subglottic stenosis and laryngotracheal reconstruction
TRANSCRIPT
![Page 1: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/1.jpg)
Surgical Management of
Advanced and Recurrent
Subglottic Stenosis
Andrew Coughlin, MD, PGY-4
Faculty Advisor: Michael Underbrink, MD
The University of Texas Medical Branch (UTMB Health)
Department of Otolaryngology
Grand Rounds Presentation
October 27, 2011
![Page 2: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/2.jpg)
Definition
Subglottic stenosis (SGS) is the narrowing of the airway below the true vocal folds.
Congenital
Acquired
Subglottis: Anterior commissure: 10mm
Posterior commissure: 5mm
Normal lumen is 4.5 to 5.5 mm
<4.0mm in full term infant is considered stenotic
<3.5mm in premature infants is considered stenotic
![Page 3: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/3.jpg)
Predisposing Factors
Subglottis most susceptible to injury
Complete circular cartilage
Narrowest part in neonates
Lined by respiratory epithelium
Fragile and easily disrupted
![Page 4: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/4.jpg)
Laryngeal Function
Breathing
Protect from aspiration
Phonating
Coughing
Valsalva
Maintaining PEEP
![Page 5: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/5.jpg)
Anatomical Considerations
The larynx is proportionally larger in children.
The narrowest portion of the pediatric airway is the subglottis.
Adult is the glottis
Positioning of Larynx
Pediatric 2nd cervical vertebrae
Adult 6th cervical vertebrae
Normal laryngeal function is important to prevent aspiration as the pediatric epiglottis is more floppy and less functional.
![Page 6: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/6.jpg)
Embryology
Larynx develops from 4th and 5th arches
Outgrowth of the primitive pharynx
Laryngotracheal opening between arches
Three masses form: Hypobranchial eminence Epiglottis
Paired arytenoid masses
Recanalization occurs and failure leads to: Atresia, stenosis, or web formation
Arytenoid masses are separated by interarytenoid notch which creates a cleft if it is not obliterated
![Page 7: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/7.jpg)
Poiseuille’s Equation
Resistance = (n x L) / r4
Therefore it is important to remember
that as the airway narrows, breathing
becomes more difficult.
This effect is worse in children because
they already have a smaller airway than
adults.
![Page 8: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/8.jpg)
Congenital SGS
Secondary to inadequate recanalization of laryngeal lumen (3rd month gestation)
Involved in 5% of SGS cases
Subclassification: - Membranous
- Cartilaginous
Varying Degrees: - Complete atresia
- Localized Stenosis
- Webs
![Page 9: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/9.jpg)
Glottic web
![Page 10: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/10.jpg)
Membranous form
Fibrous tissue hypertrophy
Hyperplastic mucous glands
Not an inflammatory cause
Usually circumferential
Often 2-3 mm below true vocal cords
Can extend superiorly to involve the
glottis
![Page 11: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/11.jpg)
Cartilaginous Form
More variable
Most often involves cricoid cartilage
Grows posteriorly from anterior cartilage
as a sheet
Leaves a small posterior opening
![Page 12: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/12.jpg)
Localized Congenital SGS
![Page 13: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/13.jpg)
Acquired SGS (95% of cases)
Prolonged intubation
Direct blunt trauma
Fume/smoke inhalation
Caustic Lye ingestion
Chronic Infections
TB, Syphilis, leprosy, typhoid fever, etc.
Chronic Inflammatory diseases
Sarcoid, Lupus, Wegner’s, GERD, RA
Laryngeal Neoplasms
![Page 14: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/14.jpg)
Intubation trauma
Causes 90% of acquired SGS in children and neonates
Incidence following intubation is 0.9-8.3% 44% for low birthweight neonates and children with
RDS
Vast improvement from 60’s and 70’s where the incidence was 12-20%
Produces pressure necrosis at the site of contact with the airway The duration of intubation The size of tube The number of intubations
![Page 15: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/15.jpg)
Intubation Trauma
Pressure necrosis of cuff
Worse with high pressure low volume
Microcirculation ceases at 30 mm Hg
Duration of Intubation (Whited 1985)
2-5 days 0-2% stenosis
5-10 days 4-5% stenosis
>10 days 12-14% stenosis
![Page 16: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/16.jpg)
Pathophysiology
Tissue Injury Necrosis,
Edema, and
Ulceration
Mucociliary
stasis
Secondary
infection and
perichondritis
Granulation tissue
proliferation and scarring
Laryngeal dysfunction and
increased susceptibility to injury Airway, voice, and
feeding abnormalities
![Page 17: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/17.jpg)
Signs and Symptoms
![Page 18: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/18.jpg)
Question 1
Subglottic
Glottic
Supraglottic
hoarse/aphonic voice, inspiratory/biphasic stridor, ± cough
muffled/throaty voice, inspiratory stridor, feeding problems, no cough
hoarse/husky voice, biphasic stridor, barking cough
![Page 19: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/19.jpg)
Common Signs and
Symptoms
1) Airway
- Biphasic stridor, dyspena, air hunger,
retractions
2) Voice
- Abnormal cry, hoarseness, aphonia
3) Feeding
- Dysphagia, recurrent aspiration pneumonia
![Page 20: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/20.jpg)
Question 1
Subglottic
Glottic
Supraglottic
hoarse/aphonic voice, inspiratory/biphasic stridor, ± cough
muffled/throaty voice, inspiratory stridor, feeding problems, no cough
hoarse/husky voice, biphasic stridor, barking cough
![Page 21: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/21.jpg)
Initial Presentation
Congenital SGS
At birth if moderate or severe
Acquired SGS
Usually within 2-4 weeks of trauma/insult
*Either type in it’s mild form can be
asymptomatic and present after a
subsequent insult to the airway
![Page 22: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/22.jpg)
Workup
![Page 23: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/23.jpg)
History and Physical Exam
Birth history (Prematurity)
Intubation history
Feeding/Voice/Breathing difficulties?
Reflux?
Infections?
Autoimmune diseases?
Other systemic symptoms?
![Page 24: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/24.jpg)
Flexible
Nasopharyngolaryngoscopy
Nose/Nasopharynx Pyriform aperture stenosis
Choanal atresia
Supraglottis Structure abnormalities
Laryngomalacia
Glottis VC mobility
Clefts/webs/masses
Immediate subglottis
![Page 25: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/25.jpg)
Radiologic Evaluation
Plain film
Quick and cost effective in children
CT
Very specific for site and length of involvment
MRI
Good for surgical planning
Ultrasound
Excellent for quick assessment of the levels and diameter of airway
![Page 26: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/26.jpg)
Soft Tissue Film
![Page 27: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/27.jpg)
Workup/Initial Evaluation
Carretta et al. (2006) Compared preoperative CT findings with
intraoperative rigid endoscopy findings
Rigid Endoscopy most reliable diagnostic entity
Rigid Endoscope is the gold standard Allows better visualization of the vocal cords
Better assessment of stenotic levels
*Must be performed delicately to prevent mucosal irritation and stenosis exacerbation
![Page 28: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/28.jpg)
Rigid Endoscopy
Important intraoperative findings
Outer diameter of largest ET tube or
bronchoscope that can be passed
Location sites and length of stenosis
Other airway anomalies
Reflux changes
![Page 29: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/29.jpg)
Additional workup
Labs PPD, RPR, C-ANCA, ANA, etc
24-hour PH monitoring (dual probe)
EGD with biopsy
If esophagitis is suspected
Modified Barium Swallow
Functional Endoscopic Evaluation of Swallowing
Test airway sensation especially if child has aversion to food.
PFT’s
Used to compare Pre-op and Post-op pulmonary function
![Page 30: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/30.jpg)
GERD and SGS
Koufman et al. (1991) 73% of 32 patients with LTS had abnormal lower pH
probe results
67% had abnormal upper pH probe results
Walner et al. (1998) 74 pediatric patients with SGS had 3 times greater
incidence of GER than the general pediatric population
*Therefore all patients should be treated with PPI therapy even if they are not symptomatic to prevent recurrence (Burton, 1997)
![Page 31: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/31.jpg)
Staging
![Page 32: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/32.jpg)
Question 2
Why are these numbers important?
0
51
71
100
![Page 33: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/33.jpg)
Cotton-Meyer Grading of
SGS
I – 0-50% narrowing
II – 51-70% narrowing
III – 71-99% narrowing
IV – Complete obstruction with no lumen
![Page 34: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/34.jpg)
Cotton-Myer
grading
system for
subglottic
stenosis
![Page 35: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/35.jpg)
Laryngeal Stenosis
Grading
Grade I
Less than 70%
Grade II
70-90%
Grade III
More than 90% with identifiable lumen
Grade IV
Complete obstruction…No lumen
![Page 36: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/36.jpg)
Grading Systems for SGS
Lano (1998)
Based on subsites involved
Does not take into account length of
stenosis or lumen diameter
Stage I – one subsite involved
Stage II – two subsites involved
Stage III – three subsites involved
![Page 37: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/37.jpg)
Grading Systems for SGS
McCaffrey (1992) Based on subsites (trachea, subglottis, glottis)
involved and length of stenosis
Does not include lumen diameter
Grade I: Confined to the subglottis or trachea and are less than 1cm long
Grade II: Isolated to the subglottis and greater than 1cm long
Grade III: Sublottic and tracheal lesions not involving the glottis
Grade IV: Glottic involvement
![Page 38: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/38.jpg)
Management
![Page 39: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/39.jpg)
Goals of Management
To produce:
1. Adequate airway
2. Competent Larynx
3. Acceptable voice
*Ultimately the goal is to treat the stenotic
segment while preserving native normal
segments
![Page 40: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/40.jpg)
History of SGS Treatment
Early 1900’s most SGS was secondary to chronic infection and was treated primarily with tracheotomy
1950’s and 60’s – increase incidence intubation practices with high tracheotomy mortality
1980’s Cotton described Anterior Cricoid Split
The last 15-20 years has brought about SS-LTR which allows removal of the tracheotomy tube shortly after surgical repair
Endoscopic techniques have also emerged as viable options for initial treatment
![Page 41: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/41.jpg)
Management Options
Tracheotomy
Endoscopic Management
Dilation
Laser excision of stenotic areas
Anterior Cricoid Split
LTR (single or two stage)
CTR
![Page 42: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/42.jpg)
Tracheotomy
Maintains adequate airway
Use smallest tube that permits ventilation
Allows air leakage to prevent pressure injury and preserve phonatory function.
Usually just temporary If cannot decannulate by 2y/o consider
endoscopic or open repair
*Must keep in mind suprastomal granulation tissue when considering decannulation
![Page 43: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/43.jpg)
Endoscopic Repair
Dilation Useful early in disease process
Local steroid injections can help reduce scarring
Scar excision with laser Become increasingly popular
Minimal damage to normal surrounding tissue
Avoids bleeding, edema, and the need for a tracheotomy in some cases
Useful in Grade I or II stenosis but often requires multiple procedures
![Page 44: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/44.jpg)
Outcomes with
Endoscopic Repair
Herrington et al. (2006) showed that 70%
of patients undergoing dilation needed
repeated procedures.
Recommend usefulness in grade I or II
stenosis before considering open
interventions.
![Page 45: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/45.jpg)
Anterior Cricoid Split
1980 – described by Cotton Alternative for Tracheotomy
Procedure Splits cricoid and first 2 tracheal rings
Neck is closed with ET tube in place to act as a stent for healing.
Intubated, sedated, paralyzed in ICU for 7-14 days
Patients must have adequate pulmonary function to permit decannulation
Best indicated for mild anterior narrowing
![Page 46: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/46.jpg)
Anterior Cricoid Split
![Page 47: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/47.jpg)
Strict Criteria
Extubation failure ≥2 occasions
Weight >1500g
No assisted ventilation 10 days prior
Oxygen requirement <30%
No CHF for >1 month
No acute URI
No antihypertensive meds >10 days
![Page 48: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/48.jpg)
External Expansion
Surgery
Reserved for grade III and IV stenosis, or refractory grade II
Combines laryngeal and cricoid split with cartilage grafts and stenting
Success rates are greater than 90% Success defined by decannulation
Repair at youngest age possible: Improved speech and language development
Decreased tracheotomy mobidity/mortality
![Page 49: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/49.jpg)
Costal Cartilage Grafts
Abundant
Can obtain any size necessary
Generally use the 5th rib
Stenting required for several days as
suturing does not ensure that the graft
stays in it’s place.
![Page 50: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/50.jpg)
Approach to obtaining
graft
![Page 51: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/51.jpg)
Other grafts
Auricular cartilage
Thyroid alar cartilage
Hyoid bone
![Page 52: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/52.jpg)
Anterior laryngofissure
with graft
Good for:
Anterior stenosis
Anterior wall collapse
Perichondrium of the anterior graft is placed on the lumen side
Re-epithelialization
Barrier to infection
Large external flange to prevent prolapse of graft into the airway
![Page 53: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/53.jpg)
Anterior Grafts:
Modified boat shape
![Page 54: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/54.jpg)
Placement of anterior graft
![Page 55: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/55.jpg)
Laryngofissure with posterior
cricoid division +/- grafting
Indications:
Posterior subglottic or glottic stenosis
Circumferential stenosis
Cricoid deformity
Key points
Avoid complete laryngofissure to avoid damage to anterior commissure
Knots buried to keep them extraluminal
Patients often receive stenting 3-6 months
![Page 56: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/56.jpg)
Posterior Grafts:
Regular boat shape
![Page 57: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/57.jpg)
Single-staged Laryngotracheal
Reconstruction (SS-LTR)
Allows for shorter stenting period
Anterior graft, posterior graft, or both
ET tube initially to support the graft
2-4 days if Anterior graft only
7 days if Posterior graft is used as well
Best results if patient >4Kg and >30wks
![Page 58: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/58.jpg)
Two-Staged LTR
The main difference is that a more
permanent stent is used to maintain the
airway while the graft heals
Montgomery T-tubes (silastic)
Aboulker Stents (teflon)
Stents can be left for months
*Considered to be inert and prevent tissue
injury
![Page 59: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/59.jpg)
Stents
Counteract scar contractures and provide a scaffold for the airway.
Can also hold grafts in place and increase success rates.
Types of stents T-tubes most common in adults but these can become blocked
in children
Aboulker stents more commonly used in children for two stage procedures
ET tubes act as stents in the immediate perioperative period for SS-LTR
Patients must be evaluated for granulation tissue prior to stent removal with fiberoptic exam
![Page 60: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/60.jpg)
Montgomery T-tube Stent
![Page 61: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/61.jpg)
Aboulker Stent
![Page 62: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/62.jpg)
Aboulker Stent with
wired-in tracheostomy
tube
![Page 63: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/63.jpg)
Granulation Tissue
Formation
Nouraei et al. (2006) studied stent colonization and it’s correlation with granulation tissue formation
Colonization with S. aureus and P.aeruginosa statistically showed increased rates of granulation tissue
What didn’t play a role? Duration of stent placement
Polymicrobial colonization (oral flora)
Currently recommend antibiotics for 1 week post-op with coverage for Staph and Pseudomonas.
![Page 64: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/64.jpg)
SS-LTR vs Two-Stage LTR
Saunders et al. (1999) Patients undergoing Two-Stage LTR had
More severe stenosis (Grade 2.56)
Previous laryngeal surgery
SS-LTR patients Less severe stenosis (Grade 2.14)
Fewer post reconstruction procedures
Higher decannulation rate
Single stage procedure significantly better for Number of postoperative procedures (p=0.006)
Decannulation rate (p=0.03)
![Page 65: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/65.jpg)
SS-LTR vs Two-Stage LTR
Smith et al. (2010)
71 patients
22 SS-LTR (average grade 2.1)
62 Two-Stage LTR (average grade 2.9)
Operation specific decannulation rate was
better for SS-LTR (91% vs 68%) however
overall decannulation rate was not
significantly different (100% vs 93%)
![Page 66: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/66.jpg)
Decannulation Rates for
LTR
Younis et al. (2004)
Overall success rate of 86%
Anterior graft (100%)
Anterior and posterior graft (83%)
Revision cases (70%)
Koltai et al. (2006)
89% successful decannulation
![Page 67: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/67.jpg)
Cricotracheal Resection
(CTR)
![Page 68: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/68.jpg)
Cricotracheal Resection (CTR)
1953 – Conley describes 1st CTR in adults
1978 – Savary described 1st CTR in children
Best results in patients with isolated tracheal stenosis
More difficult approach with subglottic stenosis
Well tolerated in patients with grade III or IV stenosis
CTR > LTR in grade IV stenosis
![Page 69: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/69.jpg)
CTR
![Page 70: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/70.jpg)
CTR Failure Risk Factors:
White and colleagues (2005)
96% of patients had grade III or IV stenosis
94% overall decannulation rate
Statistically Significant Odds Ratio: Vocal cord paralysis post-op decreased decannulation (OR
5.2)
Statistically Insignificant Odds Ratio: Down syndrome
Trach tube at time of CTR
Use of chin to chest sutures
Eosinophilic Esophagitis was significant but not enough patients to analyze They suggest EGD with biopsy preoperatively for all patients
including PPI therapy 6 months post-op.
![Page 71: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/71.jpg)
CTR Complications:
Rutter and colleagues (2001)
Described the following complications: Anastomotic webbing
Almost all cases and usually asymptomatic
Arytenoid prolapse (45%) 60% asymptomatic
40% required partial laser arytenoidectomy
Restenosis (20%) 11% were still trach dependent
Postoperative infection (5%)
Recurrent laryngeal nerve palsy (5%)
Anastomotic dehiscence (0%) although previously has been reported
![Page 72: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/72.jpg)
Outcomes of breathing,
voice, and swallowing
Jacquet and colleagues (2005) studied post-CTR outcomes
Airway 95% of patients had no exertional dyspnea
Voice 21% had no vocal abnormalities
49% had mild dysphonia
Overall, 70% showed post-operative improvement
Swallowing 89% of patients with pre-operative swallowing
problems showed post-operative improvement.
![Page 73: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/73.jpg)
Ikonomidis et al (2010)
Why push earlier surgery?
Improved quality of life
Decreased financial burden on families
Improved speech and language
development
No chance of accidental death from plugging
which was reported as 2% in this series
![Page 74: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/74.jpg)
Ikonomidis et al (2010)
Retrospective review of CTR in children <10kg
Less than 10kg (36pts) Average weight 8.8kg smallest was 4.4kg
<1y/o (11pts), 1-2y/o (18pts), 2-3 y/o (7pts)
Single stage in 27 patients with 100% decannulation
Two stage in 9 patients with 92% decannulation
No significant difference between this group and the comparison group weighing >10kg (65pts) after cox regression analysis
![Page 75: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/75.jpg)
Postoperative Care (Gupta
et al. 2010)
Requires ICU with specialized staff
Nasotracheal Intubation 7-14 days
Sedation and paralysis
Steroids 12 hours before and for 5 days after decannulation
Leak test prior to extubation
Precedex during tracheal extubation
Antibiotics 2 weeks if no stenting
Months if stenting is performed
All get anti-reflux medications
Enteral feeding
Chest physiotherapy and log rolling
High index of suspicion for nosocomial infections
![Page 76: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/76.jpg)
Recommendations
Tracheotomy is #1 option to acutely Oropharyngeal phase is voluntary; Esophageal Phase not voluntary
tain airway Grade I and II Stenosis
Endoscopic Repair
Grade III or refractory cases LTR with anterior and/or posterior rib grafts
Grade IV CTR is the treatment of choice
Earlier treatment is better to preserve or encourage normal functional developement
![Page 77: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/77.jpg)
Summary
Subglottic stenosis is a common problem in patients with prolonged intubation
Each patient needs an appropriate workup including history, physical, and laryngoscopic examination
Management is driven by grading
Always remember to maximize airway, voice, and swallowing
![Page 78: Subglottic Stenosis and Laryngotracheal Reconstruction](https://reader036.vdocument.in/reader036/viewer/2022081512/5885e3b01a28abbd3d8bec7b/html5/thumbnails/78.jpg)
References 1. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
2. Muller CD and Pou AM. Subglottic Stenosis. Quinn’s Online Textbook of Otolaryngology. November 13, 2002
3. Whited RE: A study of endotracheal tube injury to the subglottis. Laryngoscope. 95: 1216-1219, 1985.
4. Carretta A, Melloni G, Ciriaco P, et al: Preoperative assessment in patients with postintubation tracheal stenosis. Rigid and flexible
bronchoscopy versus CT scan with multiplanar reconstruction. Surg Endosc 20:905-908, 2006.
5. Koufman JA. The otolarngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using
ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury.
Laryngoscope 1991; 101(suppl 53):1-64
6. Walner DL et al. Gastroesophageal reflux in patients with subglottic stenosis. Arch Otolaryngol Head Neck Surg 1998; 124(5):551-555
7. Burton DM. Gastroesophageal reflux. In: Holinger LD, Lusk RP, Green CG, eds. Pediatric Laryngology and Bronchoesophagology. Philadelphia,
Pa: JB Lippincott Raven; 1997:317-323
8. Lano, CF et. al. Laryngotracheal reconstruction in the adult: a ten year experience. Ann Otlo Rhinol Laryngol 1998; 107:92-96
9. McCaffrey TV. Classification of laryngotracheal stenosis. Laryngoscope 1992:102:335-340
10. Prescott CA. Protocol for management of the interposition cartilage graft laryngotracheoplasty. Ann Otol Rhinol Laryngol. 1988;97(3, pt 1):239-
242.Herrington, H. C., Webber, S. M., Anderson, P. E. (2006). Modern management of laryngotracheal stenosis. Laryngoscope. 116(9):1553-7
11. Cotton RT, Seid AB: Management of the extubation problem in the premature child: Anterior cricoid split as an alternative to tracheotomy. Ann
Otolo Rhinol Laryngol 1980; 89:508
12. Saunders MW, Thirlwall A, Jacob A, Albert DM. Single- or two-stage laryngotracheal reconstruction: comparison of outcomes. Int J Pediatr
Otorhinolaryngol.1999;50(1):51-54.
13. Smith LP, Zur KB, Jacobs IN. Single- vs Double-Stage Laryngotracheal Reconstruction. Arch Otolaryngol Head Neck Surg 2010,136:60-65.
14. Younis RT, Lazar RH, Bustillo A. Revision single-stage laryngotracheal reconstruction in children. Ann Otol Rhinol Laryngol. 2004
May;113(5):367-72.
15. Koltai PJ, Ellis B, Chan J, Calabro A. Anterior and posterior cartilage graft dimensions in successful laryngotracheal reconstruction. Arch
Otolaryngol Head Neck Surg 2006;132:631–634.
16. Nouraei SA, Petrou MA, Randhawa PS, Singh A, Howard DJ, Sandhu GS: Bacterial colonization of airway stents: a promoter of
granulation tissue formation following laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg 2006,132:1086-1090.
17. White DR, Cotton RT, Bean JA, Rutter MJ. Pediatric cricotracheal resection: surgical outcomes and risk factor analysis. Arch Otolaryngol Head
Neck Surg. 2005;131(10):896-899.
18. Rutter MJ, Hartley BE, Cotton RT. Cricotracheal resection in children. Arch Otolaryngol Head Neck Surg. 2001;127(3):289-292
19. Jaquet Y, Lang F, Pilloud R, Savary M, Monnier P. Partial cricotracheal resection for pediatric subglottic stenosis: long-term outcome in 57
patients. J Thorac Cardiovasc Surg. 2005;130(3):726-732
20. Idonomidis C, George M, Jaquet Y, Monnier P. Partial cricotracheal resection in children weighing less than 10 kilograms. Otolaryngology - Head
and Neck Surgery 2010; 142(1): 41-47.
21. Gupta P, Tobias J, Goyal S et al. Perioperative care following complex laryngotracheal reconstruction in infant and children. Saudi Journal
Anaesthesia 2010; 4(3): 186-196.