Office-based corticosteroid injections as adjuvant therapy for subglottic stenosis

Symptom-Free Intervals Following Laser Wedge Excision for Recurrent Idiopathic Subglottic Stenosis

OBJECTIVE

Analyze the duration of symptom-free intervals following laser wedge excision (LWE) for recurrent idiopathic subglottic stenosis (iSGS). Secondary aim includes evaluating the influence of patient-related or disease factors.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary center.

METHODS

Review of iSGS patients who underwent LWE between 2002 and 2021. LWE patients without prior airway surgery were labeled LWE primary (LWEP) and those with prior history of dilation were labeled LWE secondary (LWES). A conditional frailty repeated events model was used to analyze the median time to recurrence (MTR) for each nth recurrence. Secondary analysis included stratification by use of medical therapy and initial preoperative characteristics of scar (Myer-Cotton grade, distance between the glottis and superior-most aspect of scar, DGS; length of scar, DL).

RESULTS

Two hundred and ten iSGS patients underwent LWE (131 LWEP, 79 LWES). The proportion of patients experiencing at least 1, 3, 6, and 12 recurrences, respectively, was 68.0% (n = 143), 40.7% (n = 85), 20.0% (n = 42), and 5.2% (n = 11). There was exponential time-shortening from the 1st to 12th recurrence (P < .0001). While MTR was 4.1 years after the first LWE, this fell to 2.8, 1.7, 1.0, and 0.7 years for the 2nd, 3rd, 6th, and 12th recurrences. Furthermore, LWEP patients experienced longer MTR than LWES counterparts within the first 6 recurrences (P < .01). There was no significant relationship between intersurgical interval and medication adherence, DL, DGS, or grade for recurrences beyond the first (P = .207, P = .20, P = .43, P = .16).

CONCLUSION

Symptom-free intervals in iSGS shorten with each subsequent recurrence and LWE. The difference in MTR between LWEP and LWES groups was significant within the first 6 recurrences with LWEP having longer MTR.

LEVEL OF EVIDENCE: 3

Laser Versus Cold Steel for Endoscopic Management of Subglottic Stenosis

OBJECTIVE

Endoscopic management of subglottic stenosis (SGS) includes a wide range of techniques. This 17-year review compares treatment outcomes between carbon dioxide (CO2) laser and cold steel.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care center.

METHODS

A chart review was performed for all patients undergoing endoscopic treatment of SGS at Cleveland Clinic between July 12, 2000 and September 1, 2017. Data collected included demographics, stenosis etiology, stenosis severity, comorbidities, treatment modality, and airway procedure history. The primary endpoint was repeated treatment-free survival (RTFS) within 2 years using a Kaplan-Meier analysis and Cox proportional hazard model.

RESULTS

A total of 139 patients (median [interquartile range] aged 48.7 [37.8, 57.0] years; 83.4% female) were included in the analysis, with etiologies including idiopathic (56.8%), granulomatosis with polyangiitis (25.2%), and intubation (16.5%). All patients underwent either cold steel (107 patients) or CO2 laser (32 patients) lysis of stenosis with concurrent dilation. RTFS within 2 years was 50.2% for CO2 laser and 31.9% for cold steel (hazard ratio [HR] and 95% confidence interval [CI]: 1.69, 0.96-2.97, P = .07). In patients with no prior airway procedures, there was no difference in RTFS between laser and cold knife (P = .41). However, in patients with prior airway procedures, RTFS was significantly greater in the laser group, even after adjusting for age, smoking history, and stenosis etiology (50.0% vs 16.8%, adjusted HR and CI: 2.82, 1.14-6.98, P = .025).

CONCLUSION

Endoscopic lysis of SGS with CO2 laser should be considered in revision cases.

Predictors of Clinical Outcomes in Adult Laryngotracheal Stenosis

OBJECTIVES

Sequelae of laryngotracheal stenosis (LTS) can be devastating, often necessitating tracheostomy. This study aims to describe the characteristics and outcomes of patients with LTS and identify risk factors for long-term tracheostomy dependence stratified by etiology.

METHODS

A retrospective chart review was performed on 215 patients diagnosed with LTS from 09/01/2011 to 12/31/2020. Patients were grouped based on the cause of LTS. Patient factors were compared to evaluate risk factors for long-term tracheostomy dependence.

RESULTS

Of the 215 patients, 129 (60%) were classified as iatrogenic, 41 (19%) idiopathic, 10 (4.7%) cancer treatment, 18 (8.3%) autoimmune, and 17 (8%) patients unknown. Idiopathic patients were significantly less likely to be tracheostomy-dependent compared with iatrogenic patients (p < 0.001) and cancer patients (p < 0.05). The mortality rate did not significantly differ among the categories (p = 0.1078). Significant improvement was seen after treatment, as the median percent of stenosis at presentation was 52.5%, and the median percent of stenosis at the most recent visit was 10% (p < 0.001). The autoimmune group received the most steroid injections (mean = 6.56; SD = 11.96). The idiopathic group had the longest surgery-free interval (mean = 30.8 months; SD = 27.7).

CONCLUSION

Iatrogenic and cancer patients were more likely to be tracheostomy-dependent. There was a significant improvement in percent and length of stenosis after treatment, with the idiopathic group having the longest surgery-free interval. Mortality risk did not differ among the different etiologies of LTS.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:257-263, 2024.

The Subglottic Stenosis 6 Questionnaire: A Novel Quality-of-Life Survey Validated to Predict Need for Intervention in Patients With Idiopathic Subglottic Stenosis

BACKGROUND

Idiopathic subglottic stenosis (iSGS) is a recurrent, chronic disease defined by fibroinflammatory narrowing of the subglottic airway. A key challenge in treatment is monitoring disease progression, which may be debilitating and unpredictable in its timing.

RESEARCH QUESTION

Can the Subglottic Stenosis 6 (SGS-6) questionnaire be validated as a novel quality-of-life (QOL) instrument to monitor breathing, disease progression, and disease severity proactively in patients with iSGS?

STUDY DESIGN AND METHODS

Panel data from 51 patients with iSGS were collected from January 2012 through June 2022, representing 1,684 patient encounters including routine office visits and treatment encounters. Subjective QOL scores (including the novel SGS-6 and established RAND-36 and EuroQol Five Dimensions [EQ-5D] Visual Analog Scale) and objective pulmonary function test (PFT) results were collected at each visit. Subjective SGS-6 QOL scores were repeated within 1 week of initial reporting. Panel regression analyses were performed to assess the relationship between SGS-6 scores, PFT results, and a patient's need for intervention. Minimal clinically important differences (MCIDs) for SGS-6 and peak expiratory flow percentage (PEF%) were assessed using receiver operating characteristic (ROC) curve analysis and a patient's need for intervention as the external anchor.

RESULTS

Each one-point increase in SGS-6 score (of a maximum of 27) was associated with a 3.26% decrease in PEF%, a 1.93-point decrease in RAND-36 Physical Health composite score, a 1.27-point decrease in RAND-36 Mental Health composite score, and a 0.88-point decrease in EQ-5D Visual Analog Scale score. The intracorrelation coefficient for the SGS-6 composite score is 0.838 (95% CI, 0.770-0.888). Compared with patient baselines, SGS-6 scores were 4.66 points greater at the time of intervention with an MCID of 2.25 from a patient's baseline. The area under the ROC curve for SGS-6 and a patient's intervention point was 0.81.

INTERPRETATION

iSGS disease severity can be modeled using the SGS-6 questionnaire, offering physicians and patients a potentially new method of tracking disease progression and need for intervention remotely.

Cost-Effectiveness of Steroids for Prolonging the Surgery-Free Interval in Subglottic Stenosis

OBJECTIVES

Repeat endoscopic dilation (ED) in the operating room for subglottic stenosis (SGS) remains an economic burden to patients. The cost-effectiveness (CE) of adjuvant serial intralesional steroid injections (SILSI) to prolong the surgery-free interval (SFI) in SGS patients requiring ED has yet to be studied.

METHODS

Details of the cost of SILSI and ED were received from our tertiary academic center. SFI, cost of intervention, and the effect of SILSI on prolonging SFI were collected from a systematic review by Luke et al. SGS etiologies in the review included idiopathic, iatrogenic, or autoimmune. A break-even analysis, comparing the cost of SILSI alone with the cost of repeat ED, was performed to determine if SILSI injections were cost-effective in prolonging the SFI.

RESULTS

Average extension of the SFI with SILSI was an additional 219.3 days compared to ED alone based on a systematic review of the literature. 41/55 (74.5%) cases did not require further ED once in-office SILSI management began. SILSI administered in a 4-dose series in 3-to-7-week intervals (~$7,564.00) is CE if the reported recurrence rate of SGS requiring ED (~$39,429.00) has an absolute risk reduction (ARR) of at least 19.18% with the use of SILSI. Based on the literature, SILSI prevents ~3 out of every 4 cases of SGS at sufficient follow-up from undergoing repeat ED, resulting in an ARR of ~75%.

CONCLUSIONS

SILSI is economically reasonable if it prolongs the SFI of at least one case of recurrence out of 5. SILSI, therefore, can be CE in extending the interval for surgical ED.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:3436-3442, 2023.

Effect of Intralesional Steroid Injections Among Patients with Acquired Laryngotracheal Stenosis Undergoing Endoscopic Balloon Dilation Using Pulmonary Function Tests

Objectives: Laryngotracheal stenosis (LTS) is characterized by an abnormal decrease in the upper airway diameter. The pulmonary function test (PFT) is an effective adjunctive diagnostic tool for upper airway obstruction. LTS can be managed with either open surgery or less invasive endoscopic approaches, among which endoscopic balloon dilation is the main method; this may include concurrent intralesional steroid injection (ILSI), which has the potential of improving the outcomes. However, the effectiveness of ILSI is unclear. We aimed to compare the improvement in PFT parameters among patients with acquired LTS following endoscopic balloon dilation who received and did not receive ILSIs. We also compared the recurrence times and rates between the 2 patient cohorts. Methods: We retrospectively collected data regarding pre- and postoperative PFTs, as well as inter-dilation interval records, obtained between June 2015 and April 2020. Results: We included 34 patients with acquired etiologies. The most common cause of stenosis was intubation (52.9%), followed by trauma (29.4%). Further, 52.9% of the patients received ILSIs. Symptom recurrence was reported in 23 (67.6%) cases, with no significant between-group difference -0.1389 [95% confidence interval (CI): -0.4483, 0.1705]. The mean (standard deviation) duration of the first reintervention was 8.62 (8.00) and 7.38 (3.20) months among patients who did and did not receive ILSIs, respectively (mean difference -1.23, P = .614, 95% CI -6.30, 3.84). Conclusion: Our findings indicated that PFT parameters improved following endoscopic balloon dilation, with forced expiratory volume in 1 second being significantly higher with concurrent ILSI. However, there was no between-method difference in the treatment effectiveness. Additionally, the restenosis recurrence rate was consistent with that reported in the literature.

Serial In-Office Steroid Injections for Airway Stenosis: Long-Term Benefit and Cost Analysis

OBJECTIVES

To evaluate the long-term benefit of serial in-office steroid injections (SISI) in the treatment of subglottic and proximal tracheal stenosis (SG/PTS). Evaluate cost of SISI compared to endoscopic dilation (ED).

STUDY DESIGN

Retrospective study and cost analysis.

METHODS

All patients with SGS/PTS with at least two consecutive in-office steroid injections between 2013 and 2021 were evaluated. Patients with less than 2 years of follow-up data after the initial SISI series were excluded. Demographics, etiology of stenosis, total injections performed, time between steroid series, surgery-free interval (SFI) and adverse events were collected. For patients with known surgical history before SISI, pre-SISI SFI was compared. Institutional billing records and the national CMS average reimbursement were evaluated. Total charges for three treatment strategies (ED alone, ED with post-operative SISI and primary intervention with SISI) were also compared.

RESULTS

Forty-nine patients were included; 29 (59%) idiopathic, 11 (22%) traumatic and 9 (18%) rheumatologic. Mean (SD) follow-up time after the first SISI was 3.41 years (1.5), range (2.08-7.25 years). 79% (39/49) did not require additional surgery during the entire follow-up period. The SFI improved from a mean 13.5 months (SD 12.6; range 2-42 months) pre-SISI to a mean (SD) of 42 months (SD 20.2; range 10-87 months) (p < 0.0001) after SISI. Annual average charges for ED alone in our cohort was $15,383.28, compared to $7,070.04 for SISI.

CONCLUSIONS

SISI are an effective treatment for patients with SG/PTS. In-office steroid injections could offer cost savings for the patient.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2673-2679, 2023.

Impact of Serial Intralesional Steroid Injections on Idiopathic Subglottic Stenosis

OBJECTIVES

Serial intralesional steroid injection (SILSI) has been increasingly used to treat idiopathic subglottic stenosis (iSGS). Prior studies have shown effectiveness, but not in all patients. This multi-institutional study evaluates the effect of SILSI on time to recurrent operation, peak expiratory flow (PEF), and dyspnea.

METHODS

Post-hoc secondary analysis of the North American Airway Collaborative data were performed to evaluate the outcomes of iSGS patients undergoing and not undergoing SILSI. The primary outcome was time to recurrent operation, evaluated using Kaplan-Meier curves and Cox regression analysis. Secondary outcomes were change in PEF and clinical chronic obstructive pulmonary disease questionnaire (CCQ) score. Within patients undergoing SILSI, demographics, time from last procedure, and PEF at initiation of SILSI were evaluated to determine the effect on recurrence.

RESULTS

Two hundred and ninety patients were included, 238 undergoing endoscopic dilation alone and 52 undergoing dilation and SILSI. No differences in baseline characteristics were observed. There was no difference in time to recurrence (hazard ratio: 0.64; p = 0.183). There were no differences in PEF or CCQ across the 2.5-year study period. Among 52 patients undergoing SILSI, PEF at the time of starting SILSI did not affect recurrence (χ2  = 0.09, p = 0.77).

CONCLUSION

Patients undergoing and not undergoing SILSI had similar times to recurrence, PEF, and CCQ. Factors predicting recurrence among patients undergoing SILSI were not identified. These results support a randomized controlled trial with a uniform SILSI protocol to quantify the effects of SILSI on objective and subjective outcomes and help determine which iSGS patients benefit most.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2255-2263, 2023.

The Effect of Subglottic Steroid injection on Blood Glucose in a Cohort of Patients With Subglottic Stenosis

OBJECTIVE

The objective of this work was to assess the effect of a single intralesional subglottic steroid injection on fasting blood glucose over 7 days in a cohort of patients with subglottic stenosis.

METHODS

A prospective cohort study of patients undergoing intralesional steroid injections at a tertiary academic center. Patients had baseline bloodwork performed, including fasting blood glucose (FBG), and hemoglobin A1C levels. Demographic data and risk factors were collected. Fasting capillary glucose (FCG) was measured using a capillary glucometer and performed by patients daily from days 0 to 7 after a single injection of Triamcinolone into the subglottic airway. Data were analyzed using descriptive and comparative statistics.

RESULTS

Eleven patients were enrolled, and 10 completed data collection over 7 days. All were female, with a mean age of 52.6 years (SD 17.5). Two patients were diabetic (non-insulin dependent). There was a statistically significant increase in FCG on day 1 post-injection (mean = 122.4 mg/dl compared to 100.7 mg/dl) that normalized for all patients within 24-72 h. The mean increase in FCG was 21.5% (SD 22.5%) of the initial value for the cohort. The diabetic group had statistically significant higher glucose values on day 1 compared to the non-diabetic group (146.5 mg/dl compared to 117.0 mg/dl).

CONCLUSION

A single subglottic steroid injection appears to cause a transient increase in FCG 1 day post injection, which resolves after 24-72 h and can be more pronounced in diabetic patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Case report: Idiopathic subglottic stenosis in a girl; successful treatment with macrolides

An 8-year-old girl presented with treatment-refractory cough and inspiratory stridor. Bronchoscopies showed progressive scarring leading to narrowing of the proximal trachea (Myer-Cotton Grade 2) and epithelial metaplasia of the tracheal and bronchial mucosa. After excluding other causes of congenital and acquired tracheal stenosis, an idiopathic subglottic tracheal stenosis (iSGS) was diagnosed. Because of the patient's young age, a judicious therapeutic approach seemed appropriate. Therapy with azithromycin, followed by roxithromycin, was started. Symptoms almost completely subsided, spirometry normalized, and endoscopic and histologic findings improved considerably. Therapy has been continued for more than 3 years with normal lung function values, and no compromise on physical activities and development. In instances of iSGS, therapy with macrolides is worth considering before more invasive procedures such as dilatation, laser, intralesional injections, or surgical resection are performed.

Serial Intralesional Steroid Injection for Subglottic Stenosis: Systemic Side Effects and Impact on Surgery-Free Interval

Objectives

In-office serial intralesional steroid injections (SILSIs) have become a commonly used treatment for subglottic stenosis. We characterized the impact of SILSIs on the time between operating room visits and incidence of glucocorticoid systemic side effects.

Study Design

Retrospective case series.

Setting

Academic tertiary care center.

Methods

All patients with subglottic stenosis receiving SILSIs at 1 institution from 2016 to 2020 were included. Surgery-free interval was compared using paired t tests. Side effect incidence was calculated with Kaplan-Meier methodology for visualization.

Results

Nineteen patients and 207 procedures were included. The majority of patients were White (95%) and female (95%) and had idiopathic subglottic stenosis (53%). Mean surgery-free interval for all patients was 8.7 months (95% CI, 5.6-11.8) before initiating SILSIs. Of 11 patients with calculable surgery-free interval, 10 experienced improvement, with a mean surgery-free interval increase of 4.6 months (95% CI, 2.4-6.7). Seven patients have not required surgery since initiation of SILSIs, with a mean follow-up time of 28 months (95% CI, 25-31). Noncutaneous systemic side effects occurred at a mean 3.2 months (95% CI, 2.4-4.0) from first injection and included Cushing’s syndrome, increased intraocular pressure, central serous chorioretinopathy, and new insulin requirement in the setting of diabetes.

Conclusions

Ninety-one percent of patients who initiated SILSIs and had a subsequent return to the operating room experienced a mean 4.6-month increase in surgery-free interval. Systemic side effects of glucocorticoids occurred in 32% of patients after initiating SILSIs. This should be considered in preprocedure counseling and side effect monitoring during treatment.

Efficacy of Office-Based Intralesional Steroid Injections in the Management of Subglottic Stenosis: A Systematic Review

OBJECTIVE

To determine the efficacy of office-based intralesional steroid injections (ILSI) as a management therapy for adult subglottic stenosis (SGS).

DATA SOURCES

A systematic review was completed using PubMed and Science Direct for office-based management of SGS due to various etiologies.

REVIEW METHODS

The primary end point measured was a change in surgery free interval (SFI) between endoscopic procedures due to office-based serial ILSI. The secondary end point was to determine what percentage of patients did not require further operative intervention for SGS maintenance therapy after changing management to office-based serial ILSI.

RESULTS

We identified 187 abstracts, 4 of which were included in the analysis. The total number of participants was 55. The mean age was 50.4, and 78.1% were women. The etiologies were as follows: idiopathic (58.2%), postintubation/tracheotomy (29.1%), and autoimmune (12.7%). The SFI was reported in 3 of the 4 studies. The reported mean pre-ILSI SFI was 362.9 days and the post-ILSI SFI was 582.2 days. The secondary outcome was reported in 3 of the 4 studies. Forty-one of the 55 patients (74.5%) did not require further operative intervention during the duration of the study.

CONCLUSION

This review explored office-based ILSI as a potential treatment option for patients with SGS. The limited data presented found ILSI significantly lengthened SFI, potentially reducing surgical burden. In addition, ILSI was found to be safe with few reported side effects.

Differing Progression to Posterior Glottic Stenosis in Autoimmune and Idiopathic Subglottic Stenosis

OBJECTIVES/HYPOTHESIS

We sought to characterize rates of progression to posterior glottic stenosis (PGS) from autoimmune or idiopathic subglottic stenosis.

STUDY DESIGN

This was a retrospective review.

METHODS

Patients from a tertiary-care laryngology practice over a 10-year period with autoimmune or idiopathic subglottic stenosis (SGS) were included. Patients with a history of prolonged intubation or other causes of iatrogenic stenosis were excluded. PGS was confirmed on videostrobolaryngoscopy recordings by a fellowship-trained laryngologist. PGS type (1-4) was also recorded. Demographic information was recorded, and if applicable, autoimmune disease type was specified. Time until PGS was recorded along with the number of interventions. Chi-squared analysis was used to compare PGS in autoimmune and idiopathic SGS.

RESULTS

A total of 77 patients were identified with autoimmune (32 patients) or idiopathic (45 patients) subglottic stenosis. Autoimmune pathologies included systemic lupus erythematosus, granulomatosis with polyangiitis (GPA), rheumatoid arthritis, relapsing polychondritis, and sarcoidosis, with GPA the most common (14/32). Patients with autoimmune SGS had a higher rate of PGS (10 of 32) compared to idiopathic subglottic stenosis (1 of 45) for an odds ratio of 20 (95% CI: 2.4-166.4, P = .006). Patients with idiopathic SGS were more likely to be female (all 45 compared to 29/32 autoimmune, P = .07) and older (mean 53 (range 29-75) compared to 46 (20-82), P = .02).

CONCLUSIONS

In this large patient cohort, autoimmune SGS patients were found to have a higher likelihood of developing PGS compared to their idiopathic counterparts, suggesting that counseling for this progression may be warranted.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1816-1820, 2021.