IMPROVISED T-TUBE FOR MANAGEMENT OF COTTON-MYER GRADE IV SUBGLOTTIC STENOSIS

Abstract

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Post-intubation and post-tracheostomy injury are among the most common etiologies of subglottic stenosis. Bronchoscopic interventions for the treatment of subglottic stenosis include laser therapy, balloon dilation, and/or stent placement. The Montgomery T-tube (MTT) is a silicone tube with a vertical limb that works as a stent within the trachea and a horizontal limb which functions as a tracheostomy tube (TT). It has unique indications, such as proximal stenosis that result in loss of voice who do not respond to common intervention or are not surgical candidates. Utmost care is required in the maintenance of a MTT, and patients with poor access to medical care or poor compliance may not be appropriate candidates. CASE PRESENTATION: A 56-year-old-male with history of motor vehicle collision complicated by post-intubation tracheal stenosis requiring tracheostomy presented in interventional pulmonology clinic for loss of voice. Patient had a Shiley 6.0 cuffless fenestrated TT at this visit. Patient underwent flexible bronchoscopy and electrocautery radial incisions and balloon dilation for a Cotton-Myer Grade III subglottic stenosis 2 cm below the vocal cords (VC). Due to recurrence of symptoms, repeat FB was performed 4 weeks later and was remarkable for a Cotton Meyer grade IV subglottic stenosis 1 cm below the VC. Patient had multiple clinic visits before his repeat FB where he was found to have >50% occlusion of his TT inner cannula with mucus and lacked compliance with suctioning despite repeated education. He underwent rigid bronchoscopy and had sequential dilations using a balloon over a guide-wire that was inserted through the center of the stenosis. A 14x40mm silicone stent was placed inside the airway with the proximal end of the stent 0.5 cm below the VC. The TTs’ obturator was inserted through the tracheostomy stoma and gently pushed to visualize an indentation on the stent. The stent was removed and jet ventilation was continued. A side-hole was punched at the marked location of the stent and the fenestrated TT fit was tested. The stent was placed back in the trachea with the customized hole placed anteriorly and the TT was inserted through the stent. The fenestrations aligned with the tracheal lumen and VC. Patient was able to speak with capping or finger occlusion and on 18-month follow up maintains his speech and TT maintenance. DISCUSSION: Montgomery t-tube is a rarely used stent with unique indications. Its placement and long-term management requires subspecialized training in IP or ENT. Because the tube does not have an inner cannula, regular daily suctioning and care is required for its maintenance. When troubleshooting is required, most doctors are not familiar with the t-tube, hence proximity to a center with specialized teams may be necessary. CONCLUSIONS: The use of the modified t-tube may decrease the risk of complications in the aforementioned patient population. Reference #1: D'Andrilli, A., Venuta, F., & Rendina, E. A. (2016). Subglottic tracheal stenosis. Journal of thoracic disease, 8(Suppl 2), S140–S147. Reference #2: Hu, H., Zhang, J., Wu, F., & Chen, E. (2018). Application of the Montgomery T-tube in subglottic tracheal benign stenosis. Journal of Thoracic Disease, 10(5), 3070–3077. Reference #3: Fiorelli, A., Natale, G., Freda, C., Cascone, R., Carlucci, A., Costanzo, Santini, M. (2019). Montgomery T-tube for management of tracheomalacia: Impact on voice-related quality of life. The Clinical Respiratory Journal, 14(1), 40–46. DISCLOSURES: No relevant relationships by Kevin Davidson, source=Web Response no disclosure on file for Ray Shepherd; no disclosure on file for Samira Shojaee; No relevant relationships by Zulma Swank, source=Web Response