Tracheal Stenosis

Size the lesion before you touch the airway - CT of the neck and chest plus the last bronchoscopy report give level, length, and percent narrowing. Cotton-Myer grades it: I under 50%, II 51% to 70%, III 71% to 99%, IV complete. Spirometry with a flow-volume loop sets the functional baseline.

Symptoms localize the level - extrathoracic stenosis gives inspiratory stridor, hoarseness, and inspiratory wheeze; intrathoracic stenosis gives expiratory difficulty that worsens lying flat. Wheeze that does not answer a bronchodilator is the tell that this is not asthma.

Keep them breathing - the standard approach is direct laryngoscopy and rigid bronchoscopy with spontaneous ventilation maintained, then placing the endotracheal tube under direct vision above the stenosis. If an orotracheal tube cannot be passed, awake tracheostomy is the plan. A patient who already has a tracheostomy is intubated through it.

When the tube will not seal - in high subglottic stenosis there may be no room between the cords and the lesion for a cuff. Superimposed high-frequency jet ventilation through a rigid bronchoscope positioned above the stenosis provides continuous minute ventilation, CO2 removal, and oxygenation.

Cuff pressure is the part you own - poor cuff management occurs in more than half of general anesthetics and drives tracheal ischemia, tracheal rupture, sore throat, and recurrent laryngeal nerve palsy. Measure it with a manometer rather than estimating by pilot-balloon feel.

After tracheal resection the neck stays flexed - a Guardian chin stitch runs from the submental crease to the manubriosternal junction as a reminder. Do not extend the neck moving or repositioning the patient, because it tensions the anastomosis, and do not overflex either, which risks spinal cord ischemia. Some patients stay intubated and sedated in the ICU for a few days to let the anastomosis heal.

Watch for post-resection laryngeal edema - about 5% after cricotracheal resection, and it can persist one to two weeks. New stridor or hoarseness gets flexible bronchoscopy; mild edema is managed with head elevation, voice rest, systemic corticosteroids, nebulized epinephrine, and heliox, and severe edema may need reintubation or tracheostomy.

Tracheoinnominate fistula is the catastrophe - anterior anastomotic dehiscence can erode into the innominate artery. Bleeding around a fresh tracheal anastomosis or tracheostomy is an airway emergency and a hemorrhage emergency at the same time.

Tracheal stenosis is a fixed narrowing of the trachea or subglottis, most often the late bill for an endotracheal tube. When cuff pressure exceeds tracheal mucosal capillary perfusion pressure — roughly 35 mmHg, with ischemic necrosis described beyond 20 to 25 mmHg — the mucosa ulcerates and heals as a fibrotic stricture; cicatricial bands and tracheomalacia appear one to three weeks after extubation and progress from there. Tracheostomy, trauma, inhalation burns, radiation, tumor, and autoimmune disease (granulomatosis with polyangiitis most classically, also rheumatoid arthritis, lupus, sarcoidosis, scleroderma) reach the same end point. The adult airway is narrowest at the subglottis at the level of the cricoid — exactly where the tube sits. The trachea can narrow by up to 75% before symptoms appear, so the first complaint is already a late one.