1. Review the cotton stenosis grading system.

Myer-Cotton staging system

 For mature, firm, circumferential stenosis, confined to the subglottis
 Describes the stenosis based on the percent relative reduction in cross-sectional area of the
subglottis
o Determined by differing-sized endotracheal tubes
o Four grades of stenosis:
 grade I lesions have less than 50% obstruction
 grade II lesions have 51% to 70% obstruction
 grade III lesions have 71% to 99% obstruction
 grade IV lesions have no detectable lumen or complete stenosis

2. Compare and contrast pediatric vs. adult laryngeal anatomy.

Laryngeal Size
 Infant larynx is 1/3 the size of an adult larynx, but proportionally larger compared to the rest
of the infant tracheobronchial tree
 In the infant, the vocal process of the arytenoids takes up half the length the vocal folds (vs.
1/4 length in adults)
 The narrowest portion of the airway in the older child and adult is the glottic aperture, while
the narrowest part of the airway in the infant is the subglottis
o In fact, this area is so narrow that 1mm decrease in diameter causes 60% reduction in
cross-sectional area
 The structures of the infant larynx are also more pliable and less fibrous, making the infant
airway more susceptible to narrowing from edema and less easily palpable
Laryngeal Location
 The infant larynx is positioned higher in the neck than the adult larynx.
o The superior border of the larynx of the infant is located at about the level of the first
cervical vertebrae with the cricoid positioned at about the fourth cervical vertebrae
o This results in the hyoid overriding the superior larynx in an infant, with the thyroid
notch usually being impalpable as a consequence
o The adult cricoid rests at about the level of the sixth cervical vertebrae
Epiglottis
 At birth, shaped like the Greek letter omega (Ω)
o Narrower and softer than that found in older children and adults, with a less stable
base, and a more acute angle between the epiglottis and glottis (which allows the
epiglottis to fall into the laryngeal inlet)
 With growth, cartilaginous support of the epiglottis becomes more rigid and the angle of the
thyroid cartilage changes from 110-120 degrees to an angle of 90 degrees in the adolescent
male (remains more obtuse in females).

3. Review the histopathologic classification of congenital subglottic stenosis.

Divided into membranous and cartilaginous types
 Membranous type
o Usually circumferential and presents as a fibrous soft tissue thickening in the
subglottis caused by increased fibrous connective tissue or hyperplastic mucous
glands, with no inflammatory reaction
 o Usually includes the area 2 to 3 mm below the true vocal cords, but it may extend
upward to include the true cords
o Examples: granulation tissue, submucosal gland hyperplasia, submucosal fibrosis
o Can also get subglottic webs – mimics cricoid cartilage deformities; anteriorly based,
with a small posterior opening that may be only the size of a pinpoint; the superior
surface is covered with squamous epithelium and the inferior surface is mucous
membrane; slight female predominance
 Cartilaginous type
o Commonly presents as a thickening or deformity of the cricoid cartilage that creates a
shelflike plate of cartilage on the inner surface of the cricoid ring, extending
posteriorly as a solid sheet and leaving only a small posterior opening
o Examples: normal shape but small for infant’s size, abnormal shapes (large anterior
lamina, large posterior lamina, generalized thickening, elliptical shape, submucosal
cleft), trapped first tracheal ring
 Can also have combinations

10. Discuss the pros and cons of single stage laryngotracheal reconstruction. Otolaryngol
Head Neck Surg 2000;123:430.
Pros
 If successful, it avoids tracheostomy and longterm stenting and comorbidities
o Including: granulation tissue, infection, dislodgment of the stent, dysphagia,
aspiration with stent in place
Cons
 First of all, this is not for everyone
o Patients with compromised pulmonary reserve or complex, multilevel stenosis still
need 2-stage procedure
 Relies on the reconstructed airway after extubation
o Kept intubated until they met criteria for extubation, then downsized in OR, 24 hours
later – extubated (this requires a lot of ICU / possible sedation time)
o If patients develop respiratory distress, stridor, or repeated desaturations, they will
likely need reintubation or tracheotomy
 In fact, 29% in this study did need reintubation and 52% of those needed
trachs
 Reintubation risks injury to surgical site, prolonged ICU care, and sometimes
tracheostomies (though 84-96% are ultimately decannulated)
 Those at greatest risk:
 Age <4yo (young kids usually have greater need for sedation while
intubated, smaller airway diameters. However, once reintubated and
edema, granulation tissue, sedation withdrawal resolve, patients are re-
extubated without increased risk of requiring trach)
 Advanced stenosis (grade ¾), preoperatively
 If you were younger than 4 with moderate-to-severe tracheomalacia,
you were 35x more likely to be reintubated than other patients
 Other risk factors: pre-extubation leak pressures more than 20cm
water, use of sedation >48 hours
 Those requiring anterior and posterior costal cartilage grafts were
significantly more likely to be reintubated (47%) and require trach
(34%). 3% remain trach dependent.
o The anterior and posterior expansion of the cricoid makes the
ring less stable than keeping majority of cricoid ring in
continuity
o In addition, these patients generally started with higher grade
stenosis