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 complications of tracheostomy are described in Chapter 10, "Tracheostomy: Uses, Varieties, Complications." The majority of these lesions may be avoided by elective performance, use of careful technique, and proper management of tracheostomy. The later complications detailed in this chapter at first seemed unavoidable and unpredictable; in large part, they no longer are. Despite great strides that have been taken in their prevention, postintubation lesions continue to be the most frequently seen surgical tracheal problems. Their clinical characteristics and nature must be made better known so that patients will not continue to suffer delay in recognition of the lesions and so that optimal treatment is given.

The tracheal surgeon must become familiar with laryngeal lesions that result from intubation. Since most patients are initially ventilated through an endotracheal tube, the larynx may also sustain lasting laryngeal injury, even though the patient presents clinically with a tracheal lesion or a tracheostomy. Serious complications may result if a surgeon repairs the trachea without prior assurance of laryngeal competence. For example, an inadequate glottis that is not recognized because of the presence of a tracheostomy preoperatively, and is diagnosed only after tracheal reconstruction, may require either endotracheal intuba-

figure 11-1 The spectrum of postintubation laryngeal and tracheal lesions. Various combinations of these lesions are seen in a single patient. Focus on a laryngeal or tracheal lesion should not lead to overlooking a lesion elsewhere in the airway. TEF = tracheoesophageal fistula; TIF = tracheo-innominate artery fistula.

Glottis

Cricoid

Stoma

Malacia

Cuff level

Tip of tube

Glottis

Cricoid

Stoma

Malacia

Cuff level

Tip of tube

Subglottic stenosis

Glottis

Subglottic stenosis

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