An 80-year-old man who was recovering from a recent stroke and a complex medical history presented to us with a recent history of shortness of breath and wheezing for two days. He had undergone a tracheostomy during his stroke treatment due to prolonged ventilation, and it was initially suspected that he had a post-tracheostomy stenosis. He underwent evaluation by pulmonology and a scan revealed a mass in the mid-posterior tracheal wall, roughly 3 cm in length and obstructing the lumen by >80% with focal invasion of the cricoid ring, which forms the cartilaginous base of the voice box on which the vocal cords sit. Endoscopy showed that the tumor was obstructing the airway with each expired breath. It was suspected to be cancerous. After evaluation by the head and neck surgery and anesthesia teams, multiple plans were discussed to completely remove the tumor and re-establish the airway.
Complete resection of the upper trachea and the cricoid ring (the cartilaginous base of the voice box framework) would likely be too high-risk a surgery for the patient to withstand, and the previous tracheostomy scar would increase the likelihood of failure. A pure bronchoscopy approach where the tumor could be completely removed using an endoscope also would not be feasible since there was a risk of bleeding and airway obstruction, and the location of the tumor made complete removal unlikely. After extensive discussion, a hybrid approach was planned. Under local anesthesia, the previous tracheal scar was freed, an anterior tracheal opening was created, and the patient was administered general anesthesia. After that bronchoscopy debulking was performed to remove most of the tumor from the lumen. A carbon dioxide fiber laser was then used to completely excise the tumor from within the trachea up to the cricoid ring. The opening in the trachea was then carefully closed. The patient was safely extubated and was completely relieved of his airway obstruction, discharged home on day 5. This was a novel approach, not having been described before for the treatment of these tumors, which allowed adequate access and complete removal, with minimal side-effects of surgery and quick recovery.
Treatment of complex airway problems pose a major challenge to even experienced teams. Limited working space and complex anatomy make approaches difficult and working in the airway while allowing the patient to breathe pose numerous challenges. Hybrid approaches allows the best of both worlds – bronchoscopy approaches allow minimal access and quick recovery, while surgery allow definitive access and completeness of treatment. Newer technologies like laser and cryotherapy allow precise treatment with very little collateral damage to the surrounding normal tissue. Dr Vivek Gundappa, Consultant Pomologist notes, “Tracheal masses are rare; they present with severe respiratory distress whether cancerous or not, and a multi-disciplinary approach is essential to mitigate them”.
Coordinated approaches between airway surgeons, interventional pulmonologists, and anesthetists allow low complication rates and quick return to function. In addition to cancer, other problems include post-tracheostomy scarring and fibrosis, post-acid-ingestion injuries, and benign tumors. Dr Narayana Subramaniam, Senior Consultant and Director of Head and Neck Surgery and Oncology and Director of Clinical Innovation commented, “This gentleman had a complex tumor and a previous surgery in the same site which made treatment difficult. Additionally, he had a complex medical history that required a tailor-made approach that reduced the risk of extensive surgery while being effective. We were happy to offer him a good result with excellent coordination and planning between surgeons, pulmonologists, and anesthetists. The Sparsh Yelahanka Complex Airway Clinic offers multi-disciplinary care to patients with airway problems. With significant expertise in interventional pulmonology, surgery, anesthesiology, radiology, and pathology, as well as the best technology, we can offer the best quality care for people with these difficult groups of disorders.
By: Dr Narayana Subramaniam, Senior Consultant and Director Head and Neck Surgery and Oncology and Director of Clinical Innovation, Sparsh Hospital