What are the treatment options for subglottic stenosis?

Treatment Options for Subglottic Stenosis

The optimal treatment for subglottic stenosis depends on the severity, etiology, and location of the stenosis, with endoscopic techniques being first-line for mild to moderate cases and surgical reconstruction reserved for severe or recurrent stenosis. 1

Diagnostic Evaluation

• Endoscopy: Microlaryngoscopy and bronchoscopy are crucial to determine:

  • Location and extent of stenosis
  • Severity (using Myer-Cotton grading system)
  • Associated pathology 1

• Imaging: Contrast-enhanced CT scan and/or MRI to assess:

  • Extent of stenosis
  • Cartilage involvement
  • Treatment planning 1

Treatment Algorithm

1. Endoscopic Management (First-line for mild to moderate stenosis)

• Balloon Dilation: Mechanically expands the narrowed airway segment

  • Can be used alone or in combination with other techniques
  • May require repeat procedures due to significant recurrence rates 1, 2

• Laser Treatment:

  • CO₂ laser for precise management with radial incisions
  • Particularly effective for excision/ablation of stenotic tissue 1, 2

• Adjunctive Measures:

  • Mitomycin Application: Significantly extends time between procedures (by approximately 157 days) 2
  • Steroid Injection: Commonly used but has not shown significant impact on surgical intervals 2

2. Medical Management

• For Inflammatory Stenoses:

  • Immunosuppressive therapy as first-line treatment 1
  • Surgical approaches reserved for fibrotic or non-responsive cases

• For Acute Exacerbations:

  • β-adrenergic agents (e.g., racemic epinephrine) for temporary relief by reducing edema
  • Systemic corticosteroids, particularly during respiratory infections 3, 1

3. Surgical Options (For severe or recurrent stenosis)

• Anterior Cricoid Split:

  • Allows widening of subglottic space
  • May prevent need for tracheostomy in appropriate candidates 3

• Laryngotracheal Reconstruction:

  • Used for gradual correction of subglottic stenosis
  • Often requires temporary tracheostomy 3, 1

• Cricotracheal Resection with Anastomosis:

  • For subglottic and tracheal stenosis 4

• Tracheostomy:

  • Indicated when other means of correcting obstruction have been ruled out
  • Note: May delay speech development and requires specialized care 3

Special Considerations

Etiology-Based Approach

• Congenital Stenosis:

  • Often requires surgical correction
  • May need tracheostomy 1

• Post-intubation Stenosis (accounts for ~90% of acquired cases):

  • Generally responds well to endoscopic management
  • Less likely to have vocal fold immobility or cartilage involvement 4

• External Injury Stenosis (trauma, strangulation):

  • Often has worse outcomes
  • Higher rates of vocal fold immobility and cartilage involvement
  • More likely to require external surgical procedures 4

• Autoimmune-Related Stenosis:

  • Treatment decisions should be based on clinical symptoms
  • May require immunosuppressive therapy before considering surgical options 1

Prevention

• Risk factors for developing stenosis include:
  • Intubation for 7+ days
  • Three or more intubations
  • Inappropriately sized endotracheal tubes 1

Monitoring and Follow-up

• Regular endoscopic evaluation to assess treatment response
• Monitoring for signs of recurrence, especially after endoscopic procedures
• Vigilance during respiratory infections, which may exacerbate symptoms 3

Pitfalls to Avoid

• Delayed Diagnosis: Post-extubation stridor should prompt evaluation for stenosis
• Inappropriate Tube Size: Using endotracheal tubes that are too large significantly increases stenosis risk
• Overlooking Associated Conditions: Vocal cord immobility or laryngeal clefts may coexist and affect management
• Limited Endoscopic Indications: Endoscopic procedures are most effective for short, recent, grade I or II mucosal stenosis; more severe cases typically require external approaches 1, 4