Case Of Subglottic Stenosis Research Articles

Clinical Manifestations and Treatment of Idiopathic and Wegener Granulomatosis–Associated Subglottic Stenosis

To compare and contrast the manifestations and surgical management of subglottic stenosis in patients with airway obstruction attributed to granulomatosis with polyangiitis (GPA), previously known as Wegener granulomatosis, and those with idiopathic subglottic stenosis (iSGS). Retrospective medical chart review. Review of subglottic stenosis cases seen in the otolaryngology department of an academic medical center from 2005 through 2010. Data were obtained on disease presentation, operative management. and findings. Tertiary referral center. A total of 24 patients with iSGS and 15 patients with GPA-associated subglottic stenosis (GPA-SGS). All individuals with iSGS were female, and 40% of patients with GPA-SGS were male (P < .01). Patients with iSGS tended to have a higher Myer-Cotton stenosis grade at the time of dilation than those with GPA-SGS (P = .02). Individuals with GPA-SGS were more likely to undergo tracheotomy as a result of disease-related complications than individuals with iSGS (P < .01). No patients with an open airway reconstruction in the iSGS group required follow-up mechanical dilation. In contrast, all patients with open airway reconstructions in the GPA-SGS group underwent more than 1 subsequent airway dilation (P < .01). While surgical utilization is the mainstay of treatment in iSGS and GPA-SGS, iSGS occurs almost exclusively in females and presents with a greater degree of stenosis at the time of endoscopic dilation. In contrast, GPA-SGS is associated with greater rates of tracheotomy. Open airway reconstruction may be used in the treatment of iSGS and GPA-SGS but is much more effective in iSGS.

Total cricoidectomy and laryngotracheal reconstruction for subglottic stenosis with glottic involvement

We present a case of subglottic stenosis involving the glottis with inflammatory destruction of the cricoid cartilage after prolonged endotracheal intubation. Total cricoidectomy and laryngotracheal anastomosis were performed with T-tube placement that was retained for five months postoperatively. After decannulation of the T-tube, the airway was well restored, with good vocal cord opening. Good respiratory and phonatory results were obtained during normal daily activity, although a slightly hoarse voice was present, but no aspiration was observed. Total cricoidectomy and laryngotracheal reconstruction may be considered suitable for subglottic stenosis with glottic involvement, if accompanied by inflammatory destruction of the cricoid cartilage.

Endoscopic management of subglottic stenosis

Objective: To assess the possibility of restoring normal breathing for cases of subglottic stenosis by simple endoscopic dilatation.Methods: Retrospective review of all subglottic stenosis cases with tracheostomy that presented between 1999 and 2008 to King Abdulaziz Aziz University Hospital in Riyadh, Saudi Arabia. The review mainly involved cases who underwent endoscopic laser dilatation.Result: Out of 21 cases, about 50% were decanulaed after endoscopic CO2 laser dilatation with a total mean of further procedures being 1.4.Conclusion: Decision of open airway reconstruction should be carefully made even for higher grades since some may benefit from simple dilatation.

Powikłania tracheotomii przezskórnej – opis przypadku

Tracheotomy is one of the most oldest operations in surgery. Percutaneous dilational tracheotomy has become increasingly popular as an alternative to standard tracheotomy over the last 30 years. It is particularly useful in patients who require prolonged mechanical ventilation, in the intensive care units. Percutaneous tracheotomy is a technique that can be performed at the bedside. It is cost effective, minimally invasive and can be done rapidly. We report a case of subglottic stenosis after percutaneous tracheotomy. A 56- year old obese man with chronic obstructive lung disease, insulin-independent diabetes, arterial hypertention and atrial fibrillation was admitted to the ENT Department because of stridor. 3 months earlier he had undergone percutaneous dilational tracheotomy due to respiratory failure. Laryngostroboscopy and a CT scan were performed, and showed 25 mm subglottic airway obstruction of the trachea. The incidence of asymptomatic subglottic tracheal stenosis after decannulation of percutaneous tracheotomy patients has been reported in over 25% with to 2% case reports of symptomatic stenosis. Although percutaneous dilational tracheotomy is considered as a safe procedure, there is a high incidence of tracheal stenosis.

Endoscopic Treatment of Subglottic Stenosis due to Percutaneous Tracheostomy Tube Placement

Percutaneous dilatational tracheostomy was initially described by Ciaglia et al in 1985. Since that time, its popularity has increased, and it has become the procedure of choice in some institutions. Most studies comparing open versus percutaneous tracheostomy tube placement have shown either no statistical difference or fewer complications using the percutaneous method. At our institution, we have seen numerous cases of subglottic stenosis (SGS) following percutaneous tracheostomy tube placement which have required further intervention. The purpose of this study is to determine decannulation rates and predictive factors following endoscopic repair in patients with SGS resulting from percutaneous tracheostomy tube placement. Endoscopic Treatment of Subglottic Stenosis due to Percutaneous Tracheostomy Tube Placement

A case of subglottic stenosis treated with topical mitomycin C

A case of subglottic stenosis treated with topical mitomycin C

Tracheopathia chondro-osteoplastica – an unusual cause of stridor

A case of tracheopathia chondro-osteoplastica causing sub-glottic stenosis is described. Case report and literature review. A 37-year-old man presented with a 15-year history of gradually worsening dyspnoea and stridor due to sub-glottic stenosis. His medical and radiographic records were reviewed. This patient's presentation, histopathological findings and radiology images are presented and discussed. Histopathological evaluation of microlaryngoscopy biopsy specimens, taken during laser debulking of the stenosis, confirmed the presence of tracheopathia chondro-osteoplastica. This is the first reported case of sub-glottic stenosis caused by tracheopathia chondro-osteoplastica which required an urgent tracheostomy.

Laryngopharyngeal Reflux Mimicking Limited Wegener Granulomatosis

We present a case of subglottic stenosis (SGS) in a young patient with positive ANCA but a wrong diagnosis of Wegener granulomatosis (WG). Instead, she was diagnosed as having laryngopharyngeal reflux (LPR). Pitfalls of ANCA testing in this scenario, the route to diagnosis of LPR and the contribution of this entity to subglottic stenosis (SGS) in WG are discussed. Caution when interpreting ANCA results is mandatory to avoid improper management.

A Case of Subglottic Stenosis Caused by Percutaneous Needle Cricothyrotomy

輪状甲状靭帯穿刺は，緊急時の気道確保手技として知られるほか，近年は喀痰吸引等の呼吸経路管理に施行されることがある。今回われわれは，外科手術後の喀痰吸引を目的に行われた輪状甲状靭帯穿刺により生じた肉芽腫により声門下気道狭窄を呈した症例を経験したのでこれを報告する。 症例は59歳，男性。外科手術後，喀痰吸引のためにトラヘルパー®による輪状甲状靭帯穿刺が行われた。その後，徐々に増悪する呼吸苦•喘鳴が出現。診察の結果，声門下腔前壁の，輪状甲状靭帯穿刺部に一致する部位に腫瘤性病変が認められた。画像所見では声門下左壁から前壁にかけての隆起に加え，輪状軟骨の骨化と肥厚が認められた。腫瘤からの生検では，炎症細胞浸潤を伴う肉芽組織との診断が得られ，これらの結果から声門下狭窄の原因はトラヘルパー®により輪状軟骨が損傷された結果生じた肉芽組織によるものと考えられた。肉芽組織は抗生剤投与により縮小。残存肉芽を内視鏡下に鉗除し，声門下にT-tubeを2カ月間留置。T-tube抜去後6カ月経過後も再発がないことを確認し気管切開孔を閉鎖した。 輪状甲状靭帯穿刺に際しては合併症としての気道狭窄の発生を十分に考慮する必要がある。

Laryngotracheal Consequences of Pediatric Cardiac Surgery

To determine the incidence and character of clinically significant laryngotracheal anomalies in pediatric patients undergoing surgical repair of congenital cardiac defects at a tertiary care center. Single-center retrospective review. The charts of pediatric patients who required surgical treatment for congenital heart disease over a 4-year period were reviewed. Forty-eight of 1957 patients were seen in inpatient consultation by the otolaryngology service. The parameters studied included cardiac diagnosis, reason for consultation, findings on examination, and follow-up. There were 16 (33%) cases of subglottic stenosis, which were graded according to the Cotton-Myer classification system as follows: grade 1 (n=8); grade 2 (n=3); and grade 3 (n=5). Three of the 16 patients with subglottic stenosis required tracheotomy and 4 required laryngotracheal reconstruction. Nine (19%) of the 48 patients were diagnosed as having unilateral true vocal cord paralysis and 3 (6%) as having bilateral paralysis. With the exception of 1 patient, all patients with true vocal cord paralysis on the left side had undergone repair of the aortic arch. Pediatric patients with congenital cardiac disease are predisposed to laryngeal anomalies owing to (1) frequent intubation, (2) prolonged ventilatory support, and (3) recurrent laryngeal nerve injury. In our patients, subglottic stenosis was the most common laryngeal abnormality. When recognized early, in the eschar phase, most of these cases can be managed with sequential endoscopic debridement, which is conceptually similar to debridement that is performed after functional endoscopic sinus surgery. Established stenosis requires more vigorous intervention, the invasive degree of which depends on the length and circumference of the narrowing. Unilateral vocal paralysis tends to be a self-limited problem, while an elegant solution to bilateral paralysis remains elusive.

Percutaneous Tracheostomy

Tracheotomy is one of the most oldest operations in surgery. Percutaneous dilational tracheotomy has become increasingly popular as an alternative to standard tracheotomy over the last 30 years. It is particularly useful in patients who require prolonged mechanical ventilation, in the intensive care units. Percutaneous tracheotomy is a technique that can be performed at the bedside. It is cost effective, minimally invasive and can be done rapidly.We report a case of subglottic stenosis after percutaneous tracheotomy. A 56- year old obese man with chronic obstructive lung disease, insulin-independent diabetes, arterial hypertention and atrial fibrillation was admitted to the ENT Department because of stridor. 3 months earlier he had undergone percutaneous dilational tracheotomy due to respiratory failure. Laryngostroboscopy and a CT scan were performed, and showed 25 mm subglottic airway obstruction of the trachea.The incidence of asymptomatic subglottic tracheal stenosis after decannulation of percutaneous tracheotomy patients has been reported in over 25% with to 2% case reports of symptomatic stenosis. Although percutaneous dilational tracheotomy is considered as a safe procedure, there is a high incidence of tracheal stenosis.

Laryngotracheal reconstruction in subglottic stenosis: An ancient problem still present

Background: Subglottic stenosis is an ancient but persistent problem as a cause of airway obstruction. The etiology and the results of surgical treatment with thyrotracheal anastomosis were reviewed. Methods: Fifty-six patients with subglottic stenosis were studied. All were subjected to laryngotracheal reconstruction by thyrotracheal anastomosis with partial resection of the cricoid. Results: Of all 56 cases of subglottic stenosis, 48 (86%) had history of previous tracheal intubation, and only 8 (14%) had different non-neoplastic obstructive processes such as scleroma, direct injury, hamartoma, and amyloidosis. Immediate results were good in all cases. After 1 year follow-up, results of thyrotracheal anastomosis were successful in 44 (91%). In 4 other cases a restenosis was observed. Eight patients were lost to follow-up. Conclusions: Subglottic stenosis is still frequent after tracheal intubation, but other causes must be considered. Laryngotracheal reconstruction with thyrotracheal anastomosis with partial cricoid resection was feasible with good results in 91% of the cases with follow-up, but this procedure must be performed by a skilled surgical team. (Otolaryngol Head Neck Surg 2001;125:397-400)

Laryngotracheal stenosis in children after intubation. Report of five cases.

Acquired laryngotracheal stenosis is a serious long term complication of tracheal intubation with an incidence of 0.7 to 8% in intubated children. We report five cases of subglottic stenosis over a 4.5-year period and review the pathology and pathogenesis of the condition. A diagnosis of subglottic stenosis was suspected when extubation failed due to the onset of dyspnoea or laryngeal stridor. An incidence of 0.9% of all intubated children was observed. We conclude that the main components contributing to stenosis are pathologies with decreased mucosal capillary perfusion pressure and intubation conditions.

声門下狭窄の治療経験

33 cases of subglottic stenosis were treated at the authors' clinic over 13 years (1982-1994). Most of these 33 cases were due to long-term endotracheal intubation and tracheostomy. We operated on 20 of these cases with subglottic stenosis. After these operations, systemic administration of antibiotics and local inhalation of steroids were essential. T-tubes were more effective in selected cases, combined with the surgical procedure. Recently, laser have been used as one treatment technique. This may become a very useful tool, if indications are selected properly. We have experienced three severe complications in spite of the treatment. An obstruction of a T-tube developed due to sputum, a removed T-tube accidentally, and a trachea was burn by KTP laser. Finally, we report on a new device named the L-tube that removes some of the deficiencies of the T-tube.

T-チューブを用いた小児の声門下狭窄の症例

A case of subglottic stenosis following endotracheal intubation in a child treated using a Silicone T-tube is reported.During the placement of a T-tube, restenosis occurred after infection, and obstruction developed due to sputum. After approximately 100 days, the T-tube was removed. In children, however, using a Silicone T-tube is better using other techniques.Care during T-tube insertion is very important, but advantages a Silicone T-tube has greater than other techniques in pediatric cases.

Auricular Cartilage Grafts in Laryngotracheal Reconstruction

Introduction of the anterior cricoid split (decompression) and laryngotracheal reconstruction with costal cartilage graft has resulted in the successful management of many cases of subglottic stenosis. However, the procedure does not allow uniform extubation, and laryngotracheal reconstruction with costal cartilage may be too aggressive for neonates. We have explored the use of autogenous auricular cartilage graft in laryngotracheal reconstruction. Its high rate of success and low morbidity have enabled us to expand the indications. We report our experience in 23 patients with auricular cartilage grafts.

Update of the Cincinnati, Ohio, Experience With Pediatric Laryngotracheoplasty

Dr Robin T. Cotton, Cincinnati, Ohio, presented his experience with 203 cases of subglottic stenosis operated on during the preceding 10 years. The results were presented at the 1989 Triological Society meeting in San Francisco, Calif, by Dr Cotton, and his associates, Robert P. Miller, MD, Chicago, Ill, and Steven Gray, MD, Iowa City, Iowa. Noting the absence of uniform grading for subglottic stenoses, Dr Cotton presented his staging system as follows: grade I, less than 70% obstruction of the airway; grade II, 70% to 90% obstruction; grade III, 90% to 99% obstruction; and grade IV, total airway obstruction. Methods of reconstruction include anterior costal grafting (189 cases), posterior costal grafting, the modified Rethi procedure with stenting (65 cases), posterior cricoid splitting with anterior-posterior grafting, and the Evans castellation procedure. Dr Cotton noted that in his 98 grade II cases 95% were decannulated, with 83% requiring only one procedure. Further,

Sliding flap tracheoplasty.

The optimal method for surgical management of subglottic stenosis is based upon careful assessment of the location, caliber, length, and maturity of the stenotic segment, as well as associated conditions. For patients with a mature stenosis of short length, excision of the anterior arch of the cricoid and first ring and immediate reconstruction by means of a sliding flap of the next two to three rings of trachea offer a one-stage definitive treatment without the need for grafting. We report four cases of subglottic stenosis and one case of cricoid chondroblastoma in which reconstruction of the airway was successful and prompt. For carefully selected cases, sliding flap tracheoplasty may be a useful alternative to procedures in which the airway is expanded by means of grafting.

Surgical treatment of subglottic stenosis in children--laryngotracheal plastic surgery with autogenous costal cartilage graft

We performed laryngotracheal plastic surgery by transplantation of autogenous costal cartilage graft in 9 cases of subglottic stenosis (2 with congenital type and 7 with acquired type). Of 9 cases, 3 cases had the lesion after long-term intubation, 2 cases after tracheotomy and 2 cases after laryngo-tracheo-bronchitis. Five cases aged one year and the remaining 4 cases 2 years, 3 years, 4 years and 6 years old, respectively. We could successfully decannulate in all the 9 cases after our plastic surgery. The period from surgical treatment to decannulation varied from 9 days to 6 months. However, 8 cases were decannulated in 2 months after surgery. Cotton et al (1978) did not use any stents in their treatment for subglottic stenosis, but we did in all of our cases. We preferred stents of the silicone Y-tube, and the recommendable duration of cannulation is 4 weeks.

Subglottic stenosis: a clinicopathological study.

Subglottic stenosis is the most common serious long-term complication of endotracheal intubation in neonates and its pathogenesis is poorly understood. We describe the experience of one unit with 15 cases of subglottic stenosis requiring operative intervention seen over a 3-year period and review the pathology and pathogenesis of the condition. In 1 instance operative intervention was successful in treatment and avoided the need for long-term tracheostomy. A possible aetiological factor in at least 2 of the cases of subglottic stenosis was insertion of the wide shoulder of the endotracheal tube through the vocal cords. It is suggested that subglottic stenosis is due to reparative fibrosis following particularly severe acute intubation injury. Another factor may be delayed healing of the subglottic mucosa possibly exacerbated by full thickness cricoid cartilage necrosis. Although severe subglottic injury may occur at any time that the endotracheal tube is in situ, the most critical period is the first week of intubation.