PostintubationSubglotticStenosis

AbdelWahabM,ElDegwiA,ElOkdaM,EmamH&YousefK.Shabana
E.N.T.Dept.MansouraFacultyofMedicine

ORLDepartment,FacultyofMedicine,
MansouraUniversity,
Mansoura,Egypt

Correspondence:
AbdelWahabM.,
ORLDepartment,AudiologyUnit,
FacultyofMedicine,
MansouraUniversity,
Mansoura,Egypt
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Runningtitle:
PostintubationSubglotticStenosis

Abstract:
Subglotticandproximaltrachealstenosesarethemostcripplingcomplicationsofendotracheal
intubation1Therehavebeeninnumerableapproachestothemanagementviaendoscopictechniques
or open surgical procedures, which bear testimony to the difficulty in obtaining predictably
satisfactoryresults3.Aimofourprojectisevaluationoftheefficacyandlongtermresultsofthe
combinedapproach(endoscopicandcricoidsplit)inmanagingpostintubationsubglotticstenosisin
adults.
This study was done on nineteen patients of postintubation subglottic stenosis. Thorough
endoscopicdiagnosisbyvideotelelaryngoscopyand(CT)scanwasperformedforallpatients.The
stepsoftheprocedureincludea)Microlaryngoscopicexcisionofthestenoticfibrosisassistedby
microcoagulationusingBoucheiersinstruments,b)Splittingtheanteriorcricoidarchforcomplete
excisionoffibrotictissues.C)StentingtheinteriorofthelarynxbysiliconeTtube.Thepatients
werefollowedupfortwoyears.
Thestudygroupconsistedof 19 males. Themeanageofthepatientswas 36.73.7 yearswitha
rangeof 1468 years. Nopatientsdevelopedstridorafterextractionofthestentandsucceededto
depend on their natural airway. Recurrence of the scar occurred in 37% of cases. Early
tracheostomyincomatosedpatientsismuchmore betterthanprolongedendotrachealintubationto
avoid postintubation subglottic stenosis. Silicone tubes must be used only for prolonged
endotracheal intubation. This is attributed to the innert nature of silicone that could avoid
subglotticstenosis.Adultsubglotticregionisfullygrownandso,shouldstenosisoccur,excision
andstentingisexpectedtoleadtomarkedimprovement.

Keywords:Subglotticstenosis,Postintubation.
Postintubationsubglotticstenosis

Introduction:
Acquiredsubglotticstenosisduetoendotrachealintubation isthepredominantcauseof
subglotticstenosisthatrequiressurgery. Thereisatwofoldchallengeintreatingthisproblem:(1)
toaccuratelyandpreciselydefinethesite(s)andnatureoftheobstruction,and(2)tochoosean
appropriateprocedureforsurgicalcorrection1.
Surgicalcorrectionaimstoprovideanadequatelyenlargedlumenwhilepreservingvocalquality
andairwayprotection.Treatmentsuccessispredicteduponathoroughpreoperativeevaluation
and tailoring the repair plan to address the severity and location of the individual lesion.
Understandingthecomplexpathophysiologyofsubglotticstenosisalongwiththewidevarietyof
availablesurgicaloptionswillaidthesurgeoninachievingasuccessfuloutcome2.
Therehavebeeninnumerableapproachestothemanagementviaendoscopicoropensurgical
techniques,whichbeartestimonytothedifficultyinobtainingpredictablysatisfactoryresults3.
Endoscopicmanagementissuccessfulinthemajorityofpatientsiftheyareselectedproperly.
Abundantscarringinvolvingthewholecircumferenceorextendingbeyondonecmverticallymay
jeopardizetheendoscopicmanagement.Moreover,endoscopicmanagementdoesnotprecludethe
useofopensurgicalproceduresifnecessary4.Modernopensurgicalmanagementincludesawide
variety of surgical procedures. These can broadly be divided into two groups. First,
laryngotrachealreconstruction(LTR)procedures,inwhichthecricoidcartilageissplitandthe
framework is expanded with various combinations of cartilage grafts and stents andsecond,
cricotrachealresection(CTR)whereasegmentalexcisionofthestenoticsegmentisdoneandan
endtoendanastomosisisperformed5.

Postintubationsubglotticstenosis

Cricoidsplitwithoutgraftingorstentinghasbeencriticizedbecausesplittingthecricoidduring
hightracheotomyhadbeenbelievedtobetheprincipalcauseofsubglotticstenosisformanyyears.
Thisarticleisdesignedtoevaluatetheanteriorcricoidsplit(ACS)approachinmanagingpost
intubationsubglotticstenosisinadults,aidedbyendoscopicexcisionofthecephalicpart.We
analyze the subglottic pathology, and determine the efficacy, and longterm results of the
managementprocedure.

Pathophysiology
Themostcommoncauseofsubglotticstenosisismechanicaltraumafromanendotrachealtube
cuff. If the cuff inflation pressure meets or exceeds the capillary perfusion pressure of the
subglotticmucosacontactingit,ischemiaandnecrosisofthemucosaoccur.Theintubationtime
requiredforthiscomplicationto occurdependsonboththedegreeofmechanicaltraumaandthe
capillaryperfusionpressureofthesubglotticmucosa.Withischemiaandnecrosisofsubglotticor
tracheal mucosa, the underlying soft tissue and cartilage could be exposed to bacterial
contamination.Mucociliarystasisalsooccurs,andthesubsequentaccumulationofsecretionsalso
contributes to local tissue infection. If the process continues, the infection penetrates the
perichondriumtoreachthecartilage.Theresultingchondritisdestroys cartilage,andthesupport
oftheairwayislost8.Theprocessmayreverseatanypoint,andhealingbegins.Scartissueforms
andcontractscircumferentiallyinthesubglottis,formingacicatrixandthusreducingthecross
sectional area of the airway. The degree of stenosis depends on the severity of the original
infection, the extent of cartilagedestruction,andtheamountofscarring.Symptomstypically
developinonetothreemonthsfollowingextubation.

Postintubationsubglotticstenosis

Patientsandmethods:
Thisstudywas doneonnineteenpatientswithpostintubationsubglotticstenosisforwhom
tracheotomywasperformed.ThepatientswerepresentedtootolaryngologyserviceinMansoura
University Hospital Mansoura, Egypt for seek of tracheotomy decannulation. The study was
conductedintheperiodofJanuary 1997 toJanuary 1999. Completehistorytakingandthorough
endoscopicdiagnosisbyvideotelelaryngoscopyrevealedsubglotticstenosisinallofthem.Portex
styletswereusedasmeasureofairwaydiameter.Thestyletthatbarelypassedthroughthestenosis
wasconsideredtheactualmeasure.Theavailablestyletshadthreedifferentsizesaccordingtotheir
diameterandlength: small (2.1mmdiameterand 34cmlong), medium (2.9mmdiameterand 38cm
long), andlarge (3.9 diameterand 45cmlong). Endotrachealtubeswereusedasmeasureofairway
diameterlargerthan3.9mm.Verticaldimensionofthestenosiswasalsomeasuredbyusingthe
portexstylets.First,thestyletwasintroducedthroughthestenoticsegmentuntilitcouldbejust
visualizedbeepingthroughthecaudalendofthestenosis. Thiswasaidedbya 2.7mm 30 Hopkins
telescopeplacedatthetracheotomy.Thestyletwasmarkedwhereitpassedincisors.Thestylet
wasthenwithdrawntothecephalicendofthestenosisandmarkedagainwhereitpassedthe
incisors.Thestyletwasthenwithdrawntotheglottisandmarkedforthethirdtime.Thedistance
betweenthemarksindicatesthelengthofthestenosisandthedistancebetweenthestenosisand
the glottis. Computerizedtomography(CT)scanwasperformedforallpatientstoassessthe
laryngealcontouranddiameter.Criteriaforentrytothestudywereairwaydiameteroflessthan
Postintubationsubglotticstenosis

5mm (fig. 1), andatleasttwoyearsoffollowupafterrepair. Patientswhohadlaryngoscleroma,

laryngealfractures,seriouschestinjuries,cardiopulmonarydisease,orothersystemicillnesses
wereexcludedfromtheanalysis.Caseshavingmorethanonecmverticaldepthofstenosisinthe
subglotticregionwerealsoexcludedfromthestudy.

Technique:
A combined technique of both endoscopic and anterior cricoid split approaches was
performedonallcasesundergeneralanesthesia.
Microlaryngosurgery was firstly done toexcisethecephalicendofthestenoticpartbyusing
microcoagulatorofBouchier (fig. 2). Then, ananteriortransverseneckincisionwasmadeatthe
levelofthecricoidcartilage.Subplatysmalflapswereelevatedsuperiorlytothethyroidnotchand
inferiorlytothesuprasternalnotch.Thestrapmuscleswereseparatedverticallyinthemidlineand
retracted.Theanteriorcricoidringwasdividedverticallywitheitheraknifeorasaw,accordingto
the degree of ossification. The goal was to open the lower part of the stenotic segment. To
maximallypreservevoice,greatcarewasexperiencedinordernottoextendtheincisiontothe
anteriorcommissure.Submucosalresectionofscartissueswasattemptedmeticulouslytoavoid
scarregenerationthatcouldhappenifmuchmucosahasbeendamaged.TheMontgomeryLong
TrachealTTubeINVOTECofouterdiameter1214mmwasinsertedintheinteriorofthe
larynx (fig. 3). Thewholetubewaswithdrawnfromthetracheotomybyusingacatheterpassing
throughtheendoscope,theverticallimbwassetjustbelowthevocalcords,andthehorizontal
limbwasemergingfromthetracheotomy.TheTtubewasleftinplacefor6months.

Postintubationsubglotticstenosis

Results:
Thestudygroupconsistedof 19 males. Themeanageofthepatientswas 36.73.7 years
witharangeof 1468years.
Innerdiameterofstenosisinallcaseswaslessthan5mm.Itwasbelow2.1mminseven,2.1
2.8mminfive, 2.93.8mminfive, and 3.95 mmintwo(table 1). Firmscartissueswerenotedin
13cases(average5.6monthsafterintubation),andtheremainingsixcasesshowedvoluminous
grayishglisteningsofttissues(average3.3monthsafterintubation).Spilloveroccurredinthree
patients,whowerereadmittedtothetheaterfortrimmingoftheupperendsoasnottotouchthe
vocalfolds.
DecannulationoftheTtubestentwasdonewithoutdifficultyin 19/19 (100%) ofcases, noone
developedstridorafteritsextraction,andallpatientssucceededtodependontheirnaturalairway.
Theadequacyofairwaywasfurtherlyconfirmedobjectivelybyintroducingtheappropriatetube
sizefortheage.Inallcases,thetubewaseasilyadmittedintothesubglottiswithadditionalleak
withnormalventilationpressureupto 25cmwater. Followupofthepatientsshowedrecurrence
of scar tissue in7/19 patients (37%) at the end of the twoyear period. Reductionofairway
diameterby2mmintheanteriorpartatthesplitsiteofthecricoidhasoccurredinthree,and
circumferentialscarringhasoccurredinfour.However,theydidnotexperiencestridorinthe
Postintubationsubglotticstenosis

ordinarylifestyle.

Table1:Preoperativesubglotticairwaydiameter
Airway
diameter

<2.1mm

2.12.8mm

2.93.8mm

3.95mm

Numberof
cases

Discussion
Prolongedendotrachealintubation,withpossibleinjuryofsubglotticmucosa,mayleadto
subglotticstenosis.Thisstudyincluded19adultmalepatientswithpostintubationsubglottic
stenosis,presentedtoENTdepartmentwithtracheotomy.ThoroughENTexaminationincluding
videotelelaryngoscopy,measuringportexstylets,andCTconfirmedthepresenceofsubglottic
stenosiswithan airwaydiameteroflessthan 5mminallofthem.
Microlaryngosurgery was firstly done toexcisethecephalicendofthestenoticpartbyusing
microcoagulator of Bouchier. This helps avoid splitting the thyroid cartilage and anterior
commissurethatmayresultinwebformationofanteriorcommissureandsubsequentdysphonia.
Althoughrecurrenceofscarringoccurredinmorethanonethirdofthecases(37%)inthetwo
yearperiodoffollowup,itseemsalogicalsequenceofsurgeryondiffusefibroustissues.We
expectedthatthesubmucosalexcisiontechniquesaswellastheuseofinertsiliconestenthelp
preserveawiderareaofintactmucousmembraneandlimittheamountofsubsequentfibrosis.
TheMontgomeryTtube(aperformedhollowsiliconetube)hastheadvantageofbeingbotha

Postintubationsubglotticstenosis

stent and a tracheotomytube.Itismadeofsilicone,thuscausinglittletissuereaction,andis

sufficientlysoftsoasnottoinjuretheliningstructureofthelarynx.Itisselfsecured,relatively
easytoplaceandremoveundergeneralanesthesia,andallowsnormalrespirationandspeech.
During surgery the upper end of the tube was adjusted by microlaryngoscopy to avoid
postoperative spillover. The tube was left in place for six months. The Montgomery T tube,
however,hastheriskofobstruction,especiallywhentheinnerdiameterissmall.Thisriskhasbeen
limited in our series, being all adults, as we used the size 1214mm. Proper suctioning help
minimizetheriskofobstructioncausedbyaccumulationofmucoidandviscidsecretions.The
patientsfamilyandcaregiversneedtobeawareofthepossibleriskofobstructionandshouldbe
welltrainedandequippedforemergentremovalofthetubeandreplacementwithatracheotomy
tubeshouldobstructionoccur.
In 1980, Cotton6 publishedtheanteriorcricoidsplitprocedureasanalternativetotracheotomyin
theneonatewhocouldnotbesuccessfullyextubated. In 1988, 67 patientswhohadundergonethis
procedurewerereportedand 47 (70%) hadbeensuccessfullyextubated7.Currentlythisoperation
isperformedtoavoidatracheotomyinthemajorityofchildrenwithearlysubglotticstenosiswho
failextubation. Ourresultsshowed 100% decannulationrate, thismightbeattributedtothelarger
dimensionsofairwayintheadultlarynx.
In1989Cottonetal10publishedanupdateoftheCinncinatiexperienceofLTR.Grade1(upto
50%obstruction)patientsmostlydidnotrequiretracheotomiessodecannulationrateswerenot
given.129procedureswereperformedon 98patientswithgrade 2 (51%70% obstruction) and
97%wereultimatelydecannulated.Ninetyfourprocedureshadbeencarriedouton 80patients
with grade 3 (70%99% obstruction) and ultimately 91% were decannulated. Twentyeight
procedureshadbeencarriedouton 25 patientswithgrade 4 (nodetectablelumen) andultimately

Postintubationsubglotticstenosis

72%weredecannulated.In 1992Ochietal11 througha 10yearreviewpublisheddecannulation

ratesof88%forgrade1,89%forgrade2,78%forgrade3,and50%forgrade4subglottic
stenoses.
Withthe introduction of CTR5, it is natural to compare outcomes with the previoussurgical
techniques.Inthecomparisonofdifferentsurgicaltechniquesforairwayreconstruction,theuseof
decannulationrateasaprincipaloutcomemeasurehasseverallimitations.First,mostgrade1,
some grade 2, and evenafewofgrade3patientsdidnothaveatracheotomytobeginwith.
Second,patientsmayrequireatracheotomyforreasonsotherthansubglotticstenosis.Thisisnot
uncommon.Surgerymaysuccessfullycorrectthesubglotticproblembutthepatientmayremain
tracheotomy dependent due to different causes like tracheomalacia, supraglottic collapse or
suprastomalcollapseandgranulation.Inthissituationthesurgeryforsubglotticstenosismay
reallybesuccessfulalthoughthepatientisadecannulationfailure.Despitethis,decannulationrates
for patients with severe grade III and grade IV subglottic stenoses remain broad and easily
understandablemeasureofsuccess.Furthermore,inthepublishedliteratureitisusuallytheonly
outcomemeasureavailable.

Postintubationsubglotticstenosis

10

Conclusion:
1. Earlytracheotomyincomatosedpatientsismuchbetterthanprolongedendotrachealintubation
toavoidpostintubationsubglotticstenosis.
2. Siliconetubesmustbeusedonlyforprolongedendotrachealintubation.Thisisattributedtothe
inertnatureofsiliconethatcouldavoidsubglotticstenosis.
3.Adultsubglotticregionisfullygrownandso,shouldstenosisoccur,excisionandstentingis
expectedtoleadtomarkedimprovement.
4.ALongerfollowupperiodisrecommendedtoassessthelongtermoutcomeofthespecial
procedure.
Postintubationsubglotticstenosis

11

5.Thelowrateofrecurrenceinouradultseriesmaybeattributedtothelowrateofscar
reformationwithsubmucosalexcisiontechnique,

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