Laryngeal Stenosis Treatment & Management

Updated: Jun 18, 2018
  • Author: Mark E Gerber, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Therapy

See the list below:

  • Prevention

    • Select appropriate endotracheal tube size.

    • Sedate patient appropriately to avoid movement of the tube in the airway.

    • Avoid unnecessary prolonged intubation.

    • Avoid aggressive endolaryngeal dissection or laser use.

    • Explore laryngeal fractures early to minimize sequelae.

    • Avoid high tracheotomy and cricothyroidotomy, if possible.

  • Supportive therapy [4]

    • Administer humidified oxygen and monitor airway closely in a supervised setting.

    • Symptomatic patients benefit from preoperative systemic steroids.

    • Treat gastroesophageal reflux aggressively.

    • When the stenosis is due to infections or inflammatory disorders, appropriate management in the form of antibiotics and/or steroids is important.

    • Steroid injection into posterior glottic or subglottic scars has had mixed results and is not used routinely.

    • Inhalational steroids (dexamethasone) are sometimes used to reduce formation of granulation tissue in the airway.

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Surgical Therapy

Overall, the trend in management of glottic and subglottic stenosis is shorter stenting periods and less-invasive techniques. [4]

Glottic stenosis endoscopic methods

In congenital glottic stenosis, the thickness of the web determines the treatment modality; thin webs that transilluminate respond well to endoscopic lysis (either sharply or with a carbon dioxide laser) or serial dilations. Thicker webs may require an open procedure. Endoscopic techniques have been used to perform a posterior cricoid split [5] and rib grafting, [6] with good results. [7, 8, 9]

In the treatment of bilateral recurrent nerve paralysis, the patient may be treated endoscopically with posterior cricoid split and rib grafting, arytenoidectomy, or posterior cordectomy.

A retrospective study by Yilmaz et al reported that the microtrapdoor flap technique can successfully be used to treat short-segment laryngeal stenosis. The study involved 34 patients with glottic stenosis, including one with combined supraglottic and glottic stenosis. One year postoperatively, 33 patients (97%) had no breathing difficulty on exertion. [10]

Glottic stenosis open methods

Open techniques involve an anterior laryngofissure with grafting or placement of laryngeal keels or stents. A tracheotomy may be necessary in approximately 40% of patients with a subsequent open laryngeal repair.

Subglottic stenosis endoscopic methods

Soft subglottic stenoses may respond well to serial endoscopic dilations. Dilation has little role in the management of cartilaginous stenosis. Endoscopic scar excision with cauterization, cryosurgery, and serial electrosurgical resection has been used with limited success. The carbon dioxide laser can be useful for treating early stenosis with granulation tissue. This treatment may improve the airway without causing significant bleeding or edema.

Endoscopic treatment is not successful in cases of the following:

  • Circumferential cicatricial scarring

  • Abundant scar tissue more than 1 cm in length

  • Severe bacterial infection

  • Exposed perichondrium or cartilage after use of the carbon dioxide laser

  • Combined laryngotracheal stenoses

  • Previous failed endoscopic procedures

In the treatment of idiopathic progressive subglottic stenosis (IPSS), Dedo recommends against segmental resection; Dedo instead performs a CO2 laser submucosal resection with local mucosal rotation flaps technique that addresses half of the stenosis endoscopically every 2 months with the goal of ameliorating the condition, not curing it. [11]

For IPSS, others perform CO2 laser radial incisions with dilation, intralesional steroid injections, and application of mitomycin-C. Greater success is achieved with this technique if the stenoses are more than 1 cm thick.

A retrospective study by Maldonado et al indicated that CO 2 laser vaporization of fibrotic scar tissue can effectively control symptoms in idiopathic subglottic stenosis. The investigators also noted, however, that over a 5-year follow-up period, the stenosis recurred in 60% of patients, although their research suggested that aggressive medical management can reduce the recurrence rate. [12]

According to a study by Taylor et al, the likelihood of undergoing a tracheotomy owing to disease-related complications, as well as the likelihood of needing additional dilation after open airway reconstruction, was greater in individuals with Wegener granulomatosis – associated subglottic stenosis than in those with idiopathic subglottic stenosis. [13]

Mitomycin-C is an antineoplastic antibiotic that acts as an alkylating agent inhibiting cell division, protein synthesis, and fibroblast proliferation. It is applied topically for a 4-minute period after incisions are made. It can be beneficial in the modulation of wound healing and in decreasing scar formation. However, stenoses most amenable to mitomycin tend to be thin. Long-term relapse with mitomycin-C has been reported, and, while a second application 3-6 weeks apart has been shown to slow the rate of relapse for 2-3 years, at 5 years, the relapse rate is equivalent.

Recently, balloon dilation has been described as a safe and effective method to manage adults with idiopathic subglottic stenosis with findings of a single discrete stenotic area on microlaryngoscopy and bronchoscopy. [14] Dilations with a 10-mm to 14-mm balloon in a single procedure or in 2 consecutive dilations within 7 days were performed. Patients who underwent a single procedure in this study have remained symptom free for up to 30 months after balloon dilation. [15]

Subglottic stenosis open methods

In general grades III and IV subglottic stenosis require open methods. A tracheotomy is often required prior to definitive open surgical repair. Multiple techniques exist for expansion of the airway, combining the use of laryngeal and cricoid splits, cartilage grafts, and stenting.

The anterior cricoid split technique is most often used in cases of congenital subglottic stenosis due to a small cricoid ring or localized submucosal fibrosis with a normal cricoid cartilage in neonates who have failed extubation. Anterior cricoid decompression with cartilage grafting is used for anteriorly based subglottic stenosis. A combined laryngofissure with posterior cricoid split is the method of choice for combined posterior glottic and subglottic stenoses, moderate subglottic stenosis with loss of cartilaginous support, and complete glottic and subglottic stenoses. Scar removal is unnecessary in this procedure.

Autogenous costal cartilage is the graft material of choice in children when augmentation of cricoid cartilage is needed. Auricular or thyroid ala cartilage may be used in selected cases.

Stents are used to hold the reconstructed area in place and are necessary when using grafts to expand stenosed areas of the airway. The airway may be stented postoperatively with an endotracheal tube, or a molded silicone or Teflon stent may be placed intraoperatively.

Partial cricotracheal resection can be performed in cases of severe circumferential subglottic stenosis. Patients with vocal cord paralysis may require more than one procedure prior to decannulation, but overall decannulation rates with cricotracheal resection are high.

Buccal mucosa graft over a posterior cricoid split for subglottic stenosis has also been described with an overall success rate of 80%. However, it should be noted that poor postoperative voice outcomes with significant postoperative posterior glottic chinks occur if division of the interarytenoid muscle with stent placement is performed for concomitant posterior glottic stenosis.

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Intraoperative Details

Small anterior webs less than 2-3 mm wide that produce minimal or no symptoms do not generally require surgery. Successful repair of webs requires adequate coverage of denuded surfaces.

Glottic stenosis endoscopic methods

The tissue is dilated with round smooth dilators, and systemic steroids are often supplemented. Thin anterior webs may be managed successfully by microendoscopic incision of the web with a knife or carbon dioxide laser. The procedure should be staged for each side separately to avoid recurrence. Endoscopic keel placement in children is generally unsuccessful. In contrast, most glottic stenosis in adults can be treated endoscopically with or without a keel. Posterior glottic stenosis may be divided endoscopically if it is due to a simple interarytenoid adhesion with a mucosally lined sinus tract present posteriorly. Scarring involving the cricoarytenoid joints requires open techniques.

Glottic stenosis open methods

Tracheotomy with laryngofissure and keel placement is necessary in cases of longer, thick, anterior glottic scars. Scar resection should be kept to a minimum to reduce mucosal loss. A keel is placed to prevent restenosis in the anterior commissure during reepithelialization. [16] The keel is designed to avoid contact with the posterior glottis to minimize scarring. Bilateral vocal cord paralysis associated with acquired glottic stenosis requires an arytenoidectomy with vocal cord lateralization in addition to correction of the glottic stenosis. Open techniques require a laryngofissure with web division and coverage of the raw area with various flaps.

Investigational techniques involve an anterior window laryngoplasty, which may become favorable to traditional open techniques. This method is expected to provide closer and more direct exposure than endoscopic techniques and to carry fewer possible complications than traditional laryngofissure.

Posterior glottic fixation has been treated by scar incision, posterior cricoidectomy with stenting, and cartilage grafting with good 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 cricoidectomy down to the hypopharyngeal mucosa, and cartilage grafting between the arytenoids. [1]

A one-stage procedure for the repair of major congenital laryngeal webs with associated subglottic stenosis has been used successfully in 5 children. This technique, reported by Biavati et al, involves anterior laryngofissure that includes division of the web with careful mucosal coverage of raw surfaces, submucous resection of the area of stenosis, costal cartilage grafting, and postoperative endotracheal tube stenting for 5-7 days. [17]

Subglottic stenosis endoscopic methods

Gentle periodic endoscopic dilation with well-lubricated, round, tracheal dilators has been recommended to treat soft congenital subglottic stenoses. The CO2 laser is most frequently used in cases of early stenoses with granulation tissue, thin circumferential webs, and crescent-shaped bands. Microcauterization and cryosurgery have fallen into disfavor due to inconsistent results.

Another therapy, balloon laryngotracheoplasty, can serve as either an alternative or adjunct treatment in pediatric patients with subglottic or laryngeal stenosis. Considered a low-risk therapy, it can reduce the chance of morbidity associated with open surgery. However, the procedure's success depends on early identification and treatment of laryngotracheal stenoses. [18]

A case series reported by Blanchard et al indicated that congenital laryngeal stenosis can be treated safely and effectively using endoscopic laryngoplasty with incision of the subglottic laryngeal cartilages with cold steel instruments and balloon dilation. According to the investigators, this operation may be viable as a first-line procedure, with appropriate prolonged follow-up, and an alternative to open laryngoplasty (which could subsequently be used if the endoscopic procedure failed). [19]

Subglottic stenosis open methods

Open techniques generally are required for grade III and IV stenoses and many grade II stenoses. These techniques may be classified broadly into splits, augmentations, and resections.

The anterior cricoid split procedure generally is performed on a neonate who meets certain specific criteria. The procedure is used to avoid tracheotomy in neonates. A median vertical incision is made through the first 2 tracheal rings, cricoid cartilage, and the bottom one-third of the thyroid cartilage. The split permits distraction of the cricoid ring up to 3 mm with an endotracheal tube stenting the laryngeal framework for 7-14 days postoperatively. Other split procedures consist of posterior and lateral divisions of the cricoid.

Although anterior cricoid split has been considered the first alternative to tracheostomy in infants less than 6 months of age, single-stage laryngotracheoplasty has been demonstrated as an equally viable first alternative to tracheostomy if subglottic stenosis is the primary airway lesion. [20]

Augmentation procedures are required when distraction of the laryngeal framework greater than 3 mm is necessary. Autogenous costal cartilage is the graft material of choice in children because of its size and rigidity. A 4-cm section of the fifth rib is routinely obtained. This technique can be performed as a single-stage laryngotracheoplasty with postoperative stenting by a nasotracheal tube or as a 2-stage procedure, leaving the tracheotomy in place and placing an endolaryngeal stent. The larynx may be augmented anteriorly, posteriorly, or both.

A cartilage graft in the posterior glottis or subglottis may be necessary in cases of posterior glottic stenosis, subglottic stenosis, or both; isolated subglottic shelves; circumferential subglottic stenosis; and total or near-total obstruction at the glottic or subglottic level.

Stents are used to provide stability to the reconstructed airway, counteract scar contractures, and promote a scaffold for epithelium to cover the lumen of the airway. Stenting is necessary when a graft has been used to expand the airway.

The most commonly used stent is the endotracheal tube. Duration of stenting depends on the function of the stent. Nasotracheal tubes after single-stage laryngotracheoplasty are typically removed after one week. When the larynx has been distracted but not grafted, stenting is usually required for 3-6 months. The Cotton-Lorenz stent (rigid Teflon) is commonly used in children because it is inert, does not adhere to tissue, and provides firm support.

Individualization of laryngeal stent use in patients following reconstructive surgery must take into account the severity and location of the stenosis, as well as the type and length of the stent and how long it will be used. Preliminary data analyses from a comparison of open Aboulker stents with soft silastic stents indicated that the two devices have equal decannulation rates and that the soft silastic stents are associated with better postoperative feeding. However, the silastic stents were also associated with increased granulation tissue development and seemed to extend the time needed for decannulation. Laryngeal stents must be monitored to make sure that their position is stable and that they are removed in a timely fashion. In addition, persistent evaluations for the development of granulation tissue are necessary. [21]

Short-segment severe stenoses of the cricotracheal region may be resected with partial resection of the anterior cricoid and primary anastomosis. This procedure is for cases of isolated severe subglottic or upper tracheal stenosis with a normal lumen of at least 10 mm below the glottis but can be combined with other procedures. The dissection is performed in the subperichondrial plane to resect cricoid cartilage, if needed. The risk of recurrent laryngeal nerve injury is present because of its proximity to the resected portion. Many times, stenting is not necessary.

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Postoperative Details

Excellent intensive care unit support is absolutely essential to the success of open laryngeal surgery, particularly with single-stage procedures.

  • Steroids (dexamethasone 1 mg/kg/d) are begun 16-24 hours before planned extubation and typically are continued 48-72 hours after extubation.

  • Aggressive pulmonary toilet may be necessary after extubation, including racemic epinephrine treatments, humidification, and chest physiotherapy.

  • The airway is endoscopically evaluated prior to extubation. If the patient is not sedated, he or she may be extubated immediately afterward. The patient may be extubated the next day after placing an endotracheal tube one-half size smaller.

  • Keels or stents typically remain in place for 2-6 weeks postoperatively.

  • When an endotracheal tube is used as a stent, the patient typically is extubated 7 days postoperatively. When posterior grafts are placed, the patient usually is extubated 14 days postoperatively.

  • After open procedures, monitor patients closely for the development of a pneumothorax or neck hematoma.

  • Because of the possible complications, all open airway procedures should include the use of drains to allow the escape of air to prevent subcutaneous emphysema.

  • A postoperative chest radiograph is obtained to check endotracheal tube placement and evaluate for pneumothorax.

  • Any costal cartilage harvest site should be examined daily.

  • Antibiotics should be administered for 2-3 weeks after any open procedure and while a keel or stent is in place, and an antireflux regimen should be followed.

  • Systemic diseases (eg, diabetes) that may impede tissue revascularization must be monitored closely.

  • Periodic endoscopy is recommended every 4 weeks postoperatively to assess stent location and monitor formation of granulation tissue.

  • Postoperative paralytics should be avoided if at all possible for the following reasons:

    • Sedatives and analgesics may be easily titrated.

    • Prolonged postparalytic neuromuscular weakness has been documented.

    • Patients are unable to breathe spontaneously if accidentally extubated.

    • Patients cannot show evidence of respiratory distress early in cases of an occluded airway.

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Follow-up

See the list below:

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

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

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

  • Older children should undergo 4-6 weeks of postoperative voice therapy.

  • After stent or keel removal, endoscopy should be repeated 2-4 weeks later.

  • Many times, endoscopy is repeated when signs or symptoms of airway difficulty return.

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Complications

See the list below:

  • Emergent complications include airway obstruction, stent aspiration, hematoma formation, and pneumothorax.

  • Airway obstruction is often caused by a mucus plug, which 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 according to the technique and include recurrence, aspiration, infection, keel extrusion, chondritis, granulation tissue formation, dysphonia, and tracheotomy dependence.

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Outcome and Prognosis

Involvement of the glottis in subglottic stenosis has been found to have an unfavorable effect on outcome, although isolated glottic stenosis tends to have a significantly better outcome when compared with other areas of laryngeal stenosis.

In adults, resection of laryngotracheal stenosis with primary anastomotic reconstruction can achieve decannulation rates up to 97%. Advanced age may be correlated with unsuccessful airway patency, but other parameters, such as chronic obstructive lung disease, diabetes, grade of stenosis, and revision versus primary surgery, did not correlate with airway patency, according to Wolf et al. [22] Partial cricoidectomy with primary thyrotracheal anastomosis can achieve similar results. In adults, there is a high rate of reoperation and need for tracheotomy if a single-stage laryngotracheal reconstruction with cartilage grafting without stenting is undertaken.

The anterior cricoid split procedure consistently yields a higher than 70% success rate (decannulation) when specific criteria are followed.

In a study of endoscopic posterior cricoid split with costal cartilage graft placement, Gerber et al reported good success with regard to decannulation rates and tracheostomy avoidance for children with subglottic and/or glottic stenosis. [23]

In 16 patients undergoing partial cricotracheal resection with primary anastomosis for grade III or IV subglottic stenosis, Stern et al report a 94% decannulation rate. Younis et al report a series of 21 pediatric patients undergoing single-stage laryngotracheal reconstruction, with anterior rib grafts, without stenting, and with immediate postoperative extubation in 20 of 21 patients.

A study by Timman et al indicated that in the treatment of laryngotracheal or tracheal stenosis, laryngotracheal resection and reconstruction and segmental tracheal resection (STR) with either end-to-end tracheal anastomosis (ETE) or cricotracheal anastomosis are safe and effective approaches; the overall success rate in the study was 92%. However, compared with STR-ETE, laryngotracheal resection and reconstruction was more commonly associated with airway-related complications (7% vs 30%, respectively). [24]

Voice outcomes vary according to the method of treatment and degree of stenosis but generally are unchanged or improved. However, in the above-mentioned study by Timman and colleagues, 34% of laryngotracheal resection patients experienced early voice alterations without recurrent laryngeal nerve palsy, compared with 16% of patients who underwent STR-ETE. [24]

An increased understanding of voice outcomes has become possible with the help of new technologies and improvements in the quantification of dysphonia. Research has indicated that an association exists between voice outcomes and various surgical factors, such as the use of laryngofissures, posterior graft placement, and the duration of stenting. Significant surgical advances that have influenced voice outcome have included less frequent use of complete laryngofissures, the employment of smaller posterior grafts, and the reduction of stenting periods.

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Future and Controversies

Stent placement, duration, and material are controversial issues. Postoperative movement of the arytenoids on a stent may have a negative effect on the healing process.

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