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Agrawal A, Baird BJ, Madariaga MLL, Blair EA, Murgu S. Multi-disciplinary management of patients with benign airway strictures: A review. Respir Med 2021; 187:106582. [PMID: 34481304 DOI: 10.1016/j.rmed.2021.106582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022]
Abstract
Histologically benign airway strictures are frequently misdiagnosed as asthma or COPD and may present with severe symptoms including respiratory failure. A clear understanding of pathophysiology and existing classification systems is needed to determine the appropriate treatment options and predict clinical course. Clinically significant airway strictures can involve the upper and central airways extending from the subglottis to the lobar airways. Optimal evaluation includes a proper history and physical examination, neck and chest computed tomography, pulmonary function testing, endoscopy and serology. Available treatments include medical therapy, endoscopic procedures and open surgery which are based on the stricture's extent, location, etiology, morphology, severity of airway narrowing and patient's functional status. The acuity of the process, patient's co-morbidities and operability at the time of evaluation determine the need for open surgical or endoscopic interventions. The optimal management of patients with benign airway strictures requires the availability, expertise and collaboration of otolaryngologists, thoracic surgeons and interventional pulmonologists. Multidisciplinary airway teams can facilitate accurate diagnosis, guide management and avoid unnecessary procedures that could potentially worsen the extent of the disease or clinical course. Implementation of a complex airway program including multidisciplinary clinics and conferences ensures that such collaboration leads to timely, patient-centered and evidence-based interventions. In this article we outline algorithms of care and illustrate therapeutic techniques based on published evidence.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology & Bronchoscopy, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA.
| | - Brandon J Baird
- Section of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Maria Lucia L Madariaga
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Elizabeth A Blair
- Section of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Septimiu Murgu
- Interventional Pulmonology, Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA.
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Schirmer JH, Aries PM, de Groot K, Hellmich B, Holle JU, Kneitz C, Kötter I, Lamprecht P, Müller-Ladner U, Reinhold-Keller E, Specker C, Zänker M, Moosig F. [S1 guidelines Diagnostics and treatment of ANCA-associated vasculitis]. Z Rheumatol 2019; 76:77-104. [PMID: 29204681 DOI: 10.1007/s00393-017-0394-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jan Henrik Schirmer
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
| | - Peer M Aries
- Rheumatologie im Struenseehaus, Hamburg, Deutschland
| | - Kirsten de Groot
- Medizinische Klinik III, Sana Klinikum Offenbach, Offenbach, Deutschland
- KfH Nierenzentrum Offenbach, Offenbach, Deutschland
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitiszentrum Süd, Medius Klinik Kirchheim, Kirchheim, Deutschland
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | - Christian Kneitz
- Klinik für Innere Medizin II, Rheumatologie, klinische Immunologie und Geriatrie, Klinikum Südstadt, Rostock, Deutschland
| | - Ina Kötter
- Abteilung für Rheumatologie, klinische Immunologie und Nephrologie, Asklepios Klinikum Altona, Hamburg, Deutschland
| | - Peter Lamprecht
- Klinik für Rheumatologie und klinische Immunologie, Universität zu Lübeck, Lübeck, Deutschland
| | - Ulf Müller-Ladner
- Abteilung für Rheumatologie und Klinische Immunologie, Campus Kerckhoff, Justus-Liebig Universität Giessen, Bad Nauheim, Deutschland
| | - Eva Reinhold-Keller
- Klinik für Rheumatologie und klinische Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Christof Specker
- Klinik für Rheumatologie und klinische Immunologie, Universitätsmedizin Essen, St. Josef Krankenhaus Werden, Essen, Deutschland
| | - Michael Zänker
- Abteilung für Innere Medizin, Immanuel Klinikum Bernau Herzzentrum Brandenburg, Bernau, Deutschland
- Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Frank Moosig
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
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Subglottic Stenosis in Granulomatosis With Polyangiitis: The Role of Laryngotracheal Resection. Ann Thorac Surg 2018; 105:249-253. [DOI: 10.1016/j.athoracsur.2017.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 06/11/2017] [Accepted: 07/17/2017] [Indexed: 11/20/2022]
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Lewis S, Earley M, Rosenfeld R, Silverman J. Systematic review for surgical treatment of adult and adolescent laryngotracheal stenosis. Laryngoscope 2016; 127:191-198. [DOI: 10.1002/lary.26151] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Sean Lewis
- Department of Otolaryngology; State University of New York Downstate Medical Center; Brooklyn New York U.S.A
| | - Marisa Earley
- Department of Otolaryngology; State University of New York Downstate Medical Center; Brooklyn New York U.S.A
| | - Richard Rosenfeld
- Department of Otolaryngology; State University of New York Downstate Medical Center; Brooklyn New York U.S.A
| | - Joshua Silverman
- Department of Otolaryngology; State University of New York Downstate Medical Center; Brooklyn New York U.S.A
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The efficacy of submucosal corticosteroid injection and dilatation in subglottic stenosis of different aetiology. The Journal of Laryngology & Otology 2016; 130:674-9. [DOI: 10.1017/s0022215116001122] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To determine the long-term efficacy of submucosal corticosteroid injection plus dilatation for subglottic stenosis as a single modality treatment in granulomatosis with polyangiitis and relapsing polychondritis, as compared with idiopathic subglottic stenosis and traumatic subglottic stenosis.Method:Patients who underwent dilatation for autoimmune causes were identified. Corticosteroid injection into the submucosa of a stenotic segment was followed by serial dilatation. Definitive improvement was defined as good airway patency for more than 24 months with no further procedures needed. Clinical, demographic and procedural data were recorded.Results:Patients (n = 45) were divided into three subglottic stenosis groups: traumatic (n = 24), idiopathic (n = 9) and autoimmune (n = 12). Patients were treated with dilatations, with a median follow-up time of 76 months. Six patients were tracheostomy-dependent. There were no statistical differences in the number of final improvements between autoimmune, idiopathic and traumatic groups, with values of 75, 56 and 71 per cent, respectively. There was no statistical difference between granulomatosis with polyangiitis plus relapsing polychondritis and idiopathic subglottic stenosis in terms of decannulation rates.Conclusion:Granulomatosis with polyangiitis and relapsing polychondritis patients have better improvement rates than patients with other subglottic stenosis types.
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Allen CT, Lee CJ, Meyer TK, Hillel AD, Merati AL. Risk stratification in endoscopic airway surgery: is inpatient observation necessary? Am J Otolaryngol 2014; 35:747-52. [PMID: 25097181 DOI: 10.1016/j.amjoto.2014.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/30/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE To compare post-operative complication rates between inpatient and outpatient endoscopic airway surgery in patients with laryngotracheal stenosis. Secondary objectives included characterization of a cohort of patients with this disease. METHODS Retrospective review of patients with laryngotracheal stenosis in a tertiary care laryngology practice over a 5-year period. RESULTS Ninety-one patients underwent 223 endoscopic airway surgeries. Of 114 outpatient interventions, 1 patient (0.8%) sought emergent medical care following discharge for respiratory distress. Of 109 procedures resulting in admission, no patients required transfer to a higher level of care, endotracheal intubation or placement of a surgical airway. There was no statistically significant difference in complication rates between patients treated as outpatients or inpatients (p=0.33, chi square). There were no cardiopulmonary events. There were no pneumothoraces despite frequent use of jet ventilation. The most common etiologic category was idiopathic (58%), followed by granulomatosis with polyangiitis (16%) and history of tracheotomy (12%). Most patients with idiopathic disease were female (p<0.001, Fisher's exact test). CONCLUSION Patients undergoing endoscopic surgery for airway stenosis rarely have post-operative complications, and outpatient surgery appears to be a safe alternative to post-operative admission and observation.
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Affiliation(s)
- Clint T Allen
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, 1959 NE Pacific St, Box 356515, Seattle, WA.
| | - Chia-Jung Lee
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, 1959 NE Pacific St, Box 356515, Seattle, WA
| | - Tanya K Meyer
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, 1959 NE Pacific St, Box 356515, Seattle, WA
| | - Allen D Hillel
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, 1959 NE Pacific St, Box 356515, Seattle, WA
| | - Albert L Merati
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, 1959 NE Pacific St, Box 356515, Seattle, WA
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Ching HH, Mendelsohn AH, Liu IY, Long J, Chhetri DK, Berke GS. A Comparative Study of Cricotracheal Resection and Staged Laryngotracheoplasty for Adult Subglottic Stenosis. Ann Otol Rhinol Laryngol 2014; 124:326-33. [DOI: 10.1177/0003489414554942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Cricotracheal resection (CTR) and laryngotracheoplasty (LTP) are open surgical treatments for severe subglottic stenosis. This study aims to compare the applications and outcomes of these techniques. Method: Patients with subglottic stenosis at a tertiary academic institution from 2000 to 2012 were identified by diagnosis codes. Patients who underwent LTP or CTR were included. Records were reviewed for treatment data and outcomes. Patients with a history of head and neck malignancy or stenosis without cricoid involvement were excluded. Result: Sixty-one and 20 patients underwent LTP and CTR, respectively. When comparing patients receiving LTP and CTR, there was a significant difference in stenosis etiology ( P = .014). The groups were similar in Cotton-Myer grade ( P = .102). At last follow-up, 80.3% of LTP patients and 90.0% of CTR patients were decannulated. On multivariate analysis, there was a significant association between stenosis grade and decannulation in the LTP group ( P = .01). Decannulation was not associated with stenosis grade in the CTR group. In both groups, there was no significant association between decannulation and sex, stenosis etiology, or stenosis length. Conclusion: Cricotracheal resection and LTP have both shown excellent long-term decannulation rates. Etiology and stenosis grade are likely to be determining factors when recommending specific surgical interventions for subglottic stenosis.
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Affiliation(s)
- Harry H. Ching
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Abie H. Mendelsohn
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Isabelle Y. Liu
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jennifer Long
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Dinesh K. Chhetri
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gerald S. Berke
- Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Mueller A, Holl-Ulrich K, Gross WL. Granuloma in ANCA-associated vasculitides: another reason to distinguish between syndromes? Curr Rheumatol Rep 2014; 15:376. [PMID: 24078103 DOI: 10.1007/s11926-013-0376-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The 2012 renewed Chapel Hill Consensus Conference (CHCC) officially named three clinicopathological entities, i.e. granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and microscopic polyangiitis (MPA), as major variants of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). Recent genetic and cohort studies revealed the need for further differentiation between the entities, for example regarding differences in outcome. As well as ANCA reactivity, upper and lower airway disease were found to be differentiating factors for AAV variants, improving prognostic ability regarding relapse prediction and associated clinical features. Extravascular granulomatosis, or "granuloma", which describes both clinically relevant granulomatous manifestations and histopathologically documented granulomatous inflammation, is characteristic of localized and systemic GPA, but not MPA. This review summarizes new knowledge regarding granuloma in the head and neck region of AAV, its histomorphological equivalents in the upper and lower respiratory tract, and evidence for a granulomatous phenotype of a persistent localized GPA variant. This comprises the development of disease activity and damage scores for extravascular lesions in the ear, nose, and throat (ENT) regions, and imaging techniques. In addition, findings linking extravascular manifestations to granulomatous inflammation are described. We hypothesize that, as for ANCA, necrotizing granulomatous inflammation and its clinical manifestations are discriminators, assisting subclassification of AAV and/or GPA subphenotypes which will be useful both for designing clinical trials and for treating patients successfully.
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Affiliation(s)
- Antje Mueller
- Department of Rheumatology, University of Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany,
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Parker NP, Misono S, Goding GS, Bandyopadhyay D. In response to Endoscopic cold incision, balloon dilation, mitomycin C application, and steroid injection for adult laryngotracheal stenosis. Laryngoscope 2014; 124:E105. [PMID: 24549988 DOI: 10.1002/lary.24128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 02/21/2013] [Accepted: 02/21/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Noah P Parker
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota
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Abstract
Tracheobronchial stenosis, narrowing of the airways by neoplastic or nonneoplastic processes, may be focal, as occurs with postintubation tracheal stenosis or a focal narrowing from a tumor, or more diffuse, such as those caused by inflammatory diseases. Symptoms develop when the narrowing impedes flow and increases resistance within the airways. Computed tomography defines the extent and severity of disease; endoscopy facilitates understanding of the cause so that an algorithm for treatment can be devised. Bronchoscopic interventions include balloons, ablative treatment, and stenting to provide symptomatic relief. Surgical resection may be curative and a multidisciplinary approach to tracheobronchial stenosis is required.
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Affiliation(s)
- Jonathan Puchalski
- Thoracic Interventional Program, Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, Laboratory of Clinical Investigation (LCI), New Haven, CT 06510, USA.
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Taylor SC, Clayburgh DR, Rosenbaum JT, Schindler JS. Progression and management of Wegener's granulomatosis in the head and neck. Laryngoscope 2012; 122:1695-700. [PMID: 22674560 DOI: 10.1002/lary.23273] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Revised: 01/19/2012] [Accepted: 02/01/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS To describe the otolaryngologic presentation and natural history of granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis, and to compare otolaryngologic outcomes of patients with systemic GPA to those with a limited form of GPA confined to the head and neck. STUDY DESIGN Retrospective chart review. METHODS Review of GPA cases (identified by serology, biopsy, or clinical presentation) seen in the otolaryngology department of an academic medical center. RESULTS A total of 24 patients were identified; each patient was followed for an average 6.8 years. Sinusitis and subglottic stenosis were the most commonly observed head and neck manifestations at diagnosis, seen in 64% and 36%, respectively. Over time, disease spread to additional sites in more than half the cohort (n = 14), but only two of 13 patients with disease initially limited to the head and neck developed pulmonary disease, and none developed renal disease. Cumulatively, otitis media was more likely to be observed in patients with systemic disease (P = .04). Patients with localized (n = 12) and systemic (n = 12) GPA did not have significantly different rates of surgical interventions (0.55 vs. 0.72 surgical interventions/patient-year of follow-up, respectively, P = .19). CONCLUSIONS GPA has a variety of head and neck manifestations, most commonly sinusitis, nasal disease, subglottic stenosis, and otitis media. GPA commonly progresses to involve additional sites, regardless of the extent of disease. These patients require frequent surgical intervention, and the clinician should remain vigilant for progression of disease.
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Affiliation(s)
- Stanford C Taylor
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
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