Question

Briefly discuss the evaluation protocol and surgical management of a case of congenital subglottic stenosis.

Hint:

Surgical management, including dilation and reconstructive surgery, is tailored based on the severity of congenital subglottic stenosis and the child’s overall health.

Answer 1

Evaluation Protocol of Congenital Subglottic Stenosis:
1. Clinical History:
- A detailed history is taken, including prenatal history (e.g., maternal illnesses or medication use), birth history (e.g., premature birth), and any history of breathing difficulty in the newborn period.
- Symptoms of stridor, noisy breathing, and recurrent respiratory infections are common in infants with congenital subglottic stenosis.
2. Physical Examination:
- Stridor: A characteristic high-pitched sound heard during inhalation, indicating upper airway obstruction.
- Signs of respiratory distress: Tachypnea, use of accessory muscles, and retractions during breathing.
- Cyanosis may be seen in severe cases of airway obstruction.
3. Imaging:
- Flexible Laryngoscopy: A key diagnostic tool to directly visualize the airway, assess the degree of stenosis, and determine if there are other abnormalities in the vocal cords or trachea.
- Rigid Bronchoscopy: Used to evaluate the stenosis more thoroughly, particularly if surgical intervention is planned. This can help measure the degree of airway narrowing and determine whether other parts of the airway are involved.
- CT Scan: May be used in more severe cases to assess the extent of the stenosis and any associated airway anomalies.
4. Pulmonary Function Tests (PFTs):
- In older children, PFTs may be used to assess the functional impact of the stenosis, particularly in terms of airflow and ventilation.
Surgical Management of Congenital Subglottic Stenosis:
1. Endoscopic Procedures:
- Dilation: For mild stenosis, dilation with balloon catheters or other endoscopic tools can help widen the subglottic area and improve airflow.
- Laser Resection: In cases of localized subglottic stenosis, laser surgery can be used to excise scar tissue and reduce stenosis, allowing for better airway patency.
2. Tracheotomy:
- In severe cases of congenital subglottic stenosis, particularly in infants with complete or near-complete airway obstruction (Grade III or IV), a tracheotomy may be required to maintain an open airway and support breathing.
3. Open Surgical Procedures:
- Cricoid Split or Laryngotracheal Reconstruction: For more extensive stenosis, especially when the stenosis involves the cricoid cartilage, surgical procedures like cricoid split or laryngotracheal reconstruction (LTR) may be necessary. These surgeries involve making an incision in the cricoid ring to expand the airway and restore normal airflow.
- Postoperative Care: Close monitoring in the ICU for respiratory support, pain management, and prevention of infections is crucial after surgery.
4. Follow-Up and Long-Term Management:
- Regular follow-up is necessary to monitor for recurrence of stenosis and assess the child’s airway function as they grow.
- In some cases, further dilations or surgical interventions may be needed as the child grows, particularly in cases with recurrent stenosis.