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© 1987 S. Karger AG, Basel
0301 - 1569/87/0493-0145S2.75/0
ORL 49: 145-148 (1987)
Dilatation of Laryngeal and Tracheal Stenoses
U. Ganzer
HNO Klinik, Klinikum Mannheim der Universität Heidelberg, FRG
Key Words. Laryngotracheal stenosis • Dilatation
Independent of the different etiology of
laryngeal and tracheal stenoses, their patho­
physiological development is, on principle,
the same in most cases: local ischemia and
infection give rise to a granulomatous in­
flammation rich in capillaries, myofibro­
blasts and collagenous fibres of type III.
Later on, a disintegration of the connective
tissue as a result of decreasing capillary cir­
culation can be observed, which is followed
by hyalinisation and collagen formation with
atypical cross-linking. This tissue, however,
represents an incompressible, very rigid scar
without elastic fibres. Each individual stage
of cicatrisation may narrow parts of the up­
per respiratory tract and entail dyspnea.
An effective treatment therefore has to
consider not only the etiology and the local­
isation as well as the dimension of the steno­
sis, but also the momentary stage of scar for­
mation. This is the explanation for the great
variety of therapeutic schedules in congeni­
tal and acquired laryngotracheal stenoses.
Among these, dilatation is the only conserva­
tive management, i.e. it requires no recon­
structive surgery. It can be defined as the
active widening of an already existing or just
developing narrowness until the opening
within the stenosis is large enough to allow
respiration. Additional endoscopic division
and excision of bands, webs and scars as well
as local injection of glucocorticoids and hyaluronidase may be useful [2, 6, 9], Usually
tracheostomy must precede dilatation.
There are two methods of dilatation: re­
peated and permanent dilatation [7], The
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Abstract. 21 patients suffering from laryngeal or tracheal stenosis have been treated by
dilatation. Of these, 9 regained health and needed no reconstructive surgery after dilatation.
With regard to these results and those presented in the literature, the dilatation technique is a
suitable method especially in infancy and if the stenosis is situated between the vocal cords
or within the trachea. Yet, satisfactory results are only available if dilatation has been strictly
indicated.
Ganzer
146
Table I. Etiology and localisation of 2 1 stenoses treated by dilatation
Localisation
Connatal
Intubation
Erosion
Wegener's
granulomatosis
Total
Glottis
Subglottis
Laryngotracheal
Trachea
Complete respiratory tract
1 G)
1 G)
-
2(1)
1 (1)
9(6)
4(3)
-
-
-
2 (-)
1 (-)
3(2)
2(2)
9(6)
4(3)
3 (-)
Total
2(2)
16(11)
2 (-)
1 (-)
21 (13]
Number of children is indicated in parentheses.
Materials and Methods
During the last decade, we have treated 21 pa­
tients with air way obstruction by endoscopic man­
agement. 13 of them were children, 7 less than 3 years
old, and 8 were adults. The most frequent etiology
was intubation damage, the main localisations were
the laryngotracheal transition and the trachea alone
(table I).
In two thirds of the cases, the stenoses devel­
oped due to granulation tissues or collagenic scars,
especially within the laryngotracheal transition (ta­
ble II).
In infants younger than 1 year, we preferred bou­
gienage alone because of the great irritability of the
mucosa to stents and tubes as well as the danger of
tube obstruction. In older children and adults, how­
ever, we performed permanent dilatation with T
tubes. To avoid aggravation of cartilage necrosis or
induction of general complications, we generally pre­
ferred not to apply glucocorticoids.
Results
In 11 out of 21 cases, the described con­
servative management was successful, 5
times with bougienage alone and 6 times
with additional insertion of a T tube. Thera­
peutic success means that 3 months after
decannulation, the tracheostoma could be
closed. Nevertheless 2 of the bougienated
cases relapsed, one 6 weeks, and the other 3
months later. Therefore the healing rate de­
creases to 9 out of 21 patients, which is
equivalent to 43% (table III).
Table IV demonstrates the failures with
regard to pathological findings: the rigid
scars did not respond to the dilatation tech­
nique, and the cicatrices were mostly found
within the laryngotracheal transition.
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first actually corresponds to bougienage with
hard-rubber bougies, the Jackson laryngeal
dilator or bronchoscopes with graduated
size. Within the scope of the latter, the steno­
sis is extended with a bougie at first and then
a stent or a tube, for instance the Montgom­
ery T tube.
In this article, the therapeutic results
achieved by dilatation technique, as well as
its advantages or disadvantages will briefly
be commented on, comparing our own pa­
tient material to the data presented in the
literature.
Laryngotracheal Stenosis
147
Table II. Pathological findings depending on the localisation of stenosis
Localisation
Webs and
bands
Granulation
tissue
Collagenic
scars
Total
shrivelling
Total
Glottis
Subglottis
Laryngotracheal
Trachea
Complete respiratory tract
1 O)
1G)
2(1)
_
-
1 G)
-
-
-
2(2)
2(2)
-
7(4)
2(1)
-
3 (-)
3(2)
2(2)
9(6)
4(3)
3 (-)
Total
2(2)
7(6)
9(5)
3 (-)
21 (13)
Number of children is indicated in parentheses.
Table III. Therapeutic results with regard to the
localisation of stenosis
Table IV. Pathological findings and therapeutic
results after dilatation
Localisation
Pathological
findings
Total
yes
no
3(2)
2(2)
2a (2)
2b (2)
2 (-)
_
11 (8)
Total
7(4)
20)
1 (-)
3(2)
2(2)
9(6)
4(3)
3 (-)
10(5)
12(13)
-
Number of children is indicated in parentheses.
a One relapse 6 weeks later.
b One relapse 3 months later.
Discussion
Our results are in contrast to the pub­
lished successes with dilatation treatment. In
the literature, healing rates of about 70% similar to those of reconstructive surgery are reported [1, 3, 4, 5, 8]. A closer look,
however, reveals that a number of patients
Webs and bands
Granulation tissue
Collagenic scars
Total shrivelling
Total
Decannulation
Total
yes
no
2(2)
5(4)
2(2)
2 (-)
_
2(2)
7(3)
1 (-)
2(2)
7(6)
9(5)
3 (-)
11 (8)
10(5)
21 (13)
Number of children is indicated in parentheses.
surely would have regained health with drugs
only or even without any therapy. Further­
more, the papers partly lack the definition of
therapeutic success and a sufficient long­
term follow-up.
From our results and, with regard to the
just mentioned reservation, those of the lit­
erature, it follows that dilatation of laryngeal
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Glottis
Subglottis
Laryngotracheal
T rachea
Complete
respiratory tract
Dccannulation
Ganzer
148
failures will not impair subsequent recon­
structive surgery, dilatation should be per­
formed in cases of developing stenosis, espe­
cially in infancy.
References
1 Bos, C.E.; Berkovits, R.N.P.; Strubcn, W.H.:
Wider application of prolonged nasotracheal intu­
bation. J. Lar. Otol. 87: 263-279 (1973).
2 Crysdale, W.S.: Laryngeal and tracheal stenosis in
children; in Lehmann, Torhill, Schmitz, Otolaryn­
gologic clinics of North America, vol. 12/4, pp.
817-822 (Saunders, Philadelphia 1979).
3 Fearon, B.; Crysdale, W.S.: Bird. R.: Subglottic
stenosis of the larynx in infant and child. Methods
of management. Ann. Otol. Rhinol. Lar. 87: 645648 (1978).
4 Hawkins, D.B.; Luxford. W.M.: Laryngeal steno­
sis from endotracheal intubation. A review of 58
cases. Ann. Otol. Rhinol. Lar. 84: 454-458
(1980).
5 Kotton, B.: The treatment of subglottic stenosis in
children by prolonged dilatation. Laryngoscope
89: 1983-1990 (1979).
6 Maniglia, A.J.: Conservative surgical manage­
ment of tracheal stenosis. ORL 39: 380-393
(1977).
7 Minnigerode, B.: Hartgummi-Bougie-Behandlung
subglottischer Kehlkopfstenosen im Kindesalter.
HNO 20: 370-371 (1972).
8 Simon, U.; Poivret, Ph.; Gazel. P.; Borclly, J.;
Wayoff, M.: Traitement endoscopique des sté­
noses laryngo-trachéales. Réflexions critiques à
propos de 23 observations. J. fr. Oto-Rhino-Laryng. 32: 467-471 (1983).
9 Waggoner, L.G.; Belenky, W.M.; Clark, Ch.E.:
Treatment of acquired subglottic stenosis. Ann.
Otol. Rhinol. Lar. 82: 822-826 (1973).
Received: July 25, 1986
Accepted: July 30, 1986
U. Ganzer, MD,
HNO Klinik, Klinikum Mannheim der
Universität Heidelberg,
Thcodor-Kutzer-Ufer,
D-6800 Mannheim 1 (FRG)
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and tracheal stenoses is justified ( 1) in in­
fants younger than 3 years, especially with
regard to the unknown fate of the laryngeal
cartilage operated on in this age; (2) if connatal webs and bands are present within or
close to the glottic space; (3) in the case of
granulomatous obstruction; (4) in the case of
perichondritic tumefaction; (5) in the pres­
ence of tracheal stenoses with a short vertical
extension and (6) if the anterior tracheal wall
is displaced following tracheostomy. Finally,
dilatation may be useful (7) in patients in a
generally bad condition or in cases of total
shrivelling of the upper respiratory tract.
On the other hand, dilatation is not very
successful in (l)th e majority of stenoses of
grown-ups; (2) if rigid collagenic scars are
obvious; (3) in stenoses of the laryngotra­
cheal transition, and (4) in vertically extend­
ing tracheal stenoses (table IV).
On the whole, dilatation may be a suit­
able treatment for laryngeal and tracheal ste­
noses especially in infants and children if
strictly indicated [4], Patients younger than
1 year should only be bougienated, older
ones should be equipped additionally with a
tube or stent after tracheostomy. Insurance
of laryngeal breathing with vocal cord ab­
duction is important in tracheostomized pa­
tients to avoid renewed glottic bands. Local
or systemic application of glucocorticoids
may be helpful in some cases. However, care
must be taken to avoid aggravating cartilage
necrosis or general complications. If possi­
ble, granulomatous tissues, bands or webs
should be removed and cicatrix division
should be performed before bougienage. Fi­
nally, the earlier dilatation is carried out, i.e.
before the manifestation of a rigid scar, the
better the results are.
Thus a number of laryngeal and tracheal
stenoses can be repaired. Since treatment
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