Acute and chronic stenosis of the larynx and trachea - Treatment

Treatment of acute and chronic stenosis of the larynx and trachea is divided into conservative and surgical. Conservative treatment methods are used when acute stenosis of moderate degree with mild clinical manifestations is detected; acute trauma not accompanied by significant damage to the mucous membrane; early post-intubation changes in the larynx and trachea without a tendency to progressive narrowing of their lumen. Conservative management of patients with acute and chronic stenosis of I-II degree in the absence of pronounced clinical manifestations is also allowed.

There are various surgical treatment methods for the treatment of chronic cicatricial stenosis of the larynx and trachea, including a wide range of injuries to the upper respiratory tract from the supraglottic part of the larynx to the carina. Currently, there are two main areas of reconstructive surgery of the larynx and trachea: laryngeal-tracheal reconstruction and circular resection of the pathological area. The choice of method depends on the patient's indications and contraindications.

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Indications for hospitalization

Indications for urgent hospitalization are the presence of acute stenosis of the larynx and trachea, decompensation of chronic stenosis. Planned hospitalization is carried out for staged surgical treatment.

Goals of treatment of acute and chronic stenosis of the larynx and trachea

The main goal of treatment is to restore the structure and function of the hollow organs of the neck by surgical reconstruction and prosthetics of damaged laryngeal-tracheal structures. The final stage of treatment is decannulation of the patient.

Drug treatment of acute and chronic stenosis of the larynx and trachea

Drug therapy for acute laryngeal stenosis is aimed at quickly suppressing inflammation and reducing swelling of the mucous membrane of the larynx and trachea. For these purposes, drugs are used that reduce tissue infiltration and strengthen the vascular wall (hormones, antihistamines, calcium preparations, diuretic drugs). Steroid hormones are prescribed in the acute period for 3-4 days intravenously, and then 7-10 days orally with a gradual reduction in dose until the inflammatory phenomena subside and breathing is normalized.

When hormonal drugs are prescribed after reconstructive surgery, reparative processes, formation of granulation tissue, and epithelialization of the wound surface proceed more favorably; the likelihood of engraftment of auto- and allografts increases.

The issues of indications and terms of treatment of various forms of stenosis should be decided taking into account the possibility of damage to internal organs. The presence of long-term stenosis is considered the basis for taking measures to prevent the development or treatment of already developed lesions of the corresponding organs and body systems. In the absence of emergency indications in the preoperative period, a comprehensive examination is carried out, according to indications - consultations with specialists (cardiologist, therapist, endocrinologist, neurosurgeon) and correction of existing disorders. Antibiotic prophylaxis is prescribed 48 hours before the expected planned surgery. To prevent purulent-septic complications and infection of transplants during urgent tracheostomy, antibiotics are administered intraoperatively.

The main reasons for repeated surgical interventions in patients with chronic laryngeal tracheal stenosis are purulent-inflammatory complications causing graft extrusion, restenosis of the formed laryngeal tracheal lumen. Etiotropic and pathogenetic therapy is prescribed taking into account the results of microbiological examination of wound discharge and the sensitivity of microorganisms to antibiotics. The drugs are administered parenterally or intravenously for 7-8 days. After the improvement of the patient's condition, they switch to oral antibiotics for 5-7 days. All operations using implants are considered "dirty", accompanied by a high risk of developing infections in the surgical area. In terms of efficiency and safety, the most acceptable are cephalosporins of the first and second generations (cefazolin, cefuroxime) and inhibitor-protected aminopenicillins (amoxicillin + clavulanic acid, ampicillin + sulbactam).

The timing of anti-inflammatory therapy is adjusted depending on concomitant diseases. Thus, in patients with viral hepatitis, the reparative properties of tissues are significantly reduced. The postoperative period is usually complicated by inflammation in the area of the operation and excessive scar formation. Symptomatic therapy is prescribed to such patients depending on the severity of inflammatory phenomena, simultaneously with the prescription of hepatoprotectors. To prevent uncontrolled cicatricial process, it is necessary to use drugs that stimulate the regenerative capacity of tissues and prevent the formation of coarse scars.

Symptomatic therapy consists of 8-10 sessions of hyperbaric oxygenation and general strengthening therapy. To eliminate inflammatory phenomena in the area of surgery, topical preparations are used: ointments with fusidic acid, mupirocin, heparinoid, as well as those containing sodium heparin + benzocaine + benzyl nicotinate or allantoin + sodium heparin + onion extract. To improve the regenerative capacity of the tissues of the larynx and trachea, drugs are prescribed that improve tissue blood flow (pentoxifylline, actovegin), antioxidants (ethylmethylhydroxypyridine succinate, retinol + vitamin E, meldonium), a complex of B vitamins (multivitamin), glycosamine powders (10-20 days) and physiotherapy (phonophoresis and electrophoresis, magnetolaser therapy for 10-12 days).

During the first 3 days after surgery, sanitizing endofibrotracheobronchoscopy is performed daily with the introduction of antibiotics and mucolytic drugs (0.5% hydroxymethylquinoxylinedioxide solution, acetylcysteine, trypsin + chymotrypsin, solcoseryl). Subsequently, endofibrotracheobronchoscopy should be performed every 5-7 days to perform sanitization and monitor treatment until the inflammation of the tracheobronchial tree has completely subsided.

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Surgical treatment of acute and chronic stenosis of the larynx and trachea

In laryngeal-tracheal reconstruction, interventions are used, the essence of which is to change the structure of the elements of the cartilaginous framework of the respiratory tube, replace the epithelial structures of the tracheal mucosa and implant or transpose structures that provide vocal and protective functions.

The development of reconstructive surgery of the larynx and trachea includes two main directions:

• improvement of surgical techniques and prevention of complications;
• prevention of stenosis in the early and late postoperative period.

The scope of surgical intervention is determined in each specific case depending on the etiology of the underlying disease, with the condition of maximum radicality of the operation. Myoarytenoidchordectomy with laterofixation of the opposite vocal fold, redressing of the cricoid cartilage, formation of laryngeal and tracheal structures using allochondria are possible.

Laryngeal-tracheal reconstruction in its primary form is a set of manipulations that result in the creation of a breathing circuit from the vestibular part of the larynx to the thoracic part of the trachea. The missing sections of the walls of the larynx and trachea are formed (using auto- and allo-tissues) and functional prosthetics are performed.

The following methods of larynx and trachea reconstruction are distinguished:

• resection of the cricoid cartilage arch and the initial section of the trachea with thyrotracheal anastomosis;
• formation of damaged structures of the larynx and trachea with the interposition of a cartilaginous implant;
• plastic surgery of the defect using a vascularized free flap;
• structural plastic surgery with muscle flaps and allograft tissues;
• plastic surgery of defects using periosteal or perichondrial flaps;
• Circular resection with end-to-end anastomosis;
• endoprosthetics of the reconstructed larynx using stents - prostheses of various designs.

The development and improvement of flexible fiber optics has allowed endoscopy to be used quite widely for both diagnostics and treatment of laryngeal and tracheal stenosis. As a rule, these interventions are used for cicatricial-granulation forming stenosis, laryngeal papillomatosis, for endolaryngeal myoarytenoidchordectomy, as well as dissection of postoperative scars in limited stenoses no longer than 1 cm. Endoscopic intervention is often used in combination with radical and staged reconstructive plastic surgeries.

To increase the effectiveness of operations on the larynx and trachea, a number of rules are followed. First, the surgeon must be familiar with information on laryngeal-tracheal surgery and have a sufficient number of observations and assistance in operations. Great importance is attached to a thorough preoperative examination and the choice of the optimal surgical approach, planned step by step. Intraoperative findings often seriously affect the outcome of operations, so it is necessary to remember that the examination does not give a complete picture of the disease.

The following criteria are important in assessing damage to the larynx and cervical trachea: location, degree, size, density and boundaries of damage, degree of narrowing of the air column and its nature; mobility of the vocal folds; degree of destruction of the cartilaginous rings; ossification of cartilage; degree of functional impairment.

The question of the scope of surgical intervention is decided strictly individually. The main task of the first stage of surgical treatment is the restoration of respiratory function. Sometimes the first stage is limited to tracheostomy only. If the patient's condition allows, tracheostomy is combined with tracheoplasty or laryngotracheoplasty, implantation of allochondria, plastic surgery of the defect with a displaced skin flap, mucous membrane. The number of subsequent stages also depends on many factors - the course of the wound process, the nature of secondary scarring, the general reactivity of the body.

To normalize breathing in case of acute obstruction of the upper respiratory tract, tracheostomy is performed; if it is impossible to perform, conicotomy is used in rare cases. In the absence of conditions for intubation, the intervention is performed under local anesthesia. When restoring the lumen of the respiratory tract in patients with acute stenosis, decannulation or surgical closure of the tracheostomy is possible. In chronic stenosis of the larynx and trachea, tracheostomy is the first stage of surgical treatment. It is performed with careful adherence to surgical technique and in accordance with the principle of maximum preservation of the tracheal elements.

Technique of tracheostomy formation surgery

When performing a tracheostomy, it is necessary to take into account the degree of hypoxia, the general condition of the patient, the individual constitutional parameters of his physique (hyper-, a- or normosthenic), the possibility of extension of the cervical spine to access the anterior wall of the trachea.

Difficulties in performing a tracheostomy may arise in patients with a short, thick neck and a poorly extending cervical spine.

Preference is given to general anesthesia (endotracheal combined anesthesia with the introduction of muscle relaxants), but local anesthesia with 1% lidocaine solution is more often used. The patient is positioned in the reverse Trendelenburg position - on the back with the head pulled back as far as possible and a cushion under the shoulders. Excessive tilting of the head leads to displacement of the trachea in the cranial direction and a change in anatomical landmarks. In such a situation, it is possible to perform an excessively low tracheostomy (at the level of 5-6 half rings). With hyperextension of the neck, displacement of the brachiocephalic arterial trunk above the jugular notch is also possible, which is accompanied by the risk of its damage when isolating the anterior wall of the trachea.

A midline incision is made in the skin and subcutaneous tissue of the neck from the level of the cricoid cartilage to the jugular notch of the sternum. The anterior wall of the trachea is isolated layer by layer using curved clamps in a blunt manner. This should not be done over a large area, especially along the lateral walls, since there is a risk of disruption of the blood supply to this section of the trachea and damage to the recurrent nerves. In patients with a long, thin neck, in this position the isthmus of the thyroid gland is shifted upward; in patients with a thick, short neck and a retrosternal location of the thyroid gland - downwards behind the sternum. If displacement is impossible, the isthmus of the thyroid gland is crossed between two clamps and stitched with synthetic absorbable threads on an atraumatic needle. The tracheostomy is formed at the level of 2-4 half rings of the trachea. The size of the incision should correspond to the size of the cannula; an increase in length can lead to the development of subcutaneous emphysema, a decrease - to necrosis of the mucous membrane and adjacent cartilages. To form a tracheostomy, the edges of the skin are brought to the edges of the incision without much tension and sutured behind the intercartilaginous spaces. Tracheostomy single- or double-cuff thermoplastic tubes of the appropriate diameter are inserted into the lumen of the trachea. The main differences between these tubes are that their angle is 105°. Such anatomical bending allows to minimize the risk of complications associated with irritation caused by contact of the digital end of the tube with the tracheal wall.

Immediately after the end of the tracheostomy, endofibrotracheobronchoscopy is performed to sanitize the lumen of the trachea and bronchi. To restore the lumen of the hollow organs of the neck, different types of laryngotracheoplasty and prosthetics of the larynx and trachea are used.

Reconstructive interventions on the larynx are complex and require technical support for all stages of the operation. Prosthetics play a special role in the process of rehabilitation of laryngeal functions.

Depending on the specific pathological changes and the surgical rehabilitation plan, all prosthetic options are divided into two types - temporary and permanent.

The main tasks of prosthetics:

• maintaining the lumen of a hollow organ:
• ensuring the formation of the walls of the respiratory tract and digestive tract:
• dilation of the formed lumen of the larynx and trachea. Laryngeal tracheal prostheses are divided into removable (reusable) and permanent, which are sewn or inserted into the lumen of hollow organs and removed upon achieving the functional result of treatment. The following requirements are imposed on the laryngeal tracheal prostheses used: lack of toxicity; biological compatibility; resistance to the effects of tissues and body environments; the ability to create the necessary geometry; density and elasticity: impermeability to air, liquid and microorganisms; the possibility of quick and reliable sterilization. Functional prosthetics for the purpose of correct formation and healing of the surgical wound involves the use of tracheotomy tubes made of modern thermoplastic materials of the required size. The duration of wearing the prosthesis is determined individually depending on the severity of the pathological process and the volume of reconstructive surgery. The stage of postoperative prosthetics is considered complete after complete epitelization of all wound surfaces. By this time, the main physiological functions of the hollow organs of the neck are compensated, or long-term temporary prosthetics are necessary to achieve this. T-shaped silicone tubes of the appropriate size are used as long-term prosthetics.

Treatment of patients with bilateral laryngeal paralysis depends on the etiology of the disease, duration and severity of clinical symptoms, degree of functional disorders, nature of adaptive and compensatory mechanisms. There is currently no single tactic for treating bilateral laryngeal paralysis. Surgical treatment methods for bilateral laryngeal paralysis are divided into two groups.

Methods aimed at fixed expansion of the lumen of the glottis

Depending on the approach to the vocal folds, the following are distinguished:

• translaryngeal;
• endolaryngeal;
• extralaryngeal.

Methods to restore vocal fold mobility

In translaryngeal methods, access to the affected vocal fold is achieved through a laryngofissure, dissection of the internal membrane of the larynx, submucous removal of the vocal fold with the muscle mass and partial or total removal of the arytenoid cartilage. Measures aimed at preventing the formation of a scar in the area of the operation include the use of various roller tampons, dilators, tubes and prostheses in the postoperative period, among which T-shaped tubes made of various materials are the most widely used.

Endolaryngeal methods of treating median laryngeal paralysis include various methods of laterofixation of the vocal fold in direct laryngoscoliosis. Partial removal of the arytenoid cartilage is allowed. The advantages of endolaryngeal operations are that they are less traumatic and preserve the vocal function to a greater extent. Endolaryngeal surgery is not indicated for patients with ankylosis of the cricoarytenoid joints, if it is impossible to install a direct laryngoscope (obese patients with a thick short neck). The complexity of postoperative intraorgan prosthetics can lead to the formation of cicatricial membranes and adhesions in the posterior part of the glottis and cicatricial deformation of its lumen.

Extralaryngeal methods allow preserving the integrity of the mucous membrane of the larynx. Surgical access to the vocal part of the larynx is carried out through a formed "window" in the plate of the thyroid cartilage. The complexity of the method is mainly due to the difficulty of submucosal application of a laterofixing suture and its fixation with maximum abduction of the vocal fold.

The most frequently used methods are functionally justified translaryngeal plastic surgery. In this case, unilateral myoarytenoidchordectomy is performed in combination with laterofixation of the opposite vocal fold, followed by prosthetics of the formed lumen of the larynx.

If the patient's general somatic condition prevents subsequent decannulation, laryngotracheoplasty is not performed. A permanent tracheostomy is created, and the patient is taught to independently change the tracheotomy tube; in this situation, he remains a chronic cannulator.

In widespread cicatricial stenosis of the laryngeal-tracheal localization, there is always a deficit of supporting viable tissues in the area of narrowing or organ defect, a sharp decrease or absence of the anatomical lumen of the larynx and trachea due to the destruction of cartilaginous elements and cicatricial degeneration of the mucous membrane with the development of laryngeal-tracheal atresia. This requires an individual approach in choosing the method of surgical treatment and prosthetics. To restore the anatomical and physiological characteristics of the larynx and trachea, reconstructive surgeries are performed using aldotransplants and laryngeal-tracheal prostheses.

Under favorable circumstances, a two-stage operation allows for full restoration of the structural elements of the larynx and trachea. Allochondral cartilages are implanted paratracheally during the primary reconstructive operation. If this is impossible for a number of reasons (larynx detachment from the trachea with a diastasis of 4 cm or more), the larynx and posterior tracheal wall structures are formed along the entire length at the reconstruction stage, and subsequently the lateral walls of the trachea. Restoration of breathing through natural pathways helps to normalize the functions and physiological work of the respiratory muscles through the reflected respiratory cycle. Restored afferentation in the central nervous system contributes to a faster recovery of the patient.

Further management

After discharge from the hospital, the patient should be observed by an otolaryngologist at the local outpatient clinic and the surgeon who performed the operation, monitoring the condition of the upper respiratory tract every 2-3 weeks. Patients are prescribed physiotherapy procedures, inhalations, phonopedic exercises and breathing exercises.

The period of disability for acute stenosis of the larynx and trachea depends on the etiology of the disease and the degree of damage to the hollow organs of the neck and is on average 14-26 days.

Patients with chronic stenosis of the larynx and trachea with impaired anatomical and functional indicators have persistent impairment of working capacity for the entire period of treatment and rehabilitation.