What are the treatment options for subglottic stenosis?

Treatment of Subglottic Stenosis

For severe subglottic stenosis, anterior cricoid split should be attempted first to avoid tracheostomy, but if this fails or the patient doesn't meet criteria, tracheostomy with subsequent laryngotracheal reconstruction is necessary. 1

Surgical Management Algorithm

Mild to Moderate Stenosis (Grades 1-2)

• Endoscopic approaches are first-line treatment for lower-grade stenosis, including balloon dilation, laser radial incisions (CO2 laser or cold knife), or combination techniques 2, 3, 4
• Adjunctive mitomycin application significantly extends the interval between procedures (from 317 to 474 days), making it a valuable addition to endoscopic treatment 4
• Serial intralesional steroid injections (SILSI) can serve as primary treatment for grade 1 stenosis or as adjuvant therapy for grade 2 stenosis, with mean surgery-free interval increases of 481 days 5
• Success rates for endoscopic management as primary treatment reach 58% when properly selected 3

Severe Stenosis (Grades 3-4)

• Anterior cricoid split is the preferred initial surgical approach when stenosis is severe but the patient meets criteria, allowing subglottic space widening and healing without tracheostomy 1
• If anterior cricoid split fails or patient doesn't meet criteria, tracheostomy is mandatory to bypass obstruction, though this delays speech development and increases care complexity 1
• Laryngotracheal reconstruction can be performed gradually after tracheostomy placement using various surgical techniques 1
• Complete high subglottic stenosis not amenable to resection may be managed with tracheal rendezvous technique and T-tube placement as an alternative to open resection 6

Inflammatory/Vasculitic Stenosis (GPA-Associated)

• Immunosuppressive therapy (glucocorticoids plus other agents) is recommended over surgical dilation alone for actively inflamed subglottic stenosis with GPA 1
• Surgical dilation with intralesional glucocorticoid injection is more appropriate for longstanding, fibrotic stenoses unresponsive to immunosuppression 1
• Concurrent medical and surgical treatment may be considered for stenoses requiring immediate intervention due to critical narrowing 1

Endoscopic Technique Selection

Neither balloon dilation alone, laser alone, nor combination techniques significantly alter surgical intervals, so technique choice should be based on stenosis characteristics and surgeon expertise 4. However:

• Laser resection with endoluminal stenting (Dumon prosthesis) can optimize surgical timing or provide palliation without tracheostomy, though patients require permanent aerosolized therapy and periodic bronchoscopy 2
• Balloon dilation under direct visualization or fluoroscopic guidance effectively treats distal tracheal and bronchial stenoses 1
• Electroresection is an alternative for fixed airway obstruction 1

Medical Management

Acute Exacerbations

• Racemic epinephrine provides temporary relief for mild to moderate stenosis during upper respiratory infections by reducing superimposed edema 1
• Systemic corticosteroids have been used early in stenosis course, though formal efficacy assessment is lacking 1

Adjunctive Pharmacotherapy

• Pharmacotherapy aims to reduce edema on already-narrowed airways and minimize resistive pressure losses at the glottic level 1

Critical Pitfalls to Avoid

Tracheostomy should only be undertaken after exhausting other obstruction-correction methods because it delays speech development and increases specialized care requirements 1. The evidence strongly emphasizes this as a last resort.

Grade of stenosis does not significantly alter endoscopic surgical intervals, but success likelihood with minimally invasive procedures as primary treatment decreases with worsening initial stenosis grade 3, 4. Specifically, grade 3 stenosis patients who failed prior endoscopic treatment typically require tracheal resection and do not benefit from SILSI 5.

Steroid injection alone does not extend surgical intervals, but mitomycin application does—this is a key distinction when planning adjunctive therapy 4.

Outcomes and Follow-Up

• Endoscopic interventions achieve resolution in 58% of properly selected patients as primary treatment 3
• When used adjunctively after laryngotracheoplasty, endoscopic procedures achieve 60% success for symptom resolution and decannulation 3
• Surgical resection patients (laryngotracheal resection) demonstrate excellent long-term outcomes with normal breathing and speech at 15 months to 12 years follow-up 2