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Laryngotracheal and subglottic stenosis
The commonest cause of acquired laryngeal and tracheal stenosis is prolonged intubation; the Myer-Cotton grade, the length of the stenosis and whether cartilage is intact decide whether endoscopic treatment is enough or open surgery is needed — expansion with a cartilage graft (LTR) or resection of the narrowed segment (CTR or tracheal resection).
Why it matters in the exam
Myer-Cotton grading by percentage of obstruction: grade I — up to 50%; II — 51% to 70%; III — 71% to 99%; IV — no lumen. Risk factors after intubation: an oversized tube, long duration, much tube movement, infection and reflux. Other causes: idiopathic subglottic stenosis (almost only in women), GPA (granulomatosis with polyangiitis), relapsing polychondritis, trauma and radiotherapy. The sign is exertional breathlessness and stridor that worsen gradually — sometimes misdiagnosed as "asthma that does not respond".
Endoscopic treatment — radial CO2 laser incisions, balloon dilation, steroid injection and sometimes mitomycin C — suits a thin (less than 1 cm), web-like stenosis of grade I to II without cartilage loss. The advantage of balloon dilation over rigid dilators is an even radial force without shearing, so less mucosal trauma. Open surgery suits a long stenosis, grade III to IV, or one with cartilage loss: laryngotracheal reconstruction with a costal cartilage graft (LTR), or cricotracheal resection (CTR) when there is enough margin below the vocal folds.
In adult tracheal resection up to about half of the tracheal length can be removed; after surgery the chin is fixed to the chest for about a week to reduce tension on the anastomosis. Dangerous complications: anastomotic breakdown, restenosis and fistula to the innominate artery. A single-stage operation ends with a temporary endotracheal tube only, while a two-stage operation leaves a tracheostomy. The risk of revision surgery is lower with a low-grade stenosis, no active systemic disease and no reflux or uncontrolled diabetes. Before any repair, active inflammatory disease (GPA) must be settled and reflux treated.
Key points
- Prolonged intubation — the commonest cause.
- Myer-Cotton: up to 50, 70, 99, no lumen.
- Thin and low grade — endoscopic.
- Long or high grade — LTR or CTR.
- Balloon — radial force without shear.
Summary table
| Myer-Cotton grade | Obstruction | Usual treatment |
|---|---|---|
| I | Up to 50% | Endoscopic: balloon, laser, steroid |
| II | 51% to 70% | Endoscopic, and on failure — open |
| III | 71% to 99% | LTR with cartilage graft or CTR |
| IV | No lumen | CTR or tracheal resection, sometimes in two stages |
| Idiopathic in women | Subglottic stenosis without a cause | Repeated dilations or CTR |
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Sources
- Myer CM, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based upon endotracheal tube sizes, 1994 — Grading
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Chronic airway stenosis: endoscopic and open management
- Grillo HC. Surgery of the Trachea and Bronchi, 2004 — Tracheal resection and reconstruction
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.