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Otolaryngology and Facial Plastic Surgery > LARYNGOLOGY
Subglottic Stenosis in Adults
Article Last Updated: Feb 8, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: James D Garnett, MD, Director of Voice and Swallowing Center, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center
James D Garnett is a member of the following medical societies: American Academy of Otolaryngic Allergy and American Academy of Otolaryngology-Head and Neck Surgery
Editors: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
subglottic stenosis in adults, subglottic stenosis, acquired glottic stenosis, congenital glottic stenosis, narrowing of the subglottic area, acquired chronic subglottic stenosis, intubation, glottis, membranous stenosis, cartilaginous stenosis
Problem
Partial or complete narrowing of the subglottic area may be congenital or acquired. The problem is rare and challenging, affecting soft tissue and cartilage support. Iatrogenic injuries cause most of the problems seen. Often, subglottic stenosis has an insidious onset, and early manifestations are usually mistaken for other disorders (eg, asthma, bronchitis).
Etiology
Congenital Stenosis is said to be congenital in the absence of a history of intubation or other acquired causes. Congenital laryngeal webs account for approximately 5% of congenital anomalies of the larynx, with 75% occurring at the glottic level and the rest occurring at the subglottic or supraglottic level. Most severe cases are diagnosed in childhood. Acquired Trauma is the most common cause of stenosis in both children and adults. Approximately 90% of all cases of acquired chronic subglottic stenosis in children and adults result from endotracheal intubation. The reported rate of stenosis following intubation ranges from 0.9-8.3%. Intubation causes injury at the level of the glottis due to pressure between the arytenoid cartilages. Intubation causes injury in the subglottis due to the complete cartilaginous ring or can cause injury distally in the trachea. Pressure and/or motion of the tube against the cartilage framework may cause ischemia and necrosis. Duration of intubation is the most important factor in the development of stenosis. Severe injury has been reported after 17 hours, but it may occur much sooner. A 7-10 day period of ICU intubation is acceptable, but the risk of laryngotracheal injury increases drastically after that. Size of the tube is also important. Tubes should be no larger than 7-8 mm in internal diameter for adult males. Tubes should be no larger than 6-7 mm in internal diameter for adult females. The size of the endotracheal tube needed correlates best with the patient's height. Stenosis could also be secondary to foreign body, infection, inflammation, or chemical irritation. Respiratory epithelium is susceptible to injury. Initial edema, vascular congestion, and acute inflammation can progress to ulceration and local infection with growth of granulation tissue. Finally, fibroblast proliferation, scar formation, and contracture can occur and result in stenosis. Systemic factors may increase the risk of injury and include the following:
- Gastric acid reflux
- Chronic illness
- Immunocompromised patient
- Anemia
- Neutropenia
- Toxicity
- Poor perfusion
- Radiation therapy
Other causes include the following:
- External trauma, penetrating and blunt
- Tracheotomy, especially a high tracheotomy or cricothyroidotomy
- Percutaneous tracheotomy (This has an emerging role as a cause.)1
- Chondroradionecrosis after radiation therapy; may occur up to 20 years later
- Chronic infection
Chronic inflammatory diseases include the following:
- Wegener granulomatosis
- Sarcoidosis
- Relapsing polychondritis
- Chronic inflammation secondary to gastroesophageal reflux and other conditions
- Neoplasm
Pathophysiology
Congenital stenosis has two main types, membranous and cartilaginous.
In membranous stenosis, fibrous soft tissue thickening is caused by increased connective tissue or hyperplastic dilated mucus glands with absence of inflammation. Membranous stenosis is usually circumferential and may extend upward to include the true vocal folds.
In cartilaginous stenosis, a thickening or deformity of the cricoid cartilage most commonly occurs, causing a shelflike plate of cartilage and leaving a small posterior opening. Cartilaginous stenosis is less common than membranous stenosis.
Acquired subglottic stenosis is secondary to localized trauma to subglottic structures. Usually, injury is caused by endotracheal intubation or high tracheostomy tube placement. If irritation persists, the original edema and inflammation progress to ulceration and granulation tissue formation. This may or may not involve chondritis with destruction of the underlying cricoid cartilage and loss of framework support.
When the source of irritation is removed, healing occurs with fibroblast proliferation, scar formation, and contracture, leading to stenosis or complete occlusion of the airway.
Clinical
Adults with mild congenital stenosis are usually asymptomatic, and they are diagnosed after a difficult intubation or while undergoing endoscopy for other reasons.
Patients with acquired stenosis are diagnosed from a few days to 10 years or more following initial injury. The majority of cases are diagnosed within a year. Symptoms include the following:
- Dyspnea (may be on exertion or with rest, depending on severity of stenosis)
- Stridor
- Hoarseness
- Brassy cough
- Recurrent pneumonitis
- Cyanosis
Many patients would have been diagnosed with asthma and recurrent bronchitis prior to discovery of stenosis. A high index of suspicion is warranted with the onset of respiratory symptoms following intubation, regardless of the duration of intubation.
Indications for treatment are to improve compromised airways and progress toward decannulation. Speedy intervention prior to cartilage damage or scar contracture is preferred when the diagnosis is made early.
The subglottic area is circumferentially bound by the cricoid cartilage, which is part of the larynx. The adult trachea is 10-13 cm long and 17-24 mm in diameter and extends from the inferior border of the cricoid cartilage to the carinal spur.
The first tracheal cartilage is partly inset in the lower border of the cricoid and, on occasion, may be fused with it. All of the tracheal rings are incomplete posteriorly.
Primarily, arterial supply to the larynx comes from branches of the superior and inferior thyroid arteries. The superior thyroid artery sends a superior laryngeal branch through the thyrohyoid membrane. The inferior thyroid artery sends an inferior laryngeal branch with the recurrent laryngeal nerve to enter the larynx near the cricothyroid joint.
The tracheal blood supply is segmental. Branches of the inferior thyroid artery supply the upper trachea. Branches of the bronchial arteries, with contributions from subclavian, supreme intercostal, internal thoracic, and innominate arteries, supply the lower trachea. The branches arrive to the trachea via lateral pedicles.
Sensory innervation to the subglottic mucosa is by the recurrent laryngeal nerve. The thyroid gland is adherent to the trachea at the second and third tracheal rings, but the lateral lobes overlie the cricoid cartilage and can approximate the lower lateral thyroid laminae.
Most contraindications are relative and include the following:
- General medical state of the patient precluding general anesthesia
- Factors affecting wound healing (eg, diabetes mellitus)
- Active inflammatory state (eg, Wegener granulomatosis); relative contraindication to surgical intervention and warrants medical treatment
- Any active infection at the site; should be medically managed
Contraindications specific to long-term tracheostomy are debatable and include the following:
- Circumferential scarring with cicatricial contracture
- A scar greater than 1 cm in vertical height
- Loss of cartilage
- History of severe bacterial infection associated with tracheostomy
- Posterior glottic stenosis with arytenoid fixation
- Prior radiotherapy (relative contraindication)
Contraindications reported for open repair include the following:
- Contraindication to general anesthesia
- Need for tracheotomy
- Significant gastroesophageal reflux
Lab Studies
- In the absence of a history of prior trauma or when suggested by other findings, evaluate for inflammatory or infectious causes, including the following:
- Wegener granulomatosis
- Relapsing polychondritis
- Syphilis
- Tuberculosis
- Sarcoidosis
- Leprosy
- Diphtheria
- Scleroma
Imaging Studies
- Radiography
- Standard chest radiographs can often provide a great deal of information regarding the tracheal air column.
- Anteroposterior filtered tracheal views and lateral soft tissue views of the neck provide specific information regarding the glottic/subglottic air column.
- MRI is useful in evaluating length and width of the stenotic region by means of coronal and sagittal views.
- CT scan
- CT scanning is not as helpful as MRI because its views are generally only in the axial plane.
- Thin cuts (1 mm) with sagittal and/or coronal reconstructions may be helpful, however. This is the preferred initial imaging study of the author.
Other Tests
- Flow-volume loops do not offer more specific information regarding stenosis than what is gained from imaging. However, flow-volume loops may be helpful in monitoring for restenosis after intervention.
Diagnostic Procedures
- Videostrobolaryngoscopy is extremely helpful in evaluating the glottic and supraglottic larynx for possible concomitant injury.
- Visualization of the larynx by flexible fiberoptic or rigid telescopic (90- or 70-degree scopes) in the clinic is crucial to the evaluation of airway lesions.
Medical therapy
- Any underlying medical cause must be addressed (eg, control of infectious etiology, inflammatory causes such as Wegener granulomatosis).
- Antireflux management
- Proton pump inhibitor (eg, omeprazole, 20 mg PO bid or equivalent)
- Ranitidine, 300 mg PO bid-qid, if proton pump inhibitor is not an option
- Dietary and lifestyle modification; crucial but often overlooked in antireflux management
- Use of systemic steroids in early stenosis is an option but has not been thoroughly investigated.
Surgical therapy
- Long-term tracheostomy
- Long-term intraluminal stent
- Endoscopic repair
- Not indicated following blunt or penetrating neck trauma
- Advocated as a preferred initial approach in chronic subglottic stenosis
- May require several procedures to obtain desired result
- Carbon dioxide laser is very useful in this setting, or neodymium: yttrium-aluminum-garnet (Nd:YAG) laser can be used.
- Open Repair
- Open repair is indicated following failure of the endoscopic approach when extent of stenosis is severe or factors are unfavorable for this approach.
- Choose the specific technique based on length of resection, need for cartilage, and need for mucosal coverage.
- Stent placement is required in some procedures.
- Other Procedures
- Anterior cricoid division with interposition graft (eg, hyoid-sternohyoid muscle, split clavicle muscle, rib)
- Anterior and/or posterior cricoid split with stenting
- Anterior laryngofissure with anterior lumen augmentation
- Trachelopexy with muscle-fascia repair
- Resection of stenotic segment with end-to-end repair
- Staged free-graft repair
Preoperative details
- The length of stenosis, its severity, involvement of cartilage, and degree of scar maturity must be known prior to any attempts at repair. The endoscopic approach has a high failure rate if the stenosis is longer than 1.0-1.4 cm.
- Detect any proximal or distal injuries (eg, supraglottic stenosis, posterior glottic scar, arytenoid fixation, distal tracheal stenosis).
- Use imaging and endoscopic investigation.
- Begin antireflux management approximately 1 month prior to repair.
Intraoperative details
In the endoscopic management of the stenosis, mitomycin-C has become routinely used. The concentration is usually 0.4mg/ml and is applied topically on a cottonoid pledget. The length of application varies from 2-3 repeat applications of 2 minutes each to a single application of 5 minutes.
The handling and disposal of the mitomycin-C should be per the hospital protocol for chemotherapeutic agents. Care should be taken to avoid contact with unprotected skin.
Postoperative details
- Endoscopic Approach
- Antibiotics for 1-3 weeks, depending on wound extent and general health of the laryngotracheal mucosa
- Intensive antireflux management
- Wound reassessment in 6 weeks to determine state of healing and need for further procedures
- Tracheostomy care if applicable
- Inhaled steroid sprays (not nasal sprays) are sometimes useful to reduce granulation tissue at the surgical wound.
- Open Approach
- Admit patient into an ICU setting.
- Administer antibiotics appropriate to the surgical repair and wound bed.
- Some authorities advocate suppression antibiotics when a stent is used.
- Initiate antireflux management.
- The role of postoperative intubation still is controversial.
- Some authorities desire immediate extubation postrepair; some support 1-2 days of postoperative intubation in the ICU; and some require extubation in the operating room rather than in the ICU.
- Some recommend prolonged postoperative neck flexion by splint or chin-to-chest suture in an end-to-end anastomosis.
Follow-up
- At least 1-2 years of postrepair evaluation as the scar continues to remodel and mature
- Symptomatic and/or flow-volume loop evaluations
- Imaging in questionable cases
- Capping trials and endoscopy prior to decannulation if tracheostomy is present
- Mucus plug occlusion
- Wound infection or abscess formation
- Granulation tissue formation
- Bleeding/hematoma
- Subcutaneous emphysema
- Pneumothorax and/or pneumomediastinum
- Stent problems (eg, migration, breakage)
- Reformation of stenosis
- Injury to recurrent or superior laryngeal nerves
- Airway obstruction
- Death
Overall goals are improvement of airway function and preservation of laryngeal function. The endoscopic approach was found to be successful in 57-90% of cases. Intraluminal stents were found to be successful in 80% of cases.
- Open Approach
- End-to-end anastomosis was found to be successful in 80-90% of cases.
- Mortality was reported at 10-20%; it has decreased with experience.
- Morbidity is 20-50%, secondary to the effect on laryngeal function and swallowing.
- Augmentation Techniques
- Successful case rates of 60-96% have been reported.
- Grafts are susceptible to infection, resorption, displacement, and extrusion.
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Subglottic Stenosis in Adults excerpt Article Last Updated: Feb 8, 2008
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