LARYNGOTRACHEAL STENOSIS


Airway obstruction at the level of the larynx and trachea (laryngotracheal stenosis or LTS) is a serious medical condition, which can gravely affect the patient's life and forces him to be under constant medical care. Such patients have to be constantly on a tracheostomy tube and many of them also have problems with communication due to difficulty in voicing.

What causes Laryngotracheal Stenosis?

The causes are several, with trauma being at fault in the majority of cases.
Trauma to the larynx and trachea may be caused in several ways :


- Medical procedures such as an endotracheal intubation or tracheostomy or laryngeal surgery.

- Neck trauma, as during a road traffic accident, injuries at work, sports trauma and homicidal or suicidal injuries.

- Due to ingestion of chemical substances which may be suicidal or accidental.


Other less common factors causing LTS include
:

- Various congenital deformities in this region.

- Infections such as diphtheria, tuberculosis and rhinoscleroma.

- Immunological disorders such as Wegener's granulomatosis and pemphigis vulgaris.

Congenital Glottic Stenosis     Post.Glottic Band Subglottic Stenosis

The increased accidental rate and crime rate in the urban population has consequently led to a rise in the incidence of LTS, which adds up to 0.9% to 3% of cases, according to various sources.

Peculiar to Indian conditions, as our experience shows, is the large incidence of LTS arising due to prolonged endotracheal intubations.


How is Laryngotracheal Stenosis managed ?

 


Firstly, an accurate picture about the degree and extent of the stenosis has to be obtained. This is done by examining the airway with the help of rigid and flexible endoscopes. Sometimes it may be necessary to view the affected part through the tracheostoma with a flexible endoscope. These investigations are augmented by imaging techniques such as radiographs, CT and MRI scans, which give valuable information about the extent of the stenosis and the structures involved.


Other investigations include a voice analysis to assess vocal cord function and pulmonary function tests to determine the condition of the lower respiratory tract.

Different surgical techniques have been devised to manage LTS :

- Open surgery
- Augmentation surgery
- Endoscopic surgery
- Laser surgery


The basic principle is to excise and remove the stenotic lesion and prevent reformation of scar tissue.
In the last few years laser surgery for LTS has shown very encouraging results and is proving to be a valuable development.
The laser, as a cutting tool for LTS surgery, has several advantages over conventional "cold" instruments.

• These include :
- Precision surgery through a small operative field.
- Better haemostasis.
- Less tissue oedema during and after surgery.
- Reduced formation of scar tissue and adhesions.
- Faster healing.
- Reduced surgical time and less hospitalisation.

How is Laryngotracheal Stenosis managed ?

 


The patient is kept under observation to ensure that proper healing is taking place. The site of surgery is periodically examined with endoscopes.

• The process of decanulation or weaning off from the tracheostomy tube is then started.
This involves removing the tube for progressively increasing periods of time, so that the patient can start breathing the normal way again

• Special care is taken to avoid excessive secretions and crust formation in the airway.

• At the same time pulmonary function tests may be required to monitor the condition of the lower respiratory tract.

• At the same time pulmonary function tests may be required to monitor the condition of the lower respiratory tract.

• The voice quality of the patient is also monitored, and if necessary, voice therapy is given to the patient to improve vocal cord function.

Bilateral Abductor Palsy
Pre Operative 

Post Operative


In our VOICE clinic we have been using the diode laser and the CO2 laser for the surgical treatment of LTS. 61 patients have been operated in the last 5 years and the results with the lasers have been very encouraging.

Besides laryngotracheal stenosis, we are also involved in the surgical treatment of other causes of airway obstruction such as laryngeal papillomatosis and various laryngeal tumours.


Posterior Glottic Web

Pre Operative  

Post Operative


Subglottic Stenosis

Pre Operative

Intra Operative

Post Operative


Stenosis at Laryngeal Inlet


Pre Operative

Post Operative

DEENANATH MANGESHKAR HOSPITAL & RESEARCH CENTER