2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Reprinted by permission of Laryngoscope. 2018; 128(3):610-617.

The Laryngoscope V C 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Awake Serial Intralesional Steroid Injections Without Surgery as a Novel Targeted Treatment for Idiopathic Subglottic Stenosis

Ramon A. Franco Jr., MD ; Inna Husain, MD; Lindsay Reder, MD; Paul Paddle, MD

Objectives/Hypothesis: The fibrotic/erythematous appearance of the subglottis in idiopathic subglottic stenosis (iSGS) hints that it might respond to repeated intralesional steroid treatment similar to keloids. Study Design: Retrospective cohort study. Methods: Thirteen iSGS subjects (six treated in-office with serial intralesional steroid injections [SILSI] versus seven treated endoscopically in the operating room [OR] followed by awake SILSI) between October 2011 and April 2017. Forced spirometry was performed before injections and at each follow-up visit (peak expiratory flow [%PEF] and peak inspiratory flow). Steroids were injected via transcricothyroid or transnasal routes. Injections were grouped into rounds of four to six injections separated by 3 to 5 weeks. Results: Thirteen subjects with a mean follow-up of 3 years (3.3 years for SILSI and 2.7 years for OR). Awake-only SILSI subjects had a mean improvement/round of 23.1% %PEF (range, 65.4%–88.6%), whereas the OR-treated subjects had a mean %PEF improvement/round of 25.1% (range, 57.4%–82.5%). Both groups had improved breathing, and the improve- ments were statistically equal ( P 5 .569). SILSI subjects underwent 5.3 injections/round in 1.3 rounds, whereas OR subjects had 5.9 injections/round over 2.1 rounds. Statistically significant improvement was seen in %PEF for both groups (SILSI P 5 .007, OR P 5 .002). Overall, SILSI achieved sustained %PEF above 80% in 83% (5/6) and OR 1 SILSI 86% (6/7). Conclusions: SILSI in the awake outpatient setting can improve the airway caliber in iSGS and is equivalent to endo- scopic OR treatment. We believe iSGS can be viewed as a chronic scarring/inflammatory condition that can benefit from ste- roid scar-modification therapy. Key Words: Airway stenosis, reconstruction, idiopathic subglottic stenosis, steroid injection, in-office treatment. Level of Evidence: 4 Laryngoscope , 00:000–000, 2017

INTRODUCTION Idiopathic subglottic stenosis (iSGS) is a poorly understood and devastating progressive inflammatory cicatricial narrowing of the laryngeal airway that causes breathing difficulty nearly exclusively in women. The endoscopic appearance of the subglottis in iSGS suggests a combination of inflammation and scar, much like keloids in the skin (Fig. 1). The natural history of iSGS From the Division of Laryngology, Department of Otolaryngology ( R . A . F .), Harvard Medical School and Massachusetts Eye and Ear Infir- mary, Boston, Massachusetts, U.S.A.; Monash Health and Alfred Health ( P . P .), Victoria, Melbourne, Australia; Department of Otolaryngology ( I . H .), Rush University Medical Center, Chicago, Illinois, U.S.A.; and the Department of Otolaryngology ( L . R .), University of Southern California, Los Angeles, California, U.S.A. Editor’s Note: This Manuscript was accepted for publication on July 26, 2017. All work was performed at the Massachusetts Eye and Ear Infir- mary, Boston, Massachusetts, U.S.A. Presented at the 138th Annual Meeting of the American Laryngo- logical Association at COSM, San Diego, California, U.S.A., April 26–28, 2017. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ramon A. Franco Jr., MD, Medical Direc- tor, Voice and Speech Laboratory, Division of Laryngology, Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114. E-mail: ramon_ franco@meei.harvard.edu

includes airway narrowing and increasing dyspnea typi- cally treated with repeated surgical interventions. Although many consider iSGS to be a surgical dis- ease, the impressive level of scarring, inflammation, and the progressive nature of the disease, regardless of treat- ment modality offered, mandates a rethinking of the central role of surgery as monotherapy for this disease process. Although historically, cricotracheal resection (CTR) has been successful in restoring long-term airway patency (about 90%), 1 it is not ideal for all subjects because it requires open surgery under general anesthe- sia, which is not suitable for all subjects, 1 leaves the subject with a weak, dysphonic, and permanently husky and lower pitch voice without much pitch range (unable to sing), and often with some continued need for post- CTR dilations. 2 Because this is an idiopathic process, there is a problem with determining the margins of resection because the stenosis can extend up to the level of the vocal folds, making resection very difficult and risking severely damaging the voice. 1 Like conservative treatment for airway stenosis due to scarring, surgical monotherapy for keloids (skin scars), without steroid injections, has a high rate of recurrence (45%–100%). 3 We hypothesized that serial intralesional steroid injection (SILSI) could treat sub- glottic scar similar to skin scars. We compared two groups treated in the office with SILSI where only the

DOI: 10.1002/lary.26874

Laryngoscope 00: Month 2017

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