Reconstructing Airways, Reconstructing Lives

Doctor checks patients throat


Yash Patil, MD, above, demonstrates a lymph node exam. Photo by Cindy Starr / Mayfield Clinic.

Pull back the curtain on the nationally acclaimed ear, nose and throat team at the University of Cincinnati (UC) Gardner Neuroscience Institute, and you find several outstanding programs. The Adult Airway Reconstruction Program, directed by Yash Patil, MD, is one of them.

This highly specialized program serves patients who have suffered damage to the trachea (windpipe) or larynx (voicebox). A minority of patients are adults who have undergone prior airway reconstructions as children. Many more are adults who have suffered 1) trauma to the trachea or larynx in an auto accident; 2) burns to the airway in a fire; 3) or, most commonly, scarring caused during a prolonged hospitalization that required a breathing tube. Autoimmune diseases, inflammatory conditions, infection, tumors, and reflux disease also can contribute to airway problems.

Symptoms of airway damage can include exercise intolerance , difficulty breathing, sleep apnea, hoarseness and loss of voice. The Adult Airway Reconstruction Program, considered by many experts to be one of the nation’s busiest,  is part of the Neurosensory Disorders Center at the UC Gardner Neuroscience Institute, an internatioally recognized center of excellence within UC Health. The Airway Reconstruction Program draws patients from around the United States and the world and features an all-star cast, including six otolaryngologists¹ who perform surgical procedures and a physician assistant .² The multidisciplinary program also calls upon pulmonologists, sleep specialists, speech pathologists, thoracic and general surgeons, gastroenterologists and critical care specialists known as neuro-intensivists. Cincinnati Children’s Hospital Medical Center is a frequent collaborator.

Dr. Patil, an assistant professor of otolaryngology at UC, estimates that the program treated 90 new patients in 2011. Those patients required some 250 diagnostic procedures and more than 100 interventions (including 20 major interventions) for treatment of stenosis, a narrowing of the trachea, an elegant, ringed organ that extends down from the voicebox for about four inches before branching into two separate tubes called the bronchi. “Breathing is very much about having a trachea free of obstruction,” Dr. Patil says.

An intervention can involve dilating – or widening – the airway, or removing a damaged portion during a major surgical procedure. During an open intervention to treat an obstruction, Dr. Patil says, “We remove a portion of the windpipe, typically 1 to 4 centimeters in length, and we mobilize the good ends of the airway and bring them back again. It’s like putting together two ends of pipe after removing a broken portion.”

A majority of patients will have more than one procedure, and healing can take months. Their experience begins with a complete office evaluation and proceeds with complete office testing, diagnostics and, finally, intervention.

“The typical patient we have has had a prolonged hospitalization and is not maximized for immediate intervention,” Dr. Patil says. “So the first time we meet them, we make a proper introduction. Over weeks to months we follow them, slowly maximizing them for therapy. If the patient has been in a car accident and has lost his leg, for example, we would not operate until he had his prosthesis and was able to walk. If the patient is diabetic, we first control the diabetes well; if the patient is obese, we try to manage his weight as well as possible; if the patient smokes, obviously she must stop smoking. If she has acid reflux, we control that gastric acid reflux maximally, and so on.”

Once the patient is maximized medically, a treatment plan is developed. “Often these patients have more than one lesion in their airway,” Dr. Patil notes. “So they can have a vocal cord paralysis and a stenosis of their trachea. Those are very complex cases, and you have to understand what is causing the problem: is it vocal cord paralysis, is it stenosis, is it obesity, is it pulmonary function? So in trying to understand how to manage patients you must have the backing of a multidisciplinary team that takes the whole patient into account.”

Relationships can last many months, as Airway Program physicians follow their patients through the process of rebuilding their lives, from leaving a nursing home to learning to eat and speak again.

Success can be emotionally moving. “The first time you hear someone talk, it’s amazing,” Dr. Patil says. “Literally, you have known them for six months to a year, and you’ve never heard their voice. The first time you hear their voice and they hear their voice, it can be absolutely shocking. It can almost bring you to tears. It’s a moment that your patient, and the patient’s loved ones, never forget.”

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