ENT (Otorhinolaryngology) · MU Sofia

40. Stenosis of the larynx and upper respiratory tract.

Covers laryngotracheal stenosis, defined as a narrowing of the airway from the supraglottis to the proximal trachea, and walks through its congenital and acquired causes, the stages of scarring, and classifications by onset, site and Cotton-Myer grade in a table. It then describes the clinical picture, investigations such as laryngoscopy, CT and pulmonary function tests, treatment from emergency care to endoscopic and open surgery, complications, and differential diagnoses.

Inside: 1 section · 3 labelled pictures · 1 table · 15 flashcards · 4 min

Topic 40 of 52 in the MU Sofia syllabus for ENT (Otorhinolaryngology) (Medicine, Year 4). The free AceMed note covers it in 1 section, about 540 words (4 min of reading), with 15 flashcards.

In this note

  1. Stenosis of the larynx and upper respiratory tract.

Stenosis of the larynx and upper respiratory tract.

1. Definition: Laryngotracheal Stenosis is a congenital or acquired narrowing of the airway at the level of the supraglottis, glottis, subglottis, or the proximal trachea, leading to increased airway resistance and respiratory obstruction.

2. Etiopathogenesis

  • Congenital: Rare (approx. 5%). Laryngomalacia, Subglottic stenosis, malformed cricoid cartilage, laryngeal web.
  • Acquired (Most Common):
  • Iatrogenic: Prolonged endotracheal intubation is the cause in up to 90% of cases.
  • Trauma: External blunt trauma to the neck, inhalation burns, or corrosive ingestion.
  • Inflammatory/Autoimmune: Granulomatosis with polyangiitis (GPA), Sarcoidosis, and GERD
  • Infectious: Diphtheria, Epiglottitis, Laryngotracheobronchitis
  • Idiopathic: Primarily affects adult females with no history of trauma or intubation.

Pathogenesis

  1. 1. Mucosal injury → inflammation and edema
  2. 2. Ulceration and granulation tissue formation
  3. 3. Fibrosis and scar contraction
  4. 4. Permanent airway narrowing (stenosis)

3. Classification

1. According to Onset

  • Acute stenosis – rapid onset, life threatening, urgent interv
  • Chronic stenosis- gradual devlp, progr respr diff

2. According to Site

  • Supraglottic
  • Glottic
  • Subglottic (most common post-intubation)
  • Tracheal

3. According to Degree (Cotton–Myer Classification – subglottic)

4. Clinical Picture

  • Stridor: The hallmark sign.
  • Inspiratory: Supraglottic/Glottic.
  • Biphasic: Subglottic/Cervical trachea.
  • Dyspnea: Initially on exertion, progressing to dyspnea at rest.
  • Dysphonia: Hoarseness occurs if the glottis (vocal cords) is involved.
  • Recurrent "Croup": Especially in children
  • Ineffective Cough: Difficulty clearing secretions.
  • Anxiety
  • Reduced exercise tolerance
  • Signs
  • Suprasternal retractions
  • Use of accessory muscles
  • Cyanosis (late sign)
  • Tachypnea

5. Paraclinical and Radiological Examinations- clinical eval

  • Laboratory: ABG: hypoxemia ± hypercapnia, CBC if infection suspected
  • Flexible Laryngoscopy (Gold Standard): For an awake assessment of vocal cord mobility.
  • Microlaryngoscopy and Bronchoscopy (MLB): Performed under general anesthesia to accurately measure the length, diameter, and "softness" of the scar.
  • Imaging:
  • CT Neck/Chest with contrast- chronic cases: Defines length and severity of stenosis + Detects cartilage involvement
  • X-ray (Lateral Neck): May show "steeple sign" or focal narrowing.
  • Pulmonary Function Tests (PFTs): Characterized by a "flattening" of both the inspiratory and expiratory limbs of the flow-volume loop (Fixed extra-thoracic obstruction).

6. Treatment Options

  • Acute Stenosis: Emergency Management = Airway first, Oxygen, Nebulized adrenaline + IV corticosteroids, Endotracheal intubation
  • Tracheostomy (if needed)
  • Chronic Stenosis: Definitive Management = Anti-reflux therapy, Voice rest, Steroids (early inflammation)
  • Medical: Steroids (to reduce edema) and PPIs (to treat laryngopharyngeal reflux, which worsens scarring).
  • Endoscopic Procedures (Grades I-II):
  • Balloon Dilation: Stretching the narrowed area.
  • Laser Excision: CO2 or KTP laser to radicalize the scar.
  • Mitomycin-C: A topical "anti-scarring" agent applied during surgery.
  • Open Surgery (Grades III-IV):

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