Subglottic Stenosis in Adults Treatment & Management

• 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.
  • In active inflammatory states of the subglottis, such as granulation tissue, inhaled steroids are of potential benefit (eg, Flovent 220, 2 puffs twice a day for 2 weeks; this is an off-label use based on the author's own experience).

• 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.
  • Airway management may be via supraglottic jet ventilation, intermittent apneic technique, spontaneous ventilation, or a laser safe tube through an already established tracheotomy tract.
  • Growing evidence shows efficacy of dilation of the stenotic area as being very helpful.
    • Traditional rigid dilators ("Olive" or Jackson tracheal dilators) are effective in dilation, but they often shear the mucosa, creating a potential for cicatricial contraction.
    • Newer balloon dilators may offer an advantage of dilation without shear.
• 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

• 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.

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.

• 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 proceduresPostoperative view of subglottic stenosis after 4-quadrant carbon dioxide laser division and endoscopic balloon dilation. Note the excellent view of distal airway.
  • 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.

• 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

• 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

Overall goals are improvement of airway function and preservation of laryngeal function.

The endoscopic approach was found to be successful in 57-90% of cases.

Intraluminal stents were found to be successful in 80% of cases.

• Open Approach

  • End-to-end anastomosis was found to be successful in 80-90% of cases.
  • Mortality was reported at 10-20%; it has decreased with experience.
  • Morbidity is 20-50%, secondary to the effect on laryngeal function and swallowing.
• Augmentation Techniques

  • Successful case rates of 60-96% have been reported.
  • Grafts are susceptible to infection, resorption, displacement, and extrusion.