CO2 laser wedge excision and steroid injection for Subglottic Stenosis

Contributors: Jan Kasperbauer

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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