Thorax (1967), 22, 572.

Tracheal stricture following tracheostomyP. B. DEVERALL

From Killingbeck Hospital, Leeds, 14

Six cases of tracheal obstruction following tracheostomy are described in which surgicalintervention was necessary. These occurred in a series of 104 tracheostomies. In adults thestrictures have occurred at the site of pressure of the tracheostomy tube cuff. Management hasbeen by excision of the stricture with end-to-end reconstruction. Tracheal narrowing in childrenhas been of a different type, occurring at stomal level, and management has been more difficult.

Experience with tracheostomy has been obtainedin this unit mainly with post-operative open-heartcases and chest injuries, and in all age groupsexcept the neonate. It has been used wheneverassisted ventilation has been necessary for longerthan 24 hours. Tracheostomy in this group ofpatients has been used for intervals of from twoto three days up to six weeks. Complications havebeen tube displacement, blockage, tracheal stric-ture, tracheal perforation, haemorrhage, tracheo-oesophageal fistula, and infection. The latter hasbeen with a variety of organisms, but in the lasttwo years Pseudomonas pyocyanea infection hasbecome increasingly common and has proved verydifficult to treat except when associated withremoval of the tracheostomy tube. Meade (1961)records one case of tracheal stenosis in 212 cases.Putney (1955) describes the condition in twochildren, while Watts (1963) commented on therarity of this complication. More recently, Gibson(1967) and Johnston, Wright, and Hercus (1967)have published papers stressing the greater inci-dence of tracheal damage and stricture followingtracheostomy. Fraser and Bell (1967) have alsodescribed a case of stricture occurring at the sitewhere previous tracheostomy tube cuff pressurehad been present.

This paper describes and discusses six examplesof patients with tracheal stricture occurring in aseries of 104 tracheostomies. The mortality in thisseries resulting directly from tracheostomy com-plications is 3%. A further subglottic stricture,which developed in a patient in whom the cricoidring and first tracheal ring were damaged, isexcluded.

CLINICAL EXPERIENCE

CASE 1 A 50-year-old man suffered chest injuries

following a road accident in April 1962 and requiredassisted ventilation, a tracheostomy tube being inposition for three weeks. Slight stridor was firstnoticed about one month later, but the symptoms onlybecame severe in March 1963. A tracheogram showeda stricture at the level of the manubrium sterni. Atoperation in April 1963 a 1 cm. long stricture wasfound involving the whole circumference of thetrachea and corresponding to the position of the cuffof a tracheostomy tube in position. The stoma sitewas marked only by scar tissue anterior to the trachea.The stricture was resected and end-to-end anasto-mosis was performed. There were no post-operativecomplications and a bronchoscopy in October 1965showed a normal tracheal lumen.

CASE 2 A 36-year-old woman suffered chest injuriesfollowing a road accident in November 1962 andrequired assisted ventilation, a tracheostomy tubebeing in position for four weeks. Towards the end ofthis period difficulty was experienced with trachealsuction, and on viewing the trachea with a broncho-scope granulation tissue was found at the site of thetip of the tracheostomy tube. This tissue was removedwith nibbling forceps. The patient remained well afterdischarge until April 1963, when she complained of'difficult breathing and breathlessness'. A tracheogram(Fig. 1) showed a moderately tight stricture. In May1964 she complained of stridor and operation wascarried out. The stricture was 2 cm. in length andcircumferential. Its position corresponded to the siteof the cuff of the tube. Resection and end-to-endanastomosis was possible and she did well. A furthertracheogram in September 1964 (Fig. 2) showed somenarrowing at the suture line, but the patient hasremained free of symptoms.

CASE 3 A 22-year-old woman had a closed mitralvalvotomy in 1957 and this was repeated in 1963. Shefailed to achieve the expected benefit and furtherinvestigation revealed tricuspid stenosis. This wasrelieved by open operation with extracorporeal

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FIG. 1. Case 2 (left and right) Pre-operative tracheogram.

FIG. 2. Case 2 (left and right) Post-operative tracheogram.

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perfusion in November 1964. On the second post-operative day she developed pulmonary oedema, andpositive pressure ventilation with a tracheostomy wasneeded for 10 days. In February 1965 she wasre-admitted with pneumonia and severe breathlessness.A bronchoscopy showed a tight tracheal stricture. Atoperation in March 1965 there was a stricture at theformer cuff site, and resection with end-to-endanastomosis was possible. She has remained well.

CASE 4 A 12-year-old girl with Fallot's tetralogy hada total correction performed in January 1966. Positivepressure ventilation was necessary post-operatively.A tracheostomy tube was in position for 16 days.One week after removal of the tube severe stridor wasevident and bronchoscopy revealed a tight stricturewith much granulation tissue at the stoma level.Immediate excision and end-to-end anastomosis wasattempted, but further obstruction with granulationtissue necessitated the re-creation of a tracheostomythrough the same site. In June 1966 a further resectionwas performed. On this occasion it was decided toleave a nasotracheal tube in position. All was welluntil five days later, when tube blockage with cardiacarrest occurred. Resuscitation was not successful.At necropsy the tracheal anastomosis was satis-

factory, but further tracheal damage and narrowingwas present at a site corresponding to the tip ofprevious intratracheal tubes.

CASE 5 A 4-year-old girl had an operation for aorticcoarctation with a patent ductus arteriosus in May1966. Post-operatively she developed severe secretionalairway obstruction and a tracheostomy was created.The tube was in position for nine days. After onlya few days stridor became evident. Bronchoscopyrevealed the trachea to be angled forwards at thestoma site and narrowed by granulation tissue. It waspossible to pass a nasotracheal tube across this area,but the child suffered a fatal secondary haemorrhagefrom the aortic suture line some three days later.

Post-mortem examination of the trachea showedsevere distortion at the tracheal stoma site with con-centric granulation tissue formation and the anglingpreviously described.

CASE 6 A 45-year-old woman had a mitral valvereplacement using a 3M Starr Edwards prosthesis on28 November 1966. Assisted ventilation was necessaryfor 10 days post-operatively and a tracheostomy tubewas in position for one day longer. She recovered welland went home on 7 January 1967. She was re-admitted on 16 January 1967 following the suddenonset of breathlessness with stridor. Bronchoscopy onthe following day revealed a tight tracheal strictureat the cuff site. Immediate excision (Fig. 3) with end-to-end anastomosis was carried out and the patienthas done well. There was some hoarseness of voice fortwo weeks after operation.

FIG 3. Case 6. Tracheal stricture excised.

DIAGNOSIS

The possibility of tracheal stricture should beconsidered in any patient who previously has hada tracheostomy. Stridor is commonly but notalways present. Patients may complain of breath-lessness or difficult breathing. We have seen anepisode of pneumonia as the first presentingfeature. In children, stridor is usual, but we haveseen two patients with a proved slight degree ofstricture not as yet justifying surgery in whom adry repetitive cough was the complaint: in bothof them a rising respiratory rate was presentbefore the onset of stridor, soon after removal ofthe tube. If suspected, confirmation of thediagnosis is obtained by a tracheogram and/ orbronchoscopy.

OPERATION

In all the cases described it has been possible toperform the operation through the neck. We haveas yet no experience of intrathoracic trachealstricture requiring an approach through the chest.General anaesthetic is administered through an

endotracheal tube sited above the stricture. Noattempt should be made to dilate the stricture or

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to pass an endotracheal tube through it. Thestricture is exposed through a cervical collarincision, the trachea being mobilized inside itsfascial coat as far down into the mediastinum as ispossible. The site of the stricture is usuallyobvious, palpation revealing an area of thickeningof the tracheal wall. The trachea is then openedbelow the stricture, the lumen being swabbed forbacteriological-examination, and then a sterilecuffed endotracheal tube is introduced into thelower trachea through the wound for continuationof the anaesthetic. A further tracheal incisionabove the stricture permits this to be examinedand the degree of involvement of the tracheaestimated. If the stricture be circumferentialresection of this segment and end-to-end anasto-mosis using 3 /0 everting silk sutures is performed,first suturing the posterior wall. Tissue forcepsare used to secure and lift the lower segment. Anassistant approximates the tracheal ends duringsuture, tying to avoid tension. A trans-oral endo-tracheal tube is then reintroduced and the anteriortracheal suture line is completed. It may be tempt-ing, if only the anterior part of the trachea isinvolved, to wedge resect this portion and thenresuture the trachea. There is a tendency with thismanceuvre to cause puckering of the posteriormembranous tracheal wall, so reproducing narrow-ing. If possible the suture line is covered with thethyroid isthmus and the neck incision is closedwithout drainage. Haemostasis is vital.

Post-operatively no endotracheal tube isused. The patient is nursed in an atmosphere ofhigh humidity, and appropriate antibiotics areadministered.

DISCUSSION

The indications for, management of, and com-plications following tracheostomy have beendiscussed by Bjork and Engstr6m (1955), Watts(1963), and Clarke (1965). Watts quotes a mortalitydirectly related to the creation of a tracheostomyof 2%. We have three such deaths in a series of104 cases-case 4 in this paper, a woman whodeveloped a tracheo-oesophageal fistula, andanother patient who died from haemorrhagefollowing perforation of the anterior tracheal wallby the tip of a silver tube. This type of tube is nolonger used.The technique of the operation of tracheostomy

varies, but in this series the flap technique (Fig. 4)(Bjork and Engstrom, 1955) has been used withattachment of the tracheal flap to the superficialfascia and lower skin edge. A vertical skin incision

FIG. 4. Tracheostomy technique with attachment of thetrachealflap to skin.

was used in cases 1 and 3. There does not appearto be any relation between skin incision andstricture formation, but there is no doubt aboutthe better cosmetic result following a transverseincision.We would not now recommend the use of the

flap procedure in children. It seems that contrac-tion of scar tissue anterior to the trachea producesangling forwards of the relatively soft trachealtissue at the stoma site. This angling plus thesmaller tracheal lumen may be sufficient toproduce significant narrowing accentuated by thedevelopment of granulation tissue and furtherincreased by puckering of the membranousposterior tracheal wall. In case 4 the resultingdeformity was similar to a double-barrelled colos-tomy, and a similar case was described byClarke (1965).

Similar distortion has not been seen in the adult.This may be due to the firmer adult trachea orto its relatively wider lumen.

In the adult cases all the strictures seen wereat the level of the cuff of the tracheostomy tube.Our present practice is to release the cuff for 5minutes in every hour and to use the minimumcuff inflation necessary to secure absence of airleak. The largest possible size of tracheostomytube should be used. We have noticed on severaloccasions in non-survivors of open-heart pro-cedures that the tracheal mucosa is completelydestroyed at the cuff site even when this practiceis correctly followed. Gibson (1967) comments onthe high incidence of tracheal damage.

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The flap procedure eliminates the danger ofanterior tube displacement, permits of easier andsafer reintroduction of tubes, and provides easyaccess to the bronchial tree for bronchoscopy. Thetracheal window should be of the minimum sizenecessary. If this is exceeded there is a tendencyfor the lateral walls of the window to collapse intothe trachea. In children there is disagreement asto whether the tracheal opening should consist ofa vertical slit or a small window, the latter withouta flap. Pressure necrosis of the edges of the slitafter a tube has been in position for a few daysproduces a situation similar to a window, but withthe disadvantage that there is necrotic trachealtissue in the area where subsequent healing is tooccur.

In our experience, tracheal strictures followingtracheostomy have been of two types-the firm,fibrous, non-infected stricture developing over aperiod of time, and the early onset soft strictureoccurring soon after removal of the tube and inwhich infection is probably present with granula-tion tissue adding to the tracheal narrowing. Wehave not been able to relate the presence of aspecific infection to the subsequent developmentof stricture.

In the former group, excision with end-to-endanastomosis has given good results and has beenpossible in all our cases. Flavell in 1959 describedthis technique, and a further successful result waspublished by Binet and Aboulker (1961). Trachealtension at the suture line may be reduced by usingthe Z plasty technique described by Narodick,Worman, and Pemberton (1965) and Worman,Starr, and Narodick (1966). Recurrent laryngealnerve damage has occurred in one patient (case 6).We have no experience of the staged plastic

reconstruction (Gibson, 1967), though this maywell have value in strictures longer than 2 5 cm.Miscall, McKittrick, Giordano, and Nolan (1963)describe the excision of a 4-cm. stricture withend-to-end reconstruction, though extensive media-stinal mobilization was necessary through asternal-splitting incision. Johnston et al. (1967)describe a conservative approach and recommendrepeated tracheal dilatation as the treatment ofchoice. This may be true with the lesser degreesof narrowing, but with the tight strictures attemptsat dilatation to introduce an endotracheal tubehave been associated with bleeding. The patientsare usually extremely frightened by theirsymptoms and have been immensely grateful forthe restoration of a normal tracheal lumen.Attempts at immediate reconstruction in the

second type of stricture have failed in our hands.Naso-tracheal intubation across the area ofnarrowing would need to be for a time whichwould likely produce vocal cord damage. Webelieve that re-creation of tracheostomy throughthe damaged area is necessary with the introduc-tion of a tracheostomy tube of the non-cuffedPortex Great Ormond Street pattern. This tubeshould be left in position for a minimum of threemonths to permit organization of healing tissuesand eradication of infection. Repair is then carriedout.To leave a naso-tracheal plastic tube across the

repair site is an attractive idea, but it has thedisadvantage of vocal cord damage and irritationof the tracheal mucosa, and, most important, wehave found that it is difficult to manage a childwith a small-lumen tube. These tubes block easily,either by secretions or by becoming kinked at softpalate level, and often need to be replaced every24 to 48 hours with full bronchial toilet undergeneral anaesthetic at the same time. Facilities forimmediate extubation and bronchoscopy must bepresent at all times. The provision of effective andadequate humidification is essential. Previoustechniques of humidification have been unreliableand we have, as yet, insufficient experience withultrasonic techniques to evaluate their properties.

REFERENCES

Binet, J. P., and Aboulker, P. (1961). Un cas de stenose tracheal,apres tracheotomie, resection-suture de la trachee. Guerison.Men?. Acad. Chir., 87, 39.

Bjork, V. O., and Engstrom, C. G. (1955). The treatment of ventilatoryinsufficiency after pulmonary resection with tracheostomy andprolonged artificial ventilation. J. tIhorac. Surg., 30, 356.

Clarke, D. B. (1965). Tracheostomy in a thoracic surgical unit. Thorax,20, 87.

Flavell, G. (1959). Resection of tracheal stricture following tracheo-tomy, with primary anastomosis. Proc. roy. Soc. Med., 52, 143.

Fraser, K., and Bell, P. R. F. (1967). Distal tracheal stenosis followingtracheostomy. Brit. J. Surg., 54, 302.

Gibson, P. (1967). Aetiology and repair of tracheal stenosis followingtracheostomy and intermittent positive pressure respiration.Thorax, 22,1.

Johnston, J. B., Wright, J. S., and Hercus, V. (1967). Tracheal stenosisfollowing tracheostomy-a conservative approach to treatment.J. thorac. cardiovasc. Surg., 53, 206.

Meade, J. W. (1961). Tracheostomy-its complications and theirmanagement. Neiv Engl. J. Med., 265, 519.

Miscall, L., McKittrick, J. B., Giordano, R. P., and Nolan, R. B.(1963). Stenosis of trachea, resection and end to end anastomosis.Arch. Surg., 87, 726.

Narodick, B. G., Worman, L. W., and Pemberton, A. H. (1965).Relaxation technique for tracheal reconstruction. Ann. thorac.Surg., 1, 190.

Putney, F. J. (1955). Complications aid postoperative care oftracheo-tomv. Arch. Otolaryng., 62, 272.

Watts, J. McK. (1963). Tracheostomy in modern practice. Brit. J.Surg., 50, 954.

Worman, L. W., Starr, C., and Narodick, B. G. (1966). Tracheoplastytechnics for reconstruction after extensive resection. Amer. J.Surg., 111, 819.

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