Holmium Laser as a Definitive Single-Modality Treatment for Severe Subglottic Stenosis in an infant: A Case Report

Holmium Laser as a Definitive Single-Modality Treatment for Severe Subglottic Stenosis in an infant: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Holmium Laser as a Definitive Single-Modality Treatment for Severe Subglottic Stenosis in an infant: A Case Report Naser El-Mefleh, Mulham Jarjanazi, Aya Nakwan, Linah Kaf Alghazal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7624238/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Nov, 2025 Read the published version in Journal of Pediatric Endoscopic Surgery → Version 1 posted You are reading this latest preprint version Abstract Introduction: Subglottic stenosis (SGS) is a pathological narrowing of the airway within the subglottic region, situated just below the vocal cords. This condition can cause significant respiratory compromise, ranging from dyspnea to life-threatening hypoxemia. While SGS may be congenital or acquired, the acquired form is more prevalent and is most frequently iatrogenic. Prolonged endotracheal intubation or tracheostomy are common causes, with post-intubation SGS accounting for approximately 90% of acquired cases in the pediatric population. Case Presentation: A 45-day-old male infant presented with a history of biphasic stridor and recurrent acute respiratory infections. Diagnostic bronchoscopy identified a Myer-Cotton grade III subglottic stenosis. The lesion was successfully managed in a single procedure using a Holmium laser via a rigid bronchoscope. At the seven-month follow-up, the infant remained in good health with no respiratory complications. Discussion The Holmium laser has been established as a viable pediatric tool, with applications in excising tracheal granulomas, webs, and stenoses, as well as in managing other pathologies such as hemangiomas and bronchogenic cysts. Its technical profile is particularly advantageous for the delicate pediatric airway. The laser is hydrophilic, touch-triggered, and characterized by a minimal thermal injury zone of 0.5–1.0 mm, which helps to minimize collateral damage. While many authors recommend adjunctive cryotherapy post-ablation to reduce the risk of restenosis, this was not employed in the present case. Conclusion Management of pediatric SGS typically requires a multi-modality approach. However, this case demonstrates that the Holmium laser can serve as a definitive single-modality treatment, even in very young infants with severe (Myer-Cotton grade III) stenosis. The patient showed no evidence of restenosis and maintained excellent respiratory function at the seven-month follow-up. Figures Figure 1 Introduction Subglottic stenosis (SGS) is a pathological narrowing of the airway just below the vocal cords -the subglottic region- that can lead to significant respiratory compromise, ranging from dyspnea to life-threatening hypoxemia. It may be congenital or acquired, with varying etiologies and severity. Congenital subglottic stenosis, a rare condition, often results from incomplete tracheal ring formation or vascular compression, typically presenting in neonates with stridor or cyanosis [ 1 , 2 , 3 ]. Acquired SGS is more common and frequently stems from iatrogenic causes, particularly prolonged intubation or tracheostomy, with post-intubation SGS accounting for 90% of acquired SGS in children [ 4 , 5 , 6 ]. Other causes include external trauma, autoimmune diseases (e.g., relapsing polychondritis), malignancies, irradiation, and idiopathic fibrosis [ 1 , 4 , 6 ]. Bronchoscopy remains the gold standard for diagnosis and classification. Stenoses are categorized as simple (segments 1 cm, with malacia, cartilage involvement, or inflammation) [ 8 ]. Management depends on stenosis type and patient factors including endoscopic interventions such as balloon dilation and laser ablation, and open surgery as tracheal resection or slide tracheoplasty [ 8 , 9 , 10 ]. Among endoscopic techniques, CO₂ and KTP lasers are well-established, but the Holmium-YAG laser has been rarely reported for subglottic stenosis, particularly in pediatric cases [ 5 , 6 , 11 ]. Here, we present a case of definitive subglottic stenosis treatment using Holmium laser monotherapy, achieving long-term success without adjunctive procedures. Case presentation A full-term male infant was born with a weight of 5 kg without any health complications. At the age of five days, he presented to a pediatric emergency unit experiencing biphasic respiratory distress (inspiratory and expiratory), along with recurrent acute respiratory infections, for which he required an admission to a neonatal Intensive care unit (NICU), and was intubated for six days. He was later intubated again for three days. At the age of 45 days, the patient was referred to the pediatric surgery department for diagnostic bronchoscopy with a suspected tracheoesophageal fistula. Rigid bronchoscopy revealed a Myer-Cotton grade III subglottic stenosis. Management was performed using a DORNIER Medilas H20 Holmium laser, through a Storz rigid bronchoscope of the size 3.5 mm, initiating from an energy of 0.4 J and a pulse frequency of 4 Hz, reaching 0.8 J, and 6 Hz, respectively [Figure 1 ]. Following clinical improvement and resolution of symptoms, the patient was discharged on 3rd day with scheduled follow-up. In five months of follow up, he required two separate admissions to the inpatient ward due to respiratory tract infections. On both occasions, he was managed conservatively and discharged without the need for further intervention. Currently, at 7 months of age, the infant is in good general health, with a weight of 8 kg. Discussion Jiao et. al (2019) hypothesized that younger patients are more susceptible to post-intubation SGS due to key anatomical differences: Smaller subglottic diameter, looser basal mucosal tissue, and more abundant lymphatic and vascular tissue, and further noted that every 1 mm reduction in lumen diameter may result in 60% reduction of the effective ventilatory area, significantly raising airway resistance [ 6 ]. Even though benign lesions most often cause pediatric central airway stenosis compared to the adult form, the condition can progress rapidly in younger children because of the anatomic immaturity of their airways, leading to possibly life-threatening complications, including severe dyspnea, recurrent apnea, and infection [ 7 ], as reflected by the patient in our case, who required NICU admission and two separate intubations. Currently, there is no definitive consensus on the management of subglottic or tracheal stenosis. Interventional bronchoscopy includes laser, stenting and mechanical dilatation, the application of which in tracheal surgery has increased in recent years [ 12 , 13 ]. Although open surgical interventions like laryngotracheal reconstruction (LTR) and cricotracheal resection (CTR) achieve high success rates, they have significant morbidity, prolonged hospital stays, and complications such as recurrent nerve palsy [ 14 , 15 ]. As alternatives, minimally invasive bronchoscopic techniques such as balloon dilation, cryotherapy, electrosurgery, stenting, and laser ablation (e.g., CO2, Nd:YAG) have emerged [ 16 – 20 ]. Nevertheless, these alternatives present their own limitations, including the potential for mucosal damage, scar tissue formation, and unreliable long-term results [ 16 , 18 ]. Monnier et al. (2005) reported a case series of 115 patients ranging from 6 months to 73 years old with supraglottic, glottic, subglottic, tracheal, or combined glotto-subglottic stenoses, treated with endoscopic means, with CO2 laser implemented in 100 patients. Their success rate diminished drastically from preoperative grade I to grade III stenoses, according to the Myer-Cotton classification, where the improvement to a nearly normal (> 80% luminal size) airway declined from 92% for grade I to 46% for grade II and only 13% for grade III stenoses, and conclude that only grade I to grade III stenoses presenting as web-like diaphragms without loss of cartilage support represent good indications for a first try endoscopic laser treatment [ 5 ]. Squiers et al. (2014) reported an 8-year experience of using Holmium laser in 261 procedures performed on 99 adult patients with either benign or malignant airway obstructions, noting the usefulness and safety of Holmium [ 21 ]. Pioneering work by several authors established the Holmium laser as a viable pediatric tool with favorable success rates. It has been applied in the excision of tracheal granulomas, webs, stenoses, tongue hemangiomas, oral cavity papillomas, in functional endoscopic sinus surgery, and in the management of bronchogenic cysts [ 22 , 23 ]. Jiao et al. (2019) reported a prospective case series of 16 children with post-intubation SGS ranging from 2 months to 12.25 years old, three of which were Myer-Cotton grade II, 12 were grade III, and one was grade IV, who received Holmium laser treatment combined with cryotherapy delivered via flexible bronchoscopy, leading to clinical cure in 15 children and clinical improvement in the remaining one [ 6 ]. Zhang et al. (2023) reported a case series of 28 infants with subglottic and/or tracheal stenoses, 19 of which were Myer-Cotton grade III and 9 were grade IV, who underwent Holmium laser treatment with cryoablation and/or balloon dilatation and budesonide inhalation therapy, 16 had web-like stenosis and 12 had scar contracture stenosis. In the web-like stenosis group, half underwent balloon dilation with cryotherapy, while the other half received balloon dilation alone. Initial treatment was successful in 62.5%, with an additional 31.25% achieving success after revised treatments. In the scar contracture stenosis group, 50% received balloon dilation with cryotherapy, 33.3% underwent cryotherapy alone, and 16.7% had balloon dilation only. Initial success was lower in this group (23.1%), but 61.5% achieved improvement after 1–4 additional treatments [ 7 ]. The Holmium laser's technical profile makes it particularly advantageous for pediatric applications. It is hydrophilic, touch-triggered, and has a minimal thermal injury zone of 0.5–1.0 mm. These properties help minimize collateral damage, a critical advantage in the narrow pediatric airway [ 6 , 7 ]. Furthermore, its thin silica fiber is compatible with small-caliber bronchoscopes, enhancing its suitability for infants [ 7 ]. These characteristics may contribute to a reduced risk of restenosis, a common complication following extensive CO2 laser use in advanced stenoses [ 5 ], but most authors still advocate for adjunctive cryotherapy post-ablation to further prevent restenosis [ 7 ]. Conclusion In contrast to the more frequent multi-modality treatment approach in cases of pediatric subglottic stenosis, our case demonstrates that the Holmium laser, as a single-modality treatment, could be sufficient for a definitive cure even in the youngest patients and with severe Myer-Cotton grades, with no signs of restenosis in the patient in our case at seven months of follow-up. Declarations The authors did not receive support from any organization for the submitted work. The authors have no competing interests to declare that are relevant to the content of this article. Written informed consent was obtained from the parents for the submission of the case report to the journal. Author Contribution All authors contributed equally to writing the main manuscript text, preparing the figures, and reviewing the manuscript. References Morita K, Maeda K, Yabe K, Oshima Y. Management of congenital tracheal stenosis in the neonatal period. *Pediatr Surg Int*. 2017;33(10):1059-1063. doi:10.1007/s00383-017-4137-9. Ho AS, Koltai PJ. Pediatric tracheal stenosis. *Otolaryngol Clin North Am*. 2008;41(5):999-1021. doi:10.1016/j.otc.2008.04.006. Ono S, Maeda K, Baba K, et al. Balloon tracheoplasty as initial treatment for neonates with symptomatic congenital tracheal stenosis. *Pediatr Surg Int*. 2014;30(9):957-960. doi:10.1007/s00383-014-3571-1. Gelbard A, Francis DO, Sandulache VC, et al. Causes and consequences of adult laryngotracheal stenosis. *Laryngoscope*. 2015;125(5):1137-1143. doi:10.1002/lary.25056. Monnier P, George M, Monod ML, Lang F. The role of the CO₂ laser in the management of laryngotracheal stenosis. *Eur Arch Otorhinolaryngol*. 2005;262(8):602-608. doi:10.1007/s00405-005-0948-8. Jiao A, Liu F, Lerner AD, Rao X, Guo Y, Meng C, Pan Y, Li G, Li Z, Wang F, Zhao J, Ma Y, Liu X, Ni X, Shen K. Effective treatment of post-intubation subglottic stenosis in children with holmium laser therapy and cryotherapy via flexible bronchoscopy. Pediatr Investig. 2019 Mar 22;3(1):9-16. doi: 10.1002/ped4.12113. PMID: 32851282; PMCID: PMC7331425. Zhang L, Yuan S, Pan C, et al. Outcomes of Holmium Laser, Cryoablation, and Budesonide Inhalation for Treating Severe Central Airway Stenosis in Infants. *J Invest Surg*. 2023;36(1):2257792. doi:10.1080/08941939.2023.2257792. Dalar L, Karasulu L, Abul Y, et al. Bronchoscopic treatment in the management of benign tracheal stenosis. *Ann Thorac Surg*. 2016;101(4):1310-1317. doi:10.1016/j.athoracsur.2015.10.005. Terra RM, Bibas BJ, Minamoto H, et al. Decannulation in tracheal stenosis deemed inoperable is possible after long-term airway stenting. *Ann Thorac Surg*. 2019;107(2):440-444. doi:10.1016/j.athoracsur.2018.08.077. Antón-Pacheco JL, Cano I, Comas J, et al. Management of congenital tracheal stenosis in infancy. *Eur J Cardiothorac Surg*. 2006;29(6):991-996. doi:10.1016/j.ejcts.2005.12.061. Blackmore K, Kubba H, Clement WA. Laser division of congenital complete tracheal rings. *Int J Pediatr Otorhinolaryngol*. 2010;74(11):1327-1330. doi:10.1016/j.ijporl.2010.07.019. Jeong BH, Um SW, Suh GY, et al. Results of interventional bronchoscopy in the management of postoperative tracheobronchial stenosis. J Thorac Cardiovasc Surg. 2012;144:217–22. Fiorelli A, Messina G, Fiorito R, Martone M, Ferraro F, Santini M. Endotracheal tube for relocating dislocated airway stent: a case report. Shanghai Chest. 2022;6:1–5. Bajaj Y, Cochrane LA, Jephson CG, Wyatt ME, Bailey CM, Albert DM, et al. Laryngotracheal reconstruction and cricotracheal resection in children: Recent experience at Great Ormond Street Hospital. Int J Pediatr Otorhinolaryngol. 2012 Apr;76(4):507–11. Timman ST, Schoemaker C, Li WWL, Marres HAM, Honings J, Morshuis WJ, et al. Functional outcome after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis. Ann Cardiothorac Surg. 2018 Mar;7(2):227–36. Quesnel AM, Lee GS, Nuss RC, Volk MS, Jones DT, Rahbar R. Minimally invasive endoscopic management of subglottic stenosis in children: Success and failure. Int J Pediatr Otorhinolaryngol. 2011 May;75(5):652–6. Bent JP, Shah MB, Nord R, Parikh SR. Balloon Dilation for Recurrent Stenosis after Pediatric Laryngotracheoplasty. Ann Otol Rhinol Laryngol. 2010 Sep;119(9):619–27. Maresh A, Preciado DA, O’Connell AP, Zalzal GH. A Comparative Analysis of Open Surgery vs Endoscopic Balloon Dilation for Pediatric Subglottic Stenosis. JAMA Otolaryngol Neck Surg. 2014 Oct 1;140(10):901. Ozkul Y, Songu M, Imre A, Ates D, Arslanoglu S, Pinar E, et al. CO 2 laser treatment of tracheal stenosis. Acta Otolaryngol (Stockh). 2015 Nov 2;135(11):1160–2. Mehta AC, Lee FYW, Cordasco EM, Kirby T, Eliachar I, De Boer G. Concentric Tracheal and Subglottic Stenosis. Chest. 1993 Sep;104(3):673–7. Squiers JJ, Teeter WA, Hoopman JE, Piepenbrok K, Wagner R, Ferguson R, Nagji AS, Peltz M, Wait MA, DiMaio JM. Holmium:YAG laser bronchoscopy ablation of benign and malignant airway obstructions: an 8-year experience. Lasers Med Sci. 2014 Jul;29(4):1437-43. doi: 10.1007/s10103-014-1536-1. Epub 2014 Mar 1. PMID: 24584844. Fong M, Clarke K, Cron C. Clinical applications of the holmium:YAG laser in disorders of the paediatric airway. J Otolaryngol. 1999 Dec;28(6):337-43. PMID: 10604163. El-Mefleh, N. Treatment of mediastinal bronchogenic cyst by rigid bronchoscopy and laser. J Ped Endosc Surg 6 , 147–150 (2024). https://doi.org/10.1007/s42804-024-00227-x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Nov, 2025 Read the published version in Journal of Pediatric Endoscopic Surgery → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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14:01:18","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":59797,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7624238/v1/0c8896f77e68927f646694a9.html"},{"id":93335861,"identity":"3bd08def-2593-4afc-b779-8d242493af50","added_by":"auto","created_at":"2025-10-12 14:01:17","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":103305,"visible":true,"origin":"","legend":"\u003cp\u003eBronchoscopy identified a Myer-Cotton grade III stenosis below the glottis. The lesion was successfully managed in a single procedure using a Holmium laser via the same rigid bronchoscope used in diagnosis, achieving airway patency down to the level of the carina.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7624238/v1/edd851c0f76e2cd2529f6190.jpeg"},{"id":97178424,"identity":"3a8b71fc-192b-4d61-8b04-073e69341ab2","added_by":"auto","created_at":"2025-12-01 16:09:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":414204,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7624238/v1/a718f940-2837-4639-b46c-1a7da627f420.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Holmium Laser as a Definitive Single-Modality Treatment for Severe Subglottic Stenosis in an infant: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSubglottic stenosis (SGS) is a pathological narrowing of the airway just below the vocal cords -the subglottic region- that can lead to significant respiratory compromise, ranging from dyspnea to life-threatening hypoxemia. It may be congenital or acquired, with varying etiologies and severity. Congenital subglottic stenosis, a rare condition, often results from incomplete tracheal ring formation or vascular compression, typically presenting in neonates with stridor or cyanosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Acquired SGS is more common and frequently stems from iatrogenic causes, particularly prolonged intubation or tracheostomy, with post-intubation SGS accounting for 90% of acquired SGS in children [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Other causes include external trauma, autoimmune diseases (e.g., relapsing polychondritis), malignancies, irradiation, and idiopathic fibrosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Bronchoscopy remains the gold standard for diagnosis and classification. Stenoses are categorized as simple (segments\u0026thinsp;\u0026lt;\u0026thinsp;1 cm, limited to mucosa) or complex (segments\u0026thinsp;\u0026gt;\u0026thinsp;1 cm, with malacia, cartilage involvement, or inflammation) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Management depends on stenosis type and patient factors including endoscopic interventions such as balloon dilation and laser ablation, and open surgery as tracheal resection or slide tracheoplasty [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among endoscopic techniques, CO₂ and KTP lasers are well-established, but the Holmium-YAG laser has been rarely reported for subglottic stenosis, particularly in pediatric cases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Here, we present a case of definitive subglottic stenosis treatment using Holmium laser monotherapy, achieving long-term success without adjunctive procedures.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA full-term male infant was born with a weight of 5 kg without any health complications. At the age of five days, he presented to a pediatric emergency unit experiencing biphasic respiratory distress (inspiratory and expiratory), along with recurrent acute respiratory infections, for which he required an admission to a neonatal Intensive care unit (NICU), and was intubated for six days. He was later intubated again for three days. At the age of 45 days, the patient was referred to the pediatric surgery department for diagnostic bronchoscopy with a suspected tracheoesophageal fistula. Rigid bronchoscopy revealed a Myer-Cotton grade III subglottic stenosis. Management was performed using a DORNIER Medilas H20 Holmium laser, through a Storz rigid bronchoscope of the size 3.5 mm, initiating from an energy of 0.4 J and a pulse frequency of 4 Hz, reaching 0.8 J, and 6 Hz, respectively [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. Following clinical improvement and resolution of symptoms, the patient was discharged on 3rd day with scheduled follow-up. In five months of follow up, he required two separate admissions to the inpatient ward due to respiratory tract infections. On both occasions, he was managed conservatively and discharged without the need for further intervention. Currently, at 7 months of age, the infant is in good general health, with a weight of 8 kg.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eJiao et. al (2019) hypothesized that younger patients are more susceptible to post-intubation SGS due to key anatomical differences: Smaller subglottic diameter, looser basal mucosal tissue, and more abundant lymphatic and vascular tissue, and further noted that every 1 mm reduction in lumen diameter may result in 60% reduction of the effective ventilatory area, significantly raising airway resistance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Even though benign lesions most often cause pediatric central airway stenosis compared to the adult form, the condition can progress rapidly in younger children because of the anatomic immaturity of their airways, leading to possibly life-threatening complications, including severe dyspnea, recurrent apnea, and infection [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], as reflected by the patient in our case, who required NICU admission and two separate intubations.\u003c/p\u003e\u003cp\u003eCurrently, there is no definitive consensus on the management of subglottic or tracheal stenosis. Interventional bronchoscopy includes laser, stenting and mechanical dilatation, the application of which in tracheal surgery has increased in recent years [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Although open surgical interventions like laryngotracheal reconstruction (LTR) and cricotracheal resection (CTR) achieve high success rates, they have significant morbidity, prolonged hospital stays, and complications such as recurrent nerve palsy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. As alternatives, minimally invasive bronchoscopic techniques such as balloon dilation, cryotherapy, electrosurgery, stenting, and laser ablation (e.g., CO2, Nd:YAG) have emerged [\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Nevertheless, these alternatives present their own limitations, including the potential for mucosal damage, scar tissue formation, and unreliable long-term results [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMonnier et al. (2005) reported a case series of 115 patients ranging from 6 months to 73 years old with supraglottic, glottic, subglottic, tracheal, or combined glotto-subglottic stenoses, treated with endoscopic means, with CO2 laser implemented in 100 patients. Their success rate diminished drastically from preoperative grade I to grade III stenoses, according to the Myer-Cotton classification, where the improvement to a nearly normal (\u0026gt;\u0026thinsp;80% luminal size) airway declined from 92% for grade I to 46% for grade II and only 13% for grade III stenoses, and conclude that only grade I to grade III stenoses presenting as web-like diaphragms without loss of cartilage support represent good indications for a first try endoscopic laser treatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSquiers et al. (2014) reported an 8-year experience of using Holmium laser in 261 procedures performed on 99 adult patients with either benign or malignant airway obstructions, noting the usefulness and safety of Holmium [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePioneering work by several authors established the Holmium laser as a viable pediatric tool with favorable success rates. It has been applied in the excision of tracheal granulomas, webs, stenoses, tongue hemangiomas, oral cavity papillomas, in functional endoscopic sinus surgery, and in the management of bronchogenic cysts [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Jiao et al. (2019) reported a prospective case series of 16 children with post-intubation SGS ranging from 2 months to 12.25 years old, three of which were Myer-Cotton grade II, 12 were grade III, and one was grade IV, who received Holmium laser treatment combined with cryotherapy delivered via flexible bronchoscopy, leading to clinical cure in 15 children and clinical improvement in the remaining one [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Zhang et al. (2023) reported a case series of 28 infants with subglottic and/or tracheal stenoses, 19 of which were Myer-Cotton grade III and 9 were grade IV, who underwent Holmium laser treatment with cryoablation and/or balloon dilatation and budesonide inhalation therapy, 16 had web-like stenosis and 12 had scar contracture stenosis. In the web-like stenosis group, half underwent balloon dilation with cryotherapy, while the other half received balloon dilation alone. Initial treatment was successful in 62.5%, with an additional 31.25% achieving success after revised treatments. In the scar contracture stenosis group, 50% received balloon dilation with cryotherapy, 33.3% underwent cryotherapy alone, and 16.7% had balloon dilation only. Initial success was lower in this group (23.1%), but 61.5% achieved improvement after 1\u0026ndash;4 additional treatments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Holmium laser's technical profile makes it particularly advantageous for pediatric applications. It is hydrophilic, touch-triggered, and has a minimal thermal injury zone of 0.5\u0026ndash;1.0 mm. These properties help minimize collateral damage, a critical advantage in the narrow pediatric airway [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, its thin silica fiber is compatible with small-caliber bronchoscopes, enhancing its suitability for infants [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These characteristics may contribute to a reduced risk of restenosis, a common complication following extensive CO2 laser use in advanced stenoses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], but most authors still advocate for adjunctive cryotherapy post-ablation to further prevent restenosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn contrast to the more frequent multi-modality treatment approach in cases of pediatric subglottic stenosis, our case demonstrates that the Holmium laser, as a single-modality treatment, could be sufficient for a definitive cure even in the youngest patients and with severe Myer-Cotton grades, with no signs of restenosis in the patient in our case at seven months of follow-up.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors did not receive support from any organization for the submitted work. The authors have no competing interests to declare that are relevant to the content of this article. Written informed consent was obtained from the parents for the submission of the case report to the journal.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed equally to writing the main manuscript text, preparing the figures, and reviewing the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMorita K, Maeda K, Yabe K, Oshima Y. Management of congenital tracheal stenosis in the neonatal period. *Pediatr Surg Int*. 2017;33(10):1059-1063. doi:10.1007/s00383-017-4137-9.\u003c/li\u003e\n\u003cli\u003eHo AS, Koltai PJ. Pediatric tracheal stenosis. *Otolaryngol Clin North Am*. 2008;41(5):999-1021. doi:10.1016/j.otc.2008.04.006.\u003c/li\u003e\n\u003cli\u003eOno S, Maeda K, Baba K, et al. Balloon tracheoplasty as initial treatment for neonates with symptomatic congenital tracheal stenosis. *Pediatr Surg Int*. 2014;30(9):957-960. doi:10.1007/s00383-014-3571-1.\u003c/li\u003e\n\u003cli\u003eGelbard A, Francis DO, Sandulache VC, et al. Causes and consequences of adult laryngotracheal stenosis. *Laryngoscope*. 2015;125(5):1137-1143. doi:10.1002/lary.25056.\u003c/li\u003e\n\u003cli\u003eMonnier P, George M, Monod ML, Lang F. The role of the CO₂ laser in the management of laryngotracheal stenosis. *Eur Arch Otorhinolaryngol*. 2005;262(8):602-608. doi:10.1007/s00405-005-0948-8.\u003c/li\u003e\n\u003cli\u003eJiao A, Liu F, Lerner AD, Rao X, Guo Y, Meng C, Pan Y, Li G, Li Z, Wang F, Zhao J, Ma Y, Liu X, Ni X, Shen K. Effective treatment of post-intubation subglottic stenosis in children with holmium laser therapy and cryotherapy via flexible bronchoscopy. Pediatr Investig. 2019 Mar 22;3(1):9-16. doi: 10.1002/ped4.12113. PMID: 32851282; PMCID: PMC7331425.\u003c/li\u003e\n\u003cli\u003eZhang L, Yuan S, Pan C, et al. Outcomes of Holmium Laser, Cryoablation, and Budesonide Inhalation for Treating Severe Central Airway Stenosis in Infants. *J Invest Surg*. 2023;36(1):2257792. doi:10.1080/08941939.2023.2257792.\u003c/li\u003e\n\u003cli\u003eDalar L, Karasulu L, Abul Y, et al. Bronchoscopic treatment in the management of benign tracheal stenosis. *Ann Thorac Surg*. 2016;101(4):1310-1317. doi:10.1016/j.athoracsur.2015.10.005.\u003c/li\u003e\n\u003cli\u003eTerra RM, Bibas BJ, Minamoto H, et al. Decannulation in tracheal stenosis deemed inoperable is possible after long-term airway stenting. *Ann Thorac Surg*. 2019;107(2):440-444. doi:10.1016/j.athoracsur.2018.08.077.\u003c/li\u003e\n\u003cli\u003eAnt\u0026oacute;n-Pacheco JL, Cano I, Comas J, et al. Management of congenital tracheal stenosis in infancy. *Eur J Cardiothorac Surg*. 2006;29(6):991-996. doi:10.1016/j.ejcts.2005.12.061.\u003c/li\u003e\n\u003cli\u003eBlackmore K, Kubba H, Clement WA. Laser division of congenital complete tracheal rings. *Int J Pediatr Otorhinolaryngol*. 2010;74(11):1327-1330. doi:10.1016/j.ijporl.2010.07.019.\u003c/li\u003e\n\u003cli\u003eJeong BH, Um SW, Suh GY, et al. Results of interventional bronchoscopy in the management of postoperative tracheobronchial stenosis. J Thorac Cardiovasc Surg. 2012;144:217\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eFiorelli A, Messina G, Fiorito R, Martone M, Ferraro F, Santini M. Endotracheal tube for relocating dislocated airway stent: a case report. Shanghai Chest. 2022;6:1\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eBajaj Y, Cochrane LA, Jephson CG, Wyatt ME, Bailey CM, Albert DM, et al. Laryngotracheal reconstruction and cricotracheal resection in children: Recent experience at Great Ormond Street Hospital. Int J Pediatr Otorhinolaryngol. 2012 Apr;76(4):507\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eTimman ST, Schoemaker C, Li WWL, Marres HAM, Honings J, Morshuis WJ, et al. Functional outcome after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis. Ann Cardiothorac Surg. 2018 Mar;7(2):227\u0026ndash;36.\u003c/li\u003e\n\u003cli\u003eQuesnel AM, Lee GS, Nuss RC, Volk MS, Jones DT, Rahbar R. Minimally invasive endoscopic management of subglottic stenosis in children: Success and failure. Int J Pediatr Otorhinolaryngol. 2011 May;75(5):652\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eBent JP, Shah MB, Nord R, Parikh SR. Balloon Dilation for Recurrent Stenosis after Pediatric Laryngotracheoplasty. Ann Otol Rhinol Laryngol. 2010 Sep;119(9):619\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eMaresh A, Preciado DA, O\u0026rsquo;Connell AP, Zalzal GH. A Comparative Analysis of Open Surgery vs Endoscopic Balloon Dilation for Pediatric Subglottic Stenosis. JAMA Otolaryngol Neck Surg. 2014 Oct 1;140(10):901.\u003c/li\u003e\n\u003cli\u003eOzkul Y, Songu M, Imre A, Ates D, Arslanoglu S, Pinar E, et al. CO\u003csub\u003e2\u003c/sub\u003e laser treatment of tracheal stenosis. Acta Otolaryngol (Stockh). 2015 Nov 2;135(11):1160\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eMehta AC, Lee FYW, Cordasco EM, Kirby T, Eliachar I, De Boer G. Concentric Tracheal and Subglottic Stenosis. Chest. 1993 Sep;104(3):673\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eSquiers JJ, Teeter WA, Hoopman JE, Piepenbrok K, Wagner R, Ferguson R, Nagji AS, Peltz M, Wait MA, DiMaio JM. Holmium:YAG laser bronchoscopy ablation of benign and malignant airway obstructions: an 8-year experience. Lasers Med Sci. 2014 Jul;29(4):1437-43. doi: 10.1007/s10103-014-1536-1. Epub 2014 Mar 1. PMID: 24584844.\u003c/li\u003e\n\u003cli\u003eFong M, Clarke K, Cron C. Clinical applications of the holmium:YAG laser in disorders of the paediatric airway. J Otolaryngol. 1999 Dec;28(6):337-43. PMID: 10604163.\u003c/li\u003e\n\u003cli\u003eEl-Mefleh, N. Treatment of mediastinal bronchogenic cyst by rigid bronchoscopy and laser. \u003cem\u003eJ Ped Endosc Surg\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 147\u0026ndash;150 (2024). https://doi.org/10.1007/s42804-024-00227-x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7624238/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7624238/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eSubglottic stenosis (SGS) is a pathological narrowing of the airway within the subglottic region, situated just below the vocal cords. This condition can cause significant respiratory compromise, ranging from dyspnea to life-threatening hypoxemia. While SGS may be congenital or acquired, the acquired form is more prevalent and is most frequently iatrogenic. Prolonged endotracheal intubation or tracheostomy are common causes, with post-intubation SGS accounting for approximately 90% of acquired cases in the pediatric population.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e\u003cp\u003eA 45-day-old male infant presented with a history of biphasic stridor and recurrent acute respiratory infections. Diagnostic bronchoscopy identified a Myer-Cotton grade III subglottic stenosis. The lesion was successfully managed in a single procedure using a Holmium laser via a rigid bronchoscope. At the seven-month follow-up, the infant remained in good health with no respiratory complications.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e\u003cp\u003eThe Holmium laser has been established as a viable pediatric tool, with applications in excising tracheal granulomas, webs, and stenoses, as well as in managing other pathologies such as hemangiomas and bronchogenic cysts. Its technical profile is particularly advantageous for the delicate pediatric airway. The laser is hydrophilic, touch-triggered, and characterized by a minimal thermal injury zone of 0.5\u0026ndash;1.0 mm, which helps to minimize collateral damage. While many authors recommend adjunctive cryotherapy post-ablation to reduce the risk of restenosis, this was not employed in the present case.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eManagement of pediatric SGS typically requires a multi-modality approach. However, this case demonstrates that the Holmium laser can serve as a definitive single-modality treatment, even in very young infants with severe (Myer-Cotton grade III) stenosis. The patient showed no evidence of restenosis and maintained excellent respiratory function at the seven-month follow-up.\u003c/p\u003e","manuscriptTitle":"Holmium Laser as a Definitive Single-Modality Treatment for Severe Subglottic Stenosis in an infant: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 14:01:13","doi":"10.21203/rs.3.rs-7624238/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b0959dfc-3f86-41ec-8d12-e717839570c9","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:02:18+00:00","versionOfRecord":{"articleIdentity":"rs-7624238","link":"https://doi.org/10.1007/s42804-025-00296-6","journal":{"identity":"journal-of-pediatric-endoscopic-surgery","isVorOnly":false,"title":"Journal of Pediatric Endoscopic Surgery"},"publishedOn":"2025-11-25 15:57:50","publishedOnDateReadable":"November 25th, 2025"},"versionCreatedAt":"2025-10-12 14:01:13","video":"","vorDoi":"10.1007/s42804-025-00296-6","vorDoiUrl":"https://doi.org/10.1007/s42804-025-00296-6","workflowStages":[]},"version":"v1","identity":"rs-7624238","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7624238","identity":"rs-7624238","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}