Subglottic stenosis can occur from a variety of causes and is often treated with balloon dilation +/- CO2 laser radial incisions. This video shows an approach used for many years at our institution (wedge excisions without dilation) with good success.
"Micro direct laryngoscopy, kenalog injection, and CO2 laser wedge excisions." The procedure begins with kenalog 40 mg/cc injection, typically 1 cc total into multiple areas of the stenosis. Then, the CO2 laser is set on a range between 2-4 watts and used to ablate tissue. Typically three separate areas in the subglottis are excised leaving small bridges of normal tissue in between to avoid circumferential scarring. In this video, the posterior wedge needed further re-excision to achieve the correct depth (typically at the level of the cricoid plate, leaving the perichondrium intact). Mitomycin C (0.4 mg/cc) topical application is performed at the end (not shown) for 2 separate 2 minute intervals. Jet ventilation or apneic technique both can work well for ventilation. Typically on our 8-10 week follow up, these bridges have regressed in size and the airway is well healed and fully patent.
Patients with subglottic stenosis due to scar, inflammatory related, or idiopathic stenosis.
Patients with cartilage infracture secondary to trauma which would typically need an open approach.
Typical Micro DL set up with operating microscope, laryngoscope suspended and line of sight CO2 laser.
Pertinent history such as current limitations in breathing, hoarseness, intubations, neck trauma, previous neck/laryngeal surgery, GERD symptoms, sinusitis, renal disease, smoking history. Full pulmonary function testing. Labs such as p-ANCA and c-ANCA to rule out GPA, occasionally other labs such as C-reactive protein, ESR, CBC, ANA.
Avoid glottis or cricoarytenoid joints when lasering around the subglottis.
The advantage is early full excision of scar without the need for balloon dilation. At times, the balloon dilator can extend into the glottis and cause scar to extend up to the cricoarytenoid joint which can limit motion.
Pneumothorax, trachea-esophageal fistula.
Pneumothorax, trachea-esophageal fistula.None
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Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
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Review CO2 laser wedge excision and steroid injection for Subglottic Stenosis.