Question

Outline the Cotton-Mayer staging of subglottic stenosis. What are the management options of paediatric subglottic stenosis grade 3 and grade 4?

Hint:

Cotton-Mayer grading helps guide treatment decisions for subglottic stenosis, with endoscopic interventions used for less severe cases and surgical procedures like tracheostomy and LTR for severe cases.

Answer 1

Step 1: Overview of Cotton-Mayer Staging of Subglottic Stenosis:
Cotton-Mayer staging is used to classify the severity of subglottic stenosis, which refers to the narrowing of the subglottic region of the airway. This staging system helps determine the extent of the stenosis and the appropriate management approach. 1. Grade 1: Mild subglottic stenosis, involving less than 50% of the airway.
2. Grade 2: Moderate subglottic stenosis, involving 51% to 70% of the airway.
3. Grade 3: Severe subglottic stenosis, involving 71% to 99% of the airway.
4. Grade 4: Complete obstruction, where the airway is almost entirely blocked, with less than 1% of the airway remaining.

Step 2: Management Options for Pediatric Subglottic Stenosis Grade 3:
For grade 3 stenosis, which involves severe narrowing of the airway, the following management options are considered:
1. Endoscopic Intervention:
- Laser Ablation: Laser treatment can be used to remove the fibrous tissue causing the narrowing.
- Dilation: Balloon dilation or surgical dilation can be used to expand the narrowed subglottic area.
2. Tracheostomy: In cases where endoscopic procedures fail to provide sufficient airway relief, a tracheostomy may be considered to bypass the obstruction.
3. Stenting: A stent can be placed in the airway to maintain patency and prevent the stenosis from worsening.
4. Steroid Injections: Steroid therapy may be used to reduce inflammation and fibrosis in the affected area.

Step 3: Management Options for Pediatric Subglottic Stenosis Grade 4:
For grade 4 stenosis, where the airway is almost completely obstructed, immediate and more aggressive management is required:
1. Surgical Resection: The affected subglottic tissue may need to be surgically removed to restore an adequate airway. This is often performed through an open surgical approach.
2. Tracheostomy: A tracheostomy is commonly performed for airway management in grade 4 stenosis. This allows the patient to breathe while further treatments are considered.
3. Laryngotracheal Reconstruction (LTR): LTR is a more advanced surgical procedure where the stenosed section of the airway is reconstructed, often using cartilage grafts to widen the airway.
4. Long-Term Follow-up: Children with grade 4 stenosis require long-term monitoring for possible recurrence of stenosis and other complications.