Cicatricial stenosis of the larynx: causes, symptoms, diagnosis, treatment

Cicatricial stenosis of the larynx is one of the frequent complications of nonspecific and specific infectious diseases of it (abscesses, phlegmon, gum, tuberculoid, lupus, etc.), as well as her injuries (wounds, blunt trauma, burns) that lead to cicatricial laryngeal obstruction and development syndrome of chronic insufficiency of the respiratory function of the larynx.

[1], [2], [3], [4]

What causes cicatricial stenosis of the larynx?

The causes of cicatricial stenosis of the larynx can be divided into three categories:

1. post-traumatic, emerged as a result of an accident, and postoperative (iatrogenic);
2. chronic inflammatory ulcerative-necrotic processes;
3. acute inflammatory processes.

Cicatricial stenosis of the larynx can result from her injury and injury, especially when the larynx cartilage and fragments that form its skeleton are damaged and shifted. Secondary perichondritis and chondrites arising from open wounds of the larynx, or damage to the larynx by caustic liquids often result in necrosis, failure of the larynx walls and scarring of the larynx. Clinical practice shows that even timely application of complex treatment, including the most modern antibiotics, does not always manage to prevent posttraumatic complications leading to cicatricial stenosis of the larynx.

Another no less frequent cause of cicatricial stenosis of the larynx is surgical intervention on it. Thus, thyrotoxic (laryngophyssura), performed for chordectomy with recurrent nerve palsy or in situ cancer of the vocal fold, or partial laryngectomy, may result in Rubs stenosis of the larynx, especially if the patient is predisposed to form keloid scars.

Surgical interventions performed as a first aid for asphyxia (tracheotomy, conicotomy, etc.) can lead to severe stenosis of the larynx and trachea, preventing decanulation. According to Ch. Jackson, 75% of stenosis of the larynx and trachea arise precisely as a consequence of urgent surgical interventions on the larynx and trachea. The cause of cicatricial stenosis of the larynx may be damage that occurs at the time of intubation of the trachea, if the intubation tube is in the larynx and trachea for longer than 24-48 hours. Such acute stenoses are caused by acute infectious diseases manifested by larynx lesions (diphtheria, measles, scarlet fever, herpangina, ), in which especially early there are deep bedsores in the larynx with a lesion of the perichondrium. These complications are especially common in children whose larynx is rather narrow for a prolonged intubation tube.

Often, the tracheotomy tube, even if the tracheotomy was made lege artis, can cause the formation of bedsores, ulcers, granulations, especially the so-called supracircular spur, which results from the pressure of the tube on the anterior wall of the trachea, which, when approaching the posterior wall of the trachea, causes the narrowing of the lumen of the latter.

In some cases granulation forms in this area, which completely cover the lumen of the trachea above the tracheotomy tube. The emergence of these granulations is often the reason for insufficiently valuable care of the tracheostomy and cannulae, which is not replaced in a timely manner and systematically not cleaned. The use of an elongated cannula can provoke ankylosis of the perichnecherylar joints, and in children - lag in the development of the larynx.

Cicatricial stenosis of the larynx can occur as a result of planned surgical interventions on the larynx or the application of chemical or diathermic cauterization of it. This stenosis is especially frequent after the extirpation of the papillomas of the larynx in young children. It is noted that the use of endolaryngeal laser surgery is more favorable for the postoperative wound process. The use of massive doses of laryngeal irradiation in malignant tumors, causing radiation epithelium, is often complicated by the formation of cicatricial stenosis of the larynx. Chronic ulcerative-proliferative processes in the larynx now occur rarely and do not so often cause cicatricial stenosis of the larynx. However, if these I processes occur, they after themselves leave deep lesions with massive scarring of the larynx and the emergence of extensive stenoses. The most significant factor in the occurrence of cicatricial stenosis of the larynx is the gummy process in the tertiary period of syphilis. Ulcerative gums after healing leave behind deep scars formed on the eve of the larynx or in the lining space. Anologic changes cause both productive and ulcerative-proliferative forms of tuberculosis of the larynx. However, the larynx of the larynx leaves behind the scars mainly in the region of the epiglottis, while the stenoses of the larynx cavity occur very rarely with it. The cause of cicatricial stenosis of the larynx is scleroma.

Frequent causes of cicatricial stenosis of the larynx are banal inflammatory processes, accompanied by the defeat of the submucosal layer and perichondrium.

In rare cases, cicatricial stenoses of the larynx appear as complications of the laryngeal manifestations of some infectious diseases (diphtheria, typhus and typhoid fever, influenza, scarlet fever, etc.), which were observed much more frequently in the preantibiotics period.

Pathological anatomy of cicatricial stenosis of the larynx

Usually cicatricial stenosis of the larynx occurs in the narrowest parts of this organ, especially at the level of vocal folds and in the lining space and most often in children. Most often, cicatricial stenosis of the larynx arises as a result of proliferative processes, as a result of which the development of connective tissue, which converts to fibrous tissue, is prone to contracting fibers and contracting surrounding anatomical formations. If the alterative process also concerns the cartilage of the larynx, then deformation and lagging in the laryngeal lumen occurs with the formation of especially strong and massive scars. In lighter forms of cicatricial stenosis of the larynx, their immobility occurs at the level of the vocal folds, and in the cases of the laryngeal joints their ankylosis arises, while the respiratory function can remain in a satisfactory state, but the voice formation suffers sharply.

After the subsidence of the inflammatory process (ulceration, granulation, specific granulomas) on the site of inflammation, reparative processes arise due to the appearance of fibroblasts and the formation of dense scar tissue. The severity of the scar process is directly dependent on the depth of the larynx lesion. Especially pronounced cicatricial stenosis of the larynx arises after the transferred chondroperichondritis. In some cases, chronic inflammatory processes in the larynx may cause the development of its scarring stenoses without previous ulceration. A typical example of this is the scleroma of the larynx, the infiltrates of which are localized mainly in the underlayment space. In rare cases, total stenosis of the larynx can occur with the formation of a callous "plug" completely filling the laryngeal lumen and the initial trachea.

Symptoms of cicatricial stenosis of the larynx

Minor cicatricial formation in the epiglottis or throat precondition can cause such symptoms of cicatricial stenosis of the larynx as periodic hoarseness, choking, sometimes sensations of sadness and paresthesia that cause the appearance of a paroxysmal cough. If there is a restriction of the mobility of the vocal folds with some adduction, the insufficiency of the respiratory function of the larynx can manifest itself under physical exertion (dyspnea). With significant cicatricial stenosis of the larynx, there is a state of permanent insufficiency of the respiratory function of the larynx, the severity of which is determined by the degree of stenosis and the rate of its development. The slower the stenosis of the larynx, the better the patient adapts to the resulting oxygen deficiency, and vice versa. If the tracheotomized patient develops signs of insufficient breathing, then in the vast majority of cases, this is due to the narrowing of the lumen of the intercalary tube by drying out secretions. It should be borne in mind that in the presence of compensated cicatricial stenoses of the larynx, the emergence of acute banal laryngitis can lead to acute stenosis of the larynx with unpredictable consequences.

When endoscopic examination of the larynx, various aspects of cicatricial stenosis of the larynx are usually identified; often with mirrored laryngoscopy it is not possible to detect the lumen through which breathing is carried out. Along with the violation of the respiratory function of the larynx, often a violation of the lantern function of varying degrees - from the periodically arising hoarseness of the voice to the complete impossibility to pronounce the sound in any key. In these cases, only whisper speech is possible.

Diagnosis of cicatricial stenosis of the larynx

Diagnosis of cicatricial stenosis of the larynx, as such, does not cause difficulties (anamnesis, laryngoscopy - indirect and direct), difficulties can arise only in establishing their causes in the absence of clear anamnestic data. If the changes in the nasopharynx and pharynx are found to be the same as in the larynx, then it should be assumed that the revealed cicatricial phenomena are caused by a syphilitic, lupus or sclerotic process. In this case, resort to serological methods of diagnosis and biopsy.

In the presence of cicatricial stenosis of the larynx of any etiology, in all cases, X-ray examination of the chest organs, radiography of the larynx, direct laryngo- and tracheoscopy. At certain indications, the esophagus is examined to exclude its diseases, which can have an adverse effect on the larynx. If a patient already has a tracheotomy, endoscopic examination of the larynx does not cause complications. If laryngoscopy is performed against a background of insufficient breathing, then an emergency tracheotomy should be ensured in this same room, as with endocosmetic stenosis of the larynx, endoscopic manipulations can cause the laryngeal obstruction (spasm, edema, wedge of the endoscope tube) and acute asphyxia to develop rapidly. In tracheotomized patients, retrograde laryngoscopy can be performed through a tracheostomy using a nasopharyngeal mirror or a fibrolaringoscope. This method can be used to determine the nature of stenosing tissue, its extent, the presence of a floating spur, etc. The most difficult to visualize are cicatricial stenoses of the lining space. In this case, tomography and CT are used.

Differential diagnosis of cicatricial stenosis of the larynx is based on data of anamnesis, laryngoscopy, additional research methods, including laboratory ones, when suspicion of the presence of specific diseases.

[5], [6], [7], [8]

Treatment of cicatricial stenosis of the larynx

Treatment of cicatricial stenosis of the larynx is one of the most difficult tasks in otorhinolaryngology, which is caused by the high tendency of laryngeal tissues to form scar scarring even in the most sparing reconstructive surgical interventions. To a certain extent, the formation of cicatricial stenoses of the larynx can be prevented or reduced with the help of corticosteroids, timely reduction of local inflammatory necrotic processes both vulgar and specific nature, effective treatment of generalized infectious diseases manifested by laryngeal involvement. If, in order to provide emergency care, the patient has had a conicotomy or an upper tracheotomy, then in the near future he needs to undergo a lower tracheotomy, providing uncomplicated healing of the "intercricotyroid" wound (conicotomy) or upper tracheostomy. In all cases of medical treatment for cicatricial stenosis of the larynx, as soon as possible natural breathing should be achieved, as it not only prevents the formation of scarring, but also provides children with a normal development of the larynx and speech function.

Preventive tracheotomy in persons with chronic cicatricial stenosis of the larynx and unsatisfactory respiratory function of it is permissible, because sooner or later this surgical intervention will still not pass this patient, but will already be made in a hurry for life indications. On the other hand, since such stenoses often show planned surgical intervention to restore the laryngeal lumen, the presence of a tracheostomy is an obligatory condition for carrying out this intervention.

Spikes or scar membranes located between the vocal folds are subjected to diathermocoagulation or removal using a surgical laser. In most cases, after this operation, it is necessary to dilute the vocal folds immediately after the operation with a special dilator, for example, using an Ilyachenko dilator consisting of a tracheotomy tube and a balloon inserted into the larynx between the vocal folds for several days.

The laryngeal bugees are continuous and hollow. Some of them are used in conjunction with tracheotomy tubes. The simplest kind of simple guttural bougie used without tracheotomy cannula is a cotton-tampon swab in the form of a cylinder of the appropriate diameter and length, a tampon is inserted into the narrowed part of the larynx above the tracheostomy. To expand the larynx without a preliminary laryngo-fissure or tracheotomy, use hollow rubber boules of the Schreter or metal buoys of different diameters. Due to the length and shape, these bougies are easily inserted and can remain in the larynx of the larynx from 2 to 60 mi, and the patients themselves hold them at the entrance to the mouth with their fingers. With laryngostomy, to expand or form a laryngeal lumen, it is recommended to use AF Ivanov's rubber tees, which provide breathing both through the nose and mouth, and through the tube.

Solid bougies connected to the tracheotomy tube (bougies Thosta, Bruggemann, etc.) serve only as an expander, and hollow ("chimneys" of NA Pautov), an analogue of a chimney furnace, or compound rubber cannulas by I.Yu. Laskov and Others additionally provide breathing through the oral cavity and nose. In cicatricial stenoses, extending to the upper sections of the trachea, elongated tracheotomy tubes are used. When blocking the larynx, its anesthesia is mandatory only at the first sessions of this procedure; In the future, as the patient becomes accustomed to blocking, anesthesia can be avoided.

With extended cicatricial stenosis of the larynx, laryngotomy is produced with subsequent removal of scar tissue, and bleeding surfaces are covered with free epidermal patches, fixed in the larynx with appropriate rubber fixatives (dummies). BSKrylov (1965) proposed the plasticity of the larynx to be carried by a non-free flap of the mucous membrane, mobilized from the region of the laryngopharynx, which is fixed by means of an inflated rubber canister, the pressure in which is regulated by means of a manometer (preventing the necrosis of the graft from excess pressure).

Treatment of cicatricial stenosis of the larynx is extremely difficult, ungrateful and prolonged, requiring great patience of both the doctor and the patient. Often, to achieve even a satisfactory result, many months, and often years, are required. And the result, to which one should strive, is providing the patient with guttural breathing and closing the tracheostomy. For this it is necessary to possess not only filigree endolaryngeal microsurgical surgical technique, but also modern endoscopic means and endoscopic surgical instruments. Surgical treatment should be supplemented with thorough post-operative care, means of preventing purulent complications, and after healing of wound surfaces and epithelization of the internal surfaces of the larynx - and appropriate phoniatric rehabilitation measures.

What is the prognosis of cicatricial stenosis of the larynx?

Cicatricial stenosis of the larynx has a different prognosis. It depends on the degree of stenosis, the rate of its development, the age of the patient and, of course, on the cause of its occurrence. If cicatricial stenosis of the larynx is caused by a specific infectious process or massive trauma of the larynx, the prognosis for restoring the respiratory function of the larynx is determined by the underlying disease and the effectiveness of its treatment. With respect to the restoration of the respiratory function of the larynx, the most serious is the prognosis for total, tubular stenoses and cicatricial stenoses of the larynx caused by extensive chondroperihondiritis of the larynx. Often with such stenoses, patients are doomed to a lifelong wearing of a tracheostomy. The prognosis in children is complicated by the difficulties of treatment, and with sufficient duration of the latter - the lag in the development of the larynx and speech function.