Current Otolaryngology > IX. Trachea & Esophagus > Chapter 35.

Benign & Malignant Disorders of the

Trachea >
ANATOMY OF THE TRACHEA
ANATOMIC RELATIONSHIPS
The trachea is a fibrouscular tube supported b! cartilaginous rings that e"tends fro
the inferior border of the cricoid cartilage to the carinal bifurcation. It easures #$%#3 c
in length and &.$%&.5 c in lateral diaeter. In infants and children' the pro"ial half of
the trachea is e"trathoracic' beginning at the le(el of the fourth cer(ical (ertebra. In
adults' it begins around the si"th cer(ical (ertebra' lea(ing onl! the pro"ial third
e"trathoracic. The carina occurs at the le(el of the sternoanubrial )unction anteriorl!'
and at the fourth or fifth thoracic (ertebra posteriorl!. The trachea slides freel! *ithin its
anatoic plane and cer(ical fle"ion or +!phosis a! transfer the entire trachea into the
thora".
,s the trachea courses inferiorl!' it igrates fro an anterior' subcutaneous position in
the nec+ to a deep' posterior position near the (ertebral colun at the carina. Throughout
its course' the posterior *all of the trachea is applied to the esophagus' *hich lies )ust
left of the tracheal idline' passing behind the origin of the left ain bronchus.
In the nec+' the trachea is flan+ed b! the carotid sheaths bilaterall!. The th!roid gland is
adherent to the anterior and lateral aspects of the trachea at its ost superior liits.
More inferiorl!' the lateral argins of the trachea are bounded b! l!ph nodes and loose
connecti(e tissue. The right recurrent lar!ngeal ner(e loops around the origin of the right
subcla(ian arter! and ascends to the lar!n"' l!ing *ithin the tracheoesophageal groo(e
onl! as it approaches the th!roid gland. , right' nonrecurrent lar!ngeal ner(e occurs in
#- of patients and is associated *ith an anoalous subcla(ian arter!. The left ner(e
recurs around the aortic arch and ascends the length of the trachea *ithin the
tracheoesophageal groo(e.
The aorta arches o(er the left ain bronchus at its origin and slightl! indents the
anterolateral *all of the distal trachea on that side. It gi(es rise to the brachiocephalic
trun+' *hich courses obli.uel! across the anterior trachea and di(ides into the right
carotid and subcla(ian arteries at the thoracic inlet. In children and occasionall! in adults'
the brachiocephalic arter! crosses the trachea ore superiorl! and is found at the base of
the nec+.
The left brachiocephalic (ein crosses the trachea anterior to the aortic arch (essels and
recei(es a (ariable net*or+ of descending inferior th!roidal and th!ic (eins. The
a/!gous (ein )oins the superior (ena ca(a after looping o(er the right ain bronchus near
its origin at the carina. 0ust anterior and inferior to the carina' the right pulonar! arter!
courses to*ard the right hilu.
STRUCTURE
The tracheal rings' deri(ed fro splanchnic esoder' occup! the anterior t*o1thirds of
the tracheal circuference. The rings are incoplete posteriorl!' resulting in a flattened'
ebranous portion of tracheal *all that consists of fibrouscular tissue. There are
appro"iatel! t*o cartilaginous rings per centieter of tracheal length' *ith the
inter(ening spaces coprised of an in(esting fibroelastic ebrane. The first ring is
attached to the inferior boarder of the cricoid cartilage b! the cricotracheal ligaent and
is generall! broader than the rest. The tracheal rings are highl! elastic but a! ossif!
*ith ad(anced age or after traua.
Tracheal uscle fibers' of esoderal origin' are contained in scattered' longitudinal
bundles and in a thin' trans(erse la!er of the ebranous *all' the trachealis uscle.
The respirator! epitheliu arises fro foregut endoder and in the trachea consists of
pseudostratified' ciliated colunar cells and ucus glands.
,noalies of tracheal de(elopent gi(e rise to a nuber of clinicall! iportant anatoic
lesions. 2ailure of tracheoesophageal septation a! result in agenesis of the trachea
3fatal at birth4' stenosis of the trachea or esophagus' or a tracheoesophageal fistula.
Tracheal stenosis also a! be caused b! copression fro anoalous ediastinal
(asculature or the presence of coplete tracheal rings. 5uerous (ariations of aberrant
tracheal bronchi ha(e been described' including unilateral' bilateral' and double ipsilateral
configurations.
BLOOD SUPPLY
The blood suppl! of the trachea is deri(ed fro ultiple sources and is shared *ith the
esophagus. The inferior th!roid arter! and tracheoesophageal branches of the subcla(ian
arter! suppl! the upper trachea' *hile the lo*er third is supplied b! the bronchial arteries
and branches fro the intercostal and internal aar! arteries. The (essels approach
the tracheoesophageal groo(e laterall! and di(ide to send branches to each organ.
Intercartilaginous branches tra(erse the tracheal circuference and interconnect (ia
longitudinal arcades and a rich' subucosal ple"us. Circuferential dissection *ith
disruption of the lateral (ascular pedicles should be liited to #%& c of an! portion of
the trachea that is to reain in situ.
,llen M6. 6urgical anato! of the trachea. Chest Surg Clin N Am. &$$37#33&48#9#. 3,
thorough re(ie* of the surgical anato! of the trachea.4 :;MID8 #&<553$=>
Cauld*ell E?' 6is+ert @A' Binninger @E' ,nson B0. The bronchial arteries8 an anatoic
stud! of #5$ huan cada(ers. Surg Gynecol Obstet. #9C=7=D8395. :no ;MID nuber
a(ailable> 3Definiti(e stud! of tracheal blood suppl!.4
6alassa 0@' ;earson B?' ;a!ne ?6. Aross and icroscopical blood suppl! of the trachea.
Ann Thorac Surg. #9<<7&C8#$$. 3Classic stud! of the tracheal blood suppl!' particularl!
as related to tracheal resection.4 :;MID8 3&<95=>
?atanabe ,' Ea*abori 6' Fsanai G' Taniguchi M' Goso+a*a M. ;reoperati(e coputed
toograph! diagnosis of non1recurrent inferior lar!ngeal ner(e. Laryngoscope.
&$$#7###8#<5D. 3Docuents association of nonrecurrent lar!ngeal ner(e *ith aberrant
right subcla(ian arter!.4 :;MID8 ##=$#9C$>
TRACHEAL INJURIES
TRAUMA
Essentals o! Dagnoss
Gistor! of traua to head' nec+' or chest.
;ain' d!spnea' stridor' heopt!sis' d!sphonia.
6ubcutaneous or deep cer(ical eph!sea.
;neuoediastinu' pneuothora" despite chest tube drainage.
"eneral Cons#eratons
In)uries to the trachea fro blunt or penetrating traua are rare' *ith an incidence of
$.5%&.$- in blunt traua patients' and 3%D- in patients *ith penetrating cer(ical
*ounds. The echaniss of in)ur! ost coonl! reported include gunshot and stab
*ounds' hanging' and deceleration in)uries. ;enetrating tracheal *ounds' *hich ost
coonl! in(ol(e the cer(ical air*a!' result in focal tissue loss and are fre.uentl!
associated *ith serious in)uries to ad)acent organs' such as blood (essels or the
esophagus. Blunt traua t!picall! produces a(ulsion1t!pe in)uries at the lar!ngeotracheal
)unction or at branch points in the tracheobronchial tree' ost *ithin &.5 c of the
carina. Blunt tracheal in)uries are rarel! isolated' occurring ost fre.uentl! in patients
*ith ultis!ste traua.
Cln$al Fn#ngs
SYMPTOMS AND SI"NS
The e"aination of an! traua patient should occur in the setting of a coordinated'
coprehensi(e traua e(aluation. Tracheal in)ur! a! be suspected based on the li+el!
tra)ector! of a penetrating ob)ect or on the patientHs presenting histor! and ph!sical
e"aination. 6igns and s!ptos of lar!ngotracheal traua include pain' hoarseness'
d!spnea' stridor' d!sphonia' subcutaneous eph!sea' and heopt!sis. ;lain chest
radiographs and cer(ical fils a! re(eal subcutaneous air' tracheal de(iation'
pneuoediastinu' or pneuothora".
2urther assessent of tracheal *ounds is indi(iduali/ed based on the patientHs associated
in)uries. The definiti(e diagnosis 3and repair4 of air*a! traua a! be facilitated in
patients undergoing operati(e e"ploration' usuall! for associated (ascular in)uries.
IMA"IN" STUDIES
Angogra%&y
In stable patients' the e(aluation of potential tracheal in)uries should be coordinated *ith
the assessent of ad)acent structures' *ith angiograph! of the aortic arch and thoracic
outlet (essels usuall! ta+ing precedence.
Co'%ute# To'ogra%&y (CT) S$annng
CT scanning readil! deonstrates the anifestations of tracheal traua' including
pneuoediastinu' pneuothora"' and air *ithin the tissue planes of the nec+.
Go*e(er' it is rarel! able to define the e"act location or e"tent of the in)ur!.
Bron$&os$o%y
Bronchoscop! reains the gold standard for defining the precise location and e"tent of
tracheal in)uries. ,t bronchoscop!' a thorough e(aluation is essential and re.uires the
eticulous e(acuation of secretions and aspirated blood in order to allo* ade.uate
inspection of the tracheal ucosa. Careful anipulation of the endotracheal tube is
re.uired in intubated patients to (isuali/e the pro"ial trachea.
Treat'ent
The treatent of tracheal in)uries is not standardi/ed' but the first priorit! in all cases is
to establish an ade.uate' reliable air*a!. Insertion of an endotracheal tube' often difficult
in the presence of upper air*a! traua' a! be facilitated b! fle"ible bronchoscop!.
Tracheosto!' *hen re.uired' should be perfored at the le(el of the in)ur! in order to
inii/e the aount of tracheal daage.
NONSUR"ICAL MEASURES
In stable patients' inor or occult in)uries a! be successfull! treated *ith conser(ati(e
easures. If the patient is not intubated' antibiotic co(erage and close obser(ation is
often sufficient. If echanical (entilation is necessar!' treatent should also include
placeent of the endotracheal cuff be!ond the in)ur! and a(oidance of high air*a!
pressures. 6uch conser(ati(e easures should also be initiated for larger tracheal *ounds
and a! allo* for an electi(e repair rather than an urgent e"ploration.
SUR"ICAL MEASURES
;atient instabilit! or *orsening pneuoediastinu' persistent pneuothora" despite
chest tube drainage' e(idence of ediastinitis' or inade.uate (entilation or o"!genation
andates operati(e inter(ention. The operati(e approach to tracheal repair is dictated b!
the location of the *ound and associated in)uries. , lo* collar incision pro(ides e"posure
of all but the ost distal trachea and a! be e"tended into a partial or coplete edian
sternoto!' if needed. The distal trachea is best approached through a right' fourth
intercostal thoracoto!' *hich allo*s access to the trachea' the carina' the right and
pro"ial left ain bronchi' and the entire intrathoracic esophagus. In)uries to the thoracic
trachea' ho*e(er' are usuall! associated *ith in)uries to the heart and great (essels'
*hich are best approached b! a edian sternoto!. In such cases' the trachea a! be
e"posed b! transpericardial dissection bet*een the superior (ena ca(a and the ascending
aorta.
6iple tracheal in)uries a! be debrided and repaired priaril!' *ith care ta+en to
preser(e the lateral (ascular pedicles and the recurrent lar!ngeal ner(es. ?ounds causing
significant daage re.uire circuferential tracheal resection and end1to1end
anastoosis. ,n anterior longitudinal tracheoto! (ia a cer(ical incision allo*s for the
repair of in)uries to the ebranous trachea *ithout lateral or posterior dissection.
Prognoss
@esults of both repaired and conser(ati(el! anaged tracheal in)uries are generall! good'
and are related ore to the patientHs associated in)uries than to tracheal healing. , dela!
in the diagnosis of tracheal or associated in)uries increases ortalit! significantl!. Minor
in)uries and priaril! repaired *ounds heal *ell *ith inial foration of granulation
tissue or stenosis. 6e(ere tracheal in)uries anaged conser(ati(el! e(entuall! re.uire
repair in order to achie(e decannulation as the! t!picall! heal *ith significant stenosis.
Cassada DC' Mun!i+*a M;' Moni/ M;' Dieter @, 0r' 6chuchann A2' Enderson BB. ,cute
in)uries of the trachea and a)or bronchi8 iportance of earl! diagnosis. Ann Thorac
Surg. &$$$7D98#5D3. 3@etrospecti(e re(ie* of single center e"perience anaging tracheal
traua.4 :;MID8 #$==#=C&>
2rancis 6' Aaspard D0' @ogers 5' 6tain 6C. Diagnosis and anageent of lar!ngotracheal
traua. J Nat Med Assoc. &$$&79C8&#. 3, re(ie* and discussion of the anageent of
lar!ngotracheal in)uries in a series of traua patients.4 :;MID8 ##=3<3C=>
Aranhol T' 2arer DB. The surgical air*a!. Respir Care Clin N Am. &$$#7<8#3. 3@e(ie*
of diagnosis' anageent' and outcoe of pediatric tracheal in)uries.4 :;MID8 ##5=C=$&>
Guh 0. Manageent of tracheobronchial in)uries follo*ing blunt and penetrating traua.
Am Surg. #99<7D38=9D. 3@etrospecti(e re(ie* of an urban traua centerHs e"perience
anaging tracheal traua.4 :;MID8 93&&DD=>
Bee @B. Trauatic in)ur! to the cer(icothoracic trachea and a)or bronchi. Chest Surg
Clin N Am. #99<7<8&=5. 3Coprehensi(e re(ie*.4 :;MID8 9#5D&93>
@ossbach MM' 0ohnson 6B' Aoe/ M,' 6a+o EI' Miller FB' Calhoon 0G. Manageent of
a)or tracheobronchial in)uries8 a &=1!ear e"perience. Ann Thorac Surg. #99=7D58#=&.
3Barge re(ie* of an urban traua centerHs e"perience anaging tracheal in)uries.4 :;MID8
9C5D##C>
6hrager 0B. Tracheal traua. Chest Surg Clin N Am. &$$37 #33&48&9#. 3, re(ie* of the
incidence' diagnosis' and anageent of tracheal in)uries.4 :;MID8 #&<553#C>
Iatrogen$ * Ot&er Tra$&eal In+ures
Iatrogenic in)ur! of the trachea is infre.uent' occurring alost e"clusi(el! in relation to
endotracheal intubation. Bess coon iatrogenic causes include percutaneous
tracheosto!' transhiatal esophageal obili/ation' edian sternoto!' and laser1
associated endotracheal fire. Tracheoesophageal and tracheoinnoinate arter! fistulas' as
*ell as tracheoalacia' are rare coplications of air*a! anipulation and a (ariet! of
other conditions. ;aro"!sal coughing and se(ere (oiting a! cause spontaneous
tracheal tears.
INTUBATION INJURIES
Essentals o! Dagnoss
Gistor! of difficult or urgent intubation.
Difficult! achie(ing ade.uate (entilation or o"!genation.
;neuoediastinu or pneuothora".
More coon in *oen.
"eneral Cons#eratons
Traua due to endotracheal intubation a! occur at an! le(el of the air*a!' fro the
posterior phar!n" to the ain ste bronchi. , histor! of ultiple attepts at a difficult or
eergent intubation is t!pical' though in)uries a! follo* seeingl! routine intubations
as *ell. ?oen are affected far ore fre.uentl! than en are.
Cln$al Fn#ngs
Intubation in)uries are t!picall! liited to the posterior ebranous trachea' but a!
e"tend its entire length and e(en in(ol(e the carina and ain ste bronchi. E"tensi(e
in)uries usuall! coproise air*a! anageent and are diagnosed at the tie of their
occurrence. Minor lacerations a! go unrecogni/ed until signs such as
pneuoediastinu or pneuothora" are seen on chest "1ra!.
Treat'ent * Prognoss
6table patients a! be successfull! anaged conser(ati(el!' as outlined abo(e for inor
tracheal traua. Jnstable patients and those failing conser(ati(e anageent re.uire
operati(e repair. Most lacerations a! be approached through a cer(ical anterior
longitudinal tracheoto!' a(oiding lateral and posterior dissection. E"tensi(e and (er!
distal lesions re.uire a right thoracoto! for repair. Gealing of intubation in)uries is
e"cellent and patient sur(i(al is related to the underl!ing illness that necessitated
intubation.
Borasio ;' ,rdissone 2' Chiapo A. ;ost1intubation tracheal rupture8 a report of ten
cases. Eur J Cardiothorac Surg. #99<7#&89=. 3@etrospecti(e re(ie* of surgical and
conser(ati(e anageent.4 :;MID8 9&D&$==>
Gofann G6' @ettig A' @ad+e 0' 5eef G' 6ilber @E. Iatrogenic ruptures of the
tracheobronchial tree. Eur J Cardiothorac Surg. &$$&7&#8DC9. 3@etrospecti(e re(ie* of #9
patients *ith iatrogenic traua.4 :;MID8 ##93&#D&>
Ealoud G' 6olle10uettner 2M' ;rause A' Bist ?2. Iatrogenic ruptures of the
tracheobronchial tree. Chest. #99<7##&8<<C. 3@etrospecti(e re(ie* of #& patients *ith
iatrogenic tracheal in)uries.4 :;MID8 93#5=#C>
Mussi ,' ,brogi MC' Menconi A' @ibechini ,' ,ngeletti C,. 6urgical approaches to
ebranous tracheal *all lacerations. J Thorac Cardioasc Surg. &$$$7#&$8##5.
3@etrospecti(e re(ie* of surgical and conser(ati(e anageent of intubation in)uries that
ephasi/es cer(ical e"posure techni.ue.4 :;MID8 #$==CDD3>
TRACHEOINNOMINATE ARTERY FISTULA
Essentals o! Dagnoss
;resence of endotracheal or tracheosto! tube.
;reonitor! or e"sanguinating heorrhage around or through the
endotracheal or tracheosto! tube.
Pat&ogeness
, tracheoinnoinate arter! fistula is a rare coplication of tracheal intubation in *hich
erosion into the innoinate arter! causes assi(e bleeding. The innoinate arter!' *hich
arises fro the aortic arch' courses obli.uel! across the anterior surface of the fifth or
si"th tracheal ring to suppl! the right subcla(ian and coon carotid arteries. In children
and occasionall! in adults' it crosses the trachea at the base of the nec+. The ost
coon cause of a tracheoinnoinate arter! fistula is erosion through the tracheal *all
into the arter! b! the tip' balloon' or shaft of a tracheosto! or endotracheal tube. The
placeent of a tracheosto! too lo* or near an unusuall! high arter! increases the ris+.
@arel!' a tracheoinnoinate arter! fistula occurs after tracheal resection.
Cln$al Fn#ngs
Mortalit! fro tracheoinnoinate arter! fistulas is appro"iatel! 9$- and patient
sur(i(al depends on tiel! diagnosis and treatent. ;reonitor! bleeding around or
through the tracheosto! tube coonl! precedes an e"sanguinating heorrhage and
should be considered a true surgical eergenc!. ,n! such bleeding should be rigorousl!
in(estigated to e"clude arterial in)ur! as the source. The diagnosis a! re.uire
bronchoscop! and *ound e"ploration' *hich are best perfored in the operating roo.
Treat'ent
NONSUR"ICAL MEASURES
The diagnosis becoes self1e(ident in patients *ith assi(e bleeding' and onl! rapid
control of both the arter! and the air*a! *ill sa(e the patientHs life. The initial control of
the arter! should be attepted b! o(er1distention of the tracheosto! 3or endotracheal
tube4 cuff. If this is unsuccessful' the arter! should be copressed against the
anubriu anteriorl! *ith a finger introduced through the tracheosto! *ound. ?hile
these aneu(ers are perfored' an oral endotracheal tube should be placed'
resuscitation instituted' and the operating roo readied. Control of the arter! is
aintained during transport to the operating roo and during prepping and draping of
the patient.
SUR"ICAL MEASURES
The tracheosto! incision should be de(eloped to include a partial edian sternoto!
*ith e"tension into the right third or fourth intercostal space. The innoinate (ein should
be carefull! a(oided. ,fter pro"ial and distal control of the arter! is achie(ed' the
daaged portion should be resected and the ends o(erse*n. ;riar! repair of the arter!
should not be attepted as it in(ariabl! fails' leading to recurrent bleeding and increased
ortalit!. The need for (ascular reconstruction is contro(ersial. The tracheal defect a!
be debrided and repaired or pac+ed and allo*ed to heal secondaril!.
0ones 0?' @e!nolds M' Ge*itt @B' Drapanas T. Tracheo1innoinate arter! erosion8
successful surgical anageent of a de(astating coplication. Ann Surg. #9<D7#=C8#9C.
3E"tensi(e retrospecti(e stud! and literature re(ie* discusses causation' predisposing
factors' anageent' and outcoes of tracheoinnoinate arter! fistula.4 :;MID8
<=&3=9>
,llan 06' ?right CD. Tracheoinnoinate fistula8 diagnosis and anageent. Chest Surg
Clin N Am. &$$37#33&4833#. 3, coprehensi(e re(ie* of the pathogenesis' diagnosis and
anageent of tracheoinnoinate arter! fistulas.4 :;MID8 #&<553#<>
TRACHEOESOPHA"EAL FISTULA
Essentals o! Dagnoss
Gistor! of prolonged echanical (entilation or a neoplas of the upper
aerodigesti(e tract' especiall! if irradiated.
Increased tracheal secretions containing gastric contents' aspiration *ith
pulonar! se.uela' gastric distention.
"eneral Cons#eratons
,n ac.uired tracheoesophageal fistula is an abnoral counication bet*een the
trachea and the esophagus. It is an infre.uent coplication of a (ariet! of conditions'
occurring ost coonl! in relation to prolonged echanical (entilation' upper
aerodigesti(e tract tuors' and traua. Fther causes include ediastinal inflaation
and operati(e anipulation' particularl! esophagecto! *ith in(ol(eent of the gastric
neoesophagus.
Pat&ogeness
In the case of patients re.uiring prolonged (entilation' fistula foration t!picall! is caused
b! pressure necrosis of the tissues interposed bet*een the endotracheal or tracheosto!
tube cuff and a nasogastric tube in the esophagus. The process often is associated *ith a
circuferential tracheal in)ur! and a! in(ol(e the entire ebranous trachea.
Cln$al Fn#ngs
6igns of a tracheoesophageal fistula include persistent aspiration and its pulonar!
se.uelae 3eg' pneuonia4' as *ell as increased tracheal secretions and gastric distention.
The diagnosis of a suspected tracheoesophageal fistula a! be confired b! direct
(isuali/ation through the tracheostoa or (ia bronchoscop!. Esophagoscop! is rarel!
needed unless an esophageal process underlies the fistula. Contrast studies are usuall!
unnecessar!.
Treat'ent
The treatent of a tracheoesophageal fistula is dictated b! its cause' its location' and the
need for continued echanical (entilation. ;atients *ith incurable alignant disorders
ideall! are treated *ith stenting of the esophagus' the trachea' or both. Benign fistulas
are best anaged surgicall!7 ho*e(er' the repair of a tracheoesophageal fistula in
patients re.uiring prolonged (entilation should not be attepted *hile the patient
reains intubated as such efforts in(ariabl! fail.
NONSUR"ICAL MEASURES
Jntil the patient can be *eaned fro the (entilator' conser(ati(e easures should be
used to optii/e the patientHs condition. The nasogastric tube should be reo(ed to
pre(ent further in)ur! and because soe spontaneous healing a! occur. Aastric and
)e)unal tubes should be placed for drainage and alientation' respecti(el!. The tracheal
cuff should be positioned distal to the fistula to inii/e further pulonar! soilage' and
aggressi(e suctioning and pulonar! toilet instituted. If the fistula is too distal to control
*ith the cuffed tube' esophageal di(ersion a! be re.uired.
SUR"ICAL MEASURES
The definiti(e repair of ost tracheoesophageal fistulas a! be perfored through a
cer(ical incision' *ith a partial upper sternoto!' if needed. More distal or e"tensi(e
fistulas a! re.uire a right thoracoto!. Fnce identified' the fistula is di(ided and the
esophagus is debrided and repaired in t*o la!ers. If the in)ur! to the trachea is liited'
priar! repair of the defect a! be sufficient. Barger areas of daage to the trachea'
including circuferential in)uries and stenosis' re.uire segental resection and priar!
anastoosis. , pedicle of strap uscle should be interposed bet*een the tracheal and
esophageal repairs.
Prognoss
6urgical repair achie(es closure of tracheoesophageal fistulas in ore than 9$- of cases.
6egental resection of the in(ol(ed trachea a! ipro(e results' e(en in the absence of
circuferential in)ur!. Coplications include recurrent fistula in #$- of patients and
esophageal stricture in #5-. The forer is treated b! reoperation and the latter b!
endoscopic dilatation.
Baisi ,' Bona(ina B' 5arne 6' ;eracchia ,. Benign tracheoesophageal fistula8 results of
surgical therap!. !is Esophagus. #9997#&8&$9. 3@etrospecti(e re(ie* of a single centerHs
e"perience anaging tracheoesophageal fistula4. :;MID8 #$D3#9#5>
Darte(elle ;' Macchiarini ;. Manageent of ac.uired tracheoesophageal fistula. Chest
Surg Clin N Am. #99D7D8=#9. 3Coprehensi(e re(ie*.4 :;MID8 =93C$##>
Macchiarini ;' Kerho!e 0;' Chapelier ,' 2adel E' Darte(elle ;. E(aluation and outcoe of
different surgical techni.ues for postintubation tracheoesophageal fistulas. J Thorac
Cardioasc Surg. &$$$7##98&D=. 3@eports retrospecti(e results of (arious techni.ues for
anageent of tracheoesophageal fistulas4. :;MID8 #$DC9&$&>
Mathisen D0' Arillo GC' ?ain 0C' Gilgenberg ,D. Manageent of ac.uired nonalignant
tracheoesophageal fistula. Ann Thorac Surg. #99#75&8<59. 3@eport of the largest
,erican e"perience anaging tracheoesophageal fistulas4. :;MID8 #9&9D&D>
@eed M2' Mathisen D0. Tracheoesophageal fistula. Chest Surg Clin N Am.
&$$37#33&48&<#. 3, thorough re(ie* of the anageent of a *ide (ariet! of
tracheoesophageal fistulas.4 :;MID8 #&<553#3>
AC,UIRED TRACHEOMALACIA
Essentals o! Dagnoss
Gistor! of eph!sea or pol!chondritis' or tracheal intubation' in)ur!'
copression.
Brass! cough' ipaired clearance of secretions.
D!spnea on e"ertion' e"pirator! *hee/e' stridor.
;lateau in e"pirator! spirogra.
Pat&ogeness
Tracheoalacia refers to a derangeent in the structural integrit! of the trachea'
resulting in a fi"ed or d!naic obstruction of airflo*. T!picall!' the decreased rigidit! and
elasticit! of daaged tracheal rings causes the collapse of alacic segents during
e"halation. @edundanc! of the ebranous trachea seen in tracheoegal! and
eph!sea a! also cause a functional air*a! obstruction.
Congenital disorders' discussed else*here *ithin this boo+' that are associated *ith
tracheoalacia include (ascular anoalies' tracheoesophageal fistulas' and
tracheobronchoegal! related to Mounier1Euhn s!ndroe. The causes of ac.uired
tracheoalacia include traua 3particularl! postintubation in)uries4' chronic e"ternal
copression' eph!sea' and relapsing pol!chondritis. Diffuse' pathologic pliabilit! of
the tracheal cartilage de(elops in the latter t*o conditions' *hile in cases of traua or
copression' alacic collapse is liited to the daaged segents alone.
Cln$al Fn#ngs
The signs and s!ptos of tracheoalacia include ipaired e"halation anifest b!
*hee/ing' stridor' and a bar+ing cough. E"ercise tolerance and clearance of respirator!
secretions are ipaired. ;ulonar! function testing deonstrates a plateau in the
e"pirator! spirogra. The diagnosis a! be confired on CT scan *ith the coparison of
inspirator! and end1e"pirator! easureents of tracheal cross1sectional area and
diaeter' as *ell as cineradiographic studies. The collapse of alacic segents a! be
(isuali/ed during bronchoscop!.
Treat'ent * Prognoss
The treatent of ac.uired tracheoalacia is not standardi/ed due to its rarit!. The
e"ternal support of a diffusel! diseased ebranous or cartilaginous trachea *ith
prosthetic aterials' such as Marle" esh' a! stabili/e the air*a!' but a potentiall!
fatal erosion into ad)acent structures is a recogni/ed coplication. 2unctionall! significant
tracheoalacia is onl! rarel! present follo*ing the relief of e"trinsic tracheal copression.
The e"ceptional patient *ith respirator! difficult! should be anaged conser(ati(el! *ith
a short course of endoluinal stenting. 6egental resection and end1to1end anastoosis
of liited tracheoalacia resulting fro prolonged intubation and other traua is
curati(e.
,edee @' Mann ?0' B!ons AD. Tracheoalcia repair using ceraic rings. Otolaryngol
"ead nec# Surg. #99&7#$D8&<$. 36urgical series describes the indications' techni.ue' and
results of using ceraic rings for the treatent of tracheoalacia.4 :;MID8 #5=9&#9>
Geussel C;' Gafner B' Bill 0' 6chreiber ?' Thelen M' Eauc/or GJ. ;aired inspirator! and
e"pirator! spiral CT and continuous respiration cine CT in the diagnosis of tracheal
instabilit!. Eur Radiol. &$$#7##89=&. 3Deonstrates utilit! of cine CT in diagnosis of
tracheoalacia.4 :;MID8 ##C#9#<5>
0o+inen E' ;al(a T' 6utinen 6' 5uutinen 0. ,c.uired tracheobronchoalacia. Ann Clin Res.
#9<<7985&. 3@e(ie* of the clinical features of ac.uired tracheoalacia in a series of 9C
patients. 2ollo*1up stud! reported b! 5uutinen :see belo*>4. :;MID8 ==3<5=>
5uutinen 0. ,c.uired tracheobronchoalacia8 a bronchologic follo*1up stud!. Ann Clin
Res. #9<<798359. 3@eports the long1ter follo*1up' including repeat bronchoscop!' of 9C
patients *ith ac.uired tracheobronchoalacia' pro(iding insights into the natural histor!
of the condition.4 :;MID8 D#D&&5>
@ainer ?A' 5e*b! 0;' Eelble DB. Bong1ter results of tracheal support surger! for
eph!sea. !is Chest. #9D=7538<D5. 3@eports the results of patients undergoing
prosthetic splinting of ebranous trachea.4 :;MID8 5D53<53>
?right CD. Tracheoalacia. Chest Surg Clin N Am. &$$37 #33&483C9. 3, re(ie* of
tracheoalacia and its anageent.4 :;MID8 #&<553#9>
TRACHEAL STENOSIS
Essentals o! Dagnoss
Gistor! of tracheal in)ur!' intubation' ediastinal process.
?orsening *hee/e' cough' stridor and d!spnea on e"ertion.
Difficult! raising secretions' recurrent pulonar! infections.
Benign stenosis of the trachea has a di(erse causalit! that coprises congenital'
idiopathic' and ac.uired conditions. Most ac.uired stenoses de(elop as a result of the
fibrous aturation of healed tracheal in)uries. ;ostintubation in)ur! to the trachea
represents the ost coon cause of benign tracheal stenosis.
6!ptos of stenotic tracheal obstruction usuall! de(elop insidiousl! *ith stridor'
*hee/ing' cough' and d!spnea on e"ertion. The se(erit! of s!ptos and their
progression correlates *ith the degree of stenosis. 6tridor and *hee/ing is usuall!
inspirator!' but *ith intrathoracic stenosis or alacia' is *orse on e"piration. The cough
is t!picall! brass! and nonproducti(e' and recurrent infections a! occur due to the
inabilit! to clear secretions across the stenosis. D!spnea at rest occurs *hen the cross1
sectional area of the trachea is decreased b! <5-. ;atients *ith underl!ing pulonar!
disease a! de(elop significant d!spnea at lesser degrees of stenosis.
2re.uentl!' the diagnosis is dela!ed as s!ptos are attributed to astha or' in the case
of patients *ith postintubation stenosis' to the process that necessitated echanical
(entilation. Gigh1resolution spiral CT scanning *ith sagittal and coronal reconstructions
pro(ides detailed inforation regarding the e"tent and geoetr! of the stenotic segent
and e"tratracheal anato!. Bronchoscop! allo*s for the direct (isuali/ation of the entire
air*a! and perits a thorough assessent of the lesion and an! associated ucosal
daage. The use of a rigid bronchoscope ensures control of e(en (er! difficult air*a!s
and allo*s for therapeutic dilatation and clearance of secretions distal to the obstruction.
Aluec+er T' Bang 2' Bessler 6 et al. &D and 3D CT iaging correlated to rigid endoscop!
in cople" lar!ngo1tracheal stenoses. Eur Radiol. &$$#7##85$. 3Discusses the accurac! of
CT scanning in the diagnosis and characteri/ation of benign tracheal stenosis.4 :;MID8
###9C9#<>
CON"ENITAL ANOMALIES
Congenital anoalies that a! present *ith tracheal stenosis or obstruction include
tracheal agenesis or atresia' tracheoesophageal fistula' coplete tracheal rings' (ascular
rings' aberrant bronchi' and tracheoalacia. These entities usuall! coe to attention
iediatel!' but occasionall! do not cause s!ptos until later in life. 6urgical correction
is re.uired in ost cases.
IDIOPATHIC TRACHEAL STENOSIS
"eneral Cons#eratons
Idiopathic stenosis of the trachea is a rare condition in *hich dense fibrous stenosis of the
pro"ial trachea occurs in the absence of an! inciting e(ent' including infection'
ediastinal ass or inflaation' gastroesophageal reflu" disease' traua' inhalational
in)ur!' or intubation. The process affects *oen priaril! and in(ol(es the subglottic
lar!n" and the pro"ial &%C c of the trachea circuferentiall!.
Cln$al Fn#ngs
In addition to the t!pical s!ptos of tracheal stenosis' a sall percentage of patients
a! ha(e s!steic findings suggesti(e of autoiune d!sfunction' including
h!pocopleenteia' pol!arteritis' (asculitis' pol!arthritis' and (al(ular heart disease.
Treat'ent * Prognoss
The pro"iit! of the process to the (ocal cords should be established b! radiographic
studies and endoscop! as this inforation guides treatent options. Baser ablation
effecti(el! relie(es s!ptos and is occasionall! curati(e7 ho*e(er' in ost cases'
stenosis recurs. The use of topical ito!cin1C as an ad)u(ant therap! to laser resection
a! ipro(e results. In nearl! all cases' lar!ngotracheal resection is curati(e. @esolution
of the stenosis has been reported in patients *ith s!steic autoiune findings treated
*ith a/athioprine and steroids.
,shi+u 6E' Mathisen D0. Idiopathic lar!ngotracheal stenosis. Chest Surg Clin N Am.
&$$37#33&48&5<. 3, coprehensi(e re(ie* of idiopathic tracheal stenosis.4 :;MID8
#&<553#&>
Dedo GG' Catten MD. Idiopathic progressi(e subglottic stenosis8 findings and treatent in
5& patients. Ann Otol Rhinol Laryngol. &$$#7##$83$5. 3@e(ie* of a single institutionHs
e"perience anaging idiopathic subglottic stenosis.4 :;MID8 ##3$<9$C>
Arillo GC. Manageent of idiopathic tracheal stenosis. Chest Surg Clin N Am. #99D7D8=##.
3@e(ie* of the authorHs e"tensi(e e"perience anaging idiopathic stenosis.4 :;MID8
=93C$#$>
Kalde/ T,' 6hapsha! 6M. Idiopathic subglottic stenosis re(isited. Ann Otol Rhinol
Laryngol. &$$&7###8D9$. 3@etrospecti(e re(ie* discusses results of laser ablation and
ad)u(ant ito!cin1C for treatent of idiopathic stenosis.4 :;MID8 #&#=C5=9>
E-TRINSIC TRACHEAL COMPRESSION
"eneral Cons#eratons
Tracheal obstruction a! result fro e"trinsic copression of the cer(ical or ediastinal
trachea b! a (ariet! of lesions. In addition to congenital (ascular rings' aneur!ss of the
innoinate arter! and distortion of the aorta also a! produce (ascular copression of
the trachea. The latter' +no*n as postpneuonecto! s!ndroe' is a rare coplication
of pneuonecto!' in *hich ediastinal structures shift to*ards the operated side'
causing a hori/ontal rotation of the aortic arch.
6!ptos of tracheal copression are also fre.uentl! the presenting coplaints of
patients *ith ediastinal tuors' large goiters' and e"tensi(e l!phoa. 6arcoidosis'
histoplasosis' and tuberculosis a! also cause tracheal stenosis due to
l!phadenopath! and ediastinal fibrosis.
Treat'ent
The treatent of tracheal stenosis due to e"trinsic copression is directed at the
causati(e process. If the appropriate treatent does not alle(iate s!ptos'
endotracheal stenting a! pro(ide satisfactor! palliation.
Kal)i ,M' Ma/ia+ DE' 6ha)i 2M' Mat/inger 2@. ;ostpneuonecto! s!ndroe8
recognition and anageent. Chest. #99=7##C8#<DD. 3@e(ie* of a series.4 :;MID8
9=<&&#5>
POST.TRAUMATIC TRACHEAL STENOSIS
In)uries to the trachea' *hether iatrogenic or trauatic' generall! heal *ith soe degree
of tracheal stenosis. The obstruction a! be echanical in nature' due to stricture or
granuloa foration' or it a! be functional due to tracheoalacia. More than one t!pe
of lesion a! be present.
Aranulation tissue a! proliferate at the site of tracheal in)uries anaged conser(ati(el!
or repaired priaril!. Baser ablation pro(ides satisfactor! treatent but is rarel! re.uired.
6e(ere tracheal in)uries' unrecogni/ed or anaged conser(ati(el!' heal *ith significant
stricture foration. 6uch lesions produce ar+ed obstructi(e s!ptos that re.uire
operati(e repairLusuall! segental resection and end1to1end anastoosis.
POSTINTUBATION TRACHEAL STENOSIS
"eneral Cons#eratons
?ith the refineent and *idespread use of echanical (entilator! support' postintubation
tracheal in)ur! has becoe the ost iportant cause of benign tracheal stenosis.
Gistoricall!' such in)uries *ere associated *ith the high1pressure' lo*1(olue cuffs of
earl! endotracheal and tracheosto! tubes. Iet' despite the adoption of lo*1pressure'
high1(olue cuffs and an increased attenti(eness to pre(entati(e easures'
postintubation stenosis reains a fre.uent coplication of assisted (entilation' occurring
in =%#3- of (entilated patients.
Tracheal daage resulting in stenosis is seen *ith the use of both endotracheal and
tracheosto! tubes' including tubes placed b! percutaneous dilatational ethods. Each
t!pe of tube ost coonl! causes in)ur! at the le(el of the inflatable cuff' but each a!
cause daage at other le(els of the air*a! as *ell. In addition to tracheal stenosis'
s!ptos a! be caused b! granulations' tracheal pseudoebrane' subglottic
stenosis' tracheoalacia' or tracheoesophageal fistula. More than one lesion a! be
present.
Class!$aton
;ostintubation tracheal stenoses a! be classified according to the site of tracheal in)ur!
and include cuff1le(el' tracheostoa1le(el' and subglottic stenoses.
CUFF.LE/EL STENOSIS
Tracheal in)ur! at the le(el of the inflatable cuff is a direct result of ucosal ischeia
fro pressure e"erted b! the cuff. Gigh1(olue' lo*1pressure cuffs are designed to
confor to the tracheal luen across a broad area and pro(ide an ade.uate seal at cuff
pressures belo* that of ucosal perfusion' *hich is &$%3$ Gg. Jnfortunatel!' in the
ICJ setting' unless cuff pressures are s!steaticall! easured' the! are alost uniforl!
inflated abo(e C$ Gg' e(en b! e"perienced intensi(ists.
In)ur! to the tracheal ucosa a! occur after e(en brief periods of intubation. In patients
*ho re.uire prolonged assisted (entilation' the incidence of tracheal daage correlates
roughl! *ith the length of intubation. 6uperficial erosion de(elops initiall!' follo*ed b!
full1thic+ness ucosal ulceration. E"posure of the underl!ing tracheal cartilage' *hich
recei(es its blood suppl! fro the ucosa' results in ischeia.
Cr$u'!erental Da'age
Circuferential daage fro the cuff is coon and results in a greater degree of
stenosis than less e"tensi(e *ounds. ,s healing occurs' deposition of fibrous scar tissue
leads to tracheal stenosis. 6!ptos are rarel! present soon after e"tubation' but
de(elop o(er se(eral *ee+s to onths as the scar atures. The adinistration of steroids
can occasionall! inii/e the degree of e(entual stenosis7 ho*e(er' it a! predispose
the area to tracheoalacia instead.
Tra$&eal Pseu#o'e'0rane an# "ranulaton Tssue For'aton
Fther lesions that occur at the le(el of the inflatable cuff include tracheal
pseudoebrane and the foration of granulation tissue. The latter responds *ell to
endoscopic laser ablation' though repetiti(e treatents a! be necessar!.
Fbstructi(e fibrinous tracheal pseudoebrane is a rare but potentiall! fatal cause of
cuff1le(el postintubation stenosis. ,cute air*a! obstruction is caused b! a tubular'
fibrinous pseudoebrane' *hich reains in the trachea follo*ing e"tubation. The
tissue' *hich olds to the tube at the le(el of the cuff' de(elops *ithin da!s of intubation
and li+el! represents an earl! response to tracheal in)ur!. It contains inflaed and
necrotic tracheal epitheliu and is associated *ith heorrhagic ulceration of the
subucosa.
Fbstructi(e s!ptos that progress to acute respirator! distress de(elop *ithin hours to
da!s of e"tubation. 6tridor and *hee/ing a! not be present if the patient is too *ea+ to
generate sufficient airflo*' and obstruction a! be positional if the ebrane is partiall!
dislodged. Because obstructi(e fibrinous tracheal pseudoebrane has onl! recentl!
been characteri/ed' and because its presentation a! not be t!pical of tracheal stenosis'
s!ptos are usuall! attributed to other causes of poste"tubation respirator! distress.
,n accurate diagnosis re.uires bronchoscop!' *hich a! also aid in reintubation' if
necessar!. Treatent consists of aggressi(e respirator! support and the echanical
debrideent of the pseudoebrane (ia rigid bronchoscop!. @ecurrence has not
de(eloped follo*ing this approach in the onl! reported series.
TRACHEOSTOMA.LE/EL STENOSIS
;ostintubation tracheal stenosis a! de(elop at the tracheosto! site due to granulations
or scar foration. Jpon decannulation' closure of the tracheal defect is effected b!
collapse and reappro"iation of the stoal argins. 2urther *ound aturation and
scarring results in an anterolateral area of stenosis that spares the posterior ebranous
trachea' creating a triangular1shaped' stenotic luen.
6e(eral factors affect the e(entual degree of stenosis at the stoa site' including the
operati(e techni.ue' pressure necrosis' and infection. ,t tracheosto!' the sallest si/e
tube that still pro(ides an ade.uate air*a! should be used' and the tracheal incision
should be )ust large enough to allo* its passage. During the patientHs ter of assisted
(entilation' the (entilator and tracheosto! tubing should be positioned in such a *a! as
to pre(ent le(erage against the stoal argins' *hich can lead to pressure necrosis and
e"tension of the defect. 6ecretions' *hich usuall! are infected' should not be allo*ed to
accuulate around the stoa or the cuff as locali/ed infection e"acerbates tracheal in)ur!
and subse.uent stenosis.
SUB"LOTTIC STENOSIS
In)ur! to the lar!n" and subglottis a! occur follo*ing transoral intubation'
cricoth!roidoto!' or an inappropriatel! high tracheosto!. In the latter case' a
tracheoto! at the first or second tracheal ring causes a stoa1le(el in)ur!' as described
abo(e' that encroaches on the cricoid cartilage and subglottic lar!n". Direct pressure and
erosion b! the tube at the pro"ial argin a! result in loss of the anterior cricoid arch.
Translar!ngeal tubes t!picall! cause traua to the posterior lar!n"' particularl! the
interar!tenoid area' *hich a! result in glottic stenosis upon healing. The e"tension of
daage to the cricoar!tenoid )oint ipairs (ocal cord abduction. Fbstructing granulation
tissue a! also de(elop at this le(el.
Treat'ent
PRETREATMENT CONSIDERATIONS
Most cases of postintubation tracheal stenosis can be treated electi(el!. ,s pre(iousl!
described' s!ptos usuall! de(elop and progress o(er *ee+s to onths' allo*ing
ade.uate tie for an accurate diagnosis and subse.uent e(aluation. Besions that ha(e
not full! atured should be anaged conser(ati(el! to allo* acute inflaation to
subside.
EMER"ENT TREATMENT
Fbstructi(e fibrinous tracheal pseudoebrane presents acutel! *ith respirator!
distress' re.uiring eergent treatent. Fther t!pes of postintubation stenosis
occasionall! present eergentl! as *ell' due to an acute e"acerbation of s!ptos. ,
prolonged isdiagnosis or e"pectant treatent a! allo* for the de(elopent of a tight
stenosis that is tolerated b! the patient until factors such as poor underl!ing lung
function' infection due to retained secretions' irritation fro cigarette so+e' or
superiposed illness result in significant ipairent.
The eergent anageent of tracheal stenosis should secure the air*a! and stabili/e the
patient' allo*ing definiti(e treatent to proceed electi(el!. Initial easures should
include the use of huidified o"!gen' bronchodilators' inhaled or s!steic steroids'
inhaled raceic epinephrine' and helio". The latter' a i"ture of o"!gen and heliu'
ipro(es o"!gen deli(er! across the obstruction b! decreasing turbulent flo*. ;atients
*ho do not respond to the abo(e easures re.uire eergent rigid bronchoscop!' *hich is
alost uniforl! successful in securing the air*a!.
Dilatation of the lesion a! be perfored as a tepori/ing step to allo* the
postponeent of definiti(e treatent' *hich should ne(er be attepted eergentl!.
E(er! effort should be ade to a(oid tracheosto!' but if absolutel! re.uired' it should
be placed through the area of stenosis to a(oid further daaging the trachea.
DEFINITI/E TREATMENT
The successful definiti(e treatent of postintubation tracheal stenosis re.uires eticulous
planning' *hich should include a thorough e(aluation of the lesion using radiographic
iaging and bronchoscopic (isuali/ation as described pre(iousl!. ;atient conditions such
as nutritional status' steroid use' pre(ious e"posure to tracheal irradiation' propensit! for
aspiration' edical fitness for surger!' and the potential need for assisted (entilation in
the future should be carefull! considered. 6egental resection pro(ides optial
treatent for the a)orit! of lesions' though other ethods such as dilatation' laser
ablation' stenting' and plastic reconstruction a! be appropriate in certain situations.
Dlataton an# Laser A0laton
Dilatation or laser ablation of (er! short postintubation strictures 3M $.5 c4 a! be
curati(e' but in ost cases results in gradual restenosis. Though teporar!' such
procedures a! benefit patients *ho are unfit or un*illing to undergo resection7 the!
a! also be useful prior to stent placeent or *hile *aiting for lesions to ature. Baser
resection should not be attepted for subglottic lesions.
Stentng
The stenting of s!ptoatic tracheal strictures a! be used to ensure an ade.uate
air*a! during *ound aturation or *hile *aiting for the patientHs condition to ipro(e
prior to resection. Tracheal stents a! also pro(ide definiti(e treatent *hen the
patientHs condition' or characteristics of the lesion' pre(ent resection. ?hen used in such
a anner' endoluinal stents reliabl! pro(ide s!ptoatic relief' but a! not address
the underl!ing lesion. In addition' the! are prone to coplications such as obstruction b!
granulations or secretions' infection due to the retention of secretions' igration' and
erosion. 6ilastic T1tubes perit better h!giene' are not prone to obstructing granulations'
and can also be used to treat subglottic lesions. Depending upon (ariables such as the
patientHs o(erall condition and the nature of the stricture' stent reo(al a! be possible
after #%& !ears *ith good results.
Seg'ental Rese$ton an# Re$onstru$ton
6egental resection and reconstruction should be considered the ideal treatent for ost
postintubation tracheal strictures' including those of the subglottis. The a)orit! of
lesions can be e"posed through a cer(ical incision and do not re.uire speciali/ed
techni.ues of tracheal obili/ation to achie(e a priar! end1to1end anastoosis.
6trictures in(ol(ing the subglottis are best anaged b! lar!ngotracheal resection and
th!rotracheal anastoosis' though occasionall!' cople" lesions a! re.uire plastic
reconstruction for *hich a (ariet! of autologous grafts ha(e been used.
Prognoss
The results of segental resection for both tracheal and subglottic stenoses are e"cellent'
*ith a 9$%95- success rate at e"perienced centers. ;erioperati(e ortalit! is
appro"iatel! &%C-. The a)orit! of patients en)o! a noral (oice and inor or no
d!spnea on e"ertion. 6!ptoatic restenosis at the anastootic site occurs in 5%#$- of
cases and is usuall! related to probles of anastootic tension or perfusion.
;atients *ith recurrent stenosis de(elop s!ptos *ithin *ee+s of the initial operation
and fre.uentl! re.uire inter(ention such as dilatation or stenting. These patients should
be anaged )ust as those presenting *ith an initial postintubation stricture using
conser(ati(e' tepori/ing easures to aintain the air*a! until postoperati(e
inflaation subsides. The lesion should be full! characteri/ed *ith iaging studies and
bronchoscop! and the patient considered for repeat segental resection. The results of
resection and priar! anastoosis of postoperati(e strictures are nearl! as good as for
priar! lesions. 6peciali/ed techni.ues of tracheal obili/ation are often re.uired'
ho*e(er' and a slightl! larger proportion of patients e"perience aspiration' *ea+ness of
the (oice' and d!spnea on e"ertion postoperati(el!.
Bra/ 0@' 5a(arro BG' Ta+ata IG' 5asciento 0;. Endotracheal tube cuff pressure8 need for
precise easureent. Sao $aulo Med J. #9997##<8&C3. 3Cross1sectional stud! of cuff
pressures in ICJ and reco(er! roo settings deonstrates *idespread cuff
h!perinflation.4 :;MID8 #$D&5==<>
Deslee A' Brichet ,' Bebuffe A' Copin MC' @aon ;' Mar.uette CG. Fbstructi(e fibrinous
tracheal pseudoebrane8 a potentiall! fatal coplication of tracheal intubation. Am J
Respir Crit Care Med. &$$$7#D&8##D9. 32irst report identif!ing obstructi(e fibrinous
tracheal pseudoebrane as a distinct clinical entit!7 discusses patholog!' presentation'
diagnosis' and anageent in a series of patients.4 :;MID8 #$9==#C=>
Donahue DM' Arillo GC' ?ain 0C' ?right CD' Mathisen D0. @eoperati(e tracheal resection
and reconstruction for unsuccessful repair of postintubation stenosis. J Thorac Cardioasc
Surg. #99<7##C893C. 3@etrospecti(e re(ie* of largest reported series in the *orld
e"aining anageent of failed initial repair of postintubation tracheal stenosis.4 :;MID8
9C3CD==>
Donahue DM. @eoperati(e tracheal surger!. Chest Surg Clin N Am. &$$37#33&483<5.
3@e(ie* of perhaps the *orldHs largest e"perience in reoperati(e tracheal surger!.4
:;MID8 #&<553&&>
Arillo GC' Donahue DM. ;ostintubation tracheal stenosis. Semin Thorac Cardioasc Surg.
#99D7=83<$. 3Coprehensi(e treatent of postintubation tracheal stenosis including the
authorsH re(ie* of their series of 5$3 patients' the largest reported in the *orld.4 :;MID8
==999&C>
Geitiller @2. Tracheal release aneu(ers. Chest Surg Clin N Am. &$$37#33&48&$#. 3,
re(ie* of techni.ues used to obili/e the trachea for anastoosis follo*ing e"tensi(e
tracheal resection.4 :;MID8 #&<553$9>
Biu GC' Bee E6' Guang C0' Cheng C@' Gsu ?G' Guang MG. 6ilicone T1tube for cople"
lar!ngotracheal probles. Eur J Cardiothorac Surg. &$$&7&#83&D. 3@etrospecti(e re(ie*
reports results of using T1tube for treatent of a (ariet! of benign obstructing tracheal
lesions.4 :;MID8 ##=&5<CC>
;earson 2A' Aullane ;. 6ubglottic resection *ith priar! tracheal anastoosis8 including
s!nchronous lar!ngotracheal reconstructions. Semin Thorac Cardioasc Surg.
#99D7=83=#. 3Coprehensi(e treatent of subglottic stenosis includes re(ie* of an =$
patient series.4 :;MID8 ==999&5>
6chidt B' Fl/e G' Borges ,C et al. Endotracheal balloon dilatation and stent iplantation
in benign stenoses. Ann Thorac Surg. &$$#7<#8#D3$. 3@etrospecti(e re(ie* reports the
results of stenting after balloon dilatation of benign tracheal stenosis.4 :;MID8 ##3=3=#&>
?ain 0C. ;ostintubation tracheal stenosis. Chest Surg Clin N Am. &$$37#33&48&3#.
3,uthoritati(e re(ie* of the anageent of tracheal stenosis.4 :;MID8 #&<553#$>
?olf M' 6hapira I' Tali I;' 5o(i+o( I' Eronenberg 0' Iellin ,. Bar!ngotracheal
anastoosis8 priar! and re(ised procedures. Laryngoscope. &$$#7###8D&&. 3Cohort
stud! copares the results of reoperation for failed repair of lar!ngotracheal stenosis *ith
those for initial repair.4 :;MID8 ##359#3$>
TRACHEAL NEOPLASMS
Pr'ary Tra$&eal Neo%las's
Essentals o! Dagnoss
Males
, histor! of cigarette so+ing.
?orsening *hee/e' cough' stridor' and d!spnea on e"ertion.
Difficult! raising secretions' recurrent pulonar! infections.
Geopt!sis' hoarseness of (oice.
Constitutional features of alignanc! 3eg' fatigue' *eight loss4.
"eneral Cons#eratons
;riar! tracheal tuors are e"ceedingl! rare' *ith an estiated incidence of onl! &%3
cases per one illion persons per !ear. In adults' =$%9$- of tuors are alignant'
*hereas in children' 9$- are benign. Ff alignant lesions' ore than <5- are either
s.uaous cell or adenoid c!stic carcinoa. Tracheal tuors are slightl! ore pre(alent in
ales and so+ers.
Pat&ogeness
Tuors of the trachea a! be classified as priar! or secondar!. ;riar! neoplass
include a *ide (ariet! of both benign and alignant neoplass 3Table 35%#4' *hereas
secondar! neoplass 3discussed belo*4 are' b! definition' alignant.
Ta0le 12345 Tu'ors o! t&e Tra$&ea5
Bengn Neo%las's Malgnant Neo%las's
Inflaator! pseudotuor 6.uaous cell carcinoa
Gaartoa ,denoid c!stic carcinoa
6.uaous cell papilloa Mucoepideroid carcinoa
;apilloatosis 6all1cell carcinoa
Chondroa Chondrosarcoa
Chondroblastoa 6pindle1cell sarcoa
Geangioa ,denocarcinoa
Bengn Neo%las's Malgnant Neo%las's
Geangioendothelioa ,denos.uaous carcinoa
Carcinoid Carcinoid
Beio!oa Beio!osarcoa
Aranular cell @habdo!osarcoa
2ibrous histioc!toa Malignant histioc!toa
Alous Melanoa
2ibroa B!phoa
5eurofibroa Secondary tracheal neoplasms
6ch*annoa Direct in(asion
Bipoa Metastatic in(ol(eent
;leoorphic adenoa
;seudosarcoa
Cln$al Fn#ngs
SYMPTOMS AND SI"NS
Tracheal tuors cause signs and s!ptos of upper air*a! obstruction as described
pre(iousl! for tracheal stenosis. In addition' patients a! present *ith heopt!sis'
features of recurrent lar!ngeal ner(e in(ol(eent such as hoarseness' or signs of a
alignant process such as *eight loss and *ea+ness. The onset and progression of
findings correlate *ith the rate of tuor gro*th and in an! cases is (er! slo*. 6tridor
and d!spnea at rest occur *hen the tracheal luen is reduced to &5- of its noral cross1
sectional area' but patients *ith poor underl!ing lung function a! becoe s!ptoatic
sooner.
The initial s!ptos of cough' *hee/ing' and d!spnea on e"ertion are coon features
of pulonar! d!sfunction and patients often are treated inappropriatel! for astha or
other respirator! conditions. The rarit! of tracheal tuors' the paucit! of clues on
ph!sical e"a' and the absence of ob(ious signs on chest "1ra! also confuse the
diagnosis' *hich is t!picall! dela!ed for ore than a !ear after the onset of s!ptos.
Fccasionall!' subtle features such as changes in the patientHs strength or .ualit! of (oice'
a priaril! inspirator! *hee/e' and positional changes in s!ptos are recogni/ed and
lead to an earlier diagnosis.
LABORATORY FINDIN"S
Bronchoscop! is essential in the diagnosis' e"aination' and anageent of tracheal
tuors. It allo*s for a direct (isuali/ation of the tuor and its relationship to the rest of
the air*a!. The tracheobronchial tree distal to the lesion can also be e(aluated.
Bronchoscopic biopsies pro(ide a tissue diagnosis and' *hen ta+en abo(e and belo* the
lesion' identif! occult tuor spread' *hich is iportant in deterining the potential
e"tent of resection.
2acilities for rigid bronchoscop! should be readil! a(ailable if fle"ible bronchoscop! is to
be perfored' as anipulation or biops! a! result in bleeding or coplete air*a!
collapse. Bronchoscopic e"aination' therefore' is often perfored in the operating roo
and a! be dela!ed until the tie of resection. If obstructi(e s!ptos re.uire
inter(ention either prior to resection or in patients *ho are not operati(e candidates' rigid
bronchoscop! can be used to secure the air*a! and core open the luen *ith biops!
forceps' coagulation' or laser ablation. The subse.uent palliation of unresectable tuors
*ith stent placeent pro(ides a satisfactor! air*a! in ost cases.
IMA"IN" STUDIES
;lain chest "1ra!s deonstrate tracheal tuors in less than half of cases and the findings'
*hich a! be subtle' are often o(erloo+ed *ithout a high inde" of suspicion. 6piral CT
scanning *ith sagittal and coronal reconstruction pro(ides detailed inforation regarding
the e"tent of the tuor and its relationship to the lar!n" and carina. It also deonstrates
e"tratracheal in(ol(eent and etastatic disease. Contrast esophagograph! a! be
added to e"clude esophageal in(ol(eent.
The radiographic features of tracheal tuors that suggest benignit! include sooth'
sharpl! dearcated lesions M & c in si/e that are copletel! intraluinal *ith liited
tracheal in(ol(eent. Calcifications are present in =$- of chondroas. If fat is also seen
*ithin the lesion' a haartoa is li+el!. Carcinoid tuors often deonstrate ar+ed
enhanceent *ith IK contrast. Malignant lesions are generall! larger' *ith indistinct
argins that e"tend circuferentiall! and longitudinall! *ithin the trachea and in(ade the
*all.
Treat'ent
INITIAL MEASURES
Eergent anageent of respirator! distress due to partial air*a! occlusion has been
discussed pre(iousl! and is applicable to s!ptoatic tracheal tuors as *ell. The
a(ailabilit! of rigid bronchoscop! is essential in order to anage bleeding' distal
secretions' or coplete air*a! collapse. Most patients *ith tracheal tuors do not
present acutel!' *hich allo*s for electi(e treatent.
;atients *ith unresectable tuors' or those unfit or un*illing to undergo resection' a!
be anaged *ith a cobination of endoscopic ablation' stenting' and radiotherap!.
Irradiation of ost alignant tracheal neoplass pro(ides e"cellent local control7
ho*e(er' *ithout resection' ost tuors recur and long1ter sur(i(al is rare.
RESECTION AND RECONSTRUCTION
The a)orit! of tracheal tuors are best anaged b! circuferential resection and
priar! reconstruction' though soe 3eg' l!phoa and sall cell tuors4 are treated
*ith cheoradiotherap! alone. ,lthough tracheal tuors usuall! are ad(anced b! the
tie of diagnosis' e(er! patient should undergo a thorough e(aluation to deterine
operabilit!. ,ppro"iatel! half of the trachea can be safel! resected' and speciali/ed
techni.ues of lar!ngotracheal and carinal reconstruction allo* for the resection of tuors
in those locations. The presence of l!ph node or pulonar! etastases in patients *ith
indolent neoplass 3eg' adenoid c!stic carcinoa4 does not preclude eaningful sur(i(al
*ith resection of the priar! lesion.
Tuors in(ol(ing the upper t*o1thirds of the trachea can be approached through a
cer(ical incision e"tended to include a partial or coplete edian sternoto!' if needed.
5eoplass of the distal third of the trachea and carina are approached through a
sternoto! or a high' right thoracoto!. The operati(e field should allo* e"tension of a
sternoto! incision into the fourth intercostal space' if needed' and for cer(ical or hilar
tracheal obili/ation aneu(ers.
2or benign tuors' the plane of dissection is +ept close to the trachea and identification of
the recurrent ner(es is not perfored. The resection of alignant tuors' ho*e(er'
should include as uch ad)acent tissue as possible. Mediastinal l!ph nodes should be
sapled but e"tensi(e nodal dissection should be a(oided as it results in tracheal
de(asculari/ation. The recurrent lar!ngeal ner(es should be identified distant fro the
tuor and traced throughout their course. The sacrifice of an in(ol(ed ner(e is
acceptable' but the resection of both recurrent lar!ngeal ner(es should not be perfored
unless the iplications of such a step are discussed *ith the patient preoperati(el!.
Care should be ta+en during e"posure of the in(ol(ed trachea to preser(e the lateral
(ascular pedicles of an! portion that *ill not be resected. The anterior and posterior
planes a! be bluntl! obili/ed to the le(el of the ain bronchi. 2ollo*ing resection of
the tuor' the pro"ial and distal tracheal argins should be subitted for fro/en
section e"aination in order to deterine the ade.uac! of resection.
2our to fi(e centieters of trachea can be reo(ed and safel! reconstructed *ith a
priar! anastoosis. If the e"tent of the tuor re.uires further resection' additional
tracheal obili/ation can be perfored using either lar!ngeal release procedures
pro"iall! or a hilar release distall!. ?ith these techni.ues' about half of the trachea can
be safel! resected.
Fccasionall!' the liits of tracheal obili/ation and reconstruction preclude coplete
resection. Gistologicall! positi(e argins should be accepted rather than coproising
the success of the tracheal reconstruction. In(ol(ed argins do not affect healing and in
soe lesions' such as adenoid c!stic tuors' a! still be associated *ith long1ter
sur(i(al.
POSTOPERATI/E CONSIDERATIONS
;ostoperati(el!' the pre(ention of anastootic tension is paraount to the success of the
operation. ,t the conclusion of the procedure' as *ell as for the first postoperati(e *ee+'
the patientHs chin should be sutured to his chest' and his head supported in order to
aintain a"ial cer(ical fle"ion. ,n aggressi(e regie of pulonar! toilet and optial
nutrition should be obser(ed throughout the patientHs reco(er!. The identification and
anageent of aspiration or s*allo*ing difficulties is iportant' especiall! in patients
*ho ha(e undergone lar!ngeal release aneu(ers.
ADJU/ANT RADIOTHERAPY
,d)u(ant radiotherap! has been sho*n to prolong sur(i(al in patients *ith s.uaous cell
and adenoid c!stic carcinoas of the trachea *ho ha(e undergone incoplete resection
due to in(ol(ed argins. The sur(i(al of patients *ith residual carcinoa in situ is better
than that of patients *ith in(asi(e cancer at the resection argin. ,d)u(ant radiotherap!
does not appear to change the sur(i(al rate in patients *ith positi(e ediastinal l!ph
nodes or after coplete resection. Go*e(er' gi(en the narro* argins t!picall! accepted
in tracheal surger!' the potential benefits' and the lac+ of significant side effects'
ad)u(ant radiotherap! is recoendedLto a dose of 5$%D$ A!Lfor all patients
undergoing resection of s.uaous cell or adenoid c!stic tuors of the trachea.
Co'%l$atons
The ortalit! rate for resection of alignant tracheal neoplass is 5%#5- and is usuall!
due to anastootic dehiscence' pneuonia' pulonar! ebolis' or erosion into the
innoinate or pulonar! arter!. Coplications such as anastootic lea+' aspiration'
(ocal cord d!sfunction' pneuonia' and *ound infection occur in &$%C$- of cases.
,nastootic stenosis re.uiring dilatation' laser ablation' or reoperation de(elops in about
5%#C- of patients and is ore fre.uent if postoperati(e coplications occur. 2actors that
increase orbidit! and ortalit! include e"tensi(e tracheal resection' the use of tracheal
obili/ation procedures' lar!ngotracheal or carinal reconstruction' and s.uaous cell
histolog!.
BENI"N TRACHEAL NEOPLASMS
Benign priar! tracheal neoplass a! arise fro an! eleent of the air*a!.
Inflaator! pseudotuors and tracheal foreign bodies can iic trul! neoplastic
lesions. Benign tuors account for #$%&$- of adult tracheal neoplass but coprise
nearl! all pediatric lesions.
S6ua'ous Cell Pa%llo'as
6.uaous cell papilloa is a superficial sessile or papillar! tuor *ith a connecti(e tissue
core co(ered b! s.uaous epitheliu. In adults' it is usuall! solitar! and associated *ith
hea(! so+ing. In children' it is fre.uentl! ultifocal and is +no*n as %uenile
laryngotracheal papillomatosis. It is the ost coon pediatric lar!ngotracheal
neoplas' and its association *ith huan papilloa(iruses 3G;K4 D and ## is *ell
established. Bar!ngeal in(ol(eent usuall! regresses spontaneousl! at pubert!' but
tracheobronchial lesions a! not' and alignant degeneration and etastasis can occur.
6!ptoatic lesions a! be treated *ith endoscopic resection or laser ablation' but
recurrence is coon.
C&on#ro'as
Chondroas are the ost coon tracheal neoplass of esench!al origin and a!
arise fro an! of the cartilaginous eleents of the upper air*a!Lost fre.uentl! fro
the posterior cricoid laina. The! are t!picall! hard tuors co(ered b! intact ucosa.
Chondroas are *ell +no*n for alignant degeneration to chondrosarcoas' and
histiologic differentiation bet*een the t*o a! be difficult. Because incoplete resection
in(ariabl! leads to recurrence' resection rather than endoscopic ablation is the treatent
of choice.
He'ango'as
Geangioas of the upper air*a! occur in adults as *ell as children and are one of the
ost coon causes of subglottic obstruction in the pediatric population. In adults' the!
tend to occur in the lar!n" and pro"ial trachea. Geangioas de(elop in the
subucosa and appear as sessile lesions *ith a blue tint beneath a noral ucosa. Galf
of children *ith tracheal in(ol(eent *ill also ha(e a cutaneous heangioa. Fbstructi(e
s!ptos can usuall! be anaged conser(ati(el!' but' occasionall!' endoscopic laser
ablation is re.uired. Most tracheal heangioas resol(e spontaneousl! b! 3 !ears of age.
MALI"NANT TRACHEAL NEOPLASMS
Eight! to ninet! percent of priar! tracheal tuors in adults are alignant. Ff these' <$%
=$- are either s.uaous cell or adenoid c!stic carcinoa. Fther alignant tuors 3see
Table 35%#4 include carcinoid' ucoepideroid' and sall1cell neoplass.
S6ua'ous Cell Car$no'a
6.uaous cell carcinoa is the ost coon alignant neoplas of the trachea. It is
tightl! associated *ith cigarette so+ing and nearl! e(er! patient presents *ith such a
histor!. 6.uaous cell tuors of the trachea occur 3%C ties ore fre.uentl! in en
than *oen and t!picall! de(elop in the si"th to se(enth decades of life. 2ort! percent of
patients ha(e either a s!nchronous or a etachronous s.uaous cell cancer of the
respirator! tract.
6.uaous cell neoplass a! occur at an! le(el of the air*a! and in the trachea a! be
single or ultiple. Besions a! deonstrate e"oph!tic or sessile gro*th and ulceration is
coon. 5earl! half of patients *ith s.uaous cell cancer of the trachea ha(e tuors
that are unresectable at the tie of presentation due to the e"tent of the priar! lesion
or the presence of etastatic disease. Ff patients undergoing resection' one .uarter *ill
ha(e nodal etastases.
A#eno# Cyst$ Car$no'a
,denoid c!stic carcinoa is the ost fre.uentl! resected alignant tuor of the trachea
and the second ost coon o(erall. In contradistinction to s.uaous cell tuors'
adenoid c!stic cancers are not related to cigarette so+ing' occur in both se"es *ith
e.ual fre.uenc!' and a! de(elop at an! age throughout adult life' ost coonl! in
the fourth decade.
In addition' adenoid c!stic cancers are rear+able for their e"treel! slo* progression
and relati(el! fa(orable prognosis. Metastatic disease' *hich ultiatel! occurs in about
5$- of patients' does not preclude long1ter sur(i(al and should not be considered an
absolute contraindication for resection of the tracheal lesion.
,denoid c!stic carcinoa arises fro cells *ithin the ucosal glands of the trachea and
spreads in the subucosal plane both longitudinall! and circuferentiall!. The tracheal
*all is t!picall! in(aded and a significant aount of e"tratracheal tuor a! be present.
,denoid c!stic tuors rarel! in(ade other ediastinal structures' but rather push the
a*a!. E"tensi(e subucosal gro*th be!ond the (isible lesion is nearl! unifor and
intraoperati(e fro/en section e(aluation is re.uired to ensure unin(ol(ed resection
argins. Bocal recurrence can de(elop decades after incoplete resection.
Prognoss
The sur(i(al of patients follo*ing the resection of adenoid c!stic carcinoa of the trachea
is good' *ith 51 and #$1!ear sur(i(al rates of <$%<5- and 5$%55-' respecti(el!.
;atients *ith unin(ol(ed ediastinal l!ph nodes and negati(e resection argins tend to
sur(i(e longer than those *ith positi(e l!ph nodes or argins. The local recurrence of
adenoid c!stic carcinoa a! de(elop as uch as &5%3$ !ears after resection. Metastatic
disease usuall! anifests 5%#$ !ears after the diagnosis and a! reain as!ptoatic
for !ears.
Bong1ter sur(i(al after the resection of s.uaous cell cancers of the trachea is poor'
*ith a 51!ear sur(i(al rate of appro"iatel! #5%5$-. Gistologicall! in(ol(ed resection
argins significantl! decrease the sur(i(al tie. The effect on sur(i(al of ediastinal
nodal etastases in the surgical specien is unclear.
Chao M?' 6ith 0A' Baidla* C' 0oon DB' Ball D. @esults of treating priar! tuors of the
trachea *ith radiotherap!. &nt J Radiat Oncol 'iol $hys. #99=7C#8<<9. 3@e(ie* of a single
centerHs e"perience7 discusses prognostic factors.4 :;MID8 9D5&=3=>
DHCunha 0' Maddaus M,. 6urgical treatent of tracheal and carinal tuors. Chest Surg
Clin N Am. &$$37#33#4895. 3, re(ie* of the anageent of tracheal and carinal
neoplass.4 :;MID8 #&D9=DC$>
Aaissert G,. ;riar! tracheal tuors. Chest Surg Clin N Am. &$$37#33&48&C<. 3, re(ie*
of the t!pes' diagnosis' and anageent of tracheal neoplass.4 :;MID8 #&<553##>
Arillo GC' Mathisen D0' ?ain 0C. Manageent of tuors of the trachea. Oncology.
#99&7D8D#. 3F(er(ie* of tracheal tuors discusses the authorsH series of #9= patients'
the largest e"perience in the *orld.4 :;MID8 #3#3&<D>
Geitiller @2. Tracheal release aneu(ers. Chest Surg Clin N Am. &$$37#33&48&$#. 3,
re(ie* of techni.ues used to obili/e the trachea for anastoosis follo*ing e"tensi(e
tracheal resection.4 :;MID8 #&<553$9>
Ma/ia+ DE' Todd T@' Eesha()ee 6G' ?inton TB' (an 5ostrand ;' ;earson 2A. ,denoid
c!stic carcinoa of the air*a!8 thirt!1t*o !ear e"perience. J Thorac Cardioasc Surg.
#99D7##&8#5&&. 3Barge re(ie* of a single centerHs e"perience anaging adenoid c!stic
cancers.4 :;MID8 =9<5=CC>
@egnard 02' @our.uier ;' Be(asseur ;. @esults and prognostic factors in resections of
priar! tracheal tuors8 a ulticenter retrospecti(e stud!. The 2rench 6ociet! of
Cardio(ascular 6urger!. J Thorac Cardioasc Surg. #99D7###8=$=. 3European
retrospecti(e ulticenter re(ie* of &$= patients undergoing resection.4 :;MID8 =D#C#C#>
Se$on#ary Tra$&eal Neo%las's
6econdar! tracheal tuors are' b! definition' alignant' and occur ost coonl! as a
result of direct in(asion fro ad)acent organs. , (ariet! of neoplass can etastasi/e to
the trachea' but this is e"ceedingl! rare. In(asion of the trachea b! th!roid' esophageal'
and bronchogenic tuors accounts for the a)orit! of secondar! tuors.
@esection of in(asi(e th!roid tuors *ith en bloc segental tracheal resection pre(ents
the orbidit! and possible ortalit! associated *ith tracheal obstruction and a! result
in long1ter sur(i(al. Ideall!' tracheal in(ol(eent is identified preoperati(el! so that a
cobined resection can be planned. T!picall!' ho*e(er' air*a! in(ol(eent is identified
intraoperati(el! and the tuor is sipl! dissected off the trachea' resulting in incoplete
resection. @eferral for subse.uent tracheal resection in such cases pre(ents recurrence
and ipro(es sur(i(al.
Jpper lobe lung cancer and esophageal tuors that in(ade the trachea are usuall! too
*idespread to )ustif! tracheal resection. ;alliation of these and other inoperable
secondar! tracheal tuors can be achie(ed using a cobination of endoscopic ablation'
stenting' and radiotherap!.
Gaoud NT' Mathisen D0. 6urgical anageent of th!roid carcinoa in(ading the
trachea. Chest Surg Clin N Am. &$$37#33&48359. 3, re(ie* of the anageent of th!roid
carcinoa in(ading the trachea.4 :;MID8 #&<553&$>
Eoi+e E' Iaashita G' 5oguchi 6 et al. Bronchoscopic diagnosis of th!roid cancer *ith
lar!ngotracheal in(asion. Arch Surg. &$$#7#3D8##=5. 3;rospecti(e stud! reports the use
of preoperati(e bronchoscop! to deterine the need for air*a! resection.4 :;MID8
##5=55#3>
5a+ao E' Euro/ui E' 2u+ushia 6' 5a+ahara M' Tsu)ioto M' 5ishida T. Merits and
deerits of operati(e procedure to the trachea in patients *ith differentiated th!roid
cancer. (orld J Surg. &$$#7&58<&3. 3@etrospecti(e re(ie* reports results of tracheal
resection' en bloc' for in(asi(e th!roid tuors.4 :;MID8 ##3<DC$D>
5ishida T' 5a+ao E' Gaa)i M. Differentiated th!roid carcinoa *ith air*a! in(asion8
indication for tracheal resection based on the e"tent of cancer in(asion. J Thorac
Cardioasc Surg. #99<7##C3#48=C. 3, retrospecti(e re(ie* e"aining the indications for
tracheal resection in the anageent of in(asi(e th!roid cancer.4 :;MID8 9&C$&9<>
?ang 0C' Ta+ashia 6' Ta+a!aa 2 et al. Tracheal in(asion b! th!roid carcinoa8
prediction using M@I iaging. AJR Am J Roentgenol. &$$#7#<<89&9. 3Deonstrates the
(iabilit! of using cobination of M@I findings to predict tracheal in(asion.4 :;MID8
##5DD<$=>
Cop!right O&$$D The McAra*1Gill Copanies. ,ll rights reser(ed