Subglottic Tracheal Stenosis in Pregnancy: Anaesthetic Implications

Surgical Management of Airway Stenosis During Pregnancy: A Scoping Review

OBJECTIVE

There are several options for surgical management of subglottic stenosis, including endoscopic and open procedures. However, treatment algorithms, outcomes, and anesthetic management of subglottic stenosis during pregnancy are not well described.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane databases.

REVIEW METHODS

A scoping review of management of subglottic stenosis during pregnancy was performed, and then reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria consisted of those with subglottic or tracheal stenosis aged greater than 18 years, those in whom management was performed during pregnancy, and those who reported delivery related outcomes.

RESULTS

After systematic review and detailed search of 330 identified articles, 15 articles met inclusion criteria and were included in the final analysis. All studies were case reports or case series (level 4 evidence). This study identified 27 patients. The median age was 29 and the median gestational age at intervention was 28 weeks. Left lateral positioning and fetal heart rate monitoring were used in nearly every case. The most common intervention performed was endoscopic balloon dilation. In many cases, jet ventilation or transnasal humidified rapid insufflation ventilatory exchange was satisfactory for maintenance of the airway. Three women ultimately required tracheostomy prior to labor and delivery. There was no fetal death or complications reported in these studies, and all but one woman proceeded to deliver at term.

CONCLUSION

Endoscopic balloon dilation during pregnancy is safe and effective, resulting in optimized respiratory outcomes for the mother and safe delivery of the fetus. The third trimester appears to be safe for airway intervention. Laryngoscope, 134:1014-1022, 2024.

Subglottic tracheal stenosis complicating pregnancy: A case report

The case presented details an uncommon case of subglottic tracheal stenosis exacerbated by pregnancy. We outine the multidisciplinary management involved and the outcomes for the pregnancy. The case serves as a reminder that shortness of breath in pregnancy has a broad differential diagnosis, and stridor is always abnormal.

Endoscopic management of idiopathic subglottic stenosis in pregnancy

Aims

To describe the use of laser, endoscopic balloon dilatation with jet ventilation anaesthesia in the treatment of pregnant women with idiopathic subglottic stenosis.

Materials and methods

This is a case review of pregnant women with idiopathic subglottic stenosis, presenting to a tertiary referral centre with worsening breathlessness. Data were extracted from patient case notes.

Results

Four women underwent surgical management of subglottic stenosis in pregnancy. One patient required two procedures during the course of their pregnancy due to restenosis. All women had improvement in symptoms post-operatively and went on to deliver healthy babies at term.

Conclusion

Endoscopic balloon dilatation of idiopathic subglottic stenosis is a safe and viable treatment option in pregnancy and should be offered as first-line treatment in symptomatic women.

Management of subglottic stenosis in pregnancy using advanced apnoeic ventilatory techniques

Objective

To describe the use of balloon dilation with non-invasive ventilation in the treatment of pregnant patients with idiopathic subglottic stenosis.

Methods

The medical charts of four consecutive patients who underwent jet ventilation or high-flow nasal cannula oxygenation with balloon dilation for the treatment of idiopathic subglottic stenosis during pregnancy were reviewed.

Results

Objective improvement of subglottic stenosis was seen in all four cases, with end-result Myer–Cotton grade 1 lesions down from pre-procedure grade 3 lesions. Patients also reported subjective improvements in symptomatology, with no further airway issues. All patients delivered normally, at term.

Conclusion

Laryngeal dilation with continuous radial expansion pulmonary balloons using non-invasive ventilation for the treatment of idiopathic subglottic stenosis in pregnant patients is safe and efficacious, and should be the first line treatment option for this patient population. The improvement in symptoms, and lack of labour and pregnancy complications, distinguish this method of treatment from others reported in the literature.

Conservative management of subglottic stenosis in pregnancy resulting in vaginal birth

We present a case of subglottic stenosis complicating pregnancy. The patient was born prematurely at 24 weeks gestation and required a twelve-month period of intubation. Airway trauma from prolonged intubation resulted in acquired subglottic stenosis. As an adult the patient had a longstanding audible stridor; however, was not breathless during activity before or during pregnancy. The patient went into spontaneous labour at 37+4 weeks and delivered vaginally with epidural analgesia. This case is significant, as no cases of a patient with such a degree of stenosis delivering vaginally without airway treatment have been reported.

Tuberculosis-induced tracheobronchial stenosis during pregnancy

Central airway stenosis is extremely rare in pregnancy and could lead to respiratory and cardiovascular embarrassment, especially at the time of delivery. Initially, patients may not show obvious signs of respiratory difficulty. Early recognition of the disease and anticipatory management of a complicated delivery are very important. We present a pregnant patient with tuberculosis-induced severe tracheobronchial stenosis and discuss the management challenges of her delivery.

Idiopathic subglottic stenosis in pregnancy: A deceptive laryngoscopic view

A 28-year-old lady with term gestation, pre-eclampsia and a vague history of occasional breathing difficulty, on irregular bronchodilator therapy, was scheduled for category 1 lower segment caesarean section in view of foetal distress. A Cormack-Lehane grade 1 direct laryngoscopic view was obtained following rapid sequence induction. However, it was not possible to insert a 7.0 or 6.0 size styleted cuffed tracheal tube in two attempts. Ventilation with a supraglottic device was inadequate. Airway was secured with a 4.0 size microlaryngeal surgery tube with difficulty. Computed tomography scan of the neck following tracheostomy for failed extubation revealed subglottic stenosis (SGS) with asymmetric arytenoid calcification. This report describes the management of a rare case of unrecognised idiopathic SGS in pregnancy.

Severe glottic stenosis in a parturient with ectodermal dysplasia

Airway stenosis in pregnancy is challenging and the literature does not offer consensus regarding its evaluation and anesthetic management. A 21-year-old nulliparous woman with ectodermal dysplasia and severe glottic stenosis was referred to the obstetric anesthesia team for evaluation and peripartum management recommendations. She had a history of a congenital complete glottic web that required a tracheostomy at birth. After decannulation at age four, she was lost to follow-up. On examination in early pregnancy, she was found to have a dangerously narrow airway with fixed vocal cords and a glottic aperture of 2-3mm. At nine weeks of gestation an elective tracheostomy was performed under local anesthesia. She later underwent an uneventful cesarean delivery under spinal anesthesia. Ultimately, early interdisciplinary planning for an elective tracheostomy helped assure patient safety during advancing pregnancy and delivery.

Jet ventilation for the excision of vocal cord polyps in a pregnant patient

The anaesthetic management of patients presenting with laryngeal tumours and airway obstruction is difficult. We present the case of a pregnant woman at 30 weeks gestation who underwent surgical removal of two vocal cord polyps under general anaesthesia using jet ventilation

Subglottic stenosis in pregnancy

Subglottic stenosis (SGS) in pregnancy is rare but may cause a potentially life-threatening delivery and is a challenge to the anaesthetist and the obstetrician. Clinical signs of SGS may not be obvious and the diagnosis can be difficult. Patients usually present with shortness of breath rather than stridor. Many patients have been wrongly diagnosed with asthma and recurrent bronchitis before subsequent discovery of a SGS. Early diagnosis of SGS and multidisciplinary input is important in managing these patients. We present a case of a pregnant woman with a history of Wegener's granulomatosis and the successful multidisciplinary management of her SGS.

Pregnancy followed by caesarean delivery in a patient with tracheostomy and gastrostomy after corrosive acid ingestion

Corrosive acid ingestion in pregnancy is rare. We present a rare case of corrosive acid ingestion during pregnancy. The patient subsequently had tracheal stenosis and had to undergo a tracheostomy. Feeding gastrostomy was created for nutritional support of both mother and fetus. The patient delivered at term by an elective caesarean section.