eMedicine Specialties > Pediatrics: Surgery > Otolaryngology

Subglottic Stenosis: Follow-up

Author: John E McClay, MD, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's Medical Center, University of Texas Southwestern Medical School
Contributor Information and Disclosures

Updated: Oct 24, 2008

Follow-up

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 Media file 26) and can lead to airway obstruction and scarring. A carbon dioxide laser can be used to remove and control the granulation tissue well (see Media files 27-28). Certainly, any time the child has airway obstructive symptoms, bronchoscopy should be considered.

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.

Further Outpatient Care

See Further Inpatient Care.

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.

Transfer

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

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.

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:21
    • 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 Media files 29-33). 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.
  • 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.

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 Media files 33-34). 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.24

Zalzal noted that, in any child with voice abnormalities before surgery, those abnormalities persisted after surgery.25 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 Media files 29-33). Voice therapy may help relieve nonsevere glottic stenosis over time.

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.

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.

 


More on Subglottic Stenosis

Overview: Subglottic Stenosis
Differential Diagnoses & Workup: Subglottic Stenosis
Treatment & Medication: Subglottic Stenosis
Follow-up: Subglottic Stenosis
Multimedia: Subglottic Stenosis
References
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Further Reading

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Keywords

subglottic stenosis, laryngeal stenosis, SGS, cricoid ring, acquired SGS, acquired subglottic stenosis, syphilis, tuberculosis, typhoid fever, diphtheria, endotracheal intubation, pressure necrosis, exercise intolerance, prematurity, airway obstruction, inspiratory stridor, biphasic stridor, gastroesophageal reflux disease, GERD, bronchopulmonary dysplasia, cleft palate, choanal atresia, retrognathia, subglottic tumor, subglottic hemangioma, glottic stenosis, tracheal stenosis, edema, gastroesophageal reflux, GER, acute infection, croup

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Contributor Information and Disclosures

Author

John E McClay, MD, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Children's Medical Center, 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.

Medical Editor

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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

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, The Pediatric Surgery Center
Alan D Murray, MD 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.

CME Editor

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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