Tracheal stenosis is a known complication of prolonged intubation. It is difficult to treat and traditional surgical approach is associated with significant risk and complications. Recurrent stenosis due to granulation tissue necessitates repeated procedures. We describe a case of short web-like tracheal stenosis (concentric membranous stenosis less than 1 cm in length without associated cartilage damage) managed by a minimally invasive thoracic endoscopic approach. Topical application of Mitomycin C, a potent fibroblast inhibitor reduces granulation tissue formation and prevents recurrence

A Brichet

AC Erard

Bohari Samril

CB Croft

CE Lindholm

Chee Lun Lum

HC Grillo

J Braidy

Jamalul Azizi Abdul Rahman

JL Stauffer

Jyi Lin Wong

L Couraud

MJ Andrews

Mohammad Rizal Abdul Rahman

N Spittle

PE Baugne

Siew Teck Tie

VK Anand

W MacEwen

WS Krimsky

English

PubMed

Jyi Wong

Siew Tie

Chee Lum

Mohammad Rahman

Jamalul Rahman

Springer - Publisher Connector

CASE REPORT Open Access
Successful treatment of tracheal stenosis by rigid
bronchoscopy and topical mitomycin C: a case
report
Jyi Lin Wong1*, Siew Teck Tie1, Bohari Samril2, Chee Lun Lum2, Mohammad Rizal Abdul Rahman3,
Jamalul Azizi Abdul Rahman1
Abstract
Tracheal stenosis is a known complication of prolonged intubation. It is difficult to treat and traditional surgical
approach is associated with significant risk and complications. Recurrent stenosis due to granulation tissue necessi-
tates repeated procedures. We describe a case of short web-like tracheal stenosis (concentric membranous stenosis
less than 1 cm in length without associated cartilage damage) managed by a minimally invasive thoracic endo-
scopic approach. Topical application of Mitomycin C, a potent fibroblast inhibitor reduces granulation tissue forma-
tion and prevents recurrence.
Introduction
MacEwen first reported endotracheal intubation for
anesthesia in 1880 [1]. Lindholm reported injuries to the
larynx and trachea after intubation in 1969 [2]. Despite
advancement and the use of high volume, low pressure
cuffed tubes, tracheal stenosis is not an uncommon
complication of endotracheal intubation. In one pro-
spective study of critically ill patients, 11% of patients
who were intubated with high volume, low pressure
cuffed tubes developed tracheal stenosis [3]. Endotra-
cheal tube causes pressure injury to the glottis and may
result in severe commissural scarring that is difficult to
treat.
Although there have been reports of successful treat-
ment of tracheal stenosis with steroid regimens [4,5],
the mainstay of treatment for symptomatic lesions is
surgical. Various surgical methods have been described
including anterior cricotracheal splitting, laryngofissure
creation with anterior lumen augmentation, resection or
end-to-end anastomosis [6-8], but they are not without
risks. Tracheal reconstruction requires major surgery,
with a mortality of about 3% [9,10]. Rigid bronchoscopy
with tracheal dilatation and stenting has been described
as some of the treatment methods for less serious
lesions [11]. Relapses are relatively frequent, making it
the principal long-term problem with this method of
treatment [12,13].
Case presentation
A 30-year-old Malaysian woman who had bilateral
upper lobe lung bullae underwent bullectomy in May
2008 for rapidly enlarging bullae causing respiratory
compromise. Post-operatively, she was intubated for 6
days. Upon trial of extubation at day 6, she developed
shortness of breath. She was re-intubated for another 5
days before extubation was successful and she was dis-
charged 20 days post operatively.
She was well for the next one month until July 2008
when she developed a sudden onset of shortness of
breath and stridor. Intubation attempt with a 4 mm
endotracheal tube was unsuccessful leading to emer-
gency tracheostomy. Flexible bronchoscopy in the oper-
ating room revealed a membranous web-like concentric
stenosis without cartilage involvement 3 cm below the
vocal cords. Bronchoscopy through the tracheostomy
showed normal distal airways. A neck CT scan con-
firmed the presence of a short segment tracheal stenosis
(less than 1 cm) [figure 1].
In August 2008, she underwent rigid bronchoscopy
using a 12 mm Dumon rigid tracheal tube. This was fol-
lowed by examination using a small diagnostic flexible
* Correspondence: sgrejang@yahoo.com
1Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota
Kinabalu, Sabah, Malaysia
Wong et al. Cases Journal 2010, 3:2
http://www.casesjournal.com/content/3/1/2
© 2010 Wong et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
bronchoscope via the rigid bronchoscope. A pin hole
stenosis of the trachea 3 cm distal to the vocal cords
was noted with areas of granulation tissue. We failed to
pass the flexible bronchoscope through the stenosis.
Initially argon plasma coagulation (APC) was used to
devitalize the granulation tissues surrounding the steno-
sis. Rigid forceps and cryoprobe were used to remove
the necrotic tissues. The APC and cryo probes were
inserted through the side-port of the Dumon rigid
bronchoscope instead of through the working channel
of the flexible bronchoscope to minimize damage to the
working channel of the flexible bronchoscope. Bougies
was then used to dilate the stenotic area in incremental
size to a final size of 1 cm. Pledgets soaked with diluted
Mitomycin C (concentration 0.2 mg/ml) were intro-
duced using rigid forceps through the rigid broncho-
scope to the raw surface of the mucosa and direct
pressure applied via the rigid forceps [figure 2]. Pressure
was applied for 2 minutes until blanching of the mucosa
was seen. The procedure was repeated circumferentially
until all mucosa was treated. A total of 4 applications or
8 minutes of contact time was needed [figure 3].
Hemostasis was then secured with pledgets soaked with
adrenaline and the rigid bronchoscope was removed.
The whole procedure took 110 minutes.
Intravenous dexamethasone 8 mg tds was given for 3
days. At 2 weeks, a flexible bronchoscopy showed a
patent airway and she was weaned off the tracheostomy
tube after she tolerated spigotting for 48 hours [figure 4].
Repeat flexible bronchoscopy was done at 1 month
[figure 5] and then 4 month [figure 6] after the proce-
dure. The trachea remained patent. A small granulation
nodule was seen on the anterior wall of the trachea but
a 6 mm therapeutic flexible bronchoscope could easily
be passed through the stenosis.
There is no significant worsening of the narrowing
between 1 month and 4 month. She did not complain of
stridor or difficulty in breathing and was back to work.
Discussion
The optimal treatment of tracheal stenosis remains unde-
fined. Traditionally, tracheal stenosis has been managed
by thoracic and othorhinolaryngology surgeons. Endo-
scopic procedures are usually performed as a bridge to
definitive surgical intervention. With the development of
interventional pulmonology field in the last 20 years,
definitive management of tracheal stenosis using mini-
mally invasive endoscopic methods became a possibility.
Collaboration between pulmonologists and surgeons has
become increasingly important to help define the best
method of management for these patients.
Endoscopic treatment had been shown to be useful,
especially in patients who are deemed high risk and too
Figure 1 Sagittal and coronal view of the CT scan showing a
short segment stenosis just above the tracheostomy.
Figure 2 A pledget soaked with Mitomycin C applied via rigid
forceps to the stenotic area.
Figure 3 The appearance of the stenotic area immediately
after application of Mitomycin C.
Wong et al. Cases Journal 2010, 3:2
http://www.casesjournal.com/content/3/1/2
Page 2 of 4
unwell for reconstructive surgery. One of the main
drawbacks of endoscopic treatment and surgery is the
risk of recurrence of trachea stenosis due to granulation
and fibrotic tissue. Studies have shown that most of the
recurrence of tracheal stenosis occurs within one to
three months after the procedure [12,14], and use of
Mitomycin C has been reported in case studies to
reduce the rate of recurrence [13,15]. Mitomycin C
which is isolated from Streptomyces caepitocus acts as a
bifunctional alkylating agent cross-linking DNA thereby
inhibiting DNA synthesis. Both in vitro and in vivo,
Mitomycin C has been proven to be a potent inhibitor
of human fibroblasts at concentrations of 0.04 mg/L. It
has been used with some success in inhibiting the vigor-
ous granulation response noted after airway injury in
animal models and pediatric patients. It has also been
used in ophthalmology to treat glaucoma and pterygium.
In this case, we describe a successful management of a
short web-like tracheal stenosis via rigid bronchoscopy
by interventional pulmonologists with collaboration
from othorhinolaryngology surgeons. APC appears to be
an effective coagulation method. The use of APC prior
to granulation tissue removal allows for easy control of
bleeding. The application of cryoprobe to remove granu-
lation tissues also minimizes trauma to the trachea.
Nd:YAP laser would be an interesting alternative to
APC for coagulation but it was not available to us at the
time. The presence of othorhinolaryngology surgeons
during the procedure who have a good knowledge of
local airway anatomy allows identification of structures
which are distorted by granulation tissues. This prevents
the formation of false tract and accidental perforation of
the trachea.
In skilled hands, the use of a suspension laryngoscope
would be an alternative to rigid bronchoscope in this
case. Suspension laryngoscope is ideal if the lesion is
either at the vocal cords or just below the vocal cords
(subglottic). However, suspension laryngoscope needs to
be used with a caveat that there may be a higher risk of
irritation and injury to the vocal cords during insertion
of surgical instruments to reach the target area which
was 3 cm below the vocal cords. Furthermore, the use
of a suspension laryngoscope will require jet-ventilation
in order to ventilate the patient. The use of rigid
bronchoscope allows us to introduce surgical instru-
ments multiple times to the target area with minimal
risk of irritating or injuring the vocal cords.
The application of topical Mitomycin C is made possi-
ble with the rigid forceps which allows application of
sufficient force to the airway mucosa to allow proper
Figure 4 The appearance of the stenotic area 2 weeks after the
procedure.
Figure 5 The appearance of the stenotic area after one month:
Noted there was a small granulation tissue over the anterior
surface of the mucosa, but a flexible bronchoscope could still
be passed through easily.
Figure 6 The appearance of the stenotic area after 4 months:
Noted the granulation tissue was still present but not
enlarging and a flexible bronchoscope could still be passed
through easily.
Wong et al. Cases Journal 2010, 3:2
http://www.casesjournal.com/content/3/1/2
Page 3 of 4
application of Mitomycin C. It is important to apply
Mitomycin C with sufficient force and contact time to
allow Mitomycin C to work. With a contact time of 8
minutes, there is evidence of only minimal granulation
tissue or scar tissue after 4 months. Topical Mitomycin
C also appears to be safe and there is no detectable
myelosuppression.
Conclusion
Topical Mitomycin C is a useful adjunct in the manage-
ment of short concentric membranous stenosis which
does not involve the cartilage. It reduces granulation tis-
sue and prevents recurrence. Further randomized con-
trolled studies are necessary to explore the possibility of
this treatment method in the algorithm for the manage-
ment of tracheal stenosis. This may obviate the need for
invasive reconstruction surgery and repetitive
procedures.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal
Author details
1Department of Respiratory Medicine, Queen Elizabeth Hospital, Kota
Kinabalu, Sabah, Malaysia. 2Department of Othorhinolaryngology, Queen
Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia. 3Department of
Anaesthesiology, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia.
Authors’ contributions
JLW prepared the final copy of the manuscript. STT performed rigid
bronchoscopy and the initial bougie dilatation. BS prepared mitomycin C
and reviewed articles on the dosage and safety of mitomycin C before
application. CLL applied mitomycin C and guided the team on the anatomy
of the tracheal stenosis. MR was responsible for the administration of
general anaesthesia to the patient during the procedure. ARJA initiated the
idea of rigid bronchoscopy and mitomycin C application, supervised the
whole procedure and reviewed the final manuscript. All authors have read
and approved the final manuscript
Competing interests
The authors declare that they have no competing interests.
Received: 19 February 2009
Accepted: 4 January 2010 Published: 4 January 2010
References
1. MacEwen W: Clinical observations on the introduction of tracheal tubes
by the mouth instead of performing tracheotomy or laryngotomy. Br
Med J 1880, 2:122-124.
2. Lindholm CE: Prolonged endotracheal intubation. Acta Anaesthesiol Scand
Suppl 1970, 33:1-131.
3. Stauffer JL, Olson DE, Petty TL: Complications and consequences of
tracheal intubation and tracheostomy. A prospective study of 150
criticallyill adult patients. Am J Med 1981, 70:65-76.
4. Croft CB, Zub Z, Borowiecki B: Therapy of iatrogenic subglottic stenosis: a
steroid/antibiotic regimen. Laryngoscope 1979, 89:482-489.
5. Braidy J, Breton G, Clement L: Effect of corticosteroids on post-intubation
tracheal stenosis. Thorax 1989, 44:753-755.
6. Grillo HC: Management of Nonneoplastic Diseases of the Trachea.
General Thoracic Surgery Philadelphia: Lippincott Williams and WilkinsShields
TW, Cicero JL, Ponn RB , 5 2000, 885-897.
7. Anand VK, Alemar G, Waren ET: Surgical Considerations in Tracheal
Stenosis. Laryngoscope 1992, 102:237-243.
8. Couraud L, Jougon JB, Velly JF: Surgical Treatment of Nontumoral
Stenoses of the Upper Airway. Ann Thorac Surg 1995, 60:250-259.
9. Grillo HC, Donahue DN: Post-intubation tracheal stenosis. Semin Thorac
Cardiovasc Surg 1996, 8:370-380.
10. Andrews MJ, Pearson FG: Analysis of 59 cases of tracheal stenosis
following tracheostomy with cuffed tube and assisted ventilation, with
special reference to diagnosis and treatment. Br J Surg 1973, 60:208-212.
11. Spittle N, McCluskey A: Lesson of the week: trachea stenosis after
intubation. BMJ 2000, 321:1000-1002.
12. Brichet A, Verkindre C, Dupont J, Carlier ML, Darras J, Wurtz A, Ramon P,
Marquette CH: Multidisciplinary approach to post intubation trachea
stenosis. Eur Respir J 1999, 13:888-893.
13. Krimsky WS, Sharief UU, Sterman DH, Machuzak M, Musani AI: Topical
Mitomycin is an effective, Adjuvant therapy for the treatment of severe
recurrent tracheal stenosis in Adult. Journal of Bronchology 2006, 13:141-
143.
14. Baugne PE, Marquette CH, Ramon P, Darras J, Wurtz A: Traitement
endoscopique des stenoses tracheales postintubation. A propos de 58
cas. Rev Mal Respir 1995, 12:585-592.
15. Erard AC, Monnier P: Anastase Spiliopoulos and Laurent Nicod Mitomycin
C for control of recurrent bronchial stenosis: a case report. Chest 2001,
120:2103-2105.
doi:10.1186/1757-1626-3-2
Cite this article as: Wong et al.: Successful treatment of tracheal
stenosis by rigid bronchoscopy and topical mitomycin C: a case report.
Cases Journal 2010 3:2.
Publish with BioMed Central   and  every 
scientist can read your work free of charge
"BioMed Central will be the most significant development for 
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central 
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
Wong et al. Cases Journal 2010, 3:2
http://www.casesjournal.com/content/3/1/2
Page 4 of 4


Successful treatment of tracheal stenosis by rigid bronchoscopy and topical mitomycin C: a case report

Crossref

A: Traitement endoscopique des stenoses tracheales postintubation. A propos de 58 cas. Rev Mal Respir

Anastase Spiliopoulos and Laurent Nicod Mitomycin C for control of recurrent bronchial stenosis: a case report. Chest

CH: Multidisciplinary approach to post intubation trachea stenosis. Eur Respir J

Clinical observations on the introduction of tracheal tubes by the mouth instead of performing tracheotomy or laryngotomy.

Donahue DN: Post-intubation tracheal stenosis. Semin Thorac Cardiovasc Surg

Effect of corticosteroids on post-intubation tracheal stenosis. Thorax

ET: Surgical Considerations in Tracheal Stenosis. Laryngoscope

Management of Nonneoplastic Diseases of the Trachea. General Thoracic Surgery Philadelphia: Lippincott Williams and WilkinsShields TW,

McCluskey A: Lesson of the week: trachea stenosis after intubation. BMJ

Musani AI: Topical Mitomycin is an effective, Adjuvant therapy for the treatment of severe recurrent tracheal stenosis in Adult.

Pearson FG: Analysis of 59 cases of tracheal stenosis following tracheostomy with cuffed tube and assisted ventilation, with special reference to diagnosis and treatment.

Prolonged endotracheal intubation. Acta Anaesthesiol Scand Suppl

Therapy of iatrogenic subglottic stenosis: a steroid/antibiotic regimen. Laryngoscope

TL: Complications and consequences of tracheal intubation and tracheostomy. A prospective study of 150 criticallyill adult patients.

Velly JF: Surgical Treatment of Nontumoral Stenoses of the Upper Airway. Ann Thorac Surg

file:///data/remote/core/dit/data/Springer-OA/pdf/0a6/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjExODYvMTc1Ny0xNjI2LTMtMi5wZGY=.pdf

Successful treatment of tracheal stenosis by rigid bronchoscopy and topical mitomycin C: a case report

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Crossref

Springer - Publisher Connector