The Laryngoscope

Lippincott Williams & Wilkins, Inc.

2006 The American Laryngological,
Rhinological and Otological Society, Inc.

Modern Management of
Laryngotracheal Stenosis
Heather C. Herrington, BA; Stephen M. Weber, MD, PhD; Peter E. Andersen, MD

Objectives: Laryngotracheal stenosis is a complex

problem resulting most often from intubation, trauma,
or autoimmune disease. Management options include dilation or airway reconstruction including
laryngotracheoplasty (LTP), cricotracheal resection (CTR), and tracheal resection (TR). We describe
our experience with management of this difficult
problem. Study Design: Retrospective chart review
of patients treated for laryngotracheal stenosis between January 1995 and July 2005 at an academic,
tertiary referral center. Methods: A total of 127 patients were treated during the study period. Patients were followed, and hospital records were reviewed. Results: There were 38 male and 89 female
patients with an average age of 55.5 years treated
for laryngotracheal stenosis resulting from intubation (64), idiopathic (25) or autoimmune disease
(18), radiation (9), trauma (5), prior surgery (4), and
relapsing polychondritis (2). Thirty-three percent
were treated for grade I stenosis, 44% grade II, 19%
grade III, and 4% grade IV. Seventy percent of patients undergoing initial dilation required a subsequent procedure. LTP, CTR, or TR was performed
in 43%, 48%, 71%, and 100% of patients with grade I
through IV stenosis, respectively. Among 76 patients undergoing LTP, CTR, or TR, 24 (32%) required a subsequent intervention. Among 36 patients treated with primary LTP, CTR, or TR, only
10 (28%) required further therapy. Twenty-two of 35
(63%) tracheostomy-dependent patients were ultimately decannulated. Three patients died in the immediate postoperative period. Conclusions: Patients
undergoing dilation for laryngotracheal stenosis require multiple procedures. However, major reconstructive procedures are well tolerated and currently
represent a viable primary treatment for laryngotra-

From the Department of Otolaryngology and Head and Neck Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park
Road, Portland, Oregon, U.S.A.
Editors Note: This Manuscript was accepted for publication February 1, 2006.
Presented at the Combined Western/ Middle Section of the Triologic
Society. Coronado Island, California, U.S.A., February 4, 2006.
Send Correspondence to Dr. Peter Andersen, Department of Otolaryngology and Head and Neck Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-mail:
andersep@ohsu.edu
DOI: 10.1097/01.mlg.0000228006.21941.12

Laryngoscope 116: September 2006

cheal stenosis. Key Words: Laryngotracheal stenosis,

cricotracheal resection, tracheal resection, laryngotracheoplasty, intubation, trauma, airway, dilation.
Laryngoscope, 116:15531557, 2006

INTRODUCTION
Laryngotracheal stenosis (LTS) is a morbid disease
that is challenging to manage. Historically, infection and
external trauma to the airway have been the primary causes
of LTS.1 However, sequelae of intubation have become the
primary etiology.1 Nearly 10% of intubated patients will
subsequently develop LTS.2 Although the risk appears to
rise with prolonged intubation, subglottic injury has been
demonstrated within hours of intubation.3,4 Other common
etiologies resulting in LTS include post-tracheostomy airway
stenosis, radiation, benign and malignant neoplasms, and
collagen-vascular diseases.1 An additional poorly characterized population suffers from idiopathic LTS.59 Thus, a
large population of patients exists that is at risk of developing LTS.
Operative interventions range from minor, outpatient
procedures such as sequential airway dilation to major airway reconstruction such as laryngotracheoplasty (LTP), cricotracheal resection (CTR), or tracheal resection (TR). Although dilation represents a safe, well-tolerated procedure,
temporary improvement is often followed by recurrent symptomatic disease requiring repeated dilation or airway surgery. Advantages of major airway reconstruction are that
they are a single-stage, definitive treatment. However, they
do carry a higher morbidity and mortality than dilation.
Previous studies evaluating the treatment of LTS have
been hampered by small study size and are often limited to
one treatment modality rather than comparing multiple
therapies. To date, no large-scale study has compared the
use of minor procedures such as dilation to major reconstructions to determine how best to treat these difficult patients.
In this study, we describe our 10 year experience in the
management of LTS.

METHODS
We retrospectively reviewed the charts of patients who underwent treatment for LTS between January 1995 and July 2005
at our academic, tertiary referral center. One hundred twentyseven evaluable adult patients who underwent surgery for LTS
were extracted by querying the Department of Otolaryngology

Herrington et al.: Management of Laryngotracheal Stenosis

1553

Fig. 3. Cricotracheal resection specimen demonstrating subglottic

stenosis.
Fig. 1. Representative result after dilation of laryngotracheal stenosis.

and Head and Neck Surgery operative procedure database. We

used the Myer-Cotton grading system to rate the severity of
LTS.10 Grade of stenosis could not be determined by review of the
operative note in 52 patients.
Methods included dilation (Fig. 1) with a rigid bronchoscope,
Jackson laryngeal dilators, or angioplasty balloon catheters under
general anesthesia. LTP,11 CTR,7 and TR12 (Figs. 2 and 3) were
performed as previously described. LTP was performed using costal
cartilage grafting and placement of an endolaryngeal stent for a
period of 4 to 6 weeks, during which time these patients remained
tracheostomy dependent. For lesions involving only the trachea
without extension into the subglottis, TR with primary reanastomosis was performed. The majority of patients undergoing
CTR or TR was managed without tracheotomy and was extubated at
the conclusion of the surgical procedure. Surgical outcome measures
including the need for subsequent procedures, postoperative decanulation, speech and swallowing function, complications, and
mortality were evaluated.

RESULTS
Thirty-eight male and 89 female patients with an average age of 55.5 (range 21 89) years were treated for LTS
between January 1995 and July 2005 (Table I). Etiologies
included intubation injury (n 64, 50%), idiopathic disease
(n 25, 20%), autoimmune disease (n 18, 14%), radiation

injury (n 9, 7%), external trauma (n 5, 4%), prior surgery

(n 4, 3%), and relapsing polychondritis (n 2, 2%). Stenoses were localized in the subglottis (n 85, 66%) most
frequently followed by the trachea (n 21, 16%), glottis (n
17, 23%), and supraglottis (n 4, 3%). Of the 75 patients in
whom staging information was available, the grade of stenosis was found to be grade I (n 25, 33%), II (n 33, 44%),
III (n 14, 19%), and IV (n 3, 4%). Comorbidities included

TABLE I.
Patient Demographics.
No. (%)

Sex
Male
Female
Age
Average
Range
Etiology
Intubation
Idiopathic disease
Autoimmune disease
Radiation
External trauma
Prior surgery
Relapsing polychondritis
Location
Subglottic
Tracheal
Glottic
Posterior glottic
Supraglottic
Grade of stenosis
Grade I
Grade II
Grade III
Grade IV
Comorbidities
GERD
Diabetes mellitus
CHF
CVA

38 (30)
89 (70)
55.5
2189
64 (50)
25 (20)
18 (14)
9 (7)
5 (4)
4 (3)
2 (2)
85 (66)
21 (16)
17 (14)
11 (9)
4 (3)
25 (33)
33 (44)
14 (19)
3 (4)
33 (26)
22 (17)
3 (3)
2 (2)

Fig. 2. Representative cricotracheal resection.

GERD gastroesophageal reflux; CHF congestive heart failure;

CVA cerebral vascular accident.

Laryngoscope 116: September 2006

Herrington et al.: Management of Laryngotracheal Stenosis

1554

TABLE II.
Results of Major Airway Reconstruction After Primary
Dilation Treatment.

Total no.
Patients requiring subsequent treatment
Subsequent dilation
Subsequent reconstruction

TABLE IV.
Initial Tracheotomy Dependence and Decannulation Rates.

LTP
(%)

CTR
(%)

TR

20
9 (45)
8 (40)
1 (5)

14
5 (36)
2 (14)
3 (21)

3
0
0
0

LTP laryngotracheoplasty; CTR cricotracheal resection; TR

tracheal resection.

gastroesophageal reflux (n 33, 26%) and diabetes mellitus

(n 22, 17%) most commonly.
In our 10 year experience, a total of 384 procedures
were performed in 127 patients. Two hundred ninetyeight outpatient airway dilations were performed, constituting 78% of all procedures. Ninety-one (72%) patients
underwent primary dilation, of whom 12 (13%) were
cured, 4 (4%) had evidence of persistent LTS but did not
require further treatment, and 11 (12%) were lost to
follow-up. Of the remaining 64 patients, 50 (78%) underwent repeat dilation. However, 37 (58%) eventually required major airway reconstruction. Of these 37 patients
who underwent major reconstruction after a trial of dilation, 14 (38%) required subsequent intervention (Table II).
Among patients undergoing airway reconstruction,
86 procedures were performed in 76 patients. Forty-two
LTP, 28 CTR, and 16 TR were performed during the study
period. Thirty-six (28%) patients underwent primary LTP,
CTR, or TR with the remainder undergoing primary dilation (Table III), as detailed above. Twenty (55%) patients
who underwent primary major reconstruction were deemed
cured, one (3%) did not require further treatment, and five
(14%) were lost to follow-up. Although a smaller percentage
of patients required further treatment after primary reconstruction (28%) than after reconstruction following a trial of
dilation (38%), this difference was not statistically significant. Among patients undergoing initial major airway
reconstruction, 10 (28%) required further treatment. Specifically, five patients undergoing initial LTP required
repeat LTP (n 1), subsequent CTR (n 1), subsequent
TR (n 1), or dilation (n 2) because of persistent LTS.

Baseline tracheostomy
dependence no.
No. (%) decannulated
during therapy

Total procedures
Mean hospital
stay (days)
No. performed as
1 procedure
No. (%) requiring
subsequent
procedure

Dilation

LTP

CTR

TR

298

42
6.2

28
4

16
4.4

15

10

11

91
64 (70)

5 (33)

1 (10)

4 (36)

Dilations
Only

LTP/
CTR/TR

35

28

22 (63)

3 (43)

19 (67)

LTP laryngotracheoplasty; CTR cricotracheal resection; TR

tracheal resection.

Among four patients requiring another procedure after

TR, one patient each underwent LTP or TR, and two
underwent dilation. One patient undergoing primary CTR
required a subsequent dilation. Excluding a single patient
who expired after a 90 day hospital course after TR, average hospital stay for LTP, CTR, and TR were 6.2, 4, and
4.4 days, respectively (Table III).
Overall, 19 of 28 (67%) tracheostomy-dependent patients undergoing LTP, CTR, or TR were ultimately decannulated (Table IV). Of note, three of seven (43%)
tracheostomy-dependent patients who underwent dilation
were decannulated. Among 46 patients for whom postoperative voice data were available, 21 (45%) patients were
noted to be hoarse, 9 (19%) had persistent abnormality in
pitch, 9 (19%) were normal, 5 (11%) were breathy, and 1
(2%) aphonic (Table V). Twenty-three of 24 (96%) patients
undergoing primary dilation tolerated a regular diet. Similarly, among patients undergoing primary or secondary
LTP, CTR, or TR for whom data were available, 24 of 28
(86%) and 24 of 27 (89%), respectively, tolerated a regular
diet postoperatively. Three (11%) and one (3%) required
soft or liquid diet, respectively. One (4%) patient was
limited to a liquid diet. Nine patients underwent gastrostomy tube placement, of which two were indicated for
reasons other than LTS. Three of the remaining seven
(43%) patients underwent gastrostomy tube removal without event, whereas an additional patient did not require
the feeding tube but declined removal.

TABLE V.
Postoperative Speech and Swallowing Function.
Dilation
Only

TABLE III.
Overview of Procedures Performed During Study Period and
Requirement for Subsequent Intervention.

Total

Voice
Normal
Hoarse/breathy
Abnormal pitch
Aphonic
Diet
Regular
Soft
Puree
Liquid

1st
LTP

1st
CTR

1st
TR

4
5
1
0

0
4
2
0

1
2
1
0

2
4
0
1

23
0
0
1

8
2
0
1

8
1
0
0

8
0
0
0

2nd
LTP

2nd
CTR

2nd
TR

1
5
1
0

1
6
5
0

0
0
0
0

14
1
0
0

9
0
0
0

1
2
0
0

LTP laryngotracheoplasty; CTR cricotracheal resection; TR

tracheal resection.

LTP laryngotracheoplasty; CTR cricotracheal resection; TR

tracheal resection.

Laryngoscope 116: September 2006

Herrington et al.: Management of Laryngotracheal Stenosis

1555

LTS is a recalcitrant disease with high morbidity.

Numerous etiologies result in LTS and thus must be managed with a diverse armamentarium. Multiple staging
systems have been used in an attempt to better describe
and thus more effectively treat this complex problem.
Both the Myer-Cotton10 and McCaffrey13 classification
systems have been used for describing LTS. The system
created by McCaffrey predicts decannulation on the basis
of anatomic location of the stenosis. Ninety percent of stage
I and II, 70% of stage III, and 40% of stage IV patients are
successfullydecannulated.14 Althoughintroducedasastaging

system for subglottic stenosis, the Myer-Cotton system is the

most straightforward system in use. Therefore, this grading
system was chosen because it is most likely to provide useful
information between otolaryngologists and other physicians
who might have varying levels of familiarity with the abovenoted staging systems.
Prior clinical practice dictated a trial of dilation before proceeding to major reconstruction.8,9,15 Although laryngotracheal dilation often provides an improvement in
airway stenosis, this represents a maintenance procedure,
requiring chronic treatment. Alternatively, major reconstructions offer the potential for immediate decannulation
in a one-step procedure. Thus, we are now observing a
dramatic shift in this practice. Major airway reconstruction has become more tolerable and effective with acceptable morbidity and mortality, and this is reflected in
the finding that 28% of our patient population underwent
primary airway reconstruction. As such, definitive airway
reconstruction is more frequently indicated than in the past.
Mandour et al.16 sought to answer this question by
comparing patients who underwent dilation and those
who had surgical reconstruction. They concluded that
open surgery is the treatment of choice for LTS because it
provides a higher success rate and better functional
results. Interestingly, the authors found no significant
difference in posttreatment pulmonary function testing
between dilation and open surgical reconstruction. Furthermore, their study was limited by small sample size (28
patients).
Several investigators have also compared open airway
surgery versus dilation treatments in defined populations,
such as idiopathic LTS and Wegeners granulomatosis, for
example.8,9,15 However, these studies were limited by sample
size. Ultimately, each of these investigators recommended
initial treatment by dilation. However, patients with acquired stenoses resulting from a single incident such as
intubation injury may be better candidates for a one-step
reconstruction than patients with chronic, systemic disease,
such as Wegeners. Our expectation would be that for chronic
disease, dilation is likely more effective, particularly because
it may be repeated.
With regard to complications, multiple groups have
reported outcomes after treatment using single or multiple treatment modalities. However, none of these authors
compared dilation with major reconstruction. Furthermore,
most studies of airway reconstruction evaluated CTR, only
arguing that CTR is a safe and reliable procedure in properly
selected patients. Ahn et al.17 reported 2 of 59 (3%) patients
died as a result of CTR. In a series of 41 patients, Laccourreye et al.18 had no deaths. Their complications included
unilateral recurrent laryngeal nerve palsy (3), neck abscess (2), pneumothorax (1), and subcutaneous emphysema (1). Thus, the frequency and severity of complication
reflected in this study are consistent with previous investigations. Of 298 dilations performed, one patient each
experienced tracheitis and bilateral pneumothoraces requiring intervention (Table VI). Among major airway reconstruction procedures, all three modalities appeared
equally safe, with a similar distribution of complications
among each approach evaluated.

Laryngoscope 116: September 2006

Herrington et al.: Management of Laryngotracheal Stenosis

TABLE VI.
Complications.

Hematoma
Extruded
graft/infection
Subcutaneous
emphysema
Abscess
Reintubation/prolonged
intubation
Tracheitis
Tracheotomy (48 hr
postoperative)
Wound dehiscence
Arrhythmia, pleural
effusion
Bilateral
pneumothoraces
Blood transfusion
Cellulitis
Mucus plug requiring
re-operation
Tracheocutaneous
fistula
Mediastinitis, death
Mucus plug, death
Unknown cause,
death

Total

Dilation

LTP

CTR

TR

6
4

0
0

3
4

1
0

2
0

2
2

0
0

1
0

0
2

1
0

2
2

1
0

1
0

0
2

0
0

2
1

0
0

0
1

1
0

1
0

1
1
1

0
0
0

1
1
1

0
0
0

0
0
0

1
1
1

0
0
0

0
0
0

0
1
0

1
0
1

LTP laryngotracheoplasty; CTR cricotracheal resection; TR

tracheal resection.

The most common complications included hematoma

(n 6, 4.7%) and wound infection (n 4, 3.1%). Subcutaneous emphysema (n 3, 2.3%), abscess (n 2, 1.6%),
wound dehiscence (n 2, 1.6%), tracheitis (n 2, 1.6%),
cellulitis, and tracheocutaneous fistula and anemia requiring blood transfusion (n 1 each, 0.8%) were also
encountered. Emergent tracheostomy was performed in
two patients because of acute airway obstruction, whereas
postoperative airway compromise occurred in another two
patients requiring reintubation. Serious complications occurred in five patients. Three patients died, one from a
mucus plug, one from mediastinitis, and one from an
undetermined cause 3 weeks after surgery. One patient
developed a mucus plug requiring re-operation, and one
had bilateral pneumothoraces (Table VI).

DISCUSSION

1556

Our data suggest that fewer patients required subsequent intervention after primary airway reconstruction
(27%) than dilation (70%). Three patients died in the postoperative period, one on postoperative day 5 of a mucus
plug, one 3 weeks postoperatively of an unknown cause,
and one 3 months after CTR after a complicated hospital
course involving mediastinitis, pericarditis, and multiorgan failure. These findings suggest that major reconstruction procedures are well tolerated and represent a
viable first-line treatment for LTS in the properly selected
patient. However, a larger prospective study would be
required to provide definitive evidence of this assertion.
With regard to determination of which subpopulation will
benefit most from initial airway reconstruction, further
study is required.

CONCLUSION
Dilation of LTS remains a safe and effective treatment modality. However, patients undergoing dilation for
LTS usually require multiple procedures. Alternatively,
major airway reconstruction is well tolerated and currently represents a viable primary treatment for LTS with
acceptable morbidity and mortality.

BIBLIOGRAPHY
1. Lorenz RR. Adult laryngotracheal stenosis: etiology and surgical management. Curr Opin Otolaryngol Head Neck Surg
2003;11:467 472.
2. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A
prospective study of 150 critically ill adult patients. Am J
Med 1981;70:6576.
3. Klainer AS, Turndorf H, Wu WH, et al. Surface alterations
due to endotracheal intubation. Am J Med 1975;58:
674 683.
4. Gould SJ, Young M. Subglottic ulceration and healing following endotracheal intubation in the neonate: a morphometric study. Ann Otol Rhinol Laryngol 1992;101:815 820.

Laryngoscope 116: September 2006

5. Grillo HC, Mark EJ, Mathisen DJ, Wain JC. Idiopathic laryngotracheal stenosis and its management. Ann Thorac
Surg 1993;56:80 87.
6. Grillo HC, Mathisen DJ, Ashiku SK, et al. Successful treatment of idiopathic laryngotracheal stenosis by resection
and primary anastomosis. Ann Otol Rhinol Laryngol 2003;
112:798 800.
7. Ashiku SK, Kuzucu A, Grillo HC, et al. Idiopathic laryngotracheal stenosis: effective definitive treatment with laryngotracheal resection. J Thorac Cardiovasc Surg 2004;127:
99 107.
8. Valdez TA, Shapshay SM. Idiopathic subglottic stenosis revisited. Ann Otol Rhinol Laryngol 2002;111:690 695.
9. Giudice M, Piazza C, Foccoli P, et al. Idiopathic subglottic
stenosis: management by endoscopic and open-neck surgery in a series of 30 patients. Eur Arch Otorhinolaryngol
2003;260:235238.
10. Myer CM III, OConnor DM, Cotton RT. Proposed grading
system for subglottic stenosis based on endotracheal tube
sizes. Ann Otol Rhinol Laryngol 1994;103:319 323.
11. McCaffrey TV. Management of subglottic stenosis in the
adult. Ann Otol Rhinol Laryngol 1991;100:90 94.
12. Grillo HC, Donahue DM, Mathisen DJ, et al. Postintubation
tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109:486 492.
13. McCaffrey TV. Classification of laryngotracheal stenosis. Laryngoscope 1992;102:13351340.
14. McCaffrey TV. Management of laryngotracheal stenosis on
the basis of site and severity. Otolaryngol Head Neck Surg
1993;109:468 473.
15. Hoffman GS, Thomas-Golbanov CK, Chan J, et al. Treatment
of subglottic stenosis, due to Wegeners granulomatosis,
with intralesional corticosteroids and dilation. J Rheumatol 2003;30:10171021.
16. Mandour M, Remacle M, Van de Heyning P, et al. Chronic
subglottic and tracheal stenosis: endoscopic management
vs. surgical reconstruction. Eur Arch Otorhinolaryngol
2003;260:374 380.
17. Ahn SH, Sung MW, Kim KH. Factors associated with staged
reconstruction and successful stoma closure in tracheal
resection and end-to-end anastomosis. Arch Otolaryngol
Head Neck Surg 2004;130:57 62.
18. Laccourreye O, Brasnu D, Seckin S, et al. Cricotracheal anastomosis for assisted ventilation-induced stenosis. Arch Otolaryngol Head Neck Surg 1997;123:1074 1077.

Herrington et al.: Management of Laryngotracheal Stenosis

1557