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Address reprint requests to John D. Mitchell, MD, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Academic Office 1, Room 6602, C-310, 12631 E. 17th Ave, Aurora, CO 80045.
Subglottic stenosis is being recognized with increasing frequency in adults, and may be the most frequent indication for airway intervention in this patient population. A variety of factors may lead to subglottic narrowing but in many individuals, usually women, no antecedent cause is identified. Once the diagnosis is recognized, initial management with endoscopic therapy is indicated to provide symptom relief and to gain information about the suitability of open surgical intervention. In most cases, surgical resection and reconstruction will provide the best long term outcome.
Subglottic stenosis, with involvement of the lower larynx and proximal trachea, is being increasingly recognized in the adult patient population. Indeed, in many busy thoracic practices, it has become the most frequent indication for airway intervention. The usual etiologies—post–intubation injury, gastroesophageal reflux with aspiration, and following tracheostomy—remain present, although an antecedent cause cannot be found in many patients. These cases of “idiopathic” stenosis are typically seen in women aged 30-60 years, and tend to produce isolated stenosis in the subglottic region. When evaluating these patients, it is important to rule out autoimmune disorders such as Wegener granulomatosis, where the airway disease may progress despite surgical resection.
Patients present with the insidious onset of “noisy breathing,” followed by overt stridor and exercise intolerance. The latter may be at times difficult to elicit from the patient, as individuals often accommodate it subconsciously with lifestyle modifications. Voice changes, difficulty in clearing secretions, and recurrent respiratory infections may also result. Delays in diagnosis often ensue, as the patient is treated with bronchodilators and steroids for “adult-onset asthma.” The problem becomes apparent with computed tomography imaging of the neck and most importantly, bronchoscopic evaluation, which accurately defines the location, extent, and proximity of the airway stenosis to the vocal cords. These factors are critical when describing therapeutic alternatives to the patient.
Treatment options, including endoscopic therapy and surgical resection, should be confined to symptomatic patients. The breadth of endoscopic therapies, including dilation (balloon or rigid bronchoscope) as well as ablative techniques (eg, laser or cryotherapy), is beyond the scope of this article, but they should be attempted initially and occasionally produces long-lasting benefit. However, in most of the patients, the stenosis recurs. Endobronchial stenting of the subglottic larynx is difficult because of issues with stent migration and the proximity to the vocal cords. In some patients who are unfit for surgical resection, a silicone t-tube may be a better choice. However, for most of the individuals, laryngotracheal resection is the best choice to produce a durable, widely patent airway.
Conditions optimal for airway resection and reconstruction have been previously described.
Patients should be weaned from oral steroids, and active inflammation within the airway should be minimal. It is best to avoid vigorous dilation of the stenosis immediately before resection, as the mucosal disruption from endobronchial therapy may compromise anastomotic healing. During the surgery, development of the pretracheal plane allows for greater mobility of the distal airway segment, minimizing anastomotic tension. Other maneuvers such as suprahyoid release are only rarely needed in cases of extensive resection. A hilar release is not helpful in laryngotracheal resection. Proper patient positioning allows for maximal exposure of the upper airway (Fig. 1). Extubation at the end of the case should be expected, and a protective tracheostomy is rarely, if ever, necessary.
Close cooperation between the surgical and the anesthetic teams is critical for the success of the procedure. After fiberoptic inspection of the stenosis through a laryngeal mask airway, a small-bore endotracheal tube (ETT) is passed through the cords and beyond the subglottic region. If the stenosis is too severe to permit this, it can be gently dilated to allow passage. The location and length of the stenosis is carefully noted, confirming the extent of resection (Fig. 2). Once the airway is opened within the field, the indwelling ETT is withdrawn and cross-field ventilation is initiated with a new ETT and a sterile circuit is passed to the anesthesiologist; the ETT within the distal trachea may then be removed intermittently to allow suture placement. If a previously placed tracheostomy is present, it is removed just before the skin preparation and replaced with an ETT with the sterile circuit. Once the anastomotic sutures are placed, the prior indwelling ETT is advanced across the anastomotic site into the distal trachea, and cross-field ventilation is discontinued. If the original ETT retracts into the hypopharynx, the surgeon may assist in directing it back through the glottic opening by passing a sterile ETT exchanger retrograde through the cords to be retrieved by the anesthesiologist.
As noted, extubation at the end of the case is anticipated. Fiberoptic inspection of the anastomosis intraoperatively is hazardous because of the proximity to the vocal cords. However, the surgeon may get some information by deflating the ETT balloon and asking the anesthesiologist to produce low to moderate airway pressures; one wishes to see pneumostasis in the field combined with a sizable leak through the glottis, suggesting a widely patent airway. A small-bore drain and a chin-to-chest stitch to maintain mild neck flexion are routine. Some degree of glottic edema and dysfunction may be anticipated in the early postoperative period, and the patient׳s diet is advanced only when this subsides and thus aspiration risk is minimal. Before discharge, the anastomosis is inspected by fiberoptic bronchoscopy through a laryngeal mask airway in the operating room under general anesthesia.
In general, the reported surgical results are exceptional in properly selected patients,
with very low morbidity and mortality rates and long-term outcomes judged as good to excellent in 85%-97% of patients. In several studies, dysphonia (alteration in the strength of voice and inability to sing) was the most common adverse event postoperatively. Other complications, such as development of anastomotic granulation tissue, can be managed endoscopically.
in: Grillo H.C. BC Decker, Inc,
Hamilton, ON2004: 443-451