A treatment approach for managing idiopathic subglottic stenosis. Treatment approaches used in the present study are highlighted in grey. Boxes highlighted in grey represent treatments used in the present series. Technical description of endoscopic laryngotracheoplasty:
A preoperative endoscopies appearances of an ISS patient undergoing a standard endoscopic laryngotracheoplasty. Access is achieved using suspension laryngoscopy with a Dedo-Pilling surgical laryngoscope.
A1 The first step in this procedure is cruciate incision of the stenosis, which may be performed with cold steel, a CO
2, YAG or KTP laser, or coblation.
A2 Intralesional injection of 60–80 mg of triamcinolone acetonide (Kenalog
®; Bristol-Myers Squibb Co; New York, USA) into and around the lesion. Steps
A1 and
A2 may be performed in reverse order where the severity of the stenosis does not raise concern of causing near-total obstruction in the time between steroid injection and stenosis incision.
A2,
A3 The stenosis is then dilated using a controlled radial expansion balloon (CRE™, Boston Scientific Corp, Fremont, USA) Most patients are dilated to 16.5 mm, but patients with larger intrinsic subglottic diameter may be dilated to 18 mm. Dilation is typically applied for two cycles of 90 s and care is exercised to avoid applying shearing forces on the stenosis due to balloon slippage. Furthermore, the shortest available balloon length should be used to minimise application of radial forces to normal proxomal or distal mucosa which, in ISS, has a significant to fibrosis.
A4,
A5 The immediate post-dilation result. Note the presence of intact mucosal bridges between the incisions. Technical description of endoscopic laryngotracheoplasty with biological inhibition performed according to its original description [
1].
B Preoperative appearance of an ISS patient undergoing endoscopic laryngotracheoplasty with biological inhibition.
B1 Suspension laryngoscopy is established using the Dedo-Pilling laryngoscope and cruciate laser incisions are made as per
A1. The purpose of these incisions are to provide a depth gauge for the next stage and to provide areas over which a skin graft is less likely to ‘take’, in order to encourage later respiratory remucosalisation.
B2 Cold-steel debulking excision of the stenosis.
B3 Circumferential excision of the stenosis using a 27 cm tricut-blade tracheal microdebrider (Medtronic, Minneapolis, USA). Particular care is exercised, especially when treating the posterior aspect of the stenosis and most particularly when the stenosis extends to the proximal cervical trachea, to avoid creating a tracheo-oesophageal fistula. For this reason, the surgery is only performed when there is recurrence of the stenosis and good judgement of stenosis depth may be obtained from the laser cuts.
B4 Endoscopic views following circumferential subglottic and/or cervical tracheal mucosectomy and lamina propria removal.
B5 Construction of a stent from the cut limb of a 12 mm thoracic Montgomery T-tube (Boston Medical Products Inc, Shrewsbury, USA). The stent is sized to cover a distance from the conus elasticus [
25] to 1.5 cm below the lower border of the mucosectomy. The stent is covered with a paraffin sheet and a 0.01″ split-thickness skin graft. The cut dermal side points outwards and the skin/paraffin sheet is sutured to the silicone stent using a single 4/0 monofilament suture. The stent is secured with a single 0 nylon stent-holding suture that is placed through the lateral tracheal wall, the stent (
B6), and is brought out through the opposite tracheal wall and is sutured subcutaneously. More precise technical descriptions of how to construct a stent-holding suture [
29] and how to suture the paraffin sheet/skin graft composite to the silastic stent [
4] have been reported previously. By cutting a Montgomery T-tube, the tube will contain a smooth native end and a rough freshly-cut end. The smooth end is placed proximally. The patient stays in hospital for 2 weeks and receives humidification and 5 days of postoperative antibiotic prophylaxis. No tracheotomy is placed and the patient resumes eating and drinking on the first postoperative day after speech and language therapy assessment.
B7 At 2 weeks, the stent-holding suture is cut endoscopically and the stent is removed. All skin is removed using suctioning at this point. The patient is discharged the next day.
B8 Three weeks later, the patient undergoes an endoscopic procedure where two of four quadrants of skin is lasered.
B9 Three weeks after that, a further mucosal resurfacing is performed on the two other quadrants and this treatment marks the end of the planned interventions. Any intervention after this point for any indication represents a treatment failure.
B10 Treatment failure secondary to airway crusting secondary to persistent keratinisation of the airway despite adequate resurfacing. Technical description of cricotracheal resection (CTR):
C the immediate preoperative view of an ISS lesion, which had extended proximally and involved the immediate infraglottic area.
C1 The proximal trachea is mobilized through a standard cervical collar incision, taking care to avoid trauma to the recurrent laryngeal nerves. To achieve this, dissection is performed directly onto the tracheal surface and recurrent laryngeal nerves are not formally identified.
C2 In this patient a voice-sparing cricotracheal resection was not performed and the anterior arch of the cricoid cartilage was resected to allow access to the subglottis and to remove disease-bearing tissue.
C3 The diseased subglottic mucosa is resected and the remaining lateral and posterior elements of the cricoid cartilage are thinned with a drill both to remove pathological tissues and to create space into which the trachea is pulled up.
C4 The mobilised trachea is brought superiorly to sit within the subglottis. The posterior wall of the trachea is sutured to the posterior glottic mucosa using PDS.
C5 The anterior tracheal wall being sutured to the inferior border of the thyroid cartilage using Prolene, thus completing the anastomosis. Postoperatively the patient is transferred to the ITU intubated, and is brought back to the operating room 48 h later for extubation and laryngotrachesocpy. A soft collar is worn in reverse by the patient to discourage neck extension for 6 weeks