Abstract
Objective
To identify a safe approach to airway management during the endoscopic balloon dilation of subglottic stenosis
Background
Subglottic stenosis is an abnormal narrowing of the upper airway commonly managed by endoscopic technique performed on an unsecured airway.
Methods
Review of surgical treatment of subglottic stenosis cases by the senior author.
Technique
Following steroid injection and radial cuts performed either under jet anesthesia or mask ventilation with brief periods of apnea, a small endotracheal tube may be passed beyond the narrowing to permit adjacent balloon dilation with the airway secured.
Conclusions
We introduce an endoscopic subglottic balloon dilation technique done with a secured airway.
Subglottic stenosis is an abnormal narrowing of the upper airway. Acquired subglottic stenosis may result from mechanical trauma, laryngopharyngeal reflux, and autoimmune disorders including granulomatosis with polyangiitis (Wegener’s granulomatosis) as well as relapsing polychondritis. Alternatively, when there is no clear etiology, subglottic stenosis is categorized as idiopathic . Traditionally management includes surgical intervention with open resection or endoscopic management . Direct endoscopy is often the preferred initial treatment and usually employs a combination radial incisions (scissors or CO 2 laser), corticosteroid injection, and either rigid dilation or employing expanding balloon techniques ( Figs. 1–4 ). Rigid dilation has been accomplished with rigid bronchoscopes as well as with solid metal laryngeal dilators such as Jackson laryngeal dilators. Balloon dilators have found increasing use due to reports that they induce less mucosal trauma by avoiding the shearing forces of bougie techniques. Additionally, the capacity to inflate the balloon after the small diameter uninflated dilator is placed into the subglottis decreases risk of injury to the vocal cords that may occur in the course of placing a bougie dilator .
Balloon dilation is generally viewed as a safe, efficient, and minimally invasive method of dilation . However, there are specific risks associated with the dilation of the subglottis and upper trachea when a balloon is used. Achkar et al reported a complication occurring when a high pressure, non-compliant balloon catheter became entrapped while fully inflated in the subglottis . The stretched and thinned injection port prevented removal of fluid from the balloon which completely blocked the airway. Fortunately the patient did not suffer harm as balloon was removed with large endoscopic forceps before oxygen desaturations occurred.
We have employed a technique over the past 6 years as a modification to this approach by placing a small endotracheal tube beyond the stenotic segment allowing ventilation to continue during dilation with the balloon adjacent the endotracheal tube.
1
Materials and methods: Surgical technique
General anesthesia is induced while the patient is mask ventilated. With full relaxation (most often obtained with 50 mg of rocuronium after mask ventilation ensured), a laryngoscope is placed and jet anesthesia is initiated. In the rare case in which jet anesthesia is insufficient to maintain saturations due to the severity of stenosis, Jackson metal laryngeal dilators (usually 18-22) are passed to create space for placement of a 4-0 MLT® endotracheal tube. Heliox by mask ventilation has been used to help ensure ventilation in rare cases. Occasionally morbid obesity or underlying pulmonary conditions preclude successful jet anesthesia despite positioning the patient in a back-up position in which case intubation is performed before injection and radial cuts. The stenotic segment is then endoscopically visualized and injected with a mixture of triamcinolone, lidocaine, and epinephrine (creating ‘kenalog 10’ by mixing 1 cc of Kenalog 40® with 3 cc of lidocaine (1%) with 1:100,000 epinephrine). Microlaryngeal scissors are used for radial cuts. If the patient has not yet been intubated, they are then intubated with a 4-0 or 5-0 microlaryngeal endotracheal tube (MLT) and ventilation is transitioned from jet to the regular circuit via the MLT® endotracheal tube. The balloon dilation system is then introduced beyond the vocal cords adjacent the endotracheal tube and inflated — most commonly for four minutes. Replacement with re-orientation of the balloon may be done with repeated dilations as needed.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
