Laryngeal and Tracheal Stents Workup

  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Mar 24, 2010
 

Imaging Studies

  • The criterion standard for evaluating the larynx or the trachea is direct laryngoscopy and bronchoscopy.
  • Fluoroscopy can be used to help define a narrowing of the trachea or abnormal radiographic appearance of the larynx. The diagnostic information yielded from fluoroscopy is inferior to that of direct laryngoscopy and bronchoscopy in the operating room (OR); however, radiopaque stents can be placed under fluoroscopic guidance in adults and children.
  • Occasionally, an imaging study such as MRI, CT scan, or plain x-ray film helps in diagnosing laryngeal lesions that might require stenting or in defining the length of stenosis or malacia in the trachea.
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Diagnostic Procedures

The criterion standard for evaluating the larynx and trachea is direct laryngoscopy and bronchoscopy. Using these tools, the segment that requires stenting can be defined.

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Histologic Findings

Graft vascularization

Most histological studies have been performed in animals. Concern has been raised that a stent could cause impaired lumen healing, increasing the complication rate; however, a study on 36 white rabbits that had tracheoplasty with autologous cartilage grafting with and without stents showed the rate of vascularization of the graft was equal among both groups and possibly slightly superior in the stented group at 10 days following insertion.

Mucociliary transport

The laryngotracheal mucociliary transport in guinea pigs with and without stenting was evaluated in studies conducted in 1997 and 2000 by S.Y. Lee of the Department of Otolaryngology, Taiwan University, Taiwan. In these studies, stenting appeared to preserve or increase the mucociliary function of laryngotracheal mucosa in the acute phase of stenting compared to mucosa without stenting.[1, 2]

Tracheal stents

Histological evaluation has been accomplished with metal, silicone, and bioabsorbable stents.

For metal stents, the most common (eg, Palmaz stent) are placed intraluminally and are expanded with a balloon. One study reported that the stent was overgrown with tracheal epithelium; granulation tissue formation was the only complication cited. In experimental studies in cats, histological analysis revealed a mild inflammatory reaction with granulation tissue present in all animals in which the stent was not manipulated. When the stent was overexpanded, the reaction was more severe; epithelial ulceration that had sealed the lumen in most animals was noted.

In the same study, researchers opened and closed cats' tracheas with or without stent placement. Increased inflammatory reaction, granulation tissue, and epithelial damage were observed in animals with stents as opposed to control subjects without stents. Based on that study, the Palmaz stent, when used in a normal trachea on which an operation has not been performed, provokes only a very mild and clinically insignificant inflammatory reaction when appropriately expanded. However, once surgery has been performed on the trachea, the inciting inflammatory reaction can cause formation of granulation tissue.

A study from Japan examined expandable metallic stents after tracheal patch reconstruction with omentoplasty. Polypoid granulation tissue developed at both ends of the metallic stent. Histologically, epithelium was regenerated in the patched area 4 weeks postoperatively; the patched area was covered with respiratory epithelium 12 weeks postoperatively.[3]

Another study investigated the histocompatibility of 4 different types of material used to cover expandable Gianturco metallic stents in dogs: polypropylene mesh, silicone-covered mesh, polyester mesh, and expanded polytetrafluoroethylene. The polypropylene mesh appeared to be the most biocompatible of all the coverings and was histocompatible to the airway.[4]

For bioabsorbable and silicone stents, a comparison of bioabsorbable airway stents, shown in the images below, with a silicone airway stent and metallic stent was performed in Finland on rabbits.

Intraoperative picture showing a solid dissolvableIntraoperative picture showing a solid dissolvable airway stent next to a trachea in a 3-kg New Zealand white rabbit. Solid spiral dissolvable stent produced for the trSolid spiral dissolvable stent produced for the trachea of a rabbit. Scale is in centimeters.

The bioabsorbable spiral stent was manufactured with self-reinforced poly-L-lactide material, and tracheomalacia was created by extramucosal resection of cartilaginous arches of the cervical trachea. Hyperplastic polyps occurred at both ends of the silicone stent, and the internal diameter of the stent became encrusted. The bioabsorbable stent and the metallic stents were tolerated well.

Other experimental studies have been performed to evaluate histological events that occur when a bioabsorbable stent is placed, as compared with silicone stents. Silicone stents in one animal study again showed a tendency to become stenosed with encrusted material and to develop a hyperplastic bulge at both ends. Bioabsorbable stents of poly-L-lactide material showed no foreign body reaction and had a tendency to penetrate into the tracheal wall. These stents had been reabsorbed at 10-month follow-up.

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Contributor Information and Disclosures
Author

John E McClay, MD  Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Clark A Rosen, MD  Director, University of Pittsburgh Voice Center; Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine

Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Pennsylvania Medical Society

Disclosure: Bioform Medical Consulting fee Consulting; Bioform Medical Consulting fee Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert M Kellman, MD  Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society

Disclosure: GE Healthcare Honoraria Review panel membership; Revent Medical Honoraria Review panel membership

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

References

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  2. Lee SY, Yeh TH, Chen JC. Mucociliary clearance of stented laryngotracheal tract in guinea pigs in vivo. Ann Otol Rhinol Laryngol. Mar 1997;106(3):240-3. [Medline].

  3. Mitsuoka M, Hayashi A, Takamori S, et al. Experimental study of the histocompatibility of covered expandable metallic stents in the trachea. Chest. Jul 1998;114(1):110-4. [Medline].

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Note the diamond-shaped internal intraluminal component. The shape of the rib is seen on the reverse side of the carved-out diamond-shaped wound.
Another anterior graft with a diamond shape. Note that it is approximately 1.7 mm long. Again, the intraluminal site is seen facing up.
Laryngeal keel.
Representative (noninclusive) sample demonstrating various sizes of Aboulker stents, ranging from 15 mm in diameter on the left to 3 mm in diameter on the right. These stents are hollow and coated with Teflon.
An end view of an Aboulker stent, showing the central opening. These stents are hollow and coated with Teflon.
Side view of a Montgomery laryngeal stent.
Radiographic lateral neck view of a long stent connected to a metal Jackson tracheotomy tube at the bright inferior portion of the picture. The stent is seen in the airway as an oblong translucent area, with a rim of opacification around it that extends up through the larynx. A thin wire is seen connecting the stent and the tracheotomy tube.
A long Aboulker stent wired to a metal Jackson tracheotomy tube.
A Jackson tracheotomy tube wired to a long Aboulker stent.
Montgomery T-tube (7 mm) stent with caps.
Intraoperative picture showing a solid dissolvable airway stent next to a trachea in a 3-kg New Zealand white rabbit.
Solid spiral dissolvable stent produced for the trachea of a rabbit. Scale is in centimeters.
Roll of silastic sheeting.
The Dumon stent with its opening for the right mainstem bronchus.
Palmaz stent expanded over a balloon superiorly and unexpanded inferiorly.
Balloon-expanded Palmaz stent placed into a pediatric airway under fluoroscopic guidance.
Endoscopic view of a deployed Palmaz stent. The carina is seen distal.
Strecker stent in different stages of deployment.
Gianturco-Z stent.
Metallic Wallstent.
Nitinol stent. The stent is loaded in the upper catheter and then expanded in the lower.
The Dumon stent.
A bifurcated dynamic airway stent. The stent is shown loaded on its delivery device inferiorly and in its open position in the airway above.
 
 
 
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