eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Glottic Stenosis: Workup

Author: Gauri Mankekar, MBBS, MS, PhD, DNB, Consulting Surgeon, Department of Otolaryngology, PD Hinduja National Hospital, India
Coauthor(s): Debbie A Eaton, MD, Private Practice; Alan D Murray, MD, Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas Children's Hospital; Consulting Staff, Department of Otolaryngology, Medical Center of Lewisville, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, The Pediatric Surgery Center
Contributor Information and Disclosures

Updated: Sep 11, 2009

Workup

Laboratory Studies

  • Few diagnostic laboratory findings are associated with glottic stenosis, although performing a serological workup is necessary if a granulomatous disease (eg, sarcoidosis, tuberculosis, syphilis, Wegener granulomatosis) or a systemic disease (eg, rheumatoid arthritis, amyloidosis) is suspected as the cause.

Imaging Studies

  • Routine plain upper airway and chest radiographs are of limited value in the diagnosis and treatment of glottic stenosis but may provide an initial assessment of laryngotracheal air column and coexisting pulmonary disease.
  • A CT scan allows for evaluation of the length and thickness of the glottic stenotic segment in subglottic stenosis. A CT scan also allows for evaluation of the laryngeal framework in order to determine the presence of a fracture or other significant injury.
  • Spiral computed tomography with 3-dimensional reconstruction is advisable for better surgical planning and outcome, and it is complementary to rigid endoscopy in the management of these conditions.14

Other Tests

  • Pulmonary function tests (ie, maximum inspiration and expiration flow rates, flow volume loops, pressure flow loops) show characteristic changes in upper airway stenosis and may be used to compare preoperative and postoperative results.
  • Electromyography (EMG) can help to differentiate posterior glottic stenosis from bilateral vocal cord paralysis. It may also be used to evaluate the function of the intrinsic muscles of the larynx.
  • Twenty four-hour pH studies help to evaluate coexistant gastroesophageal reflux.

Diagnostic Procedures

First, the conscious patient's vocal cord mobility is assessed using either indirect laryngoscopy or fiberoptic laryngoscopy. Currently many clinicians are advocating early evaluation of the larynx (ie, within the first few hours after extubation) to diagnose and commence treatment of lesions caused by prolonged endotracheal intubation.   

Subsequently, under anesthesia, direct laryngoscopy and bronchoscopy in the operating room allow for careful evaluation of the laryngeal and distal airways and provide a means of assessing the cricoarytenoid joints.

Microlaryngoscopic assessment helps to identify the extent and character of the stenosis and the degree of arytenoid mobility and to determine if cricoarytenoid joint fixation is present.

Other important aspects of the evaluation include assessment of inflammatory changes in the larynx, the size of the airway, and evidence of gastroesophageal reflux (eg, interarytenoid edema, erythema).

Histologic Findings

In rare cases of glottic stenosis caused by a granulomatous or systemic infection or disease, biopsy is necessary to make the diagnosis. The presence or absence of caseous necrosis or vasculitis differentiates tuberculosis, sarcoidosis, and Wegener granulomatosis. Identification of causative organisms can also be accomplished using the biopsy specimen.

Staging

Cohen’s classification is as follows:15

  • Type I : This is the mildest form of the web. It involves less than 35% of the glottis. It is usually thin and uniform in thickness with no subglottic extension. The true vocal cords are usually well seen through the web. The patient usually has an adequate airway and only slight voice change.
  • Type II: The web involves 35-50% of the glottis and can be thin or thick, but the vocal cords can usually be seen within the web. These may be associated with some subglottic extension of stenosis. Patients usually don't have too much airway obstruction or airway symptoms.
  • Type III: This type involves 50-75% of the glottis. The web is usually very thick anteriorly and may thin out as it extends posteriorly. The true vocal cords may or may not be visible within the web; these almost always have a subglottic component to them. Patients have marked vocal dysfunction and have moderate-to-severe airway symptoms.
  • Type IV: This is the most severe form. The web involves 75-90% or more of the glottis and is uniformly thick both anteriorly and posteriorly. The true vocal cords are not identifiable within the web and may be one continuous, thick band. The patient is usually aphonic. Severe airway obstruction is usually present and almost always requires an emergency tracheotomy.

More on Glottic Stenosis

Overview: Glottic Stenosis
Workup: Glottic Stenosis
Treatment: Glottic Stenosis
Follow-up: Glottic Stenosis
Multimedia: Glottic Stenosis
References
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References

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Further Reading

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Keywords

glottic stenosis, glottis, larynx, vocal cords, anterior or posterior commissure webs, scar, fibrosis, fixation, vocal cords, posterior glottis, larynx, supraglottis, glottis, subglottis, stenosis, subglottic stenosis, supraglottic stenosis, anterior web, posterior web , congenital glottic stenosis, acquired glottic stenosis, upper airway stenosis, laryngofissure, tracheotomy, keel, stent, aryepiglottic fold mucosal flap, trapdoor flap, traumatic intubation, congenital laryngeal web, endotracheal tube, endotracheal intubation, ET tube, ET intubation, adult-acquired laryngeal stenosis, mitomycin-C, Wegener granulomatosis, tuberculosis, sarcoidosis, rhinoscleroma, carbon dioxide laser, CO2 laser

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Contributor Information and Disclosures

Author

Gauri Mankekar, MBBS, MS, PhD, DNB, Consulting Surgeon, Department of Otolaryngology, PD Hinduja National Hospital, India
Gauri Mankekar, MBBS, MS, PhD, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Association of Otolaryngologists of India, and Cochlear Implant Group of India
Disclosure: Nothing to disclose.

Coauthor(s)

Debbie A Eaton, MD, Private Practice
Debbie A Eaton, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Medical Association
Disclosure: Nothing to disclose.

Alan D Murray, MD, Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas Children's Hospital; Consulting Staff, Department of Otolaryngology, Medical Center of Lewisville, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, The Pediatric Surgery Center
Alan D Murray, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Surgeons, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center
John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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