Glottic Stenosis and Tracheostomy Bleeding
Glottic stenosis itself does not directly cause tracheostomy bleeding, as the glottis is anatomically above the tracheostomy site. However, the underlying conditions and complications associated with tracheostomy placement can lead to bleeding, and glottic stenosis may be part of a broader pattern of airway injury.
Understanding the Anatomic Relationship
The glottis (vocal cords) is located in the larynx, which sits above the tracheostomy stoma. A tracheostomy bypasses the glottis entirely, creating an opening in the trachea below this level. Therefore, pathology at the glottic level cannot directly cause bleeding from the tracheostomy site.
Actual Causes of Tracheostomy Bleeding
Tracheostomy-related hemorrhage is a serious complication with significant mortality implications. 1 Data from the Global Tracheostomy Collaborative shows hemorrhage occurs at a rate of 1.74 per 1000 tracheostomy bed days in adults and 0.35 per 1000 in children, and is associated with a two- to four-fold increase in mortality risk (27% mortality in adults with hemorrhage vs. 13% without; 33% in children vs. 7% without).
Common bleeding sources include:
- Granulation tissue (most common cause) 1, 2
- Traumatic suctioning 3, 2
- Wound breakdown 1
- Mucosal or vascular injury 1
- Bleeding diathesis/coagulopathy 1
- Tracheo-arterial fistula (rare but catastrophic) 3, 2
Critical Warning: Sentinel Bleeding
Blood in tracheal secretions may precede catastrophic hemorrhage and should trigger immediate evaluation. 3 If tracheo-arterial fistula is suspected (moderate bleeding from stoma or pulsation of tracheostomy tube), this represents a surgical emergency requiring:
- Immediate hyperinflation of tracheostomy cuff or intubation with cuffed tube placed distal to fistula 2
- Digital pressure to innominate artery site 2
- Emergency operating room evaluation with capability for sternotomy 3
- Definitive surgical treatment (usually innominate artery ligation) 2
A sentinel bleed occurs in approximately 50% of cases before massive hemorrhage from tracheo-arterial fistula 2.
The Glottic Stenosis Connection
While glottic stenosis doesn't cause tracheostomy bleeding, both conditions may result from the same underlying injury pattern—prolonged intubation. 4, 5, 6 Posterior glottic stenosis commonly results from endotracheal tube-related pressure necrosis and perichondritis, the same mechanism that can cause subglottic stenosis and tracheal injury. 4, 5, 7
If glottic stenosis is present in a tracheostomy patient, consider:
- The patient likely had prolonged or traumatic intubation
- There may be additional airway pathology at multiple levels (subglottic, tracheal) 5
- Failed decannulation may occur due to unresolved upper airway obstruction 3
- Endoscopic evaluation is essential before decannulation attempts 3
Clinical Approach to Bleeding
Differentiate minor bleeding from life-threatening hemorrhage:
- Minor bleeding: Conservative management with observation; usually settles without intervention 2
- Moderate to severe bleeding: Flexible endoscopy through tracheostomy tube to assess source 3
- Pulsatile bleeding or tube pulsation: Assume tracheo-arterial fistula until proven otherwise 2
The possibility of catastrophic bleeding from tracheal erosion into a major artery exists with any tracheostomy, and bleeding from suctioning trauma must be carefully differentiated from sentinel arterial bleeding. 3