Received: 24 September 2020 | Revised: 17 January 2021 | Accepted: 23 January 2021

DOI: 10.1111/ijcp.14058

ORIG INAL PAPER

RESPIRATORY MEDICINE

Bronchoscopic management as an alternative treatment in

non-­operable benign tracheal stenosis

Wael Emam1 | Yasser Mostafa1 | Ashraf Madkour1 | Khaled Wagih1 |

Hieba Ezzelregal1 | Nektarios Anagnostopoulos2 | Grigoris Stratakos2

1
Faculty of Medicine, Pulmonology
Department, Ain Shams University, Cairo, Abstract
Egypt Background: Endoluminal therapy either by dilatation, scar tissue resection or stent
2
Interventional Pulmonology Unit,
insertion is an established treatment for non-­malignant airway stenosis although the
1st Respiratory Medicine Department of the
National, Kapodistrian University of Athens, surgical approach is still considered the “gold standard.” No clear consensus exists on
Athens, Greece
the structured role of each modality.
Correspondence Aims: We aimed to investigate the role of bronchoscopic management in non-­
Wael Emam, Faculty of Medicine,
operable tracheal stenosis cases, evaluating the effectiveness and safety of each
Pulmonology Department, Ain Shams
University, Cairo, Egypt, 83 Hegaz st., procedure based on a structured algorithmic approach.
Helioples, Cairo, Egypt.
Patients and methods: This prospective study was carried out on (40) consecutive
Email: dr.waelemam88@gmail.com
patients diagnosed between March 2017 and March 2020 with tracheal stenosis not
amenable to surgery. All strictures were first evaluated by flexible bronchoscopy and
classified as simple or complex. Patients were treated following a standardised thera-
peutic algorithm approach based on published evidence and our own expertise.
Results: The mean age of the study population was 45.25 ± 18.79; lesions were clas-
sified as simple (14) and complex (24), while two patients had mixed type stenosis.
Long term success rate was 100% in simple stenosis and 87.5% in the complex ones.
Stents were deployed in 24 cases, most of which were of the complex type and only
two of the simple type. Post-­procedural mild to moderate complications were de-
tected overall in 70% of the patients. All complications were non-­life threatening,
mostly stent-­related and were effectively managed.
Conclusion: We conclude that after accurate classification and a structured algorith-
mic approach, interventional bronchoscopic management may play a crucial role in
the effective treatment of benign tracheal stenosis.

1 | I NTRO D U C TI O N Historically, surgical management has been the mainstay of

treatment in such cases, while endoscopic procedures are often
Tracheal stenosis (TS) is abnormal tracheal lumen narrowing that can viewed as a bridge to definitive surgical intervention either in simple
impair sufficient airflow and cause severe morbidity. Any level of the stenosis or in high-­risk patients. However, with the recent advances
trachea can be affected from the cricoid cartilage to the main carina. in the field of interventional pulmonology, definitive management of
TS may be congenital or idiopathic but most commonly is secondary TS using multiple endoscopic methods became increasingly common
to a variety of pathologies including tracheal trauma, malignancy, ex- especially in patients deemed non-­operable. 2
trinsic compression or iatrogenic. Endotracheal intubation and tra- We aimed to prospectively investigate the role of bron-
cheostomy are considered the most common causes of TS.1 choscopic management either by mechanical dilatation and

Int J Clin Pract. 2021;75:e14058. wileyonlinelibrary.com/journal/ijcp © 2021 John Wiley & Sons Ltd | 1 of 8
https://doi.org/10.1111/ijcp.14058
2 of 8 | EMAM et al.

electrocautery incisions of scar tissue or by stent insertion in non-­

operable tracheal stenosis cases, following a standardised algo-
What’s known?
rithmic approach. We evaluated the effectiveness and safety of
Surgical management is the mainstay of tracheal stenosis,
this approach.
while endoscopic procedures are often viewed as a bridge
to definitive surgical intervention either in simple stenosis
or in high-­risk patients.
2 | PATI E NT S A N D M E TH O DS

What’s new?
This prospective study was carried out at the Bronchoscopy Unit
of the Pulmonary Medicine Department of Ain Shams University This study is focusing on the current role of interventional
and National and Kapodistrian University of Athens between March bronchoscopic procedures (Dilatation, electrocautery and
2017 and March 2020. Consecutive patients who presented with stent placement) in the definitive management of non-­
symptoms strongly indicating stenosis of the large airways (eg, stri- operable tracheal stenosis.
dor, history of endotracheal intubation or tracheostomy, exertional
dyspnea) were considered. All patients underwent cervical CT and a
preliminary flexible video-­bronchoscopy indicating the presence of area; 2, 26-­50%; 3, 51-­75%; 4, 76-­90%; or 5, 91% to complete ob-
tracheal stenosis. Patients with malignant disease or those who were struction) as described in detail by Freitag et al3
deemed operable after thoracic surgery counselling were excluded Through Rigid Bronchoscopy combined modalities were used
from the study. Τhe cause of original intubation or tracheostomy, as needed: radial incisions of the mucosal stenosis web with elec-
the duration of intubation or tracheostomy in days as well as cer- trocautery knife or probe (Erbe, Tubingen, Germany) and balloon
vical and chest CT findings were recorded. Functional assessment bronchoplasty (CRE; Boston Scientific, Marlborough, MA, USA).
(spirometry) and basic laboratory tests were examined before and Mechanical dilatation of the stenotic lesion with the bevel and the
after bronchoscopic management, while microbiologic examination shaft of the RB and argon plasma coagulation (APC) in cases war-
of bronchial secretions was carried out during follow-­up visits. ranting further hemostasis. The flexible video-­bronchoscope was
Patients were classified as having simple (mucosal, short web often used in combination with the rigid scope to improve distal air-
stenosis) or complex (longer >1 cm, with air wall collapse, cartilage way visualisation and to aspirate the secretions.
involvement and/or tracheomalacia) symptomatic tracheal stenosis. Eventual bleeding was controlled by the compression of the tra-
In cases of focal destruction of the tracheal wall with mucosal short cheal wall by the RB or by electrocautery/ APC. LASER was not used
web stenosis, the lesions were described as mixed. Management fol- in any of the treated cases. When indicated (unstable airway, malacic
lowed an algorithmic approach adapted from previously published tracheal wall or absence of cartilaginous wall after tracheostomy)
studies (Gallucio et al). (Figure 1). Dumon silicone stents (Novatech, La Ciotat, France) were inserted
using the appropriate equipment.
Topical Mitomycin C (Mitomycin medac, vial containing
2.1 | Anaesthesia Mitomycin 2 mg) was applied as an adjunct in the management of
relapsing short concentric membranous stenosis (simple) not involv-
All patients were treated with rigid bronchoscopy under IV general ing the cartilages. Mitomycin by impairing fibroblasts activity po-
anaesthesia with propofol, remifentanil and muscle relaxant with tentially reduces granulation tissue and may prevent a recurrence.
either manual jet ventilation or controlled ventilation through the The stenotic region was topically treated with mitomycin C following
ventilation port of the rigid bronchoscope. bronchoscopic treatment. Small pieces of gauze were wetted with
mitomycin C (0.2 mg/mL) and applied to the stenotic region radi-
ally using rigid or flexible forceps several times. The total time that
2.2 | Bronchoscopic procedure the stenotic region was exposed to topical mitomycin C was about
8-­10 minutes.
All patients underwent a preliminary flexible video-­bronchoscopy All patients after procedures were instructed to use nebulisa-
(Pentax EB-­1830T3 video-­bronchoscope; Asahi Optical Co. or tion with hypertonic saline at least three times/day and mucolytics
Olympus BF-­IT 180, Tokyo, Japan) indicating the presence, degree (Acetyl cysteine).
and type of tracheal stenosis. Smoking and inhalation of any irritant substances that increase
During the flexible video bronchoscopy, the location of stenosis mucostasis and subsequently stent obstruction was discouraged.
was identified and classified into upper (I), middle (II), or lower-­third Patients receiving stents were evaluated a month after initial
of the trachea (III) stenosis. The type of stenosis was further clas- placement, 3 months afterwards and then every 6 months or when-
sified as simple, complex or mixed based on the length and the in- ever the patient reported complications related to the broncho-
volvement of the tracheal wall cartilages. The degree of stenosis was scopic intervention. Two years after stent insertion, patients were
also recorded (0, no stenosis; 1, ≤25% decrease in the cross-­sectional evaluated for stent removal and for operability. In the case of stable
EMAM et al. | 3 of 8

F I G U R E 1 Therapeutic algorithm.
Simple stenoses were dilated once or
twice. If recurring stenosis was operable
the patient was referred to the thoracic
surgeon, if non-­operable, Stent was
inserted. In non-­operable complex
stenosis, stent was inserted during initial
bronchoscopy

airway, the stent was removed and the patient was discharged, while Amongst the studied population, 24 patients had complex steno-
in case of airway wall instability after stent removal, the patient was sis, while 14 patients had simple and 2 patients had mixed stenosis.
assessed either for surgical management or for stent replacement The stenoses were classified according to the classification system
which was then repeated every 2 years. of central airway stenosis described by Freitag as shown in Table 2.
During the periodical bronchoscopic follow-­up at 1, 3, 6 and All patients underwent dilatation and electrocautery, while stent
every 6 months until definite cure, various flexible bronchoscopic insertion was deployed in 24 patients. No severe intra-­procedural
techniques (electrocautery, cryotherapy, mitomycin C applications complications or mortality were observed. Mitomycin C was applied
and balloon dilatations) were used according to indications to treat as an adjuvant “out of the protocol” technique in eight cases with
eventual complications (Figures 2-­4). multiple relapse stenosis after initial management (six simple steno-
ses and two mixed types) No recurrence was observed in four cases
(simple stenosis) after mitomycin C application. The majority of pa-
2.3 | Statistical analysis tients receiving stents had complex type stenoses and in only two
cases simple.
The collected data were revised, coded tabulated and analysed using The immediate airway patency re-­establishment was successful
statistical package for social science (IBM SPSS) version 20.0. (SPSS in all patients.
Inc). Relapse was detected during follow-­up in two cases of simple
Logistic regression analysis of parameters associated with the stenosis 4 months after 2nd dilatation and in three cases of complex
need for stent placement and their safety results were used in the type stenosis 5 ± 2 months after stent removal).
form of univariate and multivariate analysis using the backward Surveillance bronchoscopy was carried out routinely at regular
(Wald) method. intervals (1, 3, 6, 12, 18, 24 months) to remove the mucostasis and
granulation tissue that was frequently formed early at the proximal
and distal tips of the stent. Cryotherapy sessions were performed
3 | R E S U LT S additively to remove pseudomembranes which were developed
in six cases. During the study period, we were able to remove the
A total of 40 adult patients with benign tracheal stenosis inoper- stents in nine patients (37.5%) without secondary complications or
able at initial presentation, were enrolled in the study. Six patients relapse during follow-­up.
who after initial endoluminal treatment were deemed appropriate Characteristics of different types of stenoses in relation to
for surgery were directed to surgical intervention and were followed bronchoscopic modalities applied, number of stent insertion and re-
up afterwards. moval, mean duration of follow-­up success rate, mortality and com-
The clinical characteristics of the patients regarding age, gender, plications are described in Table 3.
causes of intubation, presenting symptoms and causes of inopera- In addition to surveillance bronchoscopy, the respiratory
bility are presented in Table 1. Regarding the duration of intubation, functional assessment was performed at regular intervals during
60% of PITS cases were intubated for a period of less than 15 days. follow-­
­ up of our patients. Post-­
intervention spirometry values
4 of 8 | EMAM et al.

F I G U R E 2 Simple short web stenosis. (A) Before intervention (B) After radial incisions (C) After dilatation with the shaft of rigid
tracheoscope

FIGURE 3 Complex web stenosis involving the tracheal wall. (A) Before intervention (B) after dilatation and stent placement

F I G U R E 4 Complex web stenosis (A) during stenting, (B) immediately after removal of the stent (3 years duration of stenting), (C)
2 months later and d) 6 months later

showed statistically significant improvements when compared with Over a median follow-­up of 26 months, no mortality was recorded.
pre-­intervention values as shown in Table 4. However, post-­procedural complications were common albeit rela-
Long term successful bronchoscopic management (defined as tively minor and manageable.
longstanding re-­establishment of airway patency >60% and relief
of symptoms) was attained by 100% in simple and mixed stenosis
and 87.5% in complex type stenosis. During the study period, we 4 | D I S CU S S I O N
were able to remove the stents in 9 out of the 24 patients (37.5%)
who had them deployed, while in the rest of the patients, the stents Tracheal resection of the affected part of the airway followed by
had to be replaced and reconsidered for removal on a later date. end to end anastomosis is currently considered the gold standard
EMAM et al. | 5 of 8

TA B L E 1 Clinical characteristics of the studied population TA B L E 2 Classification of benign tracheal stenosis (according to
Freitag. classification) amongst studied patients
Variables Values
Total
Age mean age
Classification no. = 40
45.25 ± 18.79
Male/female 24/16 Localisation

History of intubation 23 Subglottic 11 (27.5%)

History of tracheostomy 12 Upper trachea 21 (52.5%)

Idiopathic tracheal stenosis 5 Midtrachea 6 (15.0%)

Causes of intubation Lower trachea 2 (5.0%)

COPD 1 (2.5%) Degree of stenosis

Road traffic accident 11 (27.5%) No stenosis 0 (0.0%)

Relapse after curative surgery for PITS 6 (15.0%) <25% stenosis 0 (0.0%)

ARDS (Pneumonia) 4 (10.0%) 26%-­50% stenosis 7 (17.5%)

Myasthenia gravis 1 (2.5%) 51%-­75% stenosis 15 (37.5%)

Brain insult (Haemorhage, Tumour, Stroke) 6 (15.0%) 76%-­90% stenosis 9 (22.5%)

Myocardial infarction 5 (12.5%) 90%-­100% stenosis 9 (22.5%)

Excessive burns 2 (5.0%) Note: This table shows that (52.5%) had upper tracheal stenosis and
(27.5%) had subglottic stenosis. (according to Freitag classification)
Post-­DKA 3 (7.5%)
Shock 1 (2.5%)
study, 20% of the cases had excessively long lesions but the majority
Causes of inoperability
of patients were inoperable because of either multiple comorbidities
Recurrence after curative surgery 7 (17.9%) or denial of surgery.
Refusal of surgery 11 (28.2%) Post-­intubation tracheal stenosis was the most common cause
Multiple Co-­morbidities 11 (28.2%) (57.5%) of benign tracheal stenoses in the current study as well as in
Localisation in lower trachea 2 (5.1%) other comparative studies.12-­14 The main suggested causative factor
Length of stenosis >3 cm 8 (20%) is the loss of regional blood flow because of cuff pressure on the ad-
Major presenting symptoms jacent tracheal wall. This ischemic injury occurs within the first few
Dyspnea 40 (100.0%) hours of intubation and healing of the damaged region can result in

Wheezing 5 (12.5%) web-­like fibrosis within 3 to 6 weeks 15

Interestingly, tracheal stenosis following tracheostomy which ac-
Stridor 9 (22.5%)
counts for 30% of cases in our study, most commonly results from
Cough 5 (12.5%)
abnormal wound healing with abundant granulation tissue formation
Note: ARDS, Acute Respiratory Distress Syndrome; COPD, Chronic around the tracheal stoma site.16
Obstructive Lung Disease; DKA, Diabetic Ketoacidosis; PITS, Post-­
In this study, approximately 60% of PITS cases were intubated
Intubation Tracheal Stenosis.
for a period of less than 15 days. This data aligns with the previous
work of Sejal et al17 and Zias et al13 in which all cases developed
4
for benign TS management. However, optimal management still re- tracheal stenosis within 5 days of intubation.
mains controversial and is not universally standardised. Trauma after road traffic accidents was the commonest cause of
Bronchoscopic management of tracheal stenosis is an alternative intubation amongst studied patients. These results were consistent
to surgical operation in cases not amenable to surgery and endolu- with the results of Ciccone et al18 who discussed operative and non-­
minal treatment can have an important role in the management of operative treatment of subglottic stenosis on 18 patients, where
both simple and complex tracheal stenosis cases. trauma was the main cause of intubation in 10 patients.
A multidisciplinary management protocol integrating both op- Patients with complex stenosis in the present study were im-
erative and non-­
operative bronchoscopic strategies was recom- pressively higher in number 24/40 compared with reports in the
mended by many authors.5-­8 We adopted this algorithmic approach literature,7,19 this may be attributed to the fact that our centres (in
and applied this multidisciplinary management integrating thoracic Egypt as well as in Greece ) are the only regional referral centres for
surgery and interventional pulmonology modalities. such patients. These data are in agreement with the study of Dalar
Previous studies described as absolute contraindications to the et al20 who studied 132 consecutive patients with benign tracheal
surgical management of benign tracheal stenoses the presence of an stenosis, the majority of whom had complex stenosis.
excessively long lesion (roughly 50% or more of the whole tracheal Approximately 60% of our patients had an average degree of
length), respiratory failure, sequelae of head injury or neurosur- stenosis of >70%. Functional assessment by spirometry and flow-­
gery, cardiovascular, or other debilitating diseases.9-­11 In the present volume loop can be a simple and non-­invasive method to evaluate
6 of 8 | EMAM et al.

TA B L E 3 Characteristics of different
Type Simple Complex Mixed Total
types of stenosis
Number of cases 14 (35%) 24 (60%) 2 (15%) 40
Stent insertion 2(14%) 20(85.3%) 2(100%) 24
Mitomycin application 6 (35.7%) 0(8.3%) 2(50%) 8
Complications 4 20 4 28
Pseudomembranes 1 4 1 6
Migration 0 3 0 3
Positive microbiological 0 5 1 6
culture
Granulation tissue 1 2 1 4
Stent obstruction by 0 3 1 4
mucus secretions
Recurrent stenosis 2 after 2nd 3 after stent 0 5
dilatation removal
Stent removal 2(100%) 7(29%) 0 9 (37.5%)
Mean duration of 20 ± 6 30 ± 5 26 ± 2
follow-­up(months)
Success rate 100% 87.5% 100%
Mortality 0% 0% 0%

Note: This table shows characteristics of different types of stenosis regarding the number of cases,
complications, success rate, number of stents insertion and mortality.

TA B L E 4 Functional assessment
Post-­
amongst studied patients
Functional assessment Grading Pre-­intervention intervention

Dyspnea grade according to Grade 0 0 (0.0%) 35 (87.6%)

mMRC Grade 1 0 (0.0%) 5 (12.5%)
Grade 2 2 (5.0%) 0 (0.0%)
Grade 3 20 (50.0%) 0 (0.0%)
Grade 4 18 (45.0%) 0 (0.0%)
FEV1 (spirometry) [% change of >80% 0 (0.0%) 35(87.5%)
spirometry] Mean:94.62 ± 43.97 70%-­8 0% 0 (0.0%) 5 (12.5)
Range:29.41-­174.19
51%-­69% 6 (15%) 0
35%-­ 50% 14 (35%) 0
<35% 8 (20%) 0
Unable to do 12(30%) 0

Note: This table describes pre and post-­intervention spirometry. All cases (post-­intervention) had
marked improvement in FEV1.
Abbreviations: FEV1, Forced expiratory volume in 1 s; mMRC, Modified Medical Research Council.

improvement in upper airway obstruction following intervention. be equally effective and safe, while less expensive and more readily
A significant improvement was found in spirometric results after available. Mitomycin C was applied in a few cases of relapsing steno-
bronchoscopic intervention in comparison to the pre-­intervention sis and was associated with encouraging results. However, it was not
results. These results were consistent with Abdullah et al21 who used systematically as this was not in the aims of the present study
concluded that spirometry is a useful marker in following up patients and thus we can not draw conclusive results. All the simple steno-
with subglottic stenosis and is also a good indicator to determine ses and 87.5% of the complex type cases were successfully treated
post-­airway surgery outcomes. which in our cohort was defined as relief of dyspnea and symptoms
In our study, all patients underwent dilatation and electrocautery either after definitive treatment (no relapse after dilatation or after
without using any LASER procedures. This is interesting as most pre- stent removal) or as long-­standing symptom-­free follow-­up even
vious reports are referring to the use of LASER as the main tissue de- with chronic stent placement. These positive results were consistent
struction technique although modern electrocautery modalities may with the results of Galluccio et al7 who reported a 69% success rate
EMAM et al. | 7 of 8

TA B L E 5 Univariate and multivariate

Univariate Multivariatea
logistic regression analysis of factors
associated with stent placement OR (95% CI), P-­value OR (95% CI), P-­value

Degree of stenosis >75% 10.714 (2.32-­49.49), 0.002 12.411 (1.011-­15.801), 0.048

Complications 107.667 (10.208-­1135.586), 118.679 (7.768-­181.165),
0.000 0.001
Pseudomembrane 14.167 (1.594-­125.878), 0.017 —­

Note: Describes multivariate regression analysis regarding factors associated with stent placement.
Stenting was significantly associated with the presence of complications (OR 95% CI of 118.679
(7.768-­181.165), P = .001) and had a moderate association with severe stenosis >75% of the airway
calibre (P =.048). By running univariate analysis, the association of stenting with complications was
confirmed especially with the presence of pseudomembranes P =.017. High P-­values indicating
positive significance of associated facotrs with stenting (in bold).
Abbreviations: CI, confidence interval; OR, odds ratio.
a
The multivariate regression analysis showd that the most important factors associated with
stenting were complication with OR (95% Cl) with P-­value = .001 followed by degree of stenosis
more than 75% with OR(95% CI) with P-­value = .048

for complex tracheal stenosis treated mainly with laser resection. not define either the precise duration required for tracheal recovery
Similarly, Cavaliere et al19 reported good results in the treatment of after stent placement or the criteria for stent removal. However, as
both simple and complex tracheal stenoses. They reported a 100% a general approach, removal of the stent has been recommended by
success rate for web-­like stenoses and a 22% success rate for com- Gallaucio et al7 and Martinez-­Ballarin et al14 after 18 to 24 months,
5
plex tracheal stenosis. Conversely, Brichet et al reported a 17.6% respectively. In our study, most cases were complex lesions with af-
success for complex tracheal stenosis that was directly treated with fected tracheal cartilages, so we followed the strategy of Puma et al9
stent insertion. who proposed at least 2 years of stenting in severe circumferential
In the present study, stents were deployed in only 24 patients, stenosis with tracheomalacia.
most of whom were of the complex type and only in two cases of In comparison with previously published data, the number of
the simple type. Placement of silicone stents is indicated in benign cases in which stent removal was possible in our study, was rela-
tracheal stenosis when the airway wall is unstable or focally malacic tively low, as stents could be successfully removed in only nine
and relapse after dilatation is frequent. Amongst different silicone cases (37.5%). Martinez-­Ballarin et al14 reported successful stent
stents, the Dumon stent is excessively studied and considered as the removal in 43 (75%) out of their patients. This disagreement may be
gold standard. 22 attributed to the presence of severe, inoperable, complex lesions in
In the present study, 70% of the studied patients had mild post-­ our cohort together with severely neglected circumferential lesions
procedural complications during follow-­up. None of them were life-­ making stent removal challenging. These results are in good agree-
threatening and they were all successfully managed. Complications ment with the previous work of Park et al23 and Puma et al9 where
included: Pseudomembranes (21.4%), stent obstruction by mucus silicone stents were successfully removed in 38% of patients with
secretions (14.5%), migration (10.7%). These results were similar PITS and cicatricial stenoses, respectively. Also, Lim et al11 reporting
to Martinez-­Ballarin et al14) who reported well-­tolerated tracheal silicon stent insertion in 55 patients with PITS, were able to success-
stenting with silicone Dumon stents in 64 patients with benign tra- fully remove the stents without restenosis in only 40% of the cases
cheal stenosis. Previous studies also reported the development of after a median time of 12 months. Restenosis adversely occurred
granulation tissue in 19.3%–­33%, migration in 5%–­41.1% and mu- in the remaining 60%. It can, therefore, be stressed that inoperable
costasis in 30%–­43% of cases.11,23 patients with complex stenosis should be followed up with a longer
In the majority of cases, we used hourglass-­shaped Dumon stent duration of stent placement, provided that stent-­related complica-
with which we observed a decreased rate of migration. Three cases tions are not excessive or debilitating.
(12.5%) only needed repositioning Madkour et al24 investigated the Our study has certain limitations. We did not test stent removal
role of IB in the initial management of tracheal stenosis, reported before 24 months unless stent-­related complications occurred. The
stent migration in 27% and 12% of benign and malignant stenosis, patients’ cohort was also variable including post-­intubation, idio-
respectively. Also, Dalar et al20 had a relatively high number of stent pathic and burn-­related strictures. However, they were all benign
migrations (41.1%) explained by centrally located tracheal stenosis cases representing a real-­life patient population that any interven-
in most of his cases. tional pulmonology team may encounter. Although this study was
The higher rates of pseudomembranes and granulation tissue performed in two different institutions allowing us to study a larger
formation in our study could be explained by the continuous fric- number of cases (40), the same algorithmic approach was followed
tion between silicone stents and the airway wall. Published data do by both teams.
8 of 8 | EMAM et al.

5 | CO N C LU S I O N 9. Puma F, Ragusa M, Avenia N, et al. The role of silicone stents in the

treatment of cicatricial tracheal stenoses. J Thorac Cardiovasc Surg.
2000;120(6):1064-­1069. https://doi.org/10.1067/mtc.2000.110383
We conclude that after accurate classification, interventional bron- 10. Grillo HC. Stents and sense. Ann Thorac Surg. 2000;70(4):1142.
choscopic management may have favourable long term outcome and 11. Lim SY, Kim H, Jeon K, et al. Prognostic factors for endotracheal
a significant role in the management of benign tracheal stenosis in silicone stenting in the management of inoperable post-­intubation
patients not eligible for surgery. Bronchoscopic dilatation should be tracheal stenosis. Yonsei Med J. 2012;53(3):565-­570.
12. Weymuller EA Jr. Laryngeal injury from prolonged endotra-
considered as first-­line therapy for patients with simple stenosis,
cheal intubation. LARYNGOSCOPE. 1988;98(S45):1-­5. https://doi.
whereas patients with complex stenosis should undergo a multi- org/10.1288/00005​537-­19880​8 001-­0 0001
disciplinary approach requiring surgical intervention if operable. If 13. Zias N, Chroneou A, Tabba MK, et al. Post tracheostomy and
inoperable, bronchoscopic treatment and stent placement may be a post intubation tracheal stenosis: report of 31 cases and re-
view of the literature. BMC Pulm Med. 2008;8(1):18. https://doi.
valid alternative. Further long-­term prospective studies are needed
org/10.1186/1471-­2466-­8-­18
to validate the ideal algorithmic management for such patients. 14. Martinez-­Ballarin JI, Díaz-­Jiménez JP, Castro MJ, Moya JA. Silicone
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AU T H O R C O N T R I B U T I O N S erance and early results in 63 patients. Chest. 1996;109(3):626-­629.
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All authors contributed to the study conception and design. Material
15. Wain JC. Postintubation tracheal stenosis. Chest Surg Clin N Am.
preparation, data collection and analysis were performed by all au- 2003;13(2):231-­246.
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and all authors commented on the previous versions of the manu- sis after tracheostomy or intubation: review with special regard to
cause and management. Tex Heart Inst J. 2005;32(2):154.
script. All authors read and approved the final manuscript.
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2008;12(4):194. https://doi.org/10.4103/0972-­5229.45081
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Wael Emam https://orcid.org/0000-0002-6146-2415 operative treatment of benign subglottic laryngotracheal ste-
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