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Table of Contents
ORIGINAL ARTICLE
Year : 2010  |  Volume : 12  |  Issue : 1  |  Page : 10-13

Endoscopic management of subglottic stenosis


ENT Department, King Abdulaziz University Hospital, Riyadh, Saudi Arabia

Date of Web Publication24-Dec-2019

Correspondence Address:
MBBCH Bashaer Ahmad Abdullah
ENT Department, King Abdulaziz University Hospital, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.273966

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  Abstract 


Objective: To assess the possibility of restoring normal breathing for cases of subglottic stenosis by simple endoscopic dilatation.
Methods: Retrospective review of all subglottic stenosis cases with tracheostomy that presented between 1999 and 2008 to King Abdulaziz Aziz University Hospital in Riyadh, Saudi Arabia. The review mainly involved cases who underwent endoscopic laser dilatation.
Result: Out of 21 cases, about 50% were decanulaed after endoscopic CO2 laser dilatation with a total mean of further procedures being 1.4.
Conclusion: Decision of open airway reconstruction should be carefully made even for higher grades since some may benefit from simple dilatation.

Keywords: subglottic stenosis, dilatation, laser, airway reconstruction, decanulation


How to cite this article:
Abdullah BA, Al Ammar AY. Endoscopic management of subglottic stenosis. Saudi J Otorhinolaryngol Head Neck Surg 2010;12:10-3

How to cite this URL:
Abdullah BA, Al Ammar AY. Endoscopic management of subglottic stenosis. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2010 [cited 2022 Dec 2];12:10-3. Available from: https://www.sjohns.org/text.asp?2010/12/1/10/273966




  Introduction Top


Airway stenosis has been raised as a medical issue since the early twentieth century. John Winslow wrote that time that there was no more difficulty in laryngology than treating chronic stenosis of the larynx and trachea [1]. With the advancement in the medical field, management of such condition has become more and more promising.

The subglottis is the region extending from the insertion of the conus elasticus into the vocal folds down to the lower margin of the cricoid cartilage [2]. Subglottic stenosis (SGS) is defined as a cricoid lumen of less than 4mm in a full term newborn or 3mm in a preterm [3]. However, there is no generally accepted definition. A subglottic stenosis could be congenital or acquired, and could be cartilagenous or limited to the soft tissue. A stenosis is considered congenital when past history of airway trauma or instrumentation is absent. An acquired stenosis usually results from intubation, external trauma, infection or inflammation [3]. Having intubation as a causative factor, it can be concluded that marked advancements in ICU care and long term ventilation have had a negative impact on the incidence of SGS [4]. Depending upon the severity of the stenosis, symptoms and signs could range between mild respiratory distress to life threatening situation. Several grading systems has been published in order to help planning the management and predicting the prognosis. The most accepted one is the Myer- Cotton grading system that relay on sizing the airway by endotracheal tubes to predict the percentage of obstruction. Based on this system, SGS is graded into four grades: grade I (0-50% obstruction), grade II (50-70% obstruction), grade III (70-99% obstruction), and grade IV (total obstruction) [5]. Surgical management of subglottic stenosis has advanced greatly since the introduction of open reconstruction during the seventies of thelast century. Surgical intervention for laryngotracheal stenosis has been documented since 1871 by L. Von Schroetter [1]. It was the dilatation procedures that he started with. The term laryngotracheal reconstruction (LTR) was first used in 1981, however detailed description of the operation has been published by Cotton since 1978[1]. In 1991, Ranne and colleagues reported the first cricotracheal resection (CTR) [1]. In spite of the advancement in airway reconstruction field, simple dilatation still plays its role for mild grades [3]. In this study, we reviewed our cases of subglottic stenosis that underwent endoscopic dilatation. Since treatment decisions are based mainly on the severity of the stenosis, and the tissue characteristics forming it, decision to treat with open surgical technique was taken for some of the patient without prior endoscopic dilatation.


  Methods Top


This is a retrospective review of all subglottic stenosis cases that presented between 1999 and 2008 to King Abdulaziz Aziz University Hospital in Riyadh, Saudi Arabia. Patient population consisted of 31 cases In this review, we will be mainly discussing the cases that underwent endoscopic dilatation that involved only 21 cases out of the total population of subglottic stenosis cases. The remaining 10 cases underwent open surgical technique without prior dilatation and will not be included in this discussion. This review involved cases of subglottic stenosis in both adults and pediatric patients. All of our cases were tracheostomized, reflecting the severity of the narrowing of the airway. Dilatation was performed under general anesthesia with the use of laryngoscopy set. Our technique involved the use of CO2 laser with the power ranging between 4 and 6 watts, mostly repeated pulse. Bronchoscope was used sometime to expand the stenosed area after dilatation with laser.


  Results Top


Thirty one cases of subglottic stenosis were reviewed. They aged between 3 months and 60 years with an average of 11.18 years. Twenty four were male and 7 were female; 9 were adults and the remaining 22 were of pediatric age group. All of our cases were tracheostomized and all were graded according to Cotton - Meyer classification.

Our cases were managed as 3 groups with regard to the surgical intervention: 21 underwent endoscopic dilatation, 13 underwent LTR, and 4 underwent CTR. However, we will be concentrating on the endoscopic dilatation population. The decision of which procedure to be undertaken was dependent upon the operative findings of the initial diagnostic laryngoscopy and bronchoscopy.

[Table 1] shows the data of all cases that underwent CO2 laser dilatation. Out of 21 patients, ten were decanulated successfully. Decannulation time ranged between 2 days and 9 months with a mean of 3.5 months. All cases that had glottic web underwent web division either by laser or open technique. Five out of 10 decannulated cases needed more than one dilatation procedure with an average of 1.4. There were no post operative complications among the cases that were managed successfully with dilatation. One patient did not keep with the follow up and 2 failed the dilatation trials.
Table 1 : Laser Dilatation

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  Discussion Top


Subglottic stenosis is a disease that has a great impact on quality of life, resulting in tracheostomy dependency, Surgical management has impressively evolved over years in attempt to restore normal physiologic breathing [1].

The very initial mode of management was dilatation; and up to date this mode is still plays a role [1]. Various methods of dilation have been published in the literature including: serially sized rigid bronchoscopes, laser, stenting [6], Chevalier-Jackson dilators [7], balloon laryngoplasty [8], and microdebrider [9]. Nd-YAG, KTP, CO2 are different types of lasers that have been used. However, it was claimed that the former two types generate great heat diffusion that lead to higher rates of restenosis [10]. Moreover, they carry a high risk of transmural injury and airway penetration [9]. In our hospital, CO2 laser is in use. Twenty one cases underwent trial of dilatation initially. Our decision to try dilatation or to proceed directly to open airway reconstruction was mainly dependent upon the nature of the stenosis itself with respect to grade, thickness, and the extent [Table 1]. Eight cases out of 21 underwent open airway reconstruction after failure of dilatation and 2 are still pending. One to two trials of dilatation were given before proceeding to reconstruction. Looking at [Table 1], most of the cases that failed dilatation trial had thick, circumferential scar with associated airway anomalies. Among the group that were managed successfully with dilation, 50% of them were decanulated after a single procedure with total mean of further procedures being 1.4. The mean time of decannulation was 3.5 months. When considering the grade, 40% were of grade III and the rest ranged between I and II. There is a lot of debate in the literature regarding managing SGS cases with dilatation. P. Monnier et al, suggested in their study that CO2 laser dilatation could be tried initially with a selected group of patients and showed successful results for grades I, and II [10]. Nouraei et al, have limited their group of cases to those with post intubation stenosis and showed good results with CO2 laser dilatation saving the patient from a major surgical procedure [11]. In contrary, Mandour et al, and Heather C et al, published studies concluding that open surgery is superior to endoscopic dilatation [12],[13]. In the former study, laser dilatation was done for 13 patients with airway stenosis of grade 2-4 with stenting. However, the study was limited by small sample size. Moreover, there was significant difference between open surgery group and dilatation group regarding age, with dilatation group being older [12]. Another study considering laser dilatation was published by Giudice et al. Their study was limited to cases of idiopathic subglottic stenosis. Out of 30 cases, only 5 required open surgical procedure after failure of frequent trials of dilatation. The number of laser procedures needed for the total population ranged between 1 and 13 with mean of 2.4. However, because of unknown nature and prognosis of the pathology of interest in that study, comparing his results to ours is questionable [14]. Eighteen of our cases underwent open airway reconstruction. Eight of them underwent unsuccessful trial of dilatation before. Our open technique consisted of SLTR and CTR. There is no published data comparing the two different surgical techniques in matched patients, It has been published in the literature that CTR is the procedure of choice for grade IV and III [15],[16],[17]. All our LTR cases were grafted with rib cartilage, however, thyroid alar cartilage is gaining popularity[18]. As mentioned earlier all our cases were tracheostomized. In spite of the widespread use of S SLTR and its higher reported decannulation rate[19], having a tracheostomy in certain situations is considered an advantage[20] and prevents reintubation[21]. Our results of open airway reconstruction will be discussed in a future study.


  Conclusion Top


Surgical management of subglottic stenosis is showing a very promising future. Three modalities are currently being practiced: dilatation, LTR and CTR. Open airway reconstruction is replacing dilatation to a large extent. However, we believe that the decision of open airway reconstruction should be carefully made even for higher grades since some may benefit from simple dilatation.



 
  References Top

1.
Koempel JA, Cotton R. History of Pediatric Laryngotracheal Reconstruction. Otolaryngol Clin North Am. 2008;41(5):825-35.  Back to cited text no. 1
    
2.
Schroeder JW, Holinger L. Congenital Laryngeal Stenosis. Otolaryngol Clin North Am. 2008;41(5):865-75.  Back to cited text no. 2
    
3.
Hartnick CJ, Cotton R. Congenital Laryngeal Anomalies: laryngeal atresia, stenosis, web and clefts. Otolaryngol clin North Am. 2000;33(6):1293-308.  Back to cited text no. 3
    
4.
Cotton RT. Management of subglottic stenosis. Otolaryngol Clin North Am.2000;33(1):112-30.  Back to cited text no. 4
    
5.
Myer C, Connor D, Cotton R. Proposed Grading System For Subglottic Stenosis Based On Endotracheal Tube Sizes. Ann Otol Laryngol. 1994;103:319-23.  Back to cited text no. 5
    
6.
Clement P, Hans S, de Mones E, Sigston E, Laccourreye O, Brasnu D. Dilatation for Assisted Ventilation-Induced Laryngotracheal Stenosis. Laryngoscope .2005;115(9):1595-8.  Back to cited text no. 6
    
7.
Joao G, V Manoel E, Gonçalves, Silvia R, Cardoso U. Early diagnostic and endoscopic dilatation for the treatment of acquired upper airway stenosis after intubation in children. J Pediat Surg. 2008;43(7):1254-8.  Back to cited text no. 7
    
8.
Durden F, E Steven, Sobol. Balloon Laryngoplasty as a Primary Treatment for Subglottic Stenosis. Arch Otolaryngol Head Neck Surg. 2007;133(8):772-5.  Back to cited text no. 8
    
9.
Lando T, April M, Ward R. Minimally Invasive Techniques in Laryngotracheal Reconstruction. Otolaryngol Clin North Am. 2008;41(5):935-46.  Back to cited text no. 9
    
10.
Monnier P,George M, Monod M, Lang F. The role of the CO2 laser in the management of aryngotracheal stenosis: a survey of 100 cases. Eur Arch Otorhinolaryngol. 2005;262(8):602-8.  Back to cited text no. 10
    
11.
Nouraei S, Ghufoor K, Patel A, Ferguson T, Howard D, Sandhu G. Outcome of Endoscopic Treatment of Adult Postintubation Tracheal Stenosis. Laryngoscope. 2007;117(6):1073-9.  Back to cited text no. 11
    
12.
Mandour M, Remacle M, Heyning P, Elwany S, Tantawy A, Gaafar A. Chronic subglottic and tracheal stenosis: endoscopic management vs. surgical reconstruction. Eur Arch Otorhinolaryngol. 2003;260:374–80.  Back to cited text no. 12
    
13.
Herrington C, Stephen M, Peter E. Modern Management of Laryngotracheal Stenosis. Laryngoscope. 2006;116:1553-7.  Back to cited text no. 13
    
14.
Giudice M,Piazza C, Foccoli P, Toninelli C, Cavaliere S, Peretti G. Idiopathic subglottic stenosis: management by endoscopic and open-neck surgery in a series of 30 patients. Eur Arch Otorhinolaryngol. 2003;260:235-8.  Back to cited text no. 14
    
15.
Sandu K, Monnier P. Cricotracheal Resection. Otolaryngol Clin North Am. 2008;41(5):981-98.  Back to cited text no. 15
    
16.
Hartley B, Rutter M, Cotton R. Cricotracheal resection as a primary procedure for laryngotracheal stenosis in children. Internat J. Pediat Otorhinolaryngol. 2000;54:133–6.  Back to cited text no. 16
    
17.
Rutter M, Hartley B, Cotton R. Cricotracheal Resection in Children. Arch Otolaryngol Head Neck Surg .2001;127:289-92.  Back to cited text no. 17
    
18.
Fayoux P, Vachin F, Merrot O, Bernheim N. Thyroid alar cartilage graft in pediatric laryngotracheal reconstruction. Internat J Pediat Otorhinolaryngol. 2006;70:717-24.  Back to cited text no. 18
    
19.
Boardman S, Albert D. Single-Stage and Multistage Pediatric Laryngotracheal Reconstruction. Otolaryngol Clin North Am. 2008;41(5):947-58.  Back to cited text no. 19
    
20.
Rutter M, Link D, Liu J, Cotton M. Laryngotracheal Reconstruction and the Hidden Airway Lesion. Laryngoscope. 2000;110:1871-4.  Back to cited text no. 20
    
21.
Gustafson L,Hartley B,Liu J, Link D, Chadwell J, Koebbe C, Myer C. Single-stage laryngotracheal reconstruction in children: A review of 200 cases. Otolaryngol Head Neck Surg. 2000;123(4):430-4.  Back to cited text no. 21
    



 
 
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