With the increased awareness of the causes of laryngotracheal stenosis, the early management of the patient with a high risk of developing a stenosis can prevent further airway compromise. However, since the incidence of two major causes, blunt trauma of the neck and traumatic or prolonged endotracheal intubation have never been decreasing, the treatment of subsequent stenosis has been a challenging management problem for bronchoesophagologists.
Since the situation varies in each patient, the best way for the treatment must be carefully selected for better results: tracheal decannulation, near normal voice and normal respiratory function with good exercise tolerance.
Options in the treatment include endoscopic techniques and open surgical procedures. The scar tissue can be incised or excised endoscopically with or without the use of laser, dilated and stented with a T-tube, or can be managed by a surgery such as tracheal resection and reanastomosis, external tracheal incision with or without using graft material and possible stenting, or a staged procedure by the trough technique.
In this paper, historical analysis of studies on laryngotracheal stenosis was done with excellent literatures in regard to its causes, diagnostic methods and therapeutic variations.

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Laryngomalacia is the most common congenital anomaly of the larynx. In the majority of cases, the stridor resolves spontaneously by the age of two years. However, laryngomalacia is not a totally benign condition, and some patients have required tracheotomy. In this paper, a case of laryngomalacia with inward collapse of the arytenoids and aryepiglottic folds was reported. Using microsurgical instruments, the mucosa over the arytenoids and aryepiglottic folds was resected. The postoperative course was uneventful, and no stridor was present at follow-up seven months postoperatively.
We successfully treated a case of severe congenital subglottic stenosis with an open trough method. After the stenotic tissue of the subglottis was excised through the laryngotracheal fissure, advancement skin flaps from the adjacent neck were fashioned and sutured to the posterior mucosa remnant to form an open trough. A silicone tube stent was inserted into the trough to keep the laryngotracheal cavity wide open. Three months later, the anterior wall of the larynx and trachea was reconstructed with a composite auricular graft. To date, respiratory improvement has been maintained for six years.

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The initial evaluation of the trauma patient is directed toward determination if there is an adequate and stable airway. However, possibility of dislocation or fracture of the cervical vertebrae must be considered at the moment the initial evaluation of the airway and establishing an adequate and secure airway. In this paper recent special methods of airway management are mentioned. Secondly, this paper concerns the airway management for burned patients, especially with smoke inhalation injury. In these cases the airway obstruction tends to become worse over the first 24 hours after injury. For the burned patients due to explosions, we must also keep in mind possibility of cervical spinal injury like multiple trauma patients.
Finally, in patients with blunt trauma to the larynx and trachea the management of associated head, thoracic and abdominal injuries, however, may take precedence over the management of laryngeal and tracheal injuries. Flexible fiberoptic bronchoscopic examination of the airway is the most reliable means of establishing not only a diagnosis of tracheobronchial injury but also its site, nature and extent. Bronchoscopy should be done as soon as the injury suspected following the respiratory and circulatory stabilization.

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The laryngotracheal trauma is defined as disorders of respiration, phonation and deglutition caused by either blunt or sharp force to the anterior neck. The larynx and trachea are usually hardly injured due to their anatomical relationship. The posterior wall of the larynx and trachea is protected by vertebral bones, and the upper portion and lower portion are protected by the mandible and the clavicle, respectively. Furthermore, the larynx and trachea themselves are so elastic that they are not injured easily. However, progress of emergency medicine and motorization has been increasing the incidence of laryngotracheal trauma. The update medical technique such as tracheal intubation and laryngomicrosurgery is increasing iatrogenic laryngotracheal trauma, recently. The laryngotracheal trauma is devided into two types, closed trauma that does not produce an open wound in the skin and open trauma caused by sharp knife or gunshot. Each type of trauma is devided into fresh and obsolete cicatricial trauma. The laryngotracheal stenosis is common in patients with the latter type of trauma.

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Midline fixation of the bilateral vocal cords occurs on rare occasions. This condition has been described as bilateral abductor or posticus paralysis. However, the term of midline fixation, or immobilization in median position, is more adequate. In our clinic, electromyographic examination of the intrinsic laryngeal muscles is routinely done in these cases and we are usually able to record electrical activity from the posterior cricoarytenoid muscles (posticus). Therefore, this condition should not be called“paralysis. ”
During the past 33 years, 57 cases having this condition were seen in our clinic. Surgery for this condition and its functional results were discussed.
As for etiology, idiopathic cases were most frequent. Others were due to thyroid disease (surgery and radiation), neck trauma, rheumatic arthritis, Parkinsonism etc.
To relieve dyspnea, Woodman's operation and the widening of anterior glottis operation were performed. In one case, we did arytenoidectomy using CO2 LASER with success. To evaluate respiratory function, flow-volume loop method was simple and effective. In midline fixation of the bilateral vocal cords, marked decrease of peak expiratory flow (plateau formation) was shown. The cases with a value of peak flow less than 50% of the normal value complained marked dyspnea subjectively.
Recently, I have attempted Botulinum-toxin injection for widening the glottis. This simple treatment was discussed.

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The most common cause of acquired acute airway obstruction is usually acute inflammation below or above the level of the vocal cord. Since a child's larynx is not merely a miniature of the adult's one, symptoms are quite different from those of an adult case even if the lesion is the same. The clinical status of the patient, age, physical signs, the patient's behavior, and history of the disease provide clues to make the precise diagnosis. Radiologic evaluation has no place in the diagnosis of laryngeal inflammation.
Although very rare in children, acute epiglottitis is a potentially mortal disease and all children with this disease need an artificial airway and should be managed urgently and meticulously. On the other hand less than 10% of both acute epiglottitis in adults and acute laryngotracheitis in children needs an artificial airway. Bacterial tracheitis, usually secondary to acute laryngotracheitis, is also a life-threatening disease and patients often need tracheotomy.
Eleven-month-old girl with acute laryngotracheitis, 4-year-old boy with acute epiglottitis, 75-year-old male with acute epiglottitis, and 57-year-old female with bacterial tracheitis secondary to acute laryngotracheobronchitis are discussed.

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Tracheal stenosis due to tuberculosis is not so common. Among 111 cases of bronchial tuberculosis which were diagnosed bronchoscopically during the period from 1975 to 1986, 19 cases were combined with tracheal tuberculosis. Out of these 19 cases of tracheal tuberculosis, 18 cases were related to the tuberculous lesion of the main bronchus. This fact suggests that tracheal tuberculosis has a strong correlation with bronchial tuberculosis. Types of the tracheal lesions were classified as intramucosal tubercles in 9 cases, granulation in 8, and scar with stenosis in 2. Only one, however, had clinically significant stenosis of the trachea in this series. Another case of clinically significant tracheal stenosis due to tuberculosis was found after this series. The clinical features of these two cases were demonstrated. Case 1 was 45 year-old female patient. She complained of hoarseness and shortness of breath. Sputum was positive for tubercle bacilli. Bronchofiberscopy revealed marked stenosis of the trachea and the left main bronchus. The trachea also showed a sign of tracheomalacia. After failing in a primary operation for tracheomalacia, a T-tube stent was introduced into the trachea by tracheostomy, which has reduced the complains and improved the pulmonary function. Case 2 was 62 year-old male patient. He complained of shortness of breath. Bronchofiberscopy revealed localized stenosis of the trachea with granulation and scar, which showed a sign of malacia. His right lung was destroyed completely and tubercle bacilli were found in sputum. Right pneumonectomy was performed, combined with partial resection and anastomosis of the trachea. Histological examination of the resected trachea revealed tuberculous granulation in the mucosa and destruction of the tracheal cartilage, which caused malacia. Post-operative course was uneventful.

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Since 1980, we began applying fiberoptic bronchoscopic Nd-YAG laser treatment fortracheal-carinal tumors. Endoscopic Nd-YAG laser treatment and adjuvant therapy wereperformed in 16 cases of primary tracheal tumor (12 malignant lesions and 4 benign lesions) and 39 cases of metastatic tracheal lesions. For 28 cases presenting severe respiratory distress, the procedure was performed as an emergency life-saving procedure and dramatic improve-ment in condition was seen in 26 cases (92. 9%) . Twenty seven cases were treated by stagedlaser reduction of the residual airway lesion. Effectiveness was observed in 24 cases (88. 9%) . In these cases, after Nd-YAG laser treatment for ventilatory improvement, local or systemicadjuvant therapy was performed. Local adjuvant therapy was performed in 29 cases, 11 caseswere treated surgically (4 tracheoplasties and 10 treacheal tube stent operations) and 28 casesunderwent radiotherapy.
In addition to these cases, there were 5 cases who underwent tracheal resection withoutpreoperative Nd-YAG laser treatment. These 5 cases consisted of 3 tracheal tumors and 3metastatic lesions from the thyroid gland.
Bronchoscopic Nd-YAG laser treatment is a relatively new method for the treatment oftracheal or carinal tumor with ventilatory disturbance due to airway stenosis.

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Histopathological changes of the vocal cords after anabolic steroid administration have not been clearly resolved. In this study, histopathological changes in the larynx of anabolic steroid induced dysphonia are investigated.
The experimented animals were female guinea pigs at 4 weeks of age. Twenty guinea pigs received 50 mg of testosterone enantate intramuscularly once a week. And another twenty were used for control study (free from hormone injection) . Their voices were recorded and analysed weekly. After 5 or 6 weeks of administration of testosterone enantate, the voice became rough or breathy in all hormone group. The larynges of both groups were excised, sectioned and stained by H-E and Azan. Observation of the vocal cords was made under the light microscope. The histopathological changes were as follows. 1) Cricoarytenoid muscle fibers were hypertrophied. 2) In lamina propria, the number of fibrobrasts increased. 3) The fibers showed irreguler alignment and their continuity was broken. 4) The space among collagenous fibers became narrow.
From these observations, it can be concluded that the larynx is one of the main targets for anabolic steroid and it is suggested that the dysphonia in due to the qualitative change in the lamina propria of the vocal cord and the hypertrophy of the cricoarytenoid muscle.

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A sixty-year-old male slipped down from a silkworm trellis to an iron pole. His front neck was injured at that accident. On his visit to a local doctor, the neck wound was sutured primarily. In a short time, his neck became swollen, so that the wound was reopened by a surgeon in a different clinic. When the patient was referred to our clinic by the surgeon, 4 hours had passed since the first treatment was done.
Clinical examination revealed the partially defected epiglottis, the lacerated hypopharyngeal mucosa and the fractured hyoid bone. X-ray examination and CT revealed subcutaneous emphysema and tracheotomy was recommended. After tracheotomy was done under local anesthesia, the patient was operated on to repair the epiglottis and the hypopharynx. The left vocal cord was fixed for 3 months after surgery probably due to intubation for the general anesthesia. He was discharged after 44 days of hospitalization.
This case suggest that the first 4 to 5 hours after injury with intensive observation of the patient are the critical period for successful treatment.

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Two cases of aspiration pneumonia caused by methicillin resistant Staphylococcus aureus (MRSA) are reported.
Case 1, A 75-year-old male complained of dysphagia and misdeglutition caused by radiation myopathy. Fluoroscopy revealed lack of dilatation of the upper esophageal sphincter.
Case 2, A 81-year-old male suffered from sore throat and dysphagia after removal of a hypopharyngeal foreign body. Physical examinations revealed severe edema at the bilateral piriform sinuses.
Both cases had been intubated with a nasogastric (NG) tube and medicated β-lactam antibiotics prophylactically after the esophagoscopic examination under general anesthesia. On sixth and twelfth days after the examination, they developed aspiration pneumonia with complaints of chest pain and dyspnea, showing acute fever up, increase of white blood cell count and infiltrative shadow on chest X-p. MRSA was found from the sputa of both patients. FOM, CPZ and MINO were administered to case 1, FOM and CMZ to case 2. After medication, their conditions improved.
Our experiences of these cases suggest that NG intubation for dysphagia could be one of the causative factors of MRSA induced pneumonia.

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The Two-stage operation for sulcus vocalis is reported. First the connecting tissue from the mucous membrane to the vocal muscle was incised and the mucoepithelia and lamina propria were detached from the body (vocal muscle of the vocal fold) . Three days later, aterocollagen was injected into the submucosal layer of the vocal fold. This method brought about favorable results.

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Tracheoesophageal shunt speech is a good method for vocal rehabilitation after total laryngectomy, but the problem of leakage through the shunt should be solved.
In this study, we designed several types of mucosal flaps which protruded into the esophageal lumen to reduce shunt leakage. They were classified into 6 groups depending on the layer composition of the mucosal flap. Type I (mucosa-muscle-muscle-mucosa), Type II (mucosa-muscle-mucosa), Type III (mucosa-mucosa), Type IV (mucosa-Marlex meshmucosa), Type V (mucosa-Collagenized Marlex mesh-mucosa), Type VI (mucosamuscle-Collagenized Marlex mesh-muscle-mucosa) . These flaps were tested on 15 adult dogs. For types I-III, the height of the flaps became shorter. In most cases of type IV, Marlex mesh was exposed or extruded. In most cases of type V and type VI, a good shaped flap could be created and stayed as it was originally designed.
From these results, it was necessary to insert a supportive materials into the flap in order to stabilize the shape of the flap for a long time. Collagenized Marlex mesh seemed to be a suitable material for this purpose.

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