Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pediatric Subglottic Stenosis Surgery Treatment & Management

  • Author: John E McClay, MD; Chief Editor: Ravindhra G Elluru, MD, PhD  more...
 
Updated: Nov 30, 2015
 

Approach Considerations

No medical therapy for mature subglottic stenosis (SGS) is known. If a granular or immature SGS is noted, treatment of the inflammatory process with oral or inhaled steroids sometimes can decrease the severity of disease.

Perform surgical repair of SGS if the child has SGS and is symptomatic. Typically, children with grade I (see the image below) or mild grade II stenosis do not require surgical intervention. Children with these conditions may have intermittent airway symptoms, especially when infection or inflammation causes mucosal edema.

Subglottic view of very mild congenital subglottic 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.

Surgical intervention may be avoided if periods of airway obstruction are rare and can be treated on an inpatient or outpatient basis with anti-inflammatory and vasoconstrictive agents, such as oral, intravenous, or inhaled steroids and inhaled epinephrine (racemic treatment). If children with these conditions continue to have intermittent or persistent stridor and airway obstructive symptoms when they are well, or if they frequently become ill, surgical intervention may be necessary.

Development of upper respiratory symptoms during routine infections can indicate whether a child with SGS requires surgical reconstruction. Viral infections of the upper respiratory tract can create swelling in any area of the respiratory epithelium from the tip of the nose to the lungs. If a child with SGS has a cold, bronchitis, or both but does not have significant symptoms of stridor or upper airway obstruction, the airway may be large enough to tolerate stress, and reconstruction may not be needed. A history of recurrent croup suggests SGS.

Occasionally, older children have exercised-induced airway obstruction. At evaluation, these children may have grade I or grade II SGS. Expansion of the airway with cartilage augmentation may allow them to lead a healthy and active lifestyle.

Children with grade III (see the images below) or grade IV SGS need surgical management.

Endoscopic view of the true vocal cords in the for Endoscopic view of the true vocal cords in the foreground and the elliptical congenital subglottic stenosis (SGS) in the center of the picture.
Preoperative view of a 4-month-old infant with acq Preoperative view of a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Vocal cords are in the foreground.
Next

Medical Care

Findings from animal studies showed that treatment with antibiotics and steroids can help improve an immature or granular SGS (see the image below); however, the optimal treatment duration is unknown. Evaluate each case on an individual basis. Once SGS is mature, medical therapy is almost always unsuccessful. However, suspected gastroesophageal reflux (GER) must receive aggressive medical treatment preoperatively and postoperatively for optimal surgical results.

An intraoperative view of granular subglottic sten 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).

No special diet is necessary in the treatment of pediatric SGS. The need for restriction of activity is evaluated on an individual basis.

Previous
Next

Endoscopic Procedures

For mild or granular SGS, investigators have reported success with serial endoscopic dilation, with or without steroid injections.[22]  Endoscopic balloon dilation has only limited applicability to severe SGS.[23]

Healy popularized the use of the carbon dioxide laser as an option for soft circumferential SGS. This procedure involves incisions made in four quadrants, followed by dilation. The technique is best used in conjunction with steroids when an immature or granular SGS is present. Normally, use of a laser causes recurrence of the scar in a mature stenosis; however, in unusual types of mature SGS (eg, spiraling SGS), improvement may be accomplished with a few serial carbon dioxide laser excisions (see the images below).

Intraoperative laryngeal view of the true vocal co 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 bo 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 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 bo 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.

Although controversial (no good placebo-controlled studies have been performed to back up results), mitomycin-c has been reportedly used after carbon dioxide lasering of a mature SGS with presumed improved results over lasering alone, with or without the use of oral steroids. The author has used topical mitomycin-c after lysing an immature stenotic web, with results seemingly superior to those achieved with lysing and oral steroids alone.

Previous
Next

Open Reconstruction

The approach to open reconstruction of SGS should be based on the location and degree of scarring. Reconstruction often may be unnecessary for SGS classified as grades I and II on the Myers-Cotton scale (ie, ≤70% obstruction of the subglottic airway). When surgery is necessary on the basis of symptom severity, perform an open reconstruction in mature circumferential SGS. The surgical technique depends on adjacent areas of scarring and on the location and appearance of SGS. For severe SGS, classified as grades III and IV (ie, >70% luminal obstruction), laryngeal expansion is almost always necessary.

The goals of open reconstruction are decannulation or resolution of symptoms, with preservation of the voice by expanding the subglottic airway and stabilizing the expanded frame.

For SGS classified as grade II (50-70% stenosis), surgical reconstruction depends on many factors, including symptoms, environment, and associated medical conditions.

Various procedures for treating SGS include the following:

  • Anterior cricoid split (ACS)
  • Single-stage procedure involving anterior cartilaginous grafting with costal, thyroid, or auricular cartilage
  • Multistage procedure applying (a) anterior and posterior cartilage grafting, usually with costal cartilage, (b) anterior cartilaginous grafting with a posterior cricoid split and stent placement, (c) posterior grafting with costal cartilage, and (d) anterior and posterior costal cartilage with lateral cricoid splits
  • Cricotracheal resection

Anterior cricoid split

In 1980, Cotton and Seid described the use of ACS to avoid tracheotomy in neonates with SGS, good pulmonary and cardiac function, and airway obstructive symptoms after extubation.[2] ACS allows decompression of the edematous submucosal glands of the subglottis and thus expansion of the airway.[24]

Criteria developed to identify children who are likely to benefit from ACS include the following:

  • Patient weight of more than 1500 g
  • Failure to extubate in identified SGS
  • Oxygen requirement of less than 30%
  • No active respiratory infection
  • Good pulmonary and cardiac function

Transport the already intubated child from the intensive care unit (ICU), and make horizontal incisions over the cricoid cartilage. Divide the strap muscles in the midline, and identify the thyroid cartilage, costal cartilage, and upper tracheal rings (see the image below). Place polypropylene stay sutures (4-0) around each side of the anterior component of the cricoid ring. Use a double-sided beaver blade to make an incision in the cricoid ring as far as the tracheal rings and the inferior third to half of the laryngeal cartilage. Then, reintubate the child with an endotracheal tube appropriately sized for his or her age. Do not expand the airway more than necessary; doing so can lead to pressure on the mucosa and persistent SGS.

An intraoperative view of a split cricoid in a pat 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.

Loosely close the skin over the wound, and place a rubber band drain. Mark the sutures in the cricoid as left and right. Generally, leave the nasal tube in place for 7-10 days. If self-extubation occurs, reintubate from above. Should the endotracheal tube protrude through the airway into the neck during reintubation, the stay sutures can be lifted and crossed to block the cricoid split incision and to direct the endotracheal tube down the trachea. If this procedure is unsuccessful, the stay sutures can be pulled up to the neck and opened so that a tracheal or endotracheal tube can be placed in the airway until the child can be returned to the operating room (OR) for intubation through the mouth.

Administer antibiotics and antireflux medication during the intubation period. Begin the administration of steroids 24 hours before extubation, and continue for 48 hours afterwards. Usually, the tube can be removed after 7-10 days.

If an air leak around the endotracheal tube is present with a pressure of less than 20 cm H2O, extubation should be successful. If airway obstruction that is not amenable to medical therapy (including racemic treatments and steroids) occurs after extubation, return the patient to the OR for evaluation, or immediately reintubate in the ICU if necessary. Complications of ACS are unusual and include pneumothorax, pneumomediastinum, subcutaneous emphysema, wound infection, and persistent SGS.

The images below were obtained in a 4-month-old infant born 3 months premature who required intubation and ventilation for 3 months.

Preoperative view of a 4-month-old infant with acq 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 wit 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.

She had a grade III SGS and underwent ACS with intubation and ventilation for 1 week in the ICU. The image below shows the subglottis 1 week after extubation.

Postoperative view in a 4-month-old infant with ac 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.

The size of the larynx was determined with an endotracheal tube, and subsequent dilation of the soft mild restenosis is depicted in the images below.

Postoperative view in a 4-month-old infant with ac 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-o 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.

The child received oral steroids for 5 days and underwent follow-up bronchoscopy 2 weeks later (see the image below).

Postoperative view of the same patient (a 4-month- 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.

Single-stage laryngotracheoplasty with cartilage expansion

The second option is single-stage laryngotracheoplasty (LTP) with cartilage expansion.[25, 26]

In 1991, Seid et al reported the use of single-stage LTP.[8]  Their approach to the airway resembles ACS; however, instead of leaving the area anterior to the fibrosis, they placed a piece of costal cartilage. The procedure was performed in 13 patients with SGS grades I-IV. However, the procedure failed in a patient who had complete glottic and subglottic stenosis (grade IV). The researchers indicated that grade IV SGS was a contraindication to single-stage LTP. Two patients had grade III SGS and a successful result.

Seid et al stressed the postoperative course in these patients.[8] Instead of leaving the endotracheal tube in place for 7-10 days, they checked the air leak surrounding the endotracheal tube on a daily basis and removed it when the pressure of the leak was less than 20 cm H2O.

The authors were also concerned about the transient weakness of the extremities caused by neuromuscular blockade and hydrocortisone.[8] They used vecuronium and benzodiazepines for sedation. Aggressive pulmonary toilet was stressed because wandering atelectasis can be present in a patient who is ventilator-dependent for as long as 10 days. The authors stressed the repeated use of a full range of passive extremity motions to decrease the likelihood of transient muscle weakness during the period of induced paralysis for long-term intubation.

Seid et al believed that selection of patients was critical and that any child with difficulties in addition to SGS (eg, tracheal problems, true vocal cord paralysis) was not a good candidate for single-stage LTP.[8] The procedure could fail after extubation for reasons other than the newly repaired SGS.

In 1995, Rothschild et al reviewed the effectiveness and complications of single-stage LTP in 104 patients from the Children's Hospital of Cincinnati.[27] Repair was successful in 86-92%, depending on the year of correction. The authors did not use paralysis during the 5-day to 10-day period of endotracheal tube placement; they used sedation with chlorohydrate and benzodiazepines instead. In fact, if patients could tolerate nasotracheal intubation without much difficulty, they were allowed to engage in their usual activities (eg, eating, playing, and walking). A modified cap placed on the endotracheal tube prevents crust formation in the tube and airway during these activities.

Rothschild et al believed that younger children require heavier sedation and increased ventilation secondary to decreased respiratory effort.[27] Neuromuscular paralysis usually was avoided. Among their 104 patients, the researchers found neuromuscular weakness in only one. They did not comment about the presence or absence of pulmonary atelectasis.

The average duration of endotracheal tube placement in their patients was 9 days.[27] They did not explain why endotracheal tubes were in place longer than 10 days (as long as 26 days) in 37 children. Twenty-three children, however, had a posterior costal cartilage graft, which normally necessitates the use of stents for at least 2 weeks to stabilize the cartilaginous framework.

Seid and Cotton agreed that ICU staff who are knowledgeable and attentive are important to the success and safety of the procedure.

In 1991, Lusk et al also described a single-stage LTP in which auricular cartilage is used for reconstruction when an anterior SGS is repaired.[28] Patients had endotracheal tubes in place for 7-10 days, similar to the duration of intubation in patients in whom an ACS was performed. The authors sutured the cricoid to the strap muscles to help maintain airway patency; their success rate was similar to that of other procedures (ie, approximately 80-90%).

This author's experience with the use of auricular cartilage has been less successful. If significant anterior SGS is present, use of cartilage that is rigid enough to maintain the splay of the cricoid cartilage is usually necessary to ensure continued expansion after extubation.

Zalzal added to the efficiency of the anterior cartilage single-stage procedure by describing the technique of carving the harvested rib into the shape of a boat with flanges on each end (see the images below).[29]

Rib graft for reconstruction of subglottic stenosi 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.
Anterior rib graft with a diamond shape. Note it m 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.

In this technique, cartilage extends outside the lumen of the trachea, over the cricoid and tracheal rings, to help prevent the lumen from prolapsing into the airway (see the image below). With this technique (once any air leak is sealed during the surgery), extubation can be performed without fear of the cartilage requiring further stabilization or prolapsing into the airway.

An intraoperative aerial view of an anterior carti 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.

After the procedure has been performed and the child has been admitted to the ICU, air leaks from the neck are checked on a daily basis. Usually, the air leak seals within 48-72 hours; extubation can be accomplished with confidence that the graft is stabilized. In this way, children can avoid the complications of long-term intubation.

The use of a superior section of the thyroid cartilage, as well as the septal cartilage, as grafting material has been reported. These materials, along with the auricular cartilage, usually do not provide much support. Instead, they act mainly as a patch over the divided area of the cricoid region. In these situations, the stent provides most of the force necessary to keep the lumen open while the surrounding area heals. Some of the other types of cartilage can be used in conjunction with ACS to improve the success rate of that procedure, which has traditionally been 70-80%.

Richardson and Inglis performed a prospective study to compare the cricoid split procedure with and without costal cartilage grafting for the treatment of acquired SGS in infants younger than 6 months in whom extubation in the ICU failed.[30] They reproted improved results in 90% of patients in whom cartilage was placed between the cricoid rings to expand the airway, compared with 56% in whom cartilage was not placed. This study was prospective and included only 20 patients, but its findings indicate that placing the lumen expander at the time of surgery greatly improves the likelihood that extubation succeeds and adequate airway is maintained.

However, Zalzal and Choi pointed out that when the results of laryngotracheal reconstruction were evaluated in 48 patients aged 4 years or younger, the success was lower in children younger than 25 months than in those aged 2-4 years.[31] (Note that the patients younger than 2 years had SGS that was less severe than that of the older patients.) Zalzal and Choi still recommended laryngotracheal reconstruction in younger patients, on the grounds the procedure may aid the child's speech and language development and help prevent tracheotomy complications.

Anterior and posterior grafting

For severe SGS (grade III-IV), anterior and posterior cricoid splitting with costal cartilage grafts placed anteriorly and posteriorly has been effective in expanding the lumen and allowing decannulation. Most authors, including Zalzal and Cotton, agree that when a posterior graft is used, cartilage of sufficient strength must be placed posteriorly to keep the airway expanded.[32] Both Zalzal and Cotton have reported success rates higher than 90% with decannulation, frequently achieved with a single procedure. Occasionally, revision surgery is needed.

Often, the posterior graft is formed into an ellipse or elongated hexagon and placed so that the perichondrial side of the graft is flush with the mucosa of the posterior subglottic and tracheal wall.

Occasionally, flanges can be fashioned on the posterior graft that can be placed posteriorly and outside the lumen in a manner similar to that of the boat graft (described by Zalzal), which is placed anteriorly. For a posterior graft, sutures to the posterior cartilage split are all placed individually prior to sliding the graft in position (see image below), at which time the sutures can be tied. Seid described using fibrin glue in an animal study to keep a posterior graft in place, avoiding the arduous task of suturing it in.

An intraoperative side view of the neck with carti 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.

Place the anterior graft in a similar fashion. Construction of the flanges on the anterior graft is not as critical as it is with a single-stage procedure, in that children require stents for a minimum of 2 weeks. Usually, stents are used for 4-6 weeks when anterior and posterior grafts are placed and the tracheotomy is maintained. Once the stent is removed, follow-up bronchoscopies are performed to confirm the stenosis has not recurred before the patient is decannulated. Maintenance of a patent airway can be is evaluated with further bronchoscopies.

Usually, an Aboulker stent (see the first, second, and third images below) or Montgomery T tube (natively, as in the fourth image below, or cut to fit and used like an Aboulker stent, which are no longer commercially available) is used. Other types of stents also have been used.

Representative (noninclusive) sample of varying si 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 s 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.
End view of an Aboulker stent showing the central End view of an Aboulker stent showing the central opening. These stents are hollow and coated in Teflon.
A 7-mm Montgomery tracheotomy tube with caps A 7-mm Montgomery tracheotomy tube with caps

Often, if the collapse or scar extends into the area of the tracheotomy site, longer-term stent placement is required with an Aboulker stent that is attached to a metal Holinger tracheotomy tube with wire (see the images below) or a Montgomery T tube. Complications of short-term (4-6 weeks) stent placement, such as granulation tissue and scarring from the distal end of the short stent, can be prevented with longer-term techniques for stent use.

Diagram of a long Aboulker stent wired to a metal Diagram of a long Aboulker stent wired to a metal Jackson tracheotomy tube.
A Jackson tracheotomy tube wired to a long Aboulke A Jackson tracheotomy tube wired to a long Aboulker stent.

The surgical approach for anterior and posterior grafting is similar to the approach for ACS and anterior cartilage grafting. Specific care for the posterior cricoid split with or without grafting requires visualization of the esophagus after the posterior cricoid cartilage has been incised. During division, take care to spread the cartilage to identify the esophageal mucosa so that no inadvertent injury occurs. Additionally, make the incision in the midline to prevent injury to the recurrent laryngeal nerve and to ensure that an appropriate site is created for placement of the graft.

Partial cricotracheal resection

In Switzerland, Monnier first reported the use of partial cricotracheal resection in 31 pediatric patients with grade III and IV stenosis in whom decannulation with anterior-posterior grafting failed.[11] The decannulation rate after cricotracheal resection was 97%. Cotton and others began to evaluate the use of cricotracheal resection because of failures with grade III and grade IV stenoses. Investigators in the "Cincinnati Experience" (ie, Cotton's 20 years of experience) recently reported that decannulation occurred in 90% of children with refractory grade III and IV stenoses.[6]

The best candidates for partial cricotracheal resection are patients with severe SGS (grade III-IV) without associated glottic pathologic conditions and with a margin of at least 4 mm in the healthy airway below the vocal folds and above the stenosis. This space allows resection away from the glottic larynx, with anastomosis of healthy mucosa. Expect significant glottic edema to last 4-6 weeks; use a tracheotomy or T tube during the postoperative period to protect the airway until the edema resolves.

Perform the procedure with the patient under general anesthesia. The approach to the larynx and trachea is similar to that of other laryngotracheal reconstructive procedures. Vertically enter the airway with the beaver blade in the midline at the level of the cricoid. Make the incision superior to the inferior margin of the thyroid cartilage and inferior to the second tracheal ring.

The superior extent of the stenosis can be defined at endoscopy while the open wound is simultaneously viewed directly, so that a precise view of the scarred subglottic segment can be achieved. Make a horizontal cut just above the superior extent of the stenosis, from the anterior aspect to the posterior aspect, stopping at the level of the cricothyroid joint. By staying anterior to the cricothyroid joint at this level, injury to the recurrent laryngeal nerve can be prevented.

Make lateral cuts inferior to the cricothyroid joints, and continue inferiorly through the lateral aspects of the cricoid cartilage to expose the posterior cricoid plate. Approach the inferior area of the stenosis, and place stay sutures in the distal normal tracheal segment. Incise the trachea just below the inferior aspect of the stenosis through the anterior lateral portions of the trachea down to the membranous tracheal wall, then dissect this from the esophageal wall at the superior aspect. Connect the superior incision and remove the segment. Next, suture the uninvolved part of the trachea to the anterior thyroid ala and the exposed posterior cricoid plate.

During the dissection from the inferior aspect to the superior aspect, take care to dissect in a perichondrial plane over the cricoid to prevent injury to the recurrent laryngeal nerve. If identification of the esophagus is difficult during this portion of the procedure, a palpable dilator can be placed in the esophagus to delineate the esophageal wall.

Before anastomosis, remove the scar tissue from the inner aspect of the posterior cricoid plate by using a small curet or drill. Perform a hyoid release procedure to decrease tension at the suture line. Dissect the trachea until four or five rings are mobilized to aid in decreasing tension on the suture line. In addition, place two or three additional tension-releasing sutures on the thyroid ala and the upper tracheal rings to help release tension from the suture line. Place polypropylene stitches (0-0) from the chin to the chest of the child to keep the head flexed for a week.

In an older child with minimal glottic involvement, a single-stage procedure can be performed with nasotracheal intubation of 7-10 days' duration. In younger children with more severe glottic involvement, a Montgomery T tube can be placed for 4-6 weeks. Take meticulous care to prevent plugging of the T tube and resultant airway obstruction. Stern et al reported good results with decreased morbidity with T tubes in children.[33, 34]

Previous
Next

Complications

Failure to repair the stenosis correctly 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[31] :

  • 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 gastroesophageal reflux disease (GERD)
  • Keloid formation
  • Failure to repair all abnormalities noted at preoperative evaluation

Injury to the 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 is never restored to its preoperative state. However, once the SGS is repaired, subglottic pressure can be increased to increase volume and improve speech quality (see the 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 gl 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-yea 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 chil 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 cord 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 pat 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.

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, as well as atelectasis of lung segments, pneumonia, and neuromuscular weakness with the use of paralytic agents and steroids.

Previous
Next

Prevention

When a child is intubated for any reason, check for an air leak. When possible, the pressure should be less than 20 cm H2O in order to prevent pressure necrosis and SGS. Use appropriately sized endotracheal tubes when intubating a child for any reason. Treat intubated patients with antireflux medications.

Previous
Next

Consultations

Consult a pediatric gastroenterologist if GER is suspected or present.

Consult a pediatric pulmonologist if chronic lung disease or an oxygen requirement is present.

Previous
Next

Long-Term Monitoring

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

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

If a single-stage LTP or 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 because granulation tissue often forms in this period (see the image below) and can lead to airway obstruction and scarring.

A subglottic endoscopic view of granulation tissue 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.

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

Intraoperative suspended view through a subglottos 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 th 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.

In a child undergoing two-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 weeks), 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. Before 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 being monitored overnight, 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.

Previous
 
 
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 Center

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, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Nothing to disclose.

Chief Editor

Ravindhra G Elluru, MD, PhD Professor, Wright State University, Boonshoft School of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Dayton Children's Hospital Medical Center

Ravindhra G Elluru, MD, PhD 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, Association for Research in Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society, American Society for Cell Biology

Disclosure: Nothing to disclose.

Acknowledgements

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.

References
  1. McDonald IH, Stocks JG. Prolonged nasotracheal intubation. A review of its development in a paediatric hospital. Br J Anaesth. 1965 Mar. 37:161-73. [Medline].

  2. Cotton RT, Seid AB. Management of the extubation problem in the premature child. Anterior cricoid split as an alternative to tracheotomy. Ann Otol Rhinol Laryngol. 1980 Nov-Dec. 89(6 Pt 1):508-11. [Medline].

  3. Holinger LD, Stankiewicz JA, Livingston GL. Anterior cricoid split: the Chicago experience with an alternative to tracheotomy. Laryngoscope. 1987 Jan. 97(1):19-24. [Medline].

  4. Fearon B, Cotton R. Surgical correction of subglottic stenosis of the larynx in infants and children. Progress report. Ann Otol Rhinol Laryngol. 1974 Jul-Aug. 83(4):428-31. [Medline].

  5. Cotton RT, Evans JN. Laryngotracheal reconstruction in children. Five-year follow-up. Ann Otol Rhinol Laryngol. 1981 Sep-Oct. 90(5 Pt 1):516-20. [Medline].

  6. Cotton RT, Gray SD, Miller RP. Update of the Cincinnati experience in pediatric laryngotracheal reconstruction. Laryngoscope. 1989 Nov. 99(11):1111-6. [Medline].

  7. Cotton RT, Myer CM 3rd, Bratcher GO, Fitton CM. Anterior cricoid split, 1977-1987. Evolution of a technique. Arch Otolaryngol Head Neck Surg. 1988 Nov. 114(11):1300-2. [Medline].

  8. Seid AB, Pransky SM, Kearns DB. One-stage laryngotracheoplasty. Arch Otolaryngol Head Neck Surg. 1991 Apr. 117(4):408-10. [Medline].

  9. Cotton RT, Mortelliti AJ, Myer CM 3rd. Four-quadrant cricoid cartilage division in laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1992 Oct. 118(10):1023-7. [Medline].

  10. Zalzal GH. Treatment of laryngotracheal stenosis with anterior and posterior cartilage grafts. A report of 41 children. Arch Otolaryngol Head Neck Surg. 1993 Jan. 119(1):82-6. [Medline].

  11. Monnier P, Savary M, Chapuis G. Partial cricoid resection with primary tracheal anastomosis for subglottic stenosis in infants and children. Laryngoscope. 1993 Nov. 103(11 Pt 1):1273-83. [Medline].

  12. Stern Y, Gerber ME, Walner DL, Cotton RT. Partial cricotracheal resection with primary anastomosis in the pediatric age group. Ann Otol Rhinol Laryngol. 1997 Nov. 106(11):891-6. [Medline].

  13. Rao A, Starritt N, Park J, Kubba H, Clement A. Subglottic stenosis and socio-economic deprivation: a 6-year review of the Scottish National Service for Paediatric Complex Airway Reconstruction. Int J Pediatr Otorhinolaryngol. 2013 Jul. 77(7):1132-4. [Medline].

  14. Choi SS, Zalzal GH. Changing trends in neonatal subglottic stenosis. Otolaryngol Head Neck Surg. 2000 Jan. 122(1):61-3. [Medline].

  15. Walner DL, Loewen MS, Kimura RE. Neonatal subglottic stenosis--incidence and trends. Laryngoscope. 2001 Jan. 111(1):48-51. [Medline].

  16. Choi SS, Zalzal GH. Pitfalls in laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1999 Jun. 125(6):650-3. [Medline].

  17. Morita K, Yokoi A, Bitoh Y, Fukuzawa H, Okata Y, Iwade T, et al. Severe acquired subglottic stenosis in children: analysis of clinical features and surgical outcomes based on the range of stenosis. Pediatr Surg Int. 2015 Oct. 31 (10):943-7. [Medline].

  18. Zalzal GH, Loomis SR, Derkay CS, et al. Vocal quality of decannulated children following laryngeal reconstruction. Laryngoscope. 1991 Apr. 101(4 Pt 1):425-9. [Medline].

  19. Avelino M, Maunsell R, Jubé Wastowski I. Predicting outcomes of balloon laryngoplasty in children with subglottic stenosis. Int J Pediatr Otorhinolaryngol. 2015 Apr. 79 (4):532-6. [Medline].

  20. Walner DL, Stern Y, Gerber ME. Gastroesophageal reflux in patients with subglottic stenosis. Arch Otolaryngol Head Neck Surg. 1998 May. 124(5):551-5. [Medline].

  21. Cotton RT. Management of subglottic stenosis. Otolaryngol Clin North Am. 2000 Feb. 33(1):111-30. [Medline].

  22. Edmondson NE, Bent J 3rd. Serial intralesional steroid injection combined with balloon dilation as an alternative to open repair of subglottic stenosis. Int J Pediatr Otorhinolaryngol. 2010 Sep. 74(9):1078-81. [Medline].

  23. Maresh A, Preciado DA, O'Connell AP, Zalzal GH. A comparative analysis of open surgery vs endoscopic balloon dilation for pediatric subglottic stenosis. JAMA Otolaryngol Head Neck Surg. 2014 Oct. 140 (10):901-5. [Medline].

  24. Okamoto M, Nishijima E, Yokoi A, Nakao M, Bitoh Y, Arai H. Strategy for surgical treatment of congenital subglottic stenosis in children. Pediatr Surg Int. 2012 Nov. 28(11):1115-8. [Medline]. [Full Text].

  25. O'Connor TE, Bilish D, Choy D, Vijayasekaran S. Laryngotracheoplasty to avoid tracheostomy in neonatal and infant subglottic stenosis. Otolaryngol Head Neck Surg. 2011 Mar. 144(3):435-9. [Medline].

  26. Preciado D. A randomized study of suprastomal stents in laryngotracheoplasty surgery for grade III subglottic stenosis in children. Laryngoscope. 2013 May 13. [Medline].

  27. Rothschild MA, Cotcamp D, Cotton RT. Postoperative medical management in single-stage laryngotracheoplasty. Arch Otolaryngol Head Neck Surg. 1995 Oct. 121(10):1175-9. [Medline].

  28. Lusk RP, Gray S, Muntz HR. Single-stage laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1991 Feb. 117(2):171-3. [Medline].

  29. Zalzal GH. Rib cartilage grafts for the treatment of posterior glottic and subglottic stenosis in children. Ann Otol Rhinol Laryngol. 1988 Sep-Oct. 97(5 Pt 1):506-11. [Medline].

  30. Richardson MA, Inglis AF Jr. A comparison of anterior cricoid split with and without costal cartilage graft for acquired subglottic stenosis. Int J Pediatr Otorhinolaryngol. 1991 Sep. 22(2):187-93. [Medline].

  31. Zalzal GH, Choi SS, Patel KM. Ideal timing of pediatric laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1997 Feb. 123(2):206-8. [Medline].

  32. Zalzal GH, Cotton RT. A new way of carving cartilage grafts to avoid prolapse into the tracheal lumen when used in subglottic reconstruction. Laryngoscope. 1986 Sep. 96(9 Pt 1):1039. [Medline].

  33. Stern Y, Willging JP, Cotton RT. Use of Montgomery T-tube in laryngotracheal reconstruction in children: is it safe?. Ann Otol Rhinol Laryngol. 1998 Dec. 107(12):1006-9. [Medline].

  34. Saghebi SR, Zangi M, Tajali T, Farzanegan R, Farsad SM, Abbasidezfouli A, et al. The role of T-tubes in the management of airway stenosis. Eur J Cardiothorac Surg. 2013 May. 43(5):934-9. [Medline].

  35. Baker S, Kelchner L, Weinrich B, et al. Pediatric laryngotracheal stenosis and airway reconstruction: a review of voice outcomes, assessment, and treatment issues. J Voice. 2006 Dec. 20(4):631-41. [Medline].

  36. Cotton RT. Management of laryngotracheal stenosis and tracheal lesions including single stage laryngotracheoplasty. Int J Pediatr Otorhinolaryngol. 1995 Jun. 32 Suppl:S89-91. [Medline].

  37. Cotton RT, Myer CM 3rd, O'Connor DM, Smith ME. Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the single-stage approach. Laryngoscope. 1995 Aug. 105(8 Pt 1):818-21. [Medline].

  38. Cotton RT, O'Connor DM. Evaluation of the airway for laryngotracheal reconstruction. Int Anesthesiol Clin. 1992 Fall. 30(4):93-8. [Medline].

  39. Cotton RT, O'Connor DM. Paediatric laryngotracheal reconstruction: 20 years' experience. Acta Otorhinolaryngol Belg. 1995. 49(4):367-72. [Medline].

  40. Eliashar R, Gross M, Maly B, Sichel JY. Mitomycin does not prevent laryngotracheal repeat stenosis after endoscopic dilation surgery: an animal study. Laryngoscope. 2004 Apr. 114(4):743-6. [Medline].

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

  42. Jaquet Y, Lang F, Pilloud R, Savary M, Monnier P. Partial cricotracheal resection for pediatric subglottic stenosis: long-term outcome in 57 patients. J Thorac Cardiovasc Surg. 2005 Sep. 130(3):726-32. [Medline].

  43. Lee KH, Rutter MJ. Role of balloon dilation in the management of adult idiopathic subglottic stenosis. Ann Otol Rhinol Laryngol. 2008 Feb. 117(2):81-4. [Medline].

  44. Matt BH, Myer CM 3rd, Harrison CJ, Reising SF, Cotton RT. Tracheal granulation tissue. A study of bacteriology. Arch Otolaryngol Head Neck Surg. 1991 May. 117(5):538-41. [Medline].

  45. Myer CM 3rd, Cotton RT. Historical development of surgery for pediatric laryngeal stenosis. Ear Nose Throat J. 1995 Aug. 74(8):560-2, 564. [Medline].

  46. Myer CM 3rd, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol. 1994 Apr. 103(4 Pt 1):319-23. [Medline].

  47. Ochi JW, Seid AB, Pransky SM. An approach to the failed cricoid split operation. Int J Pediatr Otorhinolaryngol. 1987 Dec. 14(2-3):229-34. [Medline].

  48. Perepelitsyn I, Shapshay SM. Endoscopic treatment of laryngeal and tracheal stenosis-has mitomycin C improved the outcome?. Otolaryngol Head Neck Surg. 2004 Jul. 131(1):16-20. [Medline].

  49. Schmidt D, Jorres RA, Magnussen H. Citric acid-induced cough thresholds in normal subjects, patients with bronchial asthma, and smokers. Eur J Med Res. 1997 Sep 29. 2(9):384-8. [Medline].

  50. Seid AB, Canty TG. The anterior cricoid split procedure for the management of subglottic stenosis in infants and children. J Pediatr Surg. 1985 Aug. 20(4):388-90. [Medline].

  51. Seid AB, Godin MS, Pransky SM. The prognostic value of endotracheal tube-air leak following tracheal surgery in children. Arch Otolaryngol Head Neck Surg. 1991 Aug. 117(8):880-2. [Medline].

  52. Silver FM, Myer CM 3rd, Cotton RT. Anterior cricoid split. Update 1991. Am J Otolaryngol. 1991 Nov-Dec. 12(6):343-6. [Medline].

  53. Smith ME, Marsh JH, Cotton RT, Myer CM 3rd. Voice problems after pediatric laryngotracheal reconstruction: videolaryngostroboscopic, acoustic, and perceptual assessment. Int J Pediatr Otorhinolaryngol. 1993 Jan. 25(1-3):173-81. [Medline].

  54. Walner DL, Heffelfinger SC, Stern Y. Potential role of growth factors and extracellular matrix in wound healing after laryngotracheal reconstruction. Otolaryngol Head Neck Surg. 2000 Mar. 122(3):363-6. [Medline].

  55. Walner DL, Ouanounou S, Donnelly LF. Utility of radiographs in the evaluation of pediatric upper airway obstruction. Ann Otol Rhinol Laryngol. 1999 Apr. 108(4):378-83. [Medline].

  56. Walner DL, Stern Y, Cotton RT. Margins of partial cricotracheal resection in children. Laryngoscope. 1999 Oct. 109(10):1607-10. [Medline].

  57. Zalzal GH. Stenting for pediatric laryngotracheal stenosis. Ann Otol Rhinol Laryngol. 1992 Aug. 101(8):651-5. [Medline].

  58. Zalzal GH, Loomis SR, Fischer M. Laryngeal reconstruction in children. Assessment of vocal quality. Arch Otolaryngol Head Neck Surg. 1993 May. 119(5):504-7. [Medline].

  59. Zestos MM, Hoppen CN, Belenky WM, et al. Subglottic stenosis after surgery for congenital heart disease: a spectrum of severity. J Cardiothorac Vasc Anesth. 2005 Jun. 19(3):367-9. [Medline].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.