Tracheopathia osteoplastica (TPO) is rarely encountered, and when it is, is often asymptomatic or only mildly symptomatic (see Chapter 14, "Infectious, Inflammatory, Infiltrative, Idiopathic, and Miscellaneous Tracheal Lesions"). In a few patients, however, obstruction becomes so severe that surgical relief is necessary (see Figures 14-22 A-D, 14-23A,5 in Chapter 14, "Infectious, Inflammatory, Infiltrative, Idiopathic, and Miscellaneous Tracheal Lesions," and Figures 42 and 43 [Color Plate 16]). In these patients, the entire trachea has been involved by the process, as seems usually to be the case. Bronchoscopic removal of nodules with biopsy forceps or by laser is difficult to accomplish, especially since saber-sheath deformity is often also present. TPO is so rigid that stents or T tubes can not be forced into the undilatable lumen. However, since the process only involves that part of the tracheal wall that contains cartilages, the membranous wall is spared. By incising the anterior wall of trachea from cricoid to carina, the two halves of the rigid anterolateral walls can be hinged apart, stretching the membranous wall to normal width, and in this way, opening the tracheal lumen despite persistent presence of the nodules (Figure 32-5).
Assessment of the diseased airway is necessary both bronchoscopically and radiographically, before corrective surgery. Imaging includes precise anteroposterior tomography, and now may include three-
figure 32-5 Tracheoplasty for obstructive tracheopathia osteoplastica. A, The obstructed trachea is opened from just below the cricoid to the carina. A small endotracheal tube may be passed into the left main bronchus at this point. See text for further details about maintenance of ventilation. In a patient with severe main bronchial obstruction, both main bronchi were also opened anteriorly, and a T-Y tube was placed. B, A preselected or prepared long T tube is inserted, spanning the entire length of the trachea. In many patients, a T-Y tube is necessary, with limbs extending into the bronchi. This must be planned in advance ofoperation. C, Cross-sectional diagram of a trachea obstructed by tracheopathia osteoplastica. The saber-sheath configuration seems to be common. Dashed line indicates the linear tracheotomy. Note the uninvolved but foreshortened membranous wall. D, The rigid lateral walls are hinged on the normal, soft membranous wall, to allow insertion of the silicone tube. E, The cartilaginous walls are easily re-sutured anteriorly as the membranous wall is spread. F, After firm healing has occurred in this open position, the T tube is extracted. The correction holds for the long term.
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