Chronic laryngeal stenosis

Chronic laryngeal stenosis
Chronic laryngeal stenosis is a gradual complete or partial narrowing of the laryngeal lumen. It is accompanied by a decrease in the amount of air entering the respiratory tract and as a result can lead to oxygen starvation of your body, and sometimes even to asphyxia.

The content of the article:
Causes of chronic laryngeal stenosis
Symptoms of chronic laryngeal stenosis
Diagnosis of the disease chronic laryngeal stenosis
Complications of chronic laryngeal stenosis
Principles of treatment of chronic laryngeal stenosis
Chronic laryngeal stenosis
Causes of chronic laryngeal stenosis
Permanent causes that can provoke the appearance of chronic laryngeal stenosis will be: developmental abnormalities, laryngeal injuries, laryngeal tumor, infectious and traumatic arthritis, inflammation of the cartilage and cartilage itself, as well as their complications, neuropathic laryngeal paresis, ingestion of foreign objects into the throat, various allergic reactions, surgical scars, bilateral cervical lymphadenitis, malignant tumors and benign formations, traumatic brain injuries, burns of the larynx, impaired activity of the lower laryngeal nerves, as well as inflammatory diseases.

Sometimes there is chronic stenosis as a result of an incorrectly performed tracheotomy (insertion of a tracheotomy tube into the larynx through an incision of the first ring of the trachea), incorrect selection of the tube or its prolonged and incorrect wearing.

Symptoms of chronic laryngeal stenosis
The main symptoms of the disease of chronic laryngeal stenosis primarily directly depend on the stage of the disease itself and the degree of narrowing of the laryngeal cleft, the presence of tumors. Otolaryngology currently distinguishes 4 stages in chronic laryngeal stenosis: the compensated stage, the subcompensated stage, the decompensated stage and the stage of suffocation.

The first stage of the disease is characterized by more rare and deep breathing, pauses between inhalation and exhalation, a significant decrease in the number of breaths, as well as a noticeable violation of the relationship between the normal pulse and concomitant respiratory movements. At the second subcompensated stage, based on the degree of narrowing of the laryngeal slit and on how long the disease lasts, the patient’s body itself gradually begins to breathe through the narrowed lumen. With heavy physical exertion, breathing becomes difficult, and in a state of calm it is leveled.

At this stage, the adaptation reactions can be respiratory, hemodynamic, blood, tissue. With respiratory habituation, breathing becomes more frequent, there is constant shortness of breath, and muscles uncharacteristic for this process participate in breathing. Increased pressure and acceleration of blood flow becomes constant, vascular permeability increases, and a large number of red blood cells appear in the blood, in this way the human body tries to saturate the blood with the necessary amount of oxygen. But such adaptive mechanisms work up to a certain point. Over time, hypoxia still increases and leads to the appearance of the third degree of chronic laryngeal stenosis.

During the third stage of decompensation, all the key signs of initial asphyxia and hypoxia are already clearly manifested in the human body. There is blueness of the mucous membranes, skin directly around the oral cavity, under the eyes and the whites of the eyes, there is a retraction of the intercostal spaces, when inhaling, a sharp retraction of the jugular fossa and subclavian pits, a person’s breathing becomes very frequent and is accompanied by some noise when inhaling air, also the patient has cold perspiration, the voice disappears and the person does not speak or he can only whisper. The fourth stage is the stage of complete asphyxia or suffocation, with it the human heart activity worsens, the patient’s breathing becomes shallow and quite rare, the pupils dilate, the skin turns blue, the body becomes indifferent to external stimuli, sluggish. Uncontrolled discharge of feces and urine, permanent loss of consciousness and eventually respiratory arrest is possible.

With prolonged chronic stenosis, adaptive functions can also be activated in the patient’s body, which are aimed at stable provision of the human body with the necessary amount of oxygen. At the same time, as at the second stage of the development of the disease, there is an increase in pulse, acceleration of blood flow, hypotension, shortness of breath, rapid breathing involving the muscles of the back, neck and shoulders. Also, after making certain blood tests, you can notice that anaerobic processes are triggered in all living cells, and hypertrophy of the heart muscle also appears. With chronic laryngeal stenosis, due to the constant need to wear a tracheotomy tube, the functions of humidification, warming of the upper respiratory tract, as well as mechanical and biological air purification are temporarily disabled.

Diagnosis of the disease chronic laryngeal stenosis
The main intention in the diagnosis is not so much the diagnosis as the determination of the main cause of chronic laryngeal stenosis. Diagnosis of the disease in most cases is based on the patient’s complaints, symptoms, anamnesis and on the results of such studies as:

laryngoscopy, biopsy;
bronchoscopy;
x-ray examination;
endoscopic examination.
When determining the diagnosis, a CT scan of the larynx, ultrasound examination of the thyroid gland, MRI of the brain, as well as bacteriological examination of smears from the open throat and radiography of the patient’s esophagus may be required.

Complications of chronic laryngeal stenosis
Acute lack of external respiration in chronic laryngeal stenosis leads to stagnant accumulation of sputum in the respiratory tract, which is a common cause of pneumonia and bronchitis. In patients with tracheostomy, the air entering the trachea is not warmed, moistened and purified, which in a normal healthy body occurs in the upper respiratory tract. In such cases, tracheitis and tracheobronchitis very often develop, and bronchitis has a chronic course. Lung diseases in the form of prolonged pneumonia, lead to bronchiectatic disease. A large load on the right part of the heart and the small circulatory circle leads to the appearance of pulmonary hypertension and the development of a pulmonary heart in the patient.

Principles of treatment of chronic laryngeal stenosis
If symptoms of suffocation appear, an ambulance should be called immediately. Even before the arrival of doctors, it is necessary to calm the patient, rub his hands and feet, moisten the air indoors or put the patient in the bathroom, having previously filled it with hot water. Be prepared for the fact that the patient is hospitalized. Do not be alarmed, but the first few days of treatment will take place in the intensive care unit.

The choice of treatment method directly depends on the primary disease that provoked chronic laryngeal stenosis and on the stage of the stenosis itself. Treatment can be medical and surgical. If the cause of the disease was a preliminary infectious disease, first of all, antibacterial therapy is used using antihistamines that will relieve allergic edema. In children, the cause can often be a foreign object, but its independent extraction in conditions outside the clinic is prohibited.

Surgical intervention may include the introduction of a tube, which will prevent the narrowing of the larynx, dilation with T-shaped tubes, dissection of the anterior wall of the larynx, stretching of the larynx with dilators and bouges.

In surgical cases of treatment of chronic laryngeal stenosis, the patient necessarily needs surgery, which will occur as follows: in a semi-sitting or lying position, anesthesia is administered to the patient, in cases of complete asphyxia, the operation is performed without any anesthesia, so as not to miss a single minute. Local anesthesia — 1% novocaine with an admixture of adrenaline solution 1:1000 (1 drop per 5 milliliters). After anesthesia, the hyoid bone of the patient, the excision of the thyroid cartilage and the tubercle of the cricoid cartilage begin to be probed. In order to better navigate, the median line is marked with diamond greens, as well as the level of cricoid cartilage. Next, a layered incision of the patient’s skin and subcutaneous tissue is made 6 centimeters vertically downwards strictly along the intended midline, starting from the lower edge of the cricoid cartilage. The superficial fascia is cut, and the place where the sternal-hyoid muscles connect is found under it. The hyoid muscle is dissected and the muscles are pushed apart in a blunt way. The isthmus of the thyroid gland is visible, it is very soft to the touch and is characterized by a brown-red color. Along the lower edge of the cricoid cartilage, the gland capsules are cut, which fixes the isthmus. The cricoid cartilage shifts downwards and is held with a hook with a blunt end. After that, the rings of the trachea itself, covered with fascia, will be visible. Careful homeostasis is necessary before opening the trachea. To fix the larynx, a hook with a sharp end is inserted into the thyroid-lingual membrane and fixed. In order to avoid coughing, a couple of drops of 2-3% Dicaine solution are injected into the trachea through a needle, then 2 and 3 rings of the trachea are opened with a pointed scalpel. The scalpel itself should not be inserted deeply, about 0.5 centimeters, so as not to accidentally injure the back wall of the trachea, which is devoid of cartilage and the adjacent front wall of the esophagus. With the help of a Trusseau expander, the edges in the trachea are gently pushed apart and a tracheotomy tube of the appropriate size is inserted, it is fixed on the patient’s neck with a gauze bandage. In children’s medical practice with chronic laryngeal stenosis, which is caused by diphtheria of the trachea and larynx, naso (oro)tracheal intubation is used using a flexible tube made of high-quality synthetic material. Intubation is performed strictly under direct laryngoscopy. If a long period of intubation is required, a tracheotomy will be performed, because a longer stay of the tube in the larynx can cause ischemia of the mucous membrane with further scarring and persistent stenosis of the respiratory organ.

All these are quite complex operations that can include many stages, but in most cases they give a very good result.

Postoperative therapy includes: prevention of purulent-inflammatory complications, improvement of microcirculation in the postoperative area, prevention of secondary scarring, reduction of general and local hypoxia, increased reactivity of the body and treatment of concomitant diseases, correction of hormonal abnormalities and cardiovascular disorders in the patient.

The effectiveness of treatment of patients with laryngeal stenosis of various etiologies is evaluated by doctors according to the following parameters:

restoration of a normal lumen in the respiratory tract;
the fact of decanulation;
return to the patient of stable respiratory function, vocal ability and separation function;
the duration of treatment and surgical interventions is taken into account;
the dynamics of indicators of gas and acid-base composition of blood, cardiac activity and respiratory function are observed.
To date, chronic laryngeal stenosis is completely curable, the main factor is the stage at which it is detected in the patient. If at least one of the above symptoms is detected, be sure to consult a doctor and the disease can be prevented at the medical level without hospitalization.

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