The time course of exhaled ethane in six intensive care cases

Sir, Isolated supraglottic stenosis is a very uncommon condition and is rarely discussed in the literature. Although most reports are referred to the paediatric population, we recently encountered the problem of supraglottic stenosis in a 78-year-old female patient with acute suppurative cholecystitis, who was operated urgently a few hours after her admission. The unexpected extensive supraglottic stenosis made intubation impossible. After several ineffective attempts for intubation, an urgent tracheotomy was performed in order to ventilate the patient and complete the operation. The patient had an uneventful postoperative recovery from the suppurative cholecystitis. On the 5th post-operative day, direct flexible laryngoscopy was performed, which revealed bilateral hypertrophy of the arytenoid folds with the epiglottis being fixed on them. The glottis was inspected macroscopically with a paediatric inoptic laryngoscope and appeared to be normal. The patient had no previous history of prolonged intubation, external cervical trauma, chemical burn, gastroesophageal reflux, post-infectious fibrous scar formation or irradiation; conditions that have been associated with upper airway stenosis (1–3). She had undertaken five operations in the past, without any technical problems during tracheal intubation. Additionally, a work up for autoimmune disorders was negative. Fifteen days after the abdominal operation, the patient underwent a trans-oral carbon dioxide laser resection of the arytenoids folds and epiglottis adhesiolysis, a procedure we can describe as supraglottoplasty. We preferred this kind of minimal surgery in order to avoid the serious complications of the supraglottic laryngectomy. In a previous report of 82 patients with chronic laryngeal stenosis, the authors criticized the extensive nature of supraglottic laryngectomy in the management of benign lesions (4). The endotracheal tube was removed four and a half months after the operation, being afraid of the possibility of restenosis as described in another patient with supraglottic stenosis who underwent trans-oral carbon dioxide laser supraglottic laryngectomy (5). Before the removal of the tube, we performed a flexible laryngoscopy, which revealed a 5–10% lessening of the airway orifice, comparatively to the airway caliber that we created after the resection of the arytenoids folds. Nevertheless this final orifice had at least the double diameter than the pre-operative one, permitting a normal respiratory function. The patient has remained asymptomatic in an excellent condition until now. Conclusively, an unsuspected benign isolated supraglottic stenosis can be a serious problem during an emergency general surgery operation. Unsuccessful intubation attempts may result in edema and complete airway obstruction, requiring an urgent tracheostomy in order to complete the operation. The endotracheal tube should remain on site until the definitive repair of the stenosis. A conservative surgery, such as supraglottoplasty, is preferred from a supraglottic laryngectomy because it has the same long-term results with fewer complications.