Postirradiation Stenosis

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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 stenoses. In 3 additional patients with mediastinal Hodgkin's disease, severe stenosis of the midtrachea appeared a decade or more after apparently successful management, primarily by irradiation in doses in the range of 4,500 cGy. None of these patients had recurrence of neoplasm. In 1 patient who was explored, massive fibrosis was found, encasing the area of tracheal stenosis, presumably residual scar from the destroyed lymphoma.

Another patient suffered destruction and stenosis of the larynx, the trachea, and the upper esophagus following treatment of a stubborn Graves' disease by administration of an excessive dose of radioactive iodine (RAI) (Figure 42-4). Inappropriate use of brachytherapy in the left main bronchus to deliver irradiation to the carinal area, after right pneumonectomy for adenoid cystic carcinoma, produced an oblitera-tive stenosis of the bronchus, as might be expected.

These patients have, in general, been managed as conservatively as possible. Two adults with upper laryngotracheal stenoses were handled by dilation at intervals. Fortunately, they did not require further intervention. There appeared to be no surgical route to correct the lesions because of their disposition and location,

Tracheal Softening

figure 42-4 Laryngotracheal and cervical esophageal stenosis due to excessive dose of radioactive iodine used to treat Graves' disease.

A, Densely calcified thyroid gland. The larynx is stenotic and the proximal trachea obliterated.

B, Lateral cervical view shows calcification in the thyroid, a distorted airway, and a stenotic esophagus. C, Computed tomography scan shows the calcification plus dense fibrosis encasing the trachea and esophagus. The induration involved the carotid arteries and internal jugular veins. Treatment required cervicomediastinal exenter-ation with mediastinal tracheostomy, colonic substitution for the esophagus, and omental advancement. Primary healing was achieved.

figure 42-4 Laryngotracheal and cervical esophageal stenosis due to excessive dose of radioactive iodine used to treat Graves' disease.

A, Densely calcified thyroid gland. The larynx is stenotic and the proximal trachea obliterated.

B, Lateral cervical view shows calcification in the thyroid, a distorted airway, and a stenotic esophagus. C, Computed tomography scan shows the calcification plus dense fibrosis encasing the trachea and esophagus. The induration involved the carotid arteries and internal jugular veins. Treatment required cervicomediastinal exenter-ation with mediastinal tracheostomy, colonic substitution for the esophagus, and omental advancement. Primary healing was achieved.

even if healing could have been obtained. A tracheal "button" distal to the stenosis was advised in the patient who underwent irradiation in childhood, with subsequent severe laryngeal and upper tracheal stenosis.

The patient with destruction of laryngotracheoesophageal structures by RAI had a large inflammatory mass, rigid cervical fibrosis, and multiple fistulae. She suffered from bleeding from a tracheostomy. Cervicomediastinal exenteration of the entire process, with establishment of mediastinal tracheostomy protected with the omentum, and restitution of swallowing with a colon bypass, produced a satisfactory result. The left main bronchial stenosis due to brachytherapy proved undilatable and irresectable.

Our first patient with a midtracheal stenosis and severe surrounding fibrosis due to prior treatment of Hodgkin's disease was managed by excision and end-to-end anastomosis with omental wrapping. Failure of healing led to separation, and death occurred from hemorrhage from the brachiocephalic artery. Subsequent patients were managed by dilation and placement of a T tube, with satisfactory results.

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