissections from the esophagus. B, In a low-lying stenosis, it is more convenient to divide the trachea proximal to the lesion, dilate the stenosis directly if need be, and intubate through the...

Acquired Tracheobronchoesophageal Fistulae

Tracheobronchoesophageal fistulae may be congenital or acquired.95,96 The most common congenital tracheoesophageal fistula, accounting for 80 to 90 of cases, is esophageal atresia with a low tracheoesophageal figure 4-67 Tracheobronchomalacia. Inspiratory (A) and expiratory (B) computed tomography scans of the main bronchi reveal marked collapse of the bronchi on expiration. There is also diffuse thickening and calcification of the airways, typical of relapsing polychondritis. figure 4-68...

Left Lower Lobe Bronchoplasty

This procedure is very similar to the procedure for right lower and middle lobe bronchoplasty (Figure 30-3F). The lower lobe resection is carried out in standard fashion until the bronchus is reached. The bronchus to the left upper lobe is divided at its origin, and the left main bronchus just proximal to the takeoff of the left upper lobe bronchus. Traction sutures are placed to ensure proper alignment. The remainder of the anastomosis is carried out as described previously. I have...

Techniques

This chapter assumes familiarity and competence with the endoscopic techniques and instruments discussed herein, including facile use of the rigid bronchoscope. If it is to be performed concurrently with rigid bronchoscopy, laryngoscopy is done first, almost always under general anesthesia. Where laryngeal complexities are suspected or where it is possible that a laryn-geal surgical procedure will have to be done at the time of the examination, or later as an independent but preceding...

Tracheal Resection and Reconstruction

At the simplest level, anesthesia for tracheal reconstruction is an exercise in sharing the airway. After evaluation, induction, and possibly bronchoscopy, the airway is secured with a tube distal to the lesion. Part of the value of the initial bronchoscopy is to assist planning of the means of securing the airway. The anesthesiologist should view the airway with the surgeon, and get a sense of the lumen size and course. Knowing the airway is bloody or friable will help in the...

Rigid Bronchoscopy

The rigid bronchoscope finds particular application in tracheal lesions and tracheal surgery. Unfortunately, at many institutions, its use is rare because flexible bronchoscopy is more common for routine examination. The unique feature about the rigid bronchoscope to the anesthesiologist is that it takes the place of an endotracheal tube, serving as an airway as well as a surgical tool. Rigid bronchoscopes come in various sizes, but share common features a hollow central lumen open at each end,...

Respiratory Papillomatosis

Viral papillomas are the most common benign laryngeal tumors in the pediatric population. The disease tends to be more aggressive in children, usually presenting with symptoms of airway obstruction and a higher number of recurrences, whereas in adults it tends to be milder, with hoarseness as the main complaint. The disease is associated with the human papillomavirus types 6,11, and occasionally 16.32 These lesions tend to affect areas of junction between squamous and respiratory epithelium,...

Tracheal Blood Supply

The detailed arterial supply of the trachea was described as a necessary corollary to tracheal surgery. Grillo emphasized the entry of small segmental arteries via lateral pedicles of tissue attached to either side of the trachea.84 Miura and Grillo precisely defined the blood supply to the upper trachea in 1966, usually from three principal branches of the inferior thyroid artery, with the first (or lowest) branch most often predominant.101 Salassa and colleagues completed a definitive study...

Vascularized Autogenous Tissue Flaps

Another route of reconstruction, either as a flap for tracheal repair after lateral or window resection, or as a tube after circumferential resection, was to use the patient's own tissues, preserving or reanastomosing blood supply. Since relative rigidity is necessary, free grafts of cartilage, plastic rings, or meshes were added for support. Foreign material or cartilage autografts were implanted in mesenchymal tissue. In general, lateral resection of tumor is not favored because of the...

Fibroblastic and Fibrohistiocytic Tumors

Fibroblastic and fibrohistiocytic tumors are perhaps the least delineated and clarified area in tracheal tumor pathology. Different names have been given to pathologically identical or very similar lesions, and different histopathologies have been lumped under single names. The confusion between fibroma, fibromatosis, and fibrosarcoma on the one hand, and between benign and malignant fibrous histiocytomas on the other, exemplify this situation. Inflammatory pseudotumor has also been added. It...

Malacia of Other Types

Short segment tracheomalacia, which occasionally results from postintubation injury instead of stenosis, is best treated by segmental resection and primary anastomosis (see Chapter 24, Tracheal Reconstruction Anterior Approach and Extended Resection). Tracheomalacia in children is discussed in Chapter 6, Congenital and Acquired Tracheal Lesions in Children. Rarely, long segment or subtotal tracheomalacia has been encountered with no residual rings identifiable. In a very few patients in this...

References

Acquired nonmalig- nant esophagotracheal and esophagobronchial fistula. Ann Thorac Surg 1968 6 187-95. 2. Thomas AN. The diagnosis and treatment of tracheo esophageal fistula caused by cuffed tracheal tubes. J Thorac Cardiovasc Surg 1973 65 612-9. 3. Macchiarini P, Delamore N, Beuzeboc P, et al. Tracheo- esophageal fistula caused by mycobacterial tuberculosis adenopathy. Ann Thorac Surg 1993 55 1561-3. 4. Buskens CJ, Hulscher JBF, Pockens P, et al. Benign...

Wzx

(see Chapter 14, Infectious, Inflammatory, Infiltrative, Idiopathic, and Miscellaneous Tracheal Lesions). Reconstructive procedures must be applied cautiously in certain diseases of unknown origin, such as Wegener's granulomatosis, which may have a progressive course despite surgery. If the stenosis abuts the vocal cords without any free space in the immediate subglottic larynx (Figure 25-1E), it is not possible to perform a single-stage operation for correction. One must then resort to older,...

Postirradiation Stenosis

Tracheal stenosis subsequent to irradiation is seen only occasionally. Our experience is therefore related anec-dotally. Following external irradiation of the larynx and upper trachea for thyroid cancer in a young child, the larynx failed to develop to proper size and, years later, subglottic and upper tracheal stenosis became evident. In a small number of adults, high-dose external irradiation for thyroid and laryngeal carcinomas resulted, decades later, in severe subglottic and upper tracheal...

Postintubation Lesions

The poliomyelitis epidemics of the mid-twentieth century introduced and led to an ever-widening use of mechanical ventilators to treat respiratory failure. The iatrogenic lesions that resulted provided a whole new field of endeavor for the tracheal surgeon. Gradually, a spectrum of lesions was recognized, attributable to ventilatory apparatus endotracheal and tracheostomy tubes and the cuffs necessary to seal the trachea.84,90,186,212 Principal among these were 1) circumferential stenosis that...

Malignant Tracheoesophageal Fistula

Acquired tracheoesophageal fistula due to carcinoma of the esophagus, or much less often of lung, usually predicts brief survival (see Chapter 8, Secondary Tracheal Neoplasms). Palliative management with endoesophageal tubes or coated stents may be indicated. Alternatively, a tracheal or carinal stent may be helpful, although usually less so. Rarely is operative treatment justified (see Chapter 12, Acquired Tracheoesophageal and Bronchoesophageal Fistula). A few patients with fistula due to...

General Considerations

If the lesion involves the trachea so extensively that a low cervical tracheostomy is impossible, a mediastinal stoma must be established. If the mediastinal end of the trachea is pulled up to the surface of the chest wall, then tension is produced, with likelihood of anastomotic separation, mediastinal sepsis, and death from erosion of major mediastinal vessels. Numerous solutions were attempted, including the ingenious formation of a tubular conduit into the mediastinum using crossed flaps of...

Benign Tracheoesophageal Fistula Malignant Tracheoesophageal Fistula Bronchoesophageal Fistula

The characteristics of tracheoesophageal fistulae and their surgical management differ from benign to malignant, congenital to acquired, acute to chronic, and cervical to thoracic fistulae, and from those with or without concurrent tracheal stenosis. These categories are described in Chapter 12, Acquired Tracheoesophageal and Bronchoesophageal Fistula. Techniques for surgical repair are described here. Congenital tracheoesophageal fistula is not presented. That problem is primarily esophageal...

Management ofMalacic Segments

A segment of trachea may rarely and inexplicably become malacic rather than stenotic from the effect of a cuff injury. Such a lesion is best treated by resection and anastomosis. A small number of patients with a well defined cuff stenosis may also have a malacic segment between the site of the original tracheal stoma (or an existing stoma) and the stenosis. When the distance between the stoma and the stenosis is short, and removal will not result in too extensive a resection, it is preferable...

Cameron D Wright MD

Incidence Risk Factors Prevention Diagnosis Management Bronchopleural fistula following pneumonectomy remains a dreaded complication, despite advances in thoracic surgical care. Postpneumonectomy bronchopleural fistula is often associated with an empyema, although some early fistulae have a sterile hemithorax. Most bronchopleural fistulae are a result of a faulty mechanical closure of the main bronchial stump. An empyema may cause a fistula by necessitatising through the previously closed...

Nzv

Between each of these four sutures to surround the stoma. The mucosa is accurately approximated to the skin (Figure 34-45). Multiple flat suction drains are placed through lateral stab wounds to drain the neck, mediastinum, and subcutaneous spaces. The upper incision is closed using subcutaneous and subcuticular sutures or skin sutures. Usually, the upper incision can be closed without tension. Slight duskiness may be seen in the skin around the stoma at this time. It will almost invariably...

Tracheostomy

Endotracheal intubation rather than tracheostomy is now used to establish an emergency airway. Even in difficult anatomic situations, intubation can usually be accomplished over a flexible intubating laryngoscope or bronchoscope. Failing this, a rigid bronchoscope is introduced. A ventilating bronchoscope may serve as an airway during tracheostomy, if necessary. A laryngeal mask airway may be considered. Tracheostomy is preferably done in an operating room with an airway already established by...

Prevention

The optimal approach to postpneumonectomy bronchopleural fistula is prevention. Patients with infections that might result in empyema should be optimally treated medically prior to pneumonectomy, including use of the appropriate antimicrobial therapy. Resection for tuberculosis requires prolonged preoperative antituberculosis therapy (generally at least 3 months) unless done for emergency indications. Excessive bronchial devascularization should be avoided by ligation of bronchial arteries...

Thoracic Trachea and Bronchi

Crushing chest injuries can result in trauma to the mid- and lower trachea. Partial or complete transverse tracheal division may follow sternal fracture and other chest wall injuries (see Chapter 9, Tracheal and Bronchial Trauma). A spiraling rupture from the carina, either through the cartilaginous or membranous tracheal wall, may occur alone or in conjunction with main bronchial injuries (see Chapter 9, Tracheal and Bronchial Trauma). Precise bronchoscopic identification of the injury and its...

Synovial Sarcoma

Synovial sarcoma is primarily a sarcoma of the extremities. It has been reported in the head and neck region on rare occasion and can occur in the pleura and the lung.55 Only 1 case of this tumor has been reported in the trachea.56 The patient was a 20-year-old asthmatic white male, who had worsening of respiratory symptoms necessitating bronchoscopy. On bronchoscopy, a smooth pale intratracheal mass was seen. Gross examination of the resected specimen showed extension to paratracheal tissue...

Cicatricial Stenosis

Postintubation stenosis, either stomal or cuff induced, is the most common non-neoplastic cause of severe obstruction. Other causes are idiopathic, post-traumatic, postoperative, postirradiation, postinfectious stenosis, and those due to diseases such as sarcoid, amyloid, and Wegener's granulomatosis. The security of an intensive care unit, good humidification, face mask oxygen or heliox, gentle chest physiotherapy, and mild sedation usually comforts the patient enough to permit radiologic...

Salivary Gland Type Tumors

The minor salivary glands existing in the mucous membranes of the head and neck extend downward as the submucosal glands in the trachea. Therefore, they are subject to most of the so-called salivary gland-type tumors that involve the salivary glands of the head and neck, with only few exceptions. However, the frequency of such tumors is much lower in the trachea than in the head and neck region. Pleomorphic adenoma is primarily a benign tumor of the major salivary glands. Rarely, it can arise...

I

(paralaryngeal space), and false cords. Intermediate signal intensities are given off from the true cords, aryepiglottic folds, and the intrinsic laryngeal muscles. Calcified cartilage, the airway, and blood vessels produce low signals. MRI can be used in the assessment of tracheal stenosis and tumors and other paratracheal masses that compress the trachea (Figure 4-8). The examination is performed with a T1 sequence in the axial, coronal, and sagittal planes, supplemented by an axial T2...

Cartilaginous Tumors Chondroma

Chondroma is a benign tumor composed of cartilage and can rarely arise in the trachea. Approximately 10 cases of chondroma are reported in the trachea.28,29 Grossly, it forms a hard bosselated mass protruding into the lumen. Microscopically, it is a relatively hypocellular tumor, composed of chondrocytes that sit in lacunae of hyaline cartilage. The chondrocytes may be somewhat hyperchromatic and pleomorphic. Binucleation is exceptional. Foci of ossification may be seen. Differential diagnosis...

Erosion from Tracheostomy Tube Cuff

Erosion of the anterior tracheal wall overlying the brachiocephalic artery, either due to necrosis from a high-pressure cuff or ulceration by an angulated tip of a tracheostomy tube, is now rarely seen (see Figure 27-1B). In these cases, the stoma is usually at a more nearly correct level, high in the trachea. In emergency, it is not possible or advisable to expose the fistula by finger dissection or by cutting down to it in order to place a tam-ponading finger on the artery, since the fistula...

Lower Tracheal and Carinal Lesions

The choice of surgical approach to a specific tracheal lesion is based principally on diagnosis and on observations of the extent and location of the lesion, made from imaging studies and rigid bronchoscopy, using magnifying telescopes. Also important in the equation are age, body build, and prior treatment, especially operative procedures and irradiation. Specific diagnostic factors that are assessed include 1) whether the lesion is benign or malignant 2) the exact location of the lesion 3)...

Flexible Bronchoscopy

The flexible bronchoscope does not replace the rigid instrument in diagnosis nor in management of airway lesions, but it is a very useful adjunctive tool. It should be used liberally by pulmonologists to rule out organic obstruction in patients thought to have adult onset asthma, to clarify the origin of hemoptysis (however minor), and to investigate the possible causes of recurrent or unyielding volume loss, atelectasis, or pneu-monitis. Intubation, for any reason, is facilitated by using the...

Characteristics and Origin of Lesions

Since the 1960s, the steadily increasing use of endotracheal, tracheostomy, and cricothyroidostomy tubes for the management of secretions, prevention of aspiration and, most importantly, delivery of mechanical ventilatory support for respiratory failure have produced a spectrum of upper airway lesions that range in location from the nostril to the lower trachea, and in severity from pharyngitis to complete obstruction of the airway or asphyxiating hemorrhage (Figure 11-1). Immediate and early...

Optimal Dose and Fractionation Schedule

The radiation dose schedule for postoperative therapy varies with the degree of residual tumor burden. For patients with clear but close margins with clearance of < 0.2 cm, the optimal radiation dose schedule for prevention of locoregional recurrence is in the order of 50.4 to 54 Gy, administered with daily fractions of 1.80 Gy, 5 days a week over a period of 5.6 to 6 weeks. Assuming that the radiation response of tracheal squamous cell and adenoid cystic carcinoma is similar to that of...

The T Tube and Its Placement

The tube consists of a vertical column of flexible medical silicone, which resides in the airway and is intended to span the entire length of a stenosis or other obstructive pathology. A sidearm of the same material emerges from the tube at a right angle and passes to the surface. A plug or stopper of silicone is provided to occlude the sidearm. Tubes are made in a variety of outer diameters ranging from 6 to 16 mm. The size numbers of tubes correspond to their outer diameter. Tubes are...

Minitracheostomy

Special Scalpel Minitracheostomy

Minitracheostomy is a technique used to assist in removal of airway secretions while maintaining glottic function, by placing an inlying small bore catheter in the trachea through the cricothyroid membrane.1 With the neck in extension, anatomic landmarks are precisely identified the thyroid notch, the cricoid cartilage, and the cricothyroid membrane. Five cc of 2 lidocaine hydrochloride with epinephrine is infiltrated over a site of incision in the midline of the cricothyroid membrane. The...

Postoperative Fistula

Prevention of postoperative hemorrhage from the innominate artery following tracheal resection and reconstruction has been discussed in Chapter 13, Tracheal Fistula to Brachiocephalic Artery. Should a figure 27-4 Surgical management of a fistula due to tracheal cuff injury. Exposure is the same as previously described. A, Arterial control is obtained, the artery divided above and below the fistula, and proximal and distal stumps sutured closed. The circumferentially damaged segment of trachea...

Anastomotic Complications and Their Management Summary

Achieving a successful anastomosis of the airway has been an elusive goal in the development of lung transplantation. The airway anastomosis has been properly termed the Achilles heel of lung transplantation. Impaired healing at this site was a consistent impediment to successful human lung transplantation in the past, accounting for the majority of deaths in patients surviving more than 10 days following the transplant procedure. However, systematic investigations into the processes involved...

Fenestrated Tracheostomy Tubes

Tracheostomy Tube Mechanism Simplified

Several types of fenestrated tubes are available Lo-Profile tracheostomy tube (Portex Inc.), Low-pressure cuffed tracheostomy tube (Shiley Medical, Mallinckrodt Inc.), and Tracoe flex tracheostomy tubes (Boston Medical Products) are examples of cuffed or cuffless precut fenestrated tracheostomy tubes. These are available in a variety of sizes (Figure 38-2).16 The fenestration is a hole in the outer cannula. When the inner cannula is removed, the fenestration is open, providing airflow through...

Systemic Considerations

Generally speaking, few patients should be rejected for correction of a postintubation tracheal stenosis because of age, suboptimal pulmonary or myocardial function, or associated diseases. Resection and reconstruction of the trachea for postoperative stenosis can usually be conducted so that insult to the patient's general physiology is minimal. With skillfully given anesthesia, so that the patient continues to breath spontaneously throughout the operation, and with immediate postoperative...

Trauma

Laryngeal trauma can be caused by external or internal injuries. External injuries are the result of blunt or penetrating trauma. Internal injuries are usually caused by prolonged intubation or chemical or thermal burns.30 Trauma is characterized by mucosal disruption of soft tissues, swelling, and collection of air in the soft tissue structures of the larynx including neck and mediastinum. These soft tissue injuries may be associated with cartilaginous fractures, and dislocations of the...

Management

Resection of the airway may require 1) simple circumferential removal of a segment of the upper trachea, 2) bevelled resection of one side of the anterolateral cricoid if it is involved, or 3) complex resection in which a portion of subglottic larynx on the invaded side is removed in a bayonet fashion and the distal trachea is tailored to repair the defect (Figure 8-10). Window resections are to be avoided because of the increased likelihood of leaving residual tumor and the less kindly healing...

Congenital Bronchoesophageal Fistula

Braimbridge and Keith classified BEF into four types (Figure 12-9).23 Type I seems to result, at least sometimes, from inflammatory changes in an esophageal diverticulum, which then secondarily fistulizes to a bronchus. Although some diverticula are undoubtedly congenital, traction diverticula are also likely represented in this group of lesions and the fistula itself may not therefore always be of congenital origin. Nonetheless, I retain their classification of congenital BEF's. Type I...

Blood Supply

Prior to the development of tracheal surgery, detailed description of the arterial blood supply of the trachea was unknown. Using radiographs of injected specimens of the human trachea, Miura and Grillo showed that blood supply of the cervical trachea originates from the inferior thyroid artery in a variable pattern (Figure 1-8).15 The blood supply enters the trachea through lateral tissue pedicles in segmental fashion throughout the trachea. Complete description of the entire tracheal blood...

Characteristics

The incidence of primary tracheal tumors in the general population is not precisely known. Ranke and colleagues found 2 patients with tracheogenic carcinoma in 1,744 cancer deaths.7 Culp noted 4 patients with primary tracheal tumors in 89,600 autopsies.8 It is not a surprise that the diagnosis is seldom considered, even by pulmonologists. The majority of primary tracheal tumors in adults are malignant. Thirty-six percent of a series of 198 patients with primary tracheal tumors seen at the...

Repair and Healing of the Airway

An ancient concern that cast a shadow on tracheal surgery into the twentieth century was that cartilage healed poorly. Hippocrates had cautioned, The most difficult fistulae are those which occur in the cartilaginous areas .18 In the second century ce, Aretaeus pronounced, The lips of the wound do not coalesce, for they are both cartilaginous and not of a nature to unite.7 As late as 1990, Naef repeated that tracheo-bronchial tissue, as compared to the stomach, intestine, or even skin, does not...

Imaging Technique

Anteroposterior and Lateral Films of the Neck Including Cervical Trachea. Routine radiologic investigation of the larynx and cervical trachea is composed of anteroposterior (AP) and lateral films of the neck (see Figures 4-1, 4-2) and oblique views of the trachea with the patient in a 45 to 60 rotation.12,13 The lateral view of the neck is obtained with the head slightly hyperextended to bring the larynx and upper trachea up from the retrosternal position. This lateral view provides useful...

Experience with T Tubes

In general, tracheal reconstruction after resection should stand on its own merits and not require splinting. This is also true for laryngotracheal reconstruction. In only two unusual patients were T tubes used after resection and reconstruction. In one, there was concern about a segment of uncertain stability above the anastomosis. The majority of 140 patients in whom the T tube was used suffered from postintubation lesions, burns, or malignant tracheal tumor (Table 39-1).7 The indications for...

Laser Burns

Despite warnings and precautions, occasionally, a plastic endotracheal tube has been ignited by a laser, producing disastrous tracheal and bronchial thermal burns.21 Such a lesion is managed in the same fashion as inhalation burns, but the extent and depth may well be fatal, especially if the injury extends into the bronchial tree. Even Y or T-Y stents become useless. Similar burns have been produced by inept use of the cautery during tracheostomy. A laser burn of the left main bronchus was...

Vascular Tumors Hemangioma

Capillary hemangioma affects the larynx and trachea of children far more commonly than it does adults, and because of the narrower airway lumen in this younger age group, it becomes symptomatic early in growth and causes obstructive symptoms such as stridor and dyspnea.31 Most of the cases are well circumscribed, but some diffusely infiltrate the wall and cause narrowing over a segment, or grow into adjacent mediastinal tissues.32 Conversely, a few cases of mediastinal hemangioma have been...

Eugene J Mark MD Javad Beheshti MD

Inflammatory Myofibroblast Tumor (Inflammatory Pseudotumor) There are certain infectious, inflammatory, or reactive processes that can cause various degrees of tracheal lumen obstruction by focal nodular or polypoid protrusion into the lumen, or more extensive tracheal wall thickening and luminal narrowing. Infections such as tuberculosis and histoplasmosis, inflammatory lesions such as sarcoidosis, and reactive processes such as post-traumatic granulation tissue formation and fibrosis are...

Reconstruction

After resection of the specimen, and after examination of the proximal and distal ends of the remaining trachea to be certain that the tissue is of good enough quality to promise healing without stenosis, the ease of approximation is determined. The anesthetist or an assistant is asked to put the patient's neck in flexion with a hand beneath the occiput. The chin must approach the upper sternum. This should not be done by raising the headpiece of the operating table, as this tends to thrust the...

Nerve Sheath Tumors

This category of tumors includes neurofibroma, schwannoma, and malignant peripheral nerve sheath tumor. These tumors are among the common tumors in the mediastinum, especially the posterior compartment. They may cause a pressure effect on mediastinal structures including the trachea. Neurofibromas and schwannomas are infrequent as endotracheal tumors. No case of malignant peripheral nerve sheath tumor has been reported in the trachea, but tracheal involvement has occurred in this tumor...

Other Techniques

With complex anomalies, ingenuity may be required. Congenital stenosis may be associated with anomalous right upper lobe bronchus (bronchus suis), bridging bronchi, stenotic main bronchi, degrees of figure 33-5 Tracheobronchogram showing a complex stenosis. A segment of relatively mild stenosis lies proximal to an anomalous right upper lobe bronchus. The stenotic bridge bronchus below shows maximal narrowing in its most proximal portion. The main bronchi are adequate in diameter. figure 33-6...

Principles of Surgical Treatment

The currently accepted principles of surgery for differentiated thyroid cancer call for complete removal of the local lesion and extensions in the neck. Longer survival and better control of symptoms are obtained if gross tumor is fully removed. This is usually interpreted to mean thyroidectomy and excision of involved regional lymph nodes, with persisting differences of opinion about the need for total thyroidectomy. Because of the pathological behavior of these tumors, nodal metastases are...

Summary and Conclusion

Tracheal carcinoma is rare and the therapy outcome depends on the tumor extent and histological type. Survival rates beyond 5 years are 50 to 60 after resection for operable disease, and 5 to 20 after radiation therapy for unresectable or medically inoperable tumors. Adenoid cystic carcinoma has a much longer natural history than squamous cell carcinoma. Surgery remains the choice of treatment for tracheal carcinoma. Postoperative radiation therapy should be considered for patients with either...

Tracheal Structure

The adult male trachea averages 11.8 cm in length (range 10 to 13 cm) from the lower border of the cricoid cartilage to the top of the carinal spur, varying with the patient's height. There are usually from 18 to 22 cartilages within this length, approximating almost two rings per cm.1 Cartilaginous rings may be incomplete or bifid. The lateral tracheobronchial angles are located slightly higher than the carinal spur so that the length of the trachea proper along its lateral wall is slightly...

Dissection

In many patients, dense scarring is found at the level of the stoma as well as at the site of postintubation stenosis. Scarring is heightened by prior surgical procedures. Normal subplatysmal anatomy is therefore identified first at the lateral ends of the transverse incision and dissection carried along the surface and border of the sternocleidomastoid muscles, both above and below on either side. The surgeon then works toward the midline and gradually elevates the skin and what is left of the...

Recommendations

The illustrative examples by Grillo and Ishihara and their colleagues17,18 have been amply confirmed by others in the last decade.17,18,25-30 Airway resection and reconstruction for differentiated thyroid cancer is safe, has a low morbidity and mortality and provides prolonged palliation, prevents death by asphyxiation or hemorrhage, and probably achieves cure in some patients. At issue with recommendation of the shave technique as a procedure of choice for stage I patients, is whether...