2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

A flexible distal-chip nasolaryngoscope was used to visual- ize the stenosis after adequately anesthetizing the nose (oxyme- tazoline 0.025% and lidocaine 2%) and the larynx (2mL of 4% lidocaine transtracheally). As per routine, key features of the stenosis (position, degree of narrowing, and erythema) were visually compared by the senior author ( R . A . F .) to the previous exams, and correlated to interval history and spirometry results to determine disease progression, stability, or improvement. Deciding Between OR Treatment or Awake SILSI Depending on the subject’s preference, the urgency for an immediately open airway, and after discussing the pros and cons of each approach, we decided together which option was best. Some subjects refused any suggestion of surgical intervention. Surgery was suggested when the %PEF was below 50%, the PIF was under 1.5L/sec, and in those who were symptomatic. Awake Steroid Injection (SILSI) Technique: Transcricothyroid Membrane and Transnasal Approaches Corticosteroids used (descending frequency) included tri- amcinolone acetate (Kenalog-40) 40mg/mL, dexamethasone (Decadron) 4mg/mL, methylprednisolone (Solu-Medrol) 40mg/ mL, and betamethasone (Celestone) 6mg/mL. Under flexible nasolaryngoscopic visualization, submuco- sal injection into the scar was performed by piercing the crico- thyroid membrane with a 25-gauge, 38-mm needle with the double-bend needle modification. 6 Blanching and tissue expan- sion within the subglottic scar at the level of maximal stenosis and just cephalad to it indicated proper steroid placement. A total of 0.5 to 2mL of steroid was injected each time. Occasion- ally, the injection was performed transnasally using an Interject Sclerotherapy 200-cm, 25-gauge needle (Boston Scientific, Marl- borough, MA) through the channeled videoendoscope. Regard- less of the approach used to inject steroids, subjects were asked to return every 3 to 4 weeks for repeat spirometry and injection for a total of six to seven injections; this constituted one round of treatment. OR Endoscopic Treatment All subjects who went to the OR underwent transoral endoscopic treatment under general anesthesia using intermit- tent apneic technique or supraglottic jet ventilation. Resection of the stenosis was accomplished mainly using cold instruments (forceps, scissors). Rarely, the CO 2 laser was used to remove dis- ease. A total of 4 to 10mL of triamcinolone 40mg/mL was injected into the area of stenosis followed by balloon dilation using a Boston Scientific controlled radial expansion balloon (Boston Scientific) inflated to 7 atm pressure (corresponding to a balloon diameter of 18mm). Three weeks after surgery, sub- jects started the awake SILSI protocol. SILSI Termination, Active Observation, and More Treatment The decision to stop SILSI was based upon disease improvement/decline, as judged by the subject’s functional sta- tus, stenosis appearance, and spirometry results. Disease improvement led to active observation involving office visits every 2 to 6 months, during which spirometry, an update to the breathing-specific history, and occasionally, an endoscopic air- way examination were performed. Decline in function during

second group went to the operating room (OR) before undergoing a full course of in-office SILSI. MATERIALS AND METHODS Group 1 comprised six subjects treated exclusively with in-office SILSI, whereas group 2 comprised seven subjects treated in the OR endoscopically (resection 1 steroids 1 balloon) followed by in-office SILSI. These 13 subjects were treated between October 2011 and April 2017. Subjects were included if they had at least 10 months of follow-up, completed their SILSI schedule, and could perform office-based spirometry at each visit. A diagnosis of iSGS was made if there was no evidence on history and serologic investigations of an underlying etiology. Massachusetts Eye and Ear Institutional Review Board approval (study #283895-4) was obtained. A handheld open-circuit digital spirometer (Microloop Spi- rometer; CareFusion, Sheffield, United Kingdom) (Fig. 2) was used during each visit (treatment and follow-up) to obtain the peak inspiratory flow (PIF) and peak expiratory flow (PEF) 4 using American and European Thoracic Society protocols. 5 Pul- monary function tests (PFTs) were performed prior to anesthe- tizing the airway or any interventions. Because the percentage of predicted PEF (%PEF) is normalized for the subject’s age, sex, and height, it was used as the key objective stenosis sever- ity measure that allowed us to compare results between subjects. Fig. 1. Idiopathic subglottic stenosis (iSGS) is a cicatricial inflam- matory condition that affects the laryngeal airway at the level of the cricoid usually in women. The prominent scar bands with gen- eralized erythema can be appreciated in this image of one of the 13 iSGS subjects in this study. Some of these scar bands extend up to involve the inferior aspect of the membranous vocal folds. The narrowness of the airway is apparent. Of note, all subjects in this study used their native airways to breathe (no tracheotomy tubes). The inset is a photomicrograph of the subglottic stenosis specimen. The pathologist’s official reading was that there were “fragments of squamous mucosa with marked fibrosis, acute and chronic inflammation, and granulation tissue.” This is the typical final pathologic diagnosis interpretation we see with these sam- ples at our institution. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.] Initial Clinical Presentation and Stenosis Severity Measures

Laryngoscope 00: Month 2017

Franco et al.: Intralesional Steroid Injections for iSGS

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