Glottic Stenosis Treatment & Management

The primary goals of treatment are the development of an adequate airway and preservation or improvement in voice quality.

Treatment consists of medical therapy, intralesional injections, endolaryngeal procedures, and open surgical procedures. The treatment depends on the thickness of the glottic web. Thin anterior commissure webs can be successfully excised with a carbon dioxide laser or microdebrider followed by endoscopic keel placement, while thicker webs require laryngofissure, lysis of the web, and placement of a silicone or silastic keel.

Sharouny and Omar recommended that when a keel is used for anterior glottic stenosis, it be adequately sutured to the anterior laryngeal wall to prevent complications. They described a case in which a patient returned to the clinic two weeks after placement of a custom-made keel, having aspirated it. Flexible bronchoscopy revealed that the silastic sheet from which the keel was made was in the right main bronchus; the object was removed via a flexible bronchoscope passed through the tracheostomy. ^[21]

When stenosis is due to an infection or inflammatory disorder, appropriate treatment in the form of antibiotics, corticosteroids, or both is important.

The use of systemic steroids in glottic stenosis is controversial. These agents tend to decrease scar formation but may delay wound healing. Treatment should be individualized.

Steroid injection into the posterior glottic scar may be useful in cases of inflammation during the very early stages. These injections are technically difficult, and cartilage resorption may be a serious complication. Inhalational steroids are sometimes used to reduce granulation tissue formation after stent removal.

Supportive therapy includes humidified oxygen and close airway monitoring in a supervised setting.

Always manage gastroesophageal reflux prior to any surgical intervention.

Surgical methods that rely solely on dilation are generally unsuccessful for all webs except the most translucent membranous ones.

A study by Rosen et al indicated that early posterior glottic stenosis can be better treated with teardrop-shaped laryngeal dilation than with round dilation, since the glottis is itself teardrop shaped. Teardrop dilation was performed by inserting a triangular static stent into the anterior glottis, with a round balloon dilator simultaneously employed in the posterior glottis. Results in the study patients included improved breathing, a reduced Dyspnea Index score, and decannulation. The investigators found the teardrop dilation method preferable to round dilation of the larynx because the latter compresses the membranous vocal folds (risking injury) and only minimally expands the posterior larynx. ^[22]

The use of advancement rotation flaps for the management of anterior commissure cicatrization and webs resulting from a variety of clinical conditions has been described.

In 1924, endoscopic division of webs and subsequent keel placement were first described. Since that time, multiple modifications of both the technique and keel material have been made.

Open techniques involve an anterior laryngofissure or thyrotomy with grafting or placement of keels or stents.

Arytenoidectomy and cordectomy are frrquently used to manage glottic stenosis. However, they are associated with poor quality of voice. Zeitels et al reported on the successful use of a less invasive treatment, insertion of a silastic T-tube, modified into a self-retaining interarytenoid spring, into patients with acquired posterior glottic stenosis. Of the study’s five patients, four were tracheotomy dependent (for the most part due to glottic stenosis). The spring permitted tracheotomy tube decannulation, and patient voice quality subsequent to the procedure was considered excellent. ^[23]   

In congenital glottic stenosis, the thickness of the webs determines the treatment modality. Thin webs that transilluminate respond well to endoscopic lysis (either sharply with microscissors or with a carbon dioxide laser or a microdebrider) or serial dilations. Thicker webs, in approximately 40% of patients, require tracheotomy with a subsequent open laryngeal repair.

Bogdasarian and Olson (1980) classified the extent of posterior glottic stenosis into the following 4 types: ^[24]

• Type I - Vocal process adhesion

• Type II - Posterior commissure stenosis with scarring in the interarytenoid plane and internal surface of the posterior cricoid lamina

• Type III - Posterior commissure stenosis with unilateral cricoarytenoid joint ankylosis

• Type IV - Posterior commissure stenosis with bilateral cricoarytenoid joint ankylosis

Bogdasarian and Olson recommend a graded surgical approach based on this classification scheme. They also recommend, in mild cases (type I and type II), performing scar excision, resurfacing with mucosa or split-thickness skin graft, and stenting. Arytenoidectomy and hyoid interposition have been recommended in cases of joint fixation.

Overall, the trend in glottic stenosis management is toward shorter stenting periods and less invasive techniques (eg, endoscopy, use of carbon dioxide laser, or a smaller laryngofissure).

In a literature review, Lahav et al recommended that surgical intervention for glottic stenosis begin with a discussion of expectations with the patient regarding voice versus airway functions. In addition, careful planning for anesthesia administration is required, as the surgeon and anesthetist must each understand tubeless jet ventilation options. ^[25]

The key to successful repair of webs is the adequate coverage of denuded surfaces.

Endoscopic techniques include manual or laser scar division or microdebrider web or scar lysis, endoscopic arytenoid abduction lateroplexy (EAAL), classic vocal cord laterofixation (VCL), transverse cordotomy (TC), arytenoidectomy (AE), laser arytenoidectomy, and microtrapdoor (MTD) flaps. In a study of 34 patients with glottic stenosis (33 with pure glottic stenosis, 1 with accompanying supraglottic stenosis) who underwent unilateral or bilateral microtrapdoor flap surgery, Yilmaz et al found that 33 of them were dyspnea-free on exertion at 1-year follow-up. ^[26]

Recently, endoscopic techniques have been used with good results to perform posterior cricoid splits and rib grafting.

Open techniques require laryngofissure with web division and coverage of the raw area using a variety of flaps, including native mucosa, nasal septal mucosa, buccal mucosa, perichondrocutaneous grafts, skin grafts, and cartilage grafts. An investigational technique that may become favorable to traditional open techniques involves an anterior window laryngoplasty. This method is expected to provide closer and more direct exposure than endoscopic techniques and to have fewer possible complications than traditional laryngofissure.

The MTD technique for anterior webs involves elevating the web unilaterally, ablating the scar, and redraping the preserved mucosa over the vocal cord to resurface the raw area. This technique is most successful in cases in which webs are of thin-to-moderate size (ie, < 1 cm thick). Posterior glottic webs may also be treated in a similar manner using the MTD technique, but these may require several procedures for adequate treatment.

Thin webs can be excised with the carbon dioxide laser, microscissors, or microdebrider, addressing one side of larynx at a time to avoid further webbing as well as application of either mitomycin-C or chitosan to prevent re-webbing. Thicker webs are often associated with subglottic narrowing and are more difficult to treat; they often require tracheostomy followed by laryngofissure with division of web and possibly cricoid cartilage and then closure over a keel or stent. The timing for correction is controversial.

Several techniques have been described for the management of interarytenoid fusion, including division by sharp dissection or carbon dioxide laser with stent placement. In 1994, Lichtenberger et al described a successful keel-fixing technique for the endoscopic repair of anterior commissure webs in 13 patients. This technique involves precise keel placement using an endo-extralaryngeal needle carrier. The results of Lichtenberger's study showed improved airway and voice in all patients treated, without the need for tracheotomy.

Beswick et al reported on a technique for endolaryngeal keel placement in patients with anterior glottic webs in which an endoscopic suture retriever is inserted through a percutaneously placed angiocatheter, precluding the need for a Lichtenberger needle passer. This exo-endolaryngeal technique uses materials that are readily available in most operating rooms. ^[27]

Chitose et al (2009) have described the use of a posterior mucosal flap for the treatment of posterior glottic stenosis. ^[28] Using endoscopic microscissors, they separated the posterior commissure and interarytenoid scar tissue submucosally. The bilateral corniculate cartilages of the superior arytenoids were then debulked using a CO2 laser. A posteriorly based mucosal flap obtained from the postcricoid region was extended approximately to the mucosa of the posterior commissure. The mucosal flap was sutured to the inferior subglottic mucosa by two 4-0 polyglactin absorbable sutures.

Rovó et al (2008) have described endoscopic arytenoid lateropexy for isolated posterior glottic stenosis. ^[29] Using a CO2 laser and endoscopic approach, they transected the scar between the arytenoid cartilages. A right-angled endolaryngeal scythe was used to transect the scars that had spread into the cricoarytenoid joint. A reinforced Lichtenberger needle carrier instrument was used to perform the lateropexy of the adequately mobilized arytenoid cartilages, with consideration of the real abduction of the cricoarytenoid joint.

Scar incision, posterior cricoidotomy with stenting, and cartilage grafting have been used together to treat posterior glottic fixation, with excellent airway and voice outcomes. Described by Zalzal in 1993, this technique involves an anterior laryngofissure with incision of the posterior glottic scar in the midline, posterior vertical cricoidotomy to the hypopharyngeal mucosa, and cartilage grafting between the arytenoids. ^[13] Zalzal's report detailed the treatment of 12 tracheotomy-dependent patients with glottic stenosis from endotracheal intubation; all patients were decannulated successfully after the described procedure.

Schaefer et al reported the successful mobilization of fixated arytenoids without arytenoidectomy in 4 patients with type IV posterior glottic stenosis. ^[30] The procedure described involves a midline thyrotomy with the advancement of superiorly based mucosal flaps and cricoarytenoid joint exploration with lysis of adhesions. The patients were stented postoperatively for 2-3 weeks and subsequently underwent endoscopic stent removal under general anesthesia.

A 1-stage procedure for the repair of major congenital laryngeal webs with associated subglottic stenosis has been successfully used in 5 children. The advantage of this technique is the avoidance of morbidity associated with stents, keels, and tracheotomies. Biavati et al describe this technique, which involves anterior laryngofissure with division of the web. ^[14] Careful mucosal coverage of raw surfaces, submucous resection of the stenotic area, and costal cartilage grafting complete this technique. Postoperative endotracheal tube stenting is required for 5-7 days.

Krimsky et al have reported 3 cases of glottic and subglottic narrowing treated with spray cryotherapy alone or in combination with balloon dilation. ^[31]

A study by Zeitels and Hillman indicated that endolaryngeal mobilization of local fibromucosal soft tissue flaps can help to lengthen the anterior glottic aperture in patients with anterior commissure glottic webs not covered by excessive redundant papillomatosis. In the procedure, which can be performed without the use of stents or other devices, flaps can be derived from the glottic web, contralateral vocal fold, medial aspect of the thyroid lamina, and infrapetiolar area. ^[32]

Keels or stents typically remain in place for 4-6 weeks postoperatively and may be removed endoscopically.

Postoperative paralytic agents are avoided whenever possible, especially in children, for the following reasons:

• Accidentally extubated patients are unable to breathe spontaneously.

• Sedatives and analgesics are easily titrated.

• Patients with a dislodged or obstructed tube are unable to show respiratory distress when paralyzed.

• Prolonged weakness that occurs after long-term paralysis has been documented.

After open procedures, monitor patients closely for the development of a pneumothorax or neck hematoma. Because of possible complications, include the use of drains to allow the escape of air following an open airway procedure. Always obtain a postoperative chest radiograph and daily examine any costal cartilage harvest site. Administer antibiotics for 2-3 weeks after any open procedure and while a keel or stent is in place. The patient should follow an antireflux regimen. Some authors recommend periodic endoscopy every 4 weeks to assess the stent location and monitor formation of granulation tissue. Closely monitor systemic diseases (eg, diabetes) that may impede tissue revascularization.

Close follow-up care is necessary to monitor airway patency, stenosis recurrence, and granulation tissue formation.

Granulation tissue may be treated with aerosolized steroids (dexamethasone 1 mg/kg/d) orally or through the tracheotomy tube.

Multiple recurrences after serial dilations may necessitate an open laryngeal procedure.

Most speaking patients (ie, noninfant patients) should also undergo 4-6 weeks of postoperative voice therapy. In most cases, oral intake may be resumed once the patient is extubated.

Repeat endoscopy is performed 2-4 weeks after stent or keel removal. Repeat endoscopy is often performed when signs or symptoms of airway difficulty return.

Emergent complications include airway obstruction, stent aspiration, hematoma formation, and pneumothorax. Airway obstruction is often caused by a mucus plug that should be suctioned immediately. Stent aspiration requires bronchoscopy under anesthesia for foreign body removal. Manage hematoma and pneumothorax with drainage and chest tube placement as indicated. Other potential complications vary depending on the technique used for treatment and include recurrence, aspiration, infection, keel extrusion, chondritis, granulation tissue formation, dysphonia, and tracheotomy dependence.

Involvement of the glottis in subglottic stenosis has been found to have an unfavorable effect on outcome. In addition, using multivariate analysis, a prospective study by Pullens et al indicated that in patients who undergo surgery for laryngotracheal stenosis, involvement of the glottis and the existence of comorbidities are the only factors that significantly increase the risk of a poor long-term functional outcome. ^[33]

Similarly, a study by Xie et al indicated that in adults with laryngotracheal stenosis, open airway reconstruction is less likely to result in decannulation when posterior glottic stenosis or a larger red blood cell distribution width is present. ^[34]

However, isolated glottic stenosis tends to have a significantly better outcome when compared with other areas of laryngeal stenosis.

Voice outcomes vary according to the method of treatment but are generally either unchanged or improved.

In adult-acquired laryngeal stenosis, the most important factors in predicting the rate and time of decannulation include the length of the stenotic segment and the anatomical site.

The applications of mitomycin-C or chitosan are being extensively investigated in canine subglottic stenosis and have shown promising anecdotal results in human subglottic stenosis.

In a cadaver morphometric study, Sztano et al ^[35] found that endoscopic arytenoid Abduction lateroplexy was more effective in improving posterior glottis configuration, although arytenoidectomy and vocal cord lateral fixation were also beneficial.

Postoperative movement of the arytenoids in a patient with a stent may have a negative effect on the healing process.

Further investigation of the use of different stent materials and designs or botulinum toxin (in cases of vocal cord paralysis) is needed.

Recent reports suggest that mitomycin-C application is associated with airway complications from delayed wound healing in rabbits. ^[36] This should be considered during the use of mitomycin-C in clinical practice.