International Journal of Pediatric Otorhinolaryngology 79 (2015) 2056–2058

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Endoscopic management of congenital anterior glottic stenosis

Mi Jin Yoo a,1, Soham Roy b,2, Lee P. Smith c,d,*
a
Department of Otolaryngology—Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 3400 Bainbridge Ave., Medical Arts
Pavilion, 3rd Floor, Bronx, NY 10467, USA
b
Department of Otolaryngology—Head and Neck Surgery, University of Texas Medical School at Houston, Children’s Memorial Hermann Hospital, Houston,
TX 77030, USA
c
Division of Pediatric Otolaryngology, Cohen Children’s Medical Center, New Hyde Park, NY, USA
d
Department of Otolaryngology—Head and Neck Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Congenital anterior glottic stenosis (web) is a rare condition usually presenting with airway
Received 7 July 2015 obstruction, stridor or dysphonia. Symptomatic infants may require tracheotomy to bridge the neonatal
Received in revised form 9 September 2015 period. Early open surgical reconstruction may have significant risks and failure may still result in
Accepted 13 September 2015
tracheotomy. We introduce an endoscopic surgical approach with balloon dilation for primary
Available online 25 September 2015
management of congenital anterior glottic stenosis.
Methods: We present three cases of congenital anterior glottic stenosis in children 7, 14, and 90 days old
Keywords:
presenting with stridor, dyspnea, and dysphonia. The larynx was exposed by suspension microlaryngo-
Glottic
Glottis
scopy. The glottic stenosis was incised from a posterior to anterior direction using a laryngeal sickle knife.
Stenosis Subsequently, an airway balloon was guided through the stenotic lumen. Once the balloon was inflated, the
Balloon balloon pressure was maintained for 30 s or until the patient’s oxygen saturation dropped below 92%. The
Dilation dilation was repeated two or three times. The patients were kept intubated with an uncuffed endotracheal
Web tube and monitored in the pediatric intensive care unit following surgery.
Results: All three patients were extubated within 72 h without complications. One patient failed the first
extubation attempt and was reintubated and successfully extubated 24 h later. Patients were re-
evaluated with direct microlaryngoscopy within two weeks. All patients had symptomatic relief and did
not require further surgical intervention.
Conclusion: Endoscopic balloon dilation laryngoplasty may be a safe and effective primary procedure for
pediatric patients with congenital anterior glottic stenosis. It is technically simple and obviates the
potential morbidities associated with an open surgical procedure or tracheotomy.
ß 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction During the 6th week of embryological life, the developing

Congenital anterior glottic stenosis (web) is a rare condition
often presenting with airway obstruction early in life. Based on the
severity, patients may present with stridor, dysphonia, or
respiratory distress necessitating surgical intervention to relieve
the airway obstruction. Glottic stenosis can be classified by the
degree of obstruction and degree of extension into the subglottis
by Cohen’s classification [1].
* Corresponding author at: Cohen Children’s Medical Center, Department of
Otolaryngology—Head and Neck Surgery, Hofstra North Shore-LIJ School of
Medicine, New Hyde Park, NY 11042, USA. Tel.: +1 516 470 7550;
fax: +1 516 470 4514.
E-mail address: lsmith8@nshs.edu (L.P. Smith).
1
Tel.: +1 718 920 4267.
2 associated morbidity and potential for mortality.
Tel.: +1 713 500 5410.
laryngeal opening is obliterated by actively proliferating epithelial
tissue, arising from the two arytenoid swellings and anteriorly by the
epiglottic eminence. It is theorized that congenital glottic webs and
stenoses result from failure of recanalization of the epithelial lamina
[2]. The stenosis may be thin and confined to the glottic larynx, or it
may be thick and extend inferiorly into the subglottic airway.
Tracheotomy is the gold standard management for infants with
airway obstruction such as congenital anterior glottic stenosis.
Open airway surgery such as single stage laryngotracheoplasty has
been described for managing infants with thick congenital anterior
glottic stenosis [3]. However, traditional open surgical procedures
are invasive, and may have surgical site and/or donor site morbidity.
In addition, children undergoing traditional open surgical proce-
dures for this condition may initially require a tracheotomy with its

http://dx.doi.org/10.1016/j.ijporl.2015.09.013
0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
 M.J. Yoo et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 2056–2058 2057

Fig. 1. Endoscopic images of a child with Cohen grade III stenosis. Microlaryngoscopy of the glottis: (A) prior to endoscopic division and balloon dilation and (B) following
endoscopic division and balloon dilation. Bronchoscopy of the: (C) subglottis and (D) trachea following dilation.

Endoscopic balloon dilation has recently gained popularity. It
is minimally invasive and technically simple. We introduce an
endoscopic surgical management technique with endoscopic
division and balloon dilation for primary management of congenital
anterior glottic stenosis.
2. Methods
We present three cases of congenital anterior glottic stenosis in
children 7, 14, and 90 days old. The children presented with stridor,
dyspnea, and dysphonia requiring urgent intervention. Awake
beside fiberoptic laryngoscopy was suspicious for anterior glottic
stenosis. One patient had Cohen grade II stenosis, approximately
<50% glottic obstruction with a thin anterior stenosis consistent
with a web. Two patients had Cohen grade III stenosis, <75%
obstruction with moderately thick web without subglottic
extension.
3. Surgical technique
sickle knife. The anterior limit of the incision is the approximate
location of the anterior commissure. If subglottic extension is
present, the subglottic component is divided along with the glottic
portion. We do not incise or divide the thyroid or cricoid cartilages.
A 5 mm airway balloon (Acclarent, Menlo Park, CA) is guided
through the stenotic lumen under direct visualization. The balloon
is inflated to 16 atm (which represents the burst pressure of the
balloon) and the balloon pressure is maintained for 30 s or until the
patient’s oxygen saturation dropped below 92%. The dilation is
repeated two to three times depending on surgeon preference.
Hemostasis was achieved by topically applying pledgets soaked
with oxymetazoline (0.05%). The patients are left intubated with a
3.5 uncuffed endotracheal tube and monitored in the pediatric
intensive care unit with a goal of extubating 24 to 48 h after
surgery. All patients were treated with one intra-operative dose of
intravenous dexamethasone (0.5 mg/kg) followed by a 5 day taper
of either intravenous dexamethasone or oral prednisone. All
patients were treated with proton pump inhibitor (1 mg/kg/day)
for at least one month after surgery (Fig. 1).

The procedure is performed under general anesthesia under 4. Results

spontaneous ventilation conditions. The larynx is exposed by
suspension microlaryngoscopy and the airway is carefully
evaluated using a zero degree Hopkins rod lens telescope (Karl
Storz, Tuttlingen, Germany). The vocal folds are topically
anesthetized with 0.5 ml of 2% lidocaine. The glottic stenosis is
incised from a posterior to anterior direction using a laryngeal
All three patients were extubated within 72 h without
complications. One patient failed the first extubation attempt
and was reintubated and successfully extubated 24 h later.
Patients were re-evaluated under direct microlaryngoscopy within
two weeks. All patients had symptomatic relief of airway
2058 M.J. Yoo et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 2056–2058
obstruction and did not require further surgical intervention. All
three patients had subjective improvement in their voice quality.
There were no complications related to the procedure, and
importantly a tracheotomy was avoided in all cases. One patient
with Cohen grade III stenosis has persistent exertional stridor
18 months following the procedure with evidence of sleep apnea
and recurrent anterior glottic stenosis. Symptoms began 1–2
months following the initial intervention, but the child was feeding
well and thriving with no acute life threatening events, thus we are
deferring additional procedures until the child is older. We are
planning for single stage laryngotracheal reconstruction for that
patient, but would also consider additional dilation procedures.
The remaining two patients were followed clinically for greater
than six months with no significant respiratory distress. Both
patients had mild exertional stridor, but no stridor at rest.
5. Discussion
The management of congenital anterior glottic stenosis is a
clinical challenge. Standard management has been open recon-
struction or tracheotomy. However, open reconstruction and
tracheotomy carry significant potential for morbidity and mortali-
ty. Minimally invasive balloon dilation laryngoplasty may be a less
invasive and more appealing option.
Cohen et al. first described endoscopic balloon dilation for
tracheal stenosis [4]. Since then, endoscopic intervention has
become increasingly more attractive with shorter hospital stays
and fewer complications. There is growing literature describing the
success and effectiveness of endoscopic balloon dilation for
subglottic and tracheal stenosis with an acceptably low reported
complication rate [5,6].
Rigid dilation with antegrade bougie results in longitudinal
shearing forces, which may result in subepithelial fibrosis, acute
inflammatory response, and recurrent stenosis. In contrast, balloon
dilation applies the force in a radial direction. Theoretically this
minimizes the trauma and reduces the risk of restenosis [7]. The
balloons are available in various sizes and can be placed precisely
under direct visualization to deliver the desired dilatational force
in a controlled manner.
We elected to keep the children intubated after surgery as these
young infants may be at risk of edema following endoscopic
division and dilation, and we wanted to mitigate the risk of airway
compromise during the immediate post-operative period. For
balloon dilation of typical acquired glottic and subglottic stenosis it
is our routine practice to extubate immediately after surgery (or
perform the procedure without endotracheal intubation) in
children who tolerate it.
Our report is limited in its scope because of small sample study
and lack of long-term follow up. But our focus is to highlight one
potential management strategy for congenital anterior glottic
stenosis that may be attempted by surgeons prior to open
reconstruction or tracheotomy. This technique may be the only
one required for some patients, for other patients, it may be a
temporizing measure, allowing infants to grow and develop prior
to definitive open surgical repair. In these three cases, we did not
perform repeat dilation procedures. In many cases of glottic and
subglottic stenosis, however, repeat dilation is more effective
than a single dilation procedure. It is unknown whether repeat
endoscopic division and dilation for anterior glottic stenosis would
be more effective than a single dilation procedure.
6. Conclusion
Congenital anterior glottic stenosis is a rare clinical entity.
Endoscopic balloon dilation laryngoplasty may be a safe and
effective primary procedure for pediatric patients with congenital
anterior glottic stenosis. It is technically simple and obviates the
potential morbidity associated with an open surgical procedure or
tracheotomy. In carefully selected patients, this technique may
represent a first line treatment for congenital anterior glottic
stenosis.
References
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