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Subglottic Stenosis in Children Workup

  • Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: Jul 23, 2015

Laboratory Studies

See the list below:

  • Specific laboratory studies are not required.

Imaging Studies

See the list below:

  • The criterion standard for evaluation of the airway is direct laryngoscopy and direct bronchoscopy.
  • Certain radiographic examinations can help in obtaining a diagnosis and determining the severity of the disease. Usually, the initial radiographic study used to evaluate a child with airway obstruction is anteroposterior and lateral plain neck radiography. Frequently, in a child with subglottic stenosis (SGS), the subglottis appears narrowed and peaked; this is often described as a steeple sign. In a patient with a thin web subglottic stenosis (SGS), a lateral plain film radiograph may show a faint line.
  • Fluoroscopy is often performed in children with symptoms of airway obstruction.
    • Fluoroscopy can be used to diagnose lesions of the larynx and trachea.
    • When a barium-enhanced esophagram is added to the procedure, vascular malformations, along with GERD, may be ruled out.
  • CT scans and MRIs are not often used in the primary evaluation of subglottic stenosis (SGS).

Other Tests

See the list below:

  • Investigate any indication of GERD. Walner showed that children with subglottic stenosis (SGS) have a 3-fold increase in GERD compared with the general pediatric population.
  • Currently, the best test in evaluating for GER is dual-channel pH probe testing. One probe is placed above the lower esophageal sphincter, and another is placed at the area of the cricopharyngeus near the larynx.
  • Walner and Cotton recommend treating GER for 1 month before and 12 months after airway reconstructive surgery, even if only mild disease is present.
  • If moderate or severe GERD is diagnosed, start medical therapy and confirm disease resolution with another pH probe test prior to surgery.
  • Do not perform laryngeal reconstruction until GER has resolved.
  • If reconstruction is being considered, pediatric laryngologists frequently perform tests to rule out GER, even in the absence of symptoms, because the disease may affect the outcome.
  • A recent concern suggests that an "allergic" esophagitis may exist and affect the outcome of surgery.
    • To evaluate for this entity, an esophagogastroduodenoscopy (EGD) is performed with biopsies of the proximal and distal esophagus, stomach, and duodenum.
    • If more than 15 eosinophils are found in the mucosa per high power field, the patient may have "allergic" esophagitis.
    • Evaluation and treatment for GERD must have taken place prior to this evaluation, since reflux may elicit eosinophils as well.
    • If "allergic" esophagitis is discovered, then treatment with weeks to months of oral steroids or orally applied inhaled steroids is performed to help diminish the affects of the disease and possibly allow for a better success rate of laryngeal reconstruction.

Diagnostic Procedures

In a child with mild or moderate airway obstruction, perform flexible fiberoptic nasopharyngoscopy and laryngoscopy in the clinic or the emergency department (ED). If extreme airway obstruction exists or if an active supraglottic infectious process is suspected in a young child, flexible endoscopy may be deferred in favor of formal rigid bronchoscopy in the operating room (OR). However, flexible fiberoptic nasopharyngoscopy may be performed in a controlled setting in the OR, because determination of the nature of the supraglottis and glottis in awake unsedated patients is crucial.

The procedures are described as follows:

  • Flexible fiberoptic nasopharyngoscopy and laryngoscopy
    • During flexible fiberoptic nasopharyngoscopy and laryngoscopy, topical anesthesia and decongestion can be accomplished in older infants and children with topical Afrin and lidocaine. A 3-mm endoscope can be used, even in an infant. Pass the endoscope into both nasal cavities to access pyriform aperture stenosis, midnasal stenosis, choanal atresia or stenosis, lesions of the nose and nasopharynx, and the adenoid pad.
    • Pass the endoscope into the superior oropharynx and hypopharynx. The hypopharynx and larynx can be assessed. Identify the structure and position of the supraglottis. Evaluate the epiglottis and arytenoids for malacia or stenosis. Evaluate the position and movement of the true vocal cords. Evaluate edema or erythema of the true vocal cords, epiglottis, and arytenoids.
  • Flexible endoscopy
    • This can be performed with the patient in the supine or sitting position. The supine position often results in the obstruction of certain supraglottic processes. If the goal is to obtain the best visualization of the true vocal cords and supraglottis, place a child (even an infant) in the sitting position with his or her neck extended.
    • If the child is older, the voice can be evaluated, and videostroboscopy can be performed to assess the vocal cord waveform and vocal cord mobility.
    • Occasionally, the subglottis can be visualized with flexible endoscopy; however, rigid laryngoscopy and bronchoscopy are the safest procedures and offer the best visualization for the subglottis and tracheobronchial tree.
  • Rigid laryngoscopy and bronchoscopy
    • Rigid laryngoscopy and bronchoscopy is the best single test for evaluating airway obstruction in children. The otolaryngologist must have knowledge of the pediatric airway, and the OR must have adequate bronchoscopes and telescopes of various sizes. Prepare all equipment for bronchoscopy, including laryngoscopes, light sources, video documentation equipment, telescopes, and bronchoscopes prior to the child's arrival in the OR. Throughout the procedure, maintain good communication between anesthesiologists, surgical nursing staff, and physicians, so that any potential airway obstruction can be quickly assessed and addressed.
    • Do not further injure the pediatric airway—this point is of paramount importance. Use the smallest bronchoscope or telescope alone for evaluation of the subglottis in a child who does not require ventilation throughout the procedure. This practice allows good visualization without iatrogenic injury to the area. If ventilation is required throughout the evaluation, use a bronchoscope-telescope combination.
    • If a child has a tracheotomy or is not in extreme distress, the child can breathe spontaneously and inhale oxygen and anesthetics through an endotracheal tube in the pharynx while the airways are visualized with a laryngoscope and large telescope. Frequently, the true vocal cords are anesthetized with lidocaine prior to evaluation to help prevent laryngospasm.
    • Determine the size of the child's airway by using endotracheal tubes. Myers and Cotton have established a scale for subglottic stenosis (SGS) severity that is based on the child's age and the size of the endotracheal tube that can be placed in the airway with an air leak pressure of less than 20 cm of water.
    • Evaluate the subglottis and glottis for fixation, scarring, granulation, edema, paralysis or paresis, and other abnormalities. Evaluate the distance and caliber of the stenosis. Apply the Myer and Cotton staging system only to circumferential subglottic stenosis (SGS).[10] Glottic stenosis and SGS often coexist and must be considered when reconstruction is planned.
    • Evaluate the maturity of the stenosis. If a firm white scar is present, the stenosis is mature. If the stenosis has a granular or erythematous appearance, GERD, viral infection, allergic esophagitis, or another inflammatory process may be present.
    • Examine the area below the subglottis into the trachea and bronchi for secondary lesions. The suprastomal area is important because pathological stenosis or malacia can influence the choice of surgical procedure. In severe subglottic stenosis (SGS), viewing the suprastomal area requires the passage of a tiny telescope through a narrow subglottis or a telescope or bronchoscope through a tracheotomy site, if available.
Contributor Information and Disclosures

John E McClay, MD Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical Center

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.


Russell A Faust, MD, PhD Consulting Staff, Department of Otolaryngology, Columbus Children's Hospital

Disclosure: Nothing to disclose.

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Intraoperative endoscopic view of a normal subglottis
Grade III subglottic stenosis in an 18-year-old patient following a motor vehicle accident. The true vocal cords are seen in the foreground. Subglottic stenosis is seen in the center of the picture.
Endoscopic view of the true vocal cords in the foreground and the elliptical congenital subglottic stenosis (SGS) in the center of the picture.
Subglottic view of very mild congenital subglottic stenosis. Laterally, the area looks only slightly narrow. When endotracheal tubes were used to determine its size, it was found to be 30% narrowed.
Subglottic view of congenital elliptical subglottic stenosis.
Granular subglottic stenosis in a 3-month-old infant that was born premature, weighing 800 g. The area is still granular following cricoid split. This patient required tracheotomy and eventual reconstruction at age 3 years. True vocal cords are shown in the foreground (slightly blurry).
Intraoperative laryngeal view of the true vocal cords of a 9-year-old boy. Under the vocal cords, a subglottic stenosis can be seen.
This spiraling subglottic stenosis is not complete circumferentially. Laser therapy was the treatment choice and was successful after 2 laser treatments.
Continued lasering of the subglottic stenosis. The reflected red light is the aiming beam for the CO2 laser.
Postoperative view. Some mild residual posterior subglottic stenosis remains, but the child is asymptomatic and the airway is open overall.
An intraoperative view of a split cricoid in a patient with elliptical congenital subglottic stenosis. The open airway can be seen in the center of the picture. The wound extends to the inferior one third of the thyroid cartilage.
Preoperative view of a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Vocal cords are in the foreground.
A close-up view.
Postoperative view. The patient had been intubated for 1 week and extubated for 1 week.
A subglottic view following dilation with an endotracheal tube to lyse the thin web of scar and a short course (5-day) treatment with oral steroids.
Postoperative view of a 4-month-old infant with subglottic stenosis following cricoid split. Notice very mild recurrence of scaring at the site of previous scar. Overall, the airway is open and patent. The anterior superior area can be seen, with a small area of fibrosis where the cricoid split previously healed.
Rib graft for reconstruction of subglottic stenosis. The diamond-shaped internal intraluminal component with perichondrium still present is seen on the top section of the rib and the shape of the rib is seen on the backside of the carved out diamond shape.
Anterior rib graft with a diamond shape. Note it measures approximately 1.7 mm in length. Intraluminal site is facing up. Flanges of rib are carved to remain on the outside of the trachea to prevent prolapse into the trachea.
Cartilage graft in place over the wound. Note external component of the graft still looks like a portion of the rib. The internal component has been carved in a diamond shape. This is an intraoperative photo. The cartilage graft was used in this patient for reconstruction.
Graft with all sutures in position. All the sutures are placed prior to lowering the graft into position. Then, the sutures are tied.
Representative sample of varying sizes of Aboulker stents (range of 3-15 mm). These stents are hollow and coated in Teflon.
Endoscopic view of Aboulker stent protruding through and above the true vocal cords. The arytenoids and epiglottic folds are seen.
Diagram of a long Aboulker stent wired to a metal Jackson tracheotomy tube.
A Jackson tracheotomy tube wired to a long Aboulker stent.
A 7-mm Montgomery tracheotomy tube with caps
Granulation tissue (superior center portion of the picture) that occurred at the graft site of a laryngotracheal reconstruction performed with an anterior graft.
Intraoperative suspended view with a subglottoscope of the subglottis, showing the granulation tissue just prior to removal with cup forceps and laser.
Postexcision view of granulation tissue through the subglottoscope.
Preoperative view of glottic stenosis and small glottic chink in a 2-year-old child.
Preoperative subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis.
Postoperative view of the glottic larynx in a child who underwent anterior and posterior grafting for subglottic stenosis. Note the glottis is more open and in neutral position. The scarring of the right true vocal cord appears improved.
Postoperative close up view of the true vocal cords.
Postoperative subglottic view of patient who underwent anterior and posterior grafting with successful decannulation showing open subglottis with some very mild damage to the anterior wall and the suprastomal area where the tracheostomy tube had been placed
Subglottic view of an anterior graft, placed for anterior subglottic stenosis. The white areas to the left and right are the true vocal cords. The graft is seen at the superior and mid area.
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