Laser Versus Cold Steel for Endoscopic Management of Subglottic Stenosis

OBJECTIVE

Endoscopic management of subglottic stenosis (SGS) includes a wide range of techniques. This 17-year review compares treatment outcomes between carbon dioxide (CO2) laser and cold steel.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care center.

METHODS

A chart review was performed for all patients undergoing endoscopic treatment of SGS at Cleveland Clinic between July 12, 2000 and September 1, 2017. Data collected included demographics, stenosis etiology, stenosis severity, comorbidities, treatment modality, and airway procedure history. The primary endpoint was repeated treatment-free survival (RTFS) within 2 years using a Kaplan-Meier analysis and Cox proportional hazard model.

RESULTS

A total of 139 patients (median [interquartile range] aged 48.7 [37.8, 57.0] years; 83.4% female) were included in the analysis, with etiologies including idiopathic (56.8%), granulomatosis with polyangiitis (25.2%), and intubation (16.5%). All patients underwent either cold steel (107 patients) or CO2 laser (32 patients) lysis of stenosis with concurrent dilation. RTFS within 2 years was 50.2% for CO2 laser and 31.9% for cold steel (hazard ratio [HR] and 95% confidence interval [CI]: 1.69, 0.96-2.97, P = .07). In patients with no prior airway procedures, there was no difference in RTFS between laser and cold knife (P = .41). However, in patients with prior airway procedures, RTFS was significantly greater in the laser group, even after adjusting for age, smoking history, and stenosis etiology (50.0% vs 16.8%, adjusted HR and CI: 2.82, 1.14-6.98, P = .025).

CONCLUSION

Endoscopic lysis of SGS with CO2 laser should be considered in revision cases.

Does Idiopathic Subglottic Stenosis Length and Location Change with Serial Endoscopic Interventions?

OBJECTIVES/HYPOTHESIS

The aim was to assess changes in physical parameters of subglottic stenosis (SGS) following serial endoscopic surgical intervention.

STUDY DESIGN

This was a retrospective chart review.

METHODS

A retrospective review of 52 idiopathic subglottic stenosis (iSGS) patients undergoing multiple endoscopic (excision/dilation) procedures between 2014 and 2022 was completed. Parameters including proximal stenosis distance from the vocal process and total stenosis length collected intraoperatively were compared over serial treatments. Differences between patient variables affecting distances from the vocal process and mean stenosis length were statistically analyzed utilizing nonparametric estimators including the Mann Whitney U, Fisher exact, and linear regression models.

RESULTS

For the cohort of iSGS patients (N = 52), the mean age was 55.1 (±15.1). The patients were predominantly female (96.2%) and Caucasian (84.6%). Patients underwent an average of 3.4 (±1.3) endoscopic procedures for long-term treatment of iSGS (range: 1 to 5 procedures). Patients undergoing a total of two (2) total procedures within the data collection window demonstrated a statistically significant decrease in mean stenosis length between the first and second procedures (p = 0.014). Changes in distance of the stenosis from the glottis was not found to be statistically significant (p = 0.833). There was a statistically significant decrease in mean length of stenosis from the 1st to the 2nd procedure by approximately 0.11 cm (p = 0.0003). No additional statistically significant differences in stenosis length or location were detected.

CONCLUSIONS

Serial endoscopic excision/dilation procedures (the mainstay of iSGS surgical management) do not appear to significantly lengthen intraluminal stenosis nor change the distance of the stenosis from the glottis.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1769-1772, 2024.

Surgical Management of Airway Stenosis During Pregnancy: A Scoping Review

OBJECTIVE

There are several options for surgical management of subglottic stenosis, including endoscopic and open procedures. However, treatment algorithms, outcomes, and anesthetic management of subglottic stenosis during pregnancy are not well described.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane databases.

REVIEW METHODS

A scoping review of management of subglottic stenosis during pregnancy was performed, and then reported in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria consisted of those with subglottic or tracheal stenosis aged greater than 18 years, those in whom management was performed during pregnancy, and those who reported delivery related outcomes.

RESULTS

After systematic review and detailed search of 330 identified articles, 15 articles met inclusion criteria and were included in the final analysis. All studies were case reports or case series (level 4 evidence). This study identified 27 patients. The median age was 29 and the median gestational age at intervention was 28 weeks. Left lateral positioning and fetal heart rate monitoring were used in nearly every case. The most common intervention performed was endoscopic balloon dilation. In many cases, jet ventilation or transnasal humidified rapid insufflation ventilatory exchange was satisfactory for maintenance of the airway. Three women ultimately required tracheostomy prior to labor and delivery. There was no fetal death or complications reported in these studies, and all but one woman proceeded to deliver at term.

CONCLUSION

Endoscopic balloon dilation during pregnancy is safe and effective, resulting in optimized respiratory outcomes for the mother and safe delivery of the fetus. The third trimester appears to be safe for airway intervention. Laryngoscope, 134:1014-1022, 2024.

Murine Model of Airway Fibrosis has Anatomic, Physiologic, and Molecular Congruency to Human iSGS

OBJECTIVE

To narrow knowledge gaps in the pathophysiology of idiopathic subglottic stenosis (iSGS) through comparison of a murine subglottic stenosis model with iSGS.

STUDY DESIGN

In vivo animal study.

SETTING

Academic institution.

METHODS

Murine samples/measurements were obtained from mice that underwent chemomechanical injury with a wire brush and bleomycin. Human samples/measurements were obtained from iSGS patients. Anatomic, physiologic, and epithelial molecular data were collected using histology, human peak expiratory flow (PEF) and murine airway conductance, gene expression analysis with quantitative polymerase chain reaction, and protein analysis with quantitative immunohistochemistry.

RESULTS

Anatomic patterns of scars at the subglottis and proximal trachea seen in the murine model are similar to iSGS patients. Subglottic stenosis (SGS) mice had a decrease (P = .0194) in airway conductance compared to healthy controls, similar to a decrease (P = .0001) in predilation PEF versus postdilation in iSGS patients. There was decreased epithelial gene expression of E-cadherin (ECAD) (P < 0.01), occludin (OCLN) (P < .01), and cytokeratin-5 (CK5) (P < .05) and protein expression of ECAD (H/M: P < .001), OCLN (H: P < 0.05, M: P < .001), and CK5 (H: P < .001, M: P < .01) in murine SGS and iSGS versus controls.

CONCLUSION

The murine SGS model shows anatomic, physiologic, and molecular congruency with human iSGS, making it a reasonable model to investigate iSGS. The molecular similarities in epithelial barrier dysfunction suggest it may best be suited to explore epithelial mechanisms of iSGS and therapies directed at epithelial reconstitution. This model provides a foundation to collect data that will improve understanding of iSGS, and, ultimately, translate into more accurate animal models for future use.

The Evolution and Outcomes of the "Maddern Procedure" for the Treatment of Subglottic Stenosis

INTRODUCTION

A novel technique to treat subglottic stenosis, the "Maddern Procedure", has been gaining acceptance in academic centers. This study describes the technique in detail, as well as its evolution over the first 28 patients performed at an academic center.

METHODS

A prospective case-series, with descriptive technique modifications cataloged throughout the 6 years needed to accumulate the patient cohort with a minimum of 2 years of follow-up (11/2015-11/2021). Main outcomes examined included changes to surgical indications, complications, and post-operative outcomes as measured by validated measures of voice and breathing.

RESULTS

Complete resection of subglottic scaring was performed, at first transcervically (2 pts), then transorally (26 pts). Successful performance of the procedure occurred in all patients without complications, with either successful decannulation of previously existing tracheotomies, or removal of perioperative tracheotomies. Buccal grafts (8/26) replaced skin graft as the graft of choice. Although high subglottic disease was first thought to be a contraindication, superior results became evident in cases of high stenosis rather than disease that included the upper trachea, with 4/26 patients requiring subsequent tracheal resection or tracheal dilation. Of the 22 remaining patients, 19/22 had successful arresting of restenosis, with 2/22 undergoing subsequent cricotracheal resection, and 1/22 pts requiring subglottic dilation. Overall, 19/26 Maddern pts (73%) had objectively favorable outcomes, with 24/26 (92%) reporting that they would have undergone the procedure again.

CONCLUSION

Full-thickness mucosal resection and relining of the subglottis is a developing technique that is a safe, yet technically challenging procedure which addresses the recurrent nature of the disease.

LEVEL OF EVIDENCE

Level 4 (Case-series) Laryngoscope, 133:3100-3108, 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 use of platelet-rich plasma in the treatment of cicatricial stenosis of the larynx and cervical trachea]

Despite the technical achievements of recent years in medicine, the problem of frequent recurrent stricture formation of the lumen of larynx and cervical trachea remains urgent. The etiology and pathogenesis of development of scar stenosis of the larynx and trachea were considered, and the analysis of the drugs' use for topical therapy in the comprehensive treatment of this pathology was conducted in the presented review. Special attention was paid to plasma enriched with platelets, its use in otorhinolaryngology, in particular in the treatment of laryngeal diseases. Positive and negative sides of the adjuvant therapy use have been identified. The search for means helping to prevent recurrent stricture formation of laryngeal lumen and cervical trachea determines the interest of the considered problem.

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.

Endoscopic Resection and Mucosal Reconstitution With Epidermal Grafting: A Pilot Study in Idiopathic Subglottic Stenosis

OBJECTIVE

To describe technical aspects and surgical outcomes of endoscopic resection and mucosal reconstitution with epidermal grafting (ie, the Maddern procedure) in the treatment of idiopathic subglottic stenosis.

STUDY DESIGN

Medical record abstraction.

SETTING

Johns Hopkins Hospital.

METHODS

Retrospective series of 9 adults with idiopathic subglottic stenosis who underwent the Maddern procedure by a single surgeon over a 5-year period. Prespecified outcomes included (1) perioperative outcomes (Clavien-Dindo grade 4/5 complications, need for staged tracheostomy, hospital length of stay), (2) postoperative outcomes (peak expiratory flow rate [PEFR], need for subsequent airway surgery, tracheostomy at follow-up), and (3) patient-reported quality-of-life outcomes (Clinical COPD Questionnaire, Voice Handicap Index-10, Eating Assessment Tool-10, and 12-Item Short Form Version 2). Wilcoxon matched-pairs signed rank test and Kaplan-Meier analysis were performed.

RESULTS

There were no Clavien-Dindo grade 4/5 complications; 2 patients required unplanned staged tracheostomy; and the median length of stay was 3 days. Following endoscopic resection and stent removal, a median of 2 laser resurfacing procedures were required. Two patients developed recurrent stenosis requiring cricotracheal resection (CTR). There were significant improvements in PEFR, Clinical COPD Questionnaire, and Voice Handicap Index-10, without significant difference in Eating Assessment Tool-10. The 12-Item Short Form Version 2 approximated the population norm. Kaplan-Meier analysis demonstrated significant improvement in time to surgery after the final laser resurfacing.

CONCLUSION

The Maddern procedure has a low complication rate and offers durable physiologic improvement in PEFR, limiting need for additional procedures. Risks included need for CTR salvage, temporary tracheostomy, phlegm accumulation, and laryngospasm. It is a surgical option for patients with short dilation intervals who prefer to avoid the risks of CTR.

Down-Regulation of a Profibrotic Transforming Growth Factor-β1/Cellular Communication Network Factor 2/Matrix Metalloprotease 9 Axis by Triamcinolone Improves Idiopathic Subglottic Stenosis

Idiopathic subglottic stenosis (iSGS) is a progressive fibrotic disease characterized by life-threatening airway narrowing. Although the molecular underpinnings are unknown, previous reports showing that subglottic serial intralesional steroid injections (SILSIs) improve clinical outcomes suggest a steroid-sensitive pathway in iSGS. Herein, a prospective study was conducted to determine the changes in profibrotic markers during SILSI to identify steroid-sensitive profibrotic drivers. Seven newly diagnosed patients with iSGS were recruited for SILSI. Subglottic biopsies before and after SILSI treatments were evaluated for histologic and molecular markers by confocal microscopy and RT-qPCR. At baseline, iSGS subglottises contained abundant vimentin-positive/α-smooth muscle actin-negative fibroblasts, intermingled with a matrix of fibronectin and types I and VI collagen. Transforming growth factor (TGF)-β1 was up-regulated primarily in glandular epithelium. Cellular communication network factor 2 (CCN2) was mainly up-regulated in stromal fibroblasts surrounding TGF-β1-positive glandular structures. SILSI improved iSGS by reducing fibroblast infiltration and increasing matrix remodeling. Mechanistically, SILSI counteracted the effects of TGF-β1 by inducing matrix metalloprotease 9 (MMP9) expression while repressing CCN2 expression, without affecting TGFβ1 levels. Treatment of primary iSGS-derived fibroblasts with TGF-β1 recapitulated aspects of the disease in vivo, demonstrating that the induction in CCN2 and repression of MMP9 are caused by changes in histone acetylation induced by TGF-β1. Triamcinolone counteracted the coregulation of these genes by impairing SMAD2/3 binding to promoter regions, and not through histone acetylation. In conclusion, this study shows that SILSI counteracts a dysregulated TGF-β1/CCN2/MMP9 axis involved in iSGS development.

Voice-Related Quality of Life in Idiopathic Subglottic Stenosis: Effect of Serial Intralesional Steroid Injections

OBJECTIVES

Serial intralesional steroid injection (SILSI) is an emerging treatment for idiopathic subglottic stenosis (ISGS), providing improvement in both subjective symptoms and objective airflow parameters. Little is known about how this airway remodeling affects the voice. This project analyzes subjective voice changes after SILSI and correlates these with airflow parameters.

METHODS

An ISGS database containing voice-related quality of life (V-RQOL) and spirometry (peak expiratory flow percentage [%PEF]) was retrospectively queried. Included were ISGS patients from 2009 to 2019 who had at least one SILSI treatment. Encounters without complete data were excluded. Differences between preprocedure and postprocedure metrics were calculated. Correlations and nonparametric bivariate analysis were performed.

RESULTS

Six hundred and seventeen steroid injections were performed in 55 patients, with an average of 3.5 years of follow-up. The average V-RQOL for all patient encounters, both pre- and postprocedure, showed little subjective dysphonia (83.5 of 100, 95% confidence interval [CI] 81.6 to 85.4). Considering SILSI-only treatments, there were 143 encounters with full data; of these, V-RQOL improved in 70 (49.0%), did not change in 40 (28.0%), and worsened in 33 (23.0%). Average V-RQOL improvement for the entire cohort was 1.9 points (95% CI: 0.7 to 3.2), which was small but significant (P = .0003). Across all data, there was a weak but significant correlation between PEF% and V-RQOL (ρ = 0.22, P = .0043).

CONCLUSION

SILSI was associated with improvement in subjective voice ratings in about half of patients, and the improvement correlated with improved airflow measurements. This research adds to the growing body of data regarding SILSI and suggests that further work on functional changes to the larynx with airway remodeling is imperative.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:366-369, 2021.