Causes and consequences of adult laryngotracheal stenosis

Abstract

Objectives/hypothesis: Laryngotracheal stenosis (LTS) is largely considered a structural entity, defined on anatomic terms (i.e., percent stenosis, distance from vocal folds, overall length). This has significant implications for identifying at-risk populations, devising systems-based preventive strategies, and promoting patient-centered treatment. The present study was undertaken to test the hypothesis that LTS is heterogeneous with regard to etiology, natural history, and clinical outcome.

Study design: Retrospective cohort study of consecutive adult tracheal stenosis patients from 1998 to 2013.

Methods: Subjects diagnosed with laryngotracheal stenosis (ICD-9: 478.74, 519.19) between January 1, 1998, and January 1, 2013, were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted. Records were reviewed for etiology of stenosis, treatment approach, and surgical dates. Stenosis morphology was derived from intraoperative measurements. The presence of tracheostomy at last follow-up was recorded.

Results: One hundred and fifty patients met inclusion criteria. A total of 54.7% had an iatrogenic etiology, followed by idiopathic (18.5%), autoimmune (18.5%), and traumatic (8%). Tracheostomy dependence differed based on etiology (P < 0.001). Significantly more patients with iatrogenic (66%) and autoimmune (54%) etiologies remained tracheostomy-dependent compared to traumatic (33%) or idiopathic (0%) groups. On multivariate regression analysis, each additional point on Charlson Comorbidity Index was associated with a 67% increased odds of tracheostomy dependence (odds ratio 1.67; 95% confidence interval 1.04-2.69; P = 0.04).

Conclusions: Laryngotracheal stenosis is not a homogeneous clinical entity. It has multiple distinct etiologies that demonstrate disparate rates of long-term tracheostomy dependence. Understanding the mechanism of injury and contribution of comorbid illnesses is critical to systems-based preventive strategies and patient-centered treatment.

Level of evidence: 4.

Keywords: Tracheal stenosis; intubation; laryngotracheal stenosis; subglottic; tracheostomy.

Figure 1

Heatmap grouped by different etiologies of stenosis. Each line represents an individual patient. Tracheostomy status (red indicating trach), medical comorbidities (presence highlighted in red), and sex (blue indicating male, purple indicating female). In Autoimmune subgroup: GPA (granulomatosis with polyangitis, i.e. Wegener’s granulomatosis), RPC (relapsing polychondritis), EB (epidermolysis bullosa) (A.). Location of tracheal stenosis in iatrogenic injuries. Histogram showing location of stenotic lesion in iatrogenic subgroup in relation to distance from glottis (B.). Tracheostomy status of different etiologies at last f/u. Asterisk denotes statistical significance from idiopathic group (C.)

Figure 2

Tracheostomy status of different Cotton-Myer, Lano, & McCaffrey grades at last f/u. For Cotton-Myer staging, asterisk denotes statistical significance between Grade I&II vs. III&IV (A.). Diagnosis of tracheomalacia stratified by etiology. Asterisk denotes statistical significance between iatrogenic etiology and all other groups (B.). Rate of tracheostomy in iatrogenic etiology patients with and without a diagnosis of tracheomalacia. Asterisk denotes statistical significance (C.).