Treatment for adult idiopathic and Wegener-associated subglottic stenosis

Abstract

The aim of the study is to present the results of combination treatment for adult non-traumatic subglottic stenosis (SGS). This is a retrospective chart review of 12 female patients (age range 32-76 years) with idiopathic SGS (eight patients) and Wegener's granulomatosis. All patients had a hard and 11 a short (less than 1 cm) stenosis. Eleven patients were treated with endoscopic CO(2) laser, one with Nd-YAG laser. Topical triamcinolone was applied to all. In 10 patients, topical mitomycin C (MMC) was additionally applied. Symptom severity and airway resistance (AR) were evaluated pre- and post-interventionally. Postoperatively, oral steroids (and/or methotrexate) and proton pump inhibitors (PPI) were prescribed. Follow-up period ranged between 7 and 115 months. All patients reported a significant improvement in obstructive symptoms. Average AR preoperatively was 1.004 kPa/(L/s) and postoperatively 0.526 kPa/(L/s). Three patients underwent surgery once, 2 required a second surgery, 5 were operated 3 times, one 5 times, and one 7 times. The latter two patients had not received local MMC treatment. Endoscopic laser surgery combined with local MMC and triamcinolone application and postoperative oral steroid/methotrexate and PPI therapy provides a treatment option that results in prolongation of the symptom-free time intervals and avoidance of open surgery in patients with idiopathic and Wegener-associated hard and short SGS.

Office‐based corticosteroid injections as adjuvant therapy for subglottic stenosis

“…Recent studies have prompted the consideration that better treatment modalities exist outside the surgical realm, used in combination or possibly even standalone, to achieve successful management of SGS. The concept of adjuvant therapy has already been well investigated for SGS with anti‐inflammatory/immunomodulating agents such as mitomycin C, inhaled corticosteroids, proton‐pump inhibitors, antibiotics, and methotrexate based on the principle that SGS pathophysiology is heavily driven by inflammation and fibroblast proliferation . In Maldonado et al study, a trend between aggressive medical treatment (anti‐reflux medications, inhaled corticosteroids, and trimethoprim‐sulfamethoxazole) and lowered idiopathic SGS recurrence rate was identified demonstrating a relative risk of 0.52, P = .051 with adjuvant treatments versus no further treatments after endoscopic surgery .…”

The role of pepsin in epithelia‐mesenchymal transition in idiopathic subglottic stenosis

“…Gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), also known as extraesophageal reflux , is a comorbidity of iSGS in 47% to 70% of cases. Anti‐reflux medical therapy has demonstrated success independently or as an adjunct to surgical treatment . Physiologically, relevant concentrations of bile acids induce markers of EMT in human primary tracheal epithelial cells, demonstrating a potential role for refluxed bile acids in tracheal scarring and remodeling and thus in stenosis …”

Mitomycin C in the Endoscopic Treatment of Laryngotracheal Stenosis: Systematic Review and Proportional Meta-Analysis

“…Two different interventions, with and without MMC, were performed in four studies. 6,9,13,16 In the remaining studies, the intervention was always with MMC. The type of intervention in each study, the dose and time of MMC application, the number of procedures performed, the follow-up period, and the treatment outcomes are detailed in ►Table 1.…”