Laryngeal and tracheal stenosis is a disease in which the larynx and tracheal lumen are narrowed due to trauma, lesions and other causes of granulation and fibrous tissue proliferation, and finally scar formation, or compression by its surrounding lesions, resulting in respiratory and articulatory dysfunction. Laryngeal stenosis can be divided into three types: supraglottic, glottic and infraglottic stenosis. The treatment of laryngeal and tracheal stenosis used to be mostly by stenosis expansion and open surgery. With the development of laser technology and material science, the application of minimally invasive surgery such as laser and endoluminal stent has gradually increased in recent years.
I. Indications
1.Limited supraglottic, glottic, subglottic, tracheal and main bronchial stenosis caused by granulation, fibrous tissue hyperplasia and scar formation.
2.Laryngeal stenosis due to bilateral laryngeal nerve paralysis.
3.Tracheal stenosis due to peritracheal lesions that cannot be completely removed, such as malignant tumors and other compressions.
Contraindications
1.Laryngeal stenosis due to fracture or misalignment of laryngeal cartilage stent.
2.Extensive laryngeal stenosis across the vocal fold.
3.Laryngeal and tracheal stenosis due to compression by benign or malignant tumors around the laryngeal trachea that can be completely removed by surgery.
Preoperative preparation
Routine laboratory tests and systemic examination, fiberoptic laryngoscopy or bronchoscopy, chest X-ray, laryngeal CT and other examinations before general anesthesia surgery. The diet should be abstained for 6h before surgery, and the appropriate amount of atropine and luminal should be injected intramuscularly 30min before surgery.
Anesthesia and body position
Most patients with laryngeal and tracheal stenosis have undergone tracheotomy, and general anesthesia can be administered through the cervical tracheostomy tube. Patients with laryngeal stenosis who have not undergone tracheotomy can be intubated through the mouth for general anesthesia. Patients with tracheal stenosis can have their breathing managed through the oxygen supply tube of the bronchoscope. Position: supine position.
V. Surgical steps
1. Expose the laryngeal stenosis with a support laryngoscope or apply a rigid bronchoscope to expose the tracheal stenosis.
2. Aim the operating microscope with an objective focal length of 400mm or 350mm at the laryngeal stenosis area, and adjust the magnification (1.5-2.0x) and focal length of the microscope until the operative field is clearly visible.
3. Application of CO2 laser, Nd-YAG laser, semiconductor laser, KTP contact laser and silicone, polyurethane and nickel-titanium shape memory alloy larynx, tracheal stent, etc. Depending on the area, extent and cause of the stenosis, different surgical procedures are performed for.
(1) Surgery for limited supraglottic, glottic, subglottic and tracheal stenosis due to granulation, fibrous tissue hyperplasia and scar formation: Depending on the extent of the stenosis, laser is applied to remove scar tissue from the stenosis area; supraglottic stenosis can be treated without stenting; glottic, subglottic and tracheal stenosis need to be treated with combined short-term laryngeal and tracheal stent expansion.
(2) Laryngeal stenosis due to bilateral recurrent laryngeal nerve palsy: unilateral subtotal excision of arytenoid cartilage or unilateral partial excision of the posterior end of the vocal cords should be performed by laser.
(3) Lesions that cannot be completely resected, such as tracheal and main bronchial stenosis due to compression by malignant tumors, etc.: Under rigid bronchoscopic guidance, a special stent inserter is used to place a nickel-titanium shape-memory alloy tracheal stent into the tracheal or main bronchial stenosis area. The procedure should be performed under the surveillance of X-ray fluoroscope to prevent improper stent placement.
Intraoperative points of attention
1.Adequate exposure of the operative field.
2.When laser surgery is performed, smoke should be sucked out by suction in time to avoid affecting the visual field.
3. Avoid accidental injury to normal tissues and anesthesia catheters during laser surgery.
4.The laryngeal stent should be placed firmly, and if necessary, non-absorbable wire can be used for external laryngeal fixation.
5. The process of tracheal stent placement should be monitored by X-ray fluoroscopy machine to prevent improper placement site.
VII. Postoperative treatment
1. Postoperative antibiotics and hormones are routinely given to prevent possible infection and laryngeal edema.
2.Postoperative fasting can be done for 6h to several days according to the situation. Those who have mild aspiration can be given mucous food first, and then start normal diet after the aspiration disappears after short-term training.
VIII. Complication prevention and control
The key to prevention is to stop the bleeding thoroughly during the operation.
2.Laryngeal edema rarely occurs, and can be prevented by appropriate hormone therapy after surgery; if laryngeal edema occurs and respiratory distress is severe, tracheotomy is feasible.
After laryngeal stenosis surgery, mild aspiration can occur due to incomplete closure of the vocal cords, and after swallowing training, it mostly does not affect transoral feeding.
4.Stent dislocation is mostly caused by poor stent fixation, so the selection of appropriate size stent or appropriate intraoperative fixation can play a preventive role. After postoperative dislocation, stent adjustment, stent removal or stent placement is feasible.
5, larynx, tracheal granulation tissue hyperplasia feasible laser resection or surgical clamp removal. If the granulation is more serious and leads to respiratory difficulty, tracheal intubation or tracheotomy is feasible.
6, respiratory burns rarely occur, the prevention is to avoid the use of flammable anesthetic gas and intraoperative application of wet saline gauze or cotton to protect the anesthetic catheter.