2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

of existing stenotic disease without the need for surgery. SILSI can be viewed as scar modification treatment.

Limitations of the Study The main limitations to the study are the small sample size and the retrospective nonrandomized design. iSGS is a rare entity, making it difficult to accrue large numbers into a research study. There is a necessary degree of selection bias with respect to assigning sub- jects into treatment groups. This might have impacted on any observed difference between the two groups, but would not have impacted the presence of a treatment effect in either of the groups. We do not know the opti- mal interval for steroid injections, the best steroids to use, the proper dose, or how long to treat before we stop and observe. It is very important to optimize these varia- bles to keep the inflammatory response suppressed dur- ing healing and effect a change in the iSGS process. Pulmonary function tests are effort dependent, and like all other effort-dependent variables, can vary slightly around a mean even if there is no change in the system. 1. SILSI is well tolerated as an in-office, awake treatment. 2. Steroids are ubiquitous and inexpensive. 3. Awake SILSI is minimally invasive (i.e., minimum morbidity) and quick (i.e., maximum convenience). 4. %PEF allows us to calculate intervention effects objectively and accurately monitor the degree of stenosis. 5. There is no surgical alteration of the laryngotracheal super- structure, unlike with CTR, just removal of the stenosis. 6. It does not harm the voice. The number one post-CTR com- plaint is hoarseness with inability to sing. 7. It can be combined with other treatments, such as balloon dilations or surgery. CONCLUSION This is the first study to describe clinically and sta- tistically significant, quantitative, and sustained improvements in the airway caliber of iSGS subjects using SILSI. It demonstrates that SILSI has the ability to modulate the scarring process and improve the caliber SILSI ADVANTAGES This study describes a novel treatment for iSGS with several advantages:

ACKNOWLEDGMENTS The authors acknowledge and thank the various col- leagues who worked clinically with each of these subjects and helped to care for them. Through the course of their work, they contributed to the robustness of the data that support the central idea that as surgeons we can help our subjects to heal better. These former colleagues include: Kwang Sung, MD, currently at Stanford University; Jihad Achkar, MD, in practice in Beirut, Lebanon; Joshua Silver- man, MD, PhD, at the State University of New York at Brooklyn; and Jayme Dowdall, MD, at Brigham and Wom- en’s Hospital. BIBLIOGRAPHY 1. Ashiku SK, Kuzucu A, Grillo HC, et al. Idiopathic laryngotracheal steno- sis: effective definitive treatment with laryngotracheal resection. J Thorac Cardiovasc Surg 2004;127:99–107. 2. Smith ME, Roy N, Stoddard K, Barton M. How does cricotracheal resec- tion affect the female voice? Ann Otol Rhinol Laryngol 2008;117:85–89. 3. Gauglitz GG, Korting HC, Pavicic T, Ruzicka T, Jeschke MG. Hypertrophic scarring and keloids: pathomechanisms and current and emerging treat- ment strategies. Mol Med 2011;17:113–125. 4. Nouraei SM, Franco RA, Dowdall JR, et al. Physiology-based minimum clinically important difference thresholds in adult laryngotracheal steno- sis. Laryngoscope 2014;124:2313–2320. 5. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005;26:319–338. 6. Achkar J, Song P, Andrus J, Franco R Jr. Double-bend needle modification for transthyrohyoid vocal fold injection. Laryngoscope 2012;122:865–867. 7. Robles DT, Berg D. Abnormal wound healing: keloids. Clin Dermatol 2007; 25:26–32. 8. Boyadjiev C, Popchristova E, Mazgalova J. Histomorphologic changes in keloids treated with Kenacort. J Trauma 1995;38:299–302. 9. Cruz NI, Korchin L. Inhibition of human keloid fibroblast growth by iso- tretinoin and triamcinolone acetonide in vitro. Ann Plast Surg 1994;33: 401–405. 10. Reish RG, Eriksson E. Scar treatments: preclinical and clinical studies. J Am Coll Surg 2008;206:719–730. 11. Atiyeh BS. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods. Aesthetic Plast Surg 2007;31:468–492; discussion 493–494. 12. Jalali M, Bayat A. Current use of steroids in management of abnormal raised skin scars. Surgeon 2007;5:175–180. 13. Yii NW, Frame JD. Evaluation of cynthaskin and topical steroid in the treatment of hypertrophic scars and keloids. Eur J Plast Surg 1996;19: 162–165. 14. Widgerow AD, Chait LA, Stals R, Stals PJ. New innovations in scar man- agement. Aesth Plast Surg 2000;24:227–234. 15. Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommen- dations on scar management. Plast Reconstr Surg 2002;110:560–571.

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Franco et al.: Intralesional Steroid Injections for iSGS

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