Pediatric Subglottis Stenosis Surgery Follow-up

  • Author: John E McClay, MD; Chief Editor: Glenn C Isaacson, MD, FACS, FAAP   more...
 
Updated: Dec 5, 2011
 

Further Inpatient Care

Children who undergo various laryngotracheal reconstruction procedures may have different follow-up care and courses, depending on the procedure performed.

If a single-stage laryngotracheal reconstruction or anterior cricoid split (ACS) has been performed, bronchoscopy at extubation is not necessarily required; such decisions are left to the surgeon. However, 1-3 weeks after the procedure, bronchoscopy can be used to assess for any complications. Some authors examine the children after laryngotracheal reconstruction only if they have difficulty. The author often performs laryngoscopy and bronchoscopy 1-2 weeks after extubation to evaluate the airway, since granulation tissue often forms in this period (see image below) and can lead to airway obstruction and scarring.

A subglottic endoscopic view of granulation tissueA subglottic endoscopic view of granulation tissue (superior center portion of the picture) that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft. Granulation tissue is at the superior center portion of the picture.

A carbon dioxide laser can be used to remove and control the granulation tissue well (see images below). Certainly, any time the child has airway obstructive symptoms, bronchoscopy should be considered.

Intraoperative suspended view through a subglottosIntraoperative suspended view through a subglottoscope of the subglottis, showing the granulation tissue just prior to removal with cup forceps and laser. This was taken in a patient who developed granulation tissue that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft. Postexcision view of granulation tissue through thPostexcision view of granulation tissue through the subglottoscope. This was taken in a patient who developed granulation tissue that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft.

In a child undergoing 2-stage laryngotracheal reconstruction with grafting and stent placement, the tracheotomy remains in place. The length of follow-up is determined by the duration of stent placement and the quality and quantity of symptoms after stent removal. For short-term stent placement (4-6 wk), follow-up is 2 weeks after stent removal.

If this appears satisfactory, bronchoscopy should be performed at 4 weeks. In the interval, capping of the tracheotomy can be performed intermittently to evaluate for obstruction. If the bronchoscopy at 6 weeks is satisfactory, attempted decannulation can be considered. Prior to decannulation, the tracheotomy tube usually is downsized and plugged intermittently. If the child tolerates plugging, a sleep study can be performed, or the child can be decannulated and watched in the ICU or in a regular hospital room while monitored over night, depending on the individual case. Various methods to evaluate adequate airway prior to decannulation are available.

Walner and Cotton recommend repeat endoscopy at 1, 3, 6, 12, and 24 months after reconstructive surgery. This pattern allows long-term evaluation and detection of a recurring stenosis before it reaches a critical stage. Walner and Cotton also recommend capping and downsizing the tracheotomy in the hospital before decannulation.

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Further Outpatient Care

See Further Inpatient Care.

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Inpatient & Outpatient Medications

Occasionally, inhaled steroids are used to help prevent restenosis following reconstruction. Also, treatment for gastroesophageal reflux (GER) may be necessary if it is suspected or proved, and treatment for "allergic" gastritis may be warranted.

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Transfer

Transfer patient only when airway is stable and/or protected.

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Deterrence/Prevention

When a child is intubated for any reason, check for an air leak. When possible, the water pressure should be less than 20 cm in order to prevent pressure necrosis and subglottic stenosis (SGS). Use appropriate size endotracheal tubes when intubating a child for any reason. Treat intubated patients with antireflux medications.

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Complications

Complications of laryngotracheal reconstruction include the following:

  • Failure to correctly repair the stenosis occurs more often in severe stenosis than in moderate or mild stenosis. Zalzal and Choi examined 27 patients in whom laryngotracheal reconstruction failed and found that failure was related to the following:[23]
    • Inappropriate choice of graft
    • Inappropriate choice of stent
    • Inappropriate length of stent
    • Inappropriate duration of stent placement
    • Inadequate assessment and endoscopy
    • Poor postoperative follow-up
    • Anterior suprastomal collapse
    • Slipped Aboulker stent
    • Interactive progression of GERD
    • Keloid formation
    • Failure to repair all abnormalities noted at preoperative evaluation
  • Injury to recurrent laryngeal nerve has been reported in a single case of cricoid tracheal resection. Avoidance techniques are outlined in Surgical care.
  • The voice quality of patients with glottic stenosis and SGS is decreased and never restored to the preoperative state. However, once the SGS is repaired subglottic pressure can be increased to increases volume and improve speech quality (see images below). If an anterior laryngeal fissure is required to repair the SGS, voice quality can worsen, even if the anterior cartilage is displaced only mildly. Therefore, if possible, avoid dividing the anterior commissure. Preoperative view of glottic stenosis and small glPreoperative view of glottic stenosis and small glottic chink in a 2-year-old child who underwent anterior and posterior grafting. The child's glottic narrowing is tight, and scarring of the right arytenoid has occurred. Preoperative endoscopic subglottic view of a 2-yeaPreoperative endoscopic subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis. Postoperative view of the glottic larynx in a chilPostoperative view of the glottic larynx in a child who underwent anterior and posterior grafting for subglottic stenosis. The child had glottic narrowing that is more open and in neutral position after the surgery. The scarring of the right true vocal cord appears improved, and her voice is more normal. Postoperative close-up view of the true vocal cordPostoperative close-up view of the true vocal cords in the patient with congenital and acquired vertical subglottic stenosis. A 3-month postoperative subglottic view of the patA 3-month postoperative subglottic view of the patient with congenital and acquired vertical subglottic stenosis, who underwent anterior and posterior costal cartilage grafting with successful decannulation showing open subglottis with some very mild damage to the anterior wall and the suprastomal area where the tracheostomy tube had been placed.
  • Complications from laryngotracheal reconstructive surgery itself include pneumothorax, pneumomediastinum, neck wound infection, chest wound infection, and emphysema.
  • Complications during the postoperative ICU course can include those of laryngotracheal surgery itself in addition to atelectasis of lung segments, pneumonia, and neuromuscular weakness with the use of paralytic agents and steroids.
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Prognosis

The outcome of laryngotracheal reconstruction depends on its grade and the procedure performed. Most authors report success rates of 80-90% when the patient has undergone successful preoperative evaluation and when the appropriate surgery has been performed (see images below). The presence of acute or chronic respiratory illness, GER, or a reactive larynx may decrease the success rate. Choi and Zalzal showed that age can affect success rates; scars are more likely to recur in children younger than 2 years than in others.[26]

A 3-month postoperative subglottic view of the patA 3-month postoperative subglottic view of the patient with congenital and acquired vertical subglottic stenosis, who underwent anterior and posterior costal cartilage grafting with successful decannulation showing open subglottis with some very mild damage to the anterior wall and the suprastomal area where the tracheostomy tube had been placed. A 1-week postoperative subglottic view of the surgA 1-week postoperative subglottic view of the surgical repair with an anterior graft of a congential elliptical subglottic stenosis. The white areas to the left and right are the true vocal cords. The graft is seen at the superior and mid area.

Zalzal noted that, in any child with voice abnormalities before surgery, those abnormalities persisted after surgery.[27] Subglottic pressure is required to produce a strong voice. If the narrowed subglottic airway is expanded, subglottic airflow and pressure increase, and the voice usually is stronger (see images below). Voice therapy may help relieve nonsevere glottic stenosis over time.

Preoperative view of glottic stenosis and small glPreoperative view of glottic stenosis and small glottic chink in a 2-year-old child who underwent anterior and posterior grafting. The child's glottic narrowing is tight, and scarring of the right arytenoid has occurred. Preoperative endoscopic subglottic view of a 2-yeaPreoperative endoscopic subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis. Postoperative view of the glottic larynx in a chilPostoperative view of the glottic larynx in a child who underwent anterior and posterior grafting for subglottic stenosis. The child had glottic narrowing that is more open and in neutral position after the surgery. The scarring of the right true vocal cord appears improved, and her voice is more normal. Postoperative close-up view of the true vocal cordPostoperative close-up view of the true vocal cords in the patient with congenital and acquired vertical subglottic stenosis. A 3-month postoperative subglottic view of the patA 3-month postoperative subglottic view of the patient with congenital and acquired vertical subglottic stenosis, who underwent anterior and posterior costal cartilage grafting with successful decannulation showing open subglottis with some very mild damage to the anterior wall and the suprastomal area where the tracheostomy tube had been placed.

The voice of a patient with SGS, especially those who require reconstruction, may never return to it preoperative state because the following are possible: (1) glottic stenosis, (2) imperfect closure of a laryngofissure through the anterior commissure, and (3) potential vocal cord weakness or tension caused by other laryngeal pathologic conditions. Because reconstructive techniques have improved over the last 20 years, the focus of attention in patients with SGS who require reconstruction has switched from decannulation to decannulation with improved voice outcome.

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Patient Education

Teaching parents life-saving maneuvers for a child with a tracheotomy or airway stent following laryngotracheal reconstruction is critical. Also teach parents cardiopulmonary resuscitation (CPR) before their child leaves the hospital.

For further information, see Subglottic Stenosis in Children. For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Bronchoscopy.

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Contributor Information and Disclosures
Author

John E McClay, MD  Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical School

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Orval Brown, MD  Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas

Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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.

Paul D Petry, DO, FACOP, FAAP  Consulting Staff, Freeman Pediatric Care, Freeman Health System

Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Glenn C Isaacson, MD, FACS, FAAP  Professor of Otolaryngology-Head and Neck Surgery and Pediatrics, Temple University School of Medicine

Glenn C Isaacson, MD, FACS, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society of Pediatric Otolaryngology, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Covidien Honoraria Consulting

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Intraoperative endoscopic view of a normal subglottis.
A glottic and subglottic view of a grade III subglottic stenosis in an 18-year-old patient following a motor vehicle accident. The true vocal cords are seen in the foreground. Subglottic stenosis is seen in the center of the picture.
Endoscopic view of the true vocal cords in the foreground and the elliptical congenital subglottic stenosis (SGS) in the center of the picture.
Endoscopic subglottic view of congenital elliptical subglottic stenosis, a close-up of subglottic stenosis.
An intraoperative view of a split cricoid in a patient with elliptical congenital subglottic stenosis. The open airway can be seen in the center of the picture. The wound extends to the inferior one third of the thyroid cartilage. The first 2 tracheal rings also are divided.
Rib graft for reconstruction of subglottic stenosis carved in boat type anterior graft. The diamond-shaped internal intraluminal component with perichondrium still present is seen on the top section of the rib and the shape of the rib is seen on the backside of the carved out diamond shape.
An intraoperative aerial view of an anterior cartilage graft in place over the wound. Note external component of the graft still looks like a portion of the rib. The internal component has been carved in a diamond shape. This is an intraoperative photo of the patient with elliptical congenital subglottic stenosis. The cartilage graft (rib graft for reconstruction of subglottic stenosis carved in boat type anterior graft) was used in this patient for reconstruction.
An intraoperative side view of the neck with cartilage graft (rib graft for reconstruction of subglottic stenosis carved in boat type anterior graft) to be placed into the posterior cricoid suspended and having all sutures in position, ready to be tied. All the sutures are placed prior to lowering the graft into position. Then, the sutures are tied.
A 1-week postoperative subglottic view of the surgical repair with an anterior graft of a congential elliptical subglottic stenosis. The white areas to the left and right are the true vocal cords. The graft is seen at the superior and mid area.
Subglottic view of very mild congenital subglottic stenosis. Laterally, the area looks only slightly narrow. When endotracheal tubes were used to determine its size, it was found to be 30% narrowed.
An intraoperative view of granular subglottic stenosis in a 3-month-old infant who was born premature, weighing 800 g. The area is still granular following cricoid split. This patient required tracheotomy and eventual reconstruction at age 3 years. True vocal cords are shown in the foreground (slightly blurry).
Intraoperative laryngeal view of the true vocal cords of a 9-year-old boy. Under the vocal cords, a spiraling subglottic stenosis can be seen.
A close-up view of the stenosis in a 9-year-old boy with spiraling subglottic stenosis. This spiraling subglottic stenosis is not complete circumferentially. Laser therapy was the treatment choice and was successful after 2 laser treatments.
Continued lasering of the subglottic stenosis in a 9-year-old boy with spiraling subglottic stenosis. The reflected red light is the aiming beam for the CO2 laser.
Endoscopic view of the same patient (9-year-old boy with spiraling subglottic stenosis) two months after surgery. Some mild residual posterior subglottic stenosis remains, but the child is asymptomatic and the airway is open overall.
Preoperative view of a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Vocal cords are in the foreground.
An endoscopic subglottic view of a 4-month-old with grade III subglottic stenosis born premature at 26 weeks' gestation and intubated for 3 months.
Postoperative view in a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Following cricoid split, the patient had been intubated for 1 week and extubated for 1 week.
A subglottic view of the same patient (a 4-month-old infant with acquired grade III subglottic stenosis from intubation) following dilation with an endotracheal tube to lyse the thin web of scar and a short course (5-day) treatment with oral steroids.
Postoperative view of the same patient (a 4-month-old infant with subglottic stenosis following cricoid split). This picture is 2 weeks after lysis of scar and steroids. Notice very mild recurrence of scaring at the site of previous scar. Overall, the airway is open and patent. The anterior superior area can be seen, with a small area of fibrosis where the cricoid split previously healed.
Anterior rib graft with a diamond shape. Note it measures approximately 1.7 mm in length. Intraluminal site is facing up. Flanges of rib are carved to remain on the outside of the trachea to prevent prolapse into the trachea.
Representative (noninclusive) sample of varying sizes of Aboulker stents (range of 3-15 mm). These stents are hollow and coated in Teflon.
A glottic endoscopic view of the top of Aboulker stent in the larynx protruding through and above the true and false vocal cords. The arytenoids and epiglottic folds are seen.
Diagram of a long Aboulker stent wired to a metal Jackson tracheotomy tube.
A Jackson tracheotomy tube wired to a long Aboulker stent.
A 7-mm Montgomery tracheotomy tube with caps
A subglottic endoscopic view of granulation tissue (superior center portion of the picture) that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft. Granulation tissue is at the superior center portion of the picture.
Intraoperative suspended view through a subglottoscope of the subglottis, showing the granulation tissue just prior to removal with cup forceps and laser. This was taken in a patient who developed granulation tissue that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft.
Postexcision view of granulation tissue through the subglottoscope. This was taken in a patient who developed granulation tissue that occurred at the graft site 10 days following a laryngotracheal reconstruction performed with an anterior graft.
Preoperative view of glottic stenosis and small glottic chink in a 2-year-old child who underwent anterior and posterior grafting. The child's glottic narrowing is tight, and scarring of the right arytenoid has occurred.
Preoperative endoscopic subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis.
Postoperative view of the glottic larynx in a child who underwent anterior and posterior grafting for subglottic stenosis. The child had glottic narrowing that is more open and in neutral position after the surgery. The scarring of the right true vocal cord appears improved, and her voice is more normal.
Postoperative close-up view of the true vocal cords in the patient with congenital and acquired vertical subglottic stenosis.
A 3-month postoperative subglottic view of the patient with congenital and acquired vertical subglottic stenosis, who underwent anterior and posterior costal cartilage grafting with successful decannulation showing open subglottis with some very mild damage to the anterior wall and the suprastomal area where the tracheostomy tube had been placed.
End view of an Aboulker stent showing the central opening. These stents are hollow and coated in Teflon.
 
 
 
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