What is the management for glottic stenosis?

Management of Glottic Stenosis

For patients with glottic stenosis, management should be tailored to the etiology, severity, and characteristics of the stenosis, with immunosuppressive therapy recommended as first-line treatment for inflammatory stenoses and surgical approaches reserved for fibrotic or non-responsive cases. 1

Initial Assessment

• Evaluation by specialists: Management by otolaryngologist or pulmonologist with expertise in airway stenosis 1
• Imaging: Contrast-enhanced CT scan and/or MRI to assess extent of stenosis and cartilage involvement
• Endoscopy: Microlaryngoscopy and bronchoscopy to determine:
  • Location (anterior, posterior, or complete)
  • Severity (degree of narrowing)
  • Nature (inflammatory vs. fibrotic)
  • Associated pathology (subglottic involvement)

Treatment Algorithm Based on Etiology and Characteristics

1. Inflammatory Glottic Stenosis (e.g., from GPA/Wegener's)

• First-line: Immunosuppressive therapy with glucocorticoids and other agents 1

  • Degree of immunosuppression based on severity of disease manifestations
  • Options include cyclophosphamide or rituximab for induction therapy

• For critical narrowing requiring immediate intervention:

  • Surgical dilation with intralesional glucocorticoid injection concurrent with immunosuppressive therapy 1

2. Fibrotic or Non-inflammatory Stenosis

• For mild to moderate stenosis:

  • Endoscopic techniques:
    • CO2 laser radial incisions 2, 3, 4
    • Balloon dilation 2
    • Mitomycin C application (extends interval between procedures by approximately 157 days) 2, 4
    • Intralesional steroid injection 2

• For severe stenosis or recurrent cases:

  • Surgical options:
    • Anterior cricoid split for subglottic stenosis 1
    • Laryngotracheal reconstruction 5
    • Tracheostomy for bypass when other options fail 1

3. Posterior Glottic Stenosis (often from intubation)

• Minimally invasive approach:
  • Endoscopic CO2 laser excision of scar tissue
  • Endoextralaryngeal vocal cord laterofixation to prevent restenosis 3
  • Avoid tracheostomy when possible

Special Considerations

• Congenital stenosis: Often requires surgical correction with potential need for tracheostomy 1
• Combined glottic and subglottic stenosis: More complex management, may require open surgical approach 5
• Acute exacerbations with respiratory infections:
  • β-adrenergic agents (racemic epinephrine) for temporary relief 1
  • Systemic corticosteroids to reduce edema

Adjunctive Measures

• Reflux management: Critical as reflux can worsen stenosis and impair healing 4
• Voice and swallowing therapy: Essential for functional rehabilitation
• Regular follow-up: Monitor for restenosis, especially after endoscopic procedures

Pitfalls and Caveats

1. Isolated glottic stenosis is rare - always evaluate for subglottic involvement 6
2. Endoscopic procedures often require multiple interventions - patients should be counseled about potential need for repeated procedures 4, 5
3. Avoid tracheostomy when possible due to impact on speech development and quality of life 1
4. Consider etiology in treatment planning - autoimmune causes like GPA require different approach than post-intubation stenosis 1, 4
5. Mitomycin C application shows benefit in extending time between procedures but doesn't eliminate need for repeat interventions 2

The management of glottic stenosis remains challenging with no single approach proving universally effective. Treatment decisions should prioritize securing an adequate airway while optimizing voice and laryngeal competence 6.