Evolution of individualized management of tracheal obstruction

Abstract

Tracheal stenosis may be congenital or acquired. It may occur in the subglottic area, near a tracheostoma, or more distally, and it may involve the mucosa and submucosa or the deeper structures, including cartilage. Increasing use of prolonged endotracheal intubation has resulted in more children with acquired tracheal stenosis. Recently, authors have developed and introduced new methods of managing these strictures both with and without tracheostomy, dilatations, stents, fulgurations, and local or systemic steroids. The use of these techniques is demonstrated in 8 children. Three children had congenital stenosis, 2 children had past-intubation stenosis, 1 child had stenosis secondary to resection of a mucosal tumor of the trachea, 1 child had stenosis following a long-term tracheostomy, and 1 child had stenosis following acute tracheobronchitis complicated by a high tracheostomy. Early in our experience all children were managed by tracheostomy followed by dilatations. With the advent of the new endoscopes, our management has evolved into a graduated use of the new techniques, with emphasis on avoidance of tracheostomy, if possible. Initial attempts to dilate the lesions are made without tracheostomy, and local injections of steroids and minimal fulgurations of granulation tissue are also used. To avoid excess edema, gradual repeated gentle dilatations are performed rather than vigorous ones. More extensive fulguration, systemic steroids, and tracheostomy are added if the lesions do not respond. No stents have been necessary. Our last 2 children have been managed without tracheostomy; we have used dilatation, fulguration, and steroid injection. All tracheostomies have been removed, and all 8 children are asymptomatic. Two stenoses that were present for several years have been successfully corrected. Our results with tracheal stenosis have improved with this graduated approach to management. individualized plans of treatment may permit correction of stenoses without the need for tracheostomy and its related problems.