Return to: Subglottic stenosis

See also: Adult Airway in the Operating Room; Tracheotomy - Tracheostomy

Please note specific preferences for surgical airway management per Dr. Van Daele with highlighted differences from Subglottic stenosis

Endoscopic management of subglottic stenosis​

ANESTHESIA CONSIDERATIONS

1. Communication with anesthesia staff is essential - these cases are done under intermittent apnea, with periodic intubation as needed based on O₂ saturation.
   1. ​Small endotracheal tubes (i.e. 5-0 and 6-0 MLT tubes) and a 10 cc syringe should be available and opened on the laryngoscopy table to be ready to place through the laryngoscope and ventilate as needed
2. Consider Decadron 8-10 mg IV intraoperatively to diminish edema, if not contraindicated (i.e. diabetes, peptic ulcer disease, etc.)
3. Positioning
   1. Head of bed starts out by anesthesia, then after induction the head of bed will be turned 90 degrees from anesthesia

OPERATIVE PROCEDURE

1. The entire procedure is done under intermittent apnea
   1. ​Small endotracheal tubes (5-0, 6-0 MLT tubes) should be available on the laryngoscopy table for periodic intubation as needed based on oxygen saturation
2. Place laryngoscope
   1. Kleinsasser laryngoscope preferred
      1. This should be set up with the arm closest to anesthesia attached to allow hook up to anesthesia circuit after placement/suspension. A hollow bore cannula is placed through the laryngoscope side port on the side closest to anesthesia to allow connection to the circuit. It depends on whether the operative table is turned right or left whether the cannula is placed on the right or left side of the laryngoscope. The connector from a 3-0 OETT can be used to connect to the circuit.
      2. 
   2. Should be placed deep in the larynx to partially splay apart the vocal cords, allowing better view of the subglottis, and placed into suspension
      1. Risk for post-op dysphonia from this process is greater in patients with small larynges (small women)
      2. Risk of injuring vocal cords is lessened by ensuring the tip of the laryngoscope is inserted posteriorly when placed between the vocal cords
3. Instill 4% preservative free lidocaine onto the vocal cords to prevent vasospasm
4. Intra-lesional steroid injection
   1. Kenalog 40 is used
   2. Treace injector is used to inject stenotic segment
      1. Make sure to "prime" the Treace injector such that the air from the tip of the injector has been dispelled prior to injecting into the patient
      2. Injection prior to cuts is important, otherwise injection tends to flow out via incisions rather than infiltrate tissue
5. Radial cuts
   1. Performed with CO₂ laser at the locations of the greatest stenosis and tethering
      1. Typical settings for laser are 6-8 Watts, continuous ultrapulse
6. Dilation
   1. Balloon dilation
      1. Done under apnea with CRE pulmonary balloon dilator (have multiple sizes available, most commonly use 10-12 or 12-15 mm) (see Subglottic Stenosis - Upper Tracheal Stenosis CRE Balloon Dilation for example of use with ETT in place)
      2. The balloon is positioned across the stenotic segment with telescope used for visualization and inflated to appropriate pressure for 2 minutes
         1. Time may be cut into shorter segments if there is difficulty with oxygenation while apneic
   2. ​Jackson laryngeal dilators may be used to improve the airway sufficiently to permit placement of a small endotracheal tube (4-0 or 5-0 MLT) or to permit balloon dilation
      1. Placement of Jackson dilators is limited by the size that will fit through the laryngoscope
7. Application of Mitomycin C
   1. ​Anti-neoplastic agent that inhibits fibroblast proliferation
   2. A 1/2 x 1/2 inch cottonoid pledget soaked in 10 mg/mL Mitomcyin C is applied topically to the stenotic segment and held in place for two minutes
   3. Handling and disposal of Mitomcyin C should be per the hospital protocol for chemotherapeutic agents. Care should be taken to avoid contact with unprotected skin.