Glottic and Subglottic Stenosis: Evaluation and Surgical Planning

Abstract

■ Laryngotracheal airway obstruction is generally caused by trauma to the upper airway from prolonged endotracheal intubation, which leads to pressure necrosis, granulation tissue, localized infection, and cicatrix formation. The risk of airway stenosis increases markedly after 10 days of intubation.

■ Tracheostomy can lead to delayed tracheal stenosis (typically 1–3 months after decannulation) and is typically due to collapse/contraction of the cartilaginous support.

■ Nontraumatic subglottic narrowing should be investigated thoroughly to rule out associated inflammatory and neoplastic conditions, such as Wegener’s granulomatosis and laryngopharyngeal reflux disease.

■ Physical examination of a patient with suspected laryngotracheal stenosis should include a flexible laryngoscopy and tracheoscopy (down to the carina) in the clinic setting, using topical lidocaine for endolaryngeal/tracheal anesthesia.

■ Radiographic airway studies are essential if external compression is suspected, but do not replace a laryngoscopic airway evaluation.

■ Corrective surgical procedures for laryngotracheal stenosis include endoscopic management (microlaryngoscopy with laser radial incisions with dilation), indwelling stent placement, and external treatments (cartilage expansion grafts vs. segmental resection and primary anastomosis).

■ In patients with laryngotracheal stenosis, the least invasive surgical procedures are attempted first (unless contraindicated), reserving external procedures for those cases that fail to respond to an endoscopic approach.

■ Medical comorbidities (diabetes mellitus, restrictive or obstructive pulmonary disease, and obstructive sleep apnea) may have a significant negative impact on the surgical outcome and should be carefully considered prior to undertaking these treatments.