Subglottic Stenosis in Adults Treatment & Management

Updated: Mar 03, 2016
  • Author: James D Garnett, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Therapy

See the list below:

  • Any underlying medical cause must be addressed (eg, control of infectious etiology, inflammatory causes such as Wegener granulomatosis).
  • Antireflux management
    • Proton pump inhibitor (eg, omeprazole, 20 mg PO bid or equivalent)
    • Ranitidine, 300 mg PO bid-qid, if proton pump inhibitor is not an option
    • Dietary and lifestyle modification; crucial but often overlooked in antireflux management
    • Use of systemic steroids in early stenosis is an option but has not been thoroughly investigated.
    • In active inflammatory states of the subglottis, such as granulation tissue, inhaled steroids are of potential benefit (eg, Flovent 220, 2 puffs twice a day for 2 weeks; this is an off-label use based on the author's own experience).
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Surgical Therapy

See the list below:

  • Long-term tracheostomy
  • Long-term intraluminal stent
  • Endoscopic repair
    • Not indicated following blunt or penetrating neck trauma
    • Advocated as a preferred initial approach in chronic subglottic stenosis
    • May require several procedures to obtain desired result
    • Carbon dioxide laser is very useful in this setting, or neodymium: yttrium-aluminum-garnet (Nd:YAG) laser can be used.
    • Airway management may be via supraglottic jet ventilation, intermittent apneic technique, spontaneous ventilation, or a laser safe tube through an already established tracheotomy tract.
    • Triamcinolone injected into the stenotic wound or a topical aziridine compound such as mitomycin C has the potential to reduce fibrosis and can be used in the operative setting.
    • Growing evidence shows efficacy of dilation of the stenotic area as being very helpful.
      • Traditional rigid dilators ("Olive" or Jackson tracheal dilators) are effective in dilation, but they often shear the mucosa, creating a potential for cicatricial contraction.
      • Newer balloon dilators may offer an advantage of dilation without shear.
  • Open Repair
    • Open repair is indicated following failure of the endoscopic approach when extent of stenosis is severe or factors are unfavorable for this approach.
    • Choose the specific technique based on length of resection, need for cartilage, and need for mucosal coverage.
    • Stent placement is required in some procedures.

Other procedures

These include the following:

  • Anterior cricoid division with interposition graft (eg, hyoid-sternohyoid muscle, split clavicle muscle, rib)
  • Anterior and/or posterior cricoid split with stenting
  • Anterior laryngofissure with anterior lumen augmentation
  • Trachelopexy with muscle-fascia repair
  • Resection of stenotic segment with end-to-end repair
  • Staged free-graft repair

A study by Deckard et al indicated that, as in pediatric patients, two-stage laryngotracheal reconstruction (LTR) can be successfully used to treat subglottic stenosis in adults, offering a means to avoid the complications of cricotracheal resection. In the study, 14 adult patients, most of whom had high-grade (grade III or IV) stenosis, underwent LTR, with 12 of them achieving decannulation. One of these patients, however, subsequently required salvage surgery and was decannulated again only after cricotracheal resection. Thus, 11 patients (79%) achieved decannulation with LTR alone. [3]

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Preoperative Details

See the list below:

  • The length of stenosis, its severity, involvement of cartilage, and degree of scar maturity must be known prior to any attempts at repair. The endoscopic approach has a high failure rate if the stenosis is longer than 1.0-1.4 cm.
  • Detect any proximal or distal injuries (eg, supraglottic stenosis, posterior glottic scar, arytenoid fixation, distal tracheal stenosis).
  • Use imaging and endoscopic investigation.
  • Begin antireflux management approximately 1 month prior to repair.
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Intraoperative Details

In the endoscopic management of the stenosis, mitomycin-C has become routinely used. The concentration is usually 0.4mg/ml and is applied topically on a cottonoid pledget. The length of application varies from 2-3 repeat applications of 2 minutes each to a single application of 5 minutes.

The handling and disposal of the mitomycin-C should be per the hospital protocol for chemotherapeutic agents. Care should be taken to avoid contact with unprotected skin.

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Postoperative Details

See the list below:

  • Endoscopic Approach
    • Antibiotics for 1-3 weeks, depending on wound extent and general health of the laryngotracheal mucosa
    • Intensive antireflux management
    • Wound reassessment in 6 weeks to determine state of healing and need for further procedures
      Postoperative view of subglottic stenosis after 4- Postoperative view of subglottic stenosis after 4-quadrant carbon dioxide laser division and endoscopic balloon dilation. Note the excellent view of distal airway.
    • Tracheostomy care if applicable
    • Inhaled steroid sprays (not nasal sprays) are sometimes useful to reduce granulation tissue at the surgical wound.
  • Open Approach
    • Admit patient into an ICU setting.
    • Administer antibiotics appropriate to the surgical repair and wound bed.
    • Some authorities advocate suppression antibiotics when a stent is used.
    • Initiate antireflux management.
    • The role of postoperative intubation still is controversial.
    • Some authorities desire immediate extubation postrepair; some support 1-2 days of postoperative intubation in the ICU; and some require extubation in the operating room rather than in the ICU.
    • Some recommend prolonged postoperative neck flexion by splint or chin-to-chest suture in an end-to-end anastomosis.
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Follow-up

See the list below:

  • At least 1-2 years of postrepair evaluation as the scar continues to remodel and mature
  • Symptomatic and/or flow-volume loop evaluations
  • Imaging in questionable cases
  • Capping trials and endoscopy prior to decannulation if tracheostomy is present
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Complications

See the list below:

  • Mucus plug occlusion
  • Wound infection or abscess formation
  • Granulation tissue formation
  • Bleeding/hematoma
  • Subcutaneous emphysema
  • Pneumothorax and/or pneumomediastinum
  • Stent problems (eg, migration, breakage)
  • Reformation of stenosis
  • Injury to recurrent or superior laryngeal nerves
  • Airway obstruction
  • Death
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Outcome and Prognosis

Overall goals are improvement of airway function and preservation of laryngeal function. The endoscopic approach was found to be successful in 57-90% of cases. Intraluminal stents were found to be successful in 80% of cases.

In a study of 109 patients with subglottic stenosis, D’Andrilli et al reported that the long-term results of laryngotracheal resection demonstrate it to be the definitive curative treatment for the condition, with 94.5% of the patients having good to excellent outcomes from the surgery. [4]

Open Approach

End-to-end anastomosis was found to be successful in 80-90% of cases. Mortality was reported at 10-20%; it has decreased with experience. Morbidity is 20-50%, secondary to the effect on laryngeal function and swallowing.

Augmentation Techniques

Successful case rates of 60-96% have been reported. Grafts are susceptible to infection, resorption, displacement, and extrusion.

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