Tracheostomy

Even a brief history must note the ancient use of tracheostomy for a variety of indications. The story has been traced by a number of authors.7-10 Although Aretaeus and Galen remarked on the use of tracheostomy in the second and third centuries, the arteria aspera, the rough artery, as the trachea was known for generations, only slowly entered the surgical theater. The specific technique of Antyllus in the fourth century ce is recorded.7 Fabricius of Aquapendente, who introduced the idea of a...

Results

At the outset, mortality rates from carinal pneumonectomy for bronchogenic carcinoma exceeded long-term survival rates (see Table 8-1). Jensik and colleagues reported a 5-year survival rate of 15 in 1982,35 wheras that from Deslauriers and colleagues was 13 in 1989,34 that by Dartevelle and colleagues was 23 in 1988,37 and that by Mathisen and Grillo was 19 in 1991.36 The figure of Dartevelle and Macchiarini rose to 43 in 1996.43 The overall survival rate from these authors and others was 22 12...

Right and Left Mainstem Bronchi

Resection of the mainstem bronchi encompasses the same principles as the previously described procedures (Figure 30-3G). The single most important difference is exposure of the left mainstem bronchus. If the resection requires removal of the proximal left mainstem bronchus, it may be necessary to mobilize the aortic arch for adequate exposure. The aorta is dissected circumferentially to allow passage of tapes for retraction, in order to expose the bronchus fully (see Figure 29-6B in Chapter 29,...

Secondary Tracheal Tumors

Resection of the carina for bronchogenic carcinoma has been discussed under the section, Carinal Pneu-monectomy, above. The proximity of the thyroid gland makes the trachea and lower larynx targets susceptible to invasion by cancer in this gland.200 Localized tracheal invasion by thyroid neoplasms was resected episodically as tracheal surgery evolved. Rob and Bateman, in 1949, resected six rings of trachea and a portion of cricoid for recurrence of thyroid cancer of low malignancy, 7 years...

Persistent Stoma

Most tracheostomies close promptly after extubation. Indeed, reinsertion of a tracheostomy tube may become difficult within minutes or hours after its removal. In a few patients, the stoma persists, most often in those who have carried a tracheostomy tube for a very long time, who are aged or debilitated, who suffer from metabolic diseases, or who have received prolonged corticosteroid treatment. In most of these patients, the cutaneous epithelium has healed to the tracheal epithelium. A stoma...

Csj

Larynx posterior to the airway mucosa (Figure 33-12C). The pharynx can then be reconstructed with a mucosal layer, starting superiorly and coming down inferiorly to meet with the esophageal closure. If the approach is through a right thoracotomy, we have positioned a pleural flap between the suture lines. In the neck, the sternal half of the right sternocleidomastoid muscle is brought behind the tracheostomy tube to separate the suture lines. Combination of these maneuvers has minimized...

Choice of Stent

Neither silicone nor the available metal stents conform to all the ideal characteristics for an endobronchial stent. Although each has its advocates, both of these general types of stents have advantages and disadvantages that should be considered when choosing the best stent for the individual patient (Table 40-5). There is no one stent that ideally fits all circumstances, and the full variety of silicone and expandable stents should be considered to maximize positive outcomes. Each category...

Stents

If primary removal or correction of airway lesions is not possible, other means of assuring an airway must be found. These include tracheostomy tubes, T tubes, and stents.34,35 Tracheostomy. The standard tracheostomy should be familiar to all practitioners. It can be performed under topical anesthesia in impending airway obstruction, or on a patient with an endotracheal tube in place. The management is similar to reconstructive surgery, except that extubation, neck flexion, and concerns about...

Metal Stents

Gianturco stents are constructed from metal stainless steel monofilament wires, fashioned in a zigzag pattern with 5 to 10 bands.4 The lengths of the stents are 2.5 cm for tracheal stents and 2 cm for bronchial stents. These stents can be delivered through a 12F introducer sheath. These stents are also available as tandem stents with double the length of the single stents. Because of problems with migration, small hooks are placed along the proximal and distal ends to allow for anchoring into...

Hilar Release

A hilar release has only rarely been performed for benign stenosis of the upper or midtrachea, since it hugely increases the extent of surgery otherwise planned as a cervicomediastinal procedure. The gain in length figure 24-20 Recapture of tracheal length for recontruction where a stoma has been made just proximal to a lengthy stenosis. A, Dotted lines indicate the excessively long resection that would be required. B, The stoma is allowed to heal prior to resection (C). figure 24-20 Recapture...

T34

Figure 1-6 Cross-sectional computed tomography views of tracheal anatomic relationships in the mediastinum. Diagram shows level of sections A at T3-4, and B at T4-5. A, Thoracic trachea. B, Supracarinal trachea. Mediastinal structures are labelled. figure 1-7 Many variations occur in the arrangement of the branches arising from the aortic arch. The two most common patterns are (A) with separate origins of brachiocephalic and left carotid arteries, and (B) with a common origin. In both, a...

Cicatricial Stenosis Neoplastic Obstruction

A frequent complication and presentation of tracheal disease is obstruction. Failure to recognize critical degrees of obstruction can lead to death. As noted elsewhere, a tracheal obstruction due either to benign stenosis or neoplasia, in patients who have radiologically normal lung fields, is frequently diagnosed as adult onset asthma, allowing obstruction to reach a critical level. In an emergent state, a small mucous plug or bleeding can easily cause fatal obstruction. Airway obstruction may...

Y

Figure 6-14 Right aortic arch, right descending aorta, aberrant left subclavian artery, and Kommerell's diverticulum. The airway compression is not necessarily relieved by excising the aortic diverticulum and transplanting the aberrant subclavian because of the narrow space between ascending and descending aorta. Left ligamentum arteriosum is usually present to the diverticulum or LS. E esophagus PA pulmonary artery RCC, LCC right, left common carotid arteries RS, LS right, left subclavian...

Years

Figure 7-21 Absolute survival of patients with adenoid cystic carcinoma (ACC) and squamous cell carcinoma (SCC), resected and unresected. Chart includes only patients with complete follow-up. Table 7-11 Survival after Resection of Tracheal Carcinoma (1990) Table 7-11 Survival after Resection of Tracheal Carcinoma (1990)

Radiographic Evaluation

Radiographic evaluation of foreign body aspiration is helpful, but a normal radiographic examination does not exclude the possibility of an airway foreign body. Various series have reported normal radiographs in 6 to 80 of children with proven foreign bodies in the tracheobronchial tree. Although some foreign bodies are easily seen on standard chest radiographs (Figure 36-1), 80 to 90 of aspirated foreign bodies are vegetative material, thus radiolucent and not visualized. The most common...

Infectious Inflammatory Infiltrative Idiopathic and Miscellaneous Tracheal Lesions

Inflammatory or Infiltrative Lesions Intrinsic Lesions Which Deform the Trachea In addition to clearly defined and relatively more common diseases of the trachea (ie, primary and secondary neoplasms, postintubation lesions, congenital and traumatic lesions), a wide variety of uncommon conditions may be encountered. These lesions can be either intrinsic or extrinsic. Intrinsic lesions include the following 1) those due to specific infection, such as tuberculosis and histoplasmosis 2) defined...

Conventional Twodimensional Radiation Therapy

The arrangement of radiation portals is dependent on the planned total dose, the energy levels of radiation, and the shape of the target volume. Because of the scatter irradiation of low energy beams and the large penumbra of a 60Co unit, high energy beams (10 to 25 MV photon) are preferred for curative radiation therapy, with an aimed total dose of 66 to 68 Gy. An arrangement of two parallel opposed portals (POP) applied anteroposteriorly (AP) and posteroan-teriorly (PA) to the chest is simple...

Historical Overview

Aspiration as a cause of death was recognized as early as the mid-1600s when Bradwell reported on objects that could suddenly endanger breathing, and noted that he heard of a child who had been .strangled with a Grape.1 Muys in 1690 reported a 7-year-old who died from suffocation three weeks after aspirating a bean2 In 1854, Samuel D. Gross, then Professor of Surgery at the University of Louisville, wrote a treatise on foreign body aspirations, reporting over 200 cases collected from the world...

Position

The majority of patients are positioned supine with an inflatable bag beneath the shoulders (Figures 24-3A,5). This permits extension of the neck in a controlled fashion, but allows the extension to be removed easily during tracheal anastomosis, when cervical flexion is desired. Extreme cervical extension is to be strictly avoided. The patient is usually positioned with slight flexion at the hips and at the knees so that positioning the neck and upper sternum appropriately for the surgeon,...

References

Couraud L, Bruneteau A, Martigne C, Meriot C. Preven tion and treatment of complications and sequelae of tracheal resection and anastomosis. Int Surg 1982 11. 2. Grillo HC, Zannini P, Michelassi F. Complications of tra cheal reconstruction incidence, treatment and pre- 12. vention. J Thorac Cardiovasc Surg 1986 91 322-8. 3. Grillo HC, Donahue DM, Mathisen DJ, et al. Postintuba tion tracheal stenosis results and surgical treatment. J Thorac Cardiovasc Surg 1995 109 486-93. 13. 4. Grillo HC,...

Anterior Glottic Stenosis

Anterior glottic stenosis is usually secondary to laryngeal injury anteriorly, or laryngeal surgery where the surgeon has denuded the mucosa from both the right and left vocal cords into the anterior commissure in removal of polyps. The cords will then heal together, forming a web (Figure 35-2A). Anterior glottic webs, which are thin and short, can often be treated with laser division of the web. More significant webs, and those that recur after laser division, are best treated by doing a...

Igk

May become infected from the contaminated operative field and require later removal. The general rule, that it is best to avoid foreign material in tracheal reconstruction, remains sound. No consistent success in the treatment of tracheomalacia has been reported with the use of other types of external splints, either of synthetic or cartilaginous autografts. Expandable internal stents are not safely used adjacent to tracheal anastomoses. A safer alternative, generally, for management of an...

Imaging

Air tracheograms and careful fluoroscopy provide precise information about the presence of an anomaly, its location, and type (see Chapter 4, Imaging the Larynx and Trachea) (Figure 6-18). Contrast media are usually unnecessary and may cause complications when used in tiny airways. Tomograms offer specific additional detail, but in many hospitals are no longer available of useful quality. CT scanning provides precise information on the cross-sectional area and extent of lesions, with...

Diagnosis

The diagnosis of postpneumonectomy bronchopleural fistula can be very difficult if only a pinhole fistula exists, or it can be very easy if a large bronchopleural fistula occurs with expectoration of copious amounts of serosanguineous fluid. Bronchopleural fistulae that occur early postoperatively do not usually present with infection but rather dyspnea and cough. Aspiration of even small amounts of pleural fluid into the remaining lung can cause an almost continuous irritative cough and can...

Nao

Figure 26-6 (continued) C, The tumor and fistula are converted to a neodiverticulum of the trachea. Proximal and distal esophageal ends of the diverticulum have been stapled and, if possible, reinforced with sutures. D, Completed exclusion of the fistula and anterior mediastinal bypass. The esophagogastric anastomosis will be reinforced by the upper half of the omental pedicle. The lower omental flap has been tucked into the mediastinum posteriorly, in the esophageal bed. Pyloromyotomy is added...

Lung Cancer

Ever since its introduction, sleeve lobectomy has made an important impact on the surgical treatment of lung cancer. When considering surgical options and prognosis, it is useful to distinguish four anatomic situations (as detailed in Table 16-1) in two groups of patients. The first and classic anatomic situation is a tumor found on bronchoscopy to arise in a lobar bronchus so as to preclude standard lobectomy. The second situation is where a carcinoma extrinsic to the airway may extend to the...

Nonrevascularized Grafts

In 1918, Burket reported successful fresh autografts of three- to nine-ring segments in 4 of 8 dogs.152 The other animals, plus two allografts, died with tracheal strictures. The latter died in 7 and 8 days in contrast with longer survival for autografts (except for one early breakdown). The author did not comment on this difference between autografts and allografts. Experiments have since shown that immediate orthotopic reimplantation of an animal's own...

Clinical Experience

We have used this simple, direct, efficient, safe, and low-cost procedure for over 35 years. In more recent years, a large literature has grown recommending use of the laser to treat obstructed airway tumors. It is based on the argument that bleeding will be excessive without use of the laser. It has even been argued that it is impossible to clear obstruction of the airway without a laser. We therefore examined a consecutive series of 56 patients with tumor treated by the coring technique.3 All...

Obstructing Tracheobronchial Tumors

The application of laser technology to the endoscopic treatment of patients with tracheobronchial disorders was first introduced by Strong and colleagues in 1973, who used the CO2 laser to ablate peristomal papillomas.39 The effectiveness and safety of laser application in bronchology were enhanced after the introduction of the Nd YAG laser in the 1980s.40-42 The special hemostatic qualities of this laser energy make it the most suitable laser for endoscopic removal of malignant...

Treatment of Tracheal Diseases Primary Tracheal Tumors

Thus far, this review has focused on the evolution of techniques of tracheal surgery. Application of these and other additionally developed techniques to specific diseases of the airways will now be considered. The challenge of treating the rare tracheal tumors which were seen provided the initial stimulus for tracheal resection.1,5 The very rarity of primary tracheal neoplasms, on the other hand, provided limited incentive to attack this problem systematically. In 1938, Culp collected 433...

Hermes C Grillo MD

Characteristics Clinical Presentation Diagnostic Studies Treatment and Results Primary tracheal neoplasms are still often diagnosed long after the onset of symptoms or signs, particularly in the absence of hemoptysis. Benign neoplasms may be unrecognized for many months or even for several years. The duration of symptoms for malignant lesions prior to diagnosis is 6 to 18 months, reflecting more rapid growth, and especially, onset of hemoptysis. Even pulmonologists remain unfamiliar with...

Free Grafts With and Without Foreign Material Support

The use of autogenous tissue, such as the omentum, to seal mesh prostheses was noted earlier. Foreign materials have, on the other hand, been used to support free grafts of autogenous tissues, either as patches or in tubular form. Experimental patches or tubular constructions have used the following materials fas-cia11,46,82,83 tracheal wall84 diced cartilage against wire mesh and glass cylinders13 dermal grafts laced with wire14 fascia with Tantalum wire support8 pericardium85 pericardium with...

Carinal Resection and Reconstruction

Lesions near the carina add some new challenges to the process of the tracheal resection and reconstruction discussed above.28,29 The procedure is intrathoracic, usually approached from a thoracotomy, and the lungs cannot be treated as a single entity. As in all thoracotomies, arterial monitoring is prudent and methods of postoperative analgesia, such as thoracic epidural catheters, are needed. The considerations for induction of anesthesia are similar to those for surgery for higher lesions,...

Recapture of Tracheal Length

In some patients, a tracheostomy has been made just above or below a lengthy segment of tracheal stenosis, as emergency treatment for the stenosis, unfortunately even where the stenotic segment was accessible in the neck. In some, a stoma has been located below a stenosis as a safeguard for repeated laser treatments of the stenosis. These compound the length of lesions, which might otherwise have been easily corrected by resection. The stoma may lie so close to the area of stenosis that there...

Without Pulmonary Resection

Techniques for carinal resection and reconstruction are described below, in order of increasing complexity.1,5-8 Lesion Confined to the Carina. Restitution of the carina by suturing the right and left main bronchi together and approximating these to the end of the trachea is an attractive concept, but is frequently impossible without tension (Figures 29-1A-D). The reason is that once the right and left main bronchi are sutured together, the left bronchus is held by the halter of the aortic...

Lower Tracheal and Carinal Lesions

Tumors of the lower trachea and carina are best approached through a high right posterolateral thoraco-tomy (Figure 23-7). This is particularly true for tumors of the carina and for more extensive tumors of the lower trachea. I prefer this approach for tumors of the lower trachea of any complexity, although benign stenoses and simple tumors at this level are approached anteriorly. Pearson and colleagues prefer a median sternotomy,5 whereas Perelman,6 who initially favored the transsternal...

Lymphatics

Detailed studies of tracheal lymphatic drainage are few. Following submucosal injections of India ink and dye into the canine trachea, Strauss observed that 1) tracheal lymphatic vessels were present as fine intercellular spaces beneath the mucous membrane over the cartilages, 2) the lymph flowed up or down the trachea to the nearest interspace between cartilages, 3) one to three trunks flowed horizontally in the interspaces between rings, 4) flow from the anterior wall went to either side, 5)...

Info

Figure 1-3 External laryngeal relationships. Anterior (A) and lateral (B) views. Note the position of the true vocal cords (vocal folds) in the midlarynx. The cricoid cartilage shows the configuration of a reversed signet ring. The inferior cornu of the thyroid cartilage is close to the entry point of the inferior laryngeal nerve. C, Lateral view of the interior of the larynx. Anterior surface to the left. Note the relationships of the ventricular fold (false vocal cord), ventricle and vocal...

Wallstent

The Wallstent has been the most frequently used expandable stent in the United States for tracheobronchial obstruction. These stents are popular because of their ease of delivery under fluoroscopy. They are self-expanding, with a moderate radial force and good flexibility. Rousseau and colleagues reported their experience with 39 Wallstents in the airway in 1993.36 In this series, 89 of patients had an improvement in their respiratory status immediately after stent placement that was maintained...

Threedimensional Conformal Radiation Therapy

With 3-D CT scan simulation of the chest for tracheal cancer, the radiation treatment plan is significantly improved over that of a two-dimensional treatment plan.30 A 3-D radiation plan provides accurate body contours at different levels of the target volume, improved definition of tumor size and location relative to other normal vital structures, and a precise measurement of the thickness of the pulmonary tissue in the path of the radiation beams for which a correction for the increased...

Clinical Characteristics

The majority of patients with postintubation tracheal lesions present clinically with obstruction. Principal manifestations are 1) progressive dyspnea, 2) wheezing and stridor, and 3) intermittent obstruction with retention of secretions. Pneumonitis or frank pneumonia may occur unilaterally or bilaterally. As the airway narrows, dyspnea on effort is noted first. This appears initially with marked effort, depending on the respiratory reserve of the patient. In time, dyspnea appears with less...

Requirements for Replacement

Belsey iterated the requirements for tracheal replacement to be 1) a laterally rigid but longitudinally flexible tube, and 2) a surface of ciliated respiratory epithelium.3 The second criterion has proved to be desirable, but not essential.4,5 Patients can clear secretions by cough despite conduits lined with squamous metaplastic epithelium, skin, or foreign materials (silicone tubes, coated stents, metallic and other solid prostheses). The conduit must further be initially airtight and become...

Thyroid Carcinoma

Intraluminal airway invasion by differentiated thyroid carcinoma is rare, especially as a primary presentation, with estimates ranging from 0.5 to 7 or higher.1,2 Invasive well-differentiated thyroid carcinoma may present initially with hoarseness, hemoptysis, or dyspnea. Frequently, however, the invasive carcinoma is identified by a surgeon at thyroidectomy. The thyroid surgeon who finds the trachea invaded at the time of thyroidectomy commonly shaves off the tumor from the tracheal wall....

Dynamic Obstruction

Flow-dependent obstruction is caused by a weakened tracheal wall, or by an intraluminal mass that moves with respiration. Patients will have symptoms that are manifest primarily during inspiration or expiration. Position may be an important factor in their airway patency and every effort should be made to mimic their optimal position during induction. Normal pressure relationships in the tracheobronchial tree show a gradient that directs airflow. During inspiration, the pleural and alveolar...

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...

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...

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...

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...

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...