Montgomery T-tube Research Articles

Montgomery T-tube placement in the treatment of benign tracheal lesions☆

Although surgery remains the gold standard for the treatment of benign tracheal stenosis, airway stenting may be indicated in the event of complex lesions or associated diseases. We retrospectively investigated Montgomery T-tube placement as an alternative or complementary treatment to surgery. From January 1984 to March 2008, 158 patients were treated for benign tracheal lesions. Eighty-three patients underwent airway resection and reconstruction as the only treatment. Seventy-five other patients with complex lesions or major associated diseases were treated with a T-tube and were retrospectively analysed. Seven of them had undergone unsuccessful treatment with Dumon stents. T-tube placement was the only procedure adopted in 51 patients with a contraindication to surgery (group I), a temporary measure in 15 patients prior to surgery (group II), and in 9 patients (group III) for complications of airway reconstruction, 5 of whom were referred from other institutions. Complications after T-tube placement were: stent dislocation in 3 (4%) patients, endoluminal granulomas in 14 (19%), subglottic edema in 3 (4%), and sputum retention in 7 (9%). Treatment of complications (tracheostomy cannula, steroid infiltration, Argon/LASER coagulation, and bronchoscopy) was required in 20 (27%) patients. In group I, the tube was removed in 12 (24%) patients after 35.3 +/- 8.2 months following resolution of the stenosis. In group II, the tubes were maintained in place before surgery for 17.1 +/- 4.8 months. In group III, three stents were removed following tracheal healing after 115.3 +/- 3.7 months. After 5 years the stents were in place in 82%, 7% and 100% of the patients, respectively in groups I, II and III. Montgomery T-tube placement represents a useful option in patients with complex benign tracheal stenosis or associated diseases as an alternative or complementary treatment to surgery, and is effective even when other types of stents are unsuccessful.

The use of the Montgomery T-tube in postprocedural subglottic stenosis repair.

The Montgomery T-tube is a device that supports the trachea and facilitates ventilation after laryngotracheal surgery. Because its use is sporadic, many anesthesiologists may not be familiar with this device, and its anesthetic management requires careful planning and discussion with surgeons. We describe the techniques of anesthetic management of exchanging endotracheal tube to Montgomery T-tube in case where upper tracheal stenosis exists.

Laryngeal and tracheal stents in children

To review the usage of laryngeal and tracheal stents in the treatment of benign pediatric laryngotracheal disorders, focusing primarily on their role in the management of airway stenosis. Little progress has been made in the recent past in the introduction of new laryngeal suprastomal stents in the treatment of laryngeal stenosis. The traditionally available Aboulker stent and Montgomery T-tube remain the workhorse stents used in laryngotracheal reconstructive surgery. Their use and characteristics are reviewed herein. The use of stents as a sole primary treatment of benign tracheal obstruction is limited to short-term symptom palliation, as due to the high rate of complications associated with their usage, their application should be restricted to patients in which formal surgery is contraindicated. Laryngeal and tracheal stents remain best used primarily as postoperative adjunctive devices to assist in the appropriate healing of reconstructive surgical procedures for benign laryngotracheal stenosis.

Posthemicricoidectomy reconstruction with a composite hyoid-sternohyoid osseomuscular flap: the Rethi–Ward technique

Our objective was to introduce a new technique for cricoid cartilage reconstruction. A 74-year-old male patient with a history of a 6-month progressively worsening dyspnea was found to have an extensive mass of the left cricoid cartilage. Although the extent of his disease would necessitate total laryngectomy, the patient underwent an open extended left hemicricoidectomy with reconstruction of the defect by a pedicled osseomuscular flap composed of the body of the hyoid bone and the contralateral sternohyoid muscle. Both frozen section and subsequent histopathological evaluation gave the diagnosis of a chondrosarcoma. A Montgomery T-tube was left in place for 3 months and was subsequently replaced by a tracheostomy tube to be removed 1 month later. Six months postoperatively, the patient remains in an excellent respiratory condition. The reconstructed site is patent without any signs of restenosis as up to date. We conclude that our technique appears to be a reliable alternative to total laryngectomy in cases of extended chondrosarcomas, as well as in cases where reconstruction of the cricoid cartilage is mandated. Further follow-up and additional cases are warranted.

Laryngotracheal augmentation using titanium mesh

The management of laryngotracheal stenosis is still a serious surgical challenge. The fact that there are currently numerous reconstruction procedures indicates that there is at present no standard treatment. Titanium mesh was used instead of traditional homografts in reconstruction of the anterior laryngotracheal wall in 12 tracheostomised patients with benign chronic laryngotracheal stenosis. The anterior laryngotracheal wall was split, followed by excision of scar tissue and fixation of the titanium plate at the split end. A Silastic stent was inserted above the tracheostomy tube and fixed in place by running sutures fixed to the skin by buttons. The stent was removed endoscopically six weeks later and a trial of decannulation was undertaken. Endoscopically, good epithelisation was seen on the inner surface of the mesh in 10 cases and decannulation was possible. Four of these patients required endoscopic debulking of granulation tissue. Decannulation was impossible in two cases, one due to excessive granulation tissue and the other due to prolapse of the titanium mesh into the tracheal lumen (the mesh was removed endoscopically and a Montgomery T-tube inserted). Titanium mesh was found to be a good alternative for augmentation of the anterior laryngotracheal wall. It offered rigid support, with fewer of the complications reported with other grafts.

Complications of Metal Stent Therapy in Benign Airway Obstruction

Background To describe Mayo Clinic's experience with metal stent complications in benign tracheobronchial obstruction. Methods Retrospective review of metal stents in benign airway conditions evaluated at Mayo Clinic Rochester, Minnesota. Results Twenty-eight patients were identified from 1994 to 2006; 16 males and 12 females (mean age 56 y). Mean stent duration was 22 months. Symptoms included cough, dyspnea, and hemoptysis. A metal stent was in the trachea in 8, mainstem bronchus in 12, whereas 8 patients had more than 1 stent. Tracheal stent indications included tracheomalacia, posttracheostomy stricture, idiopathic, and radiation-induced stenosis. Bronchial stent indications included bronchomalacia, postoperative bronchial torsion, Wegener granulomatosis, fibrosing mediastinitis, tracheobronchial papillomatosis, tracheoesophageal fistula, and tuberculosis. All metal stents but two were removed with rigid bronchoscopy. Indications for removal included obstructing granulation tissue, stent migration, wire fracture with granulation, inadequate stent size, and dynamic obstruction. Complications of removal included hemorrhage (>100 mL) in 2 patients. Mean operating time was 127.9 minutes. After stent removal, 10 patients required no further therapy. Silicone stents were inserted in 9, Montgomery T-tube in 4, right pneumonectomy in 2, left pneumonectomy in 1, and tracheal resection with reconstruction in 1 patient. Follow-up revealed 6 patients have died and 4 continue to receive periodic revision of silicone stents. Conclusions Metal stent complications in benign tracheobronchial obstruction include obstructing granulation tissue and stent migration. Metal stents may be difficult and time-consuming to remove and, may cause significant hemorrhage during removal. Our experience suggests these devices are not appropriate for long-term management of benign airway lesions.

Montgomery T-tube: anesthetic management

The Montgomery T-tube is a device used as a combined tracheal stent and airway after laryngotracheoplasty. It is a valuable option in the management of upper and mid–tracheal lesions. Because its use is sporadic, many anesthesiologists may not be familiar with this device, and its anesthetic management may pose a challenge. Safe management of such patients requires careful planning. We describe different techniques of anaesthetic management in two cases of injuries to the throat, for which this tube was inserted as a tracheal stent.

AIRWAY STENTS IN MANAGEMENT OF TRACHEAL STENOSIS: HAVE WE IMPROVED?

Airway stenting is an alternative approach for relieving airway stenosis when lesions are inappropriate for single-stage reconstruction. The aim of this study was to present our experience using airway stent in the management of patients with tracheal stenosis. This study retrospectively reviewed 45 patients who underwent airway stenting during a 2-year period. Between June 2002 and August 2004, 45 patients underwent rigid bronchoscopy for tracheal stenosis using an Ultraflex stent (Microvasive; Boston Scientific, Boston, MA, USA), Hood stent (Hood Laboratories, Pembroke, MA, USA) and Montgomery T-tube (Boston Medical, Westborough, MA, USA). Clinical improvement, intraoperative, early and late postoperative complications were evaluated. Ultraflex stent was used in 14 patients, Hood stent in 9 and Montgomery T-tube in 22. The overall clinical improvement was 95.5%. Four per cent of the patients (2/45) had intraoperative complications, 8.8% (4/45) had early postoperative complications and 51% (23/45) had late postoperative complications. No significant difference was determined between stent type and complication rates. Rigid bronchoscopic insertion of airway stents for tracheal stenosis is a safe and effective procedure. No difference exists between stent type and clinical improvement, intraoperative and early and late postoperative complications.

Novel Technique of Montgomery T-tube Placement Allowing for Ventilation

Novel Technique of Montgomery T-tube Placement Allowing for Ventilation

Combined Endoscopic and Open Approach to the Removal of Expandable Metallic Tracheal Stents

To review complications of indwelling tracheal stents and to describe a technique of stent removal using a combined open and endoscopic approach. Descriptive case series. Medical University of South Carolina. Six patients were identified who had undergone combined open and endoscopic removal of indwelling tracheal stents. Coated (4 patients) and uncoated (2 patients) expandable metal stents had been present for an average time of 24 months (range, 5-60 months) before removal. Medical comorbidities, characteristics of the underlying airway lesion (origin, type, and length), stent characteristics (type and duration), and the presentation and management of stent-related complications. All patients presented with worsening dyspnea and/or stridor, with 3 requiring intubation. Stent removal was performed in the operating room and consisted of initial exposure of the trachea for emergency airway access, removal of the indwelling stent under bronchoscopic and transtracheal guidance, and tracheotomy. Two patients experienced desaturations of more than 25% during the procedure, and 2 patients had stents that could be only partially removed. Five patients subsequently received Montgomery T-tubes without complications after a mean follow-up of 23 months (range, 6-40 months). Indwelling tracheal stents are becoming increasingly common in the management of benign airway stenosis. The stents frequently occlude with granulation tissue and may require removal. A combined open and endoscopic removal maximizes airway protection and minimizes potential complications.

MONTGOMERY T‐TUBE INSERTION USING A RIGID BRONCHOSCOPE UNDER DIRECT OBSERVATION

The Montgomery T-tube (T-tube) is an effective device for relieving tracheal stenosis when lesions are inappropriate for surgical reconstruction. Several techniques have been developed for the insertion of the T-tube in difficult conditions. The aim of this study was to present our experience using a rigid bronchoscope for T-tube insertion. A retrospective chart review of patients with tracheal stenosis who underwent T-tube insertion between April 2002 and July 2005 was conducted. Thirty-seven patients underwent 53 T-tube placements. Successful stent placement was achieved in all 37 patients. The T-tube was not tolerated in six patients because of granulation obstruction of the upper limb or sputum impaction. Thirty-one patients had good long-term results and enjoy adequate airway with the T-tube. There was no procedure-related mortality and there were no complications. Rigid bronchoscopic insertion of the T-tube for tracheal stenosis is a safe and an effective procedure. It ensures the correct placement of the T-tube when the technique described by Montgomery fails.

An effortless way of inserting a Montgomery T-tube stent in a closed neck

We describe a simple technique of replacement Montgomery T-tube insertion in a closed neck under general anaesthetic.

Infantile Supraglottic Hemangioma: A Case Report

Hemangiomas of the airway are benign vascular lesions that can involve any site from the nares to the tracheobronchial tree. Most of these lesions are seen in the subglottic area in infants. Supraglottic infantile hemangiomas are very rare. We report a case of supraglottic hemangioma in a 2-month-old boy who had been admitted to our hospital with inspiratory stridor and dyspnea. The hemangioma involved the left arytenoid and aryepiglottic fold. A tracheostomy was performed, and the patient was followed up endoscopically every 6 months thereafter The hemangioma disappeared when the child was 30 months old. Subsequently, a Montgomery T-tube was placed for 6 months to assist in maintaining normal breathing. The patient remains disease-free during ongoing follow-up. We also discuss the management strategies for infantile laryngeal hemangiomas.

Ventilatory management of severe tracheal stenosis

We present here a 4 year old child with severe tracheal stenosis and respiratory failure. The patient was not responding to conventional ventilation settings and had significant hypercarbia. The difficulty in mechanical ventilation was handled successfully with specific ventilatory strategy: use of low respiratory rate, long inspiratory time and normal inspiratory time: expiratory time ratio. Thereafter the child was managed surgically and the stenosis was corrected. The child was discharged after a Montgomery T-tube placement.

Successful Treatment of Laryngeal Stenosis in Laryngo‐Onycho‐Cutaneous Syndrome with Topical Mitomycin C

Laryngo-onycho-cutaneous syndrome is a very rare entity found in Punjabi families. It affects the skin, nails, and larynx. Laryngeal involvement may cause lethal airway obstruction, and has in the past proved very difficult to treat. Mitomycin C is an antibiotic that acts as an alkylating agent, inhibiting DNA synthesis. It reduces fibroblast proliferation, and has previously been used to treat choanal atresia and laryngeal stenosis. We report an 18-year-old man with complete transglottic laryngeal stenosis secondary to laryngo-onycho-cutaneous syndrome. An airway was established by dissection with a bougie and sickle knife, and was initially maintained by the upper limb of a Montgomery T-tube. Laryngeal granulation tissue present on removal of the T-tube was treated with topical mitomycin C (2 mg/mL) applied for 4 minutes on two occasions with an interval of 1 month. A year later, the airway remained patent, with no granulation tissue.

Our results in surgical treatment of laryngotracheal stenosis, ten years experience

There are numerous techniques for the treatment of laryngotracheal stenosis. The aim of this paper was to present surgical techniques and results of treatment of laryngeal and laryngotracheal stenosis in a ten-year period by retrospective analysis. Medical records of 34 patients (17 male and 17 female) surgically treated for laryngeal or laryngotracheal stenosis between 1995 and 2004 were analyzed. 19 (55.9%) patients had previous surgical procedures, whereas fifteen patients (44.1%) were diagnosed and treated for the first time. 5 patients had a glottic-subglottic stenosis, 11 patients had a subglottic stenosis, 16 patients had subglottic-tracheal stenosis and 2 patients had a glottic-subglottic-tracheal stenosis. 21 patients had normal vocal cord motion, 8 patients showed unilateral vocal cord fixation, and 5 had bilateral vocal cord fixation. Laryngotracheoplasty with anterior-posterior costal cartilage graft was performed in 24 patients, while single stage segmental laryngotracheal resection of the stenotic part was performed in 8 patients. One patient was operated in direct laryngomicroscopy and one with dilatation of the stenotic segment with T tube insertion. The most common complication was the development of granulation due to use of the Montgomery T-tube which was removed in direct laryngomicroscopy. Except for one patient, 33 (97%) patients were decannulated. There was no perioperative mortality. Although laryngotracheoplasty with anterior-posterior costal cartilage graft placement cannot be used in all cases of laryngotracheal stenosis, it was the method of choice in previously operated patients with segmental resection of the stenotic segment. This method requires use of Montgomery T-tube or anesthesiological tube, which is very hard to keep clean. Better recovery, short hospitalization and excellent results were obtained with the cricotracheal segmental resection.

A New Technique for T-Tube Insertion in Tracheal Stenosis Located Above the Tracheal Stoma

Tracheal stenosis is one of the main complications of long-term intubation. The Montgomery T-tube is a safe way to treat patients with tracheal stenosis who are unable to undergo surgical procedures. We describe a simple and practical technique for the insertion of the T-tube in tracheal stenosis located above the tracheostomy, while maintaining ventilation throughout the whole procedure.

The use of the Montgomery T-tube in difficult paediatric airways

We report our experience of using Montgomery T-tubes in children. A retrospective review of medical records was performed. Data collected included particular clinical circumstances, the details of usage of the tube, and the eventual outcome. Between January 1999 and October 2003, our unit performed 293 tracheostomies, 76 laryngotracheal reconstructions and 31 other major airway procedures in children. 10 children have had a Montgomery T-tube inserted. Nine were boys. In eight cases, the T-tube was used because of severe granulations and subsequent fibrotic narrowing in the subglottis after laryngotracheal reconstruction surgery. These children had undergone between one and four major procedures prior to T-tube placement. In the other two cases, the T-tube was used to stent severe glottic and supraglottic stenosis (due to previous laser surgery for papillomas in one case and congenital ectodermal dysplasia in the other). At the time of T-tube placement the children were aged 2-18 years (median 8 years). The tube was initially fitted so as to protrude above the glottis in all cases. In one case, the T-tube was removed on the first post-operative day. One tube was removed after a week due to severe crusting. One tube blocked after 2 weeks. One child had re-stenosis in the supraglottis necessitating the placement of a T-tube with a longer upper limb. Two children have subsequently died from non-airway causes. Two children still have their T-tube in situ, one of whom is due to have it removed in the next few weeks. Six have been successfully decannulated and are well. The Montgomery T-tube provides a useful adjunct to the management of a small number of children with the most difficult airway problems. Its use can be problematic, however, and requires awareness of its specific complications. We have confined usage to complex stenoses where a reconstruction would be inappropriate, or (in one instance) to stent an unsupported larynx after revision reconstruction (tracheal resection).

Réparation par laryngotrachéoplastie cutanéochondromyocutanée d'une perte de substance trachéale antérieure induite par un tube de Montgomery

A 37-year old patient was referred in 2000 for reconstruction of the anterior tracheal wall eroded by a Montgomery T-tube. A four-layer laryngotracheoplasty was proposed to the patient. The endotracheal plane was reconstructed by a bilateral random pattern quadrangular skin hinge flap raised from both sides of the defect. The chondral plane was realized with conchal cartilage. This cartilage graft was covered with an inferiorly based sternocleidomastoid flap. The fourth layer was a mesh split-thickness skin graft. Satisfactory and lasting results were observed during a three-year follow-up. Few articles deal specifically with tracheal reconstruction after anterior wall erosion induced by a Montgomery-T tube. We found no mention of the described four-layer flap in the literature.

Use of the laryngeal mask airway in a patient with a difficult airway during supra-stoma granuloma removal

To the Editor: Supra-stoma granuloma can be treated effectively via rigid bronchoscopy.1 General anesthesia is required and ventilation can be controlled through the bronchoscope’s side port or a cuffed tracheostomy tube. However, rigid bronchoscopy may be impossible in patients with a difficult airway. We describe a modified surgical approach of supra-stoma granuloma removal and our anesthetic management in a patient with a difficult airway. A 60-yr-old patient had speech limitation due to a tracheostomy tube and supra-stoma granuloma. She had a difficult airway, which made two attempts at rigid bronchoscopy abort. To improve her speech, the surgeons planed to remove the granuloma directly through the tracheostomy stoma, followed by insertion of a Montgomery T-tube. However, the tracheostomy tube would be removed and no secure airway existed during the procedure. Under total iv anesthesia, a cuffed tracheostomy tube was first used for ventilation. We inserted a laryngeal mask airway (LMA) as a conduit to introduce the flexible fibrescope, and found the trachea was partially occluded. We then tried to ventilate through the LMA after temporary removal of the tracheostomy tube and occlusion of the stoma, and found that ventilation was possible. The peak inspiratory pressure was 35 cm H2O for a tidal volume of 400 mL with minimal air leakage. We then decided to hyperventilate the lungs via the LMA (HV-LMA) between surgical manipulations, during periods when the airway could not be accessed. After a period of hyperventilation, the surgeons removed the tracheostomy tube and proceeded with removal of the granuloma through the stoma. When the oxygen saturation (SpO2) declined below 95%, HV-LMA was performed. Surgery continued after the SpO2 reached 99%. The procedure lasted about ten minutes and the SpO2 was kept above 92%. In this patient, the success of HV-LMA depended both on partial obstruction by the granuloma, and an excellent seal with the LMA. In a previous report, leak pressure was found to be 29 cm H2O (SD 6) for the ProSeal LMA and 19 cm H2O (SD 4) for the classic LMA.2 The patient’s narrow oropharyngeal/hypopharyngeal space might explain the excellent seal observed. To prevent stomach inflation and aspiration, we used a stethoscope over the epigastrum to monitor stomach inflation. Fortunately, granuloma removal was brief and only two periods of HV-LMA were required, attenuating the risk of gastric inflation. Nevertheless, we were well prepared and would have reinserted a cuffed tracheostomy tube for conditions like uncontrolled airway bleeding, inability to ventilate, or unstable vital signs.