KECORT Study: An International e-Delphi Study on the Treatment of KEloids Using Intralesional CORTicosteroids in Clinical Practice

BACKGROUND

Intralesional corticosteroid administration (ICA) is a first-line keloid treatment. However, it faces significant variability in current clinical and scientific practice, which hinders comparability of treatment results.

OBJECTIVES

The aim of the study was to reach consensus on different aspects of ICA using hypodermic needles in keloids among an international group of dermatologists and plastic surgeons specialized in keloid treatment to provide consensus-based clinical treatment recommendations for all physicians treating keloids.

METHODS

The keloid expert panel of 12 dermatologists and 11 plastic surgeons rated 30 statements. Two online e-Delphi rounds were held, both with a response rate of 100%. Fifteen (65%) keloid experts participated in the final consensus meetings. Consensus was defined as ≥ 75% of the participants choosing agree or strongly agree on a 7-point Likert scale.

RESULTS

Consensus was reached on treatment goals, indication for ICA, triamcinolone acetonide (TAC) 40 mg/mL as the preferred corticosteroid administered at a maximum of 80 mg per month and at intervals of 4 weeks, minimizing pain during ICA, the use of 1 mL syringes and 25 or 27 Gauge needles, blanching as endpoint of successful infiltration, caution of not injecting subcutaneously, and the option of making multiple passes in very firm keloids prior to infiltration. Consensus could not be reached on TAC dosing, methods of prior local anesthesia, and location of injection.

CONCLUSIONS

This e-Delphi study provides important clinical treatment recommendations on essential aspects of ICA in keloids. By implementing these recommendations, uniformity of ICA in keloid treatment will increase and better treatment results may be achieved.

Systemic Effects and Absorption of Subepithelial Dexamethasone Vocal Fold Injections

OBJECTIVE/HYPOTHESIS

To compare the systemic changes following two office-based procedures-subepithelial vocal fold steroid injections (VFSI) and vocal fold augmentation (VFA), and to characterize the magnitude and chronicity of the effects observed.

STUDY DESIGN

Prospective, controlled before-after comparative study.

METHODS

Patients prospectively underwent VFSI with 0.8-2 mg of dexamethasone or VFA. Serum cortisol, white cell count (WCC), and C-reactive protein (CRP) were measured at day 0 (pre-procedure), 1 and 7. Salivary cortisol was measured at baseline and daily for 7 days post-procedure.

RESULTS

Fourteen patients underwent VFSI and 36 VFA. At baseline serum cortisol measured 304.6 ± 116.6 nmol/L and fell significantly to 48.1 ± 41.8 nmol/L 1 day following dexamethasone injection (p = 0.001) and recovered by day 7 to 303.7 ± 78.7 nmol/L. Salivary cortisol demonstrated a similar pattern with significant recovery demonstrated by day 3 (p = 0.001). White cell counts were affected by the systemic absorption of exogenous steroid and normalized by day 7. Patients who underwent VFA demonstrated no significant change in their serum or salivary cortisol and no significant change in their WCC. No significant changes in CRP or patient's physiological parameters were observed in either procedure.

CONCLUSION

Our findings demonstrate systemic absorption of dexamethasone following VFSI, with acute hypothalamic-pituitary-adrenal (HPA) axis suppression which normalizes day 3 post-procedurally.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Percutaneous Ultrasound-Guided Medication Injection: A Potential Technique for Subglottic Stenosis

INTRODUCTION

Subglottic stenosis, manifested by granulation tissue hyperplasia, is challenging and requires multiple repeated treatments and stent maintenance at times. Corticosteroids prevent severe subglottic stenosis development owing to their antifibrotic and anti-inflammatory properties. Submucosal injection of glucocorticoids, a useful adjuvant therapeutic method, improves the mean interval between endoscopic procedures and reduces airway restenosis risks.

CASE PRESENTATION

We report a rare case of a man with complex subglottic stenosis who underwent balloon dilatation combined with cryotherapy, stent placement, and adjuvant submucosal triamcinolone injection. The drug was injected efficiently and safely into the submucosal layer under percutaneous ultrasound guidance, and subglottic stenosis was well-controlled at a low cost.

CONCLUSION

POCUS-guided medication injections may be a useful adjuvant medical therapy for subglottic stenosis.

Cost-Effectiveness of Steroids for Prolonging the Surgery-Free Interval in Subglottic Stenosis

OBJECTIVES

Repeat endoscopic dilation (ED) in the operating room for subglottic stenosis (SGS) remains an economic burden to patients. The cost-effectiveness (CE) of adjuvant serial intralesional steroid injections (SILSI) to prolong the surgery-free interval (SFI) in SGS patients requiring ED has yet to be studied.

METHODS

Details of the cost of SILSI and ED were received from our tertiary academic center. SFI, cost of intervention, and the effect of SILSI on prolonging SFI were collected from a systematic review by Luke et al. SGS etiologies in the review included idiopathic, iatrogenic, or autoimmune. A break-even analysis, comparing the cost of SILSI alone with the cost of repeat ED, was performed to determine if SILSI injections were cost-effective in prolonging the SFI.

RESULTS

Average extension of the SFI with SILSI was an additional 219.3 days compared to ED alone based on a systematic review of the literature. 41/55 (74.5%) cases did not require further ED once in-office SILSI management began. SILSI administered in a 4-dose series in 3-to-7-week intervals (~$7,564.00) is CE if the reported recurrence rate of SGS requiring ED (~$39,429.00) has an absolute risk reduction (ARR) of at least 19.18% with the use of SILSI. Based on the literature, SILSI prevents ~3 out of every 4 cases of SGS at sufficient follow-up from undergoing repeat ED, resulting in an ARR of ~75%.

CONCLUSIONS

SILSI is economically reasonable if it prolongs the SFI of at least one case of recurrence out of 5. SILSI, therefore, can be CE in extending the interval for surgical ED.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:3436-3442, 2023.

Long-Term Follow-up of 64 Patients With Idiopathic Subglottic Stenosis: Treatment Pathways, Outcomes, and Impact of Serial Intralesional Steroid Injections

OBJECTIVE

To describe treatment pathways and long-term outcomes in 64 patients with idiopathic subglottic stenosis (iSGS), including the impact of serial intralesional steroid injection (SILSI) on degree of stenosis, need for subsequent operation, and patient-reported outcome measures.

METHODS

Retrospective review of 64 female patients with iSGS undergoing varied management approaches, 57 of whom underwent SILSI as at least part of their care. Treatment pathways included SILSI only, endoscopic intervention followed by SILSI only, endoscopic interventions only, endoscopic intervention followed by SILSI followed by need for repeat endoscopic intervention, open surgery, and tracheotomy. Outcomes assessed included subjectively estimated percent airway stenosis, dyspnea index (DI), modified medical research council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), number of operative and office-based procedures performed, need for subsequent operative intervention, and inter-operative interval.

RESULTS

Treatment pathways included SILSI alone (n = 6), endoscopic intervention(s) followed by SILSI only (n = 31), SILSI followed by additional endoscopic or office-based procedures (n = 16), open surgery (n = 3), and tracheostomy (n = 4). 57 of 64 patients underwent SILSI as at least part of their treatment. Inter-operative interval was increased after starting SILSI. Of patients undergoing SILSI, those with more procedures or shorter inter-operative interval prior to SILSI were more likely to return to the operating room. Estimated stenosis, DI, MMRC, and VHI-10 decreased with SILSI. Stenosis was not correlated with DI, MMRC, or VHI-10, though DI was correlated with both MMRC and VHI-10 score.

CONCLUSION

Of 57 patients undergoing SILSI, 37 did not require further operative intervention. Improvements in inter-operative interval, dyspnea, and voice were observed across patients. Randomized trials to identify which patients may benefit most from SILSI are warranted.

Impact of Serial Intralesional Steroid Injections on Idiopathic Subglottic Stenosis

OBJECTIVES

Serial intralesional steroid injection (SILSI) has been increasingly used to treat idiopathic subglottic stenosis (iSGS). Prior studies have shown effectiveness, but not in all patients. This multi-institutional study evaluates the effect of SILSI on time to recurrent operation, peak expiratory flow (PEF), and dyspnea.

METHODS

Post-hoc secondary analysis of the North American Airway Collaborative data were performed to evaluate the outcomes of iSGS patients undergoing and not undergoing SILSI. The primary outcome was time to recurrent operation, evaluated using Kaplan-Meier curves and Cox regression analysis. Secondary outcomes were change in PEF and clinical chronic obstructive pulmonary disease questionnaire (CCQ) score. Within patients undergoing SILSI, demographics, time from last procedure, and PEF at initiation of SILSI were evaluated to determine the effect on recurrence.

RESULTS

Two hundred and ninety patients were included, 238 undergoing endoscopic dilation alone and 52 undergoing dilation and SILSI. No differences in baseline characteristics were observed. There was no difference in time to recurrence (hazard ratio: 0.64; p = 0.183). There were no differences in PEF or CCQ across the 2.5-year study period. Among 52 patients undergoing SILSI, PEF at the time of starting SILSI did not affect recurrence (χ2  = 0.09, p = 0.77).

CONCLUSION

Patients undergoing and not undergoing SILSI had similar times to recurrence, PEF, and CCQ. Factors predicting recurrence among patients undergoing SILSI were not identified. These results support a randomized controlled trial with a uniform SILSI protocol to quantify the effects of SILSI on objective and subjective outcomes and help determine which iSGS patients benefit most.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2255-2263, 2023.

A Novel Trans-Tracheostomal Retrograde Inhalation Technique Increases Subglottic Drug Deposition Compared to Traditional Trans-Oral Inhalation

Subglottic stenosis represents a challenging clinical condition in otolaryngology. Although patients often experience improvement following endoscopic surgery, recurrence rates remain high. Pursuing measures to maintain surgical results and prevent recurrence is thus necessary. Steroids therapy is considered effective in preventing restenosis. Currently, however, the ability of trans-oral steroid inhalation to reach and affect the stenotic subglottic area in a tracheotomized patient is largely negligible. In the present study, we describe a novel trans-tracheostomal retrograde inhalation technique to increase corticosteroid deposition in the subglottic area. We detail our preliminary clinical outcomes in four patients treated with trans-tracheostomal corticosteroid inhalation via a metered dose inhaler (MDI) following surgery. Concurrently, we leverage computational fluid-particle dynamics (CFPD) simulations in an extra-thoracic 3D airway model to gain insight on possible advantages of such a technique over traditional trans-oral inhalation in augmenting aerosol deposition in the stenotic subglottic region. Our numerical simulations show that for an arbitrary inhaled dose (aerosols spanning 1–12 µm), the deposition (mass) fraction in the subglottis is over 30 times higher in the retrograde trans-tracheostomal technique compared to the trans-oral inhalation technique (3.63% vs. 0.11%). Importantly, while a major portion of inhaled aerosols (66.43%) in the trans-oral inhalation maneuver are transported distally past the trachea, the vast majority of aerosols (85.10%) exit through the mouth during trans-tracheostomal inhalation, thereby avoiding undesired deposition in the broader lungs. Overall, the proposed trans-tracheostomal retrograde inhalation technique increases aerosol deposition rates in the subglottis with minor lower-airway deposition compared to the trans-oral inhalation technique. This novel technique could play an important role in preventing restenosis of the subglottis.

The Effect of Subglottic Steroid injection on Blood Glucose in a Cohort of Patients With Subglottic Stenosis

OBJECTIVE

The objective of this work was to assess the effect of a single intralesional subglottic steroid injection on fasting blood glucose over 7 days in a cohort of patients with subglottic stenosis.

METHODS

A prospective cohort study of patients undergoing intralesional steroid injections at a tertiary academic center. Patients had baseline bloodwork performed, including fasting blood glucose (FBG), and hemoglobin A1C levels. Demographic data and risk factors were collected. Fasting capillary glucose (FCG) was measured using a capillary glucometer and performed by patients daily from days 0 to 7 after a single injection of Triamcinolone into the subglottic airway. Data were analyzed using descriptive and comparative statistics.

RESULTS

Eleven patients were enrolled, and 10 completed data collection over 7 days. All were female, with a mean age of 52.6 years (SD 17.5). Two patients were diabetic (non-insulin dependent). There was a statistically significant increase in FCG on day 1 post-injection (mean = 122.4 mg/dl compared to 100.7 mg/dl) that normalized for all patients within 24-72 h. The mean increase in FCG was 21.5% (SD 22.5%) of the initial value for the cohort. The diabetic group had statistically significant higher glucose values on day 1 compared to the non-diabetic group (146.5 mg/dl compared to 117.0 mg/dl).

CONCLUSION

A single subglottic steroid injection appears to cause a transient increase in FCG 1 day post injection, which resolves after 24-72 h and can be more pronounced in diabetic patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Case report: Idiopathic subglottic stenosis in a girl; successful treatment with macrolides

An 8-year-old girl presented with treatment-refractory cough and inspiratory stridor. Bronchoscopies showed progressive scarring leading to narrowing of the proximal trachea (Myer-Cotton Grade 2) and epithelial metaplasia of the tracheal and bronchial mucosa. After excluding other causes of congenital and acquired tracheal stenosis, an idiopathic subglottic tracheal stenosis (iSGS) was diagnosed. Because of the patient's young age, a judicious therapeutic approach seemed appropriate. Therapy with azithromycin, followed by roxithromycin, was started. Symptoms almost completely subsided, spirometry normalized, and endoscopic and histologic findings improved considerably. Therapy has been continued for more than 3 years with normal lung function values, and no compromise on physical activities and development. In instances of iSGS, therapy with macrolides is worth considering before more invasive procedures such as dilatation, laser, intralesional injections, or surgical resection are performed.

Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era

OBJECTIVE

To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases.

REVIEW METHODS

Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings.

CONCLUSIONS

Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients.

IMPLICATIONS FOR PRACTICE

SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.

Serial Intralesional Steroid Injection for Subglottic Stenosis: Systemic Side Effects and Impact on Surgery-Free Interval

Objectives

In-office serial intralesional steroid injections (SILSIs) have become a commonly used treatment for subglottic stenosis. We characterized the impact of SILSIs on the time between operating room visits and incidence of glucocorticoid systemic side effects.

Study Design

Retrospective case series.

Setting

Academic tertiary care center.

Methods

All patients with subglottic stenosis receiving SILSIs at 1 institution from 2016 to 2020 were included. Surgery-free interval was compared using paired t tests. Side effect incidence was calculated with Kaplan-Meier methodology for visualization.

Results

Nineteen patients and 207 procedures were included. The majority of patients were White (95%) and female (95%) and had idiopathic subglottic stenosis (53%). Mean surgery-free interval for all patients was 8.7 months (95% CI, 5.6-11.8) before initiating SILSIs. Of 11 patients with calculable surgery-free interval, 10 experienced improvement, with a mean surgery-free interval increase of 4.6 months (95% CI, 2.4-6.7). Seven patients have not required surgery since initiation of SILSIs, with a mean follow-up time of 28 months (95% CI, 25-31). Noncutaneous systemic side effects occurred at a mean 3.2 months (95% CI, 2.4-4.0) from first injection and included Cushing’s syndrome, increased intraocular pressure, central serous chorioretinopathy, and new insulin requirement in the setting of diabetes.

Conclusions

Ninety-one percent of patients who initiated SILSIs and had a subsequent return to the operating room experienced a mean 4.6-month increase in surgery-free interval. Systemic side effects of glucocorticoids occurred in 32% of patients after initiating SILSIs. This should be considered in preprocedure counseling and side effect monitoring during treatment.

Development of Cushing Syndrome After Serial In-office Subglottic Steroid Injections

In-office subglottic intralesional steroid injections (SILSI) have gained popularity as an adjunct to operating room dilation in the treatment of subglottic stenosis. They are generally thought to have a low risk profile for development of systemic side effects. Here, we present a case of a 55 year old woman who developed symptoms of Cushing syndrome after receiving SILSI, including weight gain, striae, dorsal hump and alopecia. This case illustrates that despite the localized nature of SILSI, there is still a risk of developing systemic effects as a result of the treatment. Laryngoscope, 2021.

The Safety of Intralesional Steroid Injections in Young Children and Their Effectiveness in Anastomotic Esophageal Strictures-A Meta-Analysis and Systematic Review

OBJECTIVE

Intralesional steroid injections (ISI) are a widely used technique for various pediatric indications and represent a possible adjuvant treatment for anastomotic esophageal strictures. Yet, no consensus has been reached neither on their safety in the pediatric population or their effectiveness in esophageal atresia patients. This systematic review aimed to assess the safety of ISI in young children through a meta-analysis and to summarize the current knowledge on the effectiveness of ISI in anastomotic esophageal strictures.

METHODS

A systematic literature search was performed in Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar up to August 16 2021. Studies focusing on ISI and involving children up to 2 years were included in the meta-analysis for the safety assessment. All studies evaluating the use of ISI as adjuvant treatment in anastomotic esophageal strictures in children were included in the systematic review to assess the effectiveness of the intervention.

RESULTS

The literature search yielded 8,253 articles. A total of 57 studies were included, of which 55 for the safety and five for the effectiveness assessment. The overall complication rate was 7%, with a greater incidence of local complications compared to systemic complications. Six studies (with a total of 367 patients) evaluated adrenocorticotropic hormone and cortisol levels, of which four reported hypothalamic-pituitary axis suppression. Two children (0.6%) received replacement therapy and all patients recovered uneventfully. A mean number of 1.67 ISI were performed per esophageal atresia (EA) patient. A reduction of needed dilatations was seen after ISI, compared to the number of dilatations performed before the intervention (5.2 vs. 1.3).

CONCLUSION

The insufficient data emphasized the need for further prospective and comparative studies. Results from this meta-analysis and systematic review address ISI as a safe and effective technique. Close clinical follow-up and growth curve evaluation are advisable in patients receiving ISI.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier: CRD42021281584.

Intralesional betamethasone versus triamcinolone acetonide in the treatment of localized alopecia areata: a within-patient randomized controlled trial

BACKGROUND

Betamethasone can be used for intralesional infiltration, but there is little evidence in the literature to indicate its effectiveness in alopecia areata.

OBJECTIVE

To assess the safety and effectiveness of the use of different doses of intralesional betamethasone, when compared to triamcinolone acetonide for the treatment of alopecia areata.

METHODS

We recruited 12 patients with alopecia patch divided into four quadrants. Each quadrant, after randomization, received an intralesional injection with one of the following treatments: triamcinolone acetonide 2.5 mg/ml, betamethasone 0.375 mg/ml, betamethasone 1.75 mg/ml, or 0.9% saline (placebo). The intervention was repeated in the same quadrant every 4 weeks, totaling 3 sessions. Visual and dermoscopic evaluation of the results were performed. Trial registration: ReBec RBR-5kyg2r.

RESULTS

At 4 and 8 weeks of intervention, triamcinolone acetonide 2.5 mg/ml provided the best visual results. Nevertheless, at the end of the study, the best visual results were seen with both triamcinolone acetonide and betamethasone 1.75 mg/ml, with significant difference when compared to betamethasone 0.375 mg/ml and placebo (p=.0489 and <.0001, respectively). There was a progressive reduction in the number of dystrophic hairs in all quadrants.

CONCLUSION

Triamcinolone acetonide shows earlier results in repilation, but at 12 weeks betamethasone 1.75 mg/ml had similar results.

Intralesional triamcinolone acetonide therapy for inflammatory oral ulcers

OBJECTIVES

The aim of this study was to report on the clinical indications and treatment outcomes of intralesional steroid therapy (IST) for oral ulcerative conditions in an oral medicine practice.

STUDY DESIGN

This was a retrospective single-center study of patients with oral ulcerative conditions treated with IST. Demographic data, clinical diagnosis of the oral condition, size of the ulcer, and pain were abstracted from patients' electronic medical records.

RESULTS

Ninety-three patients (51 females [54.8%]) were treated for persistent traumatic oral ulcers (n = 38 [40.8%]), ulcers in oral chronic graft-versus-host disease (n = 23 [24.7%]), oral lichen planus (n = 19 [20.4%]), and other conditions (14%). Complete resolution was achieved in 81.7% of patients in a median of 96 days (range 10-357 days), with 80% fully healed in a median of 84 days (range 10-140 days). Overall, patients received a median of 2 injections (range 1-5 injections) and a median dose of 12 mg per injection (range 2-36 mg). Nearly half the patients were also treated with concomitant topical steroid therapy. After the first injection, the median pain score reduced from 5 (range 1-10) to 1 (range 0-10; P < .001) and the median size of ulcers reduced from 1 cm (range 0.1-5 cm) to 0.3 cm (range 0-2 cm; P < .001).

CONCLUSIONS

IST may be an effective treatment for inflammatory and immune-mediated oral ulcers.

Vocal fold fixation due to proximal stenosis progression complicating idiopathic subglottic stenosis

Purpose

This study examined the incidence and risk factors for vocal fold fixation due to proximal progression of idiopathic subglottic stenosis (ISS) over the course of serial treatments.

Methods

Records of 22 consecutive patients with ISS treated between 2004 and 2016 were retrospectively reviewed. Patient, stenosis, and treatment details were recorded. Cox regression was used to identify independent predictors of vocal fold fixation.

Results

All patients were female and mean age at diagnosis was 46 ± 7 years. In five patients, the stenosis was within 15 mm of the glottis at first treatment. Vocal fold fixation due to proximal stenosis progression occurred in seven (32%) patients. It led to permanent hoarseness due to unilateral vocal fold fixation in two patients and caused airway compromise due to bilateral vocal fixation in two other patients. No airway-related deaths occurred and no patient required a tracheostomy. Stenosis incision using coblation or potassium titanyl phosphate laser, and an initial glottis-to-stenosis (GtS) distance < 15 mm significantly increased the risk of proximal stenosis progression on univariable analysis.

Conclusion

Vocal fold fixation due to proximal stenosis progression is a significant complication of idiopathic subglottic stenosis and causes permanent voice and/or airway sequelae. It should be actively looked for and documented every time a patient is assessed. If a reduction in the GtS distance is observed, definitive surgery should be promptly considered before proximal stenosis progression compromises the efficacy and safety of definitive treatment or, worse, causes vocal fold fixation.