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Idiopathic Subglottic Stenosis Treatment: Steroids, Dilation or Surgery?

Author Julia Casazza covers Idiopathic Subglottic Stenosis Treatment: Steroids, Dilation or Surgery? on BackTable ENT

Julia Casazza • Updated Jun 17, 2024 • 89 hits

Idiopathic subglottic stenosis (ISS) results in progressive dyspnea that, when untreated, can cause loss of airway. While cricotracheal resection (CTR) represents traditional idiopathic subglottic stenosis tretment, updated modern procedures including endoscopic airway dilation and serial intralesional steroid injections (SILSI) can spare patients open airway surgery.

Guided by expert laryngologist Dr. Stephen Schoeff, this article delves into idiopathic subglottic stenosis treatment with excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.

The BackTable ENT Brief

• Options for idiopathic subglottic stenosis treatment include serial intralesional steroid injections (SILSI), endoscopic airway dilation, and idiopathic subglattoic stenosis surgery. Observation is not recommended due to the progressive nature of the disease.

• SILSI idiopathic subglottic stenosis treatment consists of monthly in-office steroid injections with monitoring of respiratory status. Dr. Schoeff tends to treat patients for 3-4 months.

• Endoscopic airway dilation subglottic stenosis tretment is an OR-based procedure that involves laser resection of scar tissue. It can be combined with steroid injections for optimal management.

• Cricotracheal resection and the Maddern surgeries are modern procedures that physically cut out the diseased airway.

• Tracheostomy is not an optimal idiopathic subglottic stenosis surgery option. Its utility is greatest in emergency situations.

Idiopathic Subglottic Stenosis Treatment: Steroids, Dilation or Surgery?

Table of Contents

(1) Idiopathic Subglottic Stenosis Treatment: Serial Intralesional Steroid Injections (SILSI)

(2) Idiopathilc Subglottic Stenosis Treatment: Endoscopic Dilation of the Airway

(3) Idiopathic Subglottic Stenosis Surgery for Definitive Management

Idiopathic Subglottic Stenosis Treatment: Serial Intralesional Steroid Injections (SILSI)

Steroid injections represent the least invasive option for idiopathic subglottic stenosis treatment. While the pathophysiology of idiopathic subglottic stenosis is poorly understood, emerging research suggests that loss of epithelial integrity, followed by bacterial infiltration and inflammation, triggers scar formation and airway stenosis. Accordingly, local steroid injection can calm fibroblast activity to reduce scar formation and resulting airway stenosis. Dr. Schoeff injects his patients in-clinic once monthly for 3-4 months, using peak flow spirometry to monitor respiratory function. Patients who respond insufficiently to steroid injections should consider airway dilation as a step-up in idiopathic subglottic stenosis management.

[Dr. Ashley Agan]
That's interesting that steroid injections are helpful, but oral steroids aren't helpful at all. Why do you think the concentration that you're able to deliver with an injection is just so much higher or any thoughts on that? Because we love giving steroids at ENT. To hear that steroids don't work is like, what?

[Dr. Stephen Schoeff]
It's a really interesting question. There's definitely a debate within our field. I'd say most laryngologists I know are using these, but there's a few and a few very prominent laryngologists that are pretty skeptical. There's a couple of factors. One of which is what's the underlying problem? What's going on here? Dr. Gelbard at Vanderbilt has led a lot of the high-level basic science research into this. I don't want to ignore his colleagues there, but he's the person who's, I think, spearheading it right now. He's shown that there is this lack of epithelial integrity, some invasion by bacteria. There's a little bit of a chicken or the egg question, what starts the process? We're observing the process after it started. What's going on there? Ultimately, you end up with this inappropriate fibroblast process as well that's laying down scar where you shouldn't be laying down scar and an alteration of the immune response in the sub-epithelial tissue. The steroid injection side, how that addresses it, the theory from what I understand, came from what we see in keloids and hypertrophic scar and approaching those. Dr. Franco and Dr. Dailey have both been big early adopters. Dr. Franco was the first person to describe it. Then Dr. Dailey also has been an early adopter of the steroid injections in the office and seeing really good results with these since about 2014 or so. Dr. Franco recently presented, I believe it was a poster actually, but some basic science showing that the fibroblast activity actually has changed with steroid injection. I don't think we get that from oral steroids or at least we can't give oral steroids long enough to achieve that response. Basically a fibroblast activity is changing from laying down scar to actually removing scar. That's hugely valuable, of course, when we're talking about really just needing a few millimeters of airway and needing some improvement in that scar deposition.

[Dr. Ashley Agan]
For your steroid injections, whether you decide to do initial treatment of the serial injections or at the time of your endoscopic dilation in the OR, what steroid do you use and how much do you end up giving? Do you have a special needle you like?

[Dr. Stephen Schoeff]
Yes. I'm using Kenalog 40. I think that's pretty standard across the field. We like that deposition. Of course, that's what I think a lot of facial plastic surgeons and folks have used in keloid as well. I use that just with a-- There's an Integra laryngeal injector in the OR. Usually I'm removing the tissue and then injecting steroid, and then possibly dilating a little bit after that just to make sure the airway is completely open for somebody coming out of anesthesia. Then in the clinic, I'm using either a 25-gauge needle trans-cricothyroid with a physician assistant driving a camera or I'm driving a working channel scope with a sclerotherapy needle through the channel that is, I believe, a 20, 23-gauge that we're getting into the tissue subepithelially and infiltrating with the Kenalog.

[Dr. Ashley Agan]
You just try to do several little injections around the edges of it?

[Dr. Stephen Schoeff]
Exactly. Yes. Just finding places where there is more scar deposition, where there's more tissue and filling that tissue. I generally aim to do about one milliliter, plus or minus. It just depends. Patients who have minimal stenosis, we're oftentimes doing less than that. Then usually it's done in a series. If somebody's starting out with treatment that way, we're doing it in a series of three or four injections over the course of three or four months. Oftentimes after somebody is taken to the OR, I offer a series of injections afterward as well. There's evidence that helps to improve the interoperative interval. For some patients, it really keeps them out of the OR entirely. We had a good number of patients at University of Wisconsin who stopped going to the OR with this approach. I've had that experience as well, taking over practice from a surgeon who is treating patients with dilation every six to 12 months or so based on their symptoms. A number of them have switched to steroid injections and it's been three plus years that I've been here and they've never had to go back to the OR. Some patients respond to it beautifully. Not everybody does. We still don't quite have a handle on why those patients who don't respond to it really well don't. Certainly there's some variability in that.

[Dr. Ashley Agan]
It's every- once a month for three to four months?

[Dr. Stephen Schoeff]
Correct. Then after that, and this is where I think there's a lot of variation, I think a lot of laryngologists are using that approach if somebody elects endoscopic treatment and doing this postoperatively. I think there is quite a bit of variation around the country in terms of how we approach it after that. Whether somebody- folks are followed or folks are told just to come back if their symptoms start to worsen again. There's, I think, a huge variability in terms of how that practice is approached.

Listen to the Full Podcast

Idiopathic Subglottic Stenosis Evaluation & Management with Dr. Stephen Schoeff on the BackTable ENT Podcast)
Ep 161 Idiopathic Subglottic Stenosis Evaluation & Management with Dr. Stephen Schoeff
00:00 / 01:04

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Idiopathilc Subglottic Stenosis Treatment: Endoscopic Dilation of the Airway

More invasive than stand-alone steroid injections but less invasive than open airway surgery, endoscopic dilation represents the middle ground of idiopathic subglottic stenosis treatment. Dilation is performed in the operating room with the patient sedated under general anesthesia and jet-ventilated. A Dedo laryngoscope enables visualization as the surgeon trims scar tissue using a CO2 laser. Dr. Schoeff follows the dilation protocol developed at the Mayo Clinic [1].

Immediately following surgery, patients may complain of continued respiratory difficulty and mucus. In cases where post-dilation laryngeal edema is suspected, a short course of prednisone is indicated. Mucus, a common bugbear for idiopathic subglottic stenosis patients, is managed with saline nebulizers, expectorants, and N-acetyl-cysteine. In Dr. Schoeff’s experience, most patients elect for a 3-4 month course of monthly steroid injections as an adjunct following surgery.

[Dr. Gopi Shah]
Can we talk a little bit more about the dilation technique? You're doing this in the OR. Is this with general anesthesia using rigid bronchs and suspension or is the patient still awake? You're doing topical, flexible scopes. How do you do it?

[Dr. Stephen Schoeff]
My approach is to do this under general anesthesia with paralysis, rocuronium paralysis on board as well, but we do this graduated approach. I've got a team there that's gotten really comfortable with these cases as well. We have a great team set up, and we start with induction, just using propofol, getting the patient quite deep, ensuring that they can be masked safely. We always have that ability to back out. Then we're giving rocuronium paralysis to allow for rigid instrumentation. Then I go in with a Dedo typically, or sometimes a smaller laryngoscope, depending on the patient, and start supraglottic jet ventilation. Just running a jet through the sideboard of my Dedo. From there, we actually use an oxygen mixture so we can usually ventilate with jet at 30% while removing tissue with the laser. We don't actually have intermittent apnea, but sometimes patients don't tolerate that as well, particularly patients who are more obese, for example. We will either do intermittent apnea with ventilation at 100% or just open the tissue some with a laser and or a balloon dilation and then intermittently intubate with a 502 through the laryngoscope.

…

[Dr. Stephen Schoeff]
Number one is the acute post-procedure. What are the things that could be really bad? When you're doing jet ventilation, there's a theoretical risk of pneumothorax. That's been described in the literature, and certainly I've heard of it happening. If somebody has-- I don't check an x-ray after every case. Personally, I know there are some surgeons who do. My experience has been that it's very rare for that to happen. Unfortunately, in my practice, I haven't observed it. Encouraging people, if they have dyspnea, if they're feeling really short of breath, that's a red flag. If they're in PACU and they're feeling short of breath, that's a problem. They should be breathing a lot better than they were. I check on patients, make sure that they are breathing better, meaningfully better than they were. If they're not, then we need to evaluate that. The other thing would be subglottic or laryngeal edema. Again, you'd be hearing-- They might come out of the OR with nothing, and then if the PACU says, hey, they're starting to get more stridor, they're starting to sound worse, that's a big red flag, and you need to be evaluating that and looking for swelling. The vocal folds are probably the bigger risk in that situation that you get glottic edema. In rare scenarios, that would mean reintubation, or ICU monitoring, and ideally avoiding the tracheostomy, if at all possible, but that's always your final pathway. Those are the big things in the acute, immediate, postoperative. Some surgeons will give patients prednisone bursts. If I feel like there's a little bit of laryngeal edema, but nothing significant, I may give somebody a short prednisone taper, because that's certainly laryngeal edema response to prednisone. No question. Then otherwise talking to folks about management of that mucus sensation, usually Mucinex and acetylcysteine. A couple of patients have actually elected a saline nebulizer, nebulized saline that helps to clear out that mucus and vent out the mucus. Personal steamers, all these different mucus options can definitely help with some of the symptom management. Then, like I said, I'm following the patients pretty closely. Usually I'm meeting them again within a month from surgery. Most patients elect to at least try steroid injections. Most of the time if we're doing an endoscopic procedure, I'm meeting the patients about a month after surgery

Idiopathic Subglottic Stenosis Surgery for Definitive Management

When steroid injections and dilations fail as idiopathic subglottic stenosis treatments, surgery is indicated. Surgeries used to treat idiopathic subglottic stenosis include cricotracheal resection, the Maddern procedure, and tracheostomy. Cricotracheal resection (CTR) is an open airway surgery in which the entire segment of stenotic airway is removed and the remaining segments sewn back together. While CTR eliminates the source of dyspnea, lowered vocal pitch is a dreaded side effect of the surgery. The Maddern procedure is a newer endoscopic approach that leaves airway cartilage in place, strips the scar and subglottic mucosa in the affected area, and then replaces this tissue with a split-thickness skin graft. While tracheostomy can treat idiopathic subglottic stenosis by bypassing the affected airway, it is not a preferred option due to its associated morbidity. Its use is reserved for emergency situations.

[Dr. Gopi Shah]
Just transitioning to CTR and open airway. Are there certain hard indications for CTR? Is there a certain amount of stenosis or, hey, now we're in the OR every two to three months? When do you start to that, hey, we're here now?

[Dr. Stephen Schoeff]
Yes, that's really driven by the patient scenario. I think some patients are very interested in that upfront. I would say it's a minority, but some are. Then I don't know that there is necessarily a cutoff, but certainly if patients are just needing constant, really frequent interventions, then you're really thinking about some of these more aggressive surgical options, whether that's a CTR or this what you might call an endoscopic CTR, which is the Maddern procedure that's mainly been developed at Cleveland Clinic. We're going in with a micro-debrider actually and removing the scar, and micro-debrider and then putting in a stent with a graft, either split the skin or a buccal mucosa to try and reline that tissue. It's a middle ground between the options, so to speak. They just published a series of almost 30 patients or so that have had pretty good results on average. That's definitely something that's out there as a potential middle ground between cricotracheal resection and the associated risks and potential issues there and the endoscopic options.

[Dr. Gopi Shah]
Do you ever have patients where tracheostomy is the best option? Who are those patients?

[Dr. Stephen Schoeff]
Occasionally there are patients who are just fed up with it, are either considered too high risk. Diabetes is always considered a big risk factor for cricotracheal resection. Not in my current practice, but I have seen patients who either had a mucus plugging event and presented emergently and gotten a tracheostomy or were in a place where there wasn't somebody who could do jet ventilation and things like that. I just found that once they got used to a tracheostomy, they said, oh, this is actually easier than going back to the OR, and things like that, and actually found it to be pretty manageable. I have seen a couple of patients who actually, ultimately prefer, or at least have elected just to use a tracheostomy and bypass the issue.

Podcast Contributors

Dr. Stephen Schoeff discusses Idiopathic Subglottic Stenosis Evaluation & Management on the BackTable 161 Podcast

Dr. Stephen Schoeff

Dr. Stephen Schoeff is a laryngologist at Kaiser Permanente in Tacoma, Washington.

Dr. Ashley Agan discusses Idiopathic Subglottic Stenosis Evaluation & Management on the BackTable 161 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Dr. Gopi Shah discusses Idiopathic Subglottic Stenosis Evaluation & Management on the BackTable 161 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2024, March 5). Ep. 161 – Idiopathic Subglottic Stenosis Evaluation & Management [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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