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Subglottic Stenosis: Current10.5005/Jp-Journals-10001-1272 Concepts and Recent Advances Review Article

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Subglottic Stenosis: Current10.5005/Jp-Journals-10001-1272 Concepts and Recent Advances Review Article IJHNS Subglottic Stenosis: Current10.5005/jp-journals-10001-1272 Concepts and Recent Advances REVIEW ARTICLE Subglottic Stenosis: Current Concepts and Recent Advances 1Oshri Wasserzug, 2Ari DeRowe ABSTRACT Signs and Symptoms Subglottic stenosis is considered one of the most complex and The symptoms of SGS in children are closely related to challenging aspects of pediatric otolaryngology, with the most the degree of airway narrowing. Grade I SGS is usually common etiology being prolonged endotracheal intubation. The asymptomatic until an upper respiratory tract infection surgical treatment of SGS can be either endoscopic or open, but recent advances have pushed the limits of the endoscopic occurs, when respiratory distress and stridor, which are approach so that in practice an open laryngotracheal surgical the hallmarks of SGS, appear. Grades II and III stenosis approach is considered only after failed attempts with an can cause biphasic stridor, air hunger, dyspnea, and endoscopic approach. In this review we discuss these advances, suprasternal, intercostal, and diaphragmatic retractions. along with current concepts regarding the diagnosis and Prolonged or recurrent episodes of croup should raise treatment of subglottic stenosis in children. suspicion for SGS. Keywords: Direct laryngoscopy, Endoscopic surgery, Laryngo- At times, the appearance of SGS may be insidious and tracheal surgery, Prolonged intubation, Subglottic stenosis. progressive. It is important to recognize that a compro- How to cite this article: Wasserzug O, DeRowe A. Subglottic Stenosis: Current Concepts and Recent Advances. Int J Head mised airway in a child can lead to rapid deterioration Neck Surg 2016;7(2):97-103. and require immediate appropriate intervention to avoid Source of support: Nil a catastrophic outcome. Conflict of interest: None Evaluation INTRODUCTION Relevant history includes information on birth weight, prematurity, presence or absence of stridor, prior The management of subglottic stenosis (SGS) in children is one of the most complex and challenging aspects of intubation, the duration of intubation, presence and pediatric otolaryngology. It requires a team approach, quality of cry and voice, feeding difficulties, aspiration, including pediatric otolaryngologists, anesthesiologists, choking events, recurrent episodes of croup, prior airway pulmonologists, and intensive care specialists. surgery, and pulmonary and cardiac status. The incidence of SGS is between 1 and 2% of intu- Physical examination should include a thorough head bated neonates1 and occurs in 11% of intubated children and neck examination and assessment of craniofacial under 5 years of age. The risk of developing SGS increases abnormalities, retrognathia, micrognathia, macroglossia, by 50% for every 5 days of intubation2 in children under laryngomalacia, and choanal atresia. Awake flexible 5 years. Of note, premature infants can tolerate prolonged fiberoptic laryngoscopy should be performed in order intubation better than infants born at term. to assess vocal cord function and other pathology of the This review will focus on the current concepts in the upper airway. However, the subglottis is not visualized management of children with SGS with special attention adequately with a flexible fiberoptic laryngoscopy and to lessons that have been learned through the years. the examination may be difficult in a combative child with abundant secretions. When aspiration is suspected, performing functional endoscopic evaluation of 1,2 MD swallowing should be considered but may be challenging 1,2 Department of Otolaryngology and Head and Neck Surgery in infants. However, if the index of suspicion is high, this and Maxillofacial Surgery, Pediatric Otolaryngology Unit “Dana-Dwek” Children’s Hospital, Tel Aviv Sourasky Medical test should be performed prior to reconstructive surgery. Center, Affiliated to Sackler School of Medicine, Tel Aviv A simple test by observing feeding in a child with a University, Tel Aviv, Israel tracheostomy can reveal aspiration of liquids or solids Corresponding Author: Oshri Wasserzug, MD, Department of when suctioning the tube after feeding. Otolaryngology and Head and Neck Surgery and Maxillofacial Surgery, Pediatric Otolaryngology Unit, “Dana-Dwek” Direct laryngoscopy (DL) and rigid bronchoscopy Children’s Hospital, Tel Aviv Sourasky Medical Center 6 with video assistance under general anesthesia with Weizman Street, Tel Aviv, Israel, Phone: +9726973544, e-mail: spontaneous ventilation is the gold standard for the [email protected] diagnosis of SGS. The subglottis is best evaluated using International Journal of Head and Neck Surgery, April-June 2016;7(2):97-103 97 Oshri Wasserzug, Ari DeRowe a Hopkins rod-lens telescope to determine the site, size, length, and consistency of the stenosis. The authors currently use both three-dimensional (3D) (Visionsense™) and two-dimensional (2D) endoscopic systems. Visualization is enhanced with the 3D system, and in some cases may facilitate more gentle and precise surgery (unpublished data). A prospective study comparing these two modalities is being performed. Grading The classic SGS grading system (Graph 1) was proposed by Cotton and is accepted worldwide. The modified Cotton– Myer grading scale3 was introduced in 1994 and is based on the percentage of obstruction calculated by passing an endotracheal tube through the stenosis resulting in approximation of the stenotic diameter divided by the age-appropriate endotracheal tube size (Graph 2). There are disadvantages to such a grading system. Vocal fold mobility has a great impact on the treatment of SGS. In a grade 1 stenosis but with bilateral vocal fold immobility, treatment of the stenosis will not result in an adequate airway. Other factors to be considered are the length of the stenosis. A severe stenosis that consists of a thin scar web is easily treated endoscopically, whereas a Graph 1: Cotton–Myer grading scale Typesetter long but less narrow segment may be resistant to endoscopic procedures. The consistency of the stenosis of the subglottis, in order to measure the length of the (scar tissue vs granulation tissue) also has an impact on stenotic segment and assess framework defects. treatment. Congenital SGS Imaging Subglottic stenosis is considered to be congenital when The diagnosis of SGS should be confirmed by direct there is no history of prior endotracheal intubation or laryngoscopy, and hence routine neck computed any of the causes of acquired SGS. It is the 3rd most tomography or magnetic resonance imaging (MRI) is not common congenital disorder of the larynx.4 Acquired recommended for most children. Magnetic resonance SGS is much more common than congenital SGS because angiography should be performed when one suspects that of prolonged endotracheal intubation. The symptoms the stenosis is caused by a vascular anomaly or tumor. are closely related to the degree of the narrowing. In Computed tomography (CT) or MRI is also indicated severe cases, stridor is present at birth, while in milder when DL shows complete or near-complete obstruction cases, the symptoms present only after a few months. Graph 2: Modified Cotton–Myer grading scale 98 IJHNS Subglottic Stenosis: Current Concepts and Recent Advances Congenital anterior glottic webs are frequently associ- for failure of medical therapy or increasing symptoms of ated with SGS due to a malformed cricoid ring. It is airway obstruction while on treatment.15 also occasionally reported in children with Down’s syndrome. TREATMENT The treatment paradigm is based on the presenting clinical Acquired SGS severity of breathing, history, previous interventions Acquired SGS is the most common cause of narrowing and their results, vocal cord mobility, age of the child, in the larynx. It is usually due to prolonged endotracheal comorbidities including neurological and developmental, intubation in children. Endotracheal intubation causes aspiration, and coexisting airway lesions. Taking all stenosis for a number of reasons. First, the respiratory these into consideration along with the findings on DL epithelium lining the subglottis is delicate and is easily and tracheoscopy are necessary in order to make the injured by an endotracheal tube. Second, the cricoid appropriate treatment decisions. cartilage is a complete circular ring, thus edema caused by trauma or pressure impinges directly on the internal Immediate Intervention diameter. Third, the subglottic region is the narrowest Obviously, an infant presenting to the emergency room area of the airway in children. Fourth, significant edema in respiratory distress requires immediate attention and can develop in the subglottic region quickly because of intervention. The most important sign of impending the loose areolar tissue that comprises the submucosa disaster is increased effort of breathing despite normal 5 in that region. Thus, a relatively minor injury causes oxygen saturation levels. The child can decompensate a greater narrowing that compromises the airway in suddenly. Therefore, when there is stridor and increasing children. effort of breathing, a quick decision on the safest way Acquired SGS in neonates and infants is responsible to secure the airway must be made. The safest place for 6,7 for approximately 90% of all cases. The reported inci- securing the airway in this situation is the operating dence of SGS after intubation ranges from less than 1 to room where DL or rigid bronchoscopy can be performed 8-12 13 8.3%. Of note, Walner et al reported
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