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Bell RK, Lentz SA, Patten JC, Atchinson PRA, Roginski MA. Airway and Ventilator Management in a New Presentation of Idiopathic Subglottic Stenosis: A Case Report. Air Med J 2024; 43:450-453. [PMID: 39293925 DOI: 10.1016/j.amj.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 06/04/2024] [Indexed: 09/20/2024]
Abstract
In the acute setting, subglottic stenosis poses a unique airway management challenge, particularly when presenting to a facility where subspecialty care is not available. We present a case of idiopathic subglottic stenosis with acute respiratory distress managed at a community hospital to highlight the challenges of diagnosis, initial airway management, and mechanical ventilation of this rare but life-threatening condition.
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Schweipert J, Riediger C, Balandat JE, Bonkowsky V, Kahlert C, Kraus D. The role of local expression of hormone receptors in the genesis of idiopathic tracheal stenosis. J Thorac Dis 2023; 15:2948-2957. [PMID: 37426118 PMCID: PMC10323589 DOI: 10.21037/jtd-22-1687] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 04/07/2023] [Indexed: 07/11/2023]
Abstract
Background Tracheal stenosis in adults is usually the result of mechanical injuries either from direct trauma, tracheotomy or intubation. Idiopathic stenosis in the cricotracheal section is a rare condition and occurs almost exclusively in females. Therefore, an influence of the female sexual hormones estrogen and progesterone has been assumed previously. Methods Tracheal specimens of 27 patients who received tracheal resection for either idiopathic tracheal stenosis (ITS) (n=11) or posttraumatic tracheal stenosis (PTTS) (n=16) between 2008 and 2019 in our surgical department were included and retrospectively analyzed. Immunohistochemical staining of tracheal specimens concerning the hormone receptor status of progesterone and estrogen was performed. Results While post-tracheotomy stenosis occurred in males (n=6) as well as in females (n=10), none of the patients with idiopathic stenosis were males. All of the idiopathic stenosis (n=11; 100%) showed a strong expression of the estrogen receptors (ERs) in the fibroblasts and expression of progesterone receptors (PRs) in fibroblasts in 8 of 11 (72.7%). In the post-tracheotomy patients, only 3/16 (18.8%) showed slight staining of PRs and 6/16 (37.5%) of ERs. Of those, only one male patient presented with expression of ERs and PRs and another male patient presented with isolated PRs. Oral intake of hormone compounds was seen in 11/27 (40.7%) patients: 7/11 (63.6%) in the ITS group and 4/16 (25%) in the PTTS (noteworthy that the PTTS group included 6 male patients). Conclusions Although the number of patients is small, our results show that the expression of female sexual hormone receptors in the fibroblasts of the trachea is a persistent finding in ITS. Surgery provided good results with a favorable long-term outcome without recurrence of stenosis for ITS and PTTS. Further investigation with a special focus on hormones is needed to assist in the prevention of this rare disease.
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Affiliation(s)
- Johannes Schweipert
- Department of General, Visceral and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Viktor Bonkowsky
- Department of Ear, Nose and Throat Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Dietmar Kraus
- Department of General, Visceral and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
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Miller EJ, Huning EYS. Subglottic tracheal stenosis complicating pregnancy: A case report. Obstet Med 2022; 15:205-207. [PMID: 36262817 PMCID: PMC9574454 DOI: 10.1177/1753495x21990220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/22/2020] [Accepted: 12/30/2020] [Indexed: 09/03/2023] Open
Abstract
The case presented details an uncommon case of subglottic tracheal stenosis exacerbated by pregnancy. We outine the multidisciplinary management involved and the outcomes for the pregnancy. The case serves as a reminder that shortness of breath in pregnancy has a broad differential diagnosis, and stridor is always abnormal.
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Kanzara T, Rotman A, Kinshuck A, Al Yaghchi C, Tan MY, Yu C, Sandu G. Endoscopic management of idiopathic subglottic stenosis in pregnancy. Obstet Med 2021; 14:225-229. [PMID: 34880935 DOI: 10.1177/1753495x21991407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/30/2020] [Indexed: 11/15/2022] Open
Abstract
Aims To describe the use of laser, endoscopic balloon dilatation with jet ventilation anaesthesia in the treatment of pregnant women with idiopathic subglottic stenosis. Materials and methods This is a case review of pregnant women with idiopathic subglottic stenosis, presenting to a tertiary referral centre with worsening breathlessness. Data were extracted from patient case notes. Results Four women underwent surgical management of subglottic stenosis in pregnancy. One patient required two procedures during the course of their pregnancy due to restenosis. All women had improvement in symptoms post-operatively and went on to deliver healthy babies at term. Conclusion Endoscopic balloon dilatation of idiopathic subglottic stenosis is a safe and viable treatment option in pregnancy and should be offered as first-line treatment in symptomatic women.
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Affiliation(s)
- Todd Kanzara
- ENT Department, Aintree University Hospital, Liverpool, UK
| | - Anthony Rotman
- National Centre for Airway Reconstruction, Imperial College Healthcare NHS Trust, London, UK
| | | | - Chadwan Al Yaghchi
- National Centre for Airway Reconstruction, Imperial College Healthcare NHS Trust, London, UK
| | - Min Yi Tan
- National Centre for Airway Reconstruction, Imperial College Healthcare NHS Trust, London, UK
| | - Christina Yu
- National Centre for Airway Reconstruction, Imperial College Healthcare NHS Trust, London, UK
| | - Guri Sandu
- National Centre for Airway Reconstruction, Imperial College Healthcare NHS Trust, London, UK
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Ellis H, Iliff HA, Lahloub FMF, Smith DRK, Rees GJ. Unexpected difficult tracheal intubation secondary to subglottic stenosis leading to emergency front-of-neck airway. Anaesth Rep 2021; 9:90-94. [PMID: 33982001 DOI: 10.1002/anr3.12115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 12/19/2022] Open
Abstract
A 26-year-old woman presenting for an elective day case procedure under general anaesthesia had undiagnosed subglottic stenosis leading to a life threatening airway emergency requiring emergency front-of-neck airway. We outline the case and discuss key anaesthetic considerations in subglottic stenosis, including concerning features of a medical/anaesthetic history and the potential for rapid deterioration of a stenotic airway following manipulation. We also consider the effect of anaesthesia on the calibre of subglottic stenosis and the effects of positive pressure ventilation. Subglottic stenosis is a rare condition with congenital, acquired and idiopathic origins; however, iatrogenic trauma is the most common cause. We are aware of a small number of published case reports of previously undiagnosed subglottic stenosis in adults discovered after induction of anaesthesia; situational deterioration to 'cannot intubate, cannot oxygenate' scenarios appear even rarer.
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Affiliation(s)
- H Ellis
- Department of Anaesthesia Royal Glamorgan Hospital Merthyr Tydfil UK
| | - H A Iliff
- Department of Anaesthesia Prince Charles Hospital Llantrisant UK
| | | | - D R K Smith
- Department of Ear, Nose and Throat Surgery Royal Glamorgan Hospital Merthyr Tydfil UK
| | - G J Rees
- Department of Anaesthesia Prince Charles Hospital Llantrisant UK
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Fang S, Pai B H P. Successful management of subglottic stenosis in pregnancy. BMJ Case Rep 2021; 14:14/3/e236466. [PMID: 33762270 PMCID: PMC7993347 DOI: 10.1136/bcr-2020-236466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Evaluation and management of subglottic stenosis in pregnancy is challenging. It often is not only a multidisciplinary approach between obstetricians, otolaryngologists (ENT surgeons) and anesthesiologists, but also requires a thorough understanding of possible foreseen complications by the patient as well. Hence, whenever we are presented with a challenging case requiring multidisciplinary approach involving team of physicians from different specialties, it is routine practice to huddle regarding the preoperative, intraoperative and postoperative management and care. We present a case of a 37-year-old woman with a known history of idiopathic subglottic stenosis, 16 weeks' pregnant, G4P1, with a surgical history significant for two previous subglottic dilations in the past and who now presented with an audible stridor and shortness of breath on activity. We highlighted the unique challenges encountered and the corresponding management adopted. This is a case of successful management of symptomatic worsening of subglottic stenosis managed during pregnancy.
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Affiliation(s)
- Shenghao Fang
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai West And Morningside Hospitals, Mount Sinai Health System, New York, New York, USA
| | - Poonam Pai B H
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai West And Morningside Hospitals, Mount Sinai Health System, New York, New York, USA
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McCrary H, Torrecillas V, Conley M, Anderson C, Smith M. Idiopathic Subglottic Stenosis during Pregnancy: A Support Group Survey. Ann Otol Rhinol Laryngol 2020; 130:188-194. [PMID: 32772565 DOI: 10.1177/0003489420947780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES (1) To determine how pregnancy affects idiopathic subglottic stenosis (iSGS) symptoms. (2) To determine treatments utilized (including operating room (OR) and in-office procedures) for iSGS before, during, and after pregnancy. METHODS A 24-question survey was distributed to an international iSGS support group to assess the patient experience among individuals who have been pregnant with diagnosis of iSGS. Descriptive statistics and chi2 analyses were completed. RESULTS A total of 413 iSGS patients participated; 84.7% (n = 350) of patients were diagnosed prior to menopause. A total of 25.5% patients reported being pregnant when they had airway stenosis; 71.1% of those reported more severe airway symptoms during pregnancy. The proportion of patients that reported requiring ≥1 OR interventions (microlaryngoscopy and bronchoscopy, laser, balloon dilation, or steroid injection) before, during and after pregnancy was the following, respectively: 37.3%, 35.6%, 51.3%. Whereas the proportion of patients that reported requiring ≥1 in-office interventions (awake balloon dilation or steroid injection) before, during and after pregnancy was the following, respectively: 13.6%, 11.8%, 15.8%. Number of pregnancies and age of diagnosis was not related to severity of symptoms or requiring more airway interventions (P > .05). CONCLUSIONS This survey reveals worsening of symptoms during pregnancy, however, this did not lead to increase in operative or clinic interventions to improve airway symptoms during pregnancy. Future avenues for research include optimizing management of airway symptoms during pregnancy to limit OR-based interventions. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hilary McCrary
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Vanessa Torrecillas
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Matthew Conley
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Marshall Smith
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
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Management of subglottic stenosis in pregnancy using advanced apnoeic ventilatory techniques. The Journal of Laryngology & Otology 2019; 133:399-403. [DOI: 10.1017/s0022215119000690] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveTo describe the use of balloon dilation with non-invasive ventilation in the treatment of pregnant patients with idiopathic subglottic stenosis.MethodsThe medical charts of four consecutive patients who underwent jet ventilation or high-flow nasal cannula oxygenation with balloon dilation for the treatment of idiopathic subglottic stenosis during pregnancy were reviewed.ResultsObjective improvement of subglottic stenosis was seen in all four cases, with end-result Myer–Cotton grade 1 lesions down from pre-procedure grade 3 lesions. Patients also reported subjective improvements in symptomatology, with no further airway issues. All patients delivered normally, at term.ConclusionLaryngeal dilation with continuous radial expansion pulmonary balloons using non-invasive ventilation for the treatment of idiopathic subglottic stenosis in pregnant patients is safe and efficacious, and should be the first line treatment option for this patient population. The improvement in symptoms, and lack of labour and pregnancy complications, distinguish this method of treatment from others reported in the literature.
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Kinsella S, Winton A, Mushambi M, Ramaswamy K, Swales H, Quinn A, Popat M. Failed tracheal intubation during obstetric general anaesthesia: a literature review. Int J Obstet Anesth 2015; 24:356-74. [DOI: 10.1016/j.ijoa.2015.06.008] [Citation(s) in RCA: 219] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/23/2015] [Accepted: 06/24/2015] [Indexed: 11/27/2022]
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Carness JM, Berman JL. Awake Microlaryngoscopy and Serial Balloon Dilation in a Third Trimester Multigravida with Subglottic Tracheal Stenosis. ACTA ACUST UNITED AC 2014; 3:166-8. [DOI: 10.1213/xaa.0000000000000098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nash Z, Krishna A, Darwish M, Mascarenhas L. Conservative management of subglottic stenosis in pregnancy resulting in vaginal birth. BMJ Case Rep 2014; 2014:bcr-2013-202137. [PMID: 24700036 DOI: 10.1136/bcr-2013-202137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of subglottic stenosis complicating pregnancy. The patient was born prematurely at 24 weeks gestation and required a twelve-month period of intubation. Airway trauma from prolonged intubation resulted in acquired subglottic stenosis. As an adult the patient had a longstanding audible stridor; however, was not breathless during activity before or during pregnancy. The patient went into spontaneous labour at 37+4 weeks and delivered vaginally with epidural analgesia. This case is significant, as no cases of a patient with such a degree of stenosis delivering vaginally without airway treatment have been reported.
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Affiliation(s)
- Zachary Nash
- Department of Medicine, King's College London, London, UK
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