Endoscopic Management of Subglottic Stenosis: Diagnosis and

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OHNS Website: http://ohns.ucsf.edu

Endoscopic Management of Subglottic Stenosis: Endoscopic Management of Subglottic Stenosis: Diagnosis and Surgical TechniquesDiagnosis and Surgical Techniques

Mark S. Courey, MDMark S. Courey, MDProfessor, UCSF Professor, UCSF –– Department of Department of

OHNSOHNSDirector, Division of LaryngologyDirector, Division of Laryngology


Airway ObstructionAirway Obstruction

●● SupraglottisSupraglottis

●● GlottisGlottis

●● SubglottisSubglottis

●● TracheaTrachea

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Unifying Concepts in Endoscopic Unifying Concepts in Endoscopic ManagementManagement

1.1. InciseIncise soft tissuesoft tissue stenosis/scarstenosis/scar−− Do not exciseDo not excise the stenosisthe stenosis

2.2. AvoidAvoid circumferentialcircumferential disruption of the mucosal disruption of the mucosal surfacesurface

3.3. Evaluate the degree of cartilage involvementEvaluate the degree of cartilage involvement−− If the supporting airway cartilage is involved in the stenosis, If the supporting airway cartilage is involved in the stenosis,

then endoscopic techniques are unlikely to be successfulthen endoscopic techniques are unlikely to be successful


Predictive Factors of Success in Predictive Factors of Success in Endoscopic ManagementEndoscopic Management

1.1. Incomplete circumferential involvementIncomplete circumferential involvement

2.2. Scarring shorter than 1 cm in vertical dimensionScarring shorter than 1 cm in vertical dimension

3.3. TracheomalaciaTracheomalacia or loss of cartilageor loss of cartilage

4.4. History of bacterial infection associated with tracheotomyHistory of bacterial infection associated with tracheotomy

5.5. PGS with arytenoid fixationPGS with arytenoid fixation

Simpson GT et al, Ann Otol Rhinol Laryngol 1982 July-Aug;91(4Pt1):384-8

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EtiologyEtiology

●● Iatrogenic Iatrogenic –– prolonged intubation for mechanical prolonged intubation for mechanical ventillationventillation

●● External traumaExternal trauma

●● IdiopathicIdiopathic

Nouraei SA, Ma E, Patel A, Howard DJ, Sandhu GS.Estimating the population incidence of adult post-intubation laryngotracheal stenosis. Clin Otolaryngol. 2007 Oct;32(5):411-2.


Adult Subglottic StenosisAdult Subglottic Stenosis●● EtiologyEtiology

−− Autoimmune Autoimmune ––WegenerWegener’’ss−− IdiopathicIdiopathic

●● NO cartilage involvementNO cartilage involvement

●● Surgical Technique Surgical Technique –– Endoscopic Laser Radial Incisions Endoscopic Laser Radial Incisions with Dilation and with Dilation and MytomycinMytomycin c Applicationc Application

●● Average symptom free interval 9 monthsAverage symptom free interval 9 months

Laryngoscope. 2008 Sep;118(9):1542-6Roediger FC, Orloff LA, Courey MS.

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Evaluation/ManagementEvaluation/Management

●● Office evaluation and examinationOffice evaluation and examination1.1. Thorough history Thorough history –– suspect etiologysuspect etiology

Prior intubationPrior intubationPrior surgeryPrior surgeryGERD symptomsGERD symptoms▪▪ PowitzkyPowitzky ES, ES, et alet al. Symptoms, Quality of Life, . Symptoms, Quality of Life, VideolaryngoscopyVideolaryngoscopy, and Twenty, and Twenty--

FourFour––Hour TripleHour Triple--Probe pH Monitoring in Patients With Typical and Probe pH Monitoring in Patients With Typical and ExtraesophagealExtraesophageal Reflux Annals of Otology, Reflux Annals of Otology, RhinologyRhinology & Laryngology 2003, & Laryngology 2003, 112:328112:328--332.332.

Autoimmune disordersAutoimmune disorders▪▪ Nasal crustingNasal crusting▪▪ Recurrent sinusitisRecurrent sinusitis



●● Office evaluation and examinationOffice evaluation and examination1.1. Thorough history Thorough history –– suspect etiologysuspect etiology2.2. Careful endoscopic examinationCareful endoscopic examination

Subglottis

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●● Consider high resolution CT with 3Consider high resolution CT with 3--d reconstructiond reconstruction−− Underestimates amount of cartilage involvementUnderestimates amount of cartilage involvement



●● Consider high resolution CT with 3Consider high resolution CT with 3--d reconstructiond reconstruction−− Underestimates amount of cartilage involvementUnderestimates amount of cartilage involvement−− Standard CT evaluation Standard CT evaluation 5 mm axial images5 mm axial images−− High resolution CTHigh resolution CT 1 mm axial images1 mm axial images−− Virtual endoscopyVirtual endoscopy

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●● Primary purposePrimary purpose1.1. Stage exact area of stenosisStage exact area of stenosis2.2. Define position and degree of cartilage Define position and degree of cartilage

involvementinvolvement

●● Be prepared to treatBe prepared to treat

●● Anesthetic technique Anesthetic technique –– Jet ventilationJet ventilation−− SupraglotticSupraglottic−− SubglotticSubglottic

Staging Endoscopy



●● Preoperative conversation with patient: risks and desiresPreoperative conversation with patient: risks and desires−− RisksRisks

Airway obstruction and Airway obstruction and deathdeathNeed for tracheotomyNeed for tracheotomy

Staging Endoscopy

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●● Equipment Equipment –– Operative EndoscopesOperative Endoscopes

Staging Endoscopy

Laryngoscopes and Microsubglottiscopes Bronchoscopes


MicrosubglottoscopyMicrosubglottoscopy●● Binocular visualization with the operating microscopeBinocular visualization with the operating microscope●● Bimanual manipulationBimanual manipulation●● Used with Jet VentilationUsed with Jet Ventilation●● Allows treatment of lesions for 5 to 7 cm below TVFAllows treatment of lesions for 5 to 7 cm below TVF●● Works well with the COWorks well with the CO22 laserlaser

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Laryngoscopes and Laryngoscopes and MicrosubglottiscopesMicrosubglottiscopes


Laryngoscopes and Laryngoscopes and MicrosubglottiscopesMicrosubglottiscopes

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Endoscopic Management of Airway Endoscopic Management of Airway ObstructionObstruction

●●Enhanced by the addition of the surgical laser to our Enhanced by the addition of the surgical laser to our armamentariumarmamentarium

●●COCO22 LaserLaser−− Stuart Strong, MDStuart Strong, MD−− GezaGeza JakoJako, MD, MD−− Wave guide delivery systemsWave guide delivery systems

●●Nd:YAGNd:YAG−− Fiber laser delivery systemFiber laser delivery system


Computerized Pattern GeneratorsComputerized Pattern Generators

Ablation

Incision

Ablates 250 micron Ablates 250 micron wide swath of tissuewide swath of tissue

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Modes of Laser DeliveryModes of Laser Delivery1. Continuous1. Continuous

●● Laser medium is excited with Laser medium is excited with a constant source of powera constant source of power

●● Provides a constant output of Provides a constant output of energy energy


Modes of Laser Delivery Modes of Laser Delivery 2. Pulsed 2. Pulsed

●● Laser medium is excited with a Laser medium is excited with a flashflash––lamp or an intermittent lamp or an intermittent source of powersource of power

●● Provides short Provides short ““pulsedpulsed”” output of output of energy in burstsenergy in bursts

●● Tissue can cool between bursts of Tissue can cool between bursts of energyenergy−− Thermal Relaxation Time of the tissueThermal Relaxation Time of the tissue

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COCO22 Laser Laser -- Continuous Delivery ModeContinuous Delivery Mode

●● In the tissue surrounding the impact zone, energy is In the tissue surrounding the impact zone, energy is absorbed at absorbed at subablativesubablative tissue thresholdstissue thresholds

Oral Canine Mucosa 7 days after injury with a continuous mode CO2 laser at 4 watts for 0.1second

Ablation Crater

CoagulumSubabalative Injury Zone


Laser Laser -- Pulsed Delivery ModePulsed Delivery Mode●● Allows tissue cooling between laser impactsAllows tissue cooling between laser impacts●● Reduces Reduces subablativesubablative injuryinjury

−− Thermal Relaxation Thermal Relaxation Time required for a target structure to dissipate 50% of the eneTime required for a target structure to dissipate 50% of the energy rgy absorbed to surrounding tissueabsorbed to surrounding tissueRoughly equal to the square of the diameter of the target structRoughly equal to the square of the diameter of the target structureure

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Laser Laser -- Pulsed Delivery ModePulsed Delivery Mode

Thermal Relaxation TimeThermal Relaxation Time

Thermal DamageThermal Damage


Ability to Delivery Laser Energy in a Ability to Delivery Laser Energy in a Pulsed ModePulsed Mode

COCO22

KTPKTP

Nd:YAGNd:YAG

Continuous WaveContinuous Wave Pulsed Structure WavePulsed Structure Wave

ReducesReducesThermal DamageThermal Damage

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Surgical PrecisionSurgical Precision

1.1. Selective Selective phothermolysisphothermolysis –– choose a desired choose a desired chromophorechromophore

2.2. Pulse the laser Pulse the laser –– thermal relaxationthermal relaxation

3.3. Repeat/Delay or Shuttered laser deliveryRepeat/Delay or Shuttered laser delivery−− Laser output in either a Laser output in either a continuouscontinuous mode or a mode or a pulsedpulsed mode is allowed mode is allowed

for a tenth of a secondfor a tenth of a second

−− The laser is turned off after a few tenths of a secondThe laser is turned off after a few tenths of a secondAllows the surgeon to move the laser beam to avoid:Allows the surgeon to move the laser beam to avoid:

1.1. Drilling into tissueDrilling into tissue2.2. Overlap of ablation sitesOverlap of ablation sites

Enhanced by accurate delivery of laser energyEnhanced by accurate delivery of laser energy


Settings for Laser ShutteringSettings for Laser ShutteringRepeat/DelayRepeat/Delay

●● On time On time –– 0.1 second0.1 second

●● Off time Off time –– 0.3 to 0.5 seconds0.3 to 0.5 seconds−− Repeat delayRepeat delay

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ShutterShutterLaser energy is delivered

for 0.1 to 0.2 seconds

vs. Nonvs. Non--ShutterShutterShutterShutterLaser energy is delivered

for 0.1 to 0.2 seconds

Laser energy is deliveredwithout delay


Shutter vs. NonShutter vs. Non--ShutterShutter●● Can be accomplished with all laser wavelengthsCan be accomplished with all laser wavelengths

−− CO2CO2−− KTPKTP−− PDLPDL

●● Reduces error by allowing the operator to move Reduces error by allowing the operator to move the laser beamthe laser beam

●● Avoids Avoids ““drillingdrilling”” into tissue or excessively into tissue or excessively delivering laser to one areadelivering laser to one area

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1.1. Selective Selective phothermolysisphothermolysis –– choose a desired choose a desired chromophorechromophore

2.2. Pulse the laser Pulse the laser –– thermal relaxationthermal relaxation

3.3. Repeat/Delay or Shuttered laser deliveryRepeat/Delay or Shuttered laser delivery

4.4. Pattern generators Pattern generators ●● Computerized/MechanicalComputerized/Mechanical●● COCO22 laser onlylaser only

Enhanced by accurate delivery of laser energyEnhanced by accurate delivery of laser energy



●● Pattern Generators for the COPattern Generators for the CO22 LaserLaser−− Mechanically move the laser beamMechanically move the laser beam

More rapidly than with human movementMore rapidly than with human movementMinimize overlap inherent with human Minimize overlap inherent with human movementmovement

−− PatternsPatternsLinearLinearGeometric areaGeometric area

▪▪ CirclesCircles▪▪ BoxesBoxes

−− Used in a shuttered or nonUsed in a shuttered or non--shuttered modeshuttered mode

−− Combined with pulsed delivery systemsCombined with pulsed delivery systems

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Digital Digital AcubladeAcubladeTMTM

COCO22 laserlaserArticulated ArmArticulated Arm

Pulsed Delivery ModePulsed Delivery ModeUltrapulseUltrapulseTMTM

Computerized PatternComputerized PatternGeneratorGenerator

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Digital Digital AcuBladeAcuBlade™™

Robotic Laser Microsurgery SystemRobotic Laser Microsurgery System

●● COCO22 laserlaser

●● UItrapulseUItrapulseTMTM laser mode laser mode −− Reduces laser on timeReduces laser on time−− Limits thermal damageLimits thermal damage

●● Digital pattern generatorDigital pattern generator−− Moves beam more efficiently than Moves beam more efficiently than

human handhuman hand−− Reduces human errorReduces human error

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Surgery with Pattern GeneratorsSurgery with Pattern Generators

●● Evaluation of precision Evaluation of precision –– canine modelcanine model−− Direction of incisionDirection of incision−− Depth of incision/ablationDepth of incision/ablation−− Thermal damageThermal damage

●● CPG incisions vs. hand made incisions CPG incisions vs. hand made incisions CPG incisions were more uniformCPG incisions were more uniform

−− Depth of incisionDepth of incision−− Thermal damage Thermal damage


Surgery with Pattern GeneratorsSurgery with Pattern Generators

●● Evaluation of operative time with prototype scannerEvaluation of operative time with prototype scanner−− Multiple surgeonsMultiple surgeons−− Short learning curveShort learning curve

●● Reduction in operative time by 37%Reduction in operative time by 37%−− p < 0.001p < 0.001

●● Outcomes voice and airway not significantly different Outcomes voice and airway not significantly different

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Subglottic StenosisSubglottic Stenosis

●● IdiopathicIdiopathic

●● WegenerWegener’’ss

●● Prior intubationPrior intubation

EtiologyEtiology

Involvement of ExtraInvolvement of Extra--Esophageal Reflux DiseaseEsophageal Reflux Disease


Subglottic Stenosis Subglottic Stenosis –– Management Management TechniquesTechniques

●● TracheotomyTracheotomy−− Best avoided due to increase bacterial count in tracheaBest avoided due to increase bacterial count in trachea

●● Reflux treatmentReflux treatment−− Aggressive BID therapyAggressive BID therapy−− Consider surgical intervention Consider surgical intervention –– NissenNissen if LES pH probe positiveif LES pH probe positive

●● Endoscopic evaluation and Endoscopic evaluation and POTENTIALPOTENTIAL treatmenttreatment−− Laser incisions Laser incisions –– MitimycinMitimycin C application C application –– DilationDilation

●● MitomycinMitomycin C C −− Simpson CB, James JC. The efficacy of Simpson CB, James JC. The efficacy of mitomycinmitomycin--C in the treatment of C in the treatment of

laryngotracheallaryngotracheal stenosis. Laryngoscope. 2006 Oct;116(10):1923stenosis. Laryngoscope. 2006 Oct;116(10):1923--5.5.−− Increase interval between treatment 4.9months to 23 monthsIncrease interval between treatment 4.9months to 23 months

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Subglottic Stenosis Subglottic Stenosis –– Management Management TechniquesTechniques

●● Telescopic BronchoscopyTelescopic Bronchoscopy●● Evaluate length and degree of stenosisEvaluate length and degree of stenosis●● Do not need to make airway normalDo not need to make airway normal

−− Robert Ossoff Robert Ossoff -- ““ItIt’’s a game of millimeterss a game of millimeters””−− Rationale Rationale

Flow ~ rFlow ~ r44

Minimal increases in radius improve flowMinimal increases in radius improve flow

Surgical Technique Surgical Technique –– Endoscopic EvaluationEndoscopic Evaluation


Subglottic Stenosis Subglottic Stenosis

●● Caution !! Caution !! −− Avoid excess exposure/injury to cartilageAvoid excess exposure/injury to cartilage−− Avoid injury to vocal foldsAvoid injury to vocal folds

●● MitimycinMitimycin c applicationc application−− 0.4 mg per ml0.4 mg per ml−− Topical on cottonoid Topical on cottonoid –– 3 minutes3 minutes−− Wash away excess Wash away excess −− May lead to crustingMay lead to crusting−− Delays reDelays re--epithelializationepithelialization

Surgical TechniqueSurgical Technique

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Subglottic Stenosis Subglottic Stenosis –– Case ExampleCase Example

●● Office evaluation Office evaluation −− Patient history of symptomsPatient history of symptoms

Rapidity of onsetRapidity of onsetDegree of DOEDegree of DOE

−− Indirect endoscopyIndirect endoscopy●● StudiesStudies

−− PFTPFT’’ssFixed extrathoracic obstructionFixed extrathoracic obstructionFlattening of the inspiratory and expiratory limbsFlattening of the inspiratory and expiratory limbsPeak inspiratory flow should be greater than 1.5 litersPeak inspiratory flow should be greater than 1.5 liters

−− CT?CT?







−− CT?CT?

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−− CT?CT?



●● ExposureExposure−− MicrosubglottiscopeMicrosubglottiscope

●● Jet Ventilation during anesthesia Jet Ventilation during anesthesia ●● Radial incisionsRadial incisions

−− To laser or not to laser To laser or not to laser ●● Dilation after radial incisionDilation after radial incision

−− Rigid dilatorsRigid dilators−− BronchoscopesBronchoscopes−− Balloon dilatorsBalloon dilators

Surgical TechniqueSurgical Technique

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SubgotticSubgottic StenosisStenosis

PreoperativePreoperative PostoperativePostoperative


Laser Radial Incisions for Tracheal Laser Radial Incisions for Tracheal StenosisStenosis

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Laser Radial Incisions for Tracheal Laser Radial Incisions for Tracheal StenosisStenosis


Conclusions and Future DirectionsConclusions and Future Directions

●● Endoscopic management principles Endoscopic management principles are well establishedare well established

●● Often alleviates stenosis without need Often alleviates stenosis without need for more aggressive open intervention for more aggressive open intervention –– Do not need to make airway normalDo not need to make airway normal

●● COCO22 laser enhances ability to perform laser enhances ability to perform most of these endoscopic proceduresmost of these endoscopic procedures

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Endoscopic Management of Subglottic Stenosis: Diagnosis and