Idiopathic subglottic stenosis: techniques and results

Abstract

Idiopathic subglottic stenosis is a rare condition of unknown etiology characterized by circumferential stenosis in the subglottic larynx and upper trachea. Historically, patients were treated with dilation or ablation, however this approach has proven to be largely palliative and often leads to recurrence and the need for tracheostomy. A single-staged laryngotracheal resection and reconstruction is now the preferred definitive treatment for idiopathic subglottic stenosis and can be performed with excellent patient outcomes and rare subsequent progression of the disease. Avoiding anastomotic tension and devascularization are important technical keys to minimizing complications.

Keywords: Idiopathic subglottic stenosis; laryngotracheal resection and reconstruction; suprahyoid laryngeal release; tailored cricoplasty.

Figure 1

Typical bronchoscopic appearance of a subglottic stenosis.

Figure 2

A collar incision provides optimal exposure for benign strictures of the trachea at any level. For wider access to the upper thoracic inlet and the mediastinum, a partial sternotomy may be performed.

Figure 3

Removal of the anterior cricoid plate: resection ranges from complete, with a line of transection through the cricothyroid membrane, to none, depending on the extent of proximal involvement.

Figure 4

Technique for performing a tailored cricoplasty. (A) To perform a tailored cricoplasty, thickened submucosal tissue involving the inner one third to one half of the lateral cricoid cartilage is excised; (B) the mucosa overlying the resected cartilage is preserved as a pedicled flap.

Figure 5

The exposed cricoid cartilage is resurfaced by advancing the preserved mucosal flap over the cricoid and suturing with interrupted 5-0 Vicryl suture.

Figure 6

The distal trachea is beveled below the level of the stenosis over the length of one cartilage, as shown, to fit the anterolateral subglottic defect that was created.

Figure 7

Lateral traction sutures are placed proximally and distally. The base of the posterior wall is then tied to the inferior margin of the cricoid plate. The sutures are clipped to the drapes on either side.

Figure 8

Posterior mucosal anastomotic sutures (5-0 Vicryl) are placed with knots to lie behind the mucosa. It is acceptable for the sutures to be placed with the knots lying on the inside.

Figure 9

Completion of laryngotracheal anastomosis. (A) After placement of all the posterior and posterolateral anastomotic sutures as far anteriorly as the lateral stay sutures, the patient’s neck is flexed and the stay sutures, external fixing Vicryl sutures and posterior mucosal sutures are tied; (B) the anterior and anterolateral anastomotic sutures are then placed and (C) finally tied.

Figure 10

The sternohyoid muscle is used to cover all suture lines.