Independent Researcher, Paterson, NJ 07533, USAUnited States
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Supraglottic stenosis is a rare entity, which is more common in females, and trauma is the most common cause for it. Dysphagia, dysphonia, dyspnea and stridor are the common symptoms of supraglottic stenosis. Non-symptomatic cases can be managed by observation, and symp-tomatic cases with sever airway obstruction may need a tracheostomy; some cases may need nasogastric tube to relieve dysphagia. Endoscopic approach using carbon dioxide (CO2) laser is the most common procedure used to treat supraglottic stenosis, supraglottic laryngectomy is only indicated for severe supraglottic stenosis. Supraglottic stenosis has high rate of recurrence and may need multiple surgical procedures. Supraglottic stenosis has a better prognosis than glottis and subglottic stenosis with successful treatment rate up to 83%. This is a short discus-sion about supraglottic stenosis found in literatures; the objective of this study is to present a brief review about this disease.
Keywords: were used: suraglottic and stenosis; laryngeal and stenosis
The supraglottic stenosis is a rare disease; it is usually difficult to be managed. The most com-
mon causes are iatrogenic injury from supraglottic surgery, prolonged intubation, trauma, ra-
diation therapy, caustic ingestion, and autoimmune diseases. Presenting symptoms may include
dysphagia, dysphonia, shortness of breath (SOB), stridor and potentially life-threatening air-
way obstruction. There is a controversy about the optimal treatment of supraglottic stenosis.
Historically, open supraglottic laryngectomy was the treatment of choice; however, this was as-
sociated by high morbidity connected to chronic aspiration and poor wound healing. Recently,
endoscopic approach is more favorable because it is more conservative and associated with
less morbidity.1
Literature review was conducted using PubMed (MEDLINE) and Google Scholar for English
articles, the following keywords were used: suraglottic and stenosis; laryngeal and stenosis.
All adult patients diagnosed with supraglottic stenosis following any cause were included in
the study.
cases less than 12 years and burns of the neck.
3 M
Yilmaz et al (Rhinosclerma)
3 F 2 patients had
Caustic ingestion
2 Supraglottic Zoghbi et al F 51 Radiation
Freitas et al F 78 Pemphigoid Supraglottic
4 Diffuse Amyloidosis Gilad et al Systemic F 64 suragloticpharynex
F 24 Caustic agent Glotic
Assanasen et al
M 39 Trauma Glotic
Kim et al M 65 Radiation Glotic
M Radiation
7 Supraglotic Nair et al F Caustic agent
M External trauma Glottic
Pegg et al M 83 Idiopathic Supraglotic
M Trauma Supraglotic
Lasisi et al
M Trauma Supraglotic
Krishna et al F 61 GERD Supraglotic
Saad et al F 70 TB Supraglottic
Oosthuizen et al F 13 Trauma Supraglottic
Rubino et al F 70 Radiation Posterior golttic
Latrogenic
4 patients were 4 Patients had: Autoimmune decanulated 4 patients Microlaryngoscopy One (SLE) had Supraglottic CO2 Laser Infection Yes all Dilation had Mitomicin application Trachestomy
Irradiation One was Supraglottic 2 Patients had: decanulated Glottic Laryngeal construction Multiple One stayed Subglottic surgery with stent dependent
Trauma
Yes KTP Laser Multiple Decanulated glotic
Yes Medical treatment NO Dependent
Yes No NO Dependent Amyloidosis trachea
Supraglotic Laryngeal reconstruction Yes One Dependent surgery Sub glotic
Supraglotic Laryngeal Yes One Dependent reconstruction surgery Sub glotic
Supraglotic Laryngeal reconstruction Yes One Dependent surgery Subglotic
Supraglotic Microlaryngoscopy
Yes CO2 Laser Multiple Decanulated
Yes CO2 Laser Multiple Decanulated
Supraglottic Laryngeal reconstruction
Yes surgery Multiple Dependent
Subglottic No Multiple Improved Dilation
Scar excision with cold Yes Multiple Decanulated instruments
Steroid injection
Scar excision with cold Yes Multiple Decanulated instruments
Steroid injection
Transoral supraglottic Yes One Decanulated laryngectomy
Yes CO2 Laser Multiple Decanulated
No Dilation Mitomicin Multiple Improved
application
Supraglottic Microlaryngoscopy
No Scar excision with CO2 One Improved
Keel using
1 M Trauma
Sinacori et al
1 F Caustic agent
15 Epidermolysis Kiniwa et al F 37 Supraglottic
16 Supraglottic Lyons et al f 47 Caustic agent
17 Iatrogenic Davis et al F 48 Supraglottic
2F 18 1 Trauma Duncav Age et al Supraglottic
1M
Doyle et al F Caustic Supraglottic
F 62 Iatrogenic Supraglotic
20 M 58 Iatrogenic Supraglotic Minni et al
M 35 Trauma Supraglottic
21 Iatrogenic Canis et al M Supraglottic
22 3 M 4 cases of Grant et al All four cases Supra-
1 F cause
23 Iatrogenic Alon et al 1 F Supraglotic
24 Supraglottic F. Izadi et al F 12 Fraser syndrome
Moore et al2 M 48 Trauma Supraglottic
3 M 26 3 Trauma Kacker et al Supraglotic
2 F
Sunderr Ajan et Al M Intubation Supraglottic
4 M 28 Supraglotic Stevens et al 3 Autoimmune
4 F ( 2 wager,
Mistry et al M 54 Plasmacytosis Supraglotic
Rubinstein et al F 18 TB Supraglottic
Scar excision with CO2 Multiple
ballon dilation Decanulated Yes
Scar excision with CO2 Multiple
ballon dilation
Yes Medical treatment No Decanulated Bullosa Acquisita
yes Scar excision with CO2 Multiple Decanulated Glottic microdebrider Yes Mutiple Decanulated Scar excision with CO2
All three patients had:
Yes Microlaryngoscopy Mutiple Decanulated 2 Caustic agent Scar excision with CO2
Open surgery
Yes laryngofissure One Decanulated
Remove scar tissue
One Improved No Suprglottic laryngectomy
Yes Supraglottic Laryngectomy Multiple Decanulated
Supraglottic
Yes laryngectomy Multiple Decanulated
Yes Scar excision with CO2 Multiple Decanulated
All four All four patients had: patients Iatrogenic Yes Microlaryngoscopy 4 Decanulated glottic had: Scar excision with CO2 Multiple
Dead before Yes No treatment No treatment yes Multiple Dependent Glotic Scar excision
Yes KTP Laser One Decanulated
open surgical procedure
(excision of the stenosis All Yes with repair of the supra Multiple 2 Caustic agent 5 Decanulated glottis area via
laryngofissure)
Yes Scar excision with CO2 Multiple Decanulated 5 Radiation CO2 laser All patients
Scar excision have Yes 8 Decanulated 6 patient had additional Multiple
KTP laser in clinic procedures 1 Sarcoidosis)
Dilatation to relieve Yes One Decanulated supraglottic stenosis
Yes Scar excision Multiple Decanulated
Stent
topical mitomicin
Belloso et al M 64 Wagner Supraglottic
Bahamonde et al F 69 Pemphigoid Supraglottic
M 50 Sarcoidosis Supraglottic
F 50 Sarcoidosis Supraglottic
Sims et al
F 48 Sarcoidosis Supraglottic
M 43 Sarcoidosis Supraglottic
34 Supraglottis Ma et al M 36 Amyloidosis
F Wagner Supraglotic
35 F Wagner Supraglottic Kaneko et al
F Idiopathic Supraglottic
F 50 Radiation Supraglottic
M 58 Radiation Supraglottic
Vira et al
F 60 Sarcoidosis Supraglottic
F 66 Idiopathic Supraglottic
Table 1. Supraglottic stenosis reported cases.
There were 72 patients of age ranged from 12 to 83 with major-
ity of the patients over 50 year old. There were 33 males and 39
females in the study. Forty-six patients had stenosis secondary to
trauma, 15 patients had supraglottic stenosis secondary to auto-
immune diseases, 4 patients had supraglottic stenosis secondary
to infection, 7 patients had stenosis secondary to other diseases
(Table 2 Chart 1).
Sixty patients out of them had isolated supraglottic ste-
nosis, while the other 12 patients had multiple sites laryngeal
stenosis. Sixty-five patients of them had a tracheostomy, while
Medical treatment
Yes Microlaryngoscopy One Decanulated
No Medical treatment Improved
Yes Scar excision with CO2 One Decanulated
Steroid
Yes Scar excision with CO2 Multiple Decanulated
Steroid
Yes Scar excision with CO2 Multiple Dependent
Steroid
Yes Scar excision with CO2 One Dependent
Steroid
Yes Scar excision with CO2 Multiple Decanulated anterior commissure microdebrider
Medical treatment
Yes No Dependent
Medical Treatment
No Microlaryngoscopy One Improved
KTP Laser
Yes Medical treatment No Dependent
Palliative Yes Multiple Decanulated Multiple dilation
Mitomycin application Yes Mutiple Decanulated Multiple dilation
Mitomycin application Yes Multiple Decanulated Multiple dilation
Mitomycin application
Multiple dilation Yes Multiple Decanulated
Mitomycin application
the other 7 patients did not have tracheostomy.
One was dead before the treatment, 2 patients had only medical
treatment (pemphigoid), 1 patient had only a tracheostomy as a
palliative therapy (systemic amyloidosis), 3 patients had trache-
astomy and medical treatment (2 patients of them had wagener
disease, the other patient had pemphigoid), 52 patients had en-
doscopic laryngeal surgery (one patient of them had endoscopic
supralaryngectomy, 3 patients of them had endoscopic approach
using cold instruments, while the other 48 patients had endo-
scopic approach using Laser), 9 patients had external laryngeal
Trauma 46 63.3% Caustic agent 10
Autoimmune 15 20.8%
Infection 4 5.5%
Others 7 9.7%
approach (3 patients of them had supraglottic laryngectomy,
while the other 6 patients had open surgery using laryngofis-
sure approach), 4 patients had staged laryngeal reconstruction
surgery (Table 3 Chart 2).
Sixty patients had a surgery for decanulation, 49 patients of them
had only isolated supraglottic stenosis (47 patients of them were
decanulated, 2 patients stayed dependent on tracheostomy), the
other 11 patients with multiple sites laryngeal stenosis including
supraglottic stenosis had surgery for decanulation (4 patients of
them were decanulated, while the other 7 patients of them stayed
dependent on tracheostomy. Most patients need multiple surger-
ies for decanulation. (Table 4 Chart 3).
External trauma 13 • Three patients without tracheostomy had a surgery and all of them
improved
Radiation 12 • Forty-three patients had a surgery for decanulation, thirty eight patients
of them were decanulated after surgery, while the other 5 patients stayed
dependent on tracheostomy.
Iatrogenic 10 Successful management rate (41/46) 89%
Post intubation 1
Ssarcoidosis 6 • Two patients improved after medical treatment
• One patient without tracheostomy had surgery and his situation improved. Wagener 5
• Eight patients weredecanulated after surgery.
Pemphigoid 3 • Four patients stayed dependent on tracheostomy.
TB 2
• 4 patients weredecanulated after surgery.
Sclerma 1
Plasmacytosis 1
Congenital 1 • One patient without tracheostomy had surgery and improved after it.
• Two patients had tracheostomy as palliative therapy
Amyloidosis 2 • Three patients had a surgery for decanultion,
• Two patients of them were decanulated while the other patient stayed GERD 1 dependent on tracheostomy.
Idiopathic 3 Successful management rate (3/7) 42%
Surgery for supraglottic stenosis is usually approached as same
as stenosis elsewhere in the larynx.
Non-symptomatic cases may be managed by observa-
tion. Surgery is advised for symptomatic cases.
Endoscopic approaches are more favorable than open
approaches, but open procedures is usually recommend for diffi-
cult and complex cases. For open procedures, a laryngofissure is
used to approach and to respect the scar tissue. Partial supraglot-
tic laryngectomy which can be done endoscopically or by open
approach is used for severe cases in which the stenosis extends
to the glottis. Endoscopic approaches to supraglottic stenois are
Medical treatment
Tracheastomy
Medical treatment and
Tracheastomy
Endoscopic Laryngeal Surgery (laser, dilation or cold
instruments)
External approach (open supraglottic laryngectomy or
open surgery using laryngofissure) for sever supraglottic
stenosis
Staged laryngeal construction Surgery (for severe cases
associated with stenosis in another laryngeal areas).
Patients had a Surgery for decanulation 49 11
Decanulated patients 47 4
Decanulation rate 95% 36%
less invasive and often give good results same as open approach.
CO2 laser excision is commonly used because of its ability to
resect scar and give good hemostasis at the same time. If the scar
tissue extends to the glottis, then cold resection may be good op-
tion to protect vocal folds from thermal injury.25
Laryngeal caustic injury is associated with oral, pha-
ryngeal and esophagus injury, sopanendoscopy consisting of
2 2 100%
1 0 0%
3 0 0%
52 47 90%
9 9 100%
4 1 25%
rd copy is considered to be mandatory. Up to 3rd of patients with
caustic ingestion may complain of long-term complications such
as oral, pharyngeal, laryngeal, and esophageal strictures. The
typical clinical course starts 2 weeks after caustic ingestion. The
clinical symptoms include upper airway obstruction, dysphagia,
and dysphonia/aphonia. The larynx scar is often located at su-
praglottic area without involvement of the vocal folds. The sur-
gical treatments of caustic pharyngolaryngeal stenosis include
st
sists of laryngofissure, permanent tracheostomy, and/or laryn-
gectomy. In selected cases, a complete resection of the stenosis
is performed and followed by optimal reconstruction. The 2nd
approach includes using of cold instrumentations or laser.26
Intubation usually cause stenosis in subglottic and pos-
terior glottis area, it is uncommon to induce stenosis insupraglot-
tic area.27
Laryngeal edema, chondronecrosis, necrosis of soft tis-
sue, necrosis of skin, stricture of pharynx and larynx, and carotid
stenosis occur infrequently during head and neck radiotherapy.
Treatment of laryngeal stricture caused by radiation is a trache-
ostomy for respiratory distressed patients, dilation and CO2 laser
to remove scar tissue.28
Balloon dilation for supraglottic stenosis is reported in
the literature to treat suraglottic stenosis caused by fungal infec-
tion.29
Laryngeal tuberculosis is rarely reported; it is more
common in middle-aged males, and appears with a negative
chest x-ray; hoarseness is the most common symptom. Some-
times tracheostomy is necessary to relieve severe laryngeal
obstruction. Endoscopic CO2 laser to remove scar tissue and to
insert a laryngeal stent is the treatment of choice for supraglottic
stenosis. We can also apply mitomycin-C locally.30
The therapy of laryngeal involvement of Wagner dis-
ease is based on two components; the 1st is the treatment of sys-
temic disease with steroid and immunosuppressant medications,
the second is the treatment of local symptoms with tracheos-
tomy, dilation, CO2 laser vaporization and finally resection of
the stenosis segment followed by reconstruction.31
Pemphogoid is treated with steroid, immunosuppres-
sant medications and dapsone. Tracheostomy is kept for nec-
essary cases, remission is essential so we avoid needing for
surgical intervention as well as regular assessment to prevent
recurrence.32
Laryngeal sarcoidosis more commonly involves supra-
glottic area. Laryngeal sarcoidosis usually presents with hoars-
ness, dry cough and dysphagia.
Treatment ranging from closes observing in stable as-
ymptomatic patients to emergent tracheostomy in patients with
acute respiratory distress. Systemic steroid therapy is the basic
therapy for a systemic disease. Localized laryngeal disease is
treated with resection using CO2 laser with local steroids or mi-
tomycin-C. Open surgical excision and external radiation thera-
py may be also used.33
Amyloidosis is usually localized in the head and neck
area, treatment with surgical excision is usually successful for
symptomatic cases. In the larynx, a conservative resection using
microlaryngeal surgical approach is recommended with preser-
vation of the surrounding tissue. Recent articles has advocated
nd CO2 laser as the treatment of choice, recurrence is usually rare
26 34 and can be treated with further conservative excision.34
No history of recent intubation, trauma, or autoimmune
diseases should be existed to diagnosis idiopathic supraglottic
stenosis which is more common in female.35
There are multiple articles reported that the application
of local mitomycin-C or corticosteroid during the surgery may
decrease the recurrence of the laryngeal stenosis.36
Suraglottic stenosis is more common in female, trauma is the
most common cause of supraglottic stenosis, suraglottic steno-
sis caused by infection has a better prognosis, while supraglot-
tic stenosis caused by autoimmune diseases has a lower rate of
decanulation (may be because there is no definite treatment for
autoimmune diseases and disease usually recur). Isolated su-
praglottic stenosis has a good prognosis with 95% successful
treatment rate. Endoscopic approach using laser was the most
common procedure used to treat supraglottic stenosis with 90%
successful rate.