Idiopathische progressive subglottische Stenose – chirurgische Therapieoptionen

Zusammenfassung

Die idiopathische progressive subglottische Stenose ist gekennzeichnet durch eine langsam fortschreitende, narbige Verengung des subglottischen Atemwegs. Betroffen sind fast ausschließlich Frauen zwischen der 3. und 5. Lebensdekade. Oft werden die Symptome initial als Asthma bronchiale fehlgedeutet und die Patienten erst nach ausbleibendem Therapieerfolg endoskopisch untersucht. Die therapeutischen Optionen lassen sich in endoskopische und offen chirurgische Techniken unterteilen. Mikrolaryngoskopische Laserabtragung und Dilatation führen i. d. R. zu guten Kurzzeitergebnissen. Allerdings kommt es in einem Großteil der Patienten innerhalb kurzer Zeit zur erneuten Stenosierung. Offene chirurgische Korrekturen basieren auf dem Prinzip einer kompletten Resektion der erkrankten Atemwegsanteile. Bei fortgeschrittenen Stenosen muss eine solche Resektion mit unterschiedlichen Erweiterungstechniken kombiniert werden. Folgende Operationsverfahren sind je nach Schwere und Beschaffenheit der Stenose notwendig: klassische subglottische Resektionen nach Grillo, Krikoplastien mit dorsaler oder lateraler Mukosaplastik oder eine Kombination aus Resektion und Erweitungsplastik mit Rippenknorpelinterponaten. In erfahrenen Zentren können durch die Operation Erfolgsraten von über 95 % bei gleichzeitigem funktionellem Erhalt der Stimm- und Schluckfunktion erreicht werden.

Abstract

Idiopathic subglottic stenosis is a disease characterized by slow, progressive scarring and constriction of the subglottic airway. It almost always occurs in females between the 3rd and 5th decade of life. Symptoms are frequently misinterpreted as asthma and patients are referred for endoscopic evaluation only when asthma medications fail to alleviate their symptoms. Treatment options can be divided into endoscopic and open surgical techniques. Microlaryngoscopic scar reduction by laser followed by balloon dilation usually delivers good short-term results. However, the majority of patients will experience restenosis within a short period of time. Open surgical correction techniques are based on a complete removal of the affected airway segment. This must be combined with various extended resection techniques in patients with advanced stenosis. Depending on the extent and severity of the stenosis the following surgical techniques are required: standard cricotracheal resection (Grilloʼs technique), cricoplasty with dorsal and lateral mucosaplasty, or a combination of resection and enlargement techniques using rib cartilage grafts. In experienced centres, success rates of over 95 % are reported with good functional outcome of voice and deglutition.

Schlüsselwörter

Thoraxchirurgie - Stenose - chirurgische Technik

Key words

stenosis - thoracic surgery - surgical technique

• Literatur

• 1 Brandenburg JH. Idiopathic subglottic stenosis. Trans Am Acad Ophthalmol Otolaryngol 1972; 76: 1402-1406
• 2 Freitag L, Ernst A, Unger M et al. A proposed classification system of central airway stenosis. Eur Respir J 2007; 30: 7-12
• 3 Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 1982; 33: 3-18
• 4 Monnier P, Ikonomidis C, Jaquet Y et al. Proposal of a new classification for optimising outcome assessment following partial cricotracheal resections in severe pediatric subglottic stenosis. Int J Pediatr Otorhinolaryngol 2009; 73: 1217-1221
• 5 Ashiku SK, Kuzucu A, Grillo HC et al. Idiopathic laryngotracheal stenosis: Effective definitive treatment with laryngotracheal resection. J Thorac Cardiovasc Surg 2004; 127: 99-107
• 6 Grillo HC, Mark EJ, Mathisen DJ et al. Idiopathic laryngotracheal stenosis and its management. Ann Thorac Surg 1993; 56: 80-87
• 7 Mark EJ, Meng F, Kradin RL et al. Idiopathic tracheal stenosis: a clinicopathologic study of 63 cases and comparison of the pathology with chondromalacia. Am J Surg Pathol 2008; 32: 1138-1143
• 8 Little FB, Koufman JA, Kohut RI et al. Effect of gastric acid on the pathogenesis of subglottic stenosis. Ann Otol Rhinol Laryngol 1985; 94: 516-519
• 9 Toohill RJ, Ulualp SO, Shaker R. Evaluation of gastroesophageal reflux in patients with laryngotracheal stenosis. Ann Otol Rhinol Laryngol 1998; 107: 1010-1014
• 10 Roh JL, Lee YW, Park HT. Effect of acid, pepsin, and bile acid on the stenotic progression of traumatized subglottis. Am J Gastroenterol 2006; 101: 1186-1192
• 11 Ashiku SK, Mathisen DJ. Idiopathic laryngotracheal stenosis. Chest Surg Clin N Am 2003; 13: 257-269
• 12 Gelbard A, Donovan DT, Ongkasuwan J et al. Disease homogeneity and treatment heterogeneity in idiopathic subglottic stenosis. Laryngoscope 2016; 126: 1390-1396
• 13 Dedo HH, Catten MD. Idiopathic progressive subglottic stenosis: findings and treatment in 52 patients. Ann Otol Rhinol Laryngol 2001; 110: 305-311
• 14 Nouraei SA, Sandhu GS. Outcome of a multimodality approach to the management of idiopathic subglottic stenosis. Laryngoscope 2013; 123: 2474-2484
• 15 Giudice M, Piazza C, Foccoli P et al. Idiopathic subglottic stenosis: Management by endoscopic and open-neck surgery in a series of 30 patients. Eur Arch Otorhinolaryngol 2003; 260: 235-238
• 16 Liberman M, Mathisen DJ. Tailored cricoplasty: An improved modification for reconstruction in subglottic tracheal stenosis. J Thorac Cardiovasc Surg 2009; 137: 573-578
• 17 Couraud L, Hafez A, Velly JF et al. Current reconstructive management of subglottic stenosis of the larynx with reference to sixty consecutively treated cases. Thorac Cardiovasc Surg 1985; 33: 263-267
• 18 Couraud L, Jougon JB, Velly JF. Surgical treatment of nontumoral stenoses of the upper airway. Ann Thorac Surg 1995; 60: 250-259
• 19 Morcillo A, Wins R, Gomez-Caro A et al. Single-staged laryngotracheal reconstruction for idiopathic tracheal stenosis. Ann Thorac Surg 2013; 95: 433-439
• 20 Jaquet Y, Lang F, Pilloud R et al. Partial cricotracheal resection for pediatric subglottic stenosis: long-term outcome in 57 patients. J Thorac Cardiovasc Surg 2005; 130: 726-732
• 21 Gnagi SH, Howard BE, Anderson C et al. Idiopathic subglottic and tracheal stenosis: a survey of the patient experience. Ann Otol Rhinol Laryngol 2015; 124: 734-739
• 22 DʼAndrilli A, Maurizi G, Andreetti C et al. Long-term results of laryngotracheal resection for benign stenosis from a series of 109 consecutive patientsdagger. Eur J Cardiothorac Surg 2016; [Epub ahead of print]
• 23 Piazza C, Del Bon F, Paderno A et al. Complications after tracheal and cricotracheal resection and anastomosis for inflammatory and neoplastic stenoses. Ann Otol Rhinol Laryngol 2014; 123: 798-804
• 24 Wright CD, Grillo HC, Wain JC et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004; 128: 731-739
• 25 Wang H, Wright CD, Wain JC et al. Idiopathic subglottic stenosis: factors affecting outcome after single-stage repair. Ann Thorac Surg 2015; 100: 1804-1811
• 26 Houlton JJ, de Alarcon A, Johnson K et al. Voice outcomes following adult cricotracheal resection. Laryngoscope 2011; 121: 1910-1914
• 27 Bryans L, Palmer AD, Schindler JS et al. Subjective and objective parameters of the adult female voice after cricotracheal resection and dilation. Ann Otol Rhinol Laryngol 2013; 122: 707-716