Acute and chronic stenosis of the larynx and trachea: treatment

Treatment of acute and chronic stenosis of the larynx and trachea is divided into conservative and surgical. Conservative methods of treatment are used in the detection of acute stenosis of moderate degree with unexpressed clinical manifestations; acute injury, not accompanied by significant damage to the mucosa; early post-ablation changes in the larynx and trachea without a tendency to progressive narrowing of their lumen. Also conservative management of patients with acute and chronic stenosis of I-II degree is allowed in the absence of severe clinical manifestations.

For the treatment of chronic cicatricial stenosis of the larynx and trachea, which includes a wide range of injuries of the upper respiratory tract from the nadir to the larynx to the carina, there are various methods of surgical treatment. Currently, there are two main directions of reconstructive surgery of the larynx and trachea: laryngeal tracheal reconstruction and circular resection of the pathological site. The choice of method depends on the patient's indications and contraindications.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]

Indications for hospitalization

Indications for urgent hospitalization - the presence of acute stenosis of the larynx and trachea, decompensation of chronic stenosis. Planned hospitalization is carried out for performing terminal surgical treatment.

Objectives of treatment of acute and chronic stenosis of the larynx and trachea

The main goal of the treatment is restoration of the structure and function of the hollow organs of the neck by surgical reconstruction and prosthetics of damaged laryngeal-tracheal structures. The final stage of treatment is decanulation of the patient.

Drug treatment for acute and chronic stenosis of the larynx and trachea

Drug therapy for acute stenosis of the larynx is aimed at rapid suppression of inflammation and reduced edema of the larynx and trachea. For these purposes, drugs that reduce tissue infiltration, strengthen the vascular wall (hormones, antihistamines, calcium preparations, diuretic drugs) are used. Steroid hormones are prescribed in the acute period for 3-4 days intravenously, and then - 7-10 days orally, with a gradual decrease in the dose until the inflammation stops breathing and normalizes breathing.

With the appointment of hormonal drugs after reconstructive surgery, reparative processes, the formation of granulation tissue, the epithelization of the wound surface are more favorable; the probability of engraftment of auto- and allografts increases.

The questions of indications and the timing of treatment of various forms of stenosis should be addressed in view of the possibility of affecting the internal organs. The presence of long stenosis is considered the basis for taking measures to prevent the development or treatment of already developed lesions of the relevant organs and systems of the body. In the absence of emergency indications, a comprehensive examination is performed in the preoperative period, according to the indications, consultations of specialists (cardiologist, therapist, endocrinologist, neurosurgeon) and correction of existing disorders. Antibiotic prophylaxis is prescribed 48 hours before the planned surgery. To prevent purulent-septic complications and infection of transplants with urgent tracheostomy, antibiotics are administered intraoperatively.

The main causes of repeated surgical interventions in patients with chronic laryngeal tracheal stenosis are purulent-inflammatory complications that cause extrusion of transplants, restenosis of the formed laryngeal-tracheal lumen. Etiotropic and pathogenetic therapy is prescribed taking into account the results of microbiological examination of the wound detachable and the sensitivity of microorganisms to antibiotics. The drugs are administered parenterally or intravenously for 7-8 days. After the improvement of the condition, patients are switched to oral antibiotics for 5-7 days. All operations using implants are considered "dirty", accompanied by a high risk of infection in the field of surgical intervention. From the point of view of efficacy and safety, cephalosporins of the I-II generation (cefazolin, cefuroxime) and inhibitor-protected aminopenicillins (amoxicillin + clavulanic acid, ampicillin + sulbactam) are most suitable.

The timing of the anti-inflammatory therapy is adjusted depending on the concomitant diseases. Thus, in patients with viral hepatitis, the reparative properties of tissues are significantly reduced. The postoperative period is usually complicated by inflammation in the area of the operation and excessive scar formation. Symptomatic therapy for such patients is prescribed depending on the severity of inflammatory phenomena, concomitantly with the appointment of hepatoprotectors. To prevent uncontrolled cicatricial process, it is necessary to use medicines that stimulate the regenerative capacity of tissues and prevent the formation of gross scars.

Symptomatic therapy consists of 8-10 sessions of hyperbaric oxygenation, restorative therapy. For the elimination of inflammatory phenomena in the area of operation, topical preparations of ointment with fusidic acid, mupirocin, heparinoid, and also containing heparin sodium + benzocaine + benzilnicotinate or allantoin + heparin sodium + onion extract are used. To improve the regenerative abilities of the larynx and trachea tissues, drugs that improve the tissue blood flow (pentoxifylline, actovegin), antioxidants (ztilmethylhydroxypyridine succinate, retinol + vitamin E, meldonium), vitamin B complex (multivitamin), glycosamine in powders (10-20 days ) and physiotherapy (phonophoresis and electrophoresis, magnetolaser therapy for 10-12 days).

During the first 3 days after the operation, sanative endofibrotrahexon bronchoscopy is performed daily with the administration of antibiotics and mucolytic drugs (0.5% solution of hydroxymethylquinoxylindioxide, acetylcysteine, trypsin + chymotrypsin, solcoseryl). Subsequently, endofibrotrahera bronchoscopy should be performed every 5-7 days for rehabilitation and treatment control until the inflammation of the tracheobronchial tree is completely eradicated.

[15], [16], [17], [18], [19], [20], [21]

Surgical treatment of acute and chronic stenosis of the larynx and trachea

In laryngeal tracheal reconstruction, interventions are used, the essence of which is to change the structure of the elements of the cartilaginous framework of the respiratory tube, replace the epithelial structures of the mucosa of the trachea and implant or transpose the structures that provide voice and protective function.

The development of reconstructive surgery of the larynx and trachea includes two main directions:

• improvement of surgical techniques and prevention of complications;
• prevention of stenosis in the early and late postoperative period.

The scope of surgical intervention is determined in each specific case, depending on the etiology of the underlying disease, with the condition of maximum radical operation. Possible mioaritenoiddordectomy with laterofixation of the opposite vocal fold, redression of the cricoid cartilage, the formation of the larynx and trachea structures with the help of allochrug.

The gorrano-tracheal reconstruction in the primary variant is a combination of manipulations, as a result of which a respiratory contour is created from the vestibular larynx to the thoracic trachea. Form the missing parts of the walls of the larynx and trachea (due to auto-and allotkane) and perform functional prosthetics.

There are the following ways to reconstruct the larynx and trachea:

• resection of the arch of the cricoid cartilage and the initial part of the trachea with thyreotracheal anastomosis;
• formation of damaged larynx and trachea structures with the interposition of the cartilaginous implant;
• plastic defect with a vascularized free flap;
• structural plastic with muscle grafts and allotkins;
• plastic defects with periostal or perichondrial flaps;
• circular circular resection with an anastomosis "end-to-end";
• endonrothesis of the reconstructed larynx using stents - prostheses of various design.

The development and improvement of flexible fiber optics made it possible to widely use endoscopy for both diagnosis and treatment of stenosis of the larynx and trachea. As a rule, these interventions are used for scar-granulating forming stenosis, laryngeal papillomatosis, for endolaryngeal myoaritenoidodectomy, as well as for dissecting postoperative scars with limited stenoses of not more than 1 cm. More often endoscopic intervention is used in combination with radical and stage reconstructive-plastic operations.

To improve the efficiency of operations on the larynx and trachea adhere to a number of rules. First, the surgeon should be familiar with the information on gorgan-tracheal surgery and have a sufficient number of observations and assays in operations. Great importance is attached to careful pre-operative examination and selection of the optimal surgical approach, planned step by step. Intraoperative findings often seriously affect the result of operations, so it must be remembered that the examination does not give a complete picture of the disease.

In assessing lesions of the larynx and the cervical region of the trachea, the following criteria are important: the location, extent, size, density and boundaries of damage, the degree of narrowing of the air column and its nature; mobility of vocal cords; degree of destruction of cartilaginous rings; ossification of cartilage; degree of disruption of functions.

The question of the scope of surgical intervention is decided strictly individually. The main task of the first stage of surgical treatment is the restoration of respiratory function. Sometimes the first stage is limited only to tracheostomy. If the patient's condition allows, tracheostomy is combined with tracheoplasty or laryngotracheal plastic, implantation of allochrug, plasticity of the defect by the displaced skin flap, mucous membrane. The number of subsequent stages also depends on many factors - the course of the wounded process, the nature of secondary scarring, the general reactivity of the organism.

To normalize breathing in the case of acute obstruction of the upper respiratory tract, tracheostomy is performed, and when it is impossible to perform it in rare cases, conicotomy is applicable. In the absence of conditions for intubation, the intervention is performed under local anesthesia. With the restoration of the airway lumen in patients with acute stenosis, decanalization or closure of the tracheostomy by surgical means is possible. With chronic stenosis of the larynx and trachea, tracheostomy is the first stage of surgical treatment. It is performed with careful observance of surgical techniques and in accordance with the principle of maximum safety of tracheal elements.

Technique of tracheostomy formation operation

When carrying out tracheostomy, it is necessary to take into account the degree of hypoxia, the general condition of the patient, the individual constitutional parameters of his physique (hyper-, a- or normostenic), the ability to unbend the cervical spine to access the anterior wall of the trachea.

Difficulties during tracheostomy may occur in patients with short, thick neck, poorly bending cervical spine.

Preference is given to general anesthesia (zdotrachealny combined anesthesia with the introduction of muscle relaxants), but more often use local anesthesia 1% solution of lidocaine. The position of the patient in the reverse Trendelenburg posture is on the back with the head extended to the back and the roller under the shoulders. Excessive tilting of the head leads to a mixing of the trachea in the cranial direction and a change in the anatomical landmarks. In such a situation, it is possible to perform an excessively low tracheostomy (at the level of 5-6 half-rings). In case of neck overgrowth, the displacement of the brachiocephalic artery trunk above the yawning notch is also excluded, which is accompanied by the risk of its damage with the allocation of the anterior wall of the trachea.

Produces a midline incision of the skin and subcutaneous tissue of the neck from the levels of the cricoid cartilage to the jugular cutting of the sternum. Curved clamps by a blunt path by layerwise isolate the anterior wall of the trachea. Do not do this on a large extent, especially on the side walls, since there is a possibility of a violation of the blood supply of this part of the trachea and damage to the recurrent nerves. In patients with a long thin neck in this position, the isthmus of the thyroid gland is shifted upward; in patients with a thick short neck and a squeezed arrangement of the thyroid gland - down the sternum. If it is impossible to shift, the thyroid isthmus is crossed between two clamps and stitched with synthetic absorbable threads on the atraumatic needle. The tracheostomy is formed at the level of 2-4 semicircles of the trachea. The size of the incision should correspond to the size of the cannula; an increase in length can lead to the development of subcutaneous emphysema, a decrease to necrosis of the mucosa and adjacent cartilage. To form a tracheostomy, the edges of the skin without special tension are brought to the edges of the incision and hemmed at the interchillage gaps. In the lumen of the trachea, tracheostomy single- or double-cuff thermoplastic tubes of the appropriate diameter are inserted. The main differences between these tubes are that their angle is 105 °. This anatomical bend allows you to minimize the risk of complications associated with irritation caused by the contact of the digal end of the tube with the stalk of the trachea.

Immediately after the end of tracheostomy, an endofibrotraheron bronchoscopy is performed to purify the lumen of the trachea and bronchi. To restore the lumen of the hollow organs of the neck use different types of laryngotracheal plastic and prosthetics of the larynx and trachea.

Reconstructive interventions on the larynx differ in complexity and the need for technical support for all stages of the operation. Prosthetics play a special role in the rehabilitation of laryngeal functions.

Depending on the specific pathological changes and the plan of surgical rehabilitation all options for prosthetics are subdivided into the bottom of the species - temporary and permanent.

The main tasks of prosthetics:

• maintaining the lumen of the hollow body:
• providing the formation of the walls of the respiratory tract and digestive tract:
• Dilation of the formed larynx and trachea lumen. The breech prosthesis is divided into removable (reusable) and permanent, which are sewed or inserted into the lumen of the hollow organs and extracted after the achievement of the functional result of the treatment. The following requirements are applied to the laryngeal-tracheal prostheses used: absence of toxicity; biological compatibility; resistance to the effects of tissues and body fluids; the possibility of creating the necessary geometry; density and elasticity: impermeability to air, liquid and microorganisms; the possibility of rapid and reliable sterilization. Functional prosthetics for the correct formation and healing of the surgical wound involves the use of tracheotomy tubes of modern thermoplastic materials of the required size. The duration of wearing the prosthesis is determined individually, depending on the severity of the pathological process and the volume of the reconstructive operation. The stage of postoperative prosthetics is considered complete after full coverage of all wound surfaces. By this time, the basic physiological functions of the hollow organs of the neck have been compensated, or a prolonged temporary prosthesis is needed to achieve this. Long-term prosthetics use T-shaped silicone tubes of the appropriate size.

Treatment of patients with bilateral paralysis of the larynx depends on the etiology of the disease, the duration and severity of clinical symptoms, the degree of functional disorders, the nature of the adaptive and compensatory mechanisms. There is no single tactic for treating bilateral laryngeal paralysis at the moment. Surgical methods of treatment for bilateral paralysis of the larynx are divided into two groups.

Methods aimed at a fixed widening of the lumen of the glottis

Depending on the approach to voice folds, there are:

• translarinear;
• endolaryngeal;
• extralaryngeal.

Methods to restore the mobility of vocal cords

In the case of translational methods, access to the affected voice fold is performed by laryngophyssura, dissection of the inner larynx membrane, submucosal removal of the vocal fold with the muscular massif and partial or total removal of the arytenoid cartilage. Measures aimed at preventing scar formation in the operation area include the use in the postoperative period of various tampons, dilators, tubes and prostheses, among which T-shaped tubes of various materials have become most common.

Endolaryngeal methods of treatment of median paralysis of the larynx include various methods of lateral fixation of the vocal fold in a direct larnoskolia. Partial removal of the arytenoid cartilage is permitted. The advantages of heart surgery are that they are less traumatic and retain a greater vocal function. Conduction of endolaryngeal surgery is not indicated in patients with ankylosis of the perinechnic spine, with the inability to establish a direct laryngoscope (obese patients with a thick short neck). The complexity of postoperative intraorganic prosthetics can lead to the formation of scar membranes and adhesions in the posterior part of the glottis and scar deformation of its lumen.

Extralaryngeal methods allow preserving the integrity of the mucous membrane of the larynx. Surgical access to the voice section of the larynx is carried out through a formed "window" in the plate of the thyroid cartilage. The complexity of the method is mainly due to the difficulty of submucosal application of the lateral fixing seam and its fixation with the maximum retraction of the vocal fold.

The most commonly used functionally justified methods of translarinear plastics. In this case, one-sided myoartenoidodortectomy is performed in combination with laterotrophic fixation of the opposite vocal fold, followed by prosthetics of the formed laryngeal lumen.

If the patient can not be decanalized after a general condition, laryngotracheal plastic surgery is not performed. A persistent tracheostomy is formed, the patient is taught to change the tracheotomy tube independently; in this situation, he remains a chronic cannula.

With a common cicatricial stenosis of the laryngeal tracheal localization, there is always a deficit of supporting viable tissues in the zone of constriction or organ defect, a sharp decrease or absence of anatomical laryngeal and tracheal lumen due to destruction of the cartilaginous elements and cicatricial degeneration of the mucosa with the development of laryngeal tracheal atresia. This requires an individual approach in choosing the method of surgical treatment and prosthetics. To reconstruct the anatomical and physiological characteristics of the larynx and trachea, reconstructive surgeries are performed using aldogransplants and laryngeal-tracheal prostheses.

With a favorable combination of circumstances, a two-stage operation allows the structural elements of the larynx and trachea to be fully restored. Allochondria implant paratraheally in the course of the primary reconstructive operation. If for a number of reasons this is not possible (separation of the larynx from the trachea with a diastase of 4 cm or more), the larynx and posterior tracheal structures are formed during the reconstruction stage, and later the lateral walls of the trachea. Restoration of breathing through natural ways contributes to the normalization of functions and the physiological work of the respiratory muscles through the reflected respiratory cycle. Restored afferentation in the central nervous system contributes to a faster recovery of the patient.

Further management

After discharge from the hospital, the patient should be monitored by an otorhinolaryngologist in a polyclinic at the place of residence and operated by a surgeon, monitoring the condition of the upper respiratory tract every 2-3 weeks. Patients are shown physiotherapeutic procedures, inhalations, phonopedic exercises and respiratory gymnastics.

Terms of incapacity for acute stenosis of the larynx and trachea depend on the etiology of the disease and the degree of damage to the hollow organs of the neck and averaged 14-26 days.

Patients with chronic stenosis of the larynx and trachea with a violation of anatomical and functional indicators have a persistent disability for the entire period of treatment and rehabilitation.