- Email: [email protected]
Conservatively Treated Extended Tracheal Necrosis Complicating Pharyngolaryngectomy
1810
CASE REPORT DE WOLF ET AL MALIGNANT GLOMUS TUMOR IN THE UPPER TRACHEA
Conservatively Treated Extended Tracheal Necrosis Complicating Pharyngolaryngectomy Julien De Wolf, MD, Clement Fournier, MD, Ecaterina Surmei, MD, Jocelyn Bellier, MD, and Henri Lucien Porte, MD, PhD Thoracic Surgery Department, Calmette Hospital, University Hospital of Lille, Lille, France
Tracheal necrosis is a rare life-threatening phenomenon that most often occurs after thyroid operations or prolonged intubation. Conservative treatment can be one choice in extensive tracheal necrosis. We report the case of a 59-year-old man, with tracheal necrosis that developed after pharyngolaryngectomy, that we treated conservatively using hyperbaric oxygen therapy and antibiotic therapy. The follow-up was assured by tracheobronchoscopy. A year after his discharge, the trachea was totally healed. (Ann Thorac Surg 2015;99:1810–1) Ó 2015 by The Society of Thoracic Surgeons
FEATURE ARTICLES
T
racheal necrosis (TN) is a rare consequence of pharyngolaryngectomy, being rather frequent after thyroid operations or prolonged intubation. Many different invasive surgical procedures have been used to treat extended lesions of the trachea. Conservative treatment has also been described for the management of tracheal injury. The choice of treatment should be determined by the tracheobronchoscopy evaluation and clinical status. Hyperbaric oxygen therapy (HOT) has proven to be helpful in reversing tissue oxygenation and in promoting angiogenesis.
Ann Thorac Surg 2015;99:1810–1
from 4.5 cm from under the tracheotomy to 2.5 cm above the carina, with 30% stenosis (grade II by the Freitag classification; Figs 1 and 2). The barium follow-through was normal. Considering the good overall clinical tolerance, we chose conservative treatment: the tracheotomy tube was deflated, and the patient received 14 days of intravenous antibiotic treatment with levofloxacin and amoxicillin/ clavulanate. HOT was conducted for 21 days. The treatment consisted of two 90-minute sessions of HOT per day (2.5 absolute atmospheres/100% oxygen). A follow-up tracheobronchoscopy was performed on days 3 and 7 and then weekly until complete tracheal healing was observed. The patient was discharged after 3 weeks. Systematic tracheobronchoscopy 3 months later showed an ostial stenosis of the tracheostomy and a dystrophic trachea, with no ventilatory consequences. This was treated by endoscopic dilatation. One year later, follow-up tracheobronchoscopy showed complete cicatrization of the trachea.
Comment TN is a rare, life-threatening phenomenon. The major element of tracheal injury support is tracheobronchoscopic evaluation. A standardized classification was proposed by Freitag and colleagues [1] to compare different tracheobronchial injuries and manage all tracheobronchial stenosis uniformly. The location (Table 1) and degree (Table 2) of stenosis are the most important elements to take into account. Given that our patient had good tolerance and a Freitag score of 2 and II to III based on evaluation by fibroscopy,
A 51-year-old patient who had undergone laryngopharyngectomy a month earlier for a pT3 N0 M0 squamous cell carcinoma, complicated by a sialosyrinx, was admitted to our institution with acute respiratory failure. The sialosyrinx was treated initially, keeping the tracheostomy tube inflated. Emergency tracheobronchoscopy showed tracheal necrosis (TN) with cartilaginous ring debris obstructing the tracheal lumen; this resulted in approximately 80% stenosis (grade 4 by the Freitag classification). Respiratory failure improved immediately after tracheal desobstruction by removing debris. A chest computed tomography scan confirmed bilateral basal pneumopathy without hemopneumothorax or pneumomediastinum. The posterolateral tracheal wall was irregular, matching the tracheobronchoscopy findings. A second tracheobronchoscopy performed the day after showed 6 cm of TN stretching Accepted for publication June 17, 2014. Address correspondence to Dr De Wolf, 40 rue Royale, 59000 Cedex, France; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Lille
Fig 1. Tracheal stenosis grade 2 by the Freitag classification. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.119
Ann Thorac Surg 2015;99:1810–1
CASE REPORT DE WOLF ET AL TN COMPLICATING PHARYNGOLARYNGECTOMY
1811
Table 2. Freitag Numeric Assignment of Degree of Stenosis Code 0 1 2 3 4 5
Fig 2. Tracheal necrosis location II to III by the Freitag classification.
Table 1. Freitag Scoring System According to Location Code I II III IV V
Location Upper third of the trachea Middle third of the trachea Lower third of the trachea Right main bronchus Left main bronchus
No stenosis 1–25 26–50 51–75 76–90 91–complete obstruction
perform a mediastinal tracheostomy [4]. However, this option needs to be considered in light of alterations in the quality of life. Owing to fragile vascularization and based on our experience, we considered that HOT could be helpful in healing the patient’s TN. HOT has been shown to increase a number of growth factors, including those playing a role in angiogenesis such as local nitric oxide and vascular endothelial growth factor [5, 6]. The result is neovascularization at the site of hypoxic tissue. In addition, HOT reverses inadequate tissue oxygenation by using increased atmospheric pressure and hyperoxia [7]. In one study, HOT was beneficial in the management of ischemic bronchitis. In that study, 28 (62.4%) of the 34 included ischemic bronchitis patients were cured; all of them had been treated with HOT [8]. No patients presented with any adverse effects. In conclusion, we recommend conservative treatment as the best approach to extended TN in patients with stable respiratory failure. The use of HOT should be considered in these indications. Surgical repair should be restricted to patients in whom conservative treatment has failed and guided by tracheobronchoscopic evaluation.
References 1. Freitag L, Ernst A, Unger M, Kovitz K, Marquette CH. A proposed classification system of central airway stenosis. Eur Respir J 2007;30:7–12. 2. Grillo HC, Dignan EF, Miura T. Extensive resection and reconstruction of mediastinal trachea without prosthesis or graft: an anatomical study in man. J Thorac Cardiovasc Surg 1964;48:741–9. 3. Wurtz A, Porte H, Conti M, et al. Tracheal replacement with aortic allografts. N Engl J Med 2006;355:1938–40. 4. Conti M, Benhamed L, Mortuaire G, Chevalier D, Pinc¸on C, Wurtz A. Indications and results of anterior mediastinal tracheostomy for malignancies. Ann Thorac Surg 2010;89: 1588–95. 5. Asano T, Kaneko E, Shinozaki S, et al. Hyperbaric oxygen induces basic fibroblast growth factor and hepatocyte growth factor expression, and enhances blood perfusion and muscle regeneration in mouse ischemic hind limbs. Circ J 2007;71: 405–11. 6. Boykin JV, Baylis C. Hyperbaric oxygen therapy mediates increased nitric oxide production associated with wound healing: a preliminary study. Adv Skin Wound Care 2007;20: 382–8. 7. Thom SR. Hyperbaric oxygen—its mechanism and efficacy. Plast Reconstr Surg 2011;127(Suppl 1):131S–41S. 8. Benhamed L, Bellier J, Fournier C, et al. Postoperative ischemic bronchitis after lymph node dissection and primary lung cancer resection. Ann Thorac Surg 2011;91:355–9.
FEATURE ARTICLES
we chose a conservative course of treatment. We would have considered surgical intervention only after conservative treatment failure as noted by an increase in the necrotic area, the occurrence of a perforation of the trachea, or poor respiratory tolerance requiring mechanical ventilation. During the past decade, many different surgical procedures have been tried to treat extended lesions of the trachea. Given that the length of TN was at least 6 cm, our surgical options were sparse. Extensive resection and reconstruction of the mediastinal trachea without a prothesis or graft requires careful mobilization of the entire trachea, associated with suprahyoid laryngeal release and freeing of the hilum of the right lung by entering the pleural space [2]. Accordingly, resection with an end-to-end anastomosis was, in our opinion, not a safe option, because the patient was 1.75 meters tall, with a total tracheal length of 11 cm. Other options include tracheal replacement with an aortic allograft or any other graft. This kind of procedure has never been performed successfully to treat TN [3]. Mediastinal tracheostomy was a suitable option because the necrosis stopped 2.5 cm above the carina, which is enough in our experience to
Degree of Stenosis (%)
CASE REPORT DE WOLF ET AL MALIGNANT GLOMUS TUMOR IN THE UPPER TRACHEA
Conservatively Treated Extended Tracheal Necrosis Complicating Pharyngolaryngectomy Julien De Wolf, MD, Clement Fournier, MD, Ecaterina Surmei, MD, Jocelyn Bellier, MD, and Henri Lucien Porte, MD, PhD Thoracic Surgery Department, Calmette Hospital, University Hospital of Lille, Lille, France
Tracheal necrosis is a rare life-threatening phenomenon that most often occurs after thyroid operations or prolonged intubation. Conservative treatment can be one choice in extensive tracheal necrosis. We report the case of a 59-year-old man, with tracheal necrosis that developed after pharyngolaryngectomy, that we treated conservatively using hyperbaric oxygen therapy and antibiotic therapy. The follow-up was assured by tracheobronchoscopy. A year after his discharge, the trachea was totally healed. (Ann Thorac Surg 2015;99:1810–1) Ó 2015 by The Society of Thoracic Surgeons
FEATURE ARTICLES
T
racheal necrosis (TN) is a rare consequence of pharyngolaryngectomy, being rather frequent after thyroid operations or prolonged intubation. Many different invasive surgical procedures have been used to treat extended lesions of the trachea. Conservative treatment has also been described for the management of tracheal injury. The choice of treatment should be determined by the tracheobronchoscopy evaluation and clinical status. Hyperbaric oxygen therapy (HOT) has proven to be helpful in reversing tissue oxygenation and in promoting angiogenesis.
Ann Thorac Surg 2015;99:1810–1
from 4.5 cm from under the tracheotomy to 2.5 cm above the carina, with 30% stenosis (grade II by the Freitag classification; Figs 1 and 2). The barium follow-through was normal. Considering the good overall clinical tolerance, we chose conservative treatment: the tracheotomy tube was deflated, and the patient received 14 days of intravenous antibiotic treatment with levofloxacin and amoxicillin/ clavulanate. HOT was conducted for 21 days. The treatment consisted of two 90-minute sessions of HOT per day (2.5 absolute atmospheres/100% oxygen). A follow-up tracheobronchoscopy was performed on days 3 and 7 and then weekly until complete tracheal healing was observed. The patient was discharged after 3 weeks. Systematic tracheobronchoscopy 3 months later showed an ostial stenosis of the tracheostomy and a dystrophic trachea, with no ventilatory consequences. This was treated by endoscopic dilatation. One year later, follow-up tracheobronchoscopy showed complete cicatrization of the trachea.
Comment TN is a rare, life-threatening phenomenon. The major element of tracheal injury support is tracheobronchoscopic evaluation. A standardized classification was proposed by Freitag and colleagues [1] to compare different tracheobronchial injuries and manage all tracheobronchial stenosis uniformly. The location (Table 1) and degree (Table 2) of stenosis are the most important elements to take into account. Given that our patient had good tolerance and a Freitag score of 2 and II to III based on evaluation by fibroscopy,
A 51-year-old patient who had undergone laryngopharyngectomy a month earlier for a pT3 N0 M0 squamous cell carcinoma, complicated by a sialosyrinx, was admitted to our institution with acute respiratory failure. The sialosyrinx was treated initially, keeping the tracheostomy tube inflated. Emergency tracheobronchoscopy showed tracheal necrosis (TN) with cartilaginous ring debris obstructing the tracheal lumen; this resulted in approximately 80% stenosis (grade 4 by the Freitag classification). Respiratory failure improved immediately after tracheal desobstruction by removing debris. A chest computed tomography scan confirmed bilateral basal pneumopathy without hemopneumothorax or pneumomediastinum. The posterolateral tracheal wall was irregular, matching the tracheobronchoscopy findings. A second tracheobronchoscopy performed the day after showed 6 cm of TN stretching Accepted for publication June 17, 2014. Address correspondence to Dr De Wolf, 40 rue Royale, 59000 Cedex, France; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Lille
Fig 1. Tracheal stenosis grade 2 by the Freitag classification. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.06.119
Ann Thorac Surg 2015;99:1810–1
CASE REPORT DE WOLF ET AL TN COMPLICATING PHARYNGOLARYNGECTOMY
1811
Table 2. Freitag Numeric Assignment of Degree of Stenosis Code 0 1 2 3 4 5
Fig 2. Tracheal necrosis location II to III by the Freitag classification.
Table 1. Freitag Scoring System According to Location Code I II III IV V
Location Upper third of the trachea Middle third of the trachea Lower third of the trachea Right main bronchus Left main bronchus
No stenosis 1–25 26–50 51–75 76–90 91–complete obstruction
perform a mediastinal tracheostomy [4]. However, this option needs to be considered in light of alterations in the quality of life. Owing to fragile vascularization and based on our experience, we considered that HOT could be helpful in healing the patient’s TN. HOT has been shown to increase a number of growth factors, including those playing a role in angiogenesis such as local nitric oxide and vascular endothelial growth factor [5, 6]. The result is neovascularization at the site of hypoxic tissue. In addition, HOT reverses inadequate tissue oxygenation by using increased atmospheric pressure and hyperoxia [7]. In one study, HOT was beneficial in the management of ischemic bronchitis. In that study, 28 (62.4%) of the 34 included ischemic bronchitis patients were cured; all of them had been treated with HOT [8]. No patients presented with any adverse effects. In conclusion, we recommend conservative treatment as the best approach to extended TN in patients with stable respiratory failure. The use of HOT should be considered in these indications. Surgical repair should be restricted to patients in whom conservative treatment has failed and guided by tracheobronchoscopic evaluation.
References 1. Freitag L, Ernst A, Unger M, Kovitz K, Marquette CH. A proposed classification system of central airway stenosis. Eur Respir J 2007;30:7–12. 2. Grillo HC, Dignan EF, Miura T. Extensive resection and reconstruction of mediastinal trachea without prosthesis or graft: an anatomical study in man. J Thorac Cardiovasc Surg 1964;48:741–9. 3. Wurtz A, Porte H, Conti M, et al. Tracheal replacement with aortic allografts. N Engl J Med 2006;355:1938–40. 4. Conti M, Benhamed L, Mortuaire G, Chevalier D, Pinc¸on C, Wurtz A. Indications and results of anterior mediastinal tracheostomy for malignancies. Ann Thorac Surg 2010;89: 1588–95. 5. Asano T, Kaneko E, Shinozaki S, et al. Hyperbaric oxygen induces basic fibroblast growth factor and hepatocyte growth factor expression, and enhances blood perfusion and muscle regeneration in mouse ischemic hind limbs. Circ J 2007;71: 405–11. 6. Boykin JV, Baylis C. Hyperbaric oxygen therapy mediates increased nitric oxide production associated with wound healing: a preliminary study. Adv Skin Wound Care 2007;20: 382–8. 7. Thom SR. Hyperbaric oxygen—its mechanism and efficacy. Plast Reconstr Surg 2011;127(Suppl 1):131S–41S. 8. Benhamed L, Bellier J, Fournier C, et al. Postoperative ischemic bronchitis after lymph node dissection and primary lung cancer resection. Ann Thorac Surg 2011;91:355–9.
FEATURE ARTICLES
we chose a conservative course of treatment. We would have considered surgical intervention only after conservative treatment failure as noted by an increase in the necrotic area, the occurrence of a perforation of the trachea, or poor respiratory tolerance requiring mechanical ventilation. During the past decade, many different surgical procedures have been tried to treat extended lesions of the trachea. Given that the length of TN was at least 6 cm, our surgical options were sparse. Extensive resection and reconstruction of the mediastinal trachea without a prothesis or graft requires careful mobilization of the entire trachea, associated with suprahyoid laryngeal release and freeing of the hilum of the right lung by entering the pleural space [2]. Accordingly, resection with an end-to-end anastomosis was, in our opinion, not a safe option, because the patient was 1.75 meters tall, with a total tracheal length of 11 cm. Other options include tracheal replacement with an aortic allograft or any other graft. This kind of procedure has never been performed successfully to treat TN [3]. Mediastinal tracheostomy was a suitable option because the necrosis stopped 2.5 cm above the carina, which is enough in our experience to
Degree of Stenosis (%)