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Subglottic Stenosis Saad A. Alsaleh. Introduction  Subglottic stenosis (SGS) is a congenital or acquired narrowing of the subglottic airway.  Acquired.

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Presentation on theme: "Subglottic Stenosis Saad A. Alsaleh. Introduction  Subglottic stenosis (SGS) is a congenital or acquired narrowing of the subglottic airway.  Acquired."— Presentation transcript:

1 Subglottic Stenosis Saad A. Alsaleh

2 Introduction  Subglottic stenosis (SGS) is a congenital or acquired narrowing of the subglottic airway.  Acquired SGS is the most common acquired anomaly of the larynx in children.  The most common abnormality requiring tracheotomy in children younger than 1 year.  In the early 20 th century SGS was rare.

3 Introduction  In 1965, McDonald and Stocks introduced long-term intubation as a treatment method for neonates in need of prolonged ventilation for airway support.  In the 1960s, the incidence of acquired SGS began to dramatically increase in the neonatal population.  New attention on the pediatric larynx, and airway reconstruction and expansion techniques were developed.

4 Anatomy

5 Anatomy Infant vs. Adult  At birth, the infant larynx is approximately one third the size of the adult larynx.  The narrowest portion of the airway in the older child and adult is the glottic aperture, while in the infant is the subglottis.  The infant larynx is positioned higher in the neck than the adult larynx.

6 Anatomy Infant vs. Adult  The structures of the infant larynx are more pliable and less fibrous making the infant airway more susceptible to narrowing from edema and less easily palpable.  One millimeter of edema circumferentially in the subglottis reduces the cross-sectional area by 60%.

7 AetiologySGS CongenitalAcquired

8 Congenital SGS  Accounts for 5% of all cases.  The third most common congenital airway problem (after laryngomalacia and vocal cord paralysis).  Thought to be secondary to failure of laryngeal lumen to recanalize.  Divided into membranous or cartilaginous types.

9 Congenital SGS  Defined as subglottic diameter < 4.0 mm in full term infants and < 3.5 mm in premature infants.  It is considered if there is no Hx of intubation or other forms of laryngeal trauma.  Associated with other congenital malformations.

10 Acquired SGS  Accounts for 95% of all cases.  Numerous causes including intubation (90%), trauma, infection/inflammation, thermal or caustic injuries to the subglottic mucosa.  All studies published after 1983 reported an incidence of neonatal SGS in intubated neonates as < 4.0%, and all studies published after 1990 reported an incidence of < 0.63% (Walner, 2001).

11 Acquired SGS  Pathogenesis: mucosal pressure leading to ulceration leading to chondritis and finally deposition of fibrous material.  Risk factors of developing SGS in intubated patients:  Prolonged intubation (most important).  Size of endotracheal tube.  Increased motion of tube.  Repeated intubations.  Birth weight less than 1500g.  Infection.  GERD.  Systemic illness, malnutrition, anemia, and hypoxia.

12 Diagnosis

13 Presentation  Children with SGS have an airway obstruction that may manifest in several ways.  If the stenosis is severe and congenital, the patient will present with airway distress at birth.  In neonates, SGS may manifest as stridor and obstructive breathing after extubation that requires reintubation.  In children and adults usually present with a history of prior intubation with symptoms of progressive shortness of breath and stridor.

14 Presentation  The stridor in SGS usually is biphasic.  Depending on the severity, SGS can cause patients to have decreased subglottic pressure and a hoarse or a weak voice.  Question parents about: duration, progression of Sx, change in voice or cry, hx of prematurity, birth trauma, hx of intubation, feeding problems, recent trauma or foreign body exposure, hx of GERD.

15 Examination  V/S : Assess presence of tachypnea, ↓ SpO2.  Evaluate the child's initial overall appearance:  Presence of increased breathing difficulty, especially during periods of heightened emotion.  Presence of cyanosis, suprasternal, substernal, intracostal retractions, or nasal flaring.  Evaluate presence of stridor & type.  Evaluate voice or crying quality for weakness, hoarseness, breathiness, or complete absence.

16 Examination  A complete head and neck exam should be performed on all patients.  Flexible fiberoptic nasopharyngolaryngoscopy:  Vocal cord mobility.  Reflux changes.  Subglottic abnormalities.  Other glottic and supraglottic abnormalities may be detected.


18 Examination  Evaluate the child's neurological status.  In the presence of tracheotomy, evaluate the patient's breathing while 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.

19 Radiology  the initial radiographic study used to evaluate a child with airway obstruction is an anteroposterior and lateral plain neck radiography.

20 Radiology  Airway fluoroscopy & Ba swallow can be helpful.  CT scans and MRIs are not often used in the primary evaluation of SGS.

21 Other Important Investigations  Evaluate the presence of GERD by use of dual-channel pH probe testing.  The current criteria for diagnosing lower esophageal acid reflux is: a pH of 10% of the time.

22 Diagnosis gold standard  The gold standard for diagnosis of any laryngotracheal abnormalities is direct laryngoscopy and tracheobronchoscopy under general anesthesia.  Important things to document:  The outer diameter of the largest bronchoscope or endotracheal tube that can be passed through the stenotic segment.  The location and length of the stenosis.  Other separate sites of stenosis.  Other airway anomalies in infants.  Reflux changes.

23 Grading  There are two widely excepted staging systems for classifying subglottic stenosis:  Myer-Cotton grading system.  McCaffrey system.

24 Cotton-Myer Grading System of SGS (1994)

25 McCaffrey system (1992)  Classifies laryngotracheal stenosis based on the subsites involved and the length of the stenosis. StageDescription I Lesions are confined to the subglottis or trachea and < 1cm long II Lesions are isolated to the subglottis and > 1 cm long III Subglottic/tracheal lesions not involving the glottis IV Lesions involve the glottis

26 McCaffrey system (1992)

27 Differential Diagnosis  Congenital:  Laryngeomalacia  Tracheomalcia  VC paralysis  Cysts  Clefts  Vascular compression  Mass  Infection/Inflammation:  Croup  GERD  Tracheitis  Neoplastic:  Subglottic hemangioma  Recurrent respiratory papillomas  Foreign body.

28 Management

29 Management  Medical  Observation  Tracheostomy  Airway expansion procedures

30 Medical  Diagnosis and treatment of GERD  Pediatric consultation with primary physicians and specialists (pulmonary, GI, cardiology etc.)  Adult  Assess general medical status.  Consultation with primary physician and specialists.  Optimize cardiac and pulmonary function.  Control diabetes.  Discontinue steroid use if possible before LTR.

31 Observation  Patients (children and adults) with Cotton-Myer grade I and mild grade II SGS may be managed with close observation (Walner and Cotton,1999)  If no retractions, feeding difficulties, or episodes of croup requiring hospitalization.  Should be followed with growth curves by a pediatrician and/or neonatologist.  It is recommend to repeat endoscopy every months to measure the diameter of the airway to ensure that it is enlarging as the child grows.

32 Tracheostomy  Often the initial step in treatment of pediatric acquired SGS.  Allows these patients time to grow before definitive surgical treatment is performed.  Cotton and Walner recommend waiting until the infant is at least 10 kg before performing airway reconstruction.  Allow for optimization of pulmonary function in patients with BPD  Often not performed in infants with congenital SGS.  2-5% mortality in children (Lesperance, 1996)  Accidental decannulation and plugging

33 Airway Expansion Procedures  The site, grade, and length of stenosis are the major factors in determining which surgical procedure will be used for reconstruction.  The goal is to maintain vocal function and allow for early decannulation with subsequent unrestricted activity.

34 Airway Expansion Procedures  Contraindications:  Absolute  Tracheostomy dependent (aspiration, severe BPD).  Severe GERD refractive to surgical and medical therapy.  Relative  Diabetes.  Steroid use.  Cardiac, renal or pulmonary disease.

35 Airway Expansion Procedures  Endoscopic:  Dilatation  CO 2 Laser  Open Procedures:  Anterior cricoid split  Laryngotracheal reconstruction (LTR)  Cricotracheal resection (CTR)

36 Endoscopic  Mild stenosis (Cotton-Myer grades I and II) can usually be treated with endoscopic techniques such as dilation or CO 2 laser resection.  Endoscopic dilation  Practiced frequently before advent of LTR.  Requires multiple repeat procedures.  Low success rate.  Reported success rates with endoscopic laser resection of Grade I and II stenosis range from 66-80%.

37 Endoscopic  Factors associated with failure  Previous attempts  Circumferential scarring  Loss of cartilage support  Exposure of cartilage  Posterior inlet scarring with arytenoid fixation  Combined laryngotracheal stenosis with vertical length >1cm

38 Endoscopic treatment of laryngeal and tracheal stenosis has mitomycin C improved the outcome? Endoscopic treatment of laryngeal and tracheal stenosis has mitomycin C improved the outcome? PEREPELITSYN et al, 2004  Results indicate that a statistically significant increase, from <20% to 75%, in the success rate of endoscopic treatment of acquired upper airway stenosis when topical mitomycin C is added to the treatment regimen.

39 Mitomycin Does Not Prevent Laryngotracheal Repeat Stenosis After Endoscopic Dilation Surgery: An Animal Study Mitomycin Does Not Prevent Laryngotracheal Repeat Stenosis After Endoscopic Dilation Surgery: An Animal Study Eliashar et al, The Laryngoscope  Mitomycin exerts a benefit equal to that of normal saline when applied to a well established laryngotracheal stenosis in dogs and does not prevent repeat stenosis after endoscopic dilation surgery.

40 Anterior cricoid split  The anterior cricoid split (ACS) procedure was originally described for a neonate who has had multiple failed extubations instead of performing a tracheostomy (Cotton and Seid, 1980).  Strict criteria for ACS have been established by Cotton and include:  Extubation failure on two occasions or more due to laryngeal pathology  Patient weight > 1500 grams  Minimal supplemental oxygen requirements  No active respiratory infection  Good pulmonary and cardiac function

41 Anterior cricoid split  The procedure is performed after direct laryngoscopic and bronchoscopic confirmation of the diagnosis.  A vertical midline incision is made through the cricoid cartilage and first two tracheal rings as well as the lower thyroid cartilage.  This allows the cartilages to spring open and allow edematous mucosa to drain, increasing airway size.  Prolene stay sutures are placed on either side of the cricoid cartilage and the skin is re-approximated after placement of a drain.

42 Anterior cricoid split

43  Child remains intubated 7-14 days in ICU.  Abx and antireflux meds while intubated & steroids in the first 48 hours.  Complications include pneumothorax, pneumomediastinum, subcutaneous emphysema, wound infection, and persistent SGS.  Success rate of 75.9%

44 Laryngotracheal Reconstruction  Laryngotracheal reconstruction involves scar division with distraction of the edges by interposition of graft material (augmentation) to widen the airway lumen.  Used In older pediatric patients with higher grade stenosis.  There are several techniques depending on the location and severity of the stenosis.

45 Laryngotracheal Reconstruction  It can be performed in  2 stages with a tracheostomy and formal stenting or  In a single stage by using the endotracheal tube as a stent (single-stage LTR, SS-LTR).  Laryngeal stents include: teflon stents [Aboulker stent (short or long)], and silastic stents(Montgomery stent).

46 Single Stage LTR  Introduced in 1991 by Seid et al who reported the use of single-stage laryngotracheoplasty (LTP).  Their approach to the airway resembles ACS; however, instead of leaving the area anterior to the fibrosis, a piece of costal cartilage was placed.  Remove ET tube when air leak at 20 cm H 2 O.  the procedure failed in a patient who had complete glottic and SGS (grade IV).

47 LTR with stenting  For severe SGS (grade III-IV).  Introduced in 1972 by Fearon and Cotton.  Widely used.  Tracheostomy and stent in place for several weeks to months.  Zalzal and Cotton have reported success rates higher than 90%.

48 LTR with stenting  Anterior: adequate for isolated anterior subglottic stenosis.  Anterior/posterior: for circumferential or posterior SGS.  Four quadrant division: for complete SGS.

49 Aboulker Stent

50 LTR with stenting  Complications:  Dysphagia  Aspiration  Granulation tissue  Dislodgement of stent

51 Graft material  Cartilage is preferred because it has a lower rate of resorption, are easy to carve, and are viable without a vascular pedicle.  Rib and auricular most commonly used.

52 Post-operative Care  Intensive care unit  Intensivist familiar with these cases  Abx  Antireflux  Often discharged in several days  Repeat endoscopy after 3-4 weeks for stent evaluation  Once the stent is removed, follow-up bronchoscopies are performed to confirm the stenosis has not recurred before the patient is decannulated.

53 Cricotracheal resection  First reported in 1970 and popularized in the 90s.  More technically challenging than split procedures.  This technique is indicated if there is severe deformity of the cricoid making grafting very likely to fail.  95% decannulation rate ( Monnier et al., 2003)

54 Cricotracheal resection  The best candidates for CTR are patients with severe SGS (grade III-IV) without associated glottic pathologic conditions and with a margin of at least 4 mm in the healthy airway below the vocal folds and above the stenosis.  Entails removing the anterior half of cricoid lamina as well as the mucosa covering the posterior cricoid lamina.  First several tracheal rings are removed.  Two ends of the airway are brought back together.

55 Cricotracheal resection

56  Complications:  Anastamosis failure  Granulation tissue  RLN injury  Arytenoid prolapse  Restenosis  Wound infection  Need for further procedures  Re-intubation

57 Prevention  It is important for the primary physician, anesthatist and/or intensivist to be aware of SGS as a complication of endotracheal intubation. This starts with education.  Choosing the appropriate size ETT should be determined by the patients age and size.  Blind intubations should always be avoided if possible.

58 Prevention  Once intubated, multiple measures should be taken to prevent the tube from moving.  There is no definitive safe period for intubation.  Antireflux medications.

59 Thank You

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