Acquired Subglottic StenosisGranulatio

n48 hours

Ulceration72 hours -10 days

Furrow10-30 days

Interarytenoid Scar

10-30 days

Acquired Subglottic StenosisPathogenesis• Intrinsic Factors:

o Shape and size of larynxo Infectiono Wound healingo Malnutritiono Chronic Diseaseo Activity/ movemento GERD/ LPR

• Chronic inflammation will exacerbate changes induced by ETT

• Higher rate of GER in patients with SGS than the general population

• Extrinsic Factors:oEndotracheal tube

• Size• Traumatic intubation/

Multiple reintubations• Duration of intubation

oTracheostomyoNasogastric Tube trauma

Gould SJ, Young M. Sublgottic ulceration and healing following endotracheal tube intubation in the neonate. Annals ORL; 1992, 101: 815.

Acquired Subglottic StenosisPathogenesis

• Endotracheal Tube Factors:o Size of ETT

• < 20 cm H2O pressure air leak appropriateo ETT material

• Silicone or Polyvinyl chloride tubes safesto Duration of Intubation

• Adults <7-10 days• Longer for premature infants

o Shearing motion of ETT• Increased trauma to mucosa Increases traumatic changes

o Maintenance and care of ETT and patient• Aggressive suctioning, endoscopy, reintubation

Subglottic StenosisCotton Myer Grading System

Myer CM, O’Connor DM, Coton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol, 1994; 103: 319-323.

Grading Subglottic Stenosis

ETT Size 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0

Patient Age 40 Premature 58 30

0-3 ½ mos 68 48 26 3 ½- 9 ½ mos 75 59 41 22

9 ½- 2 yrs 80 67 53 38 20 2 yrs 84 74 62 50 35 19 4 yrs 86 78 68 57 45 32 17 6 yrs 89 81 73 64 54 43 30 16

No Detect-

able Lumen

Grade IV

Grade III Grade

II Grade I

Subglottic Stenosis

Grade I: <50% Stenosis Grade II: 50-70% Stenosis

Grade III: 70-99% Stenosis Grade IV: No Detectable Lumen

Subglottic Stenosis- Treatment

• Grade I and low Grade IIo Can usually be observedo Close follow up, endoscopy for surveillance

• High Grade IIo May require surgical repairo Endoscopic dilationo Open surgical repair

• Grade III and IVo Require surgical repairo Open surgical repairo Tracheostomy as temporizing measure

Surgical Treatment- Dilation

Anterior Cricoid Split

• Described in 1980 by Cotton as alternative to tracheostomy for patients with acquired subglottic stenosis

• Patient selection:o > 2 failed extubations due to SGSo Weight >1500 gramso Off ventilator support for 10 dayso <30% O2 requirement

• Airway improved by:o Improved circulation to the cricoid and

decreased edemao Opening the cricoid allows it to “spring

open”

Laryngotracheal Reconstruction

• Anterior Grafto Use for lower grade and

primarily anterior stenoses• Anterior and Posterior

Graftso Use for posterior glottic

stenosis, circumferential stenosis, or near total/ total subglottic stenosis

Single Stage Laryngotracheal Reconstruction

• Traditional LTR with cartilage grafts and simultaneous tracheal decannulation

• Indications: o SGS without associated tracheal stenosis or tracheomalaciao Weight greater than 4 kgo Gestational age > 30 weekso No craniofacial or vertebral anomalies

• Aim to avoid complications of long term stenting and tracheostomy

• Postoperative care critical!o Nasotracheal tube “stenting”o Titrated sedation versus Paralysis

“Mini” Laryngotracheal Reconstruction

• Anterior cricoid split with thyroid ala cartilage graft

• Small retrospective series show shortened operative time compared with costal cartilage graft and no significant difference in operative outcomes

• Expands the age group for LTR to younger patients

Endoscopic Posterior Cricoid Split

• Described by Inglis et al in 2003 for management of posterior glottic stenosis with or without subglottic stenosiso 5/ 7 children decannulated within a year after

surgery• Posterior cricoid lamina is endoscopically divided and

expanded with a costal cartilage graft

Inglis AF, Perkins JA, Manning SC, Mouzakes J. Endoscopic posterior cricoid split and rib grafting in 10 children. Laryngoscope 2003; 113(11):2004-2009.

Conclusions• The most common causes of congenital stridor include

laryngomalacia, subglottic stenosis. o Tracheomalacia is the most common cause of lower airway

stridor, however is much less common than laryngomalacia• Diagnostic work up should include careful history and physical

examination. o Office laryngoscopy and/ or direct laryngoscopy and

bronchoscopy should be used to make definitive diagnosis• Many congenital airway lesions can be treated expectantly or

medically• Surgical treatment options are available, and should be

tailored to the individual patient.

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