Glottic Stenosis Treatment & Management
- Author: Gauri Mankekar, MBBS, MS, DNB, PhD; Chief Editor: Arlen D Meyers, MD, MBA more...
The primary goals of treatment are the development of an adequate airway and preservation or improvement in voice quality.
Treatment consists of medical treatment, intralesional injections, endolaryngeal procedures, and open surgical procedures. The treatment depends on the thickness of the glottic web. Thin anterior commissure webs can be successfully excised with the CO2 laser or microdebrider followed by endoscopic keel placement, while thicker webs require laryngofissure, lysis of the web, and placement of a silicone or silastic keel.
Sharouny and Omar recommended that when a keel is used for anterior glottic stenosis, it be adequately sutured to the anterior laryngeal wall to prevent complications. They described a case in which a patient returned to the clinic two weeks after placement of a custom-made keel, having aspirated it. Flexible bronchoscopy revealed that the silastic sheet from which the keel was made was in the right main bronchus; the object was removed via a flexible bronchoscope passed through the tracheostomy.
When stenosis is due to an infection or inflammatory disorder, appropriate treatment in the form of antibiotics, corticosteroids, or both is important.
The use of systemic steroids in glottic stenosis is controversial. These agents tend to decrease scar formation but may delay wound healing. Treatment should be individualized.
Steroid injection into the posterior glottic scar may be useful in cases of inflammation during the very early stages. These injections are technically difficult, and cartilage resorption may be a serious complication. Inhalational steroids are sometimes used to reduce granulation tissue formation after stent removal.
Supportive therapy includes humidified oxygen and close airway monitoring in a supervised setting.
Always manage gastroesophageal reflux prior to any surgical intervention.
Surgical methods that rely solely on dilation are generally unsuccessful for all webs except the most translucent membranous ones.
In 1924, endoscopic division of webs and subsequent keel placement were first described. Since that time, multiple modifications of both the technique and keel material have been made.
Open techniques involve an anterior laryngofissure or thyrotomy with grafting or placement of keels or stents.
In congenital glottic stenosis, the thickness of the webs determines the treatment modality. Thin webs that transilluminate respond well to endoscopic lysis (either sharply with microscissors or with a carbon dioxide laser or a microdebrider) or serial dilations. Thicker webs, in approximately 40% of patients, require tracheotomy with a subsequent open laryngeal repair.
Bogdasarian and Olson (1980) classified the extent of posterior glottic stenosis into the following 4 types:
Type I - Vocal process adhesion
Type II - Posterior commissure stenosis with scarring in the interarytenoid plane and internal surface of the posterior cricoid lamina
Type III - Posterior commissure stenosis with unilateral cricoarytenoid joint ankylosis
Type IV - Posterior commissure stenosis with bilateral cricoarytenoid joint ankylosis
Bogdasarian and Olson recommend a graded surgical approach based on this classification scheme. They also recommend, in mild cases (type I and type II), performing scar excision, resurfacing with mucosa or split-thickness skin graft, and stenting. Arytenoidectomy and hyoid interposition have been recommended in cases of joint fixation.
Overall, the trend in glottic stenosis management is toward shorter stenting periods and less invasive techniques (eg, endoscopy, use of carbon dioxide laser, or a smaller laryngofissure).
In a literature review, Lahav et al recommended that surgical intervention for glottic stenosis begin with a discussion of expectations with the patient regarding voice versus airway functions. In addition, careful planning for anesthesia administration is required, as the surgeon and anesthetist must each understand tubeless jet ventilation options.
The key to successful repair of webs is the adequate coverage of denuded surfaces.
Endoscopic techniques include manual or laser scar division or microdebrider web or scar lysis, endoscopic arytenoid abduction lateroplexy (EAAL), classic vocal cord laterofixation (VCL), transverse cordotomy (TC), arytenoidectomy (AE), laser arytenoidectomy, and microtrapdoor (MTD) flaps. In a study of 34 patients with glottic stenosis (33 with pure glottic stenosis, 1 with accompanying supraglottic stenosis) who underwent unilateral or bilateral microtrapdoor flap surgery, Yilmaz et al found that 33 of them were dyspnea-free on exertion at 1-year follow-up.
Recently, endoscopic techniques have been used with good results to perform posterior cricoid splits and rib grafting.
Open techniques require laryngofissure with web division and coverage of the raw area using a variety of flaps, including native mucosa, nasal septal mucosa, buccal mucosa, perichondrocutaneous grafts, skin grafts, and cartilage grafts. An investigational technique that may become favorable to traditional open techniques involves an anterior window laryngoplasty. This method is expected to provide closer and more direct exposure than endoscopic techniques and to have fewer possible complications than traditional laryngofissure.
The MTD technique for anterior webs involves elevating the web unilaterally, ablating the scar, and redraping the preserved mucosa over the vocal cord to resurface the raw area. This technique is most successful in cases in which webs are of thin-to-moderate size (ie, < 1 cm thick). Posterior glottic webs may also be treated in a similar manner using the MTD technique, but these may require several procedures for adequate treatment.
Thin webs can be excised with the carbon dioxide laser, microscissors, or microdebrider, addressing one side of larynx at a time to avoid further webbing as well as application of either mitomycin-C or chitosan to prevent re-webbing. Thicker webs are often associated with subglottic narrowing and are more difficult to treat; they often require tracheostomy followed by laryngofissure with division of web and possibly cricoid cartilage and then closure over a keel or stent. The timing for correction is controversial.
Several techniques have been described for the management of interarytenoid fusion, including division by sharp dissection or carbon dioxide laser with stent placement. In 1994, Lichtenberger et al described a successful keel-fixing technique for the endoscopic repair of anterior commissure webs in 13 patients. This technique involves precise keel placement using an endo-extralaryngeal needle carrier. The results of Lichtenberger's study showed improved airway and voice in all patients treated, without the need for tracheotomy.
Beswick et al reported on a technique for endolaryngeal keel placement in patients with anterior glottic webs in which an endoscopic suture retriever is inserted through a percutaneously placed angiocatheter, precluding the need for a Lichtenberger needle passer. This exo-endolaryngeal technique uses materials that are readily available in most operating rooms.
Chitose et al (2009) have described the use of a posterior mucosal flap for the treatment of posterior glottic stenosis. Using endoscopic microscissors, they separated the posterior commissure and interarytenoid scar tissue submucosally. The bilateral corniculate cartilages of the superior arytenoids were then debulked using a CO2 laser. A posteriorly based mucosal flap obtained from the postcricoid region was extended approximately to the mucosa of the posterior commissure. The mucosal flap was sutured to the inferior subglottic mucosa by two 4-0 polyglactin absorbable sutures.
Rovó et al (2008) have described endoscopic arytenoid lateropexy for isolated posterior glottic stenosis. Using a CO2 laser and endoscopic approach, they transected the scar between the arytenoid cartilages. A right-angled endolaryngeal scythe was used to transect the scars that had spread into the cricoarytenoid joint. A reinforced Lichtenberger needle carrier instrument was used to perform the lateropexy of the adequately mobilized arytenoid cartilages, with consideration of the real abduction of the cricoarytenoid joint.
Scar incision, posterior cricoidotomy with stenting, and cartilage grafting have been used together to treat posterior glottic fixation, with excellent airway and voice outcomes. Described by Zalzal in 1993, this technique involves an anterior laryngofissure with incision of the posterior glottic scar in the midline, posterior vertical cricoidotomy to the hypopharyngeal mucosa, and cartilage grafting between the arytenoids. Zalzal's report detailed the treatment of 12 tracheotomy-dependent patients with glottic stenosis from endotracheal intubation; all patients were decannulated successfully after the described procedure.
Schaefer et al reported the successful mobilization of fixated arytenoids without arytenoidectomy in 4 patients with type IV posterior glottic stenosis. The procedure described involves a midline thyrotomy with the advancement of superiorly based mucosal flaps and cricoarytenoid joint exploration with lysis of adhesions. The patients were stented postoperatively for 2-3 weeks and subsequently underwent endoscopic stent removal under general anesthesia.
A 1-stage procedure for the repair of major congenital laryngeal webs with associated subglottic stenosis has been successfully used in 5 children. The advantage of this technique is the avoidance of morbidity associated with stents, keels, and tracheotomies. Biavati et al describe this technique, which involves anterior laryngofissure with division of the web. Careful mucosal coverage of raw surfaces, submucous resection of the stenotic area, and costal cartilage grafting complete this technique. Postoperative endotracheal tube stenting is required for 5-7 days.
Krimsky et al have reported 3 cases of glottic and subglottic narrowing treated with spray cryotherapy alone or in combination with balloon dilation.
Keels or stents typically remain in place for 4-6 weeks postoperatively and may be removed endoscopically.
Postoperative paralytic agents are avoided whenever possible, especially in children, for the following reasons:
Accidentally extubated patients are unable to breathe spontaneously.
Sedatives and analgesics are easily titrated.
Patients with a dislodged or obstructed tube are unable to show respiratory distress when paralyzed.
Prolonged weakness that occurs after long-term paralysis has been documented.
After open procedures, monitor patients closely for the development of a pneumothorax or neck hematoma. Because of possible complications, include the use of drains to allow the escape of air following an open airway procedure. Always obtain a postoperative chest radiograph and daily examine any costal cartilage harvest site. Administer antibiotics for 2-3 weeks after any open procedure and while a keel or stent is in place. The patient should follow an antireflux regimen. Some authors recommend periodic endoscopy every 4 weeks to assess the stent location and monitor formation of granulation tissue. Closely monitor systemic diseases (eg, diabetes) that may impede tissue revascularization.
Close follow-up care is necessary to monitor airway patency, stenosis recurrence, and granulation tissue formation.
Granulation tissue may be treated with aerosolized steroids (dexamethasone 1 mg/kg/d) orally or through the tracheotomy tube.
Multiple recurrences after serial dilations may necessitate an open laryngeal procedure.
Most speaking patients (ie, noninfant patients) should also undergo 4-6 weeks of postoperative voice therapy. In most cases, oral intake may be resumed once the patient is extubated.
Repeat endoscopy is performed 2-4 weeks after stent or keel removal. Repeat endoscopy is often performed when signs or symptoms of airway difficulty return.
Emergent complications include airway obstruction, stent aspiration, hematoma formation, and pneumothorax. Airway obstruction is often caused by a mucus plug that should be suctioned immediately. Stent aspiration requires bronchoscopy under anesthesia for foreign body removal. Manage hematoma and pneumothorax with drainage and chest tube placement as indicated. Other potential complications vary depending on the technique used for treatment and include recurrence, aspiration, infection, keel extrusion, chondritis, granulation tissue formation, dysphonia, and tracheotomy dependence.
Outcome and Prognosis
Involvement of the glottis in subglottic stenosis has been found to have an unfavorable effect on outcome. In addition, using multivariate analysis, a prospective study by Pullens et al indicated that in patients who undergo surgery for laryngotracheal stenosis, involvement of the glottis and the existence of comorbidities are the only factors that significantly increase the risk of a poor long-term functional outcome.
However, isolated glottic stenosis tends to have a significantly better outcome when compared with other areas of laryngeal stenosis.
Voice outcomes vary according to the method of treatment but are generally either unchanged or improved.
In adult-acquired laryngeal stenosis, the most important factors in predicting the rate and time of decannulation include the length of the stenotic segment and the anatomical site.
The applications of mitomycin-C or chitosan are being extensively investigated in canine subglottic stenosis and have shown promising anecdotal results in human subglottic stenosis.
In a cadaver morphometric study, Sztano et al found that endoscopic arytenoid Abduction lateroplexy was more effective in improving posterior glottis configuration, although arytenoidectomy and vocal cord lateral fixation were also beneficial.
Future and Controversies
Postoperative movement of the arytenoids in a patient with a stent may have a negative effect on the healing process.
Further investigation of the use of different stent materials and designs or botulinum toxin (in cases of vocal cord paralysis) is needed.
Recent reports suggest that mitomycin-C application is associated with airway complications from delayed wound healing in rabbits. This should be considered during the use of mitomycin-C in clinical practice.
Sittel C. Pathologies of the larynx and trachea in childhood. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2014. 13:Doc09. [Medline].
Mackenzie, M. The Use of the Laryngoscope in Diseases of the Throat. 1st ed. 1865.
Von Schroetter L. Lectures Regarding Diseases of the Larynx (in German). Leipzig: Braumuller & Wein; 1892. 239.
Haslinger F. A case of membrane formation in the larynx: a new method of safer recovery (in German). Monatsschr Ohrenheilkd Laryngorhinol. 1924. 22:174-76.
Iglauer S. New procedure for the treatment of web in the larynx. Arch Otolaryngol. 1935. 22:597 -602.
McNaught RC. Surgical correction of anterior web of the larynx. Laryngoscope. 1950. 60:264-72.
Dedo HH, Sooy CD. Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or micro-trapdoor flap. Laryngoscope. 1984 Apr. 94(4):445-50. [Medline].
Lichtenberger G, Toohill RJ. New keel fixing technique for endoscopic repair of anterior commissure webs. Laryngoscope. 1994 Jun. 104(6 Pt 1):771-4. [Medline].
Montgomery WW. Posterior and complete laryngeal (glottic) stenosis. Arch Otolaryngol. 1973 Sep. 98(3):170-5. [Medline].
Zalzal GH. Posterior glottic fixation in children. Ann Otol Rhinol Laryngol. 1993 Sep. 102(9):680-6. [Medline].
Biavati MJ, Wood WE, Kearns DB, Smith RJ. One-stage repair of congenital laryngeal webs. Otolaryngol Head Neck Surg. 1995 Mar. 112(3):447-52. [Medline].
Cheng AT, Beckenham EJ. Congenital anterior glottic webs with subglottic stenosis: surgery using perichondrial keels. Int J Pediatr Otorhinolaryngol. 2009 Jul. 73(7):945-9. [Medline].
Crowe S, Westbrook A, Bourke M, Lyons B, Russell J. Impossible laryngeal intubation in an infant with Fraser syndrome. Paediatr Anaesth. 2004 Mar. 14(3):276-8. [Medline].
Howard NS, Shiba TL, Pesce JE, Chhetri DK. Photodocumentation of the development of type I posterior glottic stenosis after intubation injury. Case Rep Surg. 2015. 2015:504791. [Medline].
Wolf M, Primov-Fever A, Talmi YP, Kronenberg J. Posterior glottic stenosis in adults. Isr Med Assoc J. 2007 Aug. 9(8):597-9. [Medline].
Parida PK, Gupta AK. Role of spiral computed tomography with 3-dimensional reconstruction in cases with laryngeal stenosis--a radioclinical correlation. Am J Otolaryngol. 2008 Sep-Oct. 29(5):305-11. [Medline].
Boemo RL, Navarrete ML, Genestar EI, Gonzalez M, Fuentes JF, Fortuny P. Interarytenoid osseous bridge after prolonged endotracheal intubation. Acta Otorrinolaringol Esp. 2011 Jun 14. [Medline].
Cohen SR. Congenital glottic webs in children. A retrospective review of 51 patients. Ann Otol Rhinol Laryngol Suppl. 1985 Nov-Dec. 121:2-16. [Medline].
Sharouny H, Omar RB. Iatrogenic aspiration of custom-made keel: a case report. Iran Red Crescent Med J. 2014 Dec. 16 (12):e17066. [Medline].
Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg. 1980 Nov-Dec. 88(6):765-72. [Medline].
Lahav Y, Shoffel-Havakuk H, Halperin D. Acquired Glottic Stenosis-The Ongoing Challenge: A Review of Etiology, Pathogenesis, and Surgical Management. J Voice. 2015 Sep. 29 (5):646.e1-646.e10. [Medline].
Yılmaz T, Suslu N, Gunaydın RO, Kuscu O, Sozen T, Atay G, et al. Microtrapdoor Flap Technique for Treatment of Glottic Laryngeal Stenosis: Experience With 34 Cases. J Voice. 2015 Aug 28. [Medline].
Beswick DM, Clark AK, Bergeron J, Sung CK. Endoscopic suture retriever for endolaryngeal keel placement in treatment of anterior glottic webs. Ann Otol Rhinol Laryngol. 2015 Mar. 124 (3):240-3. [Medline].
Chitose S, Umeno H, Nakashima T. Endoscopic surgical treatment of posterior glottic stenosis. J Laryngol Otol. 2009 May. 123 Suppl 31:68-71. [Medline].
Rovo L, Venczel K, Torkos A, Majoros V, Sztano B, Jori J. Endoscopic arytenoid lateropexy for isolated posterior glottic stenosis. Laryngoscope. 2008 Sep. 118(9):1550-5. [Medline].
Schaefer SD, Close LG, Brown OE. Mobilization of the fixated arytenoid in the stenotic posterior laryngeal commissure. Laryngoscope. 1986 Jun. 96(6):656-9. [Medline].
Krimsky WS, Rodrigues MP, Malayaman N, Sarkar S. Spray cryotherapy for the treatment of glottic and subglottic stenosis. Laryngoscope. 2010 Mar. 120(3):473-7. [Medline].
Pullens B, Pijnenburg MW, Hoeve HJ, et al. Long-term functional airway assessment after open airway surgery for laryngotracheal stenosis. Laryngoscope. 2015 Jun 24. [Medline].
Sztanó B, Szakács L, Madani S, Tóth F, Bere Z, Castellanos PF, et al. Comparison of endoscopic techniques designed for posterior glottic stenosis-A cadaver morphometric study. Laryngoscope. 2013 Jun 22. [Medline].
Roh JL, Lee YW, Park CI. Can mitomycin C really prevent airway stenosis?. Laryngoscope. 2006 Mar. 116(3):440-5. [Medline].
Hsieh MJ, Liu YH, Yueh YS, Ko PJ. Use of microdebrider in glottic stenosis following airway stenting. Eur J Cardiothorac Surg. 2006 Aug. 30(2):388-90. [Medline].
Hueman EM, Simpson CB. Airway complications from topical mitomycin C. Otolaryngol Head Neck Surg. 2005 Dec. 133(6):831-5. [Medline].
Inglis AF Jr, Perkins JA, Manning SC, Mouzakes J. Endoscopic posterior cricoid split and rib grafting in 10 children. Laryngoscope. 2003 Nov. 113(11):2004-9. [Medline].
Liyanage SH, Khemani S, Lloyd S, Farrell R. Simple keel fixation technique for endoscopic repair of anterior glottic stenosis. J Laryngol Otol. 2006 Apr. 120(4):322-4. [Medline].
Roh JL, Yoon YH. Prevention of anterior glottic stenosis after bilateral vocal fold stripping with mitomycin C. Arch Otolaryngol Head Neck Surg. 2005 Aug. 131(8):690-5. [Medline].
Rutter MJ, Cotton RT. The use of posterior cricoid grafting in managing isolated posterior glottic stenosis in children. Arch Otolaryngol Head Neck Surg. 2004 Jun. 130(6):737-9. [Medline].
Smith MM, Kuhl G, Carvalho PR, Marostica PJ. Flexible fiber-optic laryngoscopy in the first hours after extubation for the evaluation of laryngeal lesions due to intubation in the pediatric intensive care unit. Int J Pediatr Otorhinolaryngol. 2007 Sep. 71(9):1423-8. [Medline].