Acute laryngeal stenosis - causes, symptoms, diagnosis and treatment

Causes

The pathology is secondary - laryngeal stenosis usually occurs as a consequence of various diseases and pathological conditions. A number of such pathologies have been studied. Most often they are allergic, inflammatory (including infectious-inflammatory), non-inflammatory, mechanical, chemical, and bad habits. In some cases, laryngeal stenosis occurs as a result of a combination of etiological (causal) factors.

Various types of allergic reactions can lead to the development of laryngeal stenosis - food, medication, provoked by the entry of gases and fumes of chemical compounds into the respiratory tract. Usually, acute stenosis occurs against the background of allergies, but a chronic form can develop if the patient suffers from allergic reactions all his life, due to which morphological changes gradually progress in the wall of the larynx, which lead to a narrowing of the lumen of this organ.

Inflammatory pathologies are one of the largest groups of causes that can lead to the occurrence of the described disease. The immediate cause is laryngitis - an inflammatory lesion of the mucous membrane lining the inside of the larynx. These can be its various forms - infiltrative (with the appearance of dense tissue swelling), purulent, affecting the perichondrium (the thin connective tissue membrane that covers the cartilage of the larynx) and others.

As for the non-inflammatory causes of this pathology, they usually lead to:

• neoplasms – malignant and benign;
• scars - in particular, those that occur after mechanical injuries and burns of the larynx;
• congenital defects - a violation of the correct anatomical structure that appears during the intrauterine development of the fetus;

note

Not only inflammatory and non-inflammatory lesions of the larynx can provoke this disease - it can be disorders of neighboring organs and tissues. Most often, they are neoplasms of the esophagus that grow into the larynx and cause its narrowing.

Infectious and inflammatory diseases usually lead to acute stenosis of the larynx, but with long-term infectious processes they can also trigger a chronic process. In the first case, it is most often measles (a viral pathology with damage to the mucous membranes of the oral cavity and upper respiratory tract, a typical skin rash in the form of spots and papules), scarlet fever (a disease manifested by a large number of pinpoint spots on the skin) and others. Protracted pathologies can lead to chronic laryngeal stenosis: tuberculosis (infection with Mycobacterium tuberculosis), scleroma (a chronic infection characterized by the formation of granulomas in the wall of the larynx).

Mechanical causes of laryngeal stenosis are:

• foreign bodies;
• post-traumatic consequences.

In the latter case, these are consequences that arise from external damage to the larynx or during medical procedures.

Foreign bodies rarely cause laryngeal stenosis. As a rule, these are fragments of traumatic elements that were stuck in the larynx area, were encapsulated (covered with a protective shell) and were available to the patient for a long time, which is why the tissues of the laryngeal wall reacted to them by compacting and sprouting connective tissue.

Injuries lead to laryngeal stenosis for reasons such as:

• acute reaction of the larynx to a traumatic effect, which leads to a reflex reduction in the lumen of the organ;
• restoration of the integrity of the laryngeal wall after a traumatic impact on it, the formation of scars at the site of injury.

What medical procedures can trigger the development of laryngeal stenosis? These are any procedures - diagnostic and therapeutic, during which the wall of the larynx is affected mechanically.

Of the diagnostic procedures, endoscopic examination methods most often become the background for the development of the described disorder:

• bronchoscopy – study of the condition of the inner surface of the bronchi, which is carried out using a bronchoscope (a type of endoscopic equipment with a built-in optical system and illumination);
• gastroduodenoscopy is the study of the gastrointestinal tract using a fiberscope (a type of endoscope), which can be mistakenly inserted into the lumen of the larynx. Also, narrowing of the larynx in this case occurs as a reflex response of the body to the introduction of an endoscope into the pharynx and esophagus, which are located adjacent to the larynx;
• biopsy - collection of fragments of laryngeal tissue for their subsequent examination under a microscope.

Among the treatment procedures, the trigger for the occurrence of laryngeal stenosis is usually:

• tracheal intubation - insertion of an endotracheal tube through the larynx into the trachea in order to use it to connect an artificial lung ventilation device (ALV);
• removal of tumors;
• removal of foreign bodies.

Another traumatic factor that can lead to the development of laryngeal stenosis is a burn as a result of exposure of the laryngeal wall to high temperatures and chemicals. In the first case, this is direct exposure to an open flame or hot liquids, in the second, exposure to aggressive chemicals on the wall of the larynx. A separate case is the regular accidental entry of hot drinks and food into the larynx.

Low temperatures less often lead to laryngeal stenosis, but the possibility of developing pathology in such conditions should be remembered.

Chronic laryngeal stenosis can occur if a person lives in low temperatures and constantly breathes with an open mouth. Also, a gradual narrowing of the larynx is observed if a person often takes cold food and drinks - passing regularly through the esophagus, they provoke hypothermia in the larynx, which subsequently leads to its stenosis.

Also, one of the most common causes of stenosis (namely its chronic form) is the regular exposure of certain organic and synthetic compounds to the laryngeal mucosa. As a rule, this is observed when performing certain professional duties, as well as when staying in a war zone. In peacetime, laryngeal stenosis usually occurs when inhaling gases and fumes of aggressive substances - such as toluene, benzene, vinyl chloride, and others.

Important

If a person smokes, then with a long history of smoking, chronic laryngeal stenosis may also occur. Under the influence of this factor, stenosis usually develops over a long period of time.

Therapeutic tactics

Treatment can be provided by a non-medical representative (the person experiencing the acute condition) and a physician.

Emergency care by a non-medic:

• if a child has throat stenosis, lift him by the legs, shake him off and tap him on the back between the shoulder blades with your palm. In case of stenosis by a foreign body, perform the Heimlich maneuver (push-like pressure on the epigastric region in a supine position);
• in adults - in the absence of breathing, open the mouth and pull out the foreign body from the respiratory tract, also do the Heimlich maneuver.

Emergency care provided by a doctor is distributed according to the degree of stenosis. Thus, treatment of a child at the first stage includes local therapy, which is aimed at improving venous outflow and normalizing lymphatic drainage.

It is important to apply dry heat to the neck area, give warm liquid to drink, and inhale with a decongestant mixture.

With medications, antihistamines are used.

Treatment at the second stage: oxygen inhalation, sedation of the child to reduce inspiratory dyspnea, glucocorticoids (prednisolone, dexamethasone), antihistamines (diphenhydramine, suprastin) are prescribed. Bronchodilators and mucolytics are also prescribed. Treatment at the third stage: tracheal intubation or tracheotomy is added to the above points if it is impossible to insert an endotracheal tube into the larynx.

To reduce swelling of the larynx, you can use adrenaline by inhalation. With the help of intubation, short-term stenosis can be eliminated and the patient can be connected to a ventilator.

It is important to indicate the time the tube was installed, because in a younger child it can be kept for no more than 4 days, in an older child – 10 days. In addition, it is necessary to determine the size of the endotracheal tube for high-quality ventilation of the lungs.

In an ambulance, you can perform a conicotomy (dissection of the conical fold), thyrotomy (dissection of the thyroid cartilage), cricotomy (dissection of the arch of the cricoid cartilage), while continuing artificial ventilation, suctioning blood and mucus from the trachea.

In a hospital setting, a tracheotomy can be performed.

Indications for tracheotomy: the presence of acute or chronic stenosis of an infectious, traumatic or neurological nature, respiratory failure at stages 3-4.

Treatment at the fourth stage: cardiopulmonary resuscitation, treatment of cerebral edema. In each individual case, treatment is carried out according to the protocol by a qualified medical professional.

Development of pathology

The main links in the mechanism of laryngeal stenosis are:

• muscle contraction, including spastic (sudden, severe, under the influence of external factors);
• soft tissue swelling;
• the presence of a foreign body in the wall of the larynx or in adjacent soft tissues.

Chronic stenosis can develop over several years or even decades; the acute form can occur in a few seconds. In both cases, there is a lack of oxygen in the blood and an excess of carbon dioxide.

One should take into account the fact that acute stenosis can occur against a background of chronic stenosis.

The main consequence of all forms of laryngeal stenosis is oxygen starvation of organs and tissues, regardless of what cause caused the occurrence of this pathology. As a result, failure of various organs occurs. This means that laryngeal stenosis can cause a number of disorders in organs and tissues.

Depending on various characteristics, different forms of laryngeal stenosis are distinguished:

• by development - acute, subacute, chronic;
• by severity – mild, moderate, severe;
• according to the presence of complications - complicated, uncomplicated.

Diagnostic measures

Usually, when pathology develops, there is no time left for diagnostic procedures. However, an experienced specialist can easily make a diagnosis based on the characteristic clinical picture. After symptoms have been relieved, or after hospitalization, examinations of the patient are always prescribed according to the doctor’s recommendations from the following list of procedures:

• laryngoscopy, fibrolaryngoscopy;
• MRI, CT, radiography of the larynx, esophagus, lungs;
• Ultrasound of the thyroid gland;
• respiratory function studies;
• throat swabs for bacterial culture;
• bronchoscopy;
• fibrogastroscopy;
• blood gas monitoring.

An attack of narrowing of the larynx should be differentiated from bronchial asthma, from trauma and a foreign body in the throat without swelling, from traumatic brain injuries, narrowing of the lumen of the larynx against the background of a tumor process, from myocardial infarction.

Symptoms of laryngeal stenosis

Signs of the disease arise due to obstruction of air passage through the respiratory tract. They are:

• local;
• are common.

The following local symptoms appear:

• changes in the timbre of sounds that occur when inhaling and exhaling;
• voice change;
• difficulty breathing.

note

A change in the timbre of sounds during breathing is observed because there is a lack of air, and in order to compensate for it, it is necessary to draw air more intensively into the respiratory tract. With severe stenosis, breathing may be noisy or whistling, the sounds being very similar to the sounds of a steam locomotive.

Voice changes are observed in both acute and chronic laryngeal stenosis. This is usually observed when the organ in the area of ​​the vocal cords narrows - hoarseness and/or hoarseness occurs.

Breathing impairment with laryngeal stenosis manifests itself in the form of shortness of breath - both on inspiration (inspiratory) and on exhalation (expiratory).

General symptoms develop with long-term laryngeal stenosis. It occurs due to oxygen starvation of organs and tissues, which leads to disruption of their functions. May occur:

• stomach ache;
• chest pain;
• cough;
• arrhythmias;
• headache;
• dizziness

and so on.

If the lumen of the glottis is up to 1 mm in diameter or is completely narrowed, when the passage of air is impossible, this condition can lead to terminal consequences. The patient's appearance is typical - the following is observed:

• the patient makes convulsive attempts to take a breath;
• the patient loses consciousness;
• after some time (it depends on the body’s tolerance to hypoxia), the functions of the body are sharply disrupted, against this background, and also due to the cessation of oxygen supply to the body, a critical condition occurs. The latter usually develops in acute forms of laryngeal stenosis - in the case of a chronic form, this is rarely observed, usually in advanced conditions, precisely in those people who ignore the state of their own health - in particular, in socially disadvantaged people.

Symptoms and signs

In children and adults, clinical manifestations depend on the stage of narrowing of the lumen of the larynx at which the pathological process is located.

Taking this into account, a set of symptoms characteristic of a certain stage is identified:

1. Compensated stage. It manifests itself with the following symptoms:
   satisfactory condition;
2. breathing begins to become deeper and rarer;
3. pauses between exhalation and inhalation are shortened;
4. shortness of breath occurs during movement or in case of anxiety (inhalation is difficult);
5. increased heart rate.
6. Partially compensated. At this stage, clinical manifestations are more pronounced:
   the condition worsens significantly;
7. breathing begins to quicken;
8. anxiety joins;
9. the sound of breathing can be heard from a distance;
10. mucous membranes and skin turn pale, sometimes blue appears;
11. auxiliary muscles are connected to the act of breathing (retraction of the muscles between the ribs, jugular and supraclavicular fossae, in the epigastric region is noted).
12. Decompensated. At this stage, the patient’s condition progressively worsens, and the following signs appear:
    fear, expressed anxiety arises, the patient asks for help;
13. forced pose with the head thrown back and leaning on the hands;
14. some parts of the chest are sharply retracted;
15. the skin is pale, with pronounced bluing around the mouth, eyes, hands and feet;
16. movements of the larynx during inhalation and exhalation become visible;
17. the body becomes covered with sticky sweat;
18. There is a disturbance in heart rhythm.
19. Asphyxia. This is the terminal stage. If help is not provided at this stage, death occurs. Symptoms of asphyxia are as follows:
    complete exhaustion of strength occurs (the patient is indifferent to everything, tired);
20. gray skin due to capillary spasms;
21. facial features are pointed;
22. the pulse is practically not palpable, the pressure drops;
23. heart rate is low, loss of consciousness occurs;
24. tonic-clonic convulsions appear at the slightest movement;
25. fingertips become cyanotic to black;
26. shallow, intermittent breathing;
27. convulsive syndrome;
28. urination and defecation occur involuntarily;
29. at the peak of convulsions, death occurs due to paralysis of the respiratory center.

With stenosis, a person experiences a lack of oxygen, and suffocation gradually develops.

The first two stages, if help is provided in time, are quickly reversible. If the stenosis passes into the stage of decompensation and asphyxia, then resuscitation measures cannot be avoided.

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Diagnostics

The diagnosis of laryngeal stenosis is easy to make based on the typical symptoms that arise. To understand the clinical picture, the patient’s complaints, anamnesis (history) of pathology, and the results of additional research methods are important. In acute cases, a minimum diagnostic examination is performed to provide assistance in the shortest possible time. In case of chronic stenosis, a complete comprehensive diagnosis is carried out so that it is possible to understand not only the condition of the larynx, but also other organs against the background of hypoxia.

On physical examination, the following is observed:

• during a general examination, at the compensation stage the general condition is satisfactory, then as the stenosis progresses it worsens. The skin and visible mucous membranes are first pale pink, then pale with a cyanotic tint, the intensity of which depends on the severity of hypoxia against the background of stenosis. The more the laryngeal stenosis progresses, the noisier the patient breathes. During the period of decompensation, the patient's restless behavior is noted, which is caused by the fear of death due to a feeling of lack of air. In the terminal stage, the skin acquires a pale gray tint, the patient’s consciousness is impaired (confused or superficial), then the patient loses it;
• upon local examination, the wings of the patient’s nose are swollen, the intercostal spaces may be widened. As the pathology progresses, additional muscles may be involved in the act of breathing;
• during palpation (palpation) - there is a weakening of vocal tremors (this is a fine vibration of the chest when the patient phonates, such vibration can be felt if you place your palms on the chest of the subject);
• with percussion (tapping) - without any features;
• during auscultation (listening with a phonendoscope), weakened vesicular breathing is heard, noisy or whistling sounds can also be heard.

In acute stenosis, the clinical picture is typical, so instrumental methods are practically not attractive. They are used for chronic types of pathology. This:

• laryngoscopy - using a laryngoscope (a type of endoscope) to examine the larynx;
• tracheobronchoscopy - using a bronchoscope (a type of endoscopic equipment) to examine the inner surface of the walls of the trachea and bronchi. The method is used for the purpose of differential diagnosis;
• bronchography - under general anesthesia (narcosis), a contrast agent is injected into the lumen of the bronchi, then X-ray images are taken. The method is also used for differential diagnosis, since breathing problems can also occur when bronchial obstruction is obstructed;
• X-ray examination of the esophagus with contrast - the patient takes a portion of a contrast agent, after which X-ray images are taken, with their help a differential diagnosis of pathologies of the esophagus is carried out with pathologies of the larynx, which could cause stenosis of this organ;
• biopsy - they take fragments of laryngeal tissue, which are then examined in the laboratory under a microscope;
• Ultrasound examination of the thyroid gland (ultrasound) – is carried out to study the structure of the thyroid gland, since its damage can lead to the development of an acute form of the described disease;
• computed tomography (CT) - computer slices allow you to assess the condition of the laryngeal wall to understand the severity of stenosis;
• multislice computed tomography of the larynx (MSCT) is a type of computed tomography that has been improved, which means it allows you to obtain more accurate examination results.

Laboratory research methods are used as auxiliary in diagnosing the causes of the described disorder. Typically the following methods are used:

• general blood test - if an increase in the number of leukocytes (leukocytosis) and ESR is detected, then this signals the inflammatory nature of the disease, against which the described pathology arose;

• bacterioscopic examination - a smear from the throat is examined under a microscope, in which the causative agents of an infectious disease that provoked the occurrence of laryngeal stenosis can be identified;
• bacteriological examination - a swab is cultured from the throat, the growth of colonies is expected, and the pathogen is determined based on their characteristics;
• histological examination - the tissue structure of the biopsy is studied under a microscope. The method is most important for excluding the malignant nature of the disease, which could lead to laryngeal stenosis;
• cytological examination - the cellular structure of the biopsy is studied under a microscope, the purpose is the same;
• blood gas analysis - performed to assess the degree of hypoxia (lack of oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood).

Due to the fact that laryngeal stenosis can occur against the background of very different disorders, consultation with an otolaryngologist, allergist, oncologist, surgeon, resuscitator and others may be required.

Treatment methods

All patients with acute laryngeal stenosis, as well as those with a decompensated stage to which chronic stenosis has progressed, are subject to hospitalization. The algorithm of actions with which the patient will be treated largely depends on the cause of the narrowing of the larynx. In any case, the main goal of treatment is to reduce or completely eliminate signs of suffocation and prevent hypoxia due to respiratory failure.

Often, the first therapeutic measures are carried out by emergency doctors at home, or in the car on the way to the hospital. Therefore, any medical worker, not just an ENT doctor, should be able to provide assistance. The first two stages of pathology are usually treated quite successfully with medications in a hospital:

• glucocorticosteroids, desensitizing, antihistamines in injections, later - in tablets - to relieve swelling;
• antibacterial drugs in injections - for an infectious component;
• NSAIDs - at high temperatures;
• administration of anti-diphtheria serums or other special drugs - for measles, malaria, typhoid, etc.;
• the use of sedatives, sometimes psychotropic drugs, for anxiety in patients.

Removal of a foreign body may be necessary if attacks of suffocation are caused by its entry into the upper respiratory tract. Surgical intervention in the form of emergency tracheostomy (placement of a stent in the trachea) is required when decompensated croup develops. During the operation, an incision is made in the area of ​​the front part of the trachea, a stent (tube) is inserted into it, through which air will subsequently flow.

If a person is diagnosed with chronic stenosis, then only surgical intervention can often completely eliminate the pathology, and conservative therapy is ineffective. Operations, if possible, are performed via the endolaryngeal route. During the intervention, tumors and scars are removed and stents are implanted.

If the disease is caused by paralysis of the laryngeal muscles, the vocal cord and adjacent cartilages are excised unilaterally. Modern methods that can treat chronic laryngeal stenosis are laser surgery and laryngeal dilatation (gradual expansion of the larynx with special devices).

Differential diagnosis

Differential (distinctive) diagnosis is carried out between pathologies that could lead to laryngeal stenosis.

Differential diagnostics are also carried out with such diseases and pathological conditions as:

• an attack of bronchial asthma - a chronic pathology in which the passage of small bronchi is disrupted, which causes an attack of suffocation;
• tracheal stenosis - a decrease in its lumen due to morphological or physiological reasons;
• Pharyngeal stenosis is a similar condition in the pharynx.

Recommendations from experts

To prevent the development of laryngeal stenosis, it is important to promptly treat other diseases. Acute laryngeal stenosis is dangerous because it can lead to the death of the patient. In acute and chronic forms of the disease, various complications arise and the functioning of the cardiovascular system is disrupted. To prevent the development of the disease, doctors recommend:

• promptly treat diseases associated with the larynx and respiratory organs;
• Do not consume hot drinks or food;
• do not contact for a long time with toxic substances and toxic fumes.

Laryngeal stenosis is a serious pathology that can lead to the death of the patient. If a suspicious symptom appears and your health suddenly worsens, you should immediately call an ambulance and not self-medicate.

Treatment of laryngeal stenosis, emergency care algorithm

When any type of laryngeal stenosis occurs, the primary task is to resume the passage of air through the lumen of this organ - to prevent oxygen starvation of organs and tissues. In the stage of sub- and decompensation, the patient is hospitalized in a hospital for treatment.

Methods for resuming the passage of air through the lumen of the larynx are:

• instrumental – tracheal intubation, removal of foreign bodies;
• medicinal – administration of antispasmodic drugs.

Appointments may be needed such as:

• antibacterial agents - if laryngeal stenosis occurs against the background of an infectious lesion;
• non-steroidal anti-inflammatory drugs – if the cause of the pathology is inflammatory processes;
• desensitizing agents - necessary to relieve swelling of the soft tissues of the larynx;
• glucocorticosteroid drugs - used in the absence of effect from the prescription of desensitizing agents;
• diuretics - used to relieve swelling.

If conservative treatment fails to achieve an effect, then surgical treatment is performed. Its volume depends on the type of disorder against which the laryngeal stenosis occurred. So, they carry out:

• cutting out scars;
• plastic surgery of laryngeal cartilages

and others.

note

In severe cases, a tracheostomy is performed - a hole is made in the trachea through which a special tube is inserted into its lumen to allow air to enter.

Surgical methods for treating acute laryngeal stenosis

As soon as the first symptoms appear, parents should immediately provide first aid to the child, and call an ambulance. Even if the person helped the patient cope with the attack and all the symptoms went away, it is worth waiting for the specialists to arrive. Before the ambulance arrives, the following methods should be used:

• Make the patient recline, try to stop the panic that may accompany an attack of stenosis.
• Take off too warm clothes and ventilate the room.
• Press the spoon onto the root of the tongue.
• Inhale with saline solution, mineral water, or let them breathe steam at a hot water tap.
• Rub the calves of your legs, you can take a bath with hot water and steam your legs. This will help move blood away from the upper body.
• Give the patient an antihistamine.
• In a very serious condition, you need to inhale a glucocorticosteroid (Hydrocortisone, Pulmicort) or give an injection of Prednisolone.

The choice of method of assistance for acute laryngeal stenosis depends on the stage of the stenosis, the cause of its occurrence, and the conditions in which this assistance must be provided.

In case of laryngeal edema of stage I-II, distracting procedures are used: hot foot baths, mustard plasters to the calf muscles; diuretics (furosemide or lasix), agents that prevent tissue swelling (diphenhydramine, calcium chloride, pipolfen, suprastin, corticosteroids, 40% glucose solution). To stimulate the activity of the respiratory center - lobelia; aerosols of antibiotics, inhalation of humidified oxygen, as well as alkaline, hyposensitizing, antispasmodic agents, corticosteroids.

In children with subglottic stenosis, corticosteroid drugs are used intramuscularly (hydrocortisone at the rate of 3-5 mg per 1 kg of body weight), as well as tracheal intubation with elastic tubes, followed by destenotic therapy. If swelling of the subglottic space cannot be eliminated within 2 days or it is impossible to maintain good patency of the endotracheal tube, a tracheostomy is performed.

For stages III and IV of stenosis, only surgical intervention is indicated.

In the past, doctors believed that “tracheotomy alone is worth the trouble of studying medicine,” i.e. If performed correctly and on time, this operation not only saves the patient’s life, but makes him a completely healthy person in the future, of course, taking into account the reason that required the tracheotomy. Depending on the cause of laryngeal stenosis, a throat section can be performed both in a hospital setting and in home conditions that are completely unsuitable for surgery.

Thyrotomy is a dissection of the thyroid cartilage through the protrusion of the larynx (Adam's apple), along the angle of convergence of the plates of the thyroid cartilage. It is used when a foreign body is fixed in the lumen of the larynx.

Conicotomy is an opening of the larynx in the area of ​​the elastic cone (conus elasticus). It is the operation of choice in the absence of conditions for tracheotomy, lightning-fast intervention, sometimes with any cutting instrument (penknife, razor, etc.). In the place covered by the cricothyroid (conical) ligament, as a rule, there are no large blood vessels; the skin and ligament separate the subglottic cavity from the surface of the neck. The incision of the skin and cricothyroid ligament is made quickly, passing through all layers at once, and penetrating into the space under the vocal folds.

The incision is made horizontally (parallel to the arch of the cricoid cartilage, 1 cm long) or vertically between the lower edge of the thyroid cartilage strictly in the middle and the upper edge of the cricoid cartilage (injury to the cartilage should be avoided). The last method is more gentle. Any hollow tube is inserted into the resulting channel.

Types of throat section: 1 - conicotomy; 2 - upper tracheostomy; 3 - lower tracheostomy

Tracheostomy is an opening of the trachea with the insertion of a special tube into its lumen. Indications for tracheostomy: obstruction of the upper respiratory tract (swelling of the larynx, entrapment of a foreign body in the larynx, paralysis of the recurrent nerves, trauma to the larynx, infectious granulomas of the larynx, laryngeal tumors, etc.);

the need for drainage and toilet of the tracheobronchial tree when they are blocked by products of inflammation or aspiration; the need to provide long-term artificial ventilation (traumatic brain injury, chest and spinal cord injury, etc.); the need for lower tracheobronchoscopy (unsuccessful removal of a foreign body during upper bronchoscopy). There are upper, middle and lower tracheostomies.

Upper tracheostomy is a dissection of the second and third half rings of the trachea, moving away from the subglottic cavity, so as not to increase or cause reactive edema in this area by surgical intervention and a tracheostomy cannula. With a middle tracheostomy, the third and fourth half rings are cut, with a lower one - the fourth and fifth.

A clinic or hospital should always have a set of instruments for tracheostomy ready. The set consists of the required tools: syringe, anesthesia needles; a belly and pointed scalpel; surgical tweezers, hemostatic forceps; Farabeuf and serrated hooks, including a single-pronged one for fixing the larynx;

The patient is placed on his back, a cushion is placed - first under the neck, and at the time of opening the trachea under the shoulders. In special cases, tracheostomy is performed with the patient in a sitting position with his head tilted back. The operation is performed under local anesthesia or endotracheal anesthesia. Preliminary tracheal intubation eliminates oxygen starvation and facilitates the operation.

A skin incision is made from the middle of the thyroid cartilage down 4-5 cm with an upper tracheotomy; from the lower edge of the thyroid cartilage down 4-5 cm with a middle tracheostomy and lower with a lower tracheostomy down to the jugular notch.

In the vast majority of cases, tracheostomy has to be performed in extreme situations; with severe anxiety and restless behavior of the patient, increased excursions of the larynx. In this regard, both the speed of tracheostomy and precautions that can prevent complications during surgery and in the postoperative period are necessary. Precautionary measures include the use of a belly scalpel (to avoid injury to the underlying tissue when cutting the skin).

To make an incision strictly along the midline and then go to the white line of the neck, before applying local anesthesia, you need to make a mark on the skin, a “scratch” with a scalpel according to the midline on the neck (as a result of the administration of novocaine, soft tissue displacement may occur). The roller should be placed under the patient’s shoulders only when the trachea is exposed and all that remains is to open its lumen, otherwise the placement of the roller under the shoulders will aggravate the phenomena of stenosis.

Local anesthesia for tracheostomy. Introduction of novocaine “diamond”

1) incision of the skin, subcutaneous tissue, spreading the edges of the wound, stopping bleeding;

2) exposure of the white line of the neck (the junction of the sternohyoid muscles). Between two tweezers in the center of the wound, Kupffer scissors with blunt ends are used to cut the white line in the transverse direction. This technique allows you to avoid injury to the isthmus of the thyroid gland;

3) insertion of a grooved probe under the white line upward from the incision and dissection (the same is done with the lower part of the white line);

4) hooks pull the muscles to the sides and expose the isthmus of the thyroid gland. His wound is dangerous due to severe bleeding.

Insertion of a metal tracheostomy cannula

With an upper tracheostomy, the isthmus of the thyroid gland, after dissecting the fascia that fixes it to the cricoid cartilage, is moved down or crossed between two ligatures;

5) having thus exposed the wall of the trachea, the second and third half rings of the trachea are cut with a pointed scalpel. The movement of the scalpel is from bottom to top, so as not to injure the isthmus of the thyroid gland shifted downwards;

6) you need to make sure that the lumen of the trachea is opened (usually, immediately after dissection of the tracheal wall, a strong inhalation and cough follow). If this does not happen, it is possible that only the half rings of the trachea were cut, and the mucous membrane remained uncut;

7) after dissecting the tracheal wall, the branches of a Trousseau-type retractor are inserted into the incision, the edges of the wound are moved apart and a tracheostomy cannula is inserted;

make sure that breathing through the cannula occurs freely, apply sutures to the skin around the tube. The tube is securely fixed with a gauze band on the patient’s neck, and the node should be located on the side of the neck to make it more convenient to monitor the condition of the node to avoid the tube falling out. The patient requires mandatory supervision by medical personnel and must be in a horizontal position with the head end of the bed raised high.

Late complications include arrosive bleeding, tracheoesophageal fistula, chronic cicatricial stenosis of the larynx and trachea.

Tracheostomy in young children has a number of features: the operation should be performed under intubation anesthesia; when making a tracheal incision, it is advisable to focus on the cricoid cartilage; open the trachea with a 3-4 ring incision; you cannot cut the trachea with the neck straightened, since in this case the trachea is pulled upward and the cut rings may end up behind the sternum, which will lead to the development of pneumomediastinum and pneumothorax;

the Trousseau trachea dilator is not suitable for inserting a tracheostomy cannula into the tracheal lumen in children due to trauma to the trachea (some authors believe it is advisable to use a “Mosquito” type hemostatic clamp to expand the tracheal lumen); in children it is necessary to use plastic tracheocannulas;

Forecast

The prognosis for laryngeal stenosis is different, as it depends on its degree and the provoking pathology. At the terminal stage, it is necessary to take urgent measures to resume the passage of air through the lumen of the larynx.

The prognosis worsens in cases such as:

• self-medication;
• treatment for individuals who do not have a medical education;
• the occurrence of stenosis against the background of allergic reactions;
• neglected state;
• late diagnosis;
• incorrect medical tactics;
• the occurrence of complications.

Kovtonyuk Oksana Vladimirovna, medical observer, surgeon, consultant doctor

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The general symptoms of edema, stenosis and laryngeal spasm may coincide, but in each case the clinical picture is individual.

Symptoms of laryngeal edema

• protrusion of the neck area (outside);
• blueness and swelling of the lips;
• suffocation;
• panic;
• wheezing breathing;
• need for intubation (in some cases);
• salivation;
• lacrimation;
• hyperemia;
• thickening of the epiglottis;
• identification of blood vessels on the surface of the mucosa;
• absence of a lumen in the larynx or its small diameter.

Symptoms of laryngeal spasm

• inability to breathe normally;
• passing pain;
• the transience of the attack (within 1-2 minutes the condition returns to normal);
• suffocation;
• panic;
• lacrimation;
• dryness of the oral mucosa;
• neurological consequences;
• cough;
• nausea;
• hoarse voice;
• heartburn;
• a sore throat;
• hoarseness.

When a spasm of the larynx occurs, a state of suffocation occurs, the inability to speak and breathe. In some cases, the spasm occurs in such a way that the person can breathe, but cannot speak a word.

Attacks often occur in the middle of the night, as a result of which the patient wakes up from suffocation or a feeling of lack of air. This condition is called sleep laryngospasms, and is often associated with reflux disease. Loss of consciousness may occur.

As the airway slowly returns to normal, the patient is able to take a breath. This period is characterized by so-called wheezing, or stridor. The duration of such an attack can be 1-4 minutes, after which the breathing process returns to normal.

Symptoms of laryngeal stenosis

Laryngeal stenosis does not always imply spasm or swelling, but may precede these two conditions, for example, with an insect bite (bee, spider), stenosis first occurs, and then spasm or swelling.

The main symptoms of laryngeal stenosis are:

• increase in the thickness of the walls of the larynx;
• difficulty taking a breath;
• salivation;
• lacrimation;
• feeling of panic;
• a sore throat;
• hoarse cough;
• suffocation;
• swelling of the neck;
• identification of veins in the neck;
• an increase in capillaries on the mucous membrane.

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Laryngeal stenosis is a partial or complete narrowing of the lumen of the larynx, leading to difficulty passing air during breathing. Acute laryngeal stenosis develops within a short time and a life-threatening condition occurs. Chronic laryngeal stenosis is characterized by slow development. Inflammation of the larynx is especially dangerous for children from birth to 7 years old - before this age, the child has folds of connective tissue under the larynx, which, when inflamed, swell so much that they can completely block the airways. Narrowing of the lumen of the larynx - stenosis develops rapidly: in the dead of night, a child who is quite healthy in the evening begins to have a “barking” cough, the voice disappears, and breathing becomes difficult and noisy. Swelling is very dangerous because it can completely block breathing within two hours. Such attacks require urgent emergency medical care.

Stenosis almost always develops at night. The child develops - a change in voice - a rough "barking" cough - noisy breathing with difficulty inhaling - anxiety, a disturbance in general well-being - the skin becomes pale and then bluish

Symptoms

The development of stenosis occurs over four stages, each of which is manifested by corresponding symptoms.

The first compensated stage is characterized by the following symptoms:

• there is no inspiratory dyspnea at rest;
• shortness of breath appears during walking and other physical activity.

Shortness of breath is accompanied by rapid and deep breathing. The pause between inhalation and exhalation shortens or it disappears completely due to an increase in the level of carbon dioxide. The inhalation lengthens, a characteristic loud noise (sound) appears, recognizable from a distance. Breathing with stenosis becomes less frequent, bradycardia begins: the heart rate decreases. The voice becomes rougher to the point of hoarseness.

Diagnostics and examinations

The diagnosis is usually established during a general examination of the patient, and an X-ray examination of the patient, computed tomography of the trachea and larynx are also performed. An MRI is also performed.

In addition, the condition is determined through laboratory tests, which make it possible to determine the sensitivity of the laryngeal microflora to various antibiotics. A general blood test is done; a mandatory step is the use of probes that have an optical system, which allows the doctor to assess the condition of the trachea.

Causes of stenosis, edema and spasm of the larynx

Next, the main causes of stenosis, edema and spasm of the larynx will be discussed.

Causes of laryngeal stenosis

There are many causes of laryngeal stenosis. The main ones are the following:

• goiter of the thyroid gland;
• thymoma;
• enlargement of mediastinal lymph nodes (for example, with tuberculosis);
• vascular abnormalities of the throat and larynx;
• thyroid cancer;
• lungs' cancer;
• lymphomas affecting the mediastinal lymph nodes;
• bilateral vocal cord paralysis;
• foreign body inhalation;
• sarcoidosis;
• amyloidosis;
• penetrating trauma to the larynx;
• damage to the larynx with a sharp object from the inside;
• rheumatoid arthritis;
• consequences of intubation;
• infections (diphtheria, epiglottitis);
• respiratory papillomatosis;
• polyps;
• congenital stenosis;
• laryngeal atresia;
• Wegener's granulomatosis;
• idiopathic progressive subglottic stenosis;
• tracheomalacia;
• recurrent polychondritis;
• damage to the tracheal ring due to chronic obstructive pulmonary disease;
• tracheal ring weakness;
• benign tumors of the larynx;
• tracheal injury;
• subglottic hemangioma;
• tuberculosis;
• consequences of photodynamic therapy;
• head and neck cancer;
• trachea cancer;
• erosive thyroid cancer;
• erosive esophageal cancer.

The main causes of laryngeal edema are as follows:

• exposure to harmful substances (chemical fumes);
• allergic reaction;
• thyroid diseases;
• body reaction to insect bites;
• gastroesophageal reflux disease;
• laryngopharyngeal reflux.

Causes of laryngeal spasm

• gastroesophageal reflux disease;
• laryngopharyngeal reflux;
• stressful situation;
• diseases of the nervous system;
• asthma;
• allergy;
• penetrating trauma to the larynx;
• damage to the larynx with a sharp object from the inside;
• rheumatoid arthritis;
• consequences of intubation;
• infections (diphtheria, epiglottitis);
• respiratory papillomatosis;
• polyps;
• congenital stenosis;
• laryngeal atresia.

Treatment of edema, stenosis and spasm of the larynx

Treatment methods for these three conditions are generally similar: treatment is carried out only in a hospital setting, especially in severe cases. Doctors need to determine the cause of swelling, spasm or stenosis, and only then begin treatment.

Traditional treatments involve the use of drugs to widen the airways.

Drugs used to treat laryngeal stenosis, swelling, or spasm:

• antibiotics (cephalosporin, penicillin, macrolides);
• antihistamines (tavegil and analogues);
• corticosteroids (hydrocortisone, prednisolone);
• calcium gluconate;
• ascorbic acid;
• drugs aimed at eliminating excess fluid from the body (furosemide, bumetanide, veroshpiron).

The combination of several of these drugs increases the chances of a quick recovery for the patient, especially in critical cases. For laryngeal stenosis, destenosis is used, that is, a set of measures to relieve swelling of the mucous membrane.

If medications are not effective, doctors may perform an emergency tracheostomy (inserting a special tube into the windpipe to allow the patient to breathe normally). If asphyxia is present, a conicotomy (middle incision of the larynx) is performed. This method of assistance is used only in emergency cases. After conicotomy, a tracheostomy is performed.

When a spasm of the larynx occurs, a state of suffocation occurs, the inability to speak and breathe. In some cases, the spasm occurs in such a way that the person can breathe, but cannot speak a word.

Symptoms of acute stenosis

Stenosis almost always develops at night. The child develops - a change in voice - a rough "barking" cough - noisy breathing with difficulty inhaling - anxiety, a disturbance in general well-being - the skin becomes pale and then bluish

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How to treat laryngeal stenosis? Causes, signs, symptoms, diagnosis, treatment methods for laryngeal stenosis.

Diagnostics

Symptoms of stenosis do not allow a mistaken diagnosis. In a hospital setting, fibrolaryngoscopy is performed - examination of the larynx using a special video camera - fiberscope.

Diagnosis of the disease

To understand the cause of the disease and stage, you need to see a doctor and undergo diagnostic procedures. The doctor will palpate the area of ​​the larynx and perform an external examination of the patient. The overall picture is diagnosed after assessing the clinical symptoms and diagnostic results.

Here are the main methods for determining stenosis:

• Ultrasound of the thyroid gland;
• Throat swab;
• X-ray of the larynx;
• Tomography.

After determining the exact diagnosis, you need to immediately begin treatment. The course of therapy is determined only by the attending physician.

Laryngeal stenosis in children and adults: symptoms, degrees, treatment, help

When the larynx narrows, which leads to a temporary disruption of air exchange with the environment, laryngeal stenosis occurs.

The degree of its manifestation is directly related to the degree of narrowing of the lumen of the fissure. This condition is caused by the reaction of the human body to the pathological changes occurring in it.

The result of stenosis can be suffocation or problems with the respiratory system.

Laryngeal stenosis

Both adults and children are equally susceptible to this disease. Stenosis occurs in two main forms: acute and chronic. The first category is characterized by the rapid manifestation of symptoms and the development of hypoxia (oxygen starvation).

The second form is characterized by the unhurried development of symptoms that do not weaken for quite a long time.

Left untreated, it can cause serious health problems. The doctor can diagnose this disease by the general clinical picture of the patient’s condition and the characteristic symptoms of stenosis.

According to the international classification of diseases, laryngeal stenosis is classified as a disease of the laryngeal folds. It is assigned code J38 as unclassified elsewhere. Full diagnosis coding is J38.6. The main reason for its development is inflammatory processes occurring in the throat. Less commonly, mechanical trauma can also lead to laryngeal stenosis.

Stages of development

Stenosis in the larynx goes through 4 stages of progression. Each of them is characterized by its own manifestation of symptoms and duration. The stages have the following names:

1. Compensation. This is the initial stage at which the first signs of stenosis appear: the intervals between inhalations and exhalations become shorter, breathing becomes slower, as does the heartbeat.
2. Incomplete compensation. The person's breathing sounds louder than usual. When inhaling, there is a tightening of the intercostal cavities. The patient is characterized by restless behavior and pallor.
3. Decompensation. The patient's general condition deteriorates significantly. The larynx requires much more effort to inhale and exhale air. The patient's face turns blue. He increasingly strives to take a horizontal body position or sit down, leaning on at least some surface with his head thrown back.
4. Choking. The patient quickly gets tired, he is tormented by drowsiness and apathy. At the same time, one can note a significant dilation of his pupils and increased breathing, which becomes sharp and intermittent. The skin is almost gray in color. This stage is characterized by involuntary acts of defecation or urination. At some point he may even lose consciousness.

In the first two stages, the development of symptoms occurs slowly; starting from the third stage, the speed of their appearance increases. Therefore, the most effective and fastest course of treatment is that started no later than the end of the 2nd stage. Otherwise, in most cases, surgical intervention is already required to save a person’s life.

The photo shows the degree of laryngeal stenosis

Causes and provoking factors

Both external and internal factors can lead to the development of the disease. The main diseases, infection of which provokes a narrowing of the lumen of the larynx, are:

• Measles
• Malaria
• Typhoid fever
• Syphilis
• Scarlet fever
• Tuberculosis

It is also possible that a foreign body may enter the throat, blocking the gap for normal breathing. Among the external causes of the development of cicatricial stenosis, it is worth noting trauma or injury and medical intervention.

The development of the disease is inevitable for people suffering from congenital pathologies of the larynx or having chronic throat diseases. The degree of narrowing of the lumen is negatively affected by:

1. Laryngitis
2. Angina
3. Tracheitis
4. Malignant and benign tumors

There are many diseases that can provoke the onset of an acute form of stenosis. Therefore, the difficulty of diagnosis lies in the fact that medical professionals have to deal with several different areas: allergology, otolaryngology, resuscitation, pulmonology, oncology or neurology.

Causes and symptoms of laryngeal stenosis:

Manifestations of the disease

In both adults and children, the disease occurs in 4 stages. Each of them is characterized by its own manifestation of symptoms and degree, which makes it possible to determine the general condition of the patient. At the initial stage, stenosis manifests itself:

• Noise when breathing
• Reducing the gap between inhalation and exhalation
• Blueness of the nasolabial triangle
• Flared nostrils
• The appearance of a hoarse voice

When diagnosing the disease at this stage, one can note a narrowing of the lumen of the fissure by 1/3 or 1/4. In rare cases, an additional symptom may be purulent inflammation or the development of laryngitis. When the gap narrows to half, we can talk about the transition of stenosis to the 2nd stage. Symptoms are complemented by:

Shortness of breath and cold sweat appearing on the body indicate a transition to the 3rd stage. Lips and fingertips are added to the blue nasolabial triangle. The larynx is already narrowed by 2/3. There is practically no pause between entry and exhalation. The last stage is characterized by:

• Dilated pupils
• Convulsions
• Decreased body temperature
• Blue discoloration of the skin on the body
• Decreased cardiac activity

The patient's condition is so serious that the heart may fail or breathing may completely stop. He is unable to control the urge to go to the toilet. The maximum gap clearance is no more than 1 mm. A person can lose consciousness and die if he is not given the necessary help in time.

The photo shows the diagnosis of the larynx

Algorithm for providing assistance

As a rule, emergency measures are required upon the onset of stages 3 and 4 of laryngeal stenosis. After calling an ambulance, you will have to carry out simple manipulations that will allow the patient to survive until she arrives. To do this you need:

1. Limit the patient's physical activity.
2. Humidify the air in the room.
3. Ensure unobstructed flow of fresh air into the room.
4. Calm the patient.
5. Press the spoon onto the root of the tongue.
6. Provide him with plenty of fluids.
7. Rub your calf muscles.
8. Constantly monitor the presence of breathing.

It is especially important to bring children into the proper emotional state. Fear and panic further aggravate the symptoms of a suffocation attack. If necessary, the patient can be given sedatives or psychotropic drugs. Upon arrival of the ambulance, inform the doctors about the measures you have taken.

You can reduce the symptoms of stenosis before the ambulance arrives by providing the patient with a 5-minute hot bath. You can make a foot bath only with mustard added to it. To maintain warmth, the patient should be wrapped up after the procedure. This will allow you to maintain the vasodilation that has occurred for some time.

When an attack develops in children, parents should act according to the algorithm described above, and also rub their legs and arms before the ambulance arrives; if the temperature rises, bring it down with children’s antipyretics.

It will be useful for children to breathe in hot vapors, which will make breathing easier for a while. Laryngeal stenosis has no age restrictions, so an attack can occur in a newborn child. Then you need:

1. Call an ambulance.
2. Parents should pull themselves together and not worry so that their condition is not passed on to the child.
3. The baby should be held vertically in your arms to facilitate breathing and not allowed to cry.
4. Remove or unfasten clothing that restricts the chest and neck.
5. Provide fresh air in damp rooms.
6. Give the child warm water.
7. If the attack is caused by an allergy, then give an antihistamine.

It is strictly forbidden to wrap a newborn during an attack. The optimal temperature for its ligaments is room temperature. They cannot be heated additionally, so as not to provoke the development of edema, which will further narrow the lumen.

The baby should not be given cough medicine, even if he sometimes has a cough. Steam inhalations should also not be performed. If the attack subsides before the doctors arrive, do not relax, it may recur.

How to help a child with laryngeal stenosis:

Basic treatment methods

The choice of treatment method depends on the cause of laryngeal stenosis. If it is an allergy, then first of all you should take antihistamines. When it comes to a foreign body entering the larynx, restoration of normal breathing is possible after its removal. If inflammation develops, you should take a course of antibiotics.

The stages of compensation and incomplete compensation are treated exclusively with medication. In rare cases, it is necessary to install a special tube through an incision in the neck through which the patient breathes. The tube can be installed directly into the larynx to expand the lumen, but for no more than 3 days.

When tumors develop on the ligaments, they are removed through surgery. Physiotherapeutic procedures will make you feel better and speed up the process of treatment or rehabilitation after surgery.

Drug therapy

Treatment of laryngeal stenosis with medications is effective in the first or second stages of the disease. The use of prescribed drugs is carried out under the strict supervision of the attending physician. Therapy consists of taking:

The choice of a group of medications depends on the factors provoking the narrowing of the lumen and the accompanying symptoms. Drug therapy does not require hospitalization of the patient. It is required already at the 3rd and 4th stages to perform surgical interventions.

At the stage of decompensation, the patient is taken to the hospital, and at the stage of suffocation, he is already transferred to the intensive care unit. To ensure the patient’s respiratory function, after examining the larynx and throat, nasotracheal intubation is performed.

This procedure involves inserting a tube into the trachea to open the airway.

After this medical procedure, the patient is placed in a steam-oxygen tent and treatment with medications is continued. There is a risk of post-intubation laryngeal stenosis.

The patient needs peace, clean and moist air, and absence of stress. Laser therapy, phonophoresis, and electrophoresis procedures can help you recover faster. The duration of the course of such treatment is no more than two weeks.

Traditional methods of treatment

Traditional medicine is intended only to facilitate the patient’s breathing or create conditions favorable for this. You should not use its prescriptions without the consent of your doctor.

It is not dangerous to resort to traditional methods of treatment for prevention in the initial stages of the development of stenosis. If you have problems with the respiratory system, you should increase the volume of daily drinking.

It will be healthier if you choose the following drinks:

• Milk with honey
• Milk with Borjomi water in a 1:1 ratio

Tinctures of valerian, hawthorn or motherwort will help calm the nervous system. You can strengthen the walls of blood vessels with:

1. A decoction of the juice of golden mustache and plantain leaves. Drinks are taken in a ratio of 1 to 20, a little liquid honey is added to them and mixed until smooth. The mixture is boiled in a water bath. For 2 months you should take only 2 tablespoons per day. drugs after meals.
2. Rowan decoction. To prepare it, 200 gr. crushed bark is steamed with boiling water. The resulting mass is brought to a boil over a slow window for about 120 minutes. After filtering, drink the broth 3 times a day, 3 tbsp. Course duration – 30 days. Every 3 months the course should be repeated.

If you are allergic to any of the components of the composition, you should not use this recipe. Getting an irritating allergen into the body can further aggravate the situation in the respiratory system.

In the chronic form of the disease, the functioning of the entire body is negatively affected. Lack of oxygen and disturbances in heartbeat and breathing rhythms lead to pneumonia and bronchitis.

An advanced form of pneumonia may be accompanied by the release of blood during expectoration. The reproductive and urinary systems undergo changes.

The lack of normal respiratory activity causes oxygen starvation of the brain. This results in memory deterioration, decreased vision sharpness and frequent headaches.

If a person gets the flu during stenosis, the body tries to compensate for the lack of air and thereby provokes severe attacks of suffocation. In some cases they lead to the death of the patient.

General recommendations

Preventive measures include timely treatment of laryngeal stenosis. In this case, you should strictly follow your doctor’s instructions and take all prescribed medications. It is necessary to lead a lifestyle that will allow you to avoid respiratory diseases. Regularly strengthen your immune system and strengthen your body.

If you are allergic to medications or food, you should avoid consuming them. If you have problems with your voice or throat, immediately seek advice from a specialist. Do not inhale chemical fumes or come into contact with hazardous substances without wearing protective equipment.

Advice and feedback from Dr. Komarovsky in our video:

Forecast

Timely provision of first aid and a competent course of treatment guarantee a favorable prognosis for the patient. If laryngeal stenosis is neglected or left untreated at the stage of suffocation, it can cause the death of the patient.

Source: https://gidmed.com/otorinolarintologija/zabolevanija-lor/bolezni-gorla/stenoz.html