Subglottic Stenosis

Sid M. Khosla

History

A 40-year-old white man has a 3-month history of progressive dyspnea, now occurring while at rest. He reports facial pain overlying the left maxillary sinus, nasal obstruction, chronic cough, and recent mild hoarseness. He denies any dysphagia or aspiration, but he admits that he has had severe heartburn for several years. He reports that after a severe motor vehicle accident, he was intubated for 10 days and subsequently had a tracheotomy for 3 months.

The physical examination reveals biphasic stridor with moderate retractions while breathing. There is also significant tenderness over the left maxillary sinus and erythematous, boggy nasal mucosa in the left nares. Laryngeal examination reveals slightly erythematous folds. The subglottis cannot be evaluated.

Differential Diagnosis—Key Points

1. Prolonged intubation can cause subglottic or tracheal stenosis. A tracheotomy can also cause this, especially if it is placed too high. This could be the cause in this case, but given his other symptoms, other causes should also be explored.

2. Laryngopharyngeal reflux can make subglottic stenosis worse and can prevent it from healing. A dry cough is also seen with laryngopharyngeal reflux. Although post-nasal drip has been associated with reflux, sinus pain and nasal obstruction usually are not.

3. With nasal, laryngeal, and possibly pulmonary symptoms, computed tomography needs to be done of the sinuses, neck, and lungs.

4. Inflammatory or infectious disorders may cause laryngotracheal stenosis. Wegener granulomatosis (subglottic), sarcoid (supraglottic), relapsing polychondritis, and tuberculosis are potential causes. Amyloidosis can also be a cause.

Test Interpretation

CT scans showed nonspecific left maxillary sinus disease and three nodules in the left lung.