Laryngeal Stenosis

What is laryngeal stenosis?

The larynx is a structure made up of cartilage, muscle and other soft tissues that sits above the windpipe and plays an important role in a child’s ability to breathe, speak and swallow. If the larynx narrows, either due to a problem at birth or because of an injury, it is called laryngeal stenosis.

What are the symptoms of laryngeal stenosis?

Children with airway stenosis may have symptoms including:

  • The inability to cough up secretions
  • Severe shortness of breath
  • Noisy breathing
  • Difficulty eating
  • Recurrent croup-like infections at a frequency or age that is not typical

Other times, children with airway stenosis may have no symptoms. Premature infants with airway stenosis are frequently diagnosed only after the breathing tube is removed and they are unable to breathe adequately on their own.

How is laryngeal stenosis diagnosed?

Diagnosis of laryngeal stenosis requires a visit with an ear, nose and throat specialist, or otolaryngologist, for a thorough physical examination. In children who might have airway stenosis, doctors use a microscope and camera to look at the larynx and the trachea, identifying and measuring the airway narrowing, with the child under anesthesia in the operating room. 

Evaluation may also include a laryngoscopy in the clinic, a relatively painless procedure. During the laryngoscopy, a small fiberoptic scope is passed through the nose and used to view the larynx (voice box). Most children will need little or no topical anesthesia to undergo the procedure. The patient and family will be able to see the exam on a video screen.

How is laryngeal stenosis treated?

Each child is unique, so treatments will vary depending on each case. Treatment of airway stenosis depends on the location and the severity of narrowing. If mild, treatment may only include observation. If severe, endoscopic interventions or open reconstruction of the airway may be required.

Endoscopic interventions

Endoscopic interventions are performed through the mouth, and do not require any incisions on the skin. Several endoscopic interventions have been designed to treat children with airway obstruction. Some of these include balloon dilation, endoscopic cricoid split procedures, and endoscopic posterior cartilage grafting procedures.

  • Balloon dilation involves inserting a special surgical balloon into the airway at the location of narrowing. The balloon is then inflated, expanding the area of narrowing. Balloon dilation is performed in the operating room under general anesthesia, is often performed multiple times in the treatment of airway stenosis and may be used in combination with other procedures. 
  • Endoscopic cricoid split involves making an incision in the ring of cartilage below the vocal cords (cricoid ring), allowing for the ring of cartilage to be expanded. This procedure is performed in the operating room under general anesthesia and may be performed in combination with other procedures.
  • Endoscopic posterior cartilage grafting involves making an incision in the back of the cartilage ring just below the vocal cords (cricoid ring) and placing a piece of rib cartilage into the incision. This procedure permanently widens the airway at this location and may be performed for laryngeal stenosis or bilateral vocal cord paralysis. This procedure is performed in the operating room under general anesthesia.

Open interventions

Open interventions are performed through an incision in the neck. This incision usually heals very well and can often be incorporated into the patient’s tracheostomy stoma (the hole where the tube enters) if one exists. These open surgical procedures designed to treat airway stenosis are often called “laryngotracheoplasty (LTP)” or “laryngotracheal reconstruction (LTR)” and encompass a wide variety of different techniques. It is important to remember that not all surgical procedures are appropriate for every child. Each procedure has its own set of risks and benefits and should be carefully selected only after a comprehensive evaluation with a pediatric otolaryngologist-head and neck surgeon (ENT).

Specific airway reconstruction procedures

The primary goal of airway reconstruction is to widen the area of narrowing. There are three main categories of airway reconstruction designed to achieve this:

  • Expansion laryngoplasty: Airway expansion and grafting procedure that involves making an incision in the front and/or back of the airway, expanding the narrow segment, and placing rib cartilage in the area of expansion.
  • Tracheal resection: Procedure that involves removing the narrow part of trachea and sewing together the cut ends of normal trachea. This is often performed for tracheal narrowing rather than subglottic narrowing. When the subglottis or a component of the subglottis is involved, the procedure performed is a different version of tracheal resection called a “cricotracheal resection (CTR).”
  • Slide tracheoplasty: Procedure that involves dividing the trachea at the area of narrowing, then opening the back and the front of each segment of airway at the location of stenosis. The bottom portion of the airway is then slid on top of the upper portion of the airway, allowing for a wider airway to be created when the two tracheal segments are sewn together. When the stenosis is in the top half of the trachea, the procedure is called a “cervical” slide tracheoplasty. Slide tracheoplasty is also frequently performed for tracheal stenosis that is further down the airway under the sternum (breastbone).

Single stage vs. double stage airway reconstruction

Airway reconstruction is often performed in a patient who has a tracheostomy in place. A single stage procedure refers to an airway reconstruction technique that is performed at the same time that the tracheostomy tube is removed. This is often performed for less severe stenosis but may be performed for patients with severe stenosis under select circumstances. 

A double-stage procedure refers to an airway reconstruction that is performed and allowed to heal completely before removal of the tracheostomy tube. This is frequently performed for more severe stenosis, or in revision airway reconstruction.