IgG4-related disease presenting as hoarseness and postcricoid ulcer

An Unusual Presentation of Immunoglobulin G4-Related Disease (IgG4-RD) Causing Subglottic Stenosis

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition that is known to involve multiple organs and was first described as an entity in 2003. It is characterized by lesions with a dense lymphoplasmacytic infiltrate, IgG4-positive plasma cells, storiform fibrosis, and frequently elevated serum IgG4 levels. Organs that are commonly involved include the pancreas, biliary tree, salivary glands, periorbital tissues, kidneys, retroperitoneum, lungs, pleura, thyroid, aorta, and lymph nodes. Rarer manifestations of IgG4-RD include central nervous system (CNS) involvement, prostatitis, mastitis, midline destructive disease, and nasopharyngeal disease. In this report, we discuss an atypical case of a young woman with laryngeal subglottic involvement leading to stenosis and airway obstruction, which was ultimately successfully managed with systemic immunosuppression. 

A novel treatment for supraglottic stenosis secondary to immunoglobulin G4-related disease

Although immunoglobulin G4-related disease (IgG4-RD) has a predilection for the head and neck region, laryngeal pathology is rare. We report a case of supraglottic stenosis due to IgG4-RD together with a novel treatment strategy of employing a laryngeal stent. A 69-year-old man was referred with longstanding dyspnoea and worsening inspiratory stridor. Despite two supraglottic dilations over a 12-month period, his stenosis recurred and symptoms persisted. Serum investigations revealed elevated IgG4 levels (2.390g/l), with IgG4 infiltrate in laryngeal biopsies. The patient underwent endoscopic balloon dilation, intralesional Depo-Medrone® injection, CO₂ laser therapy and insertion of a laryngeal stent to prevent re-stenosis. Rituximab and prednisolone were commenced postoperatively and the stent was removed at 6weeks. No stenosis recurrence was visualised over a further 12-month follow-up period. Sixteen cases of laryngeal lesions with confirmed IgG4 infiltrate in biopsies have been reported in the worldwide literature to date. Based on a literature review and our experience, we recommend that similar laryngeal pathologies undergo early IgG4 serological testing and biopsy immunohistochemistry. Prompt diagnostic confirmation may prevent unnecessary surgical interventions and optimise immunosuppression. Furthermore, the use of a laryngeal stent following laryngeal surgery may help reduce stenotic recurrence and promote healing.