Abstract

Objectives:
Supraglotic stenosis is an unusual subset of laryngotracheal stenosis that has distinctly different causes, symptoms, and treatment options.
A retrospective chart review on all adult patients with diagnosis of supraglotic stenosis.
Clinical records Videolaryngoscopic examinations Operative and clinic procedure records

Methods:

All patients had a minimum follow-up of 12 months.

Abstract
Results: 8 patients with supraglottic stenosis:
5 had a history of radiation therapy (62.5%)
3 associated with autoimmune disorders

Dysphagia (7cases, 87.5%)

2 with complete pharyngoesofageal stricture

3 required a percutaneous gastrostomy tube

All of the patients need more than one surgical intervention 1 of 2 cases of acute intraoperative supraglottic edema necessitated emergent tracheostomy.

Abstract
Conclusions: Supraglottic stenosis is rare condition that is often associated with external-beam radiation or autoimmune disorders. The majority had coexisting dysphagia, often associated with pharyngeal or esophageal stricture. Although endoscopic treatment (CO2 laser) is a viable option, pulsed KTP laser appears to be effective and potentially safer alternative.

No specific incidence or prevelance of supraglottic stenosis exists in the medical literature. The clinical presentation of supraglottic stenosis:
o Shortness of breath at rest or with exertion o Inspiratory stridor o Voice alterations due to resonance changes o Dysphagia

In previous literature, multiple causes and various treatment for laryngeal stenosis have been described. In this case series, they report the management of 8 cases of supraglottic stenosis performed by the senior author over a 12-year period.

A restrospective chart review was conducted on 8 adult patients at their institution with diagnosis of supraglottic stenosis (Jan 2000 March 2012).
All patients had a follow-up of at least 12 months from initial treatment.

The patients were treated with 1 or more of the following therapies:

CO2 laser

532-nm pulsed KTP (potassium titanyl phosphate) laser

Balloon dilatation Mitomycin C applicationn

Intralesional corticosteroid injections

CO2 laser
Operating room via endoscopic approach In the office setting under local anesthesia

KTP

laser

In the office setting only

Were performed in contact mode with following settings: 30W, 20-ms pulse width, 2pps, and a mean of 301.3 J per treatment

Both CO2 and KTP laser approaches: Creating wedge resections at region of greatest scar volume, with the intervening tissue left largely undisturbed. For larger scar formation, serial excisions were performed in separate areas of stenosis to avoid circumferential trauma that could induce further stenosis. Only membranous stenosis was treated (no cartilage was excised).

Topical laryngeal anesthesia was achieved with 4% lidocaine hydrochloride (5-7ml) via a flexible working channel, distal tip laryngoscope, transoral cannula or percutaneous before the procedure.

All application of mitomycin C (0.4mg/ml) and steroid injections (10mg/ml) were performed in operating room.
Controlled radial expansion balloons were used to dilate the stenotic tissue (in operating room and office setting).

The assessment of treatment success included:

Pretreatment and posttreatment endoscopic examination Subjective symptom reports

The images from clinic-based procedures (preprocedure and postprocedure) were recorded by means of nStream software.

 All 8 patients with supraglottic stenosis Age: 37 90 years Follow up: 12 -140 months All patients had sparing of glottis with fully intact vocal fold mobility. 6 of patients demostrated isolated supraglottic stenosis. 2 had extension of their stenosis superiorly (to the level of oropharynx and nasopharynx) The dimensions of stenosis at supraglottic level: 1x1 mm to 10x6 mm

 5 of the patients Have history of external-beam radiation therapy for head and neck squamous cell carcinoma that originated from: nasopharynx, hypopharynx, glottis and unknown. Time from completion of radiation therapy to onset of symptoms: 18 to 120 monts. The remaining 3 cases were related to autoimmune disorders: Sarcoidosis Erosive lichen planus Cicatricial pemphigoid

 All of the patients exhibited some degree of airway obstruction

that ultimately required intervention.

7 patients had a history of dysphagia

3 with mild symptoms were managed successfully with basic compensatory swallowing techniques (chin positioning) The other patient with recurrent esophageal stricture required frequent dilatations

3 patients required a percutaneous gastrostomy tube for all nutritional intake.

2 with complete pharyngoesophageal strictures 1 experienced severe aspiration secondary to a combination of reduced pharyngeal contraction and retroversion of epiglottis and associated sensory deficits.

 Surgical treatment result in significant improvement of

dyspnea but all patients need more than 1 surgical intervention because of symptomatic reccurent airway stenosis.
Mean: 4.0 treatments When excluded patient 6 (with severe tendency to experienced current stenosis) : Mean 2.8 treatments.

The interval between the treatment: 1.66 to 85 months

 7 patients underwent clinic-based KTP laser partial

resection:

6 patients tolerated well (4 treated with CO2 laser in operating room) 1 patient unable to tolerate on 2 separate attempts was subsequently treated in the operating room by endoscopic CO2 laser procedure.

1 patient with cicatricial pemphigoid was managed

conservatively (without KTP or CO2 laser) and has maintained widely patent supraglottic airway (follow-up: 8 months).

Serial corticosteroid injections Balloon dilatations

 Additional observation on 2 cases of acute intraoperative

supraglottic edema in the setting of suspension laryngoscopy and jet ventilation who had previously undergone radiation therapy:

1 of patients successfully managed conservatively by immediate cessation of surgery after recognition of the edema high dose parenteral corticosteroids racemic epinephrine treatments The other patient required immediate intubation with 4.0 endotracheal tube and tracheostomy because of rapidly progressive supraglottic edema.

Discussion
Given the rare incidence and the scarce medicine literature concerning the supraglottic stenosis, this study aims to define the causes and management strategies of this rare

disease.
External beam radiation was found to be the most common

cause. The second most common cause was autoimmune disorders.

Discussion
The interventions were directed at airway concerns rather than dysphagia. The causes of dysphagia:
Location of stricture

Decreased sensation
Decreased pharyngeal contracture Poor epiglottic retroversion

Discussion
Clinic-based laser partial resection under topical anesthesia was

well-tolerated and safe method without complications:

no significant bleeding no reactive airway edema

Therefore, CO2 laser treatment in operating roomwas

has aiming beam less expensive fiber more precise ablation

transitioned to clinic based KTP laser. The advantages of KTP laser:

Discussion
Current protocol:
A clinic-based KTP laser for patients with stable, noncritical

supraglottic stenosis. For patients who cannot tolerate or fail to achieve an adequate airway with the KTP laser procedure, perform endoscopic treatment with CO2 laser. Topical mitomycin C is used as part of standard airway stenosis protocol. Balloon dilatation is used occasionally as long as there is no risk of circumferential tearing of the stenotic region.

Discussion
Airway edema may have been secondary to mechanical pressure on the epiglottis caused by suspension laryngoscopy due to lymphatic disruption that is present

from previous radiation therapy.

The use of laryngoscope that is placed in vallecula, such

as Lindholm laryngoscope may reduce the chance of progressive edema formation.

Supraglottic stenosis is a rare condition that is often associated with external-beam therapy or autoimmune disorders. All of patients experienced some degree of symptomatic airway obstruction and majority had coexisting dysphagia. All patients required additional procedures because of reccurence of stenosis. Pulsed KTP laser is an effective and potentially safer alternative.