eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Subglottic Stenosis in Adults: Treatment

Author: James D Garnett, MD, Director of Voice and Swallowing Center, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center
Contributor Information and Disclosures

Updated: Feb 8, 2008

Treatment

Medical Therapy

  • Any underlying medical cause must be addressed (eg, control of infectious etiology, inflammatory causes such as Wegener granulomatosis).
  • Antireflux management
    • Proton pump inhibitor (eg, omeprazole, 20 mg PO bid or equivalent)
    • Ranitidine, 300 mg PO bid-qid, if proton pump inhibitor is not an option
    • Dietary and lifestyle modification; crucial but often overlooked in antireflux management
    • Use of systemic steroids in early stenosis is an option but has not been thoroughly investigated.

Surgical Therapy

  • Long-term tracheostomy
  • Long-term intraluminal stent
  • Endoscopic repair
    • Not indicated following blunt or penetrating neck trauma
    • Advocated as a preferred initial approach in chronic subglottic stenosis
    • May require several procedures to obtain desired result
    • Carbon dioxide laser is very useful in this setting, or neodymium: yttrium-aluminum-garnet (Nd:YAG) laser can be used.
  • Open Repair
    • Open repair is indicated following failure of the endoscopic approach when extent of stenosis is severe or factors are unfavorable for this approach.
    • Choose the specific technique based on length of resection, need for cartilage, and need for mucosal coverage.
    • Stent placement is required in some procedures.
  • Other Procedures
    • Anterior cricoid division with interposition graft (eg, hyoid-sternohyoid muscle, split clavicle muscle, rib)
    • Anterior and/or posterior cricoid split with stenting
    • Anterior laryngofissure with anterior lumen augmentation
    • Trachelopexy with muscle-fascia repair
    • Resection of stenotic segment with end-to-end repair
    • Staged free-graft repair

Preoperative Details

  • The length of stenosis, its severity, involvement of cartilage, and degree of scar maturity must be known prior to any attempts at repair. The endoscopic approach has a high failure rate if the stenosis is longer than 1.0-1.4 cm.
  • Detect any proximal or distal injuries (eg, supraglottic stenosis, posterior glottic scar, arytenoid fixation, distal tracheal stenosis).
  • Use imaging and endoscopic investigation.
  • Begin antireflux management approximately 1 month prior to repair.

Intraoperative Details

In the endoscopic management of the stenosis, mitomycin-C has become routinely used. The concentration is usually 0.4mg/ml and is applied topically on a cottonoid pledget. The length of application varies from 2-3 repeat applications of 2 minutes each to a single application of 5 minutes.

The handling and disposal of the mitomycin-C should be per the hospital protocol for chemotherapeutic agents. Care should be taken to avoid contact with unprotected skin.

Postoperative Details

  • Endoscopic Approach
    • Antibiotics for 1-3 weeks, depending on wound extent and general health of the laryngotracheal mucosa
    • Intensive antireflux management
    • Wound reassessment in 6 weeks to determine state of healing and need for further procedures
    • Tracheostomy care if applicable
    • Inhaled steroid sprays (not nasal sprays) are sometimes useful to reduce granulation tissue at the surgical wound.
  • Open Approach
    • Admit patient into an ICU setting.
    • Administer antibiotics appropriate to the surgical repair and wound bed.
    • Some authorities advocate suppression antibiotics when a stent is used.
    • Initiate antireflux management.
    • The role of postoperative intubation still is controversial.
    • Some authorities desire immediate extubation postrepair; some support 1-2 days of postoperative intubation in the ICU; and some require extubation in the operating room rather than in the ICU.
    • Some recommend prolonged postoperative neck flexion by splint or chin-to-chest suture in an end-to-end anastomosis.

Follow-up

  • At least 1-2 years of postrepair evaluation as the scar continues to remodel and mature
  • Symptomatic and/or flow-volume loop evaluations
  • Imaging in questionable cases
  • Capping trials and endoscopy prior to decannulation if tracheostomy is present

Complications

  • Mucus plug occlusion
  • Wound infection or abscess formation
  • Granulation tissue formation
  • Bleeding/hematoma
  • Subcutaneous emphysema
  • Pneumothorax and/or pneumomediastinum
  • Stent problems (eg, migration, breakage)
  • Reformation of stenosis
  • Injury to recurrent or superior laryngeal nerves
  • Airway obstruction
  • Death

More on Subglottic Stenosis in Adults

Overview: Subglottic Stenosis in Adults
Workup: Subglottic Stenosis in Adults
Treatment: Subglottic Stenosis in Adults
Follow-up: Subglottic Stenosis in Adults
References
[ CLOSE WINDOW ]

References

  1. McQueen CT, Wellendorf TG, Henrich D, et al. Subglottic stenosis: A complication of percutaneous tracheotomy. Otolaryngol Head Neck Surg. 1999;120(4):543-5. [Medline].

  2. Andrews MJ, Pearson FG. Incidence and pathogenesis of tracheal injury following cuffed tube tracheostomy with assisted ventilation: analysis of a two-year prospective study. Ann Surg. Feb 1971;173(2):249-63. [Medline].

  3. Arola MK, Inberg MV, Puhakka H. Tracheal stenosis after tracheostomy and after orotracheal cuffed intubation. Acta Chir Scand. 1981;147(3):183-92. [Medline].

  4. Cooper JD, Grillo HC. The evolution of tracheal injury due to ventilatory assistance through cuffed tubes: a pathologic study. Ann Surg. Mar 1969;169(3):334-48. [Medline].

  5. Correa AJ, Reinisch L, Sanders D, et al. Inhibition of subglottic stenosis with mitomycin-C in the canine model. Ann Otol Rhinol Laryngol. 1999;108(11):1053-60. [Medline].

  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. Esclamado R, Cummings CW. Management of the impaired airway in adults. In: Cummings CW, et al, eds. Otolaryngology-Head and Neck Surgery. Singular Publishing Group;1993:2001-19.

  8. Kurrus JA, Gray SD, Elstad MR. Use of silicone stents in the management of subglottic stenosis. Laryngoscope. 1997;107(11 pt 1):1553-8. [Medline].

  9. Langford CA, Sneller MC, Hallahan CW, et al. Clinical features and therapeutic management of subglottic stenosis in patients with Wegener's granulomatosis. Arthritis Rheum. 1996;39(10):1754-60. [Medline].

  10. Ossoff RH, Duncavage JA, Toohill RJ, Tucker GF Jr. Limitations of bronchoscopic carbon dioxide laser surgery. Ann Otol Rhinol Laryngol. Sep-Oct 1985;94(5 Pt 1):498-501. [Medline].

  11. Ossoff RH, Tucker GF Jr, Duncavage JA, Toohill RJ. Efficacy of bronchoscopic carbon dioxide laser surgery for benign strictures of the trachea. Laryngoscope. Oct 1985;95(10):1220-3. [Medline].

  12. Pearson FG, Andrews MJ. Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg. Oct 1971;12(4):359-74. [Medline].

  13. Rosenbower TJ, Morris Jr JA, Eddy VA, et al. The long-term complications of percutaneous dilatational tracheostomy. Ann Surg. 1998;64(1):82-6. [Medline].

  14. Shapshay SM, Beamis JF Jr, Dumon JF. Total cervical tracheal stenosis: treatment by laser, dilation, and stenting. Ann Otol Rhinol Laryngol. Nov 1989;98(11):890-5. [Medline].

  15. Shapshay SM, Beamis JF Jr, Hybels RL, Bohigian RK. Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation. Ann Otol Rhinol Laryngol. Nov-Dec 1987;96(6):661-4. [Medline].

  16. Simpson GT, Strong MS, Healy GB. Predictive factors of success or failure in the endoscopic management of laryngeal and tracheal stenosis. Ann Otol Rhinol Laryngol. Jul-Aug 1982;91(4 Pt 1):384-8. [Medline].

  17. Soni NK. Scleroma of the larynx. J Laryngol Otol. 1997;111(1):70-2. [Medline].

  18. Spector GJ. Respiratory insufficiency, tracheostenosis, and airway control. In: Ballenger JJ, ed. Diseases of the Nose, Throat, Ear, Head and Neck. Lippincott Williams & Wilkins;1991:530-69.

  19. Strome M. Subglottic stenosis: therapeutic considerations. Otolaryngol Clin North Am. Feb 1984;17(1):63-8. [Medline].

  20. Sulek M, Miller RH, Mattox KL. The management of gunshot and stab injuries of the trachea. Arch Otolaryngol. Jan 1983;109(1):56-9. [Medline].

  21. Wanamaker JR, Eliachar I. An overview of treatment options for lower airway obstruction. Otolaryngol Clin North Am. Aug 1995;28(4):751-70. [Medline].

  22. Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. Laryngoscope. Mar 1984;94(3):367-77. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

subglottic stenosis in adults, subglottic stenosis, acquired glottic stenosis, congenital glottic stenosis, narrowing of the subglottic area, acquired chronic subglottic stenosis, intubation, glottis, membranous stenosis, cartilaginous stenosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

James D Garnett, MD, Director of Voice and Swallowing Center, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center
James D Garnett, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Anthony P Sclafani, MD 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 College of Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University
Robert M Kellman, MD 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 College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Medical Society of the State of New York
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: Advanced Headache Intervention Consulting fee Consulting; Covidien Corp Consulting fee Consulting

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
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.