Subglottic Stenosis in Granulomatosis With Polyangiitis: The Role of Laryngotracheal Resection

Current Therapeutic Approaches to Subglottic Stenosis in Patients With GPA: A Systematic Review

BACKGROUND

The management of subglottic stenosis (SGS) in granulomatosis patients with polyangiitis (GPA) has no clear guidelines. This systematic review aimed to identify different surgical techniques and evaluate the outcomes of applied procedures.

METHODS

An electronic search was performed using 3 major databases, CINAHL, PubMed, and Clinical key, to include relevant studies published from the databases from inception through January 2017. All primary studies reporting treatment of SGS in cases with GPA were included. Articles were excluded if not relevant to the research topic or if they were duplicates, review articles, editorials, short comments, unpublished data, conference abstracts, case reports, animal studies, or non-English studies.

RESULTS

Thirteen papers were included in our systematic review with a total of 267 cases for the qualitative review Endoscopic approaches showed favorable outcomes with the need to use multiple procedures to achieve remission. The open transcervical approach showed excellent results mainly after failure of other endoscopic techniques. Tracheostomy was necessary for severe respiratory obstruction symptoms. Medical treatment was essential for stabilizing the active disease and therefore may enhance the success rate postoperatively.

CONCLUSION

Subglottic stenosis in patients with GPA requires a multidisciplinary approach to provide optimal management regarding disease activity, grade of stenosis, and severity of symptoms.

Analysis of Complications in (Crico-) Tracheal Resection Anastomosis in Adults: A Multicenter Study

OBJECTIVES

The gold standard treatments for advanced laryngotracheal stenosis (LTS) are represented by partial crico-tracheal (PCTRA) or tracheal resection and anastomosis (TRA). These procedures are potentially burdened by high postoperative complication rates. We investigated the impact of the most common stenosis and patient-related characteristics on the onset of complications in a multicentric cohort.

METHODS

We retrospectively analyzed patients who underwent PCTRA or TRA for LTS of different etiologies in three referral centers. We tested the effectiveness of these procedures, the impact of complications on the outcomes, and identified factors causing postoperative complications.

RESULTS

A total of 267 patients were included in the study (130 females; mean age, 51.46 ± 17.64 years). The overall decannulation rate was 96.4%. Altogether, 102 (38.2%) patients presented at least one complication, whereas 12 (4.5%) had two or more. The only independent predictor of post-surgical complications was the presence of systemic comorbidities (p = 0.043). Patients experiencing complications needed additional surgery more frequently (70.1% vs. 29.9%, p < 0.001), and had a longer duration of hospitalization (20 ± 10.9 vs. 11.3 ± 4.1 days, p < 0.001). Six of 102 (5.9%) patients with complications had restenosis, although this event did not occur among patients without complications.

CONCLUSION

PCTRA and TRA have an excellent success rate even when performed for high-grade LTS. However, a significant percentage of patients may experience complications associated with a longer duration of hospitalization or the need for additional surgeries. The presence of medical comorbidities was independently related to an increased risk of complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2910-2919, 2023.

Role of systemic immunosuppression on subglottic stenosis in granulomatosis with polyangiitis: Analysis of a single-centre cohort

PURPOSE

Subglottic stenosis (SGS) is a potentially life-threatening manifestation of granulomatosis with polyangiitis (GPA). Endoscopic dilation is effective, but relapses are frequent and the benefit of systemic immunosuppression in this setting is still controversial. We aimed to investigate the role of immunosuppressive treatment on SGS relapse risk.

METHODS

This is a retrospective observational study based on review of medical charts among our cohort of patients with GPA.

RESULTS

Twenty-one patients with SGS-GPA were identified, with a prevalence of 20% among our entire GPA cohort (n = 105). Compared to patients without SGS, patients with SGS-GPA had an earlier disease onset (mean age 30.2 vs. 47.3 years, p<0.001), and lower BVAS (mean 10.5 vs 13.5; p = 0.018). Five patients didn't receive systemic immunosuppression for SGS and they all (100%) relapsed after the first procedure, while among medical treatment group relapse rate was 44% (p = 0.045). When single treatment regimens are considered, rituximab (RTX) and cyclophosphamide (CYC) yielded a protective role towards the need of subsequent dilation procedure after the first if compared with absence of medical treatment. Patients with SGS and generalized disease, who initially received either a RTX- or a CYC-based induction treatment, and higher cumulative doses of glucocorticoids, showed a delayed median time to SGS relapse (36 vs. 12 months, p = 0.024).

CONCLUSIONS

Subglottic stenosis is highly prevalent in patients with GPA and may define a milder systemic disease subset occurring more frequently in younger patients. Systemic immunosuppression provides benefit in preventing recurrence of SGS in GPA patients and regimens based on cyclophosphamide or rituximab might have a non-redundant role in this setting.

Systemic and Local Medical or Surgical Therapies for Ear, Nose and/or Throat Manifestations in ANCA-Associated Vasculitis: A Systematic Literature Review

BACKGROUND

Ear, nose and throat (ENT) manifestations are common in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), yet how to treat these manifestations remains controversial. Therefore, we systematically reviewed the literature on the efficacy of therapies on ENT manifestations in AAV.

METHODS

A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline, Embase and Cochrane libraries, including clinical studies between January 2005 and January 2022, in adults with AAV and ENT involvement, reporting on the effects of local and systemic therapy. The critical appraisal was performed using tools provided by the Cochrane Library and the level of evidence (LoE) was scored according to the Oxford Centre for Evidence-based Medicine.

RESULTS

After screening 5609 identified studies, 136 full-text articles were assessed. Finally, 31 articles were included for critical appraisal and data-extraction. Nearly all studies (n = 29) were retrospective and scored low on LoE. The included studies evaluated local interventions (n = 11), glucocorticoids combined with conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) (n = 8), rituximab (n = 6), or mepolizumab (n = 6). Due to heterogeneity across studies meta-analysis was not performed. Four studies on mepolizumab for sinonasal symptoms (n = 92) showed response in 33-100% and relapse in 35%. Local therapy for subglottic stenosis was effective in 80-100% of patients in 11 studies (n = 157), but relapses were common (up to 83%). In five studies, hearing improvement was observed in 56-100%, with better outcomes when glucocorticoids were combined with csDMARDs compared to glucocorticoids only.

CONCLUSION

Response rates of ENT manifestations varied widely in studies and relapses were observed frequently. Heterogeneity among studies impaired comparison.

Multi-disciplinary management of patients with benign airway strictures: A review

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.

Pregnancy-associated idiopathic laryngotracheal stenosis: presentation, management and results of surgical treatment

OBJECTIVES

Idiopathic laryngotracheal stenosis (ILTS) is an uncommon problem arising mostly in women. In some, it arises during or is exacerbated by pregnancy. Experience with management of patients with this rare association is limited. This study seeks to evaluate the management of patients with pregnancy-associated ILTS and compare outcomes to cases not associated with pregnancy.

METHODS

Retrospective review of 15 patients undergoing surgical treatment of pregnancy-associated ILTS from 1971 to 2013. Variables of interest and airway outcomes were compared to patients with non-pregnancy-associated ILTS.

RESULTS

Pregnancy-associated ILTS was observed in 15/263 (5.7%) patients. Symptoms developed during their first pregnancy. When compared to non-pregnancy patients, these patients were younger (37 vs 47 years; P = 0.0003), had more prior tracheostomies (26.7% vs 10.9%; P = 0.085) and had more preoperative airway dilatations (86.7% vs 57.7%; P = 0.030). All patients completed pregnancy without complications and ultimately underwent laryngotracheal resection. The expression of hormonal receptors in the surgical specimens was similar in both groups (oestrogen receptors: 100% vs 75% and progesterone receptors: 71.4% vs 72.1%, in pregnancy and non-pregnancy patients, respectively). Airway outcomes were good/excellent in 13 (86.7%) patients with pregnancy-associated ILTS and 225 (90.7%) patients without pregnancy association (P = 0.642), and did not change when adjusting for other risk factors.

CONCLUSIONS

Pregnancy-associated ILTS is rare. The pathophysiology is unclear, but appearance of symptoms during pregnancy may suggest hormonal factors. To minimize foetal risk, dilatation during pregnancy followed by laryngotracheal resection after delivery is the preferred treatment. Pregnancy association does not seem to affect outcomes with expected satisfactory results in most patients.

Prevention and management of complications following tracheal resections-lessons learned at the Massachusetts General Hospital

Tracheal surgery has developed and evolved over the last 50 years, becoming an integral part of the clinical practice of modern thoracic surgeons. Today, surgeons can safely and effectively operate on most patients suffering from post-intubation tracheal stenosis, tracheal tumors and other pathologies that result in an abnormal shape and function of the central airways. The Massachusetts General Hospital (MGH) in Boston witnessed first-hand the birth and growth of tracheal surgery under Dr. Hermes Grillo, becoming a reference center and accumulating one of the largest institutional experiences in the world. This vast experience of the management of patients with tracheal pathologies has allowed our group at MGH to refine the care of these patients, including their judicious preoperative evaluation, meticulous surgical treatment, and dedicated postoperative care. However, this experience has also provided valuable lessons on the potential complications that can arise after tracheal surgery. Here, we attempt to accumulate our institutional knowledge and experience to provide a summary of the key aspects to prevent complications following tracheal resections. Unfortunately, complications can occur despite strict adherence to the core principles of tracheal surgery, and therefore, we also highlight our institutional experience with the early recognition and management of the most common and dreaded complications.