AJR 2001; 177:1423-1426
© American Roentgen Ray Society
Expandable Metallic Stent Placement in Upper Tracheal Stenosis
Value of Laryngeal Masks
Noboru Tanigawa1,
Satoshi Sawada1,
Yoshikazu Okuda1,
Mitsuharu Sougawa1,
Atsushi Komemushi1,
Masayuki Kojima1,
Yuzo Hirokawa1 and
Takashi Asai2
1
Department of Radiology, Kansai Medical University, 10-15 Fumizono, Moriguchi,
Osaka, 570-8507 Japan.
2
Department of Anesthesiology, Kansai Medical University, Moriguchi, Osaka,
570-8507 Japan.
Received November 7, 2000;
accepted after revision July 2, 2001.
Address correspondence to N. Tanigawa
Introduction
Stenotic lesions in the central airway cause serious dyspnea, whether the
lesions are benign or malignant. Tracheal stenosis, in particular, induces
severe dyspnea and may cause sudden death from occlusion with sputum. Metallic
stenting has been used to treat dyspnea caused by central airway stenosis, and
favorable outcomes have been reported
[1,
2]. Stent placement in the
airway is indicated for obstruction of the central airways, such as the
trachea, bilateral main bronchi, and intermediate branch bronchi. However, a
definite range of indication has not yet been established, and, in particular,
the limit for the use of stents is uncertain in the upper part of the trachea.
To treat patients with tracheal stenosis, we placed stents around the glottis
using the laryngeal mask to assess the value of this procedure and to define
the limits of metallic stent placement in the upper trachea. We also evaluated
the usefulness of the laryngeal mask for upper tracheal stenting.
Materials and Methods
The laryngeal mask was designed on the basis of a new concept in airway
management and has been gaining a firm position in anesthesiology practice.
The laryngeal mask is designed to form a seal around the larynx, with the
distal part of the mask conforming to the hypopharynx and the walls of the
long axis of the mask facing toward the pyriform fossae (Figs.
1 and
2).
Between July 1989 and December 2000, 70 patients with dyspnea underwent
tracheobronchial stenting for tracheobronchial stenoses due to malignant or
benign disease. In these 70 patients, four patients (two men and two women),
three with inoperable malignancy-related tracheal stenosis and one with
tracheomalacia, underwent tracheal stenting with the laryngeal mask. Their age
range was 46-67 years, with a mean age of 58.8 years. A mediastinal tumor with
unknown history was diagnosed in two patients, tracheal invasion due to
postoperative local recurrence of esophageal cancer in one, and tracheomalacia
in one. The mean distance from the proximal end of the lesions to the glottis
was 24.3 mm (range, 15-32 mm), and the mean length was 38.8 mm (range, 35-45
mm) (Table 1). The patient with
local recurrence of postoperative esophageal cancer was intubated beyond the
stenotic site of the trachea. The patient with tracheomalacia had undergone
stenting of the pharynx and larynx under local anesthesia; these stents were
inadvertently placed distally to the lesion. Self-expanding zigzag metallic
stents of our own making were placed in one patient, and Gianturco Z stents
(Cook, Bloomington, IN) in the other three.
The stents were placed in patients who were undergoing general anesthesia.
The stents were placed as follows: A bronchoscope (BF-P10; Olympus Optical,
Tokyo, Japan) was first introduced through the laryngeal mask to identify the
site of the glottis, and a skin marker was placed under fluoroscopy; the
bronchoscope was then advanced beyond the glottis, and another skin marker was
placed at the proximal end of the lesion. All patients, except the patient who
had been intubated beyond the stenotic site of the trachea, had severe
stenosis so that it was impossible to pass the lesions with the bronchoscope.
A 0.035-inch guidewire (Cook, Bloomington, IN) was therefore inserted through
a forceps hole in the bronchoscope and advanced beyond the lesion. The
bronchoscope was then withdrawn, and a sheath (Cook) for stent placement was
inserted and advanced along the guidewire beyond the stenosis. The stents were
then guided to the target site and placed by removing the sheath. Last,
dilatation of the stenotic lesion was confirmed by bronchoscopy. If the lesion
was not sufficiently dilated, additional stents were placed. Again, the
patency of the trachea was confirmed by bronchoscopy before completion of the
procedure.
Follow-up chest radiography was performed 1, 3, and 7 days after stenting,
and CT was performed 7 days after stenting. If recurrent stenosis was
suspected on the basis of chest radiographic findings or clinical symptoms, CT
and bronchial fiberscopy were performed to assess the site and nature of
restenosis.
Results
Bronchoscopy performed through the laryngeal masks enabled accurate and
easy identification of the site of the glottis as well as the proximal end of
the lesions. In all patients, stents were successfully placed at the target
sites. The mean distance of the glottis to the proximal end of the stents was
17.5 mm (range, 8-25 mm). During the procedure, when the guidewire was
advanced over the stenosis, cough reflex occurred but disappeared
spontaneously after 1-2 min. Subjective dyspnea improved in all patients as
soon as they awoke from the anesthesia. The tube was withdrawn before stenting
in the patient who had been intubated beyond the lesion before the procedure,
and a laryngeal mask was placed instead. As a result, the stents were
successfully placed at the target site.
In the patient with tracheomalacia, we first attempted to place the stents
in the pharynx and larynx while the patient was under local anesthesia.
However, the patient developed marked cough reflex throughout the procedure
and moved because of dyspnea when the sheath for stent placement was advanced
beyond the stenotic lesion. Consequently, the stents were placed distally to
the target site. During a second attempt, a laryngeal mask was placed first,
and then the stents were inserted. No cough reflex occurred during the
procedure, and the stents were easily placed at the target site (Fig.
3A,3B).
After stent placement, the subjective feeling of dyspnea disappeared in all
patients. The mean score of the Hugh-Jones classification system
[3] improved from the
preprocedural value of 4.8 (range, 4-5) to 2 (range, 1-3)
(Table 1). In each patient, a
sore throat persisted for approximately 3 days after stent placement but was
controlled with oral antiinflammatory analgesics.
Three patients with malignancy died 3, 4, and 6 months after the procedure,
and the patient with tracheomalacia was alive 12 months after the procedure.
During these follow-up periods, discomfort, pain, cough, or difficulty in
swallowing caused by stents being too close to the glottis were not reported
by any patients. No stent migration, rupture, or surrounding tissue damage
occurred as a result of patients bending their necks.
Discussion
To our knowledge, no established anesthetic procedures for stenting in the
trachea have been reported, and various procedures are currently used at
several medical institutions, depending on the site and severity of the
lesions. Stents ideally should be placed in conscious patients who are under
local anesthesia. However, if patients have severe dyspnea due to tight
stenosis, they may be momentarily suffocated when a sheath for introducing
stents passes the lesion. The patients may cough and move, making stent
placement difficult. We attempted to place stents in the patient with
tracheomalacia while he was under local anesthesia. However, he coughed and
moved, and as a consequence, the stents were placed distally to the target
site.
If the middle or lower trachea is obstructed, patients are intubated, and
stents may then be placed while the patient is under general anesthesia.
However, if the lesion is below the glottis, it is difficult to intubate the
patient. The tip of the tube may be inserted, but it is difficult to inflate
the cuff to stabilize the tube. In tubes that are commonly used in adults, the
distance from the tip of the tube to the proximal end of the cuff is
approximately 6 cm. Tracheal intubation, therefore, can be used only in
patients whose lesion is more than 6 cm from the glottis. For these reasons,
we decided to use laryngeal masks for stenting instead of tracheal intubation
in patients with upper tracheal stenosis.
The laryngeal mask was developed by Brain
[4] in 1983 to keep the
patient's airway open during administration of anesthesia. This device has
been used for difficult intubations
[5] and in emergencies to keep
the patient's airway open, but today this device is also used in short-term
surgeries [6]. To our
knowledge, only one case has been reported that describes the use of a
laryngeal mask to facilitate upper tracheal stenting
[7].
Laryngeal masks are easier to place than are tracheal intubations. In
addition, muscle relaxation is not necessary, and therefore the laryngeal
masks can be used in patients who have spontaneous breathing. This feature may
provide another benefit to patients with severe stenosis because airway
collapse can be prevented. The use of laryngeal masks enables accurate
localization of the glottis under bronchoscopy. In addition, the whole trachea
distal to the vocal cords can be freely passed, which provides optimal
conditions for stent placement.
During the postprocedural follow-up, no patients complained of discomfort,
pain, or cough reflex as a result of stents being too close to the glottis.
Stents placed in the upper trachea are located outside the thoracic cavity and
therefore are prone to migration
[8]; the stents may also
rupture or damage the surrounding tissues when the patients bend their necks.
However, no such complications occurred in our series.
Conclusion
Laryngeal mask placement is a safe and useful adjunct for placement of
stents to treat patients with upper tracheal stenosis. Stent placement in the
central airway near the glottis is safe and useful and contributes greatly to
the relief of dyspnea.
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Introduction
Materials and Methods
