Acquired Subglottic Stenosis

1
Acquired Subglottic Stenosis
Granulation 48 hours
Ulceration 72 hours -10 days
Furrow 10-30 days
Interarytenoid Scar 10-30 days
2
Acquired Subglottic StenosisPathogenesis

• Intrinsic Factors
• Shape and size of larynx
• Infection
• Wound healing
• Malnutrition
• Chronic Disease
• Activity/ movement
• GERD/ LPR
• Chronic inflammation will exacerbate changes
  induced by ETT
• Higher rate of GER in patients with SGS than the
  general population

• Extrinsic Factors
• Endotracheal tube
• Size
• Traumatic intubation/ Multiple reintubations
• Duration of intubation
• Tracheostomy
• Nasogastric Tube trauma

Gould SJ, Young M. Sublgottic ulceration and
healing following endotracheal tube intubation in
the neonate. Annals ORL 1992, 101 815.
3
Acquired Subglottic StenosisPathogenesis

• Endotracheal Tube Factors
• Size of ETT
• lt 20 cm H2O pressure air leak appropriate
• ETT material
• Silicone or Polyvinyl chloride tubes safest
• Duration of Intubation
• Adults lt7-10 days
• Longer for premature infants
• Shearing motion of ETT
• Increased trauma to mucosa ? Increases traumatic
  changes
• Maintenance and care of ETT and patient
• Aggressive suctioning, endoscopy, reintubation

4
Subglottic StenosisCotton Myer Grading System
Myer CM, OConnor DM, Coton RT. Proposed grading
system for subglottic stenosis based on
endotracheal tube sizes. Ann Otol Rhinol
Laryngol, 1994 103 319-323.
5
Grading Subglottic Stenosis
6
Subglottic Stenosis
Grade I lt50 Stenosis
Grade II 50-70 Stenosis
Grade III 70-99 Stenosis
Grade IV No Detectable Lumen
7
Subglottic Stenosis- Treatment

• Grade I and low Grade II
• Can usually be observed
• Close follow up, endoscopy for surveillance
• High Grade II
• May require surgical repair
• Endoscopic dilation
• Open surgical repair
• Grade III and IV
• Require surgical repair
• Open surgical repair
• Tracheostomy as temporizing measure

8
Surgical Treatment- Dilation
9
Anterior Cricoid Split

• Described in 1980 by Cotton as alternative to
  tracheostomy for patients with acquired
  subglottic stenosis
• Patient selection
• gt 2 failed extubations due to SGS
• Weight gt1500 grams
• Off ventilator support for 10 days
• lt30 O2 requirement
• Airway improved by
• Improved circulation to the cricoid and decreased
  edema
• Opening the cricoid allows it to spring open

10
Laryngotracheal Reconstruction

• Anterior Graft
• Use for lower grade and primarily anterior
  stenoses
• Anterior and Posterior Grafts
• Use for posterior glottic stenosis,
  circumferential stenosis, or near total/ total
  subglottic stenosis

11
Single Stage Laryngotracheal Reconstruction

• Traditional LTR with cartilage grafts and
  simultaneous tracheal decannulation
• Indications
• SGS without associated tracheal stenosis or
  tracheomalacia
• Weight greater than 4 kg
• Gestational age gt 30 weeks
• No craniofacial or vertebral anomalies
• Aim to avoid complications of long term stenting
  and tracheostomy
• Postoperative care critical!
• Nasotracheal tube stenting
• Titrated sedation versus Paralysis

12
Mini Laryngotracheal Reconstruction

• Anterior cricoid split with thyroid ala cartilage
  graft
• Small retrospective series show shortened
  operative time compared with costal cartilage
  graft and no significant difference in operative
  outcomes
• Expands the age group for LTR to younger patients

13
Endoscopic Posterior Cricoid Split

• Described by Inglis et al in 2003 for management
  of posterior glottic stenosis with or without
  subglottic stenosis
• 5/ 7 children decannulated within a year after
  surgery
• Posterior cricoid lamina is endoscopically
  divided and expanded with a costal cartilage
  graft

Inglis AF, Perkins JA, Manning SC, Mouzakes J.
Endoscopic posterior cricoid split and rib
grafting in 10 children. Laryngoscope 2003
113(11)2004-2009.
14
Conclusions

• The most common causes of congenital stridor
  include laryngomalacia, subglottic stenosis.
• Tracheomalacia is the most common cause of lower
  airway stridor, however is much less common than
  laryngomalacia
• Diagnostic work up should include careful history
  and physical examination.
• Office laryngoscopy and/ or direct laryngoscopy
  and bronchoscopy should be used to make
  definitive diagnosis
• Many congenital airway lesions can be treated
  expectantly or medically
• Surgical treatment options are available, and
  should be tailored to the individual patient.

15
Thank You!
http//www.nationwidechildrens.org/ear-nose-throat
Fundraising Driving Online Interaction and Giving