Pediatric Subglottic Stenosis Surgery Clinical Presentation

Updated: Mar 28, 2018
  • Author: John E McClay, MD; Chief Editor: Ravindhra G Elluru, MD, PhD  more...
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Presentation

History

Children with subglottic stenosis (SGS) have an airway obstruction that may manifest in several ways.

In neonates, SGS may manifest as stridor and obstructive breathing after extubation that requires reintubation. At birth, intubation in most full-term neonates should be performed with a 3.5-mm pediatric endotracheal tube. If a smaller-than-appropriate endotracheal tube must be used, narrowing of the airway may be present, which could suggest SGS.

The stridor in SGS is usually on inspiration. Inspiratory stridor can be associated with supraglottic, glottic, subglottic, and upper tracheal narrowing. Expiratory stridor is usually associated with tracheal, bronchial, or pulmonary lesions.

The severity of airway symptoms depends on the type or degree of SGS. In mild SGS, only exercise-induced stridor or obstruction may be present. In severe SGS, complete airway obstruction may be present and may require immediate surgical intervention.

Depending on the severity, SGS can cause patients to have decreased subglottic pressure and a hoarse or a weak voice. Hoarseness or vocal weakness can also be associated with glottic stenosis and vocal cord paresis or paralysis.

Always assess the history of gastroesophageal reflux disease (GERD). If GERD is present, it must always be evaluated before surgical intervention.

A child who eventually has a diagnosis of SGS often has a history of either laryngotracheal trauma or intubation and ventilation. Frequently, these patients were born prematurely, have bronchopulmonary dysplasia, and may require oxygen administration. The degree of pulmonary disease and the amount of oxygen the child requires may affect the ability to perform decannulation. Before surgical intervention, the child should not require a substantial oxygen supplementation.

Next:

Physical Examination

A child's physical examination varies, depending on the degree of SGS present.

Perform a complete head and neck evaluation. Evaluate the child's initial overall appearance, including the following:

  • Comfort level
  • Presence of increased breathing difficulty, especially during periods of heightened emotion
  • Presence of suprasternal, substernal, or intracostal retractions
  • Presence of any nasal flaring

Evaluate the child's voice, with attention to the following:

  • Presence and nature of stridor
  • Abnormal or normal speaking voice

Evaluate the child's neurologic status.

In the presence of a tracheotomy, evaluate the patient's breathing while the tracheotomy is occluded. Auscultate the child's lung field and neck to elicit any airway obstructive symptoms and to evaluate the status of their pulmonary function.

Identify associated facial abnormalities, such as cleft palate, choanal atresia, retrognathia, and facial deformities.

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