Chapter 19: Chest Wall, Pleura, and Mediastinum
All of the following increase the risk for tracheal stenosis EXCEPT
D. Excessive corticosteroid therapy
Intubation-related risk factors include prolonged intubation; high tracheostomy through the first tracheal ring or cricothyroid membrane; transverse rather than vertical incision on the trachea; oversized tracheostomy tube; prior tracheostomy or intubation; and traumatic intubation. Stenosis is also more common in older patients, in females, after radiation, or after excessive corticosteroid therapy, and in the setting of concomitant diseases such as autoimmune disorders, severe reflux disease, or obstructive sleep apnea and the setting of severe respiratory failure. However, even a properly placed tracheostomy can lead to tracheal stenosis because of scarring and local injury. Mild ulceration and stenosis are frequently seen after tracheostomy removal. Use of the smallest tracheostomy tube possible, rapid downsizing, and a vertical tracheal incision minimize the risk for posttracheostomy stenosis. (See Schwartz 10th ed., p. 607.)
Adenoid cystic carcinomas
B. Exhibit aggressive growth
C. Are not radiosensitive
D. Have a 5-year survival rate of >50%
Squamous cell carcinomas often present with regional lymph node metastases and are frequently unresectable at presentation. Their biologic behavior is similar to that of squamous cell carcinoma of the lung. Adenoid cystic carcinomas, a type of salivary gland tumor, are generally slow-growing, spread submucosally, and tend to infiltrate along nerve sheaths and within the tracheal wall. Although indolent in nature, adenoid cystic carcinomas are malignant and can spread to regional lymph nodes, lung, and bone. Squamous cell carcinoma and adenoid cystic carcinomas represent approximately 65% of all tracheal neoplasms. The remaining 35% comprises small cell carcinomas, mucoepidermoid carcinomas, adenocarcinomas, lymphomas, and others.
Postoperative mortality, which occurs in up to 10% of patients, is associated with the length of tracheal resection, use of laryngeal release, the type of resection, and the histologic type of the cancer. Factors associated with improved long-term survival include complete resection and use of radiation as adjuvant therapy in the setting of incomplete resection. Due to their radiosensitivity, radiotherapy is frequently given postoperatively after resection of both adenoid cystic carcinomas and squamous cell carcinomas. A dose of 50 Gray or greater is usual. Nodal positivity does not seem to be associated with worse survival. Survival at 5 and 10 years is much better for adenoid cystic (73 and 57%, respectively) than for tracheal cancers (47 ...