Chronic laryngeal stenosis

Chronic laryngeal stenosis
Pathological considerations
Soft tis.damage causes mucosal loss,the formation of adhesions &the organization of haematoma within the paraglottic ,the pre-epigl.& interarytenoid space.
Glottic competence can be affected by the formation of a web ,by arthrodesis of the arytenoids into an unsatisfactory position & R.L.N.damage .
Directional memory.
Once structural support has been re-established, the 2nd prerequisite is the institution of an intact epithelial lined lumen. 
Rx. Principles
Many pt.s with chronic laryngeal stenosis have an endwelling tracheostomy. The goal of Sx is to establish a ‘satisfactory airway’& allow decannulation.
If the stenosis involves the glottis &supragloteast is procedures performed to try &improve airway function can compramise the other laryngeal funcyions.
There is universal dissatisfaction with the Rx of systemic conditions causing subglottic stenosis &long term decannulation are poor(can be managed by dilatation with intralesional steroids).
Surgical resection by laser or reconstruction should be limited to those pt.s who are in remission& require .immunosupp.therapy for at least 12 months
Endoscopis resection Vs external approach
Endoscopic approaches are attractive because of decreased morbidity, shorter hospital stay & tolerance of repeated Sx.
In recent years, refinements of microlaryngeal instrumentation, rigid telescope, digital imaging, &the ready ability &clinical know-how of the CO2 laser mean many laryngeal lesions are resected endoscopically.
Success rate 40-70%.
The most frequent cause of failure is scar formation &restenosis.
CO2 laser
Chronic L.S.should be treated by CO2 laser excision initially &that open repaire reserved for cases that faile to respond to endoscopic Mx.& if the initial stenosis is so sever.
Advantages:
Enables mucosal preservation.
Allow for more controlled resection.
Achieves haemostasis.
Disadvantage over cold steel is the potential for thermal damage.
Laryngeal microdebrider
Was designed for recurrent respiratory papillomatosis & it is becoming the method of choice over CO2 laser for treating this dis.in laryngotracheal region.
Fibrous tis.can be removed with atricut (usu.4mm) blade.
Haemostasis is achieved using 1:10,000 adrenaline pledget or bipolar diathermy.
Advantages,(in comparison to CO2 laser)include: no potential for secondary scarring & stenosis as aresult of thermal damage, &significantly reduced postop.pain.
Mitomycine C
Possesses both antineoplastic &antiproliferative properties.
It has been shown that it inhibits fibroblast proliferation.
There was a significant increase in the success rates of endoscopic Rx of acquired LTS with additional topical Mitomycin C.
No advantage in the use of intralesional steroids as an adjuvant therapy.