Upper airway stenosis presents a diagnostic and therapeutic challenge due to its often insidious nature, frequently misdiagnosed as asthma, bronchitis, COPD, or CHF. Its incidence varies, with neonatal subglottic stenosis reported at 0-2% and tracheal stenosis often linked to procedures like tracheostomy or intubation. Causes can be congenital or acquired, including trauma, infections, or neoplastic diseases, with associated comorbidities such as GERD/LPR, neurologic disorders, congenital heart disease, and genetic syndromes. Clinical classifications and presentations vary, encompassing conditions like laryngomalacia and subglottic hemangioma. Diagnostic tools include endoscopic evaluations, biopsies, and imaging modalities like CT or MRI scans. Management ranges from observation and medical therapies to surgical interventions, including endoscopic techniques like laser treatments and open procedures such as laryngotracheoplasty or cricotracheal resection. Stents, such as silicone or metallic ones, may be used to maintain airway patency but can cause complications like infection or granulation tissue. Innovative treatments, such as laryngeal transplants and tissue-engineered tracheal transplants, represent advancements in care.


FULL NOTES SLIDES FOR READING 


Reading Instructions:
  1. Using Next Button: Click the "Next" button at the bottom of the in-frame slider to move to the next slide.
  2. On Touch Devices: Swipe from right to left to view the next slide.
  3. Full-Screen Mode: For the best experience, switch to full-screen mode.






FULL SLIDES OUTLINE


Stenosis of Larynx & Trachea
Introduction
Airway stenosisTherapeutic and diagnostic challenge

Insidious presentation

Many times misdiagnosed as asthma/bronchitis, COPD, CHF
Incidence & trend
Neonatal subglottic stenosis  0 - 2.0% 
     (Metaanalysis, n=544)           (Walner et al.,2001)

 Tracheal stenosis following 
          tracheostomy  0.6-21%
          laryngotracheal intubation   6% to 21% 
                                                              (Grillo et al.,1995)

Clinical anatomy
 

Contd…
Adult and infant larynx
Tracheal lengths and diameters 
Bernoullie principle
Aetiology  
Congenital
Supraglottis
Laryngomalacia

Glottis
Laryngeal web

Subglottis
Congenital subglottic stenosis
Subglottic hemangioma 
Aetiology
Acquired
Laryngotracheal trauma – External
                                            Internal
Infection
Chronic granulomatous disease
Collagen Vascular disease
Neoplastic disease
Extrinsic compression
Foreign body

Laryngomalacia
Laryngomalacia
Etiology
     Unknown

Theories
       Anatomic theory
       Cartilaginous theory
       Neurologic theory
  Comorbidities
GORD/LPR (65–100%)

Neurologic Disease (20– 45%)

Secondary Airway Lesions (7.5 to 64%)

Congenital Heart Disease (10%)

Congenital Anomalies/Syndromes/Genetic Disorders (8–20%)
Spectrum of Disease
Mild disease  
       
Moderate laryngomalacia

Severe laryngomalacia
 
 Clinical presentation
Inspiratory stridor 

Phonation- normal

Feeding difficulties, failure to thrive

Respiratory distress, cyanosis 

Holinger’s Classification

Type 1: Anterior prolapse of  arytenoid and corniculate cartilages
Type 2: Tubular epiglottis which curls on itself
Type 3: Anteromedial collapse of arytenoids
Type 4: Posterior prolapse of  epiglottis
Type 5: Short aryepiglottic folds
  Investigation


 Contd…
90% casesNo intervention, Reassurance
Anti-reflux therapy

Surgical management
Endoscopic supraglottoplasty
Tracheostomy

Success rate 94% (Richter, 2008)

Laryngeal web
Congenital /Acquired

Vocal folds (Commonest)

 Clinical presentation
Mild dysphonia

Significant airway obstruction 

Stridor  Posterior interarytenoid web

1/3rd children SAL, commonly subglottic stenosis

Anterior glottic webs
 Endoscopic approach : Cold steel or CO2 laser

Open approach:  Laryngofissure +
       Web excision + keel placement

Contd…
Posterior glottic web
Open approach : laryngofissure + posterior costal chondral graft

Endoscopic techniques:
            - CO2 laser posterior cordotomy        +/- partial arytenoidectomy
            - Mucosal advancement flaps
            - Microtrapdoor flaps
            - Vocal cord lateralization  
            - Botox injections
Subglottic haemangioma
Vascular malformation

 Biphasic stridor
Barking cough
Normal or hoarse cry
Failure to thrive 
 Contd…
 Rigid bronchoscopy

Biopsy

Plain radiographs of neck (asymmetric narrowing of  subglottis) 
 Contd…
1. Observation Small lesions  
      Tracheostomy  
2. Steroid injection Small or medium-sized lesions 
 
3. Systemic Steroid  Partial regression 

4. Laser ablation CO2  and KTP lasers

5. Oral Propranolol


Subglottic & Tracheal Stenosis

           
Congenital tracheal stenosis
Membranous webs

Segmental stenosis

Whole organ stenosis
 Management
Membranous web
       - Endoscopic rupture and dilatation
       - KTP laser excision & ballon dilatation

Long segment tracheal stenosis or cartilaginous stenosis
       - Tracheal resection & anastomosis
       - Slide tracheoplasty
Tracheomalacia
Localized/Generalized

Primary/ Secondary

Spontaneous recovery
Tracheomalacia
Mild tracheobronchomalacia - No intervention

Severe tracheobronchomalacia
       - Long-term CPAP
       - Internal or external stenting
       - Segmental resection + cartilage grafting
Vascular compression
Ring

Sling
Paediatric subglottic stenosis
Congenital 5%

Acquired 95%


SGS in intubated neonates
1970s and 1980s: 0.9 % - 8.3 %
After 1983: < 4 %
After 1990: < 0.63 %


Incidence 11.3%  
                        (Manica et al., Laryngoscope ,2013)

Definition
Normal subglottic lumen diameter
Full term 4.5-5.5 mm
Preterm 3.5 mm

Subglottic stenosis
Full term <4 mm
Preterm <3 mm

Congenital subglottic stenosis

Incomplete recanalization  

Membranous or Cartilaginous 

History of recurrent croup



Acquired subglottic stenosis
Majority due to long-term or prior intubation
Duration of intubation
ETT size, material
Number of intubations
Traumatic intubations
Movement of  ETT
Infection
Pathogenesis  
Pathogenesis
 




Clinical presentation

Prior intubation

Progressive SOB

Noisy breathing
 Contd…
History 
Intubation records
Past medical history
Diabetes
Cardiopulmonary disease
Reflux
Systemic steroid use
 Contd…
Examination
Observe
Stridor or labored breathing
Retractions
Breathing characteristics on exertion
Voice quality 
Other abnormalities  




 Investigations
Flexible nasopharyngolaryngoscopy

Rigid laryngoscopy, bronchoscopy

Oesophagoscopy

Pulmonary function tests


Cotton-Myer grading  for Subglottic stenosis
 Contd…
McCaffrey
Contd…
Lano Classification : Based on involvement of glottis, subglottis and trachea
Stage I – one subsite involved 
Stage II – two subsites involved 
Stage III – three subsites involved 


 Radiological investigations
Plain films – Neck and chest
CT
MRI



 Ultrasonography
Management  
Medical
Observation
Tracheostomy
Endoscopic Treatment
Open procedure
 Contd…
Medical
Diagnosis and treatment of reflux
Assess general medical status
Optimize cardiac and pulmonary function
Control diabetes
Discontinue steroid use before LTR
 Contd…
Observation

Reasonable in mild cases 

Repeat endoscopy every  3-6 monthly

Surgical Principles
Establish satisfactory airway  

Decannulation

Preservation of laryngeal functions
Anaesthesia
Surgical modalities
 Endoscopic approach
Dilation +/- stenting
Laser +/- stenting
Cryotherapy
Microcauterization
Excision of scar tissue 


 Contd…
Open procedure
Laryngotracheoplasty  
Laryngotracheal reconstruction
Tracheal Resection with primary anastamosis

Endoscopic Approach
Less morbidity
Shorter hospital stay
Earlier return to work
Tolerance of repeated procedures
Contd…
Factors associated with failure
Previous attempts 
Circumferential scarring
Loss of cartilage support
Exposure of cartilage 
Arytenoid fixation
Combined LTS with vertical length >1cm

Endoscopic Dilatation
Multiple procedures
Lower success rate
Cannot undergo open procedures


CO2 Laser
Primary or as an adjunct

Re-epithelialization
Minimal deep tissue injury
Haemostasis
Preservation of mucosa
Contd…
Airway fire

Laser plume

Thermal injury
Laser excision of subglottic stenosis
Laser excision of subglottic stenosis
Contd…
Endoscopic  laser treatment
CO2 laser radial incision
15% success

CO2 laser with steroid injection
18% success

CO2 laser with mitomycin-C topical application
75% success                        (Shapshay et al.,1998)
Microsurgical Debridement
Precise

Reduced injury to normal mucosa 

less pain  

Decreased operative time
External approach
Indications
Grades III and IV subglottic stenosis
Failed endoscopic management
Cicatricial scarring
Exposed perichondrium or cartilage  
Combined laryngotracheal stenosis
External approach
Anterior cricoid split
       
Anterior Cricoid split & cartilage graft
Posterior Cartilage Graft
Anterior & posterior cricoid split & cartilage graft
Cricotracheal Resection

Indication
    grade III & IV SGS 

>3 mm margin between stenosis and vocal cords


CTR Contd…
CTR Contd..
CTR Contd..
Cricotracheal Resection 
Acquired Tracheal Stenosis
Three types:
     - Cicatricial
     - Anterior wall collapse 
     - Complete stenosis
 Management
Cicatricial tracheal stenosis
        - CO2 laser excision
        - Dilatation
Anterior wall collapse
        - Augmentation with sternothyroid muscle or cartilage graft +Stent
Complete stenosis
       - Tracheal resection & anastomosis


Tracheal resection & anastomosis
Tracheal resection
Tracheal resection
Neck flexion
Tracheal resection anastomosis
2-3 cm (4-6 rings) 
 
Laryngeal resection maneuvers  
Suprahyoid release
Infrahyoid release
Intrathoracic tracheal mobilization 
Laryngeal release
Supra-hyoid release (Montgomery)

2-3 cm

Dysphagia

Laryngeal release
Infra-hyoid release (Dedo)

2.5 cm
 Intrathoracic manoeuvres
Pulmonary ligament
Mainstem bronchus
Pericardial dissection  


6.4 cm  

Maintaining patency after laryngotracheal surgery
Stents
Keel
Mitomycin
Steroids
Scar Inhibitors
Mitomycin C
Antineoplastic and antiproliferative

5-FU & B-aminopropionitrile
Inhibit collagen cross-linking and scar formation 

TGF-β


  Contd…
Stenting
Ensure adequate airway during wound maturation

Prior to definitive  resection/treatment

Palliation

Types of Stents
Laryngeal

Aboulker Stent
Montgomery LT-Stent
Laryngeal Keel
Types of Stents
SILICONE TRACHEAL STENT
Long-term tolerability
Easily removable
Poor mucocilary clearance
Can migrate
METALLIC TRACHEAL STENT
Incorporates into mucosa
Difficult to remove
Better mucociliary clearance
More reaction and granulation tissue

Tracheal Stents

Montgomery T-Tube
Healy Paediatric T-Tube
Eliachar LT-Stent
Monnier LT-Mold
Insertion of a T-tube



Complications
Local infection
Mucosal ulceration
Granulation tissue
Ischaemic mucosal injury

Recent advances
Laryngeal transplant

Kluyskens and 
    Ringoir (1969)

Strome et al. 
     (1998)
 Contd…
Tissue-engineered tracheal transplant
         (Baiguera et al., 2010)
THANK YOU