Continuing Education Activity

Tracheal resection is performed when tracheal stenosis is unresponsive to conservative management strategies, such as balloon dilation and scar excision. Tracheal resection and cricotracheal resection are 2 related surgical procedures that definitively address tracheal stenosis, depending on the location of the stenosis. Repair indications include symptomatic or progressive stenosis secondary to prolonged intubation, tracheostomy, tracheal tumors, airway trauma, tracheoesophageal fistula, tracheoinnominate fistulas, and idiopathic laryngotracheal stenosis. The procedure's high success rate and relatively low complication rate establish it as the treatment mainstay for tracheal stenosis.

This activity for healthcare professionals is designed to enhance learners' competence in identifying indications for tracheal resection and performing the procedure. Participants gain a broader grasp of the procedure's relevant anatomy and physiology, indications, contraindications, proper technique, and potential complications. Greater proficiency prepares learners to collaborate within an interprofessional team caring for patients with tracheal stenosis.

Objectives:

• Differentiate between various etiologies of tracheal stenosis (eg, post-intubation, idiopathic) to guide treatment decisions.
• Apply surgical techniques for tracheal resection with precision and attention to anatomical considerations.
• Screen patients presenting with respiratory symptoms for signs of tracheal stenosis requiring surgical intervention.
• Implement interprofessional team strategies for improving care coordination and communication to advance tracheal resection and improve outcomes.

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Introduction

While the history of mechanical ventilation dates back to at least the 1800s, positive-pressure ventilation began in the 1940s with military research into fighter pilots' respiration at high altitudes.[1] The technique was rapidly applied to replace iron lungs in patients with polio, especially during the Scandinavian polio outbreak at that time. Engstrom patented one of the first positive-pressure ventilators designed to work by introducing air directly into the trachea via a tube inserted intraluminally in 1950, and the modern ventilator rapidly expanded from there.[2]

The initial endotracheal tubes (ETTs) were low-volume, high-pressure cuff tubes. Soon after introducing these airways, the first delayed complications from endotracheal intubation and ventilation were reported.[3] Prolonged intubation, high cuff pressures, and excessive movement of the tracheostomy tube were found to cause ischemic injury and necrosis, leading to circumferential tracheal scarring and narrowing.[4][5]

The tracheobronchial cartilage was historically considered too rigid and poorly vascularized for surgical treatment. However, pioneering work by Drs Hermes Grillo and Joel Cooper showed that resection of the stenotic tracheal segment and primary reanastomosis was possible.[6] Since then, significant advancements have been made in airway management during tracheal resection and surgical techniques to reduce tension on the anastomosis.

Tracheal resection with primary anastomosis is presently a surgical procedure performed in major tertiary centers, managed by an interprofessional team of anesthesiologists, otolaryngologists, cardiothoracic surgeons, and pulmonary and critical care intensivists. Originally meant as a solution to tracheal stenosis, tracheal resection is now used to treat tracheal tumors, tracheomalacia, tracheal trauma, and tracheoesophageal and tracheoinnominate fistulas.[7][8]

Anatomy and Physiology

The trachea has a D-shaped cross-section, with 16 to 20 incomplete, horseshoe-shaped cartilaginous rings covering its anterior and lateral aspects and a membranous wall spanning its posterior side. The trachealis muscle lines the membranous (or "party") wall between the trachea and the esophagus. Intercartilaginous membranes connect each cartilaginous ring to one another vertically. The trachea begins at the inferior border of the cricoid, lying at the adult C6 vertebral level, and extends inferiorly to the carina, situated at the adult T4 vertebral level. The trachea has an average adult length of 10 to 13 cm.[9][10]

Superior to the trachea lies the larynx, consisting of 3 paired cartilages, the arytenoid, corniculate, and cuneiform, and 3 unpaired cartilages, the epiglottis, thyroid, and cricoid.[11] Unlike the tracheal rings, the cricoid is a complete cartilaginous ring with a broad posterior portion (lamina) and a narrower anterior portion (arch). The cricoid is attached inferiorly to the 1st tracheal ring by the cricotracheal ligament and superiorly, at 3 segments, by the cricothyroid ligament to the thyroid cartilage anteriorly, cricothyroid muscle laterally, and cricothyroid joints posterolaterally.[12]

The paired arytenoids lie superiorly on the posterior surface of the cricoid, forming the cricoarytenoid joint. These cartilages serve as the attachment for the intrinsic laryngeal muscles and vocal ligaments and folds.[13] The recurrent laryngeal nerve (RLN) approaches the larynx along the tracheoesophageal groove and passes under the inferior pharyngeal constrictor and behind the cricothyroid joint to enter the larynx. This location is prone to injury during thyroidectomy, parathyroidectomy, and cricotracheal resection. The left RLN lies within the tracheoesophageal groove for a longer course on the left, while the right RLN approaches from a more lateral position.[14][15][16]

The blood supply is segmental, approaching the tracheal wall laterally and dividing longitudinally into superior and inferior branches. The branches anastomose with the segmental arteries above and below. The arteries branch anteriorly and posteriorly within the intercartilaginous membrane and anastomose to the contralateral side. The trachea is divided into cervical (C6-C7) and thoracic segments (T1-T4). The tracheoesophageal branches of the inferior thyroid arteries, which branch off the thyrocervical trunk from the subclavian arteries, supply the cervical trachea. The bronchial arteries supply the thoracic segment and carina. These blood vessels branch directly from the aorta. Keen awareness of this unique arterial architecture is vital during surgery to preserve the lateral blood supply and limit circumferential dissection of the trachea within 1 to 2 cm of the anastomosis site, preventing tissue ischemia.[17]

Stenosis is recognized as the most common long-term complication after endotracheal intubation, with incidence ranging from 10% to 22%, with 1% to 2% being symptomatic.[18] Posttracheostomy tracheal stenosis is a potential long-term complication, with incidence rates of 1.7%.[19] Overinflation of endotracheal cuffs beyond 20 to 25 mm Hg can cause ischemic necrosis of the tracheal mucosa, potentially leading to stenosis. Porcine models suggest mucosal injury may begin 8 to 24 hrs after cuff inflation.[20][21] During prolonged intubations, the ETT's frequent shearing motion from respiratory cycles, suctioning, swallowing movements, head movements, coughing, and yawning can injure the tracheal mucosa.[22] Cicatricial bands often develop within 1 to 3 weeks after extubation, progressing to tracheal stenosis, though symptoms can also be quite delayed.[23]

Patients with airway stenosis often present with dyspnea on exertion, cough, wheezing, hemoptysis, or shortness of breath, although the trachea can be narrowed up to 75% before any symptoms become apparent. Symptoms of stenosis due to neoplasm can be subtle because of the slow growth of certain tracheal tumors, leading to potential misdiagnosis as asthma.[24][25] Complete surgical tracheal resection is definitive to achieve long-term survival in cases of tracheal malignancies and extensive stenosis unresponsive to conservation dilations and CO2 scar excision.[26]

Indications

The most common indication for tracheal resection is acquired stenosis, typically caused by prolonged intubation or tracheostomy, especially when recurrent or unresponsive to conservative treatments like balloon dilation or CO2 laser scar excision.[26][27] The incidence of stenosis after prolonged intubation or tracheostomy ranges from 6% to 21% and 0.6% to 21%, respectively, with postintubation stenosis affecting 4% to 13% of adults in the United States (US) and 1% to 8% of US neonates.[28] The high success rate of tracheal resection for stenosis (71%-95%) has established it as the preferred treatment method.[29]

The excision of malignant tumors is another indication of tracheal resection. Tracheal neoplasms are rare and account for less than 0.01% of all tumors and 0.2% of malignant respiratory tract lesions. The 2 most common histologic types are squamous cell carcinoma, embodying 50% to 66% of all tracheal tumors, and adenoid cystic carcinoma, representing 10% to 15%.[30] Less common tumors include mucoepidermoid carcinoma, nonsquamous bronchogenic carcinoma, sarcoma, carcinoid tumors, and melanoma.[31] Airway invasion by thyroid carcinoma is another indication for segmental laryngotracheal and tracheal resection that has been shown to improve survival in such cases.[32] Further indications include airway trauma, acquired stenosis from inhalation burns or radiation, tracheoesophageal fistulas, tracheoinnominate fistulas, congenital lesions, postinfection lesions, cartilaginous fibrosis, and idiopathic causes such as idiopathic laryngotracheal stenosis.[33]

Contraindications

Contraindications to performing tracheal resection include the following:

• Lesion requiring resection of over half of the trachea
• Severe medical comorbidities
• Reduced pulmonary function
• Prior neck or chest radiation requiring a flap reconstruction
• Presence of distant metastatic disease 

Equipment

The recommended equipment and materials for proper performance of tracheal resection include the following:

• Laryngoscope
• Rigid bronchoscope
• 0° and 30° Hopkins rod
• ETTs in multiple sizes, regular and wire-reinforced
• Tracheal or esophageal balloon
• Surgical instruments for neck dissection
• Sternotomy tray
• Surgical instruments for thoracic dissection
• Suture for tracheal anastomosis and Grillo sutures

  • Absorbable 3-0 polyglycolic (Vicryl), 4-0 polydioxanone
  • Nonabsorbable 0 Silk, 2-0 polypropylene (Prolene)

Personnel

The healthcare professionals who must be present during tracheal resection include the following:

• Surgeon
• Surgical assistant/
• Anesthesiologist
• Surgical technologist
• Circulating nurse

Preparation

Preoperative computed tomography (CT) imaging is required to delineate the length and location of the tracheal lesion. A CT tracheal protocol, including inspiratory and expiratory phases, can be obtained to assess the dynamic obstruction in tracheomalacia. For neoplastic disease, CT neck and chest with contrast is needed to evaluate for locally advanced or metastatic disease.[34]

Patients are counseled on the risks before surgery, including hemorrhage, infection, restenosis, wound breakdown, and possible additional and future procedures, including tracheostomy. Patients should know they may be intubated and sedated for a few days, per surgeon preference, in the intensive care unit to allow the tracheal anastomoses to heal appropriately, and their chin may be sutured to their chest to encourage continual neck flexion. The procedure may comprise a “clean-contaminated” portion (bronchoscopy) and a sterile, open-neck procedure. The mucosal surfaces and the neck's soft tissues are ultimately connected during the procedure. Sterile preparation and draping are at the surgeon’s preference, as are the administration and choice of antibiotics.

Technique or Treatment

Airway Management

Airway stenosis is the most common indication for tracheal and cricotracheal resection. Patients usually have a preexisting tracheostomy and can be endotracheally intubated via the extant tracheostomy. Otherwise, the patient will need direct laryngoscopy and rigid bronchoscopy, ideally while maintaining spontaneous breathing.

Under direct visualization, an ETT is placed into the trachea and above the stenosis, or the stenotic segment may be dilated to facilitate intubation.[35] Awake tracheostomy may need to be performed if orotracheal intubation is impossible. Thoughtful tracheostomy placement is important to optimize the preservation of tracheal length for reanastomosis. For severe upper subglottic stenosis, the space between the vocal cords and the stenosis might be too limited for an ETT cuff to maintain a proper seal and provide adequate ventilation.

Superimposed high-frequency jet ventilation can provide an alternative method of continuous minute ventilation, CO2 removal, and oxygenation. This step is accomplished by passing a rigid bronchoscope inferior to the vocal cords above the area of stenosis and connecting it to a mechanical jet injector.[36][37] A nasogastric tube is placed to help identify the esophagus during surgery and allow for postoperative feeding.

Rigid Bronchoscopy

The glottis, subglottis, trachea, and stenotic segment are examined during direct laryngoscopy and rigid bronchoscopy. Three distances must be measured when planning the resection portion of the procedure: vocal cords to the carina, distal tip of the lesion to the carina, and proximal tip of the lesion to vocal cords. These measurements will accurately depict the stenotic length for operative planning and determination of any release maneuvers.[38] Dilation of the stenosis using an esophageal balloon may also be performed at this time to improve ventilation and access and facilitate intubation, as discussed above.

Tracheal Resection

The patient is placed supine once the airway is secured and general anesthesia is administered. A shoulder roll is placed to enhance neck extension. The neck and chest are draped in a sterile fashion. A horizontal collar incision is made through the skin and platysma within an existing skin crease. If the patient has a tracheostomy, the tracheostoma is incorporated into the incision in an elliptical fashion. Subplatysmal flaps are raised superiorly to the hyoid bone and inferiorly to the sternal notch. The strap muscles are divided along the median raphe and retracted laterally. The thyroid isthmus is divided, and the anterior borders of the thyroid cartilage, cricoid, and trachea down to the sternal notch are defined.

Fine dissection is performed to isolate the tracheal stenosis region, avoiding compromising the lateral blood supply and the RLNs. The anterior tracheal wall is exposed above and below the tracheostoma for patients with an existing tracheostomy. The epithelized tract may be incised from the anterior tracheal cartilage or incorporated into the resection as the anterior wall of the trachea.

The airway is entered once the segment to be excised has been identified and isolated superiorly, laterally, and inferiorly by using the measurements obtained endoscopically. The measurements can be confirmed via concurrent bronchoscopy before entering the airway if desired. One surgeon can maintain sterility and observe the trachea in the operative field, while another breaks the scrub and performs a rigid bronchoscopy. The sterile surgeon can definitively confirm the stenosis's beginning by introducing a hypodermic needle into the trachea, with its position confirmed endoscopically.[39]

The anesthesiologist must be notified before entering the airway. Our general practice entails entering the airway with a horizontal transverse intercartilaginous incision inferior to the stenosis between tracheal rings. A wire-reinforced ETT is then passed into the distal trachea and connected to the ventilator circuit. A suture is placed through the distal trachea to secure it to the ETT. The patient is ventilated through the distal tracheal intubation until continuity is reestablished. The tube is temporarily retracted into the proximal trachea or larynx if orotracheal or nasotracheal intubation was previously performed.

A horizontal incision is made across the superior aspect of the desired resection. Both the inferior and superior incisions are extended through the posterior wall until the party wall fascia is identified. Dissection is performed along the party wall between the superior and inferior posterior party wall incisions. Preoperative placement of an esophageal bougie or nasogastric tube can help identify the esophagus and avoid injury during this portion of the procedure. The stenotic segment is then dissected free from the esophagus posteriorly and the surrounding tissue laterally. Care must be taken to hug the tracheal wall during dissection to avoid injuring the esophagus and RLNs.

For neoplastic disease, the tumor is resected to achieve the recommended disease-negative margins microscopically before reanastomosis. Extending circumferential skeletonization of the trachea beyond 1 to 2 cm of the resected edges should be avoided to preserve anastomotic vasculature. Extensive nodal dissection for malignant disease may risk injuring the vascular supply.

The proximal and distal tracheal segments are then reapproximated and reanastomosed. This part starts by managing the ETT. If the patient was not intubated orotracheally at the start of the case, an ETT is passed through the glottis into the proximal tracheal segment. The surgeon has control of both the proximal and distal (circuited) airway. In short-segment tracheal resection, primary anastomosis can be achieved with a limited tracheal release.

Bracing sutures may be used to help reduce tension between the proximal and distal trachea during anastomosis. The authors favor using a 3-0 polydioxanone (PDS) or polypropylene (prolene) sutures, entering and exiting 2 tracheal rings above and below the anastomosis. With the tracheal ends in close approximation, the posterior membranous wall is addressed first using simple, interrupted absorbable 3-0 polyglycolic (Vicryl) or 3-0 PDS stitches placed 3 mm apart and 3 to 4 mm from the cut edge submucosally, with the knots cinched outside the lumen.

The distal segment is extubated once the posterior wall is repaired, and the circuit is connected to the proximal circuit as the ETT is advanced until its cuff is below the anastomosis. The ETT should be secured at the mouth, and the measurement from the lip or teeth should be recorded. The cartilaginous trachea is then reapproximated with interrupted 3-0 PDS, and the knots are cinched outside the lumen.

Before sealing the anastomosis, it is important to confirm that the inflated cuff is not resting against it. If bracing sutures are used, they can also be cinched after the anastomosis for added strength. Creating a tension-free anastomosis prevents wound dehiscence and restenosis. If a tension-free anastomosis cannot be achieved, release maneuvers discussed below may be required.

To verify an air-tight closure, the wound is submerged in sterile saline, and insufflation pressure is elevated to 40 cm water. Additional simple, interrupted stitches can repair anterior air leaks. A posterior air leak may require opening the anastomosis. A closed suction drain or Penrose is placed. The skin is closed in a multilayer fashion by reapproximating the platysma and skin closure. A Grillo chin stitch is placed using a nonabsorbable, 2-0 silk suture from the chin at the submental crease to the anterior chest at the manubriosternal junction (angle of Louis). The stitch is tied loosely to remind the patient to maintain neck flexion. Neck overflexion should be avoided to prevent spinal cord ischemia.

Cricotracheal Resection

Resection for patients with severe subglottic stenosis high in the cervical trachea may require partial excision of the cricoid cartilage. The procedure starts in a similar fashion to the procedure described above, with airway management, laryngoscopy, bronchoscopy, management of the tracheocutaneous fistula (usually the case in cricotracheal resection), and neck opening. The thyroid cartilage, cricoid, and trachea are exposed. The stenotic area is isolated superiorly, inferiorly, and laterally. Endoscopic confirmation is important, as described above.

The anesthesiologist must be updated before entering the airway. Horizontal incisions are made at the inferior thyroid border. If the patient does not already have a tracheostomy, a wire-reinforced ETT is passed into the distal trachea and connected to the ventilator circuit. A suture (silk or polyglycolic acid) is placed through the distal trachea to secure it to the ETT. The patient is ventilated through the distal tracheal intubation until continuity is reestablished. The cricothyroid muscle is elevated off the anterior cricoid bilaterally. Lateral bilateral dissection of the cricoid is carried out using cold dissection in the subperichondrial plane near the cricothyroid joint, as the RLN lies superficial to the perichondrial plane posterior to the cricothyroid joint.[40]

Lateral incisions through the cricoid are made bilaterally, and the anterior arch of the cricoid is resected. Dissection is carried out along the inferior edge of the posterior cricoid until the party wall between the trachea and esophagus is entered. Placing a nasogastric tube or esophageal bougie can help localize the esophagus. The stenotic segment is then dissected free from the esophagus posteriorly along the parting wall and the surrounding tissue laterally, making sure to hug the trachea to avoid injuring the RLNs.

Two issues must be addressed during anastomosis: achieving a tension-free, leak-free anastomosis and managing airway caliber mismatch. Various methods may be used to place traction sutures to reduce tension at the primary anastomosis. Prolene 2-0 or 3-0 traction sutures are placed from the thyroid cartilage to the distal end tracheal rings to reapproximate the anastomosis. Airway caliber mismatch must be managed, as the distal tracheal lumen is usually larger than the subglottic lumen. The subglottic lumen may be enlarged by drilling the posterior cricoid with a diamond burr and performing an inferior midline thyrotomy up to the anterior commissure if necessary. The inferior triangular defect created by the thyrotomy is filled by a triangular wedge made from the first tracheal ring below the stenosis.[41]

The anastomosis is performed first between the posterior cricoid and distal tracheal ring using simple, interrupted PDS placed 3 mm apart and 3 to 4 mm from the cut edge. These posterior-wall sutures will span the posterior cricoid cartilage to the membranous trachea of the distal trachea. These sutures are cinched intraluminally. The remaining anterior and lateral anastomotic sutures are tied with knots placed outside the lumen. The reinforced ETT is then removed from the distal trachea, and an orotracheal ETT is advanced until the cuff is past the anastomosis area.

The ventilator circuit is switched over to the orotracheal ETT, and the balloon is inflated. The anterior and lateral anastomosis areas are then finished by placing simple, interrupted sutures, per surgeon preference, to seal the anastomosis between the inferior border of the thyroid cartilage and the distal tracheal rings.[42] The authors prefer to use PDS. The wound is submerged in sterile saline, and insufflation pressure is elevated to 40 cm H2O to confirm an air-tight closure. A drain is placed on each side of the trachea, and the platysma and skin are closed in a multilayered fashion. A Grillo chin stitch is placed to maintain neck flexion.

Release Maneuvers

Various release maneuvers have been used to decrease tension at the anastomosis, including anterior and posterior blunt tracheal dissection, neck flexion, thyrohyoid, suprahyoid, hilar, and intrapericardial release techniques. Neck flexion and blunt dissection along the avascular anterior and posterior trachea may be performed during cervical tracheal resections to avoid injuring the lateral tracheal blood supply. Mullikan et al showed that up to 4.5 cm of the trachea can be resected with tension-free anastomosis with only neck flexion.[43]

The thyrohyoid or suprahyoid laryngeal release allows the larynx to drop caudally and add 1 to 2 cm of tracheal length. The suprahyoid release is preferred over the thyrohyoid release, as it provides a similar length without risking injury to the superior laryngeal vessels and nerves. The technique has a lower incidence of postoperative dysphagia and aspiration.[44][45]

The suprathyroid or thyrohyoid laryngeal (Dedo) release involves transecting the thyrohyoid muscle and dividing the thyrohyoid membrane. The thyroid cartilage's superior cornu is carefully cut to avoid injuring the superior laryngeal nerve and vessels, which penetrate the thyrohyoid membrane medial to the cornu.[46] The suprahyoid (Montgomery) release involves dissection on the superior hyoid edge. The superior muscles attached to the hyoid are divided, including the mylohyoid, geniohyoid, and genioglossi. The digastric sling remains attached to the hyoid. This muscular release alone can provide significant laxity. If needed, the hyoid bone can be divided with Mayo scissors on each side, lateral to the lesser cornua, and medial to the digastric sling; this maneuver allows the hyoid body, thyroid cartilage, cricoid, and proximal tracheal segments to drop inferiorly.

For distal tracheal lesion resection, intrathoracic release maneuvers can be utilized using median sternotomy, video-assisted thoracoscopic surgery, or bilateral lateral thoracotomies. The hilum can be released through blunt dissection along the avascular plane anterior to the bilateral bronchi and division of the inferior pulmonary ligament carefully to avoid injury to the bronchial arteries. Intrapericardial release can provide another 2 cm of tracheal length by moving the carina rostrally. After the right inferior pulmonary ligament is divided, a U-shaped incision is made on the pericardium at the anterior, inferior, and posterior borders of the right inferior pulmonary vein, with care not to injure the phrenic nerve anteriorly. The intrapericardial septum that attaches the lateral atrium and vena cava to the pericardium is then divided and extended to circumscribe the right hilum completely. The maneuver is the same on the left, except this side lacks an intrapericardial septum, and the ductus arteriosus should be divided.

Complications

Multiple studies have reported a median postoperative hospitalization stay of 8 days, a success rate of 95%, and a complication rate of 18.2%.[47] Tension at the anastomotic line is the main contributor to major complications in the postoperative period, which include restenosis, tracheal wound dehiscence, and anastomotic leak. To minimize postoperative complications, the anastomosis must be allowed to heal tension-free with continuous neck flexion. Methods to maintain neck flexion include the Grillo stitch, mechanical ventilation with paralytics, neck brace, and posterior neck plaster splint. However, these methods were all found to increase hospital stay and morbidity.[48]

Patients are extubated 0 to 7 days later, depending on their age, health, and resection length. If laryngeal edema is not a precluding factor, early extubation in the operating room or within 48 hours is recommended in compliant, healthy patients. If the surgeon believes early extubation is unlikely, a tracheostomy can be placed 2 cm distal to the anastomosis.

Antiemetics and non-narcotic pain management are encouraged to prevent postoperative nausea, leading to vomiting, neck hyperextension, and potential aspiration. Voice rest may be encouraged to prevent laryngeal edema. Speech therapy with a modified barium swallow is obtained before starting a diet. Some patients may experience dysphagia due to laryngeal release maneuvers and poor voice from cricotracheal resections. The tracheal anastomosis may be reexamined via rigid or flexible bronchoscopy on postoperative day 7, at which time the Grillo stitch may be removed. A low threshold for bronchoscopy should be maintained earlier if stridor, voice changes, wound infection, subcutaneous emphysema, or excessive secretions arise.

Restenosis can present in up to 10% of patients and is the most common complication of tracheal resection, possibly due to granulation tissue development at the suture line or inadequate resection of initial stenosis. Symptoms may take several months to manifest. Thus, frequent monitoring with flexible bronchoscopy is recommended. Early restenosis can be treated with balloon dilation, budesonide inhalers, a corticosteroid injection into the granulation tissue, or mitomycin C- or corticosteroid-coated drug-eluting stents.[49]

Erythromycin has previously been used for its anti-inflammatory effect in patients with bronchiectasis, bronchiolitis asthma, and chronic obstructive pulmonary disease. The drug upregulates histone deacetylase-2, inhibiting inflammatory factor expression. Studies indicate that combining this agent with glucocorticoids may further reduce inflammation and fibrosis progression in tracheal stenosis.[50] Stenosis unresponsive to repeat dilations may require reoperation or T-tube stenting for long-term management.

Wound dehiscence is a rare (<1%) but potentially deadly complication that occurs most commonly at the anterior tracheal wall, where the tension is highest, and can present with an air leak and subcutaneous neck emphysema. An immediate investigation is required, and flexible bronchoscopy is used to locate the dehiscence area. Small dehiscences can be treated with voice rest, neck flexion, antibiotics, nasogastric tube feeding, and possible reintubation with cuff distal to the anastomosis. Larger dehiscences require direct intubation over a flexible bronchoscope to prevent laryngotracheal separation and return to the operating room for reanastomosis. A tracheostomy or T-tube stent is temporarily placed until later revision if reanastomosis is impossible.

Laryngeal edema is more common in patients undergoing cricotracheal resection (5%) and can persist for 1 to 2 weeks postoperatively. Stridor and hoarseness should be evaluated with flexible bronchoscopy. Mild edema can be treated with voice rest, head elevation, respiratory toilet, systemic corticosteroids, racemic epinephrine nebulizers, and heliox. Severe edema that does not resolve with medication and reintubation may require a tracheostomy. Wound infection can present with erythema, drainage, and increased pain. Treatment involves a wound culture, antibiotics, CT to assess for extraluminal air and fluid collection, and bronchoscopy for anastomotic dehiscence evaluation if extraluminal air is found.

Tracheoinnominate fistula occurs when the anterior anastomosis has become dehiscent, with subsequent inflammation and erosion into the innominate artery. The cardinal sign is a small-volume episode of bright-red hemoptysis that usually precedes a major life-threatening bleed. Small episodes of hemoptysis should be evaluated with a CT angiogram. A low threshold to return to the operating room for bronchoscopic evaluation of the anastomosis and anterior tracheal wall must be maintained. Major arterial hemoptysis is a life-threatening complication requiring a return to the operation room with ligation of the innominate artery or potential stenting of the innominate artery by a thoracic surgeon.

Tracheoesophageal fistula occurs when the posterior anastomosis becomes dehiscent, leading to inflammation and erosion through the party wall into the esophagus. Signs include postprandial cough and pneumonia. Barium swallow and bronchoscopy are used to confirm the diagnosis. Treatment involves tracheostomy, nasogastric tube feeding, revision of anastomosis, and 2-layer closure of the esophageal defect or interposition of a flap into the party wall. Other potential complications include RLN injury (2%), myocardial infarction, deep vein thrombosis, and prolonged hospitalization.

Johnson et al performed an analysis of 126 adult patients who underwent cervical tracheoplasty, intrathoracic tracheoplasty, or excision of tracheal stenosis and anastomosis as the principal procedures using the American College of Surgeon National Surgical Quality Improvement Program from 2014 to 2016.[51] The group found the average length of stay to be 7 days, with 35/126 (28%) experiencing at least 1 adverse event. Two patients had prolonged hospital stays longer than 30 days, 12 had pneumonia, 3 had sepsis, 6 developed wound infections, 3 developed wound dehiscence, 5 required unplanned reintubation, and 16 had an unplanned reoperation. The 30-day unplanned readmission rate was 16% (20/126), and the mortality rate was 0%. Variables that increased the risk of adverse events included American Society of Anesthesiologists class III, chronic obstructive pulmonary disease, dirty wounds, preoperative dyspnea, and chronic steroid use.

Clinical Significance

Airway surgical techniques and awareness of the impact of mechanical ventilation have significantly improved over the last half-century; however, tracheal stenosis remains a challenging problem today. Healthcare professionals who deal with these airway issues must be well-informed on airway management, disease etiology, local structures, diagnostic practices, surgical repair techniques, postoperative care, and mitigation of complications.

Enhancing Healthcare Team Outcomes

Managing tracheal stenosis requires an interprofessional team of otolaryngologists, cardiothoracic surgeons, anesthesiologists, intensivists, respiratory therapists, speech therapists, and nursing staff. Preoperative evaluation of the tracheal lesion through radiographic imaging and direct bronchoscopy is critical to determine the lesion's location, tracheal segment resectability, and need for release maneuvers. Patients must undergo cardiopulmonary clearance to ensure they can tolerate an extended operation. Clear communication between otolaryngologists and anesthesiologists is crucial intraoperatively, particularly when entering the airway and manipulating the ventilator circuit. Cardiothoracic surgery should be ready if the lesion is in the distal trachea or requires intrathoracic release maneuvers.

The patient is kept in the intensive care unit for airway monitoring in the postoperative period. Frequent pulmonary toilet management by respiratory therapists is necessary for patient comfort and safety. Any activities that increase straining, such as changes in breathing, swallowing, worsening dysphagia, or nausea, must be monitored by the nursing staff and reported immediately. Early evaluation by speech therapy is recommended to initiate proper swallowing exercises and voice control. The nursing staff educates the patient before discharge to avoid heavy lifting, straining, and activities that place too much burden on the anastomosis. Close follow-up with the otolaryngologist with flexible bronchoscopies can ensure early diagnosis of restenosis or other airway complications.

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Disclosure: Allen Young declares no relevant financial relationships with ineligible companies.

Disclosure: Jo-Lawrence Bigcas declares no relevant financial relationships with ineligible companies.