Correspondence

Midtracheal Stricture

N Engl J Med 1997; 336:1613May 29, 1997

Article

To the Editor:

The Image in Clinical Medicine by Doerfler and Naidich (Dec. 19 issue)1 reminded me of the surgical repair of three cases of tracheal stenosis I reported in 1970.2 The technique my colleagues and I used, approaching the lesion from the neck in the manner of Grillo, differed from theirs.3 If they had used a neck approach instead of a thoracotomy, I wonder whether the recurrent-nerve injury might not have occurred. Before undergoing surgical repair, our patients had been treated with repeated bronchoscopy, because we did not think tracheal resection was feasible. We were also concerned that the lesions in our patients might not be reparable from above, but Grillo (who came to Oregon to help us with the first patient) assured us that in all the patients in his series, the repair was performed with the use of a low collar incision. His technique was straightforward, and the patients did well.

Joseph B. VanderVeer, Jr., M.D.
University of Arizona, Phoenix, AZ 85012

3 References

1
Doerfler ME, Naidich DP. Midtracheal stricture. N Engl J Med 1996;335:1879-1879
Full Text | Web of Science | Medline

2
Vander Veer JB Jr. Tracheal stenosis: a disease of medical progress: surgical repair of three cases. Northwest Med 1970;69:921-925
Medline

3
Grillo HC. The management of tracheal stenosis following assisted respiration. J Thorac Cardiovasc Surg 1969;57:52-71
Web of Science | Medline

Author/Editor Response

Dr. Doerfler and a colleague reply:

To the Editor: The images were primarily intended to illustrate a noninvasive diagnosis of a severe, life-threatening midtracheal stenosis. The truly urgent nature of this patient's surgery is conveyed by the simple sentence, “Acute respiratory failure developed approximately 72 hours after admission.” The two images that were published do not fully demonstrate the extent of the tracheal injury between the stenosis and the carina, which required resection of the trachea to a level approximately 1 cm above the carina. We have used Grillo's guidelines1 for performing a majority of these procedures but would not recommend them for lesions that approach the carina. The recurrent-laryngeal-nerve injury in this patient probably did stem from surgical trauma, but we doubt that a thoracic approach is more likely to injure the recurrent nerves than a cervical approach. The recurrent laryngeal nerves run in the tracheal–esophageal groove and are most closely adherent to the trachea in the cervical region. Operating through the chest should, if anything, provide a wider margin of protection against injury of the recurrent nerves.

Martin E. Doerfler, M.D.
Lawrence R. Glassman, M.D.
New York University School of Medicine, New York, NY 10016

1 References