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Subglottic Stenosis in Children

Practice Essentials

Subglottic stenosis (SGS) is a narrowing of the subglottic airway, which is housed in the cricoid cartilage. The criterion standard for airway evaluation is direct laryngoscopy and direct bronchoscopy, while surgical therapies for subglottic stenosis (SGS) include serial endoscopic dilation, open reconstruction, the anterior cricoid split (ACS), single-stage laryngotracheoplasty with cartilage expansion, anterior and posterior cricoid splitting with costal cartilage grafts placed anteriorly and posteriorly, and partial cricotracheal resection. The image below shows an intraoperative endoscopic view of a normal subglottis.

Intraoperative endoscopic view of a normal subglot

Intraoperative endoscopic view of a normal subglottis

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The subglottic airway is the narrowest area of the airway, since it is a complete, nonexpandable, and nonpliable ring, unlike the trachea, which has a posterior membranous section, and the larynx, which has a posterior muscular section. The term subglottic stenosis (SGS) implies a narrowing that is created or acquired, although the term is applied to both congenital lesions of the cricoid ring and acquired subglottic stenosis (SGS). See the images below.

Grade III subglottic stenosis in an 18-year-old pa

Grade III subglottic stenosis in an 18-year-old patient following a motor vehicle accident. The true vocal cords are seen in the foreground. Subglottic stenosis is seen in the center of the picture.

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Endoscopic view of the true vocal cords in the for

Endoscopic view of the true vocal cords in the foreground and the elliptical congenital subglottic stenosis (SGS) in the center of the picture.

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Subglottic view of very mild congenital subglottic

Subglottic view of very mild congenital subglottic stenosis. Laterally, the area looks only slightly narrow. When endotracheal tubes were used to determine its size, it was found to be 30% narrowed.

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Subglottic view of congenital elliptical subglotti

Subglottic view of congenital elliptical subglottic stenosis.

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Granular subglottic stenosis in a 3-month-old infa

Granular subglottic stenosis in a 3-month-old infant that was born premature, weighing 800 g. The area is still granular following cricoid split. This patient required tracheotomy and eventual reconstruction at age 3 years. True vocal cords are shown in the foreground (slightly blurry).

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Intraoperative laryngeal view of the true vocal co

Intraoperative laryngeal view of the true vocal cords of a 9-year-old boy. Under the vocal cords, a subglottic stenosis can be seen.

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This spiraling subglottic stenosis is not complete

This spiraling subglottic stenosis is not complete circumferentially. Laser therapy was the treatment choice and was successful after 2 laser treatments.

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Continued lasering of the subglottic stenosis. The

Continued lasering of the subglottic stenosis. The reflected red light is the aiming beam for the CO2 laser.

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Postoperative view. Some mild residual posterior s

Postoperative view. Some mild residual posterior subglottic stenosis remains, but the child is asymptomatic and the airway is open overall.

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Preoperative view of a 4-month-old infant with acq

Preoperative view of a 4-month-old infant with acquired grade III subglottic stenosis from intubation. Vocal cords are in the foreground.

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A close-up view.

A close-up view.

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Postoperative view. The patient had been intubated

Postoperative view. The patient had been intubated for 1 week and extubated for 1 week.

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A subglottic view following dilation with an endot

A subglottic view following dilation with an endotracheal tube to lyse the thin web of scar and a short course (5-day) treatment with oral steroids.

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Postoperative view of a 4-month-old infant with su

Postoperative view of a 4-month-old infant with subglottic stenosis following cricoid split. Notice very mild recurrence of scaring at the site of previous scar. Overall, the airway is open and patent. The anterior superior area can be seen, with a small area of fibrosis where the cricoid split previously healed.

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Preoperative subglottic view of a 2-year-old patie

Preoperative subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis.

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Workup in subglottic stenosis

Diagnostic procedures include the following:

Flexible fiberoptic nasopharyngoscopy and laryngoscopy

Flexible endoscopy

Rigid laryngoscopy and bronchoscopy

Certain radiographic examinations can help in obtaining a diagnosis and determining the severity of the disease, and fluoroscopy is often performed in children with symptoms of airway obstruction.

Management of subglottic stenosis

Surgical therapies include the following:

Serial endoscopic dilation with or without steroid injections – For mild or granular subglottic stenosis (SGS)

Open reconstruction of subglottic stenosis – Often may be unnecessary for subglottic stenosis (SGS) classified as grades I and II on the Myers and Cotton scale (ie, as much as 70% obstruction of the subglottic airway)

Anterior cricoid split – Children who are likely to benefit from this procedure include the following: (1) patient weight of more than 1500 g, (2) failure to extubate in identified subglottic stenosis (SGS), (3) oxygen requirement of less than 30%, (4) no active respiratory infection, and (5) good pulmonary and cardiac function

Single-stage laryngotracheoplasty with cartilage expansion

Anterior and posterior grafting – Anterior and posterior cricoid splitting with costal cartilage grafts placed anteriorly and posteriorly; has been successful in expanding the lumen and allowing decannulation in cases of severe subglottic stenosis (grade III-IV)

Partial cricotracheal resection – The best candidates for this procedure are patients with severe subglottic stenosis (grade III-IV) without associated glottic pathologic conditions and with a margin of at least 4 mm in the healthy airway below the vocal folds and above the stenosis

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