About Airway and Tracheal Surgery
The Airway and Tracheal Surgery Program at Massachusetts General Hospital provides specialized treatments for both common and rare disorders of the trachea, offering patients state-of-the-art evaluation, diagnosis and care of trachea-related conditions.
What Are Airway and Tracheal Diseases?
Diseases of the trachea and bronchi make the essential function of breathing difficult and can greatly diminish a person’s quality of life. The trachea (windpipe) is part of the airway system that carries air from the larynx (voice box) to the bronchi (two smaller tubes in the airway) and finally to the lungs. A healthy trachea lengthens and expands with breathing.
At Massachusetts General Hospital, our skilled team of surgeons, anesthesiologists, nurses, physical therapists and speech therapists perform a high volume of surgeries and procedures every year to treat airway and tracheal conditions, attaining excellent results and outcomes for complex conditions. Our team will work with you to develop a personalized treatment plan.
Conditions We Treat
Tracheal stenosis is a narrowing of the portion of the windpipe that is below the voice box.
What are the symptoms of tracheal stenosis?
People with tracheal stenosis may experience symptoms such as:
- A hoarse voice
- Persistent coughing
- Shortness of breath
- Voice changes
- Wheezing, noisy breathing
What causes tracheal stenosis?
The most common causes of tracheal obstruction are:
- Prolonged oral intubation and ventilation (post-intubation tracheal stenosis)—unintentional injury to the trachea can occur after a breathing tube has been inserted, typically in an intensive care unit (ICU) setting, to help the patient maintain their breathing
- Tracheostomy (post-tracheostomy tracheal stenosis)—an opening in the trachea that is surgically created after a week or more in an ICU on a breathing tube and ventilator
- Idiopathic (no known cause) subglottic stenosis (idiopathic laryngotracheal stenosis)—typically seen in women with inflammatory scarring and narrowing of the lower larynx and the very top of the trachea
- Benign or malignant tumors
- Certain autoimmune or inflammatory disorders—Granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis) and relapsing polychondritis
Can tracheal stenosis be cured or treated?
Your Mass General airway and trachea team will work with you to create a personalized treatment plan following your evaluation. Post-intubation and post-tracheostomy tracheal stenosis are most often surgically treated through single-stage resection and reconstruction, which provides long-term relief while preserving both the voice and airway. Patients who undergo resection and reconstruction for tracheal stenosis will not require other interventions such as prolonged dilations, lasers and tracheostomies. The typical length of hospital stay at Mass General following surgery to treat tracheal stenosis is roughly five to seven days.
We also offer endoscopic management—dilations, laser treatments, cryotherapy and stenting—for patients with tracheal stenosis who are not candidates for a tracheal resection.
Tracheal Stenosis Patient Story
After being diagnosed with idiopathic laryngotracheal stenosis, Judith Roach was told she was inoperable. During this time, Judith struggled with being able to breathe and speak and had over 50 endoscopic operations at separate health care institutions. After researching her condition on her own, she discovered Mass General and ultimately received care from a team led by Cameron Wright, MD.
Hear Judith’s Story
Tracheal tumors, benign (not cancerous) or malignant (cancerous), are rare and cause a narrowing of the trachea that restricts airflow to the lungs.
The most common malignant tracheal cancers are:
- Adenoid cystic cancer
- Squamous cancer
The most common benign tracheal tumors are:
How are tracheal tumors diagnosed?
Tracheal tumors can be difficult to diagnose, as they often grow slowly and can produce similar symptoms as other airway diseases.
What are the symptoms of tracheal tumors?
People with a tracheal tumor may experience symptoms such as:
- Persistent coughing and coughing up blood
- Labored breathing
- Hoarseness in the throat
What causes tracheal tumors?
Some tracheal tumors, such as adenoid cystic cancer, have no known cause. Squamous cancers, a malignant tracheal tumor, are usually caused by smoking. Papillomas, a benign tracheal tumor, are caused by the human papilloma (HPV) virus.
Can tracheal tumors be cured or treated?
Tracheal tumors are most often surgically resected. During surgery, your surgeon will remove the tumor and then reconnect the ends of the healthy trachea, preserving the blood supply to the trachea throughout the duration of the operation. Mass General thoracic surgeons are specially trained in this complex surgery. Most patients also require radiation after resection of a malignant tracheal tumor.
Papillomas are treated with endoscopic (minimally invasive) techniques.
A tracheoesophageal fistula is an abnormal connection, or fistula, between two tubular structures, the esophagus and the trachea. The esophagus connects the throat to the stomach, while the trachea connects the throat to the windpipe and lungs. Normally, these two tubes are not connected.
What are the symptoms of tracheoesophageal fistulas?
People with tracheoesophageal fistulas may experience symptoms such as:
- Coughing following swallowing
- Difficulty swallowing and breathing
What causes tracheoesophageal fistulas?
Tracheoesophageal fistulas in adults are acquired, resulting from either a benign circumstance, such as a complication from a previous long intubation, or a malignancy, such as esophageal cancer.
Can tracheoesophageal fistulas be cured or treated?
With a tracheoesophageal fistula, the connection between the esophagus and trachea can usually be successfully closed by surgery. At Mass General, thoracic surgeons are specially trained to both repair the damaged trachea and the esophagus to restore a normal anatomy and function.
Tracheoesophageal Fistula Patient Story
Nancy Falconeri underwent surgery at Mass General to repair a fistula in her trachea, a complication that came after a previous surgery in her home state of New York.
“My situation was one in a million,” she says. “I had given up hope until I came to Mass General.”
Nancy describes her journey to recovery and the treatment she received for a care team led by Henning Gaissert, MD, and Steve Zeitels, MD.
Read Nancy’s Story
Tracheobronchomalacia (TBM) is a condition that causes the shape of the trachea (and often bronchi) to become altered and the airway to collapse. TBM comes in two forms:
- Excessive dynamic airway collapse, the most common form of tracheobronchomalacia and occurs when the airway’s posterior thin membraneous wall collapses and becomes narrowed, both immediately and progressively worse over time
- A weakening of the airway’s cartilaginous wall, a rarer form of tracheobronchomalacia when the weakened wall widens and splays out, causing a subsequent narrowing of the airway
What are the symptoms of tracheobronchomalacia?
People with TBM may experience symptoms such as:
- Persistent coughing
- Shortness of breath
- Difficulty raising phlegm
- Recurrent lung infections
How is tracheobronchomalacia diagnosed?
A thorough medical evaluation is a very important first step to diagnosis, as there are many causes for persistent coughing and shortness of breath. Patients seeking evaluation for TBM can expect to undergo lung function testing, including:
- A CT scan or dynamic MRI of the chest that monitors inhales and exhales to see if the trachea collapses during it
- A bronchoscopy while under local anesthesia (minimal sedation) to examine the airway during breathwork and observe the collapse in greater detail
Can tracheobronchomalacia be cured or treated?
Mass General offers minimally invasive robotic surgery for patients with tracheobronchomalacia. This minimally invasive approach allows for quicker recovery with less discomfort. During this procedure, the posterior thin membraneous wall is stiffened through suturing, which is a special type of mesh that is placed in the back wall to give the airway a more normal shape that will not collapse.
What to Expect at Mass General
A Multidisciplinary Care Team
Our team of highly skilled thoracic surgeons use a variety of techniques, including tracheal resection and reconstruction, to restore proper function of the airway (trachea and bronchi). When you come to Mass General for airway and tracheal care, you can expect a care team consisting of:
Patients may be referred to us by outside physicians who are treating an underlying condition that has created the airway and tracheal issue, such as cancer or an obstruction caused by benign disease. Patients can contact individual thoracic surgeons to inquire about treatment options. We offer both bronchoscopies (a monitoring procedure to observe the function of the trachea) and surgical options for patients with airway obstructions from benign blockages (strictures) or tumors.
Comprehensive Evaluation and Surgery
New patients undergo a comprehensive evaluation that concludes with a thorough review of the recommended course of treatment with a Mass General care team. If you elect to undergo a procedure to treat tracheal stenosis, trachea-esophageal fistulas or another disease of the trachea and airway, your care team will explain each step using diagrams and answer questions that you may have about your condition or care. As complex airway problems often require sophisticated x-ray evaluation, our team uses cutting-edge equipment if needed. Careful collaboration with our anesthesiology, radiologic, pulmonary and voice specialists—national leaders in the field in both clinical care and research—ensure the best possible treatment and outcomes.
In the operating room, you will receive general anesthesia so that the surgeon can examine the airway (trachea and bronchi) using a bronchoscope, a thin, tube-like imaging instrument for precise evaluation and measurements.
Anesthesiologists play a critical role in the management of patients with airway problems. We have a very skilled group that is amongst the most experienced nationwide in dealing with airway management. Our intensive care team cares for our airway patients on a regular basis. Our dedicated thoracic surgery floor nurses are well-trained on how to help patients recover from surgery.
After surgery, your surgeon will review the recovery plan and any additional treatment needs with you and your family. You will receive a personalized plan to ensure the best outcomes. Plans and results are communicated to referring physicians so that everyone on your care team provides you with coordinated, consistent care.
Your care team will remain in close communication with you to ensure your recovery goes smoothly, even after you are discharged and return home.
Innovative Research Approach
As a research and teaching facility, Mass General is dedicated to advancing knowledge of tracheobronchial disease and producing the next generation of thoracic surgeons skilled at managing airway conditions. Many procedures used in treating tracheal disorders carry the imprint of Mass General surgeon Hermes Grillo, MD, known as "the father of airway surgery." In the 1960s and 1970s, Dr. Grillo invented novel techniques of tracheal reconstruction that allowed patients with previously untreatable conditions, such as tracheal stenosis, to undergo surgery. This tradition has been carried on by the current group of Mass General thoracic surgeons.
Recent innovative efforts include:
- Creation of a tracheal surgery database to study outcomes and prognosis of patients with airway problems with the goal of improving patient outcomes
- Developing novel techniques to replace damaged organs, including airway and lung, via the Regenerative Medicine Laboratory
- Initiatives to identify the causes of idiopathic subglottal stenosis, a rare inflammatory disorder of unknown cause predominantly found in women
- Research into possible tracheal substitutes involving regenerative medicine and stem cells
- Using Bioprostheses, implanted devices, to solve very complicated problems of the airway and esophagus for which no other solutions exist
Tracheal stenosis following COVID-19
Endotracheal intubation and mechanical ventilation have been widely used to treat critically ill patients during the COVID-19 pandemic. Though an effective treatment for many patients with COVID-19, it has long been recognized to result in inadvertent injury of the subglottic larynx and trachea.
Harald Ott, MD, a thoracic surgeon in the Airway and Tracheal Surgery Program at Mass General, discusses how to identify the signs of tracheal stenosis following extubation and recovery from COVID-19.Read more
The surgeons in the Mass General Airway and Tracheal Surgery Program have numerous publications in nationally recognized journals, including:
- Wang H, Wright CD, Wain JC, Ott HC, Mathisen DJ. Idiopathic subglottic stenosis: factors affecting outcome following single-stage repair. Ann Thorac Surg. 2015;100:1804-11.
- Muniappan A, Wain JC, Wright CD, Donahue DM, Gaissert HA, Lanuti M, Mathisen DJ. Surgical treatment of nonmalignant tracheoesophgeal fistulae: a thirty-five year experience. Ann Thorac Surg. 2013 Apr;95(4):1141-6.
- Gaissert HA, Grillo HC, Shadmehr BM, Wright CD, Gokhale M, Wain JC, Mathisen DJ. Laryngotracheoplastic resection for primary tumors of the proximal airway. J Thorac Cardiovasc Surg. 2005;129:1006-09.
- Wright CD, Grillo HC, Hammoud ZT, Wain JC, Gaissert HA, Zaydfudim V, Mathisen DJ. Tracheoplasty for expiratory collapse of central airways. Ann Thorac Surg. 2005;80:259-266.
- Gaissert HA, Grillo HC, Shadmehr MB, Wright CD, Gokhale M, Wain JC, Mathisen DJ. Long-term survival after resection of primary adenoid cystic and squamous cell carcinoma of the trachea and carina. Ann Thor Surg. 2004;78:1889-97.
- Mitchell JC, Mathisen DJ, Wright CD, Wain JC, Donahue DM, Moncure AC, Grillo HC. Clinical experience with carinal resection. J Thorac Cardiovasc Surg. 1999;117:39-53.
- Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright DC. Postintubation tracheal stenosis: Treatment and results. J Thorac Cardiovasc Surg 1995;109:486-93.
- Tapias LF, Lanuti M, Wright CD, Hron TA, Ly A, Mathisen DJ. COVID-19 Related Post-Intubation Tracheal Stenosis: Early Experience with Surgical Treatment. Ann Surg. 2022;275:e271-3
- Madriaga ML, Soni M, Mathisen DJ, Wright CD, Li S, Lee H, Davies D, Knoll S, Muniappan A, Lanuti M, Ott H, Gaissert HA. Evaluation of Release Maneuvers After Airway Reconstruction. Ann Thorac Surg. 2022;113:406-12
- Tapias LF, Rogan TJ, Wright CD, Mathisen DJ. Pregnancy-Associated Idiopathic Laryngotracheal Stenosis: Presentation, Management and Results of Surgical Treatment. Eur J Cardiothoracic Surg. 2021;59:122-9
- Wright CD, Li S, Geller AD, Lanuti M, Gaissert HA, Muniappan A, Ott HC, Mathisen DJ. Postintubation Tracheal Stenosis: Management and Results 1993-2017. Ann Thorac Surg. 2019;108:1471-7
- Costantino CL, Geller AD, Wright CD, Ott HC, Muniappan A, Mathisen DJ, Lanuti M. Carinal Surgery: A Single-Institution Experience Spanning Two Decades. J Thorac Cardiovasc Surg. 2019;157:2073-83
- Costantino CL, Niles JL, Wright CD, Mathisen DJ, Muniappan A. Subglottic Stenosis in Granulomatosis with Polyangiitis: The Role of Laryngotracheal Resection. Ann Thorac Surg. 2017;105:249-53
- Udelsman BV, Eaton J, Muniappan A, Morse CR, Wright CD, Mathisen DJ. Repair of Large Airway Defects with Bioprosthetic Materials. J Thorac Cardiovasc Surg. 2016;152:1388-1397