Diseases of the Trachea and Airway
Diseases of the trachea and airways are uncommon and diverse. We have a special interest in these conditions, including tracheal stenosis, tracheal and airway tumors, tracheoesophageal fistula, and tracheomalacia.
Two of our surgeons (Drs. Natalie Lui and Joseph Shrager) trained at the Massachusetts General Hospital, the world leader in management of these difficult problems. We work closely with the Division of Interventional Pulmonology and the Department of Otolaryngology Head and Neck Surgery to offer the full spectrum of treatments, from bronchoscopic procedures such as ablation and stent placement, to surgical procedures such as tracheal resection and reconstruction and tracheoplasty.
The normal trachea (windpipe) brings air from the mouth and nose to the lungs (Figure 1). Tracheal stenosis is a narrowing of the trachea that can cause shortness of breath, cough, wheezing, and stridor (Figure 2). The most common cause is prolonged intubation or tracheostomy, when a tube is used to assist with breathing via a mechanical ventilator. It can also be caused by inflammatory or immunologic diseases. Another cause is idiopathic tracheal stenosis, which occurs mostly in women for unknown reasons.
Evaluation includes a computed tomography (CT) scan and bronchoscopy, during which the length of stenosis and normal trachea, as well as the health of the surrounding tissues, are evaluated. Treatment may start with bronchoscopic procedures, such as balloon or rigid bronchoscopic dilation, ablation, or stent placement.
Many patients require a more definitive surgical procedure called a tracheal resection and reconstruction (Figure 4). The goal of this operation is to remove the abnormal segment of trachea and to re-connect the two remaining ends together, allowing the patient to breathe comfortably again. Most commonly, this operation can be done through a neck incision that is well-tolerated. The operation is effective in resolving the problem in approximately 95% of patients, and it requires an approximately 5 day hospital stay.
Tracheal and airway tumors are very rare and often initially misdiagnosed (Figure 3). The most common primary tracheal tumors are squamous cell carcinoma and adenoid cystic carcinoma. Patients often have cough, wheezing, stridor, and hemoptysis (coughing up blood). Evaluation includes a CT scan and bronchoscopy, during which the exact location and character of the tumor is determined. Bronchoscopy can be "flexible" (where the bronchoscope can bend and uses video enhancement of the image) or "rigid" (where a larger, metal bronchoscope allows the use of larger instruments). Tumors that are too extensive to be completely removed by surgery are often debulked or ablated using mechanical, laser, or other energy-employing techniques such as argon beam or cryo (cold) therapy.
Resectable tracheal tumors are most often treated with a tracheal resection and reconstruction (Figure 4). Most often this operation is performed through the neck, although if the tumor is farther down the trachea, it can be done through an incision in the breastbone (sternotomy) or the right chest (thoracotomy) (Figure 5). Patients may require postoperative radiotherapy and/or chemotherapy for malignant tumors.
A tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. These are usually caused by complications of intubation, trauma, or operations such as esophagectomy or laryngectomy. Patients can become very ill due to infected fluid from the esophagus contaminating the lungs. After the associated pneumonia and poor nutritional state are improved, treatment requires a tracheal resection and reconstruction (Figure 4) as well as repair of the esophagus. The goal of this operation is for the patient to breathe and eat comfortably again.
Tracheomalacia is a weakness in the membranous (back) trachea and change in the shape of the cartilaginous (front) trachea (Figure 6). When patients with tracheomalacia exhale, the membranous trachea bows towards the cartilaginous trachea, obstructing the airway. This abnormality often extends to the bilateral mainstem bronchi, the smaller airways that split off from the trachea, in which case it is called tracheobronchomalacia.
Tracheomalacia and tracheobronchomalacia are often diagnosed after a long evaluation for shortness of breath, cough, or multiple pulmonary infections. Evaluation starts with a CT scan with images taken during both inhalation and exhalation, and bronchoscopy. The Interventional Pulmonology team often places temporary Y stents to keep the airway open and determine whether surgery is likely to improve symptoms more permanently. The Y stents cannot be left in place for long periods of time.
In select patients, this condition can be treated with tracheoplasty or tracheobronchoplasty, performed through the right chest (Figure 5). In this operation, a Y-shaped mesh is sewn to the back of the trachea and mainstem bronchi to reinforce the membranous wall and prevent collapse of the airway during exhalation or cough (Figure 6 and Figure 7). Patients often have great improvement in their breathing and functional status after this operation.
If you would like to make an appointment to see one of our surgeons for any of these problems, please call (650) 498-6000 and ask for the Thoracic Surgery new patient coordinator, or call (650) 721-2086.
The Division of Thoracic Surgery in the Department of Cardiothoracic Surgery at the Stanford School of Medicine is located in the San Francisco Bay Area in northern California. For more information about our services, please contact Donna Yoshida at (650) 721-2086 or Cliff David at (650) 721-6400. For new patient Thoracic Surgery Clinic Scheduling, please call (650) 498-6000.