American Journal of Otolaryngology–Head and Neck Medicine and Surgery 44 (2023) 103767

Contents lists available at ScienceDirect

American Journal of Otolaryngology–Head and Neck

Medicine and Surgery
journal homepage: www.elsevier.com/locate/amjoto

Anesthesia considerations during management of airway stenosis: A

systematic review☆
Angelica M. Mangahas a, *, Snehitha Talugula b, Inna A. Husain c
a
University of Illinois College of Medicine – Rockford, 1601 Parkview Ave, Rockford, IL 61107, United States of America
b
University of Illinois College of Medicine – Chicago, 1853 W Polk St, Chicago, IL 60613, United States of America
c
Community Hospital, Otolaryngology, 901 MacArthur Blvd, Munster, IN 46321, United States of America

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

Keywords: Objective: To determine the efficacy of ventilatory techniques by evaluating prevalence of technique failure and
Anesthesia intraoperative hypoxia during endoscopic management of airway stenosis.
Airway stenosis Data sources: A systematic review was conducted using PubMed and Embase for anesthesia techniques in
Endoscopic management
endoscopic management of airway stenosis.
Ventilation
Systematic review
Review methods: The primary outcome measured was reports of partial and complete technique failure. The
secondary outcome measured was intraoperative hypoxia.
Results: We identified 7704 abstracts with 17 meeting criteria for analysis. The reported partial and complete
ventilatory technique failures were: 0 % Evone Flow-Controlled Ventilation with Tritube endotracheal tube, 0 %
laryngeal mask airway, 0 % nonocclusive balloon dilator, 4.76 % spontaneous respiration using intravenous
anesthesia and Hi-flow nasal oxygen, and 30.24 % jet ventilation. The reported rate of intraoperative hypoxia
was: 0 % Evone Flow-Controlled Ventilation with Tritube endotracheal tube, 0 % spontaneous respiration using
intravenous anesthesia and Hi-flow nasal oxygen, 2.18 % jet ventilation, 3.57 % laryngeal mask airway, and 5 %
nonocclusive balloon dilator.
Conclusion: Evone Flow-Controlled Ventilation with Tritube endotracheal tube had the lowest risk of technique
failure and intraoperative hypoxia. Nonocclusive balloon dilator and laryngeal mask airway were also favorable
techniques for ventilation. Jet ventilation showed a lower rate of intraoperative hypoxia, but a higher rate of
failure. Newer techniques, such as Evone Flow-Controlled Ventilation with Tritube, nonocclusive balloon dilator
and spontaneous respiration using intravenous anesthesia and Hi-flow nasal oxygen, may offer promise
compared to older techniques like jet ventilation; however, larger studies with more uniform data are needed to
determine their efficacy.

1. Introduction management of airway stenosis includes laryngotracheal resection or

1.1. Rationale
Laryngotracheal stenosis is characterized by the narrowing of the
upper airway and can occur at any level within the larynx and trachea.
This narrowing can be caused by various etiologies and can be life-
threatening due to the restriction of pulmonary ventilation, leading to
respiratory distress and making intervention mandatory [1,2]. In­
terventions consist of open or endoscopic procedures. Open
laryngotracheoplasty [3]. Endoscopic management of airway stenosis
may include balloon or rigid dilation, scar excision, and airway stenting.
These methods are less invasive compared to open management and are
associated with faster recovery; however, they often require more in­
terventions [3,4].
Due to the nature of the shared airway during endoscopic surgical
management of upper airway stenosis, there has been increased interest
in exploring different ventilatory techniques used in endoscopic pro­
cedures. Many techniques exist as there is currently no gold standard

This manuscript was presented at the AAO-HNSF 2022 Annual Meeting & OTO Experience, Philadelphia, Pennsylvania, September 10-14, 2022.
☆

* Corresponding author at: University of Illinois College of Medicine – Rockford, ATTN: Angelica Mangahas, 1601 Parkview Ave, Rockford, IL 61107, United States
of America
E-mail address: amangah2@uic.edu (A.M. Mangahas).

https://doi.org/10.1016/j.amjoto.2022.103767
Received 15 November 2022;
Available online 23 December 2022
0196-0709/© 2022 Elsevier Inc. All rights reserved.
A.M. Mangahas et al.
Fig. 1. PRISMA flow diagram.
that provides optimal ventilation while keeping the surgical view un­
obstructed [5]. Jet ventilation is the most frequently used ventilatory
technique and can be delivered in two ways. First, a handheld device is
managed by an operator who delivers manual jets of oxygen via
supraglottic ventilation through the apparatus that is attached to a
laryngoscope. Ventilation is deemed adequate by observing the chest
rise with each delivered jet pulse. Automatic jet ventilation systems are
also used to provide infraglottic ventilation through a catheter [4].
Intermittent apnea technique is also used where the patient is inter­
mittently intubated and extubated with an endotracheal tube. Extuba­
tion is performed to allow for an apneic period, and the duration is
driven by monitoring oxygen saturation and end-tidal carbon dioxide
levels [5]. Laryngeal mask airway (LMA) can also be utilized, in which it
is inserted for “intubation” and used for ventilation [6]. An extra-small
to small diameter endotracheal (ET) tube can be used and placed beyond
the area of stenosis and provide ventilation during balloon dilation;
2
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 44 (2023) 103767
before
screening
however, the surgeon may have to alter the position of the laryngoscope
around the ET tube to gain optimal visualization [2,7,8]. Facemask
ventilation is another technique used by applying the facemask inter­
mittently throughout the procedure and providing manual ventilation
with positive pressure [9]. Tracheotomy can also be used as acute
management of airway distress as well as a method to preoperatively
secure the airway and provide ventilation through the tracheostomy [3].
Low flow oxygenation may also be utilized in which a nasal cannula
delivers oxygen at a rate of 10–15 L/min [10]. Transnasal humidified
rapid insufflation ventilatory exchange (THRIVE) is a newer technique
used for shared airway procedures, which delivers continuous humidi­
fied 100 % oxygen via a nasal cannula at a high flow rate [11]. High flow
rate is usually considered to be above 15 L/min [12]. Spontaneous
ventilation with total intravenous anesthesia using propofol target-
controlled infusion can be used as spontaneous ventilation, and oxy­
gen is maintained while being completely tubeless and providing an
A.M. Mangahas et al. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 44 (2023) 103767

Table 1
The National Institutes of Health Quality Assessment Tool for Before-After Studies (Pre-Post) With No Control Group.
Quality Assessment Tool for Before-After (Pre-Post) Meulemans Knights Hashmi Vorasubin Philips Youssef & Matrka Booth
Studies With No Control Group et al. [15] et al. [17] et al. [19] et al. [20] et al. Paddle et al. [21] et al.
[22] [10] [14]

1. Was the study question or objective clearly stated? Yes Yes Yes Yes Yes Yes Yes Yes
2. Were eligibility/selection criteria for the study Yes Yes Yes Yes Yes Yes Yes Yes
population prespecified and clearly described?
3. Were the participants in the study representative of Yes Yes Yes Yes Yes Yes Yes Yes
those who would be eligible for the test/service/
intervention in the general or clinical population of
interest?
4. Were all eligible participants that met the prespecified Yes Yes Yes Yes Yes Yes Yes Yes
entry criteria enrolled?
5. Was the sample size sufficiently large to provide No No No No No No No No
confidence in the findings?
6. Was the test/service/intervention clearly described and Yes Yes Yes Yes Yes Yes Yes Yes
delivered consistently across the study population?
7. Were the outcome measures prespecified, clearly Yes Yes Yes Yes Yes Yes Yes Yes
defined, valid, reliable, and assessed consistently across
all study participants?
8. Were the people assessing the outcomes blinded to the No No No No No No No No
participants' exposures/interventions?
9. Was the loss to follow-up after baseline 20 % or less? No No No No No No No No
Were those lost to follow-up accounted for in the
analysis?
10. Did the statistical methods examine changes in No No No No No No No No
outcome measures from before to after the
intervention? Were statistical tests done that provided p
values for the pre-to-post changes?
11. Were outcome measures of interest taken multiple No No No No No No No No
times before the intervention and multiple times after
the intervention (i.e., did they use an interrupted time-
series design)?
12. If the intervention was conducted at a group level (e. N/A N/A N/A N/A N/A N/A N/A N/A
g., a whole hospital, a community, etc.) did the
statistical analysis take into account the use of
individual-level data to determine effects at the group
level?

unobstructed view of the airway [13]. Spontaneous ventilation using
intravenous anesthesia and high flow nasal oxygenation (STRIVE Hi)
combines two ventilatory techniques. Tubeless spontaneous ventilation
using intravenous anesthesia is used with the addition of high flow
oxygenation via Optiflow nasal cannula to assist with respiratory me­
chanics [14]. Evone Flow-Controlled Ventilation is an automated flow-
controlled system and is delivered through a cuffed small lumen tube
[15]. Finally, the “Trachealator” airway balloon is a nonocclusive
balloon that can be inflated for dilatation but has an open passage that
provides continuous ventilation during the procedure [16]. Many
ventilatory options are available during endoscopic management of
airway stenosis; however, no systematic review has been completed to
assess efficacy and safety of these techniques.
1.2. Objectives
The purpose of this systematic review is to determine the efficacy of
common ventilatory techniques by evaluating the prevalence of tech­
nique failure and intraoperative hypoxia during endoscopic manage­
ment of airway stenosis. The PICO question (population [P],
intervention [I], comparison [C], and outcome [O]) generated for this
study was the following: “In adults with laryngotracheal stenosis un­
dergoing endoscopic management, which ventilatory technique mini­
mizes the risk of technique failure and intraoperative hypoxia?”
2. Methods
2.1. Protocol
This review was created based on Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
2.2. Eligibility criteria
This systematic review utilized strict inclusion and exclusion criteria.
Studies were included based on these criteria: reported anesthesia
technique, endoscopic management, all etiologies of airway stenosis,
and English language. Studies were excluded based on these criteria:
pediatric population <18 years old, animal studies, case reports, open
management, nonoperative management, Montgomery T-tube, non-
airway management procedures, posters, abstract only, and duplicate
studies.
2.3. Information sources and search strategy
This systematic review was conducted using PubMed and Embase
databases in December 2021 through May 2022. The search terms used
were “subglottic stenosis” OR “laryngotracheal stenosis” OR “tracheal
stenosis” AND “anesthesia”, “jet ventilation”, “laryngeal mask airway”,
“apneic technique”, AND/OR “intubation”. The years searched were
from January 1900 to May 2022.
2.4. Data collection process, data items, effect measures and risk of bias
Data extraction from included studies was performed independently
by two reviewers. Relevant data was extracted using a data collection
form. The form included the number of participants, type/severity/
grading of stenosis, etiology of stenosis, age, gender, BMI, comorbidities,
airway technique, and complications. The primary outcome reviewed
was reports of partial or complete technique failure. Technique failure
was measured by the need for supplementary ventilatory techniques, the
need to switch techniques or the inability to complete the procedure.
The secondary outcome was intraoperative hypoxia. Hypoxia was

3
A.M. Mangahas et al. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 44 (2023) 103767

Table 2
The National Institutes of Health Quality Assessment Tool for Before-After Studies (Pre-Post) With No Control Group.
Quality Assessment Tool for Before-After (Pre-Post) Studies With Yoo Rodney Maupeu To et al. Hofmeyr Pourciau Barry Liang
No Control Group et al. et al. [23] et al. [27] [28] et al. [16] et al. [29] et al. et al.
[25] [24] [8]

1. Was the study question or objective clearly stated? Yes Yes Yes Yes Yes Yes Yes Yes
2. Were eligibility/selection criteria for the study population Yes Yes Yes Yes Yes Yes Yes Yes
prespecified and clearly described?
3. Were the participants in the study representative of those who Yes Yes Yes Yes Yes Yes Yes Yes
would be eligible for the test/service/intervention in the general
or clinical population of interest?
4. Were all eligible participants that met the prespecified entry Yes Yes Yes Yes Yes Yes Yes Yes
criteria enrolled?
5. Was the sample size sufficiently large to provide confidence in No Yes No No No No No No
the findings?
6. Was the test/service/intervention clearly described and Yes Yes Yes Yes Yes Yes Yes Yes
delivered consistently across the study population?
7. Were the outcome measures prespecified, clearly defined, valid, Yes Yes Yes Yes Yes Yes Yes Yes
reliable, and assessed consistently across all study participants?
8. Were the people assessing the outcomes blinded to the No No No No No No No No
participants' exposures/interventions?
9. Was the loss to follow-up after baseline 20 % or less? Were those No No No No No No No No
lost to follow-up accounted for in the analysis?
10. Did the statistical methods examine changes in outcome No No No No No No No Yes
measures from before to after the intervention? Were statistical
tests done that provided p values for the pre-to-post changes?
11. Were outcome measures of interest taken multiple times before No No No No No No No No
the intervention and multiple times after the intervention (i.e.,
did they use an interrupted time-series design)?
12. If the intervention was conducted at a group level (e.g., a N/A N/A N/A N/A N/A N/A N/A N/A
whole hospital, a community, etc.) did the statistical analysis
take into account the use of individual-level data to determine
effects at the group level?

defined as reported by the primary authors. Each outcome was measured

Table 3
Jadad Score for Nekhendzy et al. [18].
Dimension
Randomization 1. Was the study described Give 1 additional point if:
as randomized (this For question 1, the method
includes the use of words to generate the sequence of
such as randomly, random, randomization was
and randomization)? described and it was
= 1 point appropriate (table of
random numbers,
computer generated, etc.)
Deduct 1 point if: For
question 1, the method to
generate the sequence of
randomization was
described and it was
inappropriate (patients
were allocated alternately,
or according to date of
birth, hospital number,
etc.)
Blinding 2. Was the study described Give 1 additional point: If
as double blind? for question 2 the method
= 1 point of double blinding was
described and it was
appropriate (identical
placebo, active placebo,
dummy, etc.)
Deduct 1 point: If for
question 2 the study was
described as double blind
but the method of blinding
was inappropriate (e.g.,
comparison of tablet vs.
injection with no double
dummy)
Withdrawals and 3. Was there a description of
Dropouts withdrawals and dropouts?
= 1 point
Total score
by occurrence and reported as a percentage of total endoscopic pro­
cedures. In order to limit bias, inclusion and exclusion criteria were set
prior to the execution of searches. Additionally, two reviewers extracted
2 the relevant data and discussed when any discrepancies occurred.
3. Results
3.1. Study selection
There were 7704 abstracts identified in the search. 7468 studies were
removed after initial screening based on exclusion criteria. After
reviewing the full text, 219 studies were removed due to no measure of
anesthetic efficacy, inability to differentiate anesthetic efficacy results
for only airway stenosis procedures, and lack of information of partici­
pants. Therefore, 17 studies were included for analysis (Fig. 1). To
determine internal validity, quality assessment tools such as The Na­
tional Institutes of Health Quality Assessment Tool for Before-After
Studies (Pre-Post) With No Control Group and Jadad Score were used
0 (Tables 1, 2, 3).
3.2. Study characteristics
There were a total of 1546 endoscopic procedures managing sub­
glottic, tracheal, laryngotracheal, posterior glottic, glottic, and supra­
glottic stenosis among the 17 studies (Tables 4, 5, 6). The average age of
patients was 47.4; however, Knight et al. [17] did not report the average
age for their study population. The patient population consisted of 1196
females and 328 males. Nekhendzy et al. [18] did not report the genders
of their 11 participants that had subglottic stenosis. Hashmi et al. [19],
Vorasubin et al. [20], Matrka et al. [21], Hofmeyr et al. [16], and Liang
1 et al. [8] did not report patients' BMI, but the average BMI for the
remaining studies was 28.875 kg/m2. There were 1041 procedures
3 managing laryngotracheal stenosis, 312 subglottic stenosis, 168 tracheal
stenosis, 13 glottic stenosis, 6 supraglottic stenosis, 3 subglottic and
tracheal stenosis, 2 posterior glottic stenosis, and 1 tracheobronchial

4
A.M. Mangahas et al. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 44 (2023) 103767

Table 4
Characteristics of studied included.
Number of Type and severity of Etiology of stenosis Mean Gender Average Airway technique Partial/ Intraoperative
procedures stenosis age BMI complete hypoxia
technique failure

Meulemans 6 3 – subglottic Iatrogenic tracheal 47 4– 27.1 Evone Flow- 0 0

et al. [15] stenosis (Cotton stenosis females Controlled
Myer grade III) Idiopathic 2– Ventilation with
1 – tracheal stenosis subglottic stenosis males Tritube
2 – posterior glottic Posterior glottic endotracheal tube
stenosis stenosis due to
arytenoid ankylosis
Knights et al. 159 69 – Cotton Myer 118 – 30.6 41 – Jet ventilation 5 – Jet 10 – Jet
[17] grade 1 subglottic females via Hunsaker ventilation via ventilation via
stenosis 41 – 35 – Jet ventilation Hunsaker Hunsaker
40 – Cotton Myer males via rigid 2 – Jet 9 – Jet ventilation
grade II subglottic bronchoscope ventilation via via rigid
stenosis 35 – Intermittent rigid bronchoscope
40 – Cotton Myer apnea technique bronchoscope 8 – Intermittent
grade 3 subglottic 21 – Small apnea technique
stenosis endotracheal tube 8 – Small
10 – Unknown 11 – Intermittent endotracheal tube
facemask 7 – Intermittent
ventilation facemask
10 – Tracheostomy ventilation
5 – Spontaneous 7 – Tracheostomy
ventilation via 3 – Spontaneous
bronchoscope ventilation via
1 – Laryngeal mask bronchoscope
airway 1 – Laryngeal
mask airway
Hashmi et al. 2 1 – Subglottic 2 – Prolonged 28 1– Laryngeal mask 0 0
[19] stenosis intubation female airway
1 – Laryngotracheal 1 – male
stenosis
Vorasubin 11 6 – Subglottic 6 – Intubation 49 9– Laryngeal mask 0 0
et al. [20] stenosis 4 – Idiopathic females airway
2 – Tracheal 1 – Wegener's 2–
stenosis Granulomatosis males
3 – Subglottic and
tracheal stenosis
Cotton Myer grade
ranged from I-III

stenosis. Etiologies of stenosis included iatrogenic, idiopathic, arytenoid
ankylosis, autoimmune, congenital, reflux, and tracheal tuberculosis.
Comorbidities were not reported by each study, but Philips et al. [22]
reported obstructive sleep apnea (OSA) (21), diabetes mellitus (19),
autoimmune disease (4), and pulmonary comorbidities (19). Youssef
and Paddle [10] reported 4 patients with cardiorespiratory comorbid­
ities. Matrka et al. [21] stated that 78.6 % of cases had at least one co­
morbidity, and 45.7 % had multiple comorbidities. Rodney et al. [23]
reported patient comorbidities including hypertension (316), coronary
artery disease (60), diabetes mellitus (151), COPD (68), active smoking
(73), history of tracheostomy (108), and history of head and neck sur­
gery (432). Nekhendzy et al. [18] reported comorbidities of OSA (2),
asthma (4), coronary artery disease (2), and hypertension (3). Barry
et al. [24] stated that 95 patients had undergone previous laryngo­
tracheal surgery, and Liang et al. [8] reported that 8 patients had mild to
severe tracheomalacia. Booth et al. [14] reported 3 patients with
comorbidities. One patient had a BMI of 42 kg/m2, emphysema and
mixed respiratory failure. Another patient had a BMI of 37 kg/m2 and
OSA, and the third patient had a BMI of 46 kg/m2 and was 23 weeks
pregnant with rest stridor and severe exertional limitation.
3.3. Outcomes measured
with Tritube endotracheal tube, laryngeal mask air, spontaneous
ventilation via bronchoscope, tracheostomy, intermittent face mask
ventilation, small endotracheal tube/extra-small diameter tube, inter­
mittent apnea technique, nonocclusive airway balloon dilator (Trache­
alator). The rates of technique failure for the remaining techniques were:
STRIVE Hi 1/21 (4.76 %), THRIVE 5 out of 39 (12.82 %), spontaneous
ventilation under total intravenous anesthesia without endotracheal
tube 4 out of 24 (16.67 %), jet ventilation 375 out of 1240 (30.24 %),
and low flow oxygenation 14/23 (60.87 %).
The secondary outcome measured was intraoperative hypoxia as
defined by each individual study. This outcome was included if reported
in the studies. Intraoperative hypoxia for each ventilatory technique
were: Evone Flow-Controlled Ventilation with Tritube endotracheal
tube 0/6, STRIVE Hi 0/21, spontaneous ventilation under total intra­
venous anesthesia without endotracheal tube 0/24, low flow oxygena­
tion 0/23, jet ventilation 27/1240 (2.18 %), laryngeal mask airway 1/28
(3.57 %), nonocclusive airway balloon dilator (Trachealator) 1/20 (5
%), small endotracheal tube/extra small diameter tube 8/84 (9.52 %),
THRIVE 4/39 (10.26 %), intermittent apnea technique 8/35 (22.86 %),
spontaneous ventilation via bronchoscope 3 out of 5 (60 %), intermittent
face mask ventilation 7 out of 11 (63.64 %), and tracheostomy 7 out of
10 (70 %).

The primary outcome measured partial or complete technique fail­
ure. Technique failure was reported in the studies; however, no tech­
nique failure was assumed when no intraoperative complications were
reported. The ventilatory techniques that demonstrated 0 % partial and
complete technique failure were Evone Flow-Controlled Ventilation
3.4. Complications reported
One case managed by STRIVE Hi was noted to have an unplanned
termination of technique after remifentanil was started. Booth et al. [14]
reported apnea and uncontrolled hypoxemia due to a large overdose of

5
A.M. Mangahas et al. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 44 (2023) 103767

Table 5
Characteristics of studies included continued.
Number of Type and severity of Etiology of stenosis Mean Gender Average Airway technique Partial/ Intraoperative
procedures stenosis age BMI complete hypoxia
technique
failure

Philips 70 50 – Subglottic 32 – Idiopathic 46.7 45 – 28.6 Low flow jet 3 4

et al. stenosis 31 – Iatrogenic females ventilation
[22] 20 – Tracheal 3 – Autoimmune 25 –
stenosis 4 – Congenital males
Cotton Myer grade
mean 2
Youssef & 35 Subglottic stenosis 45 33 – 28.2 23 – Low flow 14 – Low flow 0
Paddle Median diameter 6 females oxygenation oxygenation
[10] mm 2– 12 – THRIVE 4 – THRIVE
males
Matrka 70 Tracheal stenosis 17 – Idiopathic 47.2 45 – Manual subglottic jet 3 15
et al. 18 – Prolonged females ventilation
[21] intubation 25 –
4 – Autoimmune males
4 – Overdose,
alcoholism, or
suicide attempt
2 - Unknown
Booth et al. 21 Laryngotracheal 55 17 – 29 STRIVE-Hi 1 0
[14] stenosis females
13 –
males
Yoo et al. 24 15 – Subglottic or 12 – Prolonged 50.6 19 – 28.8 Spontaneous 4 0
[25] tracheal stenosis intubation females ventilation under total
6 – Glottic stenosis 5 – Idiopathic 17 – IV anesthesia without
3 – Supraglottic 1 – Unknown males ET tube
stenosis
Rodney 894 Laryngotracheal 52.7 743 – 29.3 Supraglottic jet 357 4
et al. stenosis females ventilation
[23] 151 –
males
Maupeu 3 Subglottic stenosis 49 15 – 25 THRIVE 0 0
et al. females
[27] 7–
males
To et al. 17 Subglottic stenosis 6 – Reflux 52 8– 27 THRIVE 1 1
[28] 9 – Cotton Myer 3 – Previous females
grade I intubation 2–
5 – Cotton Myer 3 – Wegener's males
grade II granulomatosis
2 – Cotton Myer 2 – Reflux or
grade III autoimmune given
1 – Unknown positive ANCA

remifentanil. The patient was successfully managed with tracheal intu­
bation. Another patient that underwent a procedure that utilized spon­
taneous ventilation under total intravenous anesthesia without
endotracheal tube experienced persistent laryngospasm and was tran­
sitioned to trans tracheal jet ventilation [25]. Furthermore, two notable
instances with anesthesia management with nonocclusive balloon
dilator were noted. First, a slow leak of the balloon was reported during
inflation. Hofmeyr et al. [16] stated that this was likely due to
impingement on the rigid bronchoscope. Additionally, in a patient with
severe stenosis, inflation of the balloon caused 1of the subunits to be
forced into the central lumen; however, ventilation was not impacted
[16]. Finally, while management with extra small diameter tube indi­
cated minimal technique failure or intraoperative hypoxia, other post­
operative complications were noted such as postoperative chest pain
(69.84 %), mild tracheal bleeding (73.02 %), and superficial laceration
of tracheal walls leading to mild pneumomediastinum (36.51 %) [8].
4. Discussion
The purpose of this review is to investigate the reported efficacy of
different ventilatory techniques used in endoscopic management of
airway stenosis. This systematic review identified 17 studies that met
inclusion criteria. Based on these studies, Evone Flow-Controlled
Ventilation with Tritube endotracheal tube showed the lowest rate of
technique failure and intraoperative hypoxia. LMA, STRIVE Hi, and
nonocclusive airway dilator (Trachealator) also showed low rates of
technique failure and intraoperative hypoxia. Spontaneous ventilation
under total intravenous anesthesia without endotracheal tube and
STRIVE Hi indicated low incidences of intraoperative hypoxia but had
higher rates of technique failure. More common techniques, such as
spontaneous ventilation via bronchoscope, tracheostomy, intermittent
facemask ventilation, small endotracheal tube/extra small diameter
tube, and intermittent apnea technique demonstrated no incidences of
technique failure, but showed higher rates of intraoperative hypoxia.
Hypoxia may precipitate due to hypoventilation during the endoluminal
procedure. Additionally, spontaneous ventilation is known to have great
difficulty achieving the necessary anesthesia for patients to tolerate the
procedure [13]. Compression of the small endotracheal tube by the
balloon dilator may also lead to hypoventilation [7]. These techniques,
besides small endotracheal tube, do allow for an unobstructed surgical
view as the ventilatory instrument is removed to allow for endoscopic
intervention; however, the incidence of hypoxia remains elevated. Extra
small diameter tube appears promising due to its lower incidence of
intraoperative hypoxia; however, slight retention of was CO2 was noted
[8]. Finally, the traditional jet ventilation technique showed low rates of
intraoperative hypoxia, but higher rates of technique failure.

6
A.M. Mangahas et al. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 44 (2023) 103767

Table 6
Characteristics of studies included continued.
Number of Type and severity of Etiology of stenosis Mean Gender Average Airway technique Partial/ Intraoperative
procedures stenosis age BMI complete hypoxia
technique
failure

Nekhendzy 11 Subglottic stenosis 53.05 26.1 THRIVE 0 3

et al. [18] Tracheal intubation
or supraglottic high
frequency jet
ventilation
Hofmeyr 20 7 – Subglottic stenosis 39 17 – “Trachealator” 0 1
et al. [16] (Cotton Myer grading females airway balloon
I-III) 3– (nonocclusive
12 – Tracheal stenosis males balloon dilator)
(Cotton Myer grading
I-IV)
1 – Tracheobronchial
stenosis
Pourciau 14 Tracheal or subglottic 52 5– 38 Laryngeal mask 0 0
et al. [29] stenosis females airway
2–
males
Barry et al. 126 7 – Glottic stenosis 55.2 107 – 28.8 38 – Supraglottic jet 5 0
[24] 3 – Supraglottic or females ventilation
mixed supraglottic/ 19 – 88 – Mixed
glottic stenosis males supraglottic and
20 – Subglottic or subglottic jet
mixed glottic/ ventilation
subglottic stenosis
96 – Laryngotracheal
or tracheal stenosis
Liang et al. 63 18 – Upper tracheal 24 – Iatrogenic 37 10 – Extra-small diameter 0 0
[8] stenosis tracheal stenosis due females tube
3 – Upper and middle to prolonged 16 –
tracheal stenosis endotracheal males
4 – Middle tracheal intubation or
stenosis tracheotomy
1 – Whole tracheal 2 – Tracheal
and right main tuberculosis
bronchial stenosis

[6,8,14,15].
Table 7
The studies used in this review posed limitations due to small sample
Definition of hypoxia for each study.
sizes. The studies that examined newer ventilatory techniques had much
Study Definition of hypoxia smaller sample sizes, and more positive results in measured outcomes,
Meulemans et al. [15] SpO2 <80 % while jet ventilation had the largest sample size and higher rates of
Knights et al. [17] 2 consecutive minutes during case when SpO2 <90 % technique failure and intraoperative hypoxia. Therefore, more research
Hashmi et al. [19] No set definition with larger sample sizes is needed to fully explore the efficacy of newer
Vorasubin et al. [20] No set definition
Philips et al. [22] SpO2 <88 %
ventilation techniques in order to yield more conclusive results. Addi­
Youssef and Paddle SpO2 <90 % tionally, there was no uniform definition of hypoxia as each of these
[10] studies defined hypoxia as different values of oxygen saturation
Matrka et al. [21] SpO2 <90 % (Table 7). For example, most of the studies used the utilized the defi­
Booth et al. [14] No set definition
nition of hypoxia as SpO2 <90 % or reported desaturations between 82
Yoo et al. [25] SpO2 <90 %
Rodney et al. [23] Prolonged (SpO2 <70 % for >60 s); profound (SpO2 <50 and 88 %; however, Meulemans et al. [15] set their cutoff for hypoxia as
%) SpO2 <80 %. Therefore, not only did the study that examined Evone
Maupeu et al. [27] SpO2 <90 % Flow-Controlled Ventilation with Tritube endotracheal tube have a
To et al. [28] No set definition small sample size, but they also had a lower threshold to report hypoxia.
Nekhendzy et al. [18] No set definition
Hofmeyr et al. [16] SpO2 <90 %
Rodney et al. [23] also had a lower threshold for hypoxia as they re­
Pourciau et al. [29] No set definition ported both prolonged hypoxia (SpO2 <70 % for >60 s) or profound
Barry et al. [24] No set definition hypoxia (SpO2 <50 %). Although their study showed very low rates of
Liang et al. [8] SpO2 <90 % intraoperative hypoxia when using jet ventilation, the standard to report
hypoxia was much lower compared to the other studies. Hypoxia has
traditionally been defined as PaO2 <60 mm Hg, which correlates to
Additionally, jet ventilation also raises risk of complications such as
SpO2 <90 % [26]. Thus, further studies with a uniform definition of
pneumothorax, pneumomediastinum, or other problems due to baro­
hypoxia are necessary to accurately assess the safety of each ventilatory
trauma [4]. This review suggests that newer techniques, such as Evone
technique.
Flow-Controlled Ventilation with Tritube endotracheal tube, LMA, and
Furthermore, not all studies reported patient comorbidities and,
nonocclusive airway dilator, may offer promise in minimizing failure
thus, did not explore their role as a confounding variable in measuring
and intraoperative hypoxia in endoscopic procedures. These techniques
the primary and secondary outcomes. Comorbidities were reported by
may be more favorable as they maintain ventilation while allowing a
this systematic review as indicated by the included studies; however,
less obstructed field of view and accommodation for the laryngoscope

7
A.M. Mangahas et al.
these studies did not analyze their outcomes as a function of comor­
bidities. Instead, each correlation was reported only when intra­
operative complications occurred. For example, Matrka et al. [21] noted
the failure of jet ventilation in a patient with a BMI of 63 kg/m2.
Furthermore, Hofmeyr et al. [16] indicated that the one reported
instance of intraoperative hypoxia occurred in a patient with severe
respiratory disease and had a recent occlusion of one main bronchus.
Finally, Barry et al. [24] outlined characteristics for certain patients that
failed jet ventilation. The patients had a large range of BMI (<25 to >36
kg/m2). One patient was noted to have severe tracheomalacia, while
another patient had comorbidities of tobacco abuse and coronary artery
disease. Philips et al. [22] did examine technique failure in terms of
obesity and found that 3.45 % of obese cases and 4.88 % of nonobese
cases resulted in a switch from jet ventilation to mechanical ventilation.
However, Philips et al. [22] is the only study that framed their analysis
in this fashion; therefore, the effects of BMI, respiratory, and coronary
diseases need to be further explored.
This study was also limited by the current research that investigated
the efficacy of anesthetic technique in endoscopic management of
airway stenosis. Many studies described different techniques used in
these procedures; however, few directly measured the techniques'
intraoperative effectiveness. Due to this, there is a lack of information of
intraoperative difficulties that may arise from the perspective of anes­
thesiologists and otolaryngologists. Furthermore, this study examined
different etiologies and types of airway stenosis which presented more
heterogeneity due to the limited amount of studies exploring ventilatory
techniques. For this reason, conclusions were drawn based on the data,
but research with more uniform data is needed to make more definitive
conclusions regarding the safest ventilatory technique.
5. Conclusion
This systematic review examined the efficacy of different ventilatory
techniques used in endoscopic management of airway stenosis. Seven­
teen studies were analyzed in this review. Limitations to this study
included small sample sizes, lack of standard definition of hypoxia,
inadequate report of comorbidities, and heterogeneity of data. Despite
these limitations, this review indicated that newer techniques, such as
Evone Flow-Controlled Ventilation with Tritube endotracheal tube,
LMA, and nonocclusive balloon dilator, may hold promise for mini­
mizing intraoperative technique failure and hypoxia; however studies
with larger sample sizes are needed to draw further conclusions. Most
importantly, more studies that examine intraoperative complications of
ventilatory techniques with standard measurements is needed to
determine a gold standard technique.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Angelica M. Mangahas: Project design, Data curation, Data analysis,
Writing – original draft, Writing – review & editing, Presentation of
research
Snehitha Talugula: Data curation, Data analysis, Writing – review &
editing
Inna A. Husain: Project design, Data analysis, Writing – original
draft, Writing – review & editing.
Conflict of interest
AM: None
ST: None
IH: None.
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 44 (2023) 103767
Acknowledgements
None.
References
[1] Gelbard A, et al. Causes and consequences of adult laryngotracheal stenosis.
Laryngoscope 2015;125(5):1137–43.
[2] Lahav Y, Shoffel-Havakuk H, Halperin D. Acquired glottic stenosis - the ongoing
challenge: a review of etiology, pathogenesis, and surgical management. J Voice
2015;29(5):646.e1–646.e10.
[3] Pasick LJ, Anis MM, Rosow DE. An updated review of subglottic stenosis: etiology,
evaluation, and management. Curr Pulmonol Rep 2022:1–10.
[4] Doyle DJ, Hantzakos AG. Anesthetic management of the narrowed airway.
Otolaryngol Clin North Am 2019;52(6):1127–39.
[5] Doroshenko M, Guerra A, Vu L. Airway For laser surgery. In: StatPearls. Treasure
Island (FL): StatPearls Publishing Copyright © 2022, StatPearls Publishing LLC;
2022.
[6] Jameson JJ, et al. Use of the laryngeal mask airway for laser treatment of the
subglottis. Otolaryngol Head Neck Surg 2000;123(1 Pt 1):101–2.
[7] Hulstein S, Hoffman H. Technique for improved safety in the endoscopic
management of subglottic stenosis. Am J Otolaryngol 2016;37(6):490–2.
[8] Liang YL, et al. Management of benign tracheal stenosis by small-diameter tube-
assisted bronchoscopic balloon dilatation. Chin Med J (Engl) 2015;128(10):
1326–30.
[9] Isono S, et al. Case scenario: perioperative airway management of a patient with
tracheal stenosis. Anesthesiology 2010;112(4):970–8.
[10] Youssef DL, Paddle P. Tubeless anesthesia in subglottic stenosis: comparative
review of apneic low-flow oxygenation with THRIVE. Laryngoscope 2022;132(6):
1231–6.
[11] Huang L, et al. A review of the use of transnasal humidified rapid insufflation
ventilatory exchange for patients undergoing surgery in the shared airway setting.
J Anesth 2020;34(1):134–43.
[12] Lyons C, Callaghan M. Apnoeic oxygenation with high-flow nasal oxygen for
laryngeal surgery: a case series. Anaesthesia 2017;72(11):1379–87.
[13] Booth AW, Vidhani K. Spontaneous ventilation using Propofol TCI for
microlaryngoscopy in adults: a retrospective audit. Anaesth Intensive Care 2016;44
(2):285–93.
[14] Booth AWG, et al. SponTaneous Respiration using IntraVEnous anaesthesia and Hi-
flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during
management of the obstructed airway: an observational study. Br J Anaesth 2017;
118(3):444–51.
[15] Meulemans J, et al. Evone® flow-controlled ventilation during upper airway
surgery: a clinical feasibility study and safety assessment. Front Surg 2020;7:6.
[16] Hofmeyr R, et al. Prospective observational trial of a nonocclusive dilatation
balloon in the management of tracheal stenosis. J Cardiothorac Vasc Anesth 2022;
36(8 Pt B):3008–14.
[17] Knights RM, et al. Airway management in patients with subglottic stenosis:
experience at an academic institution. Anesth Analg 2013;117(6):1352–4.
[18] Nekhendzy V, et al. The safety and efficacy of transnasal humidified rapid-
insufflation ventilatory exchange for laryngologic surgery. Laryngoscope 2020;130
(12):E874–81.
[19] Hashmi NK, Mandel JE, Mirza N. Laryngeal mask airway in laryngoscopies: a safer
alternative for the difficult airway. ORL J Otorhinolaryngol Relat Spec 2009;71(6):
342–6.
[20] Vorasubin N, et al. Airway management and endoscopic treatment of subglottic
and tracheal stenosis: the laryngeal mask airway technique. Ann Otol Rhinol
Laryngol 2014;123(4):293–8.
[21] Matrka L, et al. Airway surgery communication protocol: a quality initiative for
safe performance of jet ventilation. Laryngoscope 2020;130:S1–13.
[22] Philips R, deSilva B, Matrka L. Jet ventilation in obese patients undergoing airway
surgery for subglottic and tracheal stenosis. Laryngoscope 2018;128(8):1887–92.
[23] Rodney JP, et al. Multi-institutional analysis of outcomes in supraglottic jet
ventilation with a team-based approach. Laryngoscope 2021;131(10):2292–7.
[24] Barry RA, et al. Effect of increased body mass index on complication rates during
laryngotracheal surgery utilizing jet ventilation. Otolaryngol Head Neck Surg
2017;157(3):473–7.
[25] Yoo MJ, Joffe AM, Meyer TK. Tubeless total intravenous anesthesia spontaneous
ventilation for adult suspension microlaryngoscopy. Ann Otol Rhinol Laryngol
2018;127(1):39–45.
[26] Butterworth JF, Mackey DC, Wasnick JD. Chapter 23. Respiratory physiology &
anesthesia. In: Morgan & Mikhail's clinical anesthesiology. 5th ed. New York, NY:
The McGraw-Hill Companies; 2013.
[27] Maupeu L, et al. Indications of transnasal humidified rapid-insufflation ventilatory
exchange (THRIVE) in laryngoscopy, a prospective study of 19 cases. Clin
Otolaryngol 2019;44(2):182–6.
[28] To K, et al. The use of transnasal humidified rapid-insufflation ventilatory
exchange in 17 cases of subglottic stenosis. Clin Otolaryngol 2017;42(6):1407–10.
[29] Pourciau DC, et al. Safety and efficacy of laryngeal mask airway ventilation in
obese patients with airway stenosis. Laryngoscope 2017;127(11):2582–4.