Pediatric Subglottic Stenosis Surgery Workup
- Author: John E McClay, MD; Chief Editor: Ravindhra G Elluru, MD, PhD more...
Diagnosis of a patient with respiratory insufficiency and stridor can be quite complex. However, the fundamentals of a good history and physical exam cannot be overemphasized. Sometimes, simply observing the patient at rest or during activity can provide valuable information regarding the severity of symptoms and the level of obstruction.
A patient with inspiratory stridor can have narrowing of the airway secondary to a static lesion of the upper airway as well as dynamic collapse of the airway. Therefore, evaluation modalities must be designed to diagnose both types of narrowing of the airway. The mainstay for evaluating the airway for static and dynamic narrowing of the airway is endoscopy.
The criterion standard for evaluation of the airway is direct laryngoscopy and direct bronchoscopy (see below).
Certain radiographic examinations can help in obtaining a diagnosis and determining the severity of the disease. Usually, the initial radiographic study used to evaluate a child with airway obstruction is anteroposterior and lateral plain neck radiography. Frequently, in a child with subglottic stenosis (SGS), the subglottis appears narrowed and peaked; this is often described as a steeple sign. In a patient with a thin web SGS, lateral plain film radiography may reveal a faint line.
Fluoroscopy is often performed in children with symptoms of dynamic airway obstruction.
Computed tomography (CT) and magnetic resonance imaging (MRI) are not often used in the primary evaluation of SGS, though they are sometimes useful as adjunctive diagnostic procedures to evalute for abnormal vasculature or mediastinal masses that may compress the airway.
Endoscopy, Nasopharyngoscopy, Laryngoscopy, and Bronchoscopy
In a child with mild or moderate airway obstruction, perform flexible fiberoptic nasopharyngoscopy in the clinic or the emergency department (ED). If extreme airway obstruction is observed or if an active supraglottic infectious process is suspected in a young child, flexible endoscopy may be deferred in favor of formal rigid bronchoscopy in the operating room (OR) so that the airway can be managed definitively and under controlled circumstances. However, flexible fiberoptic nasopharyngoscopy and bronchoscopy may be performed in a controlled setting in the OR in that this allows better visualization of the dynamic nature of the airway and of possible dynamic collapse of the airway.
Flexible fiberoptic nasopharyngoscopy and laryngoscopy
During flexible fiberoptic nasopharyngoscopy and laryngoscopy, topical anesthesia and decongestion can be accomplished in older infants and children with topical oxymetazoline and lidocaine. A 3-mm endoscope can be used, even in an infant. Pass the endoscope into both nasal cavities to access pyriform aperture stenosis, midnasal stenosis, choanal atresia or stenosis, lesions of the nose and nasopharynx, and the adenoid pad.
Pass the endoscope into the superior oropharynx and hypopharynx. The hypopharynx and larynx can be assessed. Identify the structure and position of the supraglottis. Evaluate the epiglottis and arytenoids for malacia or stenosis. Evaluate the position and movement of the true vocal cords. Evaluate edema or erythema of the true vocal cords, epiglottis, and arytenoids.
This can be performed with the patient in the supine or sitting position. The supine position often results in the obstruction of certain supraglottic processes. If the goal is to obtain the best visualization of the true vocal cords and supraglottis, place a child (even an infant) in the sitting position with his or her neck extended.
If the child is older, the voice can be evaluated, and videostroboscopy can be performed to assess the vocal cord waveform and vocal cord mobility.
Occasionally, the subglottis can be visualized with flexible endoscopy; however, rigid laryngoscopy and bronchoscopy are the safest procedures and offer the best visualization for the subglottis and tracheobronchial tree.
Rigid laryngoscopy and bronchoscopy
Rigid laryngoscopy with bronchoscopy is the best single test for evaluating airway obstruction in children, especially for static lesions such as SGS. The otolaryngologist must have knowledge of the pediatric airway, and the OR must have adequate bronchoscopes and telescopes of various sizes. Prepare all equipment for bronchoscopy, including laryngoscopes, light sources, video documentation equipment, telescopes, and bronchoscopes before the child's arrival in the OR. Throughout the procedure, maintain good communication among anesthesiologists, surgical nursing staff, and physicians, so that any potential airway obstruction can be quickly assessed and addressed.
Do not further injure the pediatric airway. This point is of paramount importance. Use the smallest bronchoscope or telescope alone for evaluation of the subglottis in a child who does not require ventilation throughout the procedure. This practice allows good visualization without iatrogenic injury to the area. If ventilation is required throughout the evaluation, use a bronchoscope-telescope combination.
If a child has a tracheotomy or is not in extreme distress, he or she can breathe spontaneously and inhale oxygen and anesthetics through an endotracheal tube in the pharynx while the airways are visualized with a laryngoscope and large telescope. Frequently, the true vocal cords are anesthetized with lidocaine prior to evaluation to help prevent laryngospasm.
Determine the size of the child's airway by using endotracheal tubes. Myers and Cotton established a scale for SGS severity that is based on the child's age and the size of the endotracheal tube that can be placed in the airway with an air leak pressure of less than 20 cm H2O.
Evaluate the subglottis and glottis for fixation, scarring, granulation, edema, paralysis or paresis, and other abnormalities. Evaluate the distance and caliber of the stenosis. Apply the Myers and Cotton staging system only to circumferential SGS. Glottic stenosis and SGS often occur together and must be considered when reconstruction is planned.
Evaluate the maturity of the stenosis. If a firm white scar is present, the stenosis is mature. If the stenosis has a granular or erythematous appearance, GERD, viral infection, allergic esophagitis, or another inflammatory process may be present.
Examine the area below the subglottis into the trachea and bronchi for secondary lesions. The suprastomal area is important because pathological stenosis or malacia can influence the choice of surgical procedure. In severe SGS, viewing the suprastomal area requires the passage of a tiny telescope through a narrow subglottis or a telescope or bronchoscope through a tracheotomy site, if available.
Investigate any indication of GERD. Walner showed that children with SGS have a threefold increase in GERD as compared with the general pediatric population.
Currently, the best test in evaluating for gastroesophageal reflux (GER) is dual-channel pH probe testing. One probe is placed above the lower esophageal sphincter, and another is placed at the area of the cricopharyngeus near the larynx.
Walner and Cotton recommend treating GER for 1 month before and 12 months after airway reconstructive surgery, even if only mild disease is present.[20, 21] If moderate or severe GERD is diagnosed, start medical therapy and confirm disease resolution with another pH probe test prior to surgery.
Do not perform laryngeal reconstruction until GER has resolved. If reconstruction is being considered, pediatric laryngologists frequently perform tests to rule out GER, even in the absence of symptoms, because the disease may affect the outcome.
An "allergic" esophagitis may occur and may affect the outcome of surgery. To evaluate for this entity, esophagogastroduodenoscopy (EGD) is performed with biopsies of the proximal and distal esophagus, stomach, and duodenum. If more than 15 eosinophils are found in the mucosa per high power field, the patient may have "allergic" esophagitis. Evaluation and treatment for GERD must have taken place prior to this evaluation because reflux may elicit eosinophils as well.
If "allergic" esophagitis is discovered, then treatment with weeks to months of oral steroids or orally applied inhaled steroids is performed to help diminish the affects of the disease and possibly improve the success rate of laryngeal reconstruction.
Myers and Cotton devised a classification scheme for grading circumferential subglottic stenosis on a scale of I to IV. The scale is based on a percentage of stenosis established by the age of the patient and the size of the endotracheal tube that can be placed in the airway with an air leak less than 20 cm H2O.
The percentage of stenosis is evaluated by using endotracheal tubes of different sizes. The largest endotracheal tube that can be placed with an air leak less than 20 cm H2O is recorded and evaluated against a scale that has previously been constructed by Myers and Cotton. This grading system mainly applies to circumferential stenosis and does not apply to other types of SGS or combined stenoses, although it can be used to obtain a rough estimate.
The four grades of the Myers-Cotton system are as follows:
Grade I - Obstruction of 0-50% of the lumen
Grade II - Obstruction of 51-70% of the lumen
Grade III - Obstruction of 71-99% of the lumen
Grade IV - Obstruction of 100% of the lumen (ie, no detectable lumen)
Evaluate the subglottis and the glottis for any fixation, scarring, granulation, edema, paralysis or paresis, or other abnormalities. Evaluate the distance and the caliber of the stenosis.
Only apply the Myers-Cotton staging system to circumferential SGS. Often, glottic stenosis and SGS occur together and must be considered in the planning of reconstruction.
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].
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].
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].
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].
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].
Cotton RT, Gray SD, Miller RP. Update of the Cincinnati experience in pediatric laryngotracheal reconstruction. Laryngoscope. 1989 Nov. 99(11):1111-6. [Medline].
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].
Seid AB, Pransky SM, Kearns DB. One-stage laryngotracheoplasty. Arch Otolaryngol Head Neck Surg. 1991 Apr. 117(4):408-10. [Medline].
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].
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].
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].
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].
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].
Choi SS, Zalzal GH. Changing trends in neonatal subglottic stenosis. Otolaryngol Head Neck Surg. 2000 Jan. 122(1):61-3. [Medline].
Walner DL, Loewen MS, Kimura RE. Neonatal subglottic stenosis--incidence and trends. Laryngoscope. 2001 Jan. 111(1):48-51. [Medline].
Choi SS, Zalzal GH. Pitfalls in laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1999 Jun. 125(6):650-3. [Medline].
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].
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].
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].
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].
Cotton RT. Management of subglottic stenosis. Otolaryngol Clin North Am. 2000 Feb. 33(1):111-30. [Medline].
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].
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].
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].
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].
Preciado D. A randomized study of suprastomal stents in laryngotracheoplasty surgery for grade III subglottic stenosis in children. Laryngoscope. 2013 May 13. [Medline].
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].
Lusk RP, Gray S, Muntz HR. Single-stage laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1991 Feb. 117(2):171-3. [Medline].
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].
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].
Zalzal GH, Choi SS, Patel KM. Ideal timing of pediatric laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg. 1997 Feb. 123(2):206-8. [Medline].
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].
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].
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].
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].
Cotton RT. Management of laryngotracheal stenosis and tracheal lesions including single stage laryngotracheoplasty. Int J Pediatr Otorhinolaryngol. 1995 Jun. 32 Suppl:S89-91. [Medline].
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].
Cotton RT, O'Connor DM. Evaluation of the airway for laryngotracheal reconstruction. Int Anesthesiol Clin. 1992 Fall. 30(4):93-8. [Medline].
Cotton RT, O'Connor DM. Paediatric laryngotracheal reconstruction: 20 years' experience. Acta Otorhinolaryngol Belg. 1995. 49(4):367-72. [Medline].
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].
Hueman EM, Simpson CB. Airway complications from topical mitomycin C. Otolaryngol Head Neck Surg. 2005 Dec. 133(6):831-5. [Medline].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Silver FM, Myer CM 3rd, Cotton RT. Anterior cricoid split. Update 1991. Am J Otolaryngol. 1991 Nov-Dec. 12(6):343-6. [Medline].
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].
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].
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].
Walner DL, Stern Y, Cotton RT. Margins of partial cricotracheal resection in children. Laryngoscope. 1999 Oct. 109(10):1607-10. [Medline].
Zalzal GH. Stenting for pediatric laryngotracheal stenosis. Ann Otol Rhinol Laryngol. 1992 Aug. 101(8):651-5. [Medline].
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].
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].