الفهرس 
Aetiology and classification 28 Aetiology of congenital subglotticOnly 14 pages are availabe for public view
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Abstract
The management of SGS is a difficult problem
that continues to tax the ingenuity of the laryngologist. The condition is rare and presents
multiple problems affecting soft tissue and cartilage. Iatrogenic injuries and road traffic
accidents account for most cases. The problem of pediatric patients often must be managed
differently from those of adult patients.
Congenital SGS is the third most common congenital laryngeal anomaly. Congenital SGS may be devided
into cartilagenous and soft tissue stenosis.
Acquired SGS may be due to:
I. Trauma a. external laryngeal trauma.
b. internal laryngeal trauma.
2. chronic infection.
3. chronic inflammatory disease.
4. Laryngeal neoplasm.
5. Gastroesophageal reflux disease.
Myer et al. 1994 reported that grading of acquired SGS is according to the percentage of lumen
obstruction measured by endotracheal tube size:
Grade I: up to 50% obstruction.
Grade II: from 51% to 70% obstruction.
Grade III: above 70% with any detectable lumen. Grade VI: no detectable lumen.
Diagnosis depends on complete history intake, good physical examination and investigative
procedures.
Radiologic evaluation includes plain x-ray, xeroradiography tomography and contrast
laryngography m addition to the more recent techniques of CT. helical CT and MRI. Endoscopic
evaluation is mandatory to assess the dynamics of vocal fold function, and the extent of stenosed
segment. Acquired SGS can be prevented by early intervention following laryngeal trauma, avoiding
high tracheostomy and cricothyroidotomy except in extreme emergencies, performing intubation and
endoscopy on completely relaxed patients and avoiding aggressive endoscopic surgery for benign
laryngeal lesions.
Most cases of congenital SGS requires tracheostomy. Dilatation by laryngeal dilators can be used
especially for soft tissue stenosis as it does help improve the airway.
Various endoscopic methods of scar excision have been used, including infant urethral resectoscopes
and cryogenic probes.
COz laser become popular because it allows the surgeon to vaporize scar tissue with precision,
producing minimal damage to healthy tissue.
Open surgical methods have been recommended for congenital cases not responding to repeated serial
dilatations, cases with extensive and dense stenosis and those with cricoid abnormalities. Many
surgical procedures for the correction of SGS have been described. They involve the use of
autogenous grafts, hyoid bone, sterno-hyoid myo-osseous flaps. Stents are used to counteract scar
contracture and promote a scaffold for epithelium to cover the lumen of the airway.
The use of steroids as an adjunct to dilatation and
simple excision of scar tissue might be expected.
All cases of moderate and severe acquired SGS will require tracheostomy.
Two basic approaches are available:
1. Endoscopic methods:
It includes endoscopic dilatation, laser excision of the stenotic area and mucosal flaps.
2. Open reconstructive surgery:
Required for grade III and IV lesions.
Surgical
’
operations
in children include:
- Anterior cricoid split.
- Costal cartilage graft technique.
-Castellated laryngotracheoplasty.
- Combined laryngofissure with posterior cricoid split.
In adult surgical management includes:
- Combined laryngofissure and posterior cricoid division with costal cartilage grafting.
- Cricoid resection and thyrotracheal anastomosis.
- Thyrotomy with hyoid-sternohyoid muscle graft interposition.
The previously described techniques were developed over years and combined the use of laryngeal and
cricoid split cartilage, bone grafts and stenting. The key for successful out come is to choose the
most appropriate procedure for each patient.