International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 151-155
http://dx.doi.org/10.4236/ijohns.2013.25033 Published Online September 2013 (http://www.scirp.org/journal/ijohns)
Results of Montgomery T-Tube in Primary
Treatment of Laryngotracheal Stenosis
Hale Aslan, Sedat Öztürkcan, Erdem Eren, Mehmet Sinan Başoğlu,
Murat Songu, Erkan Kulduk, Ahmet Erdem Kılavuz, Hüseyin Katılmış
Department of Otorhinolaryngology and Head and Neck Surgery, İzmir Katip Çelebi
Universty Atatürk Research and Training Hospital, İzmir, Turkey
Received July 2, 2013; revised July 31, 2013; accepted August 8, 2013
Copyright © 2013 Hale Aslan et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: For tracheal stenosis, tracheal resection and anastomosis is widely considered the treatment of choice.
However, this surgical approach is not feasible when the glottis and subglottis are involved or in patients with a poor
general condition and tracheal stents are a plausible means of providing a permanent or temporary airway opening.
Objectives: Evaluate the features and the results of patients with Montgomery T-tube in tracheal stenosis. Methods:
Fifteen patients with Myer-Cotton grades 2-3 circular cicatricial tracheal stenosis who received a Montgomery T-tube
between 2002-2011 were analyzed in terms of age, gender, etiology, duration of intubation, location and size of the
stenotic segment on computed tomography(CT), follow-up time with the T-tube, the complications that occurred after
T-tube removed and additional tracheal surgery. Conclusion: A T-tube can be applied in tracheal stenosis at the first
treatment before attempting surgery. The patients should be closely followed-up due to the possibility of re-stenosis and
Keywords: Tracheal Stenosis; Montgomery T-Tube; Complications
Tracheal stenosis occurs most commonly following in-
tubation trauma, tracheotomy, or neck injury. Additional
etiologies include benign and malignant neoplasms and
inflammatory or systemic autoimmune diseases . The
subglottic area is most sensitive to intubation trauma due
to its flaccid areolar tissue that readily becomes edema-
tous, in contrast to the circular cricoid cartilage, which
prevents the expansion of the edema to the surrounding
Although numerous studies describe various treatment
modalities, there is no standard approach to laringora-
cheal stenosis. Endoscopic treatment includes laryngeal
microsurgery, laser-assisted excision, traditional dilation
and endoscopic stent insertion, while external surgical
treatment comprises a wide range of techniques such as
tracheal resection and anastomosis or laryngotracheal re-
construction. In order to maintain laryngotracheal pa-
tency, a Montgomery Safe T-tube may be used as a sin-
gle dilation treatment or in association with endoscopic
and/or open-neck surgery .
2. Materials and Methods
We retrospectively analyzed 15 patients with Myer-Cot-
ton grades 2-3 circular cicatricial tracheal stenosis be-
tween 2002-2012 at the Department of Otorhinolaryn-
gology in Faculty of Medicine of İzmir Katip Çelebi Uni-
versty Atatürk Training and Research Hospital. Most sur-
geries were performed by experienced surgeons. These
patients evaluated according to age, gender, etiology, du-
ration of intubation, location and size of the stenotic seg-
ment on computed tomography (CT), follow-up time
with T-tube, the complications that occured after T-tube
removed and additional tracheal surgery. This study ap-
proved by ethics committee Faculty of medicine of İzmir
Katip Çelebi Universty Atatürk Training and Research
Hospital. We assessed the location, length and anterior
posterior diameter of the stenosis by multiplanar recon-
structive computed tomography and observed directly or
indirectly with a flexible or rigid laryngoscope before
surgery. These patients underwent tracheotomy and a
Montgomery T-tube was applied either during or after
tracheotomy as the first treatment choice. The T-tubes
opyright © 2013 SciRes. IJOHNS
H. ASLAN ET AL.
were inserted by an experienced anesthesia team.
Technique of Stent Insertion
T-tube insertion was performed in the operating theatre
under general anaesthesia. The patient was ventilated
through the stoma. As a first approach using standard
direct suspension microlaryngoscopy, we performed dila-
tation of stenosis by inserting intubation tubes from 5 to
8 mm diameter. When dilatation was insufficient, the
cuff of the endotracheal tube was inflated and the ste-
notic zone was dilated. After the appropriate T-tube had
been selected according to the length of the stenosis, the
T-tube ends were crimped onto itself and clamped, a su-
ture was stitched at the upper side of the tube and its up-
per end was pulled up after securing the aspiration ca-
theter inserted into the laryngeal blade. After extubation,
the gauze was pulled out through the mouth until the
inferior intraluminal end of the T tube disappeared into
the trachea. Then, the distal end of the tube was placed.
After T tube placement, a flexible endoscope was passed
through the tube lumen to assess whether the distal end
entered the stenotic segment and the upper end ends were
<1 cm from the vocal folds. After closing of the external
legs of the T-tube, the patients were followed-up weekly.
In the first 10 cases, we left the external end of the tube
out of the tracheotomy incision. However, in the final
five cases, we shortened the external leg of the tube to
the level of the trachea, closed the cap, and buried the
end of the tube under the skin to prevent contamination
by the outer flora and to allow the patient to return to
social activities in a shorter time period (Figure 1). T-
tubes were removed an average of 6 months later, de-
pending on the health status of the individual patient.
After tube removed, the patients were assessed closely
for restenosis over a 1-month follow-up period. We eva-
luated complications and additional interventions during
and after T-tube insertion. Between the effect of entuba-
tion time, length and localization of stenosis, T-tube
length of stay and recovery of stenosis evaluated by Pear-
son correlation analysis.
3. Results and Analysis
Ten patients were male and five were female. Average
age was 43.40 ± 14.4 years. The etiology was long-term
intubation, except for two patients, and the average intu-
bation time was 12.80 ± 7.5 days. In one patient, a Cae-
sarean section was thought to be the cause and one other
had had progressive dyspnea since childhood.
In 12 (80%) patients, the stenotic segment was de-
tected in the subglottic area at the cricoid cartilage, in 1
(6, 6%) patient at both the cricoid and cervicothoracic
tracheal segment and in 2 (13, 3) patients at the cervico-
thoracic segment. The average length of the stenotic seg-
Figure 1. Montgomery T-tube applications, external end of
the T-tube outside the skin (blue arrow) at right side and
external end of the T-tube burying subcutaneous tissue
(blue arrow) at left side on computed tomograhy images.
ment was 19.0 ± 4.7 mm and the anterior posterior di-
ameter was 6.47 ± 1.8 mm. The average T-tube follow up
period was 6.0 ± 6.6 months, which varied according to
the general health condition of the patient (Table 1).
In one patient, bacterial colonization occurred in the
external end of the tube. The infection was resistant to
treatment, so no additional application could be made
and the patient quit the follow-up after 7 months with a
T-tube. In three cases, granulation tissue formed around
the tracheotomy. This tissue was removed and topical
AgNO3 cauterization yielded positive results. In one pa-
tient, tracheomalacia occurred at the upper cartilage rings.
This case was considered tracheomalacia despite repeti-
tive T-tube applications, costal graft reconstruction and
anastomosis; lastly, the T-tube was applied and its exter-
nal end was buried subcutaneously. In one patient, the
T-tube was inserted at the laryngeal stenosis after the end
to end anastomosis in tracheal stenosis this called double
stenosis. This patient was accompanied the aspiration. To
prevent this, the posterior part of the upper T-tube was
left high so as to fit into the arytenoids, and the front part
was shortened so as to extend below the vocal cords,
resolving the aspiration. Accumulation of tracheal secre-
tions occurred in the five cases in whom the T-tube was
subcutaneous burried. These patients were treated with
drainage and daily dressings. Stenosis were recovered in
three cases (21, 4%) after T-tube excision and restenosis
occurred in the other four cases (28.5%). Long term pal-
Copyright © 2013 SciRes. IJOHNS
H. ASLAN ET AL. 153
Table 1. Definitive statistical analysis.
n Minimum Maximum Mean Std.
Age 15 17 70 43.40 14,451
(day) 15 0 27 12.80 7,571
(mm) 15 10 30 19.00 4,706
diameter (mm) 15 3 8 6.47 1,846
(month) 15 2 27 6.00 6,665
liative stenting in two cases (14.2%): in one due to tra-
cheomalacia and in one due to the patient becoming bed-
ridden. Five cases (35,7%) who had the T-tube applied in
the past 7 months are still available for follow-up (Table
2). Among three recovered patients, there was no statisti-
cally significance between intubation duration, stay with
T tube duration and stenosis lenght according to Pearson
correlation analysis (p: 0.341, p: 0.143, p: 0.354) (Table
3). Patients with restenosis necessitating additional sur-
gery. Three cases applied stenotic segment resection and
end to end anastomosis, one case required reconstruction
with a costal graft due to front wall collapse. These cases
had sufficient respiration and phonation in daily activity.
Between three recovered patients and four restenosis
patients, there was no statistically significance between
intubation duration, stay with T tube duration and steno-
sis lenght according to chi-square test (p: 0.603, p: 0.225,
p: 0.311) (Table 4).
Predisposing factors for tracheal stenosis related to the
endotracheal tube include a wider tube diameter, longer
intubation time, continuous movement of the tube in the
tracheal lumen, and difficult intubation. Other etiologies
include traumatic and nonsterile aspiration, emergency
cricothyrotomy, high-level tracheotomies and mechanical
ventilation . Some studies claim that tracheal damage
begins 17 hours in adults and 1 week in infants following
intubation . One of our patients developed tracheal
stenosis after just 1 hour of general anesthesia for a Cae-
sarian section despite other patients being intubated for 7
- 27 days.
Stenosis usually occurs in the cricoid cartilage or in
the first tracheal ring due to overinflation of the tube cuff,
leading to necrosis. Tracheal stenoses arise frequently on
or directly below the vocal cords on the superior side and
in the first tracheal ring or directly below it on the infe-
rior side . Another cause of tracheal stenosis is trache-
otomy. Tracheotomy-induced stenosis is classified as sto-
mal, suprastomal, intermediate or distal . In 12 (80%)
Table 2. Outcomes of 14 patients who received a T-tube,
excluding 1 who quit due to bacterial colonization.
Stenosis status Number of patients %
Recovery of stenosis 3 21.4
Restenosis 4 28.5
Still with T-tube 5 35.7
Permanent T-tube 2 14.2
Table 3. Effect of intubation time, length of stenosis and
with T-tube duration on recovery of stenosis evaluated by
Pearson correlation analysis.
recovery of stenosis
1 14 20 60
2 10 15 60
3 20 20 420
p value p: 0.341 p: 0.143 p: 0.354
Table 4. Comparison of between three recovered patients
and four restenosis patients according to intubation dura-
tion, stay with T tube duration and stenosis length evalu-
ated by chi-square test.
Patients of recovery
stenosis (n = 3)
Restenosis (n = 4)p value
duration (day)14, 10, 20 21, 7, 9, 14 0.603
stenosis (mm)20, 15, 20 20, 20, 22, 30 0.311
Stay with T-tube
duration (day)60, 60, 420 120, 60, 180, 60 0.225
of our cases, the stenosis occurred in the subglot- tic area
at the cricoid ring level, at the T1-T2 level right below
the tracheotomy line in 2 (13, 3%) cases, and 1 (6, 6%)
case had stenosis in both the cricoid ring and below the
Myer and Cotton divided tracheal stenoses into four
categories based on the degree of obstruction: Grade 1
corresponds to <50%; Grade 2, 50% - 70%; Grade 3,
70% - 99%; and Grade 4 is total obstruction . A 50%
reduction in the airway causes exertion dyspnea and a
75% reduction causes dyspnea at rest. Typically in adults,
a decrease of the anterio-posterior diameter to 8 mm
causes exertion dyspnea and to 5 mm causes dyspnea at
rest . Our cases were grades 2 and 3 according to the
Cotton classification, with an average anterio-posterior
diameter of 6.47 ± 1.846 mm. All of the patients had
dyspnea even while at rest.
In reality, tracheal resection and anastomosis is con-
sidered the treatment of choice for tracheal stenosis .
However, when the glottis and/or the subglottis are also
Copyright © 2013 SciRes. IJOHNS
H. ASLAN ET AL.
involved this surgical approach may not be applicable;
moreover, it may not be feasible due to the extent of the
stenosis, underlying disease and general health of the
patient. Currently, many procedures are available and
consist essentially of splitting followed by reconstruction
using cartilage or bone. Endoscopic treatment includes
laryngeal microsurgery, laser-assisted excision, tradi-
tional dilation and endoscopic stent insertion .
In cases of longer stenoses, cardiac or additional air-
way problems exist and stenosis involved glottis/subglot-
tis tracheal stents are a plausible means of providing a
permanent or temporary airway opening . Various
endotracheal tube types like Montgomery T-tube, Aboul-
ker, Dumon and Cotton Lorenz exist. Metallic and sili-
cone endotracheal tubes can be placed endoscopically
without tracheotomy but have a disadvantage of obstruc-
tion of the endoluminal stents in patients with disabled
cough reflex and laryngotracheal stenosis.
Difficulties in application of expandable metallic stents
make these stents not suitable for short term relief of air-
way obstruction and migration of the stent in the airway
is a disadvantage of the sillicon Dumon stents .
The silicon rubber T-tube developed by Montgomery
in 1965 has proven widely beneficial in tracheal surgery.
The T-tube has three legs of different diameters and
lengths. Tracheotomy is needed to insert the T-tube,
which can be performed concurrently with surgery, or
later to allow completion of stomal epithelialization. The
external opening can be left open for ventilation and
cleaning but can also be closed for voice and ventilation.
Caretta et al. conducted a 158-case study which found
that the Montgomery T-tube could be used primarily or
complementary to surgical treatment and can be an effec-
tive alternative when other stents are unsuccessful .
Thus, we use primarily the Montgomery T-tube in our
clinic when stenting is desired.
The T-tube is generally well-tolerated. It can be left in
situ for years but sometimes must be changed due to in-
fection, granulation, etc. Complications include infection
or granulation at the end contacting the skin, granulation
tissue under the cords at the upper side, and bacterial
colonization or crust formation in the lumen. There is
also a risk of tracheomalacia in areas in contact with the
tube edges . The tube became colonized with resis-
tant bacteria in one patient, and we found granulation
tissue around the tracheotomy site in three patients, and
tracheomalacia in one.
The subcutaneous burying procedure, described by
Keszler in 1987, allows the patient to return to his/her
social life earlier . Cooper performed this procedure
in 47 patients in 1989 and reported satisfying results .
We experienced no problems except collection of tra-
cheal secretions in first cases in which we applied this
procedure. We treated these patients with drainage and
frequent dressing and rotated sternotyroid muscle fleb on
tracheotomy site in later patients. In our burying proce-
dure we have not observed any crusts or infections in the
tube lumen because we have prevented outside contami-
nation towards the lumen of the tube.
T-tube excision time varies according to the surgeon’s
decision, severity of the lesion, and problems relating to
control and adaptation of the patient. Gaissert et al. ap-
plied T-tubes to 16 patients and left them in place for 20
months . Morshed et al. left T-tubes in place for 3 -
60 months . Our T-tube duration was 2 - 27 months
(mean, 6.0 ± 6.665 months), depending on the clinical
condition of the patient.
Liu et al. reported regression in tracheal stenosis after
T-tube removed in 28 of 53 patients (52%) . Ma-
niglia applied the T-tube in 53 adult patients with tra-
cheal or subglottic stenosis or both, and reported achieve-
ment of a sufficient airway in 85% . Five of our
cases (33, 3%) were decanullated after T tube removed
and three patients (20%) were decanullated after addi-
tional surgeries too. This rate is lower than those reported
in the literature, possibly due to ongoing follow-up with
three cases and that some cases required a long-term
stending T-tube due to their clinical condition.
For tracheal stenosis, tracheal resection and anastomosis
is widely considered the treatment of choice. However,
this surgical approach is not feasible when the glottis and
subglottis are involved or in patients with poor general
condition. We prefer the T-tube first treatment in patients
with grades 2-3 circular cicatricial tracheal stenosis in the
Myer-Cotton classification. We follow our patients for an
average of 6 - 9 months and make additional applications
in following sessions when necessary. Given the com-
plexity of tracheal surgery, we feel that noninvasive T-
tube application should be initially attempted in tracheal
stenosis. The subcutaneus procedure is with more cases
and longer follow-ups, and we think this technique would
be more efficient, since the absence of the outer part of
T-tube enables more infection and granulatiın tissue-free
environment; also better cosmetic and social outcomes
for the patients. After discharging, we also do a monthly
follow up. None of our patients had a life threatening
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