AirwayAirway StenosisStenosis:: EvaluationEvaluation andand EndoscopicEndoscopic ManagementManagement

MurtazaMurtaza GhadialiGhadiali,, M.D.M.D. UCLAUCLA DivisionDivision ofof HeadHead andand NeckNeck SurgerySurgery NovemberNovember 1919th,, 20082008 OutlineOutline „ Introduction „ Etiology „ Autoimmune Causes „ Acquired Causes „ Role of LPR „ IPSS „ Evaluation „ H&P, Grading, DL/B „ Endoscopic Management „ Mitomycin „ TGF-β „ Lasers/Balloon Dilation IntroductionIntroduction

„ AirwayAirway StenosisStenosis isis bothboth aa therapeutictherapeutic andand diagnosticdiagnostic challengechallenge „ PresentsPresents insidiouslyinsidiously withwith progressiveprogressive SOB,SOB, brassybrassy cough,cough, wheezing/stridor,wheezing/stridor, possiblepossible recurrentrecurrent pneumonitispneumonitis „ ManyMany timestimes misdiagnosedmisdiagnosed asas asthma/bronchitis,asthma/bronchitis, COPD,COPD, CHFCHF IntroductionIntroduction

„ CommonCommon etiologyetiology (beginning(beginning 1965)1965) „ eithereither cuffedcuffed endotrachealendotracheal oror tracheotomytracheotomy tubetube „ LessLess common:common: „ externalexternal trauma/compressiontrauma/compression „ highhigh tracheotomytracheotomy incisionincision „ benignbenign tumorstumors „ ‘‘nontraumatic,nontraumatic, nonneoplasticnonneoplastic’’ causescauses EtiologyEtiology ofof SGSSGS „ I.I. CongenitalCongenital SGSSGS „ Membranous „ Cartilaginous „ II.II. AcquiredAcquired SGSSGS „ Intubation „ Laryngeal trauma „ AI (Wegener’s; Sarcoid; Amyloid; Relapsing Polychondritis) „ Infection „ IPSS (Idiopatic Subglottic Stenosis) „ GER/LPR „ Inflammatory diseases „ Neoplasms Nonneoplastic,Nonneoplastic, nontraumaticnontraumatic SubglotticSubglottic StenosisStenosis „ WegenerWegener’’ss GranulomatosisGranulomatosis „ AmyloidosisAmyloidosis „ CanCan presentpresent withwith SGSG alonealone „ SarcoidosisSarcoidosis „ CanCan presentpresent withwith SGSG alonealone „ RelapsingRelapsing PolychondritisPolychondritis SGSSGS –– WegenerWegener’’ss

„ SystemicSystemic inflammatoryinflammatory „ TreatmentTreatment disorderdisorder „ Individualized based on degree and acuity of „ AutoimmuneAutoimmune degree and acuity of stenosis „ ANCAANCA CC ++ „ No major surgery during „ 1616--23%23% incidenceincidence ofof SGSG Wegener’s flare ups stenosisstenosis „ SGSSGS cancan bebe thethe lonelone manifestationmanifestation ofof WGWG WegenerWegener’’ss GranulomatosisGranulomatosis

„ ClassicClassic triad:triad: necrotizingnecrotizing granulomasgranulomas ofof thethe upperupper respiratoryrespiratory tracttract andand lungs,lungs, focalfocal glomerulitisglomerulitis,, disseminatingdisseminating vasculitisvasculitis „ Treatment: Azathioprine, cyclophosphamide, steroids „ LaryngealLaryngeal WGWG „ Ulcerating lesions induce subglottic stenosis „ Histopathology: coagulation necrosis from vasculitis, multinucleated giant cells, palisading histiocytes AmyloidosisAmyloidosis

„ DepositionDeposition ofof extracellularextracellular fibrillarfibrillar proteinsproteins inin tissuestissues „ Primary (56%), secondary (8%), localized (9%), myeloma associated (26%), familial (1%) „ Generalized amyloid evaluated by rectal biopsy or FNA anterior abdominal wall fat „ LocationsLocations „ Tongue > orbit > larynx „ Laryngeal amyloidosis „ TVC > FVC > subglottic „ Management „ Surgical AmyloidosisAmyloidosis

„ DiagnosisDiagnosis „ CongoCongo redred stainingstaining andand greengreen birefringencebirefringence underunder polarizedpolarized lightlight „ FibrillarFibrillar structurestructure underunder electronelectron microscopymicroscopy „ BetaBeta--pleatedpleated sheetsheet onon xx--rayray crystallographycrystallography andand infraredinfrared spectroscopyspectroscopy „ 1818 biochemicalbiochemical formsforms identifiedidentified „ ALAL (plasma(plasma cells),cells), AAAA (chronic(chronic inflammation),inflammation), AAββ (cerebral(cerebral lesions)lesions) AmyloidosisAmyloidosis –– ManagementManagement

„ StepStep 11 BiopsyBiopsy thethe affectedaffected organorgan „ StepStep 22 RuleRule outout generalizedgeneralized amyloidosisamyloidosis „ RectalRectal bxbx,, echocardiography,echocardiography, bronchoscopybronchoscopy andand PFTsPFTs,, CTCT ofof neck/tracheaneck/trachea „ StepStep 33 RuleRule outout generalizedgeneralized plasmacytomaplasmacytoma „ BoneBone marrowmarrow biopsy,biopsy, bonebone marrowmarrow scintigraphyscintigraphy,, serologicserologic andand immunologicimmunologic examininationsexamininations LaryngealLaryngeal AmyloidosisAmyloidosis

„ << 1%1% ofof benignbenign laryngeallaryngeal lesionslesions „ MostMost amyloidamyloid depositsdeposits areare ALAL typetype „ TypicallyTypically inin menmen inin thethe 55th decadedecade ofof lifelife „ SxSx dependsdepends onon sitesite (e.g.(e.g. glotticglottic amyloidosisamyloidosis ÆÆ hoarseness)hoarseness) SarcoidosisSarcoidosis „ Idiopathic,Idiopathic, nonnon--caseatingcaseating granulomasgranulomas „ Generalized adenopathy (25-50%), orbit (15-25%), splenomegaly (10%), neural (4-6%) „ Symptoms: fever, weight loss, arthralgias „ Head and neck: cervical adenopathy > larynx „ Evaluation: CXR, PPD, skin test for anergy, ACE levels (elevated in 80-90%) „ Treatment „ Oral steroids „ LaryngealLaryngeal sarcoidosissarcoidosis „ Supraglottic involvement „ Typical yellow subcutaneous nodules or polyps „ Diffusely enlarged, pale pink, turban-like epiglottis RelapsingRelapsing PolychondritisPolychondritis

„ InflammationInflammation ofof cartilagecartilage andand otherother tissuestissues withwith highhigh concentrationconcentration ofof glycosaminoglycansglycosaminoglycans „ Episodic and progressive „ Ear > nasal, ocular, respiratory tract „ Treatment: symptomatic, steroids „ LaryngealLaryngeal RPRP „ Rare „ Inflammation can lead to laryngeal collapse „ Treatment usually tracheostomy AcquiredAcquired SGSSGS

„ 95%95% ofof casescases ofof SGSSGS „ MajorityMajority duedue toto longlong--termterm oror priorprior intubationintubation „ DurationDuration ofof intubationintubation „ ETTETT sizesize „ NumberNumber ofof intubationsintubations „ TraumaticTraumatic intubationsintubations „ MovementMovement ofof thethe ETTETT „ InfectionInfection „ PoetkerPoetker DMDM etet al.al. AssociationAssociation ofof airwayairway abnormalitiesabnormalities andand riskrisk factorsfactors inin 3737 subglotticsubglottic stenosisstenosis patients.patients. OtolaryngolOtolaryngol HeadHead NeckNeck SurgSurg (2006)(2006) 135,135, 434434--437437 PathogenesisPathogenesis ofof acquiredacquired SGSSGS

„ InitialInitial injuryinjury –– compressioncompression ofof mucosamucosa byby anan ETTETT oror cuffcuff „ IschemiaIschemia „ NecrosisNecrosis „ DecreasedDecreased mucociliarymucociliary flowflow „ InfectionInfection „ ThreeThree stagesstages ofof woundwound healinghealing „ Inflammatory „ Proliferative – granulation tissue „ Scar formation – contraction and remodeling PathogenesisPathogenesis SGSSGS „ MankariousMankarious etet alal (2003):(2003): InvestigatedInvestigated histopathologichistopathologic featuresfeatures ofof 66 specimensspecimens fromfrom ptspts thatthat underwentunderwent trachealtracheal resectionresection „ AnalyzedAnalyzed levelslevels ofof hyalinehyaline cartilagecartilage components:components: collagencollagen typetype II andand IIII && aggrecanaggrecan (secreted(secreted byby chondrocyteschondrocytes)) „ NormalNormal tracheal/tracheal/cricoidcricoid:: HighHigh ratioratio ofof typetype II toto IIII „ Specimens:Specimens: relativerelative decreasedecrease inin typetype II andand aggrecanaggrecan „ Regenerative cartilage: greatly increased amounts of type II collagen and aggrecan „ Suggests Type I collagen and aggrecan responsibe for cartilage structural integrity „ Regenerative fibroblasts do not deposit type I collagen

AcquiredAcquired SGSSGS andand PDTPDT

„ CiagliaCiaglia 1985:1985: PercutaneousPercutaneous dilationaldilational tracheotomytracheotomy (PDT)(PDT) „ BartelsBartels 2002:2002: 108108 PDTPDT patients;patients; 1010 withwith 66 momo f/u;f/u; 11 patientpatient withwith significantsignificant stenosisstenosis atat f/uf/u „ ?? SelectionSelection BiasBias „ AuthorsAuthors concludeconclude 10%10% stenosisstenosis raterate isis consistentconsistent withwith openopen tracheotomytracheotomy AcquiredAcquired SGSSGS andand PDTPDT

„ KlussmanKlussman etet alal (2001):(2001): ReportedReported casecase ofof completecomplete suprastomalsuprastomal trachealtracheal stenosisstenosis//atresiaatresia afterafter secondsecond PDTPDT „ ?? InitialInitial infectioninfection leadingleading toto destructiondestruction andand cartilaginouscartilaginous necrosis/Trachealnecrosis/Tracheal ringring fracturefracture leadingleading toto mucosalmucosal tearstears andand cicatricialcicatricial scarringscarring „ CautionedCautioned againstagainst useuse ofof PDTPDT inin secondarysecondary tracheotomytracheotomy AcquiredAcquired SGSSGS andand PDTPDT

„ HotchkissHotchkiss && McCaffreyMcCaffrey (2003):(2003): examinedexamined pathophysiologypathophysiology ofof PDTPDT onon 66 cadaverscadavers „ 3/63/6 TrachsTrachs werewere placedplaced incorrectlyincorrectly (range:(range: 33 trachealtracheal ringsrings awayaway toto justjust subsub--cricoidcricoid)) „ AnteriorAnterior trachealtracheal wallwall „ High degree of injury „ Severe cartilage damage at site of insertion „ Multiple, comminuted injuries in 2 or more cartilaginous rings „ Findings suggest acute, severe mechanical injury in PDT AcquiredAcquired SGSSGS && LPRLPR „ GastroesophagealGastroesophageal refluxreflux (GER)/(GER)/LaryngopharyngealLaryngopharyngeal refluxreflux (LPR)(LPR) „ 19851985 –– LittleLittle –– appliedapplied gastricgastric contents/H2Ocontents/H2O toto subglottissubglottis ofof dogsdogs „ Delayed epithelialization and stenosis formation in lesions treated with gastric contents „ 19911991 –– KoufmanKoufman –– appliedapplied acidacid andand pepsinpepsin toto subglottissubglottis ofof dogs;dogs; controlcontrol waswas H2OH2O „ 20 dogs with induced submucosal injury „ Increased level of granulation tissue and inflammation „ 78% pts with LTS: abnormal acidic pH probes; 67% pharynx reflux GER/LPRGER/LPR andand SGSSGS

„ 19981998 WalnerWalner:: 7474 pediatricpediatric patientspatients withwith SGSSGS hadhad 33 timestimes greatergreater incidenceincidence ofof GERGER thanthan thethe generalgeneral pediatricpediatric populationpopulation „ 20012001 MaronianMaronian:: 1919 ptspts withwith SGSSGS „ 99 ptspts withwith IPSS;IPSS; 1010 withwith acquiredacquired SGSSGS „ 1414 ptspts withwith pHpH testingtesting „ Abnormal (pH <4): 71%71% IPSSIPSS ptspts andand 100%100% acquiredacquired ptspts GER/LPRGER/LPR andand SGSSGS

„ DedoDedo (2001):(2001): ChallengedChallenged association;association; largestlargest reviewreview ofof 5050 ptspts withwith IPSS;IPSS; OnlyOnly 7/387/38 patientspatients hadhad refluxreflux symptomssymptoms „ AshikuAshiku (2004):(2004): 15/7315/73 IPSSIPSS patientspatients hadhad refluxreflux symptoms;symptoms; NoNo patientspatients hadhad laryngeallaryngeal signssigns ofof refluxreflux „ BothBoth groupsgroups concludedconcluded nono causalcausal relationshiprelationship betweenbetween refluxreflux andand stenosisstenosis inin theirtheir groupsgroups „ Only 2 patients in collective cohorts underwent specific reflux testing IdiopathicIdiopathic SubglotticSubglottic StenosisStenosis

„ RareRare conditioncondition ofof densedense fibrousfibrous stenosisstenosis ofof thethe proximalproximal tracheatrachea inin absenceabsence ofof incitinginciting eventevent „ AffectsAffects women;women; primarilyprimarily involvesinvolves subglotticsubglottic larynxlarynx andand proximalproximal 22--44 cmcm ofof tracheatrachea circumferentiallycircumferentially „ MayMay bebe associatedassociated withwith certaincertain autoimmuneautoimmune statesstates „ Wegener’s Granulomatosis „ Relapsing Polychondritis „ Rheumatoid Arthritis „ SLE

Ashiku SK et al. Idiopathic laryngotracheal stenosis. Chest Surg Clin North Am, 2003; 13:257 IPSSIPSS (Idiopathic(Idiopathic SubglotticSubglottic StenosisStenosis)) „ PossiblePossible hormonalhormonal causecause „ ToTo date,date, presencepresence ofof estrogenestrogen receptorsreceptors inin thethe affectedaffected airwayairway hashas notnot beenbeen conclusivelyconclusively shownshown inin thesethese patientspatients (( DedoDedo 2001)2001) „ ?? PossiblePossible linklink betweenbetween femalefemale preponderancepreponderance andand LPRLPR „ ProgesteroneProgesterone andand itsits impactimpact onon LESLES pressurepressure „ MajorMajor contributingcontributing factorfactor towardtoward heartburnheartburn andand refluxreflux inin pregnancypregnancy „ CyclicCyclic hormonalhormonal variationsvariations inin normalnormal womenwomen foundfound toto impactimpact LESLES pressurepressure leadingleading toto possiblepossible refluxreflux SGSSGS InitialInitial presentationpresentation

„ HistoryHistory ofof priorprior intubationintubation andand „ ProgressiveProgressive SOBSOB andand loudloud breathingbreathing InitialInitial PresentationPresentation

„ HistoryHistory „ ReviewReview intubationintubation recordsrecords „ PmhxPmhx „ Diabetes „ Cardiopulmonary disease „ Reflux „ Systemic steroid use InitialInitial presentationpresentation

„ PhysicalPhysical examexam –– CompleteComplete H/NH/N examexam „ ObserveObserve „ Stridor or labored breathing „ Retractions „ Breathing characteristics on exertion „ Voice quality „ Head/NeckHead/Neck „ Other abnormalities (congenital anomalies, tumors, infection) DiagnosisDiagnosis

„ DifferentialDifferential „ CongenitalCongenital „ Laryngeomalacia „ Tracheomalcia „ VC paralysis „ Cysts „ Clefts „ Vascular compression „ Mass DiagnosisDiagnosis

„ DifferentialDifferential „ Infection/InflammationInfection/Inflammation „ Epiglottitis „ GER „ Tracheitis „ NeoplasticNeoplastic „ Malignancy „ Recurrent respiratory papillomas; benign lesions „ ForeignForeign bodybody DiagnosisDiagnosis

„ RadiographsRadiographs „ PlainPlain filmsfilms –– inspiratoryinspiratory andand expiratoryexpiratory neckneck andand chestchest „ CTCT „ MRIMRI DiagnosisDiagnosis „ FlexibleFlexible nasopharyngolaryngoscopynasopharyngolaryngoscopy „ Nose/NasopharynxNose/Nasopharynx „ NPNP stenosisstenosis „ Masses,Masses, tumortumor „ SupraglottisSupraglottis „ StructureStructure abnormalitiesabnormalities „ LaryngomalaciaLaryngomalacia „ GlottisGlottis „ VCVC mobilitymobility „ Webs/massesWebs/masses „ ImmediateImmediate subglottissubglottis DiagnosisDiagnosis

„ GoldGold standardstandard forfor diagnosisdiagnosis ofof SGSSGS „ RigidRigid endoscopyendoscopy „ Properly equipped OR „ Experienced anesthesiologist „ Preop discussion about possible need for trach OperativeOperative EvaluationEvaluation „ EndoscopyEndoscopy „ Fiberoptic endoscopic assisted intubation vs. evaluation „ LMA „ Spontaneous ventilation, NO PARALYSIS ! „ Consider awake tracheotomy „ PerformPerform RigidRigid DL,DL, B,B, andand EE „ Closely evaluate the interarytenoid area for stenosis/stricture „ Evaluate position of cords „ DetermineDetermine size,size, extent,extent, andand locationlocation ofof thethe stenoticstenotic lesionlesion „ Use an ETT/bronchoscope to measure the lumen „ Measure from undersurface of the cord to the lesion „ R/o other stenotic areas GradingGrading SystemsSystems forfor SGSSGS

„ CottonCotton--MyerMyer (1994)(1994) „ McCaffreyMcCaffrey (1992)(1992) CottonCotton--MyerMyer GradingGrading SystemSystem

Classification From To Grade I 0% 50% Grade II 51% 70% Grade III 71% 99% Grade IV No Detectable Lumen „ CottonCotton--MyerMyer gradinggrading systemsystem forfor subglotticsubglottic stenosisstenosis GradeGrade IIII SGSSGS GradeGrade IIIIII SGSSGS GradeGrade IVIV SGSSGS Myer/CottonMyer/Cotton GradingGrading SystemSystem

„ MultipleMultiple revisionrevision ofof originaloriginal systemsystem proposedproposed byby CottonCotton inin 19841984 „ FirstFirst systemssystems criticizedcriticized forfor beingbeing basedbased onon subjectivesubjective interpretation,interpretation, althoughalthough statisticallystatistically provenproven toto relaterelate gradegrade withwith prognosisprognosis inin childrenchildren „ MyerMyer 1994:1994: usedused serialserial ETTETT measurementmeasurement toto derivederive CottonCotton gradegrade GradingGrading SystemsSystems forfor SGSSGS

„ CottonCotton--MyerMyer „ BasedBased onon relativerelative reductionreduction ofof subglotticsubglottic crosscross-- sectionalsectional areaarea „ GoodGood forfor mature,mature, firm,firm, circumferentialcircumferential lesionslesions „ DoesDoes notnot taketake intointo accountaccount extensionextension toto otherother subsitessubsites oror lengthlength ofof stenosisstenosis „ GoldGold--StandardStandard StagingStaging inin pediatricpediatric patientspatients McCaffreyMcCaffrey GradingGrading SystemSystem

McCaffreyMcCaffrey (1991)(1991)

„ RelativeRelative reductionreduction inin crosscross sectionalsectional areaarea notnot consistentlyconsistently reliablereliable predictorpredictor ofof decannulationdecannulation inin adultsadults

„ ReviewedReviewed 7373 casescases ofof LTSLTS inin adultsadults findingfinding locationlocation ofof stenosisstenosis toto bebe thethe mostmost significantsignificant factorfactor inin predictingpredicting decannulationdecannulation GradingGrading SystemsSystems forfor SGSSGS

„ McCaffreyMcCaffrey „ BasedBased onon subsitessubsites (trachea,(trachea, subglottis,subglottis, glottis)glottis) involvedinvolved andand lengthlength ofof stenosisstenosis „ DoesDoes notnot includeinclude lumenlumen diameterdiameter McCaffreyMcCaffrey ClinicalClinical StagingStaging

„ StageStage II:: confinedconfined toto subglottis/tracheasubglottis/trachea „ StageStage IIII:: SGS,SGS, >1cm,>1cm, confinedconfined toto cricoidcricoid „ StageStage IIIIII:: SGSSGS andand involvinginvolving tracheatrachea „ StageStage IVIV:involve:involve glottisglottis withwith fixationfixation TVCTVC GradingGrading SystemsSystems forfor SGSSGS „ McCaffreyMcCaffrey McCaffreyMcCaffrey ConclusionsConclusions

SiteSite:: glottic,glottic, tracheal,tracheal, subglottic:subglottic: majormajor factorfactor inin typetype ofof surgerysurgery „ thinthin (<1cm)(<1cm) subglotticsubglottic oror trachealtracheal lesionslesions---- EndoscopicEndoscopic „ thick(>1cm)thick(>1cm) anyany sitesite oror glotticglottic lesionslesions----OpenOpen StageStage:: prognosticprognostic predictorpredictor „ 90%90% ofof StageStage II andand IIII successfullysuccessfully treatedtreated „ 70%70% ofof StageStage III,III, 40%40% ofof StageStage IVIV ManagementManagement ofof SGSSGS

„ MedicalMedical „ ObservationObservation „ TracheotomyTracheotomy „ EndoscopicEndoscopic TreatmentTreatment „ CO2CO2 laserlaser (with(with MitomycinMitomycin C/Steroid)C/Steroid) „ RigidRigid vs.vs. BalloonBalloon DilationDilation (with(with MitomycinMitomycin)) „ OpenOpen AirwayAirway expansionexpansion procedureprocedure ManagementManagement ofof SGSSGS

„ MedicalMedical „ DiagnosisDiagnosis andand treatmenttreatment ofof GERGER „ PediatricPediatric –– consultationconsultation withwith primaryprimary physicianphysician andand specialistsspecialists (pulmonary,(pulmonary, GI,GI, cardiologycardiology etc.)etc.) „ AdultAdult „ Assess general medical status „ Consultation with PCP and specialists „ Optimize cardiac and pulmonary function „ Control diabetes „ Discontinue steroid use if possible before LTR ManagementManagement ofof SGSSGS

„ ObservationObservation „ ReasonableReasonable inin mildmild cases,cases, esp.esp. congenitalcongenital SGSSGS (Cotton(Cotton--MyerMyer gradegrade II andand mildmild gradegrade II)II) „ If no retractions, feeding difficulties, or episodes of croup requiring hospitalization „ Follow growth curves „ Repeat endoscopy q 3-6 mo „ AdultsAdults –– dependsdepends onon symptomssymptoms SurgerySurgery forfor SGSSGS

„ I.I. EndoscopicEndoscopic „ DilationDilation +/+/-- stentingstenting „ Rigid vs. balloon dilation „ LaserLaser +/+/-- stentingstenting „ II.II. OpenOpen procedureprocedure „ ExpansionExpansion procedureprocedure (with(with trachtrach andand stentstent oror SSSS--LTR)LTR) „ Laryngotracheoplasty (Trough technique with mucosal grafting +/- cartilage grafting) „ Laryngotracheal reconstruction „ Tracheal Resection with primary anastamosis ManagementManagement ofof SGSSGS

„ HowHow dodo youyou decidedecide whichwhich procedureprocedure toto performperform „ Status of the patient „ Any contraindications „ Absolute „ Tracheotomy dependent (aspiration, severe BPD) „ Severe GER refractive to surgical and medical therapy „ Relative „ Diabetes „ Steroid use „ Cardiac, renal or pulmonary disease ManagementManagement ofof SGSSGS

„ EndoscopicEndoscopic „ DilationDilation „ PracticedPracticed frequentlyfrequently beforebefore adventadvent ofof openopen LTPLTP proceduresprocedures „ OftenOften requiresrequires multiplemultiple repeatrepeat proceduresprocedures „ PotentiallyPotentially lowerlower successsuccess raterate butbut anan optionoption forfor patientspatients whowho cannotcannot undergoundergo openopen proceduresprocedures TreatmentTreatment OptionsOptions

GoalsGoals 1.1. MaintainMaintain patentpatent airwayairway 2.2. MaintainMaintain glotticglottic competencecompetence toto protectprotect againstagainst aspirationaspiration 3.3. MaintainMaintain acceptableacceptable voicevoice SurgicalSurgical ManagementManagement

ApproachesApproaches „ Endoscopic:Endoscopic: cryotherapy,cryotherapy, microcauterization,microcauterization, laserlaser incisionincision oror excisionexcision ofof scarscar tissue,tissue, dilatation,dilatation, stentingstenting

„ OpenOpen surgical:surgical: trachealtracheal resectionresection andand reanastomosis,reanastomosis, externalexternal tracheoplastytracheoplasty with/withoutwith/without graftinggrafting andand possiblepossible stentingstenting StentsStents

„ IndwellingIndwelling expandableexpandable stentsstents „ UsedUsed inin manymany organorgan systems:systems: arteries,arteries, thethe urethra,urethra, andand biliarybiliary treetree

„ TracheobronchialTracheobronchial system:system: „ LowerLower airwaysairways forfor eithereither tumors,tumors, oror bronchialbronchial stenosisstenosis afterafter lunglung transplantationtransplantation „ UpperUpper airwaysairways (Montgomery(Montgomery TT--tube,tube, silicone,silicone, meshmesh stents):stents): usedused alonealone oror withwith otherother modalitiesmodalities StentsStents

„ StentingStenting „ EnsureEnsure adequateadequate airwayairway duringduring woundwound maturationmaturation „ WhileWhile waitingwaiting forfor ptpt’’ss conditioncondition toto improveimprove priorprior toto definitivedefinitive surgicalsurgical resection/treatmentresection/treatment „ SilasticSilastic TT--TubesTubes mostmost commonlycommonly usedused „ Permit better hygiene „ Not prone to obstructing granulation „ Stent removal possible after 1-2 years with good results ExpandableExpandable StentStent

HannaHanna 19971997 „ CanineCanine model(6)model(6) „ Stenosis induced by resection of anterior cricoid arch/tracheal wall to reduce airway diameter by 50% „ 8 week stenosis maturation period „ Tracheostomy performed, followed by introduction of titanium mesh stent (Group A), +/- silicone covering (Group B) „ Euthanasia performed at 4 weeks with gross/histologic exam ExpandableExpandable StentStent

HannaHanna (1997)(1997)

„ StentsStents wellwell tolerated,tolerated, minimalminimal signssigns ofof airwayairway irritation,irritation, nono infectionsinfections

„ GroupGroup AA unableunable toto bebe decannulateddecannulated duedue toto granulationgranulation

„ GroupGroup BB allall toleratedtolerated decannulationdecannulation withoutwithout complicationcomplication ExpandableExpandable StentStent SilasticSilastic TT--TubesTubes TT--TubesTubes StentsStents

FroehlichFroehlich (1993)(1993)

„ RetrospectiveRetrospective studystudy ofof TT--tubestubes inin 1212 pediatricpediatric patientspatients

„ 1010 acquiredacquired afterafter intubation,intubation, 22 congenital,congenital, (4(4 extensiveextensive tracheomalacia)tracheomalacia)

„ 1010 withwith priorprior tracheotomytracheotomy

„ 55 CottonCotton gradegrade 2,2, 77 CottonCotton gradegrade 33 (6(6 requiredrequired anterioranterior splitsplit toto fitfit TT--tube)tube) StentsStents

FroehlichFroehlich (1993)(1993)

„ meanmean timetime fromfrom insertioninsertion toto finalfinal removalremoval 5.65.6 monthsmonths

„ 9/129/12 successfulsuccessful txtx (mean(mean timetime fromfrom dxdx toto endend ofof txtx 15.315.3 months)months)

„ Complications:Complications: tubetube migration,migration, accidentalaccidental tubetube removal,removal, tubetube occlusionocclusion StentsStents

FroehlichFroehlich (1993)(1993)

„ 75%75% successsuccess raterate ofof longlong termterm stentingstenting comparablecomparable toto eithereither cricoidcricoid splitsplit oror LTRLTR proceduresprocedures „ stenting takes longer, increased complications

„ TT--tubetube stentingstenting betterbetter reservedreserved forfor casescases notnot amenableamenable toto surgery,surgery, i.e.i.e. tracheomalaciatracheomalacia EndoscopicEndoscopic ApproachApproach

„ BenefitsBenefits patientspatients duedue toto lessless morbiditymorbidity „ ShorterShorter hospitalhospital staystay „ EarlierEarlier returnreturn toto workwork „ ToleranceTolerance ofof repeatedrepeated procedures,procedures, ifif necessarynecessary ““LasersLasers””

„ FirstFirst medicalmedical useuse (December(December 1961)1961) „ StrongStrong andand JakoJako (1972)(1972) „ First described CO2 laser for LTS management „ Types:Types: „ CO2 „ KTP „ Nd-YAG LasersLasers

„ UsedUsed asas bothboth definitivedefinitive andand asas anan adjunctadjunct toto openopen repairrepair

„ HallHall (1971)(1971) delayeddelayed collagencollagen synthesissynthesis inin laserlaser incisionsincisions

„ UsedUsed inin conjunctureconjuncture withwith otherother epithelialepithelial preservingpreserving techniquestechniques LaserLaser excisionexcision ofof subglotticsubglottic stenosisstenosis LaserLaser excisionexcision ofof subglotticsubglottic stenosisstenosis EndoscopicEndoscopic ApproachApproach

Simpson,Simpson, etet alal (1982)(1982) „ RetrospectiveRetrospective studystudy ofof 6060 patients:patients: 4949 laryngeallaryngeal (supraglottic,glottic,(supraglottic,glottic, subglottic),subglottic), 66 tracheal,tracheal, 55 combinedcombined stenosisstenosis „ FollowFollow up:up: 11--88 yearsyears „ Age:Age: 22 monthsmonths--7272 yearsyears oldold

„ COCO2 laserlaser usedused toto vaporizevaporize scarscar tissue,tissue, dividedivide fibroticfibrotic bands,bands, oror exciseexcise redundantredundant tissuetissue „ +/+/-- SilasticSilastic stenting,stenting, dilatationdilatation EndoscopicEndoscopic ApproachApproach

Simpson,Simpson, etet alal (1982)(1982) „ 39/6039/60 hadhad SilasticSilastic stentsstents placedplaced „ 1/6 supraglottic „ 2/12 glottic „ 27/31 subglottic stenosis „ 4/6 tracheal „ 4/5 combined EndoscopicEndoscopic ApproachApproach

Simpson,Simpson, etet alal (1982)(1982)

„ DilatationDilatation employedemployed 8/608/60 „ 0/49 laryngeal „ 4/6 tracheal „ 4/5 combined EndoscopicEndoscopic ApproachApproach

#CASES SUCCESS #PROCEDURES % TO SUCCESS

Laryngeal 49 77.5 2.11

Tracheal 6 33.3 6

Combined 5 20.0 1 EndoscopicEndoscopic ApproachApproach

Simpson,Simpson, etet alal (1982):(1982): ConclusionsConclusions

„ JustifiedJustified atat allall levelslevels

„ DecreasedDecreased successsuccess withwith ‘‘severesevere’’,, combined,combined, extensiveextensive (>1cm)(>1cm) oror circumferentialcircumferential stenosis;stenosis; lossloss ofof cartilage,cartilage, andand precedingpreceding bacterialbacterial infectioninfection associatedassociated withwith tracheostomytracheostomy

„ AgeAge notnot associatedassociated withwith failurefailure raterate ManagementManagement ofof SGSSGS „ EndoscopicEndoscopic „ LaserLaser „ 66-80% success rate for Cotton-Myer grade I and II stenoses (pediatric cases) „ Closer to 50% success rate in appropriately chosen adults „ Factors associated with failure „ Previous attempts „ Circumferential scarring „ Loss of cartilage support „ Exposure of cartilage „ Arytenoid fixation „ Combined laryngotracheal stenosis with vertical length >1cm ScarScar InhibitorsInhibitors „ MitomycinMitomycin CC „ AntimetaboliteAntimetabolite ofof StreptomycesStreptomyces caespitosuscaespitosus „ PossessesPossesses antineoplasticantineoplastic andand antiproliferativeantiproliferative propertiesproperties „ InhibitsInhibits fibroblastfibroblast proliferationproliferation inin vivovivo andand inin vitrovitro „ MechanismMechanism maymay involveinvolve triggeringtriggering ofof fibroblastfibroblast apoptosisapoptosis „ 55--FUFU && BB--aminopropionitrileaminopropionitrile „ InhibitInhibit collagencollagen crosscross--linkinglinking andand scarscar formationformation inin animalanimal modelsmodels „ TGFTGF--ββ SGSSGS ComparisonComparison StudyStudy

„ ShapshayShapshay (2004)(2004) „ RetrospectiveRetrospective cohortcohort studystudy „ CompareCompare efficacyefficacy ofof 33 endoscopicendoscopic techniquestechniques „ CO2CO2 laserlaser withwith rigidrigid dilationdilation „ CO2CO2 laser,laser, rigidrigid dilation,dilation, steroidsteroid injectioninjection „ CO2CO2 laser,laser, rigidrigid dilation,dilation, topicaltopical MitomycinMitomycin CC applicationapplication SGSSGS ComparisonComparison StudyStudy „ EndoscopicEndoscopic treatmenttreatment „ CO2 laser radial incision (Shapshay) „ 15% success „ CO2 laser with steroid injection „ 40 Kenalog in 3 quadrants „ 18% success „ CO2 laser with mitomycin-C topical application „ 0.4 mg/ml Mitomycin-C topically applied 4 minutes „ 75% success MitomycinMitomycin CC MetanalysisMetanalysis

Note: Lone human dissenting study was highest quality randomized clinical trial Warner and Brietzke (2008) TGFTGF--ββ

„ TGFTGF--ββ:: GFGF secretedsecreted byby fibroblasts,fibroblasts, macrophagesmacrophages andand plateletsplatelets „ ImplicatedImplicated inin scarringscarring inin manymany differentdifferent organorgan systemssystems andand inin animalanimal modelsmodels „ BiopsyBiopsy specimensspecimens ofof IPSSIPSS andand intubationintubation relatedrelated stenosisstenosis patientspatients showshow highhigh levelslevels ofof TGFTGF--ββ--22 „ IVIV andand locallocal injectioninjection ofof anan antibodyantibody availableavailable „ UsedUsed toto treattreat fibrosisfibrosis inin skin,skin, uretersureters,, kidneykidney andand eyeeye „ RecentRecent studystudy showedshowed inhibitioninhibition ofof scarringscarring inin ratrat tracheatrachea withwith continuouscontinuous infusioninfusion ofof antianti--TGFTGFββ TGFTGF--ββ Simpson CB et al (2008)

Pilot Study in Modified Canine Model

8 subjects underwent cautery injury to subglottis

4 treated with saline injection into injury site

4 treated with combination of IV and local injection of anti- TGFβ at day 0 and day 5

TGFTGF--ββ

„ Conclusions:Conclusions: „ IVIV andand locallocal TGFTGFββ injectioninjection resultedresulted inin aa reductionreduction inin trachealtracheal stenosisstenosis (p(p << .05).05) andand anan increaseincrease inin survivalsurvival timetime (p(p <.03)<.03) whenwhen comparedcompared toto salinesaline controlcontrol subjectssubjects „ AntiAnti--TGFTGFββ appearsappears toto bebe usefuluseful adjunctadjunct inin treatmenttreatment ofof LTSLTS „ FurtherFurther studystudy neededneeded toto determinedetermine optimaloptimal dosing,dosing, routeroute ofof administrationadministration andand timingtiming ofof deliverydelivery SGSSGS BalloonBalloon DilationDilation

„ DilationDilation ofof bronchtrachealbronchtracheal stenosesstenoses withwith angioplastyangioplasty balloonsballoons describeddescribed previouslypreviously inin adultsadults andand childrenchildren +/+/-- stentsstents „ AdvantageAdvantage comparedcompared toto rigidrigid oror bougiebougie dilationdilation „ BalloonsBalloons maximizemaximize thethe radialradial directiondirection andand pressurepressure ofof dilationdilation „ LessLess damagingdamaging toto trachealtracheal wallwall mucosamucosa „ FoundFound toto havehave goodgood initialinitial resultsresults „ Often requires stenting of dilated portion „ Repeated procedures necessary in active processes, e.g. Autoimmune States SGSSGS BalloonBalloon DilationDilation „ LeeLee andand RutterRutter (2008)(2008) „ 66 patientspatients withwith IPSSIPSS (single(single discretediscrete stenosisstenosis)) „ UnderwentUnderwent dilationdilation withwith 1010 toto 1414 mmmm balloonballoon inin eithereither singlesingle oror 22 consecutiveconsecutive dilationdilation (in(in 77 days)days) „ F/uF/u betweenbetween 1010 andand 3030 monthsmonths inin 44 patientspatients „ No symptoms of recurrent airway stenosis „ One patient required repeat dilation after 22 mos „ No adverse effects or complications „ Recommended burst pressure (8 to 17 atm) „ 4 cm long catheters, center of balloon positioned at midpoint of stenosis „ Airway dilated from 2.0 to 3.5 ET size larger than initial size

CombinedCombined LaserLaser && BalloonBalloon DilationDilation

„ AndrewsAndrews etet alal (2007)(2007) „ PerformedPerformed flexibleflexible bronchoscopybronchoscopy forfor combinedcombined NdNd:YAG:YAG laserlaser radialradial incisionincision atat sitesite ofof stenosisstenosis andand balloonballoon dilationdilation inin awake,awake, spontaneouslyspontaneously breathingbreathing patientspatients „ TotalTotal ofof 1818 patientspatients underwentunderwent 3636 proceduresprocedures „ 8 pts required only 1 procedure; 5 pts required 2 procedures (72%) „ 11/18 patients (60%) were obese or morbidly obese „ Average f/u 22 mos; avg time b/w procedures 9 mos „ No complication in study group

CaseCase ExampleExample

„ 5858--yearyear--oldold femalefemale withwith severalseveral monthmonth historyhistory ofof hoarsenesshoarseness „ AlsoAlso hashas aa historyhistory ofof asthmaasthma „ RecentRecent PFTsPFTs showedshowed nono evidenceevidence forfor asthma.asthma. „ AlsoAlso hadhad aa diagnosisdiagnosis ofof gastroesophagealgastroesophageal refluxreflux diseasedisease andand feelsfeels thatthat herher hoarsenesshoarseness hashas beenbeen contributedcontributed byby thethe refluxreflux diseasedisease „ IntermittentIntermittent dysphagiadysphagia CaseCase ExampleExample

„ LaryngoLaryngo videovideo stroboscopicstroboscopic examexam waswas performed:performed: showsshows normalnormal vocalvocal foldfold mobilitymobility bilaterallybilaterally „ PresencePresence ofof mildmild nodularnodular thickeningthickening ofof thethe leftleft anterioranterior vocalvocal cordcord surfacesurface „ MoreMore significantlysignificantly therethere isis approximatelyapproximately 50%50% stenosesstenoses ofof herher subglotticsubglottic airwayairway atat thethe levellevel ofof thethe cricoidcricoid cartilagecartilage andand erythemaerythema ofof thisthis areaarea

EndoscopicEndoscopic BalloonBalloon DilationDilation