Awake Microlaryngoscopy and Serial Balloon Dilation in a Third Trimester Multigravida with Subglottic Tracheal Stenosis

Abstract

Tracheal stenosis in pregnancy is a relatively rare occurrence and there are limited data regarding the perioperative management of these patients. Various surgical treatment options are available to include open repair, long-term tracheostomy, or endoscopic repair (rigid versus balloon dilation). We report the case of a woman in her third trimester of pregnancy, with known recurrent and worsening history of subglottic tracheal stenosis, who underwent awake microlaryngoscopy with potassium titanyl phosphate laser radial incision and serial tracheal balloon dilation under topical anesthesia with sedation. We further discuss her perioperative multidisciplinary management.

Management of subglottic stenosis in pregnancy using advanced apnoeic ventilatory techniques

“…Management of subglottic stenosis in pregnancy has only rarely been reported in the literature, and is limited to a small number of case reports (Table 2). 12 – 26 Management options have included no intervention, intubation, dilation under inhalational anaesthesia, dilation using topical anaesthesia with or without intravenous sedation, and tracheostomy. In one case, the patient expired several weeks after delivery from subsequent airway obstruction 14 .…”

Endoscopic management of idiopathic subglottic stenosis in pregnancy

“…One of these cases was managed under LA and sedation while the other had GA. 10 A combination of radial incisions into the stenotic segment with potassium titanyl phosphate laser and balloon dilatation has also been described in the third trimester of pregnancy. 11,12 Successful use of carbon dioxide laser and balloon dilatation under GA in the last trimester has been reported with excellent results. 8,14 Our preference is to use endoscopic balloon dilatation with steroids and laser as adjuncts, a technique we have used extensively in the non-pregnant patient with iSGS.…”

“…Reported airway management approaches of iSGS in pregnancy range from surveillance, endoscopic surgery and tracheostomy. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] Endoscopic interventions are the predominant surgical technique reported in the literature, [7][8][9][10][11][12][13][14][15][16][17] but some authors espouse the benefit of a surgical tracheostomy. 18,19 The aim of the study is to describe the use of endoscopic balloon dilation with laser and jet ventilation in the management of iSGS in pregnancy and provide an overview of the current literature.…”

Tracheal Dilatation of an Idiopathic Subglottic Stenosis in a Near-Term Parturient at 36 Weeks of Gestation Using SponTaneous Respiration Using Intravenous Anesthesia and Hi-Flow Nasal Oxygen: A Case Report

“…Instead, more reassuring may be the absence of aspirations in more than 5000 general anesthetics for cesarean deliveries in the Society for Obstetric Anesthesia and Perinatology (SOAP) serious complications registry. 11 The combination of these studies and considering that tubeless open airway surgery has been performed under general anesthesia using nasal oxygen, jet ventilation and THRIVE [3][4][5][6]12,13 in numerous publications, we concluded that it would be relatively safe to fulfill the surgeon's request for an open airway. Still acknowledging the potential risk, we remained on standby for a rapid intubation using a microlaryngoscopy tube size 4.…”

“…To our knowledge, managing a pregnant woman for a procedure in their airway under a general anesthesia without a secure airway is a rare occurrence. 8,12,13 Beyond, the original STRIVE Hi study group 8 that included a woman at 23 weeks of gestation in their cohort, there are only 2 other case reports to date describing a spontaneous breathing technique in parturients. First was a women at 29 weeks of gestation who received insufflated oxygen via a nasal airway, while receiving total intravenous anesthesia using propofol and remifentanil, without a described protocol.…”