Recognizing pediatric post-intubation tracheal stenosis: lessons from delayed diagnosis and tissue-preserving endoscopic management

Background Post-intubation tracheal stenosis (PITS) is a rare but potentially life-threatening complication of endotracheal intubation in children. Because early symptoms often mimic common pediatric respiratory disorders, diagnosis may be delayed until critical airway obstruction develops. We aimed to characterize the diagnostic course, clinical presentation, and outcomes of pediatric PITS treated using a minimally invasive, tissue-preserving endoscopic strategy. Methods We retrospectively reviewed all children with endoscopically confirmed PITS treated at a tertiary pediatric airway center between 2019 and 2026. Clinical presentation, timing of diagnosis, treatment, and outcomes were analyzed descriptively. Results Eight infants were included in this cohort, all of whom had subglottic PITS. Median age at intubation was 4.5 months and median duration of initial mechanical ventilation was 3.5 days. Respiratory symptoms developed after a median of 4.5 days following extubation, whereas PITS was diagnosed only after a median of 65 days, indicating substantial diagnostic delay. Six patients presented with stridor and dyspnea, while two developed severe respiratory failure requiring emergency intubation without preceding stridor. Six patients had Myer–Cotton grade III and two grade II stenosis. Morphology-guided endoscopic treatment included balloon dilation ( n = 4), mechanical dilation ( n = 3), or membrane resection ( n = 1), combined with temporary postoperative airway stabilization through invasive ventilation as well as local and systemic anti-inflammatory therapy. No patient developed restenosis or required tracheostomy or open airway reconstruction during long-term follow-up. Conclusions Delayed recognition appears to be a major challenge in pediatric PITS. Early endoscopic airway evaluation should be considered in children with persistent respiratory symptoms after intubation, even after short-term ventilation or in the absence of stridor. Selected patients may be successfully managed using a minimally invasive, tissue-preserving endoscopic approach.