Surgical diseases of the trachea
The trachea is the windpipe that moves air from the mouth to the lungs. It’s connected above in the neck to the larynx (“Adam’s apple”), and below, in the chest, it divides into the left and right bronchi, which connect to each lung. The surgeons in the Department of Thoracic Surgery and Lung Transplantation at Baylor University Medical Center, part of Baylor Scott & White health in Dallas diagnose and treat a variety of diseases affecting the trachea.
- Tracheal stenosis—A narrowing of the trachea, most commonly following the placement of a breathing tube (intubation) or previous surgery. Babies can also be born with this condition, but most adult cases develop due to the growth of scar tissue during prolonged placement of a breathing tube or following tracheostomy, a surgically created opening in the neck for breathing. The trachea can also be externally compressed by other structures, most commonly tumors of the thyroid gland and esophagus.
- Tracheal inflammation—Several autoimmune disorders and infections may cause the trachea to become swollen and inflamed, essentially blocking airflow similar to tracheal stenosis. These include Wegener’s granulomatosis, sarcoidosis and amyloidosis. It can also occur as a side effect of radiation therapy to the head, neck or chest for other conditions.
Benign tumors in the trachea and bronchi are much more uncommon than tumors in nearby organs or tissue that then involve the trachea:
- Carcinoid tumors—More commonly found in the bronchi than the trachea, they occur most often between the ages of 40-60 years, are not associated with smoking, and can produce hormones that cause other systemic symptoms in the heart and gastrointestinal tract.
- Papillomas—Benign growths associated with human papillomavirus (HPV), they often grow in groups (referred to as papillomatosis) and can carry the risk of transforming into squamous cell carcinoma.
- Chondroma—A very rare tumor that grows from the cartilage portion of the airway.
- Hemangioma—Tumors of the airway blood vessels that can cause significant bleeding if rupture or during surgical manipulation.
Cancer in organs and glands around the airway can affect the passage of air through the trachea:
- Thyroid gland—Benign goiter, as well as cancer of the thyroid gland, can compress the trachea in the neck or chest region and cause shortness of breath.
- Esophagus—The “food pipe” sits directly next to the trachea. Cancers of this organ can grow into the airway; develop abnormal communication with the airway (fistula); and treating of this condition with radiation therapy or stents can damage the airway.
- Lung—Lungs communicate directly with the airway at the level of the bronchi, but tumors of the upper part of the lung, as well as abnormal lymph nodes in the chest, can compress the trachea
- Squamous cell carcinoma—The most common type of tracheal tumor, it usually grows in the lower part of the trachea and tends to grow quickly and cause bleeding and shortness of breath. Smoking is the main risk factor.
- Adenoid cystic carcinoma—Much less common, these tumors grow slowly and are not associated with smoking.
Diagnosing disease in the trachea
Evaluating diseases in the trachea or bronchi can be done using a combination of non-invasive and invasive tests.
- Pulmonary function test—Determines how much air can be breathed in and out and helps classify types of airway and lung diseases. It can also be used to assess the muscles of the chest wall and mechanics of breathing.
- Ultrasound—Uses sonography to see inside the body. It is particularly useful for assessing the thyroid gland when it is abnormally large and impinging on the trachea.
- CT (computed tomography)—Uses X-ray images to create virtual images of the inside of the body. It is essential in the diagnosis of airway and lung diseases. Advanced 3D reconstructions are particularly useful in planning treatment for airway conditions.
- PET (positron emission tomography)—A scan using an injected dye to assess metabolic activity and detect the likelihood of cancer.
- Endoscopy—Fiber optic tubes that are inserted through the mouth or nose and provide a high-definition image to the surgeon, allowing direct visualization inside the body. A bronchoscopy allows the surgeon to make a special endoscopic evaluation of the larynx, trachea and bronchi. This can be augmented with endobronchial ultrasound (EBUS), which allows sonographic visualization of the tissue around the airway, most specifically the lymph nodes. EBUS is essential in diagnosing and staging tumors of the trachea, lungs and esophagus.
- Biopsy—Tumors of the airway or surrounding structures can be biopsied at the time of endoscopy or rarely at a separate appointment through the skin. Biopsy samples are evaluated under the microscope by pathologists on the medical staff, and rare cases are further reviewed at an interdisciplinary tumor board.
Tracheal disease treatment options
Diseases and conditions in the trachea are complex and require a multidisciplinary approach. Surgeons on the medical staff of the Department of Thoracic Surgery at Baylor University Medical Center in Dallas coordinate care between the thoracic surgeons, interventional pulmonologists, head and neck surgeons, radiologists, anesthesiologists and pathologists to determine the optimal strategy for each patient.
Tracheal disease treatments range from the administration of medication (such as chemotherapy) or radiation, endoscopic interventions, or open surgery. Thoracic surgeons constantly train using new products and techniques to offer the most advanced care in tracheal medicine and often provide therapy to patients deemed untreatable at other centers.
Minimally invasive options
Interventions using an endoscope can be performed as definitive treatment of many conditions or to lessen symptoms. They can typically be performed through a tiny fiberoptic camera (flexible bronchoscope), but occasionally require a larger metal scope (rigid bronchoscope); either way, no incisions are made and side effects are minimal. These interventions include:
- Tumor removal—Some tumors can be partially or completely removed through a scope with no open surgery necessary. This can be done mechanically or with the aid of argon beam or laser therapy.
- Dilation—Tracheal stenosis or pressure by an external structure can be relieved by dilating the blocked area with a balloon, which can result in temporary or permanent resolution.
- Stents—Placement of metal or silicone stents within the area can keep the constricted area open. This can be performed as a temporary or permanent measure and allows for symptom relief while other treatments are administered, such as chemotherapy or radiation.
Open tracheal surgery is complex and requires a specialized surgical center and a highly trained team. The surgeons in Dallas within the Department of Thoracic Surgery at Baylor University Medical Center all are skilled in advanced airway surgery, which is only performed a select centers in the country.
Surgery on the trachea involves removal (resection) of the diseased segment followed by reattachment of the ends of the airway (reconstruction). This is the preferred method of treating cancerous diseases, as well as benign diseases that have not responded to less-invasive techniques. Sometimes there is a need for a temporary or permanent tracheostomy, a surgically created opening in the neck for breathing.
Surgical resection and reconstruction is most often done through an incision in the neck, but occasionally requires extension of the incision into the chest through a sternotomy, or dividing the upper part of the breast bone. Diseases of the lower airway, or bronchi, can be approached through the side of the chest, dividing the muscle between the ribs (thoracotomy), and it sometimes can be performed in a minimally invasive fashion (video-assisted thoracic surgery, VATS).