Severe Subglottic Stenosis Research Articles

Difficult Airway Management with Awake Fiberoptic Intubation and Cross Table Ventilation in a Case of Acquired TEF with Severe Subglottic Stenosis

We report a case of 30-year male who presented with Acquired Tracheoesophageal Fistula with subglottic stenosis and Aspiration Pneumonitis. Patient was managed with Feeding Jejunostomy, Tracheoesophageal Fistula repair and Tracheoplasty, after which patient recovered well. Difficult airway was managed by Awake Fiberoptic Intubation and cross-table ventilation through flexometallic tube intraoperatively during TEF repair.

Shared Airway for Tracheal Resection and Anastomosis in a Patient with Severe Subglottic Stenosis after Intra-cardiac Repair for Tetralogy of Fallot

Subglottic stenosis is a condition causing narrowing of the trachea, which can occur rarely secondary to trauma, infection, tumors, inflammatory, and iatrogenic causes. In our case, the child developed subglottic stenosis post-cardiac surgery after being mechanically ventilated in the postoperative period. The causes for subglottic stenosis may be some trauma in the presence of coagulation abnormalities in cyanotic heart diseases such as TOF, the ischemia to the subglottic tissue by reduced perfusion during cardiopulmonary bypass, and/or the trauma caused by crying and fighting of the child while being with the endotracheal tube. Anesthetic management of the surgery is challenging for the anesthesiologist due to the shared airway by the surgeon and the anesthesiologist. The inability to effectively ventilate the patient after induction of general anesthesia will result in catastrophic complications. Subglottic stenosis requires careful planning and execution along with proper communication between the team.

A Pilot Study of Decellularized Cartilage for Laryngotracheal Reconstruction in a Neonatal Pig Model.

Severe subglottic stenosis develops as a response to intubation in 1% of the >200,000 neonatal intensive care unit infants per year and may require laryngotracheal reconstruction (LTR) with autologous hyaline cartilage. Although effective, LTR is limited by comorbidities, severity of stenosis, and graft integration. In children, there is a significant incidence of restenosis requiring revision surgery. Tissue engineering has been proposed to develop alterative grafting options to improve outcomes and eliminate donor-site morbidity. Our objective is to engineer a decellularized, channel-laden xenogeneic cartilage graft, that we deployed in a proof-of-concept, neonatal porcine LTR model. Meniscal porcine cartilage was freeze-thawed and washed with pepsin/elastase to decellularize and create microchannels. A 6 × 10-mm decellularized cartilage graft was then implanted in 4 infant pigs in an anterior cricoid split. Airway patency and host response were monitored endoscopically until sacrifice at 12 weeks, when the construct phenotype, cricoid expansion, mechanics, and histomorphometry were evaluated. The selective digestion of meniscal components yielded decellularized cartilage with cell-size channels. After LTR with decellularized meniscus, neonatal pigs were monitored via periodic endoscopy observing re-epithelization, integration, and neocartilage formation. At 12 weeks, the graft appeared integrated and exhibited airway expansion of 4 mm in micro-CT and endoscopy. Micro-CT revealed a larger lumen compared with age-matched controls. Finally, histology showed significant neocartilage formation. Our neonatal porcine LTR model with a decellularized cartilage graft is a novel approach to tissue engineered pediatric LTR. This pilot study sets the stage for "off-the-shelf" graft procurement and future optimization of MEND for LTR. NA Laryngoscope, 134:807-814, 2024.

Microlaryngobronchoscopy Without Tracheostomy in Large Subglottic Cyst Obliterating Airway

Extended endotracheal intubation in infancy causes various complications. Upper airway disruption is very rare but reversible cause of respiratory insufficiency. Tracheostomy may not be avoidable in severe upper respiratory tract lesions especially in large subglottic cysts and severe subglottic stenosis; however, avoiding it is a priority when possible. A 7-month-old child who had a history of newborn respiratory distress syndrome and extended endotracheal intubation developed respiratory symptoms including stridor. A subglottic cyst was found by bronchoscopy and surginally removed with the tubeless anesthesia technique without tracheostomy. This method was successful even on infants. We report this case with a review of literature.

A case of severe subglottic stenosis masking as bronchial asthma

Tracheal stenosis is an uncommon and dangerous complication after intubation and tracheostomy and its clinical presentation may be misinterpreted as bronchial asthma. A careful vigilant clinical history and examination is required for the diagnosis of such tracheal stenosis. Here, we describe a case of post intubation subglottic tracheal stenosis in a young male who presented with features mimicking bronchial asthma. IMC J Med Sci 2022; 16(2): 005. DOI: https://doi.org/10.55010/imcjms.16.015 *Correspondence: Bhupendra Kumar Jain, Department of Pulmonary Medicine, Chhindwara Institute of Medical Sciences, Chhindwara, Jabalpur Medical University, Madhya Pradesh, India; ORCID : 0000-0002-6619- 8596;Email: drbhupendrakjain@gmail.com

Incidence of Post-extubation Stridor in Infants With Cuffed vs. Uncuffed Endotracheal Tube: A Retrospective Cohort Analysis.

BackgroundEndotracheal intubation is a common procedure in Neonatal Intensive Care. While cuffed endotracheal tubes (ETT) are the standard of care in adults and children, their use in infants is controversial. The aim of this study was to compare the incidence of post-extubation stridor between uncuffed and cuffed ETTs in infants. We further evaluated the safety of cuffed ETTs in infants with a bodyweight between 2 and 3 kg and performed baseline analysis on development of subglottic stenosis.MethodsIn this retrospective study, we screened all infants admitted to two NICUs of the Medical University of Vienna between 2012 and 2019.The study cohort was screened twice: In the first screening we selected all infants who underwent the first intubation when attaining a bodyweight >2 kg (but <6 kg) to analyze the incidence of post-extubation stridor and only considered the first intubation of each included infant. Post-extubation stridor was defined as the administration of either epinephrine aerosol or any corticosteroid within 6 h post-extubation. In the second screening we searched for all infants diagnosed with acquired severe subglottic stenosis during the study period regardless their bodyweight and numbers of intubations.ResultsA total of 389 infants received at least one intubation during the study period. After excluding infants who underwent the first intubation below a bodyweight of 2 kg, 271 infants remained for final analysis with an average gestational age of 38.7 weeks at the time of intubation. Among those, 92 (33.9%) were intubated with a cuffed and 179 (66.1%) with an uncuffed ETT. Seven infants (2.6%) developed a clinically significant stridor: five of those were intubated with a cuffed and two with an uncuffed ETT (71.4 vs. 28.6%, p = 0.053). All of them had a bodyweight >3 kg at the time of intubation. Infants who developed subglottic stenosis were more often intubated with an uncuffed ETT.ConclusionIn this study, no difference in the incidence of post-extubation stridor between cuffed and uncuffed ETTs in infants with a bodyweight from 2 to 6 kg could be found. The use of uncuffed ETTs does not exhibit higher risk for the acquired subglottic stenosis in this cohort.

Successful management of acquired pinhole subglottic stenosis by multidisciplinary pediatric airway team

The concept of neonatal and pediatric airway team is somewhat new in India. : In Western countries, though this concept has been established recently, it remains only limited to children's hospitals. We report the case of a 15-month-old girl with failure to thrive and critical life-threatening severe subglottic stenosis. She was managed in a comprehensive manner by multidisciplinary pediatric airway team at a tertiary-level children's hospital.

A 10-year-old Child with Severe Subglottic Stenosis Following Intubation: A Case Report

Background: Subglottic stenosis is among the most common airway problems in children, i.e., acquired or congenital. More than 90% of acquired cases are secondary to endotracheal intubation and occur iatrogenically. Subglottic stenosis is an unexpected problem that requires timely diagnosis and intervention. Most cases of subglottic stenosis in children are mild to moderate. Case Presentation: The presented patient was a 10-year-old child who, after long intubation due to head trauma following early discharge from the surgical center, was referred to the Children’s Hospital on the same day with a complaint of high fever and shortness of breath. With the development of respiratory distress and cyanosis, the patient was transferred to the intensive care unit. Due to the impossibility of passing the tracheal tube with the appropriate age for the patient, the initial diagnosis of subglottic stenosis was established and a tracheostomy was performed. Diagnostic bronchoscopy confirmed severe subglottic stenosis, and the child was referred to a specialized Ear, Nose, Throat (ENT) center for the repair of the tracheal stenosis. Conclusion: One of the most common causes of stridor in children is subglottic stenosis following prolonged intubation. Recognizing the predisposing factors, prevention, strong clinical suspicion, timely diagnosis, and treatment can prevent further adverse complications or consequences in children.

Granulomatosis polyangitis: an otorhinolaryngological perspective

&lt;p&gt;Granulomatosis with polyangitis or Wegeners granulomatosis is a rare entity, however is known to have specific otorhinolaryngological manifestations. Initial clinical manifestations could be subtle but deteriorate rapidly with an underlying active autoimmune process which can be life threatening in severe subglottic stenosis. We report a case of Granulomatosis with polyangitis in an adolescent girl initially presented with otitis media refractory to treatment and epistaxis and rhinitis and eventually with the progression of disease presented with subglottic stenosis. Diagnosis was made by anti-neutrophil cytoplasmic antibody proteinase 3 (ANCA-PR3) positive status and histological confirmation by nasal biopsy, elevated C-reactive protein (CRP) levels and renal involvement with evidence of microalbuminuria. She underwent dilatation of the subglottic stenosis twice, with resection of the stenotic mass by coblation. The diagnostic and therapeutic challenges faced are emphasized in this report.&lt;/p&gt;

An anterior cricoid split and long-term silastic T-tube stenting for children with severe subglottic stenosis.

The management of subglottic stenosis (SGS) remains challenging. Although laryngotracheal reconstruction with a costal cartilage graft (LTR) has been widely performed, restenosis with cicatricial tissue may require long-term stenting, especially in patients with severe SGS. An anterior cricoid split (ACS) with long-term stenting has been shown to be useful for patients with mild SGS. Thus, we evaluated the clinical outcomes of patients, including severe SGS, who underwent ACS compared to those with LTR. A retrospective chart review was conducted in 25 patients with severe SGS (Grades III and IV) who underwent initial laryngoplasty (ACS or LTR) in our hospital from January 2009 to April 2018. 17 patients (8 with Grade III and 9 with Grade IV) underwent ACS, and 8 (6 with Grade III and 2 with Grade IV) underwent LTR. The median duration of stenting was 11months (range: 0.8-50) in the ACS group and 12months (range: 0.4-29) in the LTR group. Thirteen of 17 patients (76.5%) in the ACS group were decannulated, whereas 4 of 8 patients (50%) in the LTR group were decannulated (p = 0.2). ACS might be useful even for children with severe SGS. The optimal duration of stenting should be investigated further.

Effect of partial cricotracheal resection and extended cricotracheal resection for severe laryngotracheal stenosis

Objective: To assess the outcomes of partial cricotracheal resection (CTR) and extended cricotracheal resection (ECTR) for severe laryngotracheal stenosis. Methods: From November 2009 to September 2017, 18 patients underwent CTR and ECTR at the Department of Otorhinolaryngology Head and Neck Surgery, Tangdu Hospital, Air Force Medical University for severe laryngotracheal stenosis were reviewed retrospectively. There were 12-male and 6-female patients, with the age ranged from 4 to 56 years (median 25 years). The causes were postintubation in 11 cases, cervical trauma in 4, idiopathic in 3. The stenosis located in subglottic and tracheal (n=12), glottic and subglottic and tracheal (n=3), subglottic (n=2), and glottic and subglottic (n=1). Two patients had concurrent unilateral vocal cord palsy.One patient had undergone previous endoscopic balloon dilation and 8 patients had previous laryngotracheal reconstruction. The stenosis was graded according to modified Myer-Cotton classification as follows: Ⅲb (n=1), Ⅲc(n=1), Ⅳa (n=2), Ⅳb (n=12), Ⅳc (n=2). The surgical outcomes and complications were recorded. Results: Among 18 patients,11 of the 12 patients undergoing CTR were decannulated. Five of the 6 patients undergoing ECTR were decannulated. Resected airway length ranged from 1.5 to 4.0 cm (median 2.8 cm). Surgical complications included infection of incision wound in 2 cases, anastomotic granulation in 2, cervical subcutaneous emphysema in 1, aspiration in 1, and unilateral arytenoid prolapse in 1. No recurrent laryngeal nerve injury or tracheoesophageal fistula occurred. The median follow up was 11 months. Conclusions: CTR is efficient for severe subglottic and upper tracheal stenosis while ECTR is efficient for subglottic stenosis extended to the glottis. Both procedures also provide a salvage therapy for patients with previous failed treatments.

Wegener’s granulomatosis: surgical repair of severe subglottic stenosis

Laryngeal and subglottic stenosis are present in about 20% of patients with granulomatosis with polyangiitis. This atypical form of the disease can be severe and life-threatening. In what concerns to treatment, subglottic lesions are less responsive to conventional systemic therapy and interventional and surgical procedures should be considered. The authors present a case of a 30-year-old woman with diagnosis of Wegener’s granulomatosis who presented to our department with dyspnea and stridor due to a severe subglottic stenosis, requiring an emergent tracheostomy. The obstructive defect was electively and effectively repaired through a transoral laser microsurgery using local application prednisolone and mitomycin C followed by balloon dilation.

A Case of Severe Subglottic Stenosis on the 3 Day After Operation for Primary Lung Cancer - a Case Report

A Case of Severe Subglottic Stenosis on the 3 Day After Operation for Primary Lung Cancer - a Case Report

Airway Management of Severe Subglottic Stenosis with a Novel Airway Device

S ubglottic stenosis (SS) is the leading cause of stridor in pediatric age group. It involves narrowing of subglottic lumen due to incomplete recanalization during embryogenesis (congenital) or after trauma (post intubation). Stridor is the important symptom of SS and usually present in both phases of respiration. Airway management becomes a challenging task to the anesthesiologist in SS due to difficulty in maneuvering endotracheal tube (ETT) through the noncompliant stricture. Location and extent of stricture also pose difficulty in securing front of neck access [1]. After taking consent of the child’s parent for possible publication in a medical journal, we present a case of subglottic stenosis posted for emergency tracheostomy and ventilated with a novel airway device prepared by simple equipments present in operation theatre. Case Report A one-year-old baby of 11 kg presented to the emergency with chief complaint of noisy breathing developed after upper respiratory tract infection (URTI), fever and cough since 2 days. Child’s stridor started since birth that was progressive in severity and frequency, aggravated by recurrent URTI. At the time of admission, child was in severe respiratory distress with intercostals and suprasternal retraction. Nasal flaring was present with weak cry. Bilateral air entry was decreased with harsh bronchial sounds on auscultation. Hemodynamically child was unstable with heart rate 200 per minute, blood pressure 60/36 mmHg, respiratory rate 44 per minute, axillary temperature 38.5 degree Celsius and SpO2 62% at room air and 88% with Oxygen given by facemask and reservoir at 10 liters per minute. ABG showed pH 7.32, PO2 52 mm Hg, PCO2 68 mm Hg, HCO3 20.2 meq/l and Hb 10.6 mg/dl. Emergency CECT was done which showed the subglottic stenosis of 2.6 mm in length and 2.0 mm of patent airway in diameter at the narrowest point [Figure 1]. Securing the airway was planned with endotracheal intubation followed by surgical tracheostomy and definite correction. Tracheostomy could be done under sedation in a spontaneously breathing child with the aid of facemask or supraglottic airway device. However, an unsuccessful attempt in tracheostomy could completely obstruct the airway and patient may suffer hypoxia. ETT of 2.0 mm ID was not available that day so we decided to make a novel device in place of ETT. We developed a novel airway device by using 6F suction catheter (SC), 18 G intravenous needle catheter, 3.5 mm ID Endotracheal tube connector and guide wire of 10 F Foleys catheter. We cut the connecting end of SC to resize it equivalent to the length of 2.5mm ID ETT and marking the SC with marker at 6 to 10 cm, 1 cm apart. Foleys guide wire was inserted in the SC and whole

The Runaway Croup Train: Off the Pathway and Through the Woods

A previously healthy, fully immunized 23-month-old girl presented to the emergency department (ED) with 1 day of fever, cough, hoarseness, stridor only with agitation, and no drooling or retractions. She was given acetaminophen and dexamethasone 0.6 mg/kg orally. After these interventions, she improved and took a Popsicle. A chest radiograph and lateral neck radiograph were read as “prevertebral soft tissue thickening at the level of C5-C7, which can be seen with retropharyngeal infection versus projection or positioning.” This prompted an otolaryngology consult. Bedside flexible fiber-optic nasolaryngoscopy in the ED revealed mild to moderate swelling of the epiglottis with scattered foci of edema and erythema on the laryngeal surface of the epiglottis, mobile and moderately edematous vocal folds bilaterally, and moderate to severe subglottic stenosis, which are all findings typical of viral croup. Laboratory studies revealed a normal white blood cell count of 10.1 k/μL (reference range: 6–17.5), elevated C-reactive protein of 8.0 mg/dL (reference range: <0.9), elevated procalcitonin of 1.08 ng/mL (reference range: <0.5), and a normal chemistry. A nasal swab for respiratory pathogen polymerase chain reaction (PCR) was obtained. A diagnosis of epiglottitis was made, the patient was made NPO, maintenance intravenous fluids were started, intravenous ampicillin-sulbactam and intravenous dexamethasone were given and scheduled every 6 hours, and admission to the PICU was arranged. Three hours after admission to the PICU, the respiratory pathogen panel was reported as positive for parainfluenza virus 3, and 12 hours after admission, the patient was transferred from the ICU to the inpatient ward. The patient did not require any additional interventions in the ICU other than scheduled intravenous antibiotics and steroids. The next morning, 9 hours after transfer …

Severe Subglottic Tracheal Stenosis Dictates Intercontinental Transfer of a 2-Year-Old Child with Tracheostomy Tube In Situ

AbstractAtrioventricular septal defect (AVSD) is the most common congenital cardiac anomaly associated with Down’s syndrome. Children with AVSD develop pulmonary arterial hypertension and often require extensive therapy with pulmonary vasodilators in the postoperative period. The postoperative management is complicated by prolonged mechanical ventilation through endotracheal tube or tracheostomy tube. This artificial airway may trigger various airway complications including subglottic tracheal stenosis. The incidence and severity of subglottic tracheal stenosis is high in children with congenital syndromes. Inability to extubate or decannulate trachea and rapid respiratory compromise while attempting to do so directs toward a diagnosis of subglottic tracheal stenosis. The following case report discusses a 2–year-old boy from Nigeria who was discharged with tracheostomy tube in situ due to severe subglottic tracheal stenosis and surgical tracheoplasty could not be done at his present age. The implications of prolonged tracheostomy tube in situ and the hazards thereof during transfer of the child are being described.

Subglottic stenosis due to an unexpected foreign body diagnosed after emergency tracheostomy in a child

BackgroundSubglottic stenosis is a known complication of traumatic and prolonged endotracheal intubation. It is rare that the causes of severe subglottic stenosis are revealed to be an unexpected foreign body after airway securement in a child. Subglottic stenosis in a child is often associated with airway emergency, and management of difficult airway may be required.Case presentationWe report the case of an 8-year-old girl with severe subglottic stenosis who required emergency tracheostomy. Emergency tracheostomy was performed under regional anesthesia. Sevoflurane was administered with sufficient titration to maintain spontaneous breathing. At first, the cause of severe subglottic stenosis was thought to be a traumatic event that had occurred 1 month previously; however, subsequent laryngoscopy revealed that the cause of subglottic stenosis was a foreign body.ConclusionsManagement of the airway in a child with severe subglottic stenosis should be selected according to each patient’s individual circumstances.

Treatment of Iatrogenic Subglottic Stenosis by Therapeutic Fibreoptic Bronchoscopy

Endotracheal intubation is a common procedure in intensive care unit. It still qualifies as an invasive procedure. Prolonged endotracheal intubation or intubation with cuffed endotracheal tube in a newborn or young infant is a risk factor for the development of subglottic stenosis. It usually presents with stridor in childhood. The most likely mechanism of subglottic stenosis is an injury of tracheal mucosa, with secondary scar healing that consequently leads to the development of some degree of subglottic stenosis. Depending on the degree of subglottic stenosis, patients may be asymptomatic for a long time or symptoms can occur within several weeks. The incidence of stenosis is very low if intubation lasts less than a week. Sometimes the patient may develop severe subglottic stenosis after short-term endotracheal intubation. Intubation with cuffed endotracheal tube in newborn results in pressure necrosis and sloughing followed by subglottic stenosis. This article presents a case of a patient (Baby A) who had intubation with cuffed tube which landed to airway problem and stenosis and was managed successfully by taking help from an expert pediatric pulmonologist of a neighbouring country.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.13(2) 2017: 64-68

Subglottic Stenosis

Subglottic stenosis refers to narrowing of the airway diameter below the vocal folds and may be congenital or acquired. Typical signs and symptoms range from recurrent croup and exertional stridor to complete airflow obstruction requiring tracheotomy. Management of moderate and severe subglottic stenosis often requires intricate surgical techniques. To optimize the success of these surgeries, a thorough assessment of the child’s airway, lungs, reflux, and swallow needs to be evaluated. In order to provide concerted and coordinated care between typically otolaryngology (ENT), pulmonary, gastroenterology (GI), speech, swallow and language pathologists (SLP), “aerodigestive” teams have been developed and increasing in prevalence at children’s medical hospitals. This article sets out to provide a brief overview of an aerodigestive program and evaluation, review a few of the more common laryngotracheal conditions, and the surgical techniques involved to augment the airway.

Reproducing severe acute subglottic stenosis in a rabbit model

ObjectivesThe objectives of this study were to develop an animal model with consistent, severe subglottic stenosis (SGS), and to develop the timeline needed for intervention to limit rabbit mortality. MethodsSubglottic stenosis was created endoscopically using either a nylon or polypropylene brush in sixteen New Zealand White rabbits. The subglottic cross-sectional area was measured endoscopically using a right-angled probe and an open source image analysis software The cross-sectional areas of the stenotic and native airways were compared to calculate the subglottic stenosis percentage and Myer-Cotton grade classification. ResultsThe average diameter of the native subglottis was 4.7 mm (SD 0.4). The mean subglottic stenosis percentage was 73% (SD 32) for all rabbits. The three rabbits injured with the nylon brush had 30, 52, and 76% stenosis. Nine of the 12 surviving rabbits (75%) injured with the polypropylene brush had a >86% subglottic stenosis. Four rabbits in the polypropylene brush cohort died from procedural complications. ConclusionThis study demonstrates a reliable model using a polypropylene brush to create severe acute subglottic stenosis. Cartilage exposure after creating the injury was associated with more severe stenosis. Mortality rate may have been reduced if endoscopic balloon dilation was performed electively seven days after injury, rather than emergently nine days after injury. Level of evidence4.