Subglottic and Tracheal Stenosis
Train yourself adequately in laryngotracheal surgery and upper airway endoscopy before addressing the challenging surgery of laryngotracheal stenosis (LTS). Remember that inappropriate initial management of LTS may lead to permanent intractable sequelae
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10
Philippe Monnier
Core Messages
›› Train yourself adequately in laryngotracheal
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surgery and upper airway endoscopy before addressing the challenging surgery of laryngotracheal stenosis (LTS). Remember that inappropriate initial management of LTS may lead to permanent intractable sequelae and that the best chance for the patient lies in the first operation. Perform a thorough preoperative assessment of the patient’s medical condition and of the stenosis to choose the best surgical option and timing. Address only mature cicatricial stenosis for a definitive endoscopic or open surgical repair. Perform a bacteriologic aspirate of the trachea prior to any treatment. Treat gastro-oesophageal reflux. Master all types of surgeries starting from appropriate use of CO2 laser for minor stenosis to laryngotracheal reconstruction with cartilage expansion and partial cricotracheal resection for the most severe grades of stenosis.
10.1 Introduction The management of laryngotracheal stenosis (LTS) remains a challenging problem for the otolaryngologist, especially in the pediatric age group. The complexity of the various preoperative situations implies that no single treatment modality can solve the problem. One has to take into consideration the type of the stenosis (congenital or acquired), its location (supraglottic, glottic, subglottic, combined), its degree of obstruction and length in the craniocaudal axis, and finally its association with vocal cord ankylosis or neurogenic paralysis. Furthermore, the presence of tracheal damage (stenosis or localized malacia) related to the tracheostoma or to the tracheotomy cannula can further complicate the surgical management. According to the nature and severity of the condition, a variety of treatments exists. They range from endoscopic laser sessions with or without dilatation or stenting [13, 14, 36, 51] to laryngotracheal reconstruction (LTR) with anterior, posterior, or combined costal cartilage grafts [8, 43, 44], to partial cricotracheal resection (PCTR) for the most severe grades of stenosis, and to extended PCTR for combined glotto-subglottic stenosis (SGS) [37, 55]. Needless to say, thorough preoperative endoscopic assessment is prerequisite to selecting the best surgical option for a given condition.
10.2 Etiology 10.2.1 Infants and Children P. Monnier Professor and Chairman, Otolaryngology, Head & Neck Surgery Department, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland e-mail: [email protected]
10.2.1.1 Subglottis In the pediatric age group, the most common reason for SGS is prolonged intubation. In newborns, however,
M. Remacle, H. E. Eckel (eds.), Surgery of Larynx and Trachea, DOI: 10.1007/978-3-540-79136-2_10, © Springer-Verlag Berlin Heidelberg 2010
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congenital SGS represents the third most common laryngeal anomaly after laryngomalacia and bilateral vocal fold paralysis [24]. According to Holinger, congenital SGS is classified into cartilaginous and soft tissue stenoses [25].
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