Efficacy and Outcomes of Endoscopic Management of Post-Tracheostomy Tracheal Stenosis

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Efficacy and Outcomes of Endoscopic Management of Post-Tracheostomy Tracheal Stenosis: A Retrospective Study from an Interventional Center in China

Post-tracheostomy tracheal stenosis (PTTS) remains a significant clinical challenge, often resulting from mechanical injury to tracheal cartilage, ischemic necrosis, infection at the tracheostomy site, or friction from the tracheostomy tube. Despite advancements in tracheostomy care, such as high-volume low-pressure cuffs and cuff pressure monitoring, PTTS continues to impair patients’ quality of life. This retrospective study evaluates a decade of experience in managing PTTS using endoscopic techniques, highlighting patient outcomes, procedural efficacy, and predictors of success.

Study Design and Patient Characteristics

The study analyzed 87 PTTS patients treated between June 2009 and June 2019 at a single center in China. Patients were identified from a cohort of 524 individuals with airway stenosis. The mean age was 48.0 ± 17.4 years, with 65.5% (57/87) being male. A history of intubation prior to tracheostomy was reported in 43.7% (38/87) of cases. The morphological characteristics of stenosis were classified using a modified Freitag system: 90.8% (79/87) had tracheal stenosis, while 9.2% (8/87) exhibited subglottic involvement. Structurally, 78.2% (68/87) had fixed stenoses, and 21.8% (19/87) had dynamic stenoses. Over 83.9% (73/87) presented with luminal narrowing exceeding 50%, with stenosis severity ranging from 76% to 90%.

Endoscopic Treatment Protocols

All patients underwent endoscopic interventions under general anesthesia, utilizing flexible or rigid bronchoscopes. Procedural techniques included:

  • Mechanical resection: High-frequency electrosurgical knives or Nd:YAG lasers were used to excise cicatricial scar tissue.
  • Balloon dilatation: Employed in 39.1% (34/87) of cases to expand stenotic segments.
  • Cryotherapy: Applied in 69.0% (60/87) to reduce restenosis risk by inhibiting scar proliferation.
  • Local paclitaxel application: Administered topically in 34.5% (30/87) to suppress fibroblast activity and granulation tissue formation.
  • Airway stabilization: Montgomery T-tubes or covered stents were inserted in cases of dynamic stenosis (21.8%) to maintain patency.

The median number of endoscopic procedures per patient was 2 (interquartile range: 1–3).

Classification of Stenosis and Outcomes

Patients were categorized into three anatomical subtypes based on stenosis location relative to the tracheostoma:

  • Type 1: Upper tracheostomal stenosis (32 patients).
  • Type 2: Peri-tracheostomal stenosis (34 patients).
  • Type 3: Lower tracheostomal stenosis (21 patients).

Type 2 stenosis demonstrated the shortest lesion length (median 1.00 cm vs. 1.60 cm in Type 1 and 2.00 cm in Type 3; P < 0.01). Decannulation success varied significantly across subtypes: 73.5% (25/34) in Type 2 achieved airway stability, compared to 28.1% (9/32) in Type 1 and 33.3% (7/21) in Type 3 (P < 0.01). Kaplan-Meier analysis confirmed superior decannulation rates for Type 2, with log-rank tests identifying stenosis location, degree (<90% vs. ≥90%), and patient consciousness as significant prognostic factors.

Predictors of Endoscopic Success

Multivariate Cox regression analysis revealed two independent predictors of successful decannulation:

  1. Local paclitaxel use (HR = 3.69, 95% CI: 1.78–7.68, P < 0.01).
  2. Conscious patient status (HR = 2.62, 95% CI: 1.05–6.56, P = 0.04).

Other variables, including age, sex, stenosis length, and time from tracheostomy to initial treatment, did not significantly influence outcomes.

Complications and Alternative Management

One intraoperative death occurred during removal of a migrated bare-metal stent originally placed elsewhere. Two patients (2.3%) required surgical resection after failed endoscopic therapy. During follow-up (median duration unspecified), 12 patients died from primary comorbidities, while six were lost to follow-up.

Discussion

Endoscopic Versus Surgical Management

Historically, surgical resection and reconstruction achieved success rates of 90% but carried 5–15% failure and 5% mortality risks. Endoscopic techniques now offer a viable alternative, particularly for patients with extensive stenosis (>5 cm) or comorbidities precluding open surgery. In this cohort, endoscopic management achieved clinical stability in 96.6% (84/87) of cases, underscoring its efficacy as a first-line approach.

Role of Adjunctive Therapies

Cryotherapy emerged as the most frequently utilized adjunct (69.0%), likely due to its ability to modulate scar remodeling. Local paclitaxel application correlated strongly with decannulation success, aligning with prior studies demonstrating its antiproliferative effects on granulation tissue. The mechanism involves paclitaxel’s inhibition of microtubule dynamics, thereby reducing fibroblast migration and collagen deposition.

Anatomical Considerations

The superior outcomes in Type 2 stenosis may reflect shorter lesion length and peri-stomal accessibility, allowing more complete scar resection. Conversely, Type 1 and 3 stenoses often involve cartilaginous destruction or distal tracheal involvement, complicating endoscopic access. Montgomery T-tubes provided effective stabilization in 18 patients, enabling phonation and physiological breathing despite requiring long-term surveillance for granulation hyperplasia.

Limitations and Future Directions

As a retrospective single-center study, generalizability may be limited by selection bias and heterogeneous procedural techniques. Prospective trials comparing endoscopic modalities (e.g., laser vs. electrosurgery) and standardized paclitaxel protocols could refine treatment algorithms. Additionally, quantifying patient-reported outcomes, such as dyspnea scores or quality-of-life metrics, would strengthen clinical relevance.

Conclusion

Endoscopic management represents a safe, effective first-line strategy for PTTS, particularly in anatomically favorable (Type 2) lesions. Adjunctive paclitaxel application and patient consciousness status significantly enhance decannulation success, reducing reliance on invasive surgery. Future studies should optimize technique selection and evaluate long-term durability beyond initial airway stabilization.

doi.org/10.1097/CM9.0000000000001634

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