An unusual presentation of anterior subglottic stenosis.
Computed tomography identified anterior tracheal stenosis. Flexible laryngoscopy revealed the presence of granulation tissue in the anterior area of the subglottis. The patient was taken to the operating room for microlaryngoscopy. Upon visualization, polypropylene suture material was found to be firmly embedded in the granulation tissue (figure, A). Laryngeal scissors were used to cut the suture, which was then removed, and the granulation tissue was debrided (figure, B). A dynamic collapse of the anterior tracheal wall was noted at the area of the previous tracheostoma. Balloon catheter dilation was performed at the level of the prolapse, and the airway was widened significantly. After the patient awoke from the anesthesia, she exhibited complete resolution of her dyspnea and stridor.
The larynx and trachea are semirigid cylindrical structures in which wound healing processes tend to stenose the lumen. Subglottic stenosis is a well-known late complication of tracheostomy, occurring in approximately 1 to 8% of reported cases. (1,2) Symptoms usually develop 2 to 12 weeks following decannulation. (3) The etiology of subglottic stenosis following tracheostomy includes ischemia, devascularization, and granulation tissue. (4) In this case the exuberant granulation tissue and obstruction likely occurred as a result of the foreign body.
Our review of the notes from our patient's previous surgery, which had been performed at another institution, revealed that a Prolene stay suture had been placed during her tracheostomy. Placement of a stay suture during surgical tracheostomy is advocated for improving control of the airway intraoperatively and for the emergency management of inadvertent decannulation. (5) Stay sutures are typically removed at the time of decannulation. In this case, it seems likely that the failure to remove the sutures led to their subsequent migration through the tracheal wall, and the resultant foreign-body reaction led to the development of the subglottic stenosis.
This case illustrates the importance of removing nonresorbable stay sutures at the time of decannulation. As an additional safeguard, many practitioners place absorbable stay sutures. Finally, acquired subglottic stenosis should be suspected in any patient with unexplained dyspnea weeks to months following decannulation.
(1.) Grillo HC. Postintubation stenosis. In: Grillo HC, ed. Surgery of the Trachea and Bronchi. Hamilton, Ont.: B.C. Decker; 2004:30140.
(2.) Arola MK, Inberg MV, Puhakka H. Tracheal stenosis after tracheostomy and after orotracheal cuffed intubation. Acta Chir Scand 1981;147(3): 183-92.
(3.) Weber AL, Grillo HC. Tracheal stenosis: An analysis of 151 cases. Radiol Clin North Am 1978;16(2):291-308.
(4.) Madden BP, Datta S, McAnulty G. Tracheal granulation tissue after percutaneous tracheostomy treated with Nd:Yag laser: Three cases. J Laryngol Otol 2001;115(9):743-4.
(5.) Burke A. The advantages of stay sutures with tracheostomy. Ann R Coll Surg Engl 1981;63(6):426-8.
From the Department of Otolaryngology-Head and Neck Surgery, The Vanderbilt Voice Center, Vanderbilt University Medical Center, Nashville, Tenn.
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|Title Annotation:||LARYNGOSCOPIC CLINIC|
|Author:||Wright, Harry V.; Fletcher, Kenneth C.|
|Publication:||Ear, Nose and Throat Journal|
|Article Type:||Case study|
|Date:||Jun 1, 2014|
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