Laryngotracheal stenosis

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Laryngotracheal stenosis
Classification and external resources
Laryngotracheal stenosis 001.jpg
This condition can also be referred to as subglottic or tracheal stenosis.
ICD-10 Q31.1, Q32.1, J38.6, J39.8, J95.5
ICD-9 519.19, 748.3
MeSH D014135

Laryngotracheal stenosis refers to abnormal narrowing of the central air passageways. This can occur at the level of the larynx, trachea, carina or main bronchi. In a small number of patients narrowing may be present in more than one anatomical location.

Nomenclature[edit]

Laryngotracheal stenosis (Laryngo-: Glottic Stenosis; Subglottic Stenosis; Tracheal: narrowings at different levels of the windpipe) is a more accurate description for this condition when compared, for example to subglottic stenosis which technically only refers to narrowing just below vocal folds or tracheal stenosis. In babies and young children however, the subglottis is the narrowest part of the airway and most stenoses do in fact occur at this level. Subglottic stenosis is often therefore used to describe central airway narrowing in children, and laryngotracheal stenosis is more often used in adults.

Causes[edit]

Laryngotracheal stenosis is an umbrella term for a wide and heterogeneous group of very rare conditions. The population incidence of adult post-intubation laryngotracheal stenosis which is the commonest benign sub-type of this condition is approximately 1 in 200,000 adults per year.[1] The main causes of adult laryngotracheal stenosis are:

Main causes of laryngotracheal stenosis
Benign causes Malignant causes
Extrinsic compression
Intrinsic narrowing
  • At the level of subglottis/trachea
    • Intubation/tracheostomy-related (most common cause)
    • Wegener's Granulomatosis
    • Idiopathic Progressive Subglottic Stenosis
    • Amyloidosis
    • Tracheopathia osteoplastica
    • Tracheomalacia
      • Expiratory Dynamic Airway Collapse (EDAC)
      • Tracheobronchomalacia
        • Relapsing Polychondritis
        • Tracheaal ring damage due to COPD
        • Tracheal ring weakness
    • Benign tumors (e.g. Carcinoid)
    • Tracheal trauma / rupture
    • Congenital subglottic/tracheal anomalies
      • Complete tracheal rings
      • Congenital subglottic/tracheal webs
      • Subglottic haemangioma
      • Subglottic / tracheal cysts
  • Head and neck (especially laryngeal or supraglottic) cancers

Presentation[edit]

The most common symptom of laryngotracheal stenosis is gradually-worsening breathlessness (dyspnea) particularly when undertaking physical activities (exertional dyspnea). The patient may also experience added respiratory sounds which in the more severe cases can be identified as stridor but in many cases can be readily mistaken for wheeze. This creates a diagnostic pitfall in which many patients with laryngotracheal stenosis are incorrectly diagnosed as having asthma and are treated for presumed lower airway disease.[2] [3] [4] [5] .[6] This increases the likelihood of the patient eventually requiring major open surgery in benign disease [7] and can lead to tracheal cancer presenting too late for curative surgery to be performed. Recently a patient whose laryngotracheal stenosis, caused by Wegener's Granulomatosis was misdiagnosed for asthma was awarded almost £1,000,000 in damages.

Treatment[edit]

General treatment options include

  1. Tracheal dilation using rigid bronchoscope
  2. Laser surgery
  3. Tracheal resection and reconstruction

Tracheal dilation is used to temporarily enlarge the airway. The effect of dilation typically lasts from a few days to 6 months.

There are differing opinions on treating with laser surgery.

Tracheal resection is so far the best alternative to cure the stenosis completely. The narrowed part of the trachea will be cut off and the cut ends of the trachea sewn together with sutures. For stenosis of length greater than 5 cm a stent may be required to join the sections.

Late June or early July 2010, a new potential treatment was pioneered at Great Ormond Street Hospital in London, where Ciaran Finn-Lynch (aged 11) received a transplanted trachea which had been injected with stem cells harvested from his own bone marrow. The use of Ciaran's stem cells is hoped to prevent his immune system from rejecting the transplant.[8]

See also[edit]

References[edit]

  1. ^ SAR Nouraei, E Ma, A Patel, DJ Howard, GS Sandhu. Estimating the population incidence of adult postintubation laryngotracheal stenosis. Clin Otolaryngol 2007; 32: 411-412.
  2. ^ Ricketti PA, Ricketti AJ, Cleri DJ, Seelagy M, Unkle DW, Vernaleo JR. A 41-year-old male with cough, wheeze, and dyspnea poorly responsive to asthma therapy. Allerg Asthma Proc. 2010;31:355-8.
  3. ^ Scott PM, Glover GW. All that wheezes is not asthma. Br J Clin Pract. 1995;49:43-4.
  4. ^ Kokturk N, Demircan S, Kurul C, Turktas H. Tracheal adenoid cystic carcinoma masquerading asthma: a case report. BMC Pulm Med. 2004;4:10.
  5. ^ Parrish RW, Banks J, Fennerty AG. Tracheal obstruction presenting as asthma. Postgrad Med J. 1983;59:775-6.
  6. ^ Galvin IF, Shepherd DRT, Gibbons JRP. Tracheal stenosis caused by congenital vascular ring anomaly misinterpreted as asthma for 45 years. Thorac Cardiovasc Surg. 1990;38:42-4.
  7. ^ SAR Nouraei, A Singh, A Patel, C Ferguson, DJ Howard, GS Sandhu. Early endoscopic treatment of acute inflammatory airway lesions improves the outcome of postintubation airway stenosis. Laryngoscope. 2006 Aug;116(8):1417-21.
  8. ^ "New throat surgery 'a success'". BBC News. 2010-08-06.