Exploracion fisica

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Tracheal Stenosis
Julina Ongkasuwan, M.D.
February 9, 2006
My topic this morning is tracheal stenosis. An outline for my presentation today: We are going to start with a case presentation, followed by an introduction to tracheal stenosis, identify some keysto diagnosis, and then talk about some treatment modalities, both endoscopic and surgical.
Our case begins with S.A. She is a 33-year-old female with a history of acanthosis nigricans and also history of airway obstruction requiring intubation at age 21. She presented to the Methodist Hospital in July 2005, with shortness of breath and difficulty breathing. She was diagnosed with an upper airwayobstruction and taken to the operating room where she underwent endoscopy. At that point, she was noted to have an area of tracheal stenosis in the cervical trachea, just distal to the cricoid. A silicone stent was placed at that time by interventional pulmonology. She did well postoperatively and was subsequently discharged home. She represented, in September 2005, with URI-type symptoms andshortness of breath and difficulty breathing yet again. She was taken back to the operating room for a repeat endoscopy and was noted to have some granulation tissue just distal to her stent and evidence of stent infection. The stent was removed and mitomycin-C was placed at the area of stenosis as well as on the granulation tissue. She again did well postoperatively and went home.
A month later, sheagain presented to the Methodist ER, again with shortness of breath. A soft tissue neck film, which was done at this time, showed an obvious area of stenosis visible in her neck. An airway CT was also performed, which revealed an area of stenosis beneath the cricoid. 3D reconstruction showed the area of stenosis, and then the airway was patent distal to the area of obstruction down to the levelof the carina. She was taken to the OR and underwent endoscopy for the third time. In these intraoperative images, you can see her vocal cords and her immediate subglottis appear to be clear and then a tight area of stenosis just distal to the cricoid. Distal to this stenosis, the airway was open again all the way down to the carina. She underwent dilation again at this third trip to the operatingroom. As you can see here in this 3D rendering of her airway, measurements taken during endoscopy showed that the area of stenosis began approximately 3 cm below the vocal cords. This was approximately 2.8 cm in length and was located approximately 6 cm above the carina.
After this third trip to the operating room, she was presented with two different options. The first was permanent tracheostomyplacement in order to protect her airway, and the second was a tracheal resection. The patient felt very strongly that she did not want to live with a permanent tracheostomy. Thus, she was set up for a tracheal resection. In November 2005, she underwent tracheal resection with primary anastomosis in conjunction with the cardiothoracic surgery service. She did very well postoperatively with nofurther episodes of difficulty breathing and with a good swallow.
Basic anatomy of the trachea: As you know, the trachea is located in the midline. You have the glottis and the subglottis and then the cervical trachea, which we are defining as below the inferior border of the cricoid to approximately the sternal notch, and then the thoracic trachea located from the sternal notch down to the...