Subglottic Stenosis in Children

http://emedicine.medscape.com/article/864208-overview

Subglottic Stenosis in Children
Author: John E McClay, MD; Chief Editor: Arlen D Meyers, MD, MBA more... Updated: Dec 6, 2011

Background
Subglottic stenosis (SGS) is a narrowing of the subglottic airway, which is housed in the cricoid cartilage. The image below shows an intraoperative endoscopic view of a normal subglottis.

Intraoperative endoscopic view of a normal subglottis

The subglottic airway is the narrowest area of the airway, since it is a complete, nonexpandable, and nonpliable ring, unlike the trachea, which has a posterior membranous section, and the larynx, which has a posterior muscular section. The term subglottic stenosis (SGS) implies a narrowing that is created or acquired, although the term is applied to both congenital lesions of the cricoid ring and acquired subglottic stenosis (SGS). See the images below.

Grade III subglottic stenosis in an 18-year-old patient following a motor vehicle accident. The true vocal cords are seen in the foreground. Subglottic stenosis is seen in the center of the picture.

Endoscopic view of the true vocal cords in the foreground and the elliptical congenital subglottic stenosis (SGS) in the center of

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Subglottic Stenosis in Children http://emedicine. it was found to be 30% narrowed. True vocal cords are shown in the foreground (slightly blurry). Subglottic view of congenital elliptical subglottic stenosis. Laterally. a subglottic stenosis can be seen.medscape. 2 of 16 2/6/2012 12:14 AM . When endotracheal tubes were used to determine its size. Intraoperative laryngeal view of the true vocal cords of a 9-year-old boy.com/article/864208-overview the picture. the area looks only slightly narrow. This patient required tracheotomy and eventual reconstruction at age 3 years. The area is still granular following cricoid split. Under the vocal cords. Subglottic view of very mild congenital subglottic stenosis. Granular subglottic stenosis in a 3-month-old infant that was born premature. weighing 800 g.

Some mild residual posterior subglottic stenosis remains. but the child is asymptomatic and the airway is open overall. Continued lasering of the subglottic stenosis.Subglottic Stenosis in Children http://emedicine. Postoperative view.com/article/864208-overview This spiraling subglottic stenosis is not complete circumferentially. The reflected red light is the aiming beam for the CO2 laser. Laser therapy was the treatment choice and was successful after 2 laser treatments. Vocal cords are in the foreground. 3 of 16 2/6/2012 12:14 AM . Preoperative view of a 4-month-old infant with acquired grade III subglottic stenosis from intubation.medscape. A close-up view.

com/article/864208-overview Postoperative view. or diphtheria. acquired subglottic stenosis (SGS) was usually related to trauma or infection from syphilis. the airway is open and patent. Surgery without cartilage expansion In 1971.medscape. after McDonald and Stocks (in 1965) introduced long-term intubation as a treatment method for neonates in need of prolonged ventilation for airway support. typhoid fever. A metal tracheotomy tube was attached to the Aboulker stent with wires. Notice very mild recurrence of scaring at the site of previous scar. The patient had been intubated for 1 week and extubated for 1 week. attempted laryngeal dilation failed as a treatment for subglottic stenosis (SGS). children often had tracheotomies placed that caused laryngeal stenosis. Postoperative view of a 4-month-old infant with subglottic stenosis following cricoid split. tuberculosis. Overall. Acquired subglottic stenosis (SGS) occurred increasingly in the late 1960s through the 1970s. with a small area of fibrosis where the cricoid split previously healed. Preoperative subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis. History of the Procedure Early in the 20th century. Rethi and Rhan described a procedure for vertical division of the posterior lamina of the cricoid cartilage with Aboulker stent placement. The increased incidence of subglottic stenosis (SGS) focused new attention on the pediatric larynx. and the 4 of 16 2/6/2012 12:14 AM . A subglottic view following dilation with an endotracheal tube to lyse the thin web of scar and a short course (5-day) treatment with oral steroids. and airway reconstruction and expansion techniques were developed.Subglottic Stenosis in Children http://emedicine. Also. The anterior superior area can be seen. In this era.

com/article/864208-overview anterior cartilaginous incision was closed. Acquired subglottic stenosis (SGS) is caused by either infection or trauma. Cotton and Seid described a procedure.Subglottic Stenosis in Children http://emedicine. Cricotracheal resection In 1993. including thyroid cartilage. and a stent made of a rolled silicone sheet was placed in it for 6 weeks. The true vocal cords are seen in the foreground. Congenital subglottic stenosis (SGS) has several abnormal shapes. Subglottic stenosis (SGS) can be acquired or congenital. Zalzal [4] reported 90% decannulation with any degree of subglottic stenosis (SGS) with his first surgical procedure. His success rates depended on degree of stenosis: More severe forms of stenosis required multiple surgical procedures. severe SGS) often requires multiple (3-4) surgical augmentations for decannulation. Cotton used the Aboulker stent. hyoid bone. Subglottic stenosis is seen in the center of the picture. The procedure was designed for use in neonates (usually. In 1991. Cotton et al described a 4-quadrant cricoid split. in which tracheotomy is avoided. The cricoid ring was divided anteriorly and a laryngofissure was created in an attempt to expand the airway without a tracheotomy. Monnier described partial cricotracheal resection with primary anastomoses for severe SGS. reporting a decannulation rate higher than 90% for primary and rescue cricotracheal resection. septal cartilage. costal cartilage. Cotton reported his experience with laryngeal expansion with cartilage grafting. since grade III and grade IV SGS (ie. Evanston and Todd described success with a castellated incision of the anterior cricoid cartilage and upper trachea. those born prematurely) with anterior glottic stenosis or SGS who had airway distress after extubation. In 1997. 5 of 16 2/6/2012 12:14 AM . Grade III subglottic stenosis in an 18-year-old patient following a motor vehicle accident. Seid et al described a form of single-stage laryngotracheal reconstruction in which cartilage was placed anteriorly to expand the subglottis and upper trachea to avoid a tracheotomy. In 1974. In 1993. [2] [3] In 1992. Zalzal customized the reconstruction on an individual basis. Cotton described his experience with the procedure. and most patients received Aboulker stents for stabilization. Fearon and Cotton described the successful use of cartilage grafts to enlarge the subglottic lumen in African green monkeys and in children with severe laryngotracheal stenosis. along with anterior and posterior grafting. Holinger et al also described success with this procedure in 1987.[1] All augmentation materials were evaluated. After significant work. called the anterior cricoid split (ACS).medscape. it appeared that costal cartilage grafts had the highest success rate. and sternocleidomastoid myocutaneous flaps. Surgery with cartilage-grafting reconstruction In 1974. Problem Subglottic stenosis (SGS) is narrowing of the subglottic lumen. In the 1980s. auricular cartilage. In 1980. as seen in the images below. which was sewn open.

Subglottic Stenosis in Children http://emedicine. but the child is asymptomatic and the airway is open overall. 6 of 16 2/6/2012 12:14 AM . True vocal cords are shown in the foreground (slightly blurry).com/article/864208-overview Granular subglottic stenosis in a 3-month-old infant that was born premature. Postoperative view. Laser therapy was the treatment choice and was successful after 2 laser treatments. Continued lasering of the subglottic stenosis.medscape. weighing 800 g. Some mild residual posterior subglottic stenosis remains. The reflected red light is the aiming beam for the CO2 laser. a subglottic stenosis can be seen. Intraoperative laryngeal view of the true vocal cords of a 9-year-old boy. The area is still granular following cricoid split. This spiraling subglottic stenosis is not complete circumferentially. Under the vocal cords. This patient required tracheotomy and eventual reconstruction at age 3 years.

com/article/864208-overview Preoperative view of a 4-month-old infant with acquired grade III subglottic stenosis from intubation. A subglottic view following dilation with an endotracheal tube to lyse the thin web of scar and a short course (5-day) treatment with oral steroids.medscape. 7 of 16 2/6/2012 12:14 AM . with a small area of fibrosis where the cricoid split previously healed. Overall.Subglottic Stenosis in Children http://emedicine. The anterior superior area can be seen. A close-up view. Postoperative view of a 4-month-old infant with subglottic stenosis following cricoid split. the airway is open and patent. Notice very mild recurrence of scaring at the site of previous scar. Postoperative view. The patient had been intubated for 1 week and extubated for 1 week. Vocal cords are in the foreground.

Subglottic view of congenital elliptical subglottic stenosis. the incidence of acquired subglottic stenosis (SGS) was as high as 24% in patients requiring such care. malnutrition. In the late 1960s. Elliptical cricoid cartilage was the most commonly observed congenital abnormality. Over the past 40 years. Epidemiology Frequency The frequency of congenital subglottic stenosis (SGS) is unknown. anemia. and in no patient did subglottic stenosis (SGS) develop over a 3-year period. The etiology of acquired subglottic stenosis (SGS) is related to trauma of the subglottic mucosa. penetrating. the condition has typically been related to mechanical trauma. In the 1970s and 1980s. as shown below. Half of these children had an elliptical cricoid cartilage. Choi reported that the incidence of subglottic stenosis (SGS) had remained constant at the Children's National Medical Center in Washington. acquired subglottic stenosis (SGS) has been related to infections such as tuberculosis and diphtheria. when endotracheal intubation and long-term ventilation for premature infants began. usually from endotracheal intubation but also from blunt. In 1996.Subglottic Stenosis in Children http://emedicine. which Tucker first described in 1979. the duration of intubation. the motion of the tube. Holinger evaluated 29 pathological specimens obtained in children with congenital cricoid anomalies. 2.[5] Walner recently reported that. a report from France also described no incidence of subglottic stenosis (SGS) in the neonatal population who underwent intubation with very small endotracheal tubes (ie. Historically. estimates of the incidence of subglottic stenosis (SGS) were 1-8%. and repeated intubations. Local bacterial infection may 8 of 16 2/6/2012 12:14 AM .medscape. Etiology The cause of congenital subglottic stenosis (SGS) is in utero malformation of the cricoid cartilage. DC. Injury can be caused by infection or mechanical trauma. a thickened anterior cricoid. among 504 neonates who were admitted to the level III ICU at the University of Chicago in 1997. The incidence of acquired subglottic stenosis (SGS) has greatly decreased over the past 40 years. Additional factors that affect wound healing include systemic illness. it was approximately 1-2% in children who had been treated in the neonatal ICU. In 1998.com/article/864208-overview Preoperative subglottic view of a 2-year-old patient with congenital and acquired vertical subglottic stenosis. Other observed abnormalities included a flattened anterior shape. and hypoxia.5-mm internal diameter) in attempts to prevent trauma to the airway. or other trauma. 281 were intubated for an average of 11 days. Factors implicated in the development of subglottic stenosis (SGS) include the size of the endotracheal tube relative to the child's larynx. and a submucosal posterior laryngeal cleft.

and may require oxygen administration. as it passes through or remains for long periods in the narrowed neonatal and subglottic airway. creating a greater chance of developing stenosis. Usually. If a smaller-than-appropriate endotracheal tube must be used. Inspiratory stridor usually is associated with supraglottic lesions. even in short surgical procedures. retrognathia. so that no additional pressure necrosis occurs in the mucosa of the subglottis. and upper tracheal lesions. can lead to mucosal edema and hyperemia. Pathophysiology Acquired subglottic stenosis (SGS) is often caused by endotracheal intubation. Prior to surgical intervention. narrowing of the airway may be present. and ask the following questions: Is the child comfortable? Does the child have difficulty breathing? 9 of 16 2/6/2012 12:14 AM . Evaluate the child's initial overall appearance. the child should not require a substantial oxygen supplementation. In mild subglottic stenosis (SGS). The stridor in subglottic stenosis (SGS) is usually biphasic. only exercise-induced stridor or obstruction may be present. In severe subglottic stenosis (SGS). complete airway obstruction may be present and may require immediate surgical intervention. This practice is common among anesthesiologists.medscape. Always check for an air leak after placing an endotracheal tube because of the risk of necrosis of the mucosa. always evaluate GERD prior to surgical intervention. Depending on the severity. which irritates and inflames the area and prevents it from healing correctly. which could suggest subglottic stenosis (SGS). subglottic stenosis (SGS) may manifest as stridor and obstructive breathing after extubation that requires reintubation.Subglottic Stenosis in Children http://emedicine. these patients were born prematurely. intubation in most full-term neonates should be performed with a 3. A child with an otherwise adequate but marginal airway can become symptomatic with the development of mucosal edema associated with a routine viral upper respiratory infection (URI). the pressure of the air leak should be less than 20 cm of water. subglottic. or pulmonary lesions. Always ask about a history of recurrent croup.5-mm pediatric endotracheal tube. Children with these conditions may have subglottic narrowing and an evaluation of the airway is appropriate. The level of airway obstruction varies depending on the type or degree of subglottic stenosis (SGS). This series of events can be hastened if an oversized endotracheal tube is used. Presentation History Children with subglottic stenosis (SGS) have an airway obstruction that may manifest in several ways. Gastroesophageal reflux (GER) may play an adjuvant role in the development of subglottic stenosis (SGS) because it causes the subglottis to be continually bathed in acid. subglottic stenosis (SGS) can cause patients to have decreased subglottic pressure and a hoarse or a weak voice. Infection of the perichondrium can result in a subglottic scar. In neonates. If present. Physical examination The physical examination varies depending on the degree of subglottic stenosis (SGS) present. choanal atresia. A systemic or gastrointestinal allergy may cause the airway to be more reactive. Always assess the history of GER disease (GERD). These changes have been observed within a few hours of intubation and may progress to expose the perichondrium of the cricoid cartilage. The degree of pulmonary disease and the amount of oxygen the child requires may affect the ability to perform decannulation. bronchial. have bronchopulmonary dysplasia. and facial deformities. A child who eventually has a diagnosis of subglottic stenosis (SGS) often has a history of either laryngotracheal trauma or intubation and ventilation. Frequently. At birth. and identify associated facial abnormalities such as cleft palate. Mechanical trauma from an endotracheal tube. expiratory stridor usually is associated with tracheal. Hoarseness or vocal weakness also can be associated with glottic stenosis and vocal cord paresis or paralysis. These conditions then can progress to pressure necrosis of the mucosa. Auscultate the child's lung fields and neck to assess any symptoms of airway obstruction and to evaluate pulmonary function. Completely evaluate the head and neck.com/article/864208-overview play an important roll in the development of subglottic stenosis (SGS). Biphasic stridor can be associated with glottic.

as shown in the image below. no detectable lumen) The percentage of stenosis is evaluated by using endotracheal tubes of different sizes.Obstruction of 100% of the lumen (ie. as follows: Grade I . substernal. especially when infection or inflammation causes mucosal edema. although it can be used to obtain a rough estimate.com/article/864208-overview Does the child have difficulty breathing when emotionally upset? Does the child have any suprasternal.Obstruction of 51-70% of the lumen Grade III . Granulation tissue (superior center portion of the picture) that occurred at the graft site of a laryngotracheal reconstruction performed with an anterior graft. Children with these conditions may have intermittent airway symptoms. or intercostal retractions? Does the child have any nasal flaring? Is the voice normal? Is it weak? Is the voice breathy? Does the child have stridor? If so. inspiratory.medscape. Typically.Subglottic Stenosis in Children http://emedicine.Obstruction of 71-99% of the lumen Grade IV . 10 of 16 2/6/2012 12:14 AM . children with grade I. Myers and Cotton devised a classification scheme for grading circumferential subglottic stenosis from I-IV. Children with grade I and mild grade II subglottic stenosis (SGS) often do not require surgical intervention. or biphasic)? What is the child's neurologic status? Does the child have a tracheotomy? Can the patient occlude the tracheotomy and still breathe without laboring? Indications Staging Surgical reconstruction is performed on the basis of the symptoms.Obstruction of 0-50% of the lumen obstruction Grade II . The scale describes stenosis as a percent of area that is obstructed. This grading system applies mainly to circumferential stenosis and does not apply to other types of subglottic stenosis (SGS) or combined stenoses. what is the nature of the stridor (ie. regardless of SGS grade. expiratory. which is established endoscopically and by using noncuffed pediatric endotracheal tubes of various sizes and sizing the airway. The largest endotracheal tube that can be placed with an air leak less than 20 cm of water pressure is recorded and evaluated against a scale that has previously been constructed by Myers and Cotton. as depicted below. The system contains 4 grades. or mild grade II stenosis do not require surgical intervention.

GERD. and bronchopulmonary dysplasia may occur or be involved in the development of subglottic stenosis (SGS). divide the cricoid cartilage.com/article/864208-overview Subglottic view of very mild congenital subglottic stenosis.medscape. or if they frequently become ill. Development of upper respiratory symptoms during routine infections can indicate whether a child with subglottic stenosis (SGS) requires surgical reconstruction. Expansion of the airway with cartilage augmentation may allow them to lead a healthy and active lifestyle. If children with these conditions continue to have intermittent or persistent stridor and airway obstructive symptoms when they are well. However. glottic stenosis often can be present with subglottic stenosis (SGS). Indications Surgical intervention may be avoided if periods of airway obstruction are rare and can be treated on an inpatient or outpatient basis with anti-inflammatory and vasoconstrictive agents. these children may have grade I or grade II subglottic stenosis (SGS). a history of prolonged endotracheal tube intubation is the most common factor seen in patients with subglottic stenosis (SGS) that requires surgical correction. If a laryngofissure is required for glottic stenosis or to gain access to the posterior aspect of the stenosis for suturing of the posterior graft. At evaluation. If a child with subglottic stenosis (SGS) has a cold and/or bronchitis but no significant symptoms of stridor or upper airway obstruction. the area looks only slightly narrow. Endoscopic guidance can help in preventing injury to the glottic larynx. care must be taken to identify the anterior commissure and correctly put it back into place. older children have exercised-induced airway obstruction. Relevant Anatomy The subglottis is defined as the area of the larynx housed by the cricoid cartilage that extends from 5 mm beneath the true vocal cords to the inferior aspect of the cricoid ring. surgical intervention may be necessary. Children with grade III or grade IV subglottic stenosis (SGS) need one or more of the forms of surgical treatment discussed in Surgical therapy. bacterial infection. 11 of 16 2/6/2012 12:14 AM . Although croup. When endotracheal tubes were used to determine its size.Subglottic Stenosis in Children http://emedicine. such as oral. A history of recurrent croup suggests subglottic stenosis (SGS). and reconstruction may not be needed. it was found to be 30% narrowed. Viral infections of the upper respiratory tract can create swelling in any area of the respiratory epithelium from the tip of the nose to the lungs. intravenous. upper 2 tracheal rings. carefully perform the procedure. Intraoperative endoscopic view of a normal subglottis When creating the entry incision into the airway in an isolated subglottic stenosis (SGS). Because of the proximity and close relationship of the subglottis to the glottic larynx. and the inferior third to half of the laryngeal cartilage in the midline. depicted in the image below. the airway may be large enough to tolerate stress. good voice quality can be preserved by not violating the true vocal cords if they are uninvolved in the disease process. When SGS is corrected surgically. avoid dividing the anterior commissure. if the disease dictates or if exposure for repair cannot be obtained without dividing the anterior commissure. Laterally. Occasionally. or inhaled steroids and inhaled epinephrine (racemic treatment).

nasopharynx. American College of Surgeons. the recurrent laryngeal nerves should be far enough away from an anterior division to prevent injury. MD. or trachea that cannot be repaired. immediately suture the anterior aspect of the true vocal chords near the anterior commissure to the laryngeal cartilage with a 6-0 monofilament suture such as polydioxanone (PDS) or Monocryl. MD is a member of the following medical societies: American Academy of Otolaryngic Allergy. Specialty Editor Board Russell A Faust. Children's Hospital of Dallas. Department of Otolaryngology. Contraindications No specific absolute contraindications to the laryngotracheal reconstruction procedure exist. note that the esophagus is immediately adjacent and posterior to it. In the cricotracheal resection procedure. weighing 800 g. An additional relative contraindication to airway reconstruction is pulmonary or neurological function that is inadequate to withstand tracheotomy decannulation. if general anesthesia is absolutely contraindicated. This patient required tracheotomy and eventual reconstruction at age 3 years. However. Regardless of the cause of subglottic stenosis (SGS). When surgery is performed in the midline. if severe or complete laryngeal obstruction exists and if the child might be able to vocalize if the airway were surgically corrected. until the reactive nature of the patient's condition subsides. This lack of identification has resulted in some reported cases of paresis of the true vocal cord.medscape. surgical correction of subglottic stenosis (SGS) cannot be performed. Severe GER is another relative contraindication. True vocal cords are shown in the foreground (slightly blurry). shown below. Any surgical procedure in which the lateral cricoid is divided could jeopardize the laryngeal nerve and result in paresis or paralysis of the true vocal cords. This procedure helps prevent anterior commissure from becoming blunted and helps mark approximately where it should be once the laryngofissure is closed. Contributor Information and Disclosures Author John E McClay. Department of Otolaryngology-Head and Neck Surgery.Subglottic Stenosis in Children http://emedicine. Take care to avoid injuring the esophagus when completely dividing the posterior cricoid lamina during cartilage augmentation. reconstruction can be considered. access for suctioning secretions caused by chronic aspiration) or in those who have airway collapse or obstruction in the nasal cavity. MD Associate Professor of Pediatric Otolaryngology. no attempt is made to identify the recurrent laryngeal nerves because of dense scarring. Granular subglottic stenosis in a 3-month-old infant that was born premature. A relative contraindication to reconstruction of a narrow subglottis is present in children who have a tracheotomy and subglottic stenosis (SGS) but need a tracheotomy for other purposes (eg. oropharynx. despite the need to maintain the tracheotomy tube. The recurrent laryngeal nerves enter the larynx in the posterior lateral portion of the cricoid ring. PhD Consulting Staff. Columbus Children's Hospital 12 of 16 2/6/2012 12:14 AM . reconstruction may be beneficial. Once GER is treated successfully (medically or surgically) or resolves on its own. oral cavity. The area is still granular following cricoid split. it is usually best to delay reconstructive efforts in children who have reactive or granular airways.com/article/864208-overview Once the laryngofissure is created in the midline. When dividing the posterior cricoid lumen. and American Medical Association Disclosure: Nothing to disclose. However. University of Texas Southwestern Medical School John E McClay. supraglottic larynx. American Academy of Otolaryngology-Head and Neck Surgery.

Department of Otolaryngology-Head and Neck Surgery. American Academy of Facial Plastic and Reconstructive Surgery. Christopher L Slack. Treasure Coast Sleep Disorders Christopher L Slack. Arch Otolaryngol Head Neck Surg. and Colorado Medical Society Disclosure: Nothing to disclose. US Tobacco Corporation Unrestricted gift Unknown. Treatment of laryngotracheal stenosis with anterior and posterior cartilage grafts. Changing trends in neonatal subglottic stenosis. Omni Biosciences Ownership interest Consulting. Zalzal GH. PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery. Axis Three Corporation Ownership interest Consulting. Jan 13 of 16 2/6/2012 12:14 AM . Cotton R. American College of Legal Medicine. Apr 1991. Editor-in-Chief. Cotton RT.Subglottic Stenosis in Children http://emedicine. Pransky SM. MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery. MD. Kearns DB. O'Connor DM. Jul-Aug 1974. American Cleft Palate/Craniofacial Association.30(4):93-8. American Academy of Otolaryngology-Head and Neck Surgery. Medscape Drug Reference Disclosure: Medscape Salary Employment Gregory C Allen. [Medline]. A report of 41 children. Progress report. American Academy of Otolaryngology-Head and Neck Surgery. MD. American Society for Head and Neck Surgery. Fall 1992. Choi SS. Sentegra Ownership interest Board membership. Otolaryngol Head Neck Surg.83(4):428-31. Medvoy Ownership interest Management position. University of Nebraska Medical Center College of Pharmacy. [Medline]. MD Private Practice in Otolaryngology and Facial Plastic Surgery. Francisco Talavera. and American Medical Association Disclosure: Nothing to disclose. Chief Editor Arlen D Meyers. MBA Professor. 2. Surgical correction of subglottic stenosis of the larynx in infants and children. American Academy of Pediatrics. Christian Medical & Dental Society.com/article/864208-overview Russell A Faust. Medicine & Ethics Disclosure: Nothing to disclose. American Medical Association. PhD Adjunct Assistant Professor. Evaluation of the airway for laryngotracheal reconstruction. MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery. and American Society of Law. 5. Int Anesthesiol Clin. Syndicom Ownership interest Consulting. American Laryngological Rhinological and Otological Society. MD Assistant Professor. Fearon B. Ann Otol Rhinol Laryngol. GYRUS ACMI Honoraria Consulting References 1. Cerescan Imaging Honoraria Consulting. [Medline]. Associated Coastal ENT. 3. 4. University of Colorado School of Medicine Arlen D Meyers. MD. PharmD.medscape. American College of Surgeons. Arch Otolaryngol Head Neck Surg. MD is a member of the following medical societies: Alpha Omega Alpha. University of Colorado School of Medicine Gregory C Allen. Oxlo Consulting. Seid AB. American Laryngological Rhinological and Otological Society. Department of Otolaryngology-Head and Neck Surgery. and American Head and Neck Society Disclosure: Covidien Corp Consulting fee Consulting. American Rhinologic Society. Jan 1993.119(1):82-6. Medical Director. Zalzal GH.117(4):408-10. [Medline]. One-stage laryngotracheoplasty.

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