Glottic Stenosis Workup

  • Author: Gauri Mankekar, MBBS, MS, PhD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Aug 11, 2011
 

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.
Next

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]
Previous
Next

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 coexistent gastroesophageal reflux.
Previous
Next

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. Posterior glottis stenosis or interarytenoid adhesion has sometimes been misdiagnosed as cord paralysis. Laryngoscopy and laryngeal electromyography studies are the two diagnostic aids in this condition.[15]

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).

Previous
Next

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.

Previous
Next

Staging

Cohen’s classification is as follows:[16]

  • 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.
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Gauri Mankekar, MBBS, MS, PhD  Consulting Surgeon, Department of Otolaryngology, PD Hinduja National Hospital, India

Gauri Mankekar, MBBS, MS, PhD 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, Cook Children's Pediatric Surgery Center Plano

Alan D Murray 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.

Specialty Editor Board

John Schweinfurth, MD  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, American Laryngological Association, American Medical Association, and Triological Society

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, 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 Unrestricted 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; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

References

  1. Mackenzie, M. The Use of the Laryngoscope in Diseases of the Throat. ed. 1865.

  2. Von Schroetter L. Lectures Regarding Diseases of the Larynx (in German). Leipzig: Braumuller & Wein; 1892:239.

  3. 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.

  4. Iglauer S. New procedure for the treatment of web in the larynx. Arch Otolaryngol. 1935;22:597 -602.

  5. McNaught RC. Surgical correction of anterior web of the larynx. Laryngoscope. 1950;60:264-72.

  6. Dedo HH, Sooy CD. Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or micro-trapdoor flap. Laryngoscope. Apr 1984;94(4):445-50. [Medline].

  7. Lichtenberger G, Toohill RJ. New keel fixing technique for endoscopic repair of anterior commissure webs. Laryngoscope. Jun 1994;104(6 Pt 1):771-4. [Medline].

  8. Montgomery WW. Posterior and complete laryngeal (glottic) stenosis. Arch Otolaryngol. Sep 1973;98(3):170-5. [Medline].

  9. Zalzal GH. Posterior glottic fixation in children. Ann Otol Rhinol Laryngol. Sep 1993;102(9):680-6. [Medline].

  10. Biavati MJ, Wood WE, Kearns DB, Smith RJ. One-stage repair of congenital laryngeal webs. Otolaryngol Head Neck Surg. Mar 1995;112(3):447-52. [Medline].

  11. Cheng AT, Beckenham EJ. Congenital anterior glottic webs with subglottic stenosis: surgery using perichondrial keels. Int J Pediatr Otorhinolaryngol. Jul 2009;73(7):945-9. [Medline].

  12. Crowe S, Westbrook A, Bourke M, Lyons B, Russell J. Impossible laryngeal intubation in an infant with Fraser syndrome. Paediatr Anaesth. Mar 2004;14(3):276-8. [Medline].

  13. Wolf M, Primov-Fever A, Talmi YP, Kronenberg J. Posterior glottic stenosis in adults. Isr Med Assoc J. Aug 2007;9(8):597-9. [Medline].

  14. Parida PK, Gupta AK. Role of spiral computed tomography with 3-dimensional reconstruction in cases with laryngeal stenosis--a radioclinical correlation. Am J Otolaryngol. Sep-Oct 2008;29(5):305-11. [Medline].

  15. Boemo RL, Navarrete ML, Genestar EI, Gonzalez M, Fuentes JF, Fortuny P. Interarytenoid osseous bridge after prolonged endotracheal intubation. Acta Otorrinolaringol Esp. Jun 14 2011;[Medline].

  16. Cohen SR. Congenital glottic webs in children. A retrospective review of 51 patients. Ann Otol Rhinol Laryngol Suppl. Nov-Dec 1985;121:2-16. [Medline].

  17. Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg. Nov-Dec 1980;88(6):765-72. [Medline].

  18. Chitose S, Umeno H, Nakashima T. Endoscopic surgical treatment of posterior glottic stenosis. J Laryngol Otol. May 2009;123 Suppl 31:68-71. [Medline].

  19. Rovo L, Venczel K, Torkos A, Majoros V, Sztano B, Jori J. Endoscopic arytenoid lateropexy for isolated posterior glottic stenosis. Laryngoscope. Sep 2008;118(9):1550-5. [Medline].

  20. Schaefer SD, Close LG, Brown OE. Mobilization of the fixated arytenoid in the stenotic posterior laryngeal commissure. Laryngoscope. Jun 1986;96(6):656-9. [Medline].

  21. Krimsky WS, Rodrigues MP, Malayaman N, Sarkar S. Spray cryotherapy for the treatment of glottic and subglottic stenosis. Laryngoscope. Mar 2010;120(3):473-7. [Medline].

  22. Roh JL, Lee YW, Park CI. Can mitomycin C really prevent airway stenosis?. Laryngoscope. Mar 2006;116(3):440-5. [Medline].

  23. Berkowitz RG. The management of posterior glottic stenosis following endotracheal intubation. Aust N Z J Surg. Sep 1994;64(9):621-5. [Medline].

  24. Clerf L.H. Congenital stenosis of the larynx (in german). Ann. Otol. Rhinol. Laryngol. 1931;40:770.

  25. Flexon PB, Cheney ML, Montgomery WW, Turner PA. Management of patients with glottic and subglottic stenosis resulting from thermal burns. Ann Otol Rhinol Laryngol. Jan 1989;98(1 Pt 1):27-30. [Medline].

  26. Haslinger F. A case of membrane foramtion in larynx: a new method of safer recovery (in German). Monatsschr Ohrenheilkd Laryngorhinol. 1924;22:174 - 76.

  27. Hoasjoe DK, Franklin SW, Aarstad RF, Day TA, Stucker FJ. Posterior glottic stenosis mechanism and surgical management. Laryngoscope. May 1997;107(5):675-9. [Medline].

  28. Hsieh MJ, Liu YH, Yueh YS, Ko PJ. Use of microdebrider in glottic stenosis following airway stenting. Eur J Cardiothorac Surg. Aug 2006;30(2):388-90. [Medline].

  29. Hueman EM, Simpson CB. Airway complications from topical mitomycin C. Otolaryngol Head Neck Surg. Dec 2005;133(6):831-5. [Medline].

  30. Iglauer S. New procedure for treatment of web in the larynx. Arch Otolaryngol. 1935;22:597 -602.

  31. Inglis AF Jr, Perkins JA, Manning SC, Mouzakes J. Endoscopic posterior cricoid split and rib grafting in 10 children. Laryngoscope. Nov 2003;113(11):2004-9. [Medline].

  32. Irving RM, Bailey CM, Evans JN. Posterior glottic stenosis in children. Int J Pediatr Otorhinolaryngol. Dec 1993;28(1):11-23. [Medline].

  33. Langman AW, Lee KC, Dedo HH. The endoscopic Teflon keel for posterior and total glottic stenosis. Laryngoscope. Jun 1989;99(6 Pt 1):571-7. [Medline].

  34. Liyanage SH, Khemani S, Lloyd S, Farrell R. Simple keel fixation technique for endoscopic repair of anterior glottic stenosis. J Laryngol Otol. Apr 2006;120(4):322-4. [Medline].

  35. Massoud EA, McCullough DW. Adult-acquired laryngeal stenosis: a study of prognostic factors. J Otolaryngol. Aug 1995;24(4):234-7. [Medline].

  36. McCaffrey TV. Classification of laryngotracheal stenosis. Laryngoscope. Dec 1992;102(12 Pt 1):1335-40. [Medline].

  37. McNaught RC. Surgical correction of anterior web of the larynx. Trans Am Laryngol Rhinol Otol Soc. 1950;54th Meeting:232-42. [Medline].

  38. Montgomery WW. Management of glottic stenosis. Otolaryngologic Clinics of North America. 1979;12:841 - 7.

  39. Rahbar R, Valdez TA, Shapshay SM. Preliminary results of intraoperative mitomycin-C in the treatment and prevention of glottic and subglottic stenosis. J Voice. Jun 2000;14(2):282-6. [Medline].

  40. Rimell FL, Dohar JE. Endoscopic management of pediatric posterior glottic stenosis. Ann Otol Rhinol Laryngol. Apr 1998;107(4):285-90. [Medline].

  41. Roh JL, Yoon YH. Prevention of anterior glottic stenosis after bilateral vocal fold stripping with mitomycin C. Arch Otolaryngol Head Neck Surg. Aug 2005;131(8):690-5. [Medline].

  42. Rutter MJ, Cotton RT. The use of posterior cricoid grafting in managing isolated posterior glottic stenosis in children. Arch Otolaryngol Head Neck Surg. Jun 2004;130(6):737-9. [Medline].

  43. 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. Sep 2007;71(9):1423-8. [Medline].

  44. Smith RJ, Catlin FI. Laryngotracheal stenosis: a 5-year review. Head Neck. Mar-Apr 1991;13(2):140-4. [Medline].

  45. Spector JE, Werkhaven JA, Spector NC, Huang S, Sanders D, Reinisch L. Prevention of anterior glottic restenosis in a canine model with topical mitomycin-C. Ann Otol Rhinol Laryngol. Nov 2001;110(11):1007-10. [Medline].

  46. Tucker GF, Tucker JA, Vidic B. Anatomy and development of the cricoid: serial-section whole organ study of perinatal larynges. Ann Otol Rhinol Laryngol. Nov-Dec 1977;86(6 Pt 1):766-9. [Medline].

  47. Valdez TA, Wang Z, Schumann R, Shapshay SM. Anterior window laryngoplasty: a new anatomic approach for posterior glottic and subglottic stensosis. Ann Otol Rhinol Laryngol. Jun 2001;110(6):519-23. [Medline].

  48. Werkhaven JA, Beste D. Diagnosis and management of pediatric laryngeal stenosis. Otolaryngol Clin North Am. Aug 1995;28(4):797-808. [Medline].

  49. Zaw-Tun HI. Development of congenital laryngeal atresias and clefts. Ann Otol Rhinol Laryngol. Jul-Aug 1988;97(4 Pt 1):353-8. [Medline].

 
Previous
Next
 
Anatomical regions of the larynx.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.