Postintubation Multisegmental Tracheal Stenosis: A 24-Year Experience.

BACKGROUND: Management of multisegmental tracheal stenosis is challenging. In this 24-year longitudinal single-center study, we present an algorithmic treatment approach. METHODS: A retrospective analysis of 2167 patients with postintubation tracheal stenosis indicated 83 (3.83%) patients with multisegmental tracheal stenosis. Patients were assigned to 4 management groups according to the length, location, and severity of stenoses; tracheal infection/mucositis; laryngeal function; symptoms; general condition; and comorbid diseases. Type 1 (n = 13): 1-stage resection of both strictures, Type 2 (n = 6): 2-stage resection of both strictures, Type 3 (n = 40): resection of 1 stricture and nonresectional management of the other, Type 4 (n = 24): nonresectional management of both strictures. Outcomes were categorized as Good, Acceptable, or Poor. Univariate analyses for factors predictive of recurrence and outcome were performed. RESULTS: Follow-ups were completed in 70 (84.34%) patients (median, 22.5 months). Outcome was assessed as Good in 56 (82.35%), Acceptable in 10 (14.71%), Poor in 2 (2.94%), and mortality in 2 (2.94%) patients. The median length of airway resection was 46, 67.5, and 40 mm in Types 1-3, respectively. Only 11 (13.25%) patients had no history of tracheostomy or tracheal surgery. By univariate analysis, a shorter intubation period was associated with Good outcome (P = .017). No factors predictive of recurrence or outcome were ascertained. CONCLUSIONS: Multisegmental tracheal stenosis, generally caused by performing an inappropriate tracheostomy, is an iatrogenic disease that can be prevented. Although resection of both strictures may be feasible and is associated with Good results, in the majority of cases, a combination of surgical resection and non-resectional methods are sufficient to achieve Good results.

Prediction of Patient's Adherence to the Post-Intubation Tracheal Stenosis Follow-up Plan in Iran: Application of two Data Mining Techniques.

BACKGROUND: Timely diagnosis of post-intubation tracheal stenosis (PITS), which is one of the most serious complications of endotracheal intubation, may change its natural history. To prevent PITS, patients who are discharged from the intensive care unit (ICU) with more than 24 hours of intubation should be actively followed-up for three months after extubation. This study aimed to evaluate the abilities of artificial neural network (ANN) and decision tree (DT) methods in predicting the patients' adherence to the follow-up plan and revealing the knowledge behind PITS screening system development requirements. MATERIALS AND METHODS: In this cohort study, conducted in 14 ICUs during 12 months in ten cities of Iran, the data of 203 intubated ICU-discharged patients were collected. Ten influential factors were defined for adherences to the PITS follow-up (P<0.05). A feed-forward multilayer perceptron algorithm was applied using a training set (two-thirds of the entire data) to develop a model for predicting the patients' adherence to the follow-up plan three months after extubation. The same data were used to develop a C5.0 DT in MATLAB 2010a. The remaining one-third of data was used for model testing, based on the holdout method. RESULTS: The accuracy, sensitivity, and specificity of the developed ANN classifier were 83.30%, 72.70%, and 89.50%, respectively. The accuracy of the DT model with five nodes, 13 branches, and nine leaves (producing nine rules for active follow-up) was 75.36%. CONCLUSION: The developed classifier might aid care providers to identify possible cases of non-adherence to the follow-up and care plans. Overall, active follow-up of these patients may prevent the adverse consequences of PITS after ICU discharge.

An Overview of Tracheal Stenosis Research Trends and Hot Topics.

BACKGROUND: Tracheal stenosis remains a challenge in the thoracic surgery field. Recognizing the hot topics and major concepts in this area would help the health policy makers to determine their own priorities and design the effective research plans. The present study analyzed and mapped the topics and trends of tracheal stenosis studies over time as well as authors' and countries' contributions. MATERIALS AND METHODS: Search results were obtained employing Bibexcel. To determine cold and hot topics, co-occurrence analysis was applied using three international databases 'Web of Science', 'PubMed' and 'Scopus'. Appropriately, different categories in the articles such as keywords, authors, and countries were explored via VOSviewer and NetDraw. Afterward, the trends of research topics were depicted in four time-intervals from 1945 to 2015 by ten co-occurrence terms. RESULTS: The majority of articles were limited to case series and retrospective studies. The studies had been conducted less frequently on prevention, risk factors and incidence determination but extensively on treatment and procedures. Based on the articles indexed in WOS, 45 countries and 8,260 authors have contributed to scientific progress in this field. The highest degree of cooperation occurred between the USA and England with 15 common papers. CONCLUSIONS: Most of the published literature in tracheal stenosis research field was about surgical and non-surgical treatments. Conducting the screening and prevention studies would diminish the burden of this disease on the health system as well as the patients and their families' well-being.

An Investigation of Topics and Trends of Tracheal Replacement Studies Using Co-Occurrence Analysis.

This study evaluated tracheal regeneration studies using scientometric and co-occurrence analysis to identify the most important topics and assess their trends over time. To provide the adequate search options, PubMed, Scopus, and Web of Science (WOS) were used to cover various categories such as keywords, countries, organizations, and authors. Search results were obtained by employing Bibexcel. Co-occurrence analysis was applied to evaluate the publications. Finally, scientific maps, author's network, and country contributions were depicted using VOSviewer and NetDraw. Furthermore, the first 25 countries and 130 of the most productive authors were determined. Regarding the trend analysis, 10 co-occurrence terms out of highly frequent words were examined at 5-year intervals. Our findings indicated that the field of trachea regeneration has tested different approaches over the time. In total, 65 countries have contributed to scientific progress both in experimental and clinical fields. Special keywords such as tissue engineering and different types of stem cells have been increasingly used since 1995. Studies have addressed topics such as angiogenesis, decellularization methods, extracellular matrix, and mechanical properties since 2011. These findings will offer evidence-based information about the current status and trends of tracheal replacement research topics over time, as well as countries' contributions.

Item Selection and Content Validity of the Risk Factors of Post-Intubation Tracheal Stenosis Observation Questionnaire for ICU-Admitted Patients.

BACKGROUND: Laryngotracheal stenosis as a late complication of prolonged endotracheal intubation is a life-threatening event. In order to determine the related risk factors for this complication, which may vary among different countries, designing a valid questionnaire is necessary. The aim of this study was to select the items and evaluate the face and content validities of a questionnaire developed for assessment of risk factors of post-intubation tracheal stenosis (PITS) in patients admitted in the intensive care unit. MATERIALS AND METHODS: A mixed method study design was used in four steps in 2015, i.e., 1) a literature review, 2) focus groups with five experts in the field, 3) consultations with intensive care unit (ICU) specialists and thoracic surgeons, and 4) evaluation of content and face validity with 15 experts in a scientific panel using two self-administered questionnaires. Content validity index (CVI) was computed for individual items as well as the overall scale. RESULTS: We extracted the items from different sources of information. An initial version of the 52-item questionnaire was developed and classified into four domains including patient characteristics, intubation features, equipment-drugs, and complications. The items with an excellent modified kappa were included in the questionnaire. Five questions received more criticism instead of support and were removed (Item-CVI<0.55, fair modified kappa). The ones with an Item-CVI > 0.60 and a good modified kappa were revised, merged, or retained. The new 43-item questionnaire found a scale-level CVI, averaging (Scale-CVI/Ave) of 0.91. CONCLUSION: The PITS risk factors questionnaire was developed and validated through item selection, expert opinions, and content validity index.

The Role of Systemic Steroids in Postintubation Tracheal Stenosis: A Randomized Clinical Trial.

BACKGROUND: Most patients with postintubation tracheal stenosis are not ideal candidates for airway resection at presentation and their airways must be temporarily kept open by repeated bronchoscopic dilation (RBD). Meanwhile, some sufficiently recover by RBD without further airway resection requirement. We hypothesized whether systemic corticosteroids could lengthen RBD intervals, decrease the number of patients who eventually need airway resection, and shorten the required length of airway resection. METHODS: Between February 2009 and November 2012, a randomized double-blind clinical trial with a 1:1 ratio (corticosteroids group [group C], prednisolone 15 mg/day; placebo group [group P]) was conducted on 120 patients without tracheostomy or T tube and in no ideal situation for airway resection at presentation, whose precipitating injury had occurred recently. All underwent RBD until they became asymptomatic or prepared for airway resection. Asymptomatic patients received the capsules (prednisolone or placebo) for 6 months; others discontinued them before surgery. Those requiring RBD at short intervals underwent tracheostomy or T tube placement and were then excluded. Follow-up terminated 6 months after airway resection or capsule discontinuation. RESULTS: There were 105 patients (72 male; 50 in group C), aged 15 to 64 years, who completed their follow-up. There was no significant difference between the two groups in age, sex, history of tracheostomy, intubation cause and duration, time interval between intubation and initial bronchoscopy, length of stenosis, and subglottic involvement. Our study showed a trend for RBD with longer intervals (22 days), and fewer operations, 17% (28 of 50 versus 40 of 55) in group C, although statistically insignificant. Furthermore, the required airway resection length became significantly shorter (5.3 mm) in group C. CONCLUSIONS: Early low-dose systemic corticosteroids can be beneficial in postintubation tracheal stenosis management.

Incidence Rate of Post-Intubation Tracheal Stenosis in Patients Admitted to Five Intensive Care Units in Iran.

BACKGROUND: Tracheal stenosis is one of the worst complications associated with endotracheal intubation and it is the most common reason for reconstructive airway surgeries. Due to various local risk factors, the incidence rate of tracheal stenosis may vary in different countries. In order to estimate the incidence rate of post-intubation tracheal stenosis (PITS) in patients admitted to an intensive care unit (ICU), a follow-up study was planned. As there was no similar methodological model in the literature, a feasibility step was also designed to examine the whole project and to enhance the follow-up rate. OBJECTIVES: To estimate the PITS incidence rate in patients admitted to ICUs, as well as to evaluate the feasibility of the study. METHODS: This prospective cohort study was conducted in five hospitals in two provinces (Tehran and Arak) of Iran from November 2011 to March 2013. All patients admitted to ICUs who underwent more than 24 hours of endotracheal intubation were included. Upon their discharge from the ICUs, the patients received oral and written educational materials intended to ensure a more successful follow-up. The patients were asked to come back for follow-up three months after their extubation, or sooner in case of any symptoms developing. Those with dyspnea or stridor underwent a bronchoscopy. The asymptomatic patients were given a spirometry and then they underwent a bronchoscopy if the flow-volume loop suggested airway stenosis. RESULTS: Some seventy-three patients (70% men) were included in the study. Multiple trauma secondary to motor vehicle accidents (52%) was the most common cause of intubation. Follow-ups were completed in only 14 (19.2%, CI = 0.109 - 0.300) patients. One patient (7%, CI = 0.007 - 0.288) developed symptomatic tracheal stenosis that was confirmed by bronchoscopy. The barriers to a successful follow-up were assessed on three levels: ineffective oral education upon discharge, improper usage of educational materials, and difficulties to attending follow-up visits. There were also some important obstacles in terms of human, time, material, and cost resources, as well as data management. CONCLUSIONS: To enhance the follow-up rate, three strategies were proposed: patient-focused strategies such as emphasizing patient education upon discharge and providing rewards; structural-focused strategies such as scheduling home visits and uploading questionnaires onto the research center's website; and provider-focused strategies such as selecting coordinators with good communication skills. All necessary resources should also be re-arranged for a multicenter national study.

A Safe Method of Tracheal Polyflex Stent Placement: A Review of 20 Patients.

BACKGROUND: Surgery is an appropriate therapeutic approach for tracheal stenosis due to various benign and malignant conditions. When surgery is postponed for certain reasons, other options are chosen for airway patency. One alternative is using airway stents. OBJECTIVES: We aimed to introduce a safe method of tracheal polyflex stent placement in patients with tracheal stenoses. PATIENTS AND METHODS: During a 7-year period (2002 - 2008), polyflex stents were used 29 times among 20 patients for various indications. After encountering many difficulties in earlier cases, we gradually developed our new method and used it in most of our patients. In this method, without using large rigid bronchoscopes, the introducer tube could be used as a bronchoscope with the aid of a zero-degree lens and ventilating apparatus. In this method, the rate of possible trauma to the airway can be minimized by avoiding the use of thick rigid bronchoscopies and the stent can be placed faster and more accurately. RESULTS: Polyflex stents were used in 11 men (55%) and 9 women with a mean age of 38.5 years. Stents were removed and changed in 12 cases and replaced with another type of stent in 3 patients. Indications were recurrence of tracheal stenosis (7), multisegmental tracheal stenosis (3), anesthesia limitations (3), tracheal tumors (2), dehiscence of tracheal anastomosis (1), severe inflammation of the tracheal mucosa (1), esophagobronchial fistula (1), and external pressure on the left main bronchus (1). In one patient, a stent was used to open a kinked Dumon stent as a temporary life-saving procedure. We found 6 cases of stent migration, 3 cases of granulation tissue formation, 1 case of infection, and 1 case of surgical site dehiscence. CONCLUSIONS: Stents would be regarded as a temporary means of reaching the ideal condition for resection and reconstruction in most patients with tracheal stenoses. Although an optimal stent has not been introduced yet, we used polyflex stents in most of our patients with tracheal stenosis due to its availability and ease of use. We suggest that this method is safe and less time consuming than its traditional method of placement.

Lymphangiomatosis: The Cause of Refractory Pleural Effusion in a Patient with Lupus Erythematosus.

Mediastinal cavernous lymphangioma is a rare mediastinal lesion and its association with lupus erythematosus has not yet been reported in the literature. We present a 25 year-old female with lupus erythematosus who had bilateral massive refractory and recurrent pleural effusion as well as ascites for a long period of time. During surgery, a huge multicystic lesion with a thick wall, covering the entire parietal and visceral pleura was found, which was subsequently proven to be a cystic cavernous lymphangioma.

Comparison of radiological findings of chest x-ray with echocardiography in determination of the heart size.

BACKGROUND: Heart size is an important and effective parameter in chest X-ray (CXR) interpretation. Studies indicate that, especially in middle-aged men, increased cardiothoracic ratio (CTR) is associated with ischemic heart disease (IHD) and increased rate of morbidity and mortality. The CXR is the most common imaging examination of the heart. OBJECTIVES: A good quality posterior-anterior (PA) chest radiograph is an important indicator of the cardiac size. Nowadays, CXR has given its place to more advanced approaches such as two-dimensional echocardiography. However, CXR is still more accessible and feasible for most of the physicians. This study was designed to compare the findings of CXR and echocardiography in determination of the heart size. PATIENTS AND METHODS: This cross-sectional study was carried out from 2006 to 2007. A total of 197 patients entered the study. The cases had been undergone PA CXR and 2-D echocardiography maximum within two days. RESULTS: Of participants, 24.9% had cardiomegaly according to the findings of CXR and 50.8% based on echocardiography. There was a statistically significant difference between the mean size of Right Ventricular End Diastolic Diameter in the patients with cardiothoracic ratio < 50% and ≥ 50% (P = 0.002) as well as Left Ventricular End Diastolic Diameter (P = 0.023). Also, a statistically significant difference was seen between echocardiography and CXR findings with regard to determination of the heart size (P = 0.003). Nonetheless, it is noteworthy that sensitivity and specificity of CXR findings in the diagnosis of cardiomegaly were 34%, and 84.5%, respectively. CONCLUSIONS: CTR is the most common method of describing the heart size. Increased CTR in CXR is associated with poor prognosis, which is suggestive of importance and necessity of early diagnosis. Although CXR may not have the same diagnostic accuracy as echocardiography, its easy accessibility and high specificity in diagnosis of cardiomegaly is very helpful, which can play an important and a cost-benefit role, particularly in screening the enlarged heart size. Moreover, according to the statistics released by Medical Council of Iran, most of Iranian physicians are general practitioners and a few of them are cardiologist.

Gorham's Disease With Chest Wall Involvement: A Case Report and a Review of the Literature.

INTRODUCTION: Gorham's disease is a rare disorder characterized by osteolysis and abnormal vascular growth within bones. Diagnosis of Gorham's disease is often delayed and for accurate and early diagnosis high clinical suspicion is crucial. No specific treatment is available. Management options include surgery, radiation therapy and medical therapy. We aimed to present the first case of Gorham's disease with chest wall involvement in Iran. By review of the literature we discussed important issues of this rare disease including clinical findings, diagnosis and treatment options. CASE PRESENTATION: We present a 48-year-old man with a history of dyspnea following a blunt chest trauma who was admitted to our clinic several times due to reaccumulation of pleural fluid and chylothorax. Gorham's disease was finally established according to clinical manifestations and radiological findings including massive osteolysis in his left ribs and also histological examination. DISCUSSION: According to review of the literature and considering all treatment modalities the patients was successfully treated with a combination of radiotherapy, pamidronate and thalidomide. We suggest that this disease should be considered among differential diagnoses of patients with chest pain, pleural effusion and/or chylothorax with an unknown reason and more importantly history of chest trauma. In suspected cases, it is essential to examine biopsy specimens of the bone adjacent to the inflammated tissues in order to confirm diagnosis.

The role of T-tubes in the management of airway stenosis.

OBJECTIVES: When the T-tube is inserted as a temporary stent, it is unclear whether keeping it longer in place has any benefit on the outcome. METHODS: Among 1738 patients with airway stenosis (1996-2011), 134 underwent T-tube placement (mean duration = 14.3 months); temporarily while waiting for an appropriate time for surgery in 53 (Group 1), as an adjunct after a complex laryngotracheal resection in 27 (Group 2), after surgical failure in 43 (Group 3) and permanently in 11 unresectable strictures (Group 4). A logistic regression model was used for statistical analysis. RESULTS: Seventy percent of patients were males (age = 33.6 ± 17 years). The main cause was postintubation/post-tracheostomy stenosis in 87% of patients. The stenosis (29.6 ± 14 mm, 5-80 mm) was located in the subglottis in 33%, trachea in 47% and both in 20% of cases. To assess the effect of T-tubes on stabilizing the airway after decannulation, 50 patients who still had a T-tube at the end of follow-up or for <1.5 months were excluded. Of the remaining 84, 31.5, 91.5 and 32.5% of patients in Groups 1, 2 and 3 were stable at least 3 months after decannulation. Moreover, 70% of those who were decannulated at or before 6 months and 53.7% of those who were decannulated after 6 months underwent another intervention (P = 0.17). The age, sex, cause, site of stenosis and even duration of T-tube insertion (P = 0.07) showed no significant effect on the decannulation outcome. CONCLUSIONS: Although it seems that keeping the T-tube in place for >6 months may increase the chance of successful decannulation, it was not confirmed in our study.

Surgically treatable pulmonary arteriovenous fistula.

Arteriovenous fistuli are congenital malformations. Usually symptoms depend on size of the lesion. Lesions smaller than 2 cm are often asymptomatic. The most common symptoms are dyspnea, palpitation and fatigue. Cyanosis is indicative of right to left shunt. Helical computed tomography (CT) scan is a helpful diagnostic tool in this case. Surgery is the treatment of choice in patients with isolated lesions. Embolization is a selective method in patients with multiple or bilateral lesions. The patient was a 13-year-old boy complaining of cyanosis of lips and nails as well as dyspnea for 5 years. Definite diagnosis of pulmonary arteriovenous malformation (PAVM) in the right middle lobe was based on CT angiography. The patient underwent a thoracotomy and lobectomy of the right middle lobe. After surgery cyanosis and dyspnea were completely resolved.

A successful third resection-anastomosis in a tracheal restenosis.

Reoperation due to recurrence after tracheal resection and reconstruction still seems challenging. Although recurrence may lead to serious morbidity, an appropriate surgical technique plays a significant role in the cure of these patients. We report our experience of a patient who successfully underwent a third resection and anastomosis of the trachea. We believe that the number of previous operations is not a contraindication by itself against reoperating on a patient with restenosis. Also the success rate might be acceptably high if a sufficiently healthy tracheal length remains.

A proposed grading system for post-intubation tracheal stenosis.

BACKGROUND: Tracheal stenosis is still a serious consequence of endotracheal intubation. Previous classification systems are commonly descriptive and are not intended to deal with management approach. The aim of this study was to present a classification system for post intubation tracheal stenosis and evaluate its efficacy in distinguishing critically ill patients who need surgical intervention. MATERIALS AND METHODS: This classification system was developed based on size and type of stenosis and associated clinical signs and symptoms. Stenosis was graded based on the results of clinical examination and rigid bronchoscopy. All patients received surgical or conservative treatment based on the judgment of a surgeon experienced in management of post-intubation tracheal stenosis without considering their score. ROC curve analysis was done and cut-off point was established based on the greatest Youden index. RESULTS: Sixty patients were studied. Resection and anastomosis were done for 49 patients. The mean score for all samples was 9.18 (range 8.77-9.45). Chosen cutoff point was 8.5 and calculated sensitivity and specificity were 89% and 42%, respectively. Positive and negative predictive values were 83.7% and 54.5%, respectively. A reasonable agreement between the estimated score and surgeon's clinical judgment (kappa = 0.78) was observed. A statistically significant relationship was observed between scores greater than 8.5 and need for surgical intervention (P= 0.007). CONCLUSION: We presented a scoring system for post-intubation and tracheostomy tracheal stenosis using main factors influencing diagnosis and treatment and its efficacy was evaluated prospectively. It seems that this system would be capable of assimilating the treatment interventions and comparing them.

Thyroid cancers with laryngotracheal invasion.

OBJECTIVES: Management of thyroid cancers with laryngotracheal invasion is controversial. METHODS: A retrospective analysis of our database found 69 patients (38 females, mean age 59.6 ± 11.6) between March 1995 and July 2010; of them 42 (61%) were managed by non-resectional methods due to the extensive airway or regional involvement, severe co-morbidities, diffuse metastases or patient's preference. Segmental airway resection was performed in 27 (39%) patients; concurrent with thyroidectomy in 17 (Immediate group (IG)), and as a delayed procedure in 10 referred patients (Delayed group (DG)), who had previously undergone thyroidectomy with conservative airway management, like shaving procedures. Follow-up was completed in 81% of patients with a mean duration of 30 months. RESULTS: Tracheal or laryngotracheal resection and reconstruction was performed in 18, laryngectomy in eight and pharyngolaryngectomy in one patient. There were two anastomotic dehiscence (11.1%), one resulted in mortality (3.7%). One or a combination of bronchoscopic core-out, laser, tracheostomy and stent placement was performed in 42 non-resected patients with two mortalities (4.7%). Overall 1-, 2-, 3- and 5-year survival was 85, 85, 68 and 49% in resected group, as well as 56, 46, 40 and 31% in non-resected group (P = 0.049), respectively. Among resected group, the overall 1-, 2-, 3- and 5-year survival was 92, 92, 76 and 61% in the IG as well as 75, 75, 56 and 28% in the DG (P = 0.43). CONCLUSIONS: Complete segmental airway resection during or even after thyroidectomy could be safely performed, might be curative and may be associated with improved survival.

Primary major airway tumors; management and results.

OBJECTIVE: Primary major airway tumors are rare. A retrospective analysis of referral centers experience could be helpful for their management. METHODS: Fifty-one patients, including 44 (86%) malignant and seven (14%) benign with primary tumors of subglottis, trachea, carina, and main stem bronchi, were managed in a 14-year period. Based on computed tomography (CT) scan and rigid bronchoscopy findings, those who evaluated as resectable underwent airway resection and reconstruction. The others were managed by one or a combination of these methods: core out, laser, chemotherapy, radiotherapy, and tracheostomy. Follow-up was completed in 88.2%, mean (35.2 ± 33.2 months). RESULTS: Extraluminal extension of the tumor found in CT scan was significantly associated with unresectability (p = 0.006). Thirty-two patients underwent resection with three complications (9%) and one mortality (3%). Nineteen were managed by non-resectional methods; of these, 15 were found unresectable, because of tumor length, extensive local invasion or diffuse distant metastases, and four due to risk-benefit ratio or patient preference. Among 18 patients with adenoid cystic carcinoma 13 (72%) were resected (seven with negative margins). Overall 1-, 2-, 5-, and 8-year survival was 90.9%, 90.9%, 77.9%, and 19.5%, respectively. In unresectable tumors with adenoid cystic carcinoma, overall 1- and 2-year survival was 60% and 40%, respectively. Data analysis found significant association of long-term survival with resection (p = 0.005) but not with negative margins in adenoid cystic carcinoma. Among 15 patients with carcinoid tumors, all were alive at the end of follow-up, except one who died after surgery. CONCLUSIONS: Airway resection, if feasible, may extend survival and may even be curative, with low morbidity and mortality, in most patients with major airway tumors.

Major airways trauma, management and long term results.

PURPOSE: The number of patients with traumatic and iatrogenic tracheobronchial injuries is increasing. Early diagnosis, prompt establishment of a secure airway, and appropriate management could prevent sequelae and lead to a good outcome. METHODS: Between "1994-2007", 35 patients with major airways trauma were managed. This descriptive and retrospective study evaluates clinical findings, diagnostic approaches, initial managements, definitive surgical or nonsurgical treatments and follow-up results. SPSS was used for descriptive outcomes. RESULTS: There were 27 males (77%) and 8 females, with a mean age of 28.2. There were 16 blunt, 11 penetrating and 8 iatrogenic traumas, at the level of the larynx in 1, larynx and hypopharynx in 3, laryngotracheal in 12, tracheal in 13, tracheobronchial in 1, and main bronchi in 5 patients. Fourteen patients (40%) were initially managed, and 21 patients were referred to us after their initial managements at outside hospitals. There were 7 complications (20%); one resulted in mortality (2.9%). The overall final results were good in 57.1%, acceptable in 31.4% and poor in 5.7% of patients, (mean follow-up time, 58.2 months). The respiratory status and the phonation looked better in the initially managed than the delayed managed group. CONCLUSION: We recommend that, patients only become respiratory stable with minimum intervention and then be referred to centers with sufficient experience in airway surgery.

The etiological factors of recurrence after tracheal resection and reconstruction in post-intubation stenosis.

We assessed several factors which might be responsible for the recurrence of post-intubation airway stenosis in a large group of patients who underwent resection and reconstruction surgery by one surgical team. Four hundred and ninety-four patients underwent reconstruction of post-intubation airway stenosis during 1995-2006. The case group comprised patients who had developed recurrence, while controls had no recurrence. The diagnosis of the recurrence was made based on the presence of clinical signs or symptoms and bronchoscopic evaluation. The following variables were compared in both groups: age, sex, duration of intubation, reason for intubation, period of time between intubation and surgery, history of previous tracheotomy, previous therapeutic interventions, subglottic involvement, length of resection, presence of unusual tension at the site of anastomosis and anastomotic infection. Fifty-two patients (10.5%) developed recurrence. Lengthy resection, presence of tension at the site of anastomosis, anastomotic infection and subglottic involvement were significantly higher in the case group. Logistic regression model showed that the three main predictors are anastomotic infection (OR=3.44), subglottic involvement (OR=2.43), and presence of tension (OR=1.97), respectively. It is concluded that the surgeon can play an important role in avoiding recurrence by decreasing tension, preventing infection, and preserving subglottic structure.

Postintubation multisegmental tracheal stenosis: treatment and results.

BACKGROUND: A number of postintubation tracheal stenoses involve different and separate segments. Treatment of these types of strictures is complicated with obscure results, infrequently reported in literature. METHODS: A total of 648 patients underwent treatment for tracheal or subglottic stenosis from September 1993 through October 2005; of those, 26 cases had two separate stenotic segments. Four types of therapeutic approaches were considered for these 26 patients: one-stage resection of the stenotic sites; two-stage resection of the stenotic sites; resection of one stricture and treatment of the second one by nonresectional methods such as dilatation, laser, stenting, T-tube, or tracheostomy; or treatment of both lesions by nonresectional methods. The therapeutic approach for each patient was determined by the surgeon and was based on the nature and location of stenoses, length of stenoses and the distance between the two stenotic sites. RESULTS: There were 20 male patients (76.9%) and 6 female patients (23.1%), with a mean age of 23.9 years (range, 4 to 64). Fourteen patients had tracheal stenosis and 12 had both tracheal and subglottic involvement. Five patients underwent type 1 therapeutic approach whereas 4, 9, and 8 patients underwent types 2, 3, and 4, respectively. Mean length of resection was 58.9 mm in those who underwent complete resection of the stenotic sites (range, 30 to 90 mm). There were 2 complications, 1 stomal fistula and 1 wound infection. Follow-up was accomplished in all patients with a mean period of 21.5 months (range, 1 to 108). Sixteen patients achieved satisfactory results (good voice and airway), 7 are still under treatment (requiring stent, tracheostomy, or repeated dilatation), and 3 died (2 type 3 and 1 type 4). Two deaths were due to T-tube obstruction, and 1 was due to acute obstruction of the stenotic part. CONCLUSIONS: Resection of both strictures and reconstruction of airway are feasible in some patients with multisegmental tracheal stenosis with good results. When resection of both strictures is not feasible, a combination of resectional and nonresectional managements could be helpful for the vast majority of patients.