Surgical Treatment of Benign Subglottic Stenosis. JLKasperbauer MD Mayo Clinic Rochester, MN USA

Transcription

1 Surgical Treatment of Benign Subglottic Stenosis JLKasperbauer MD Mayo Clinic Rochester, MN USA

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3 Goals Review Subglottic Stenosis Anatomy, Airway Dynamics, Etiology Idiopathic Subglottic Stenosis Definition, History, Differential Diagnosis, Evaluation Treatment Options a. endoscopic b. resection

4 Our Method a. endoscopic operative approach b. medical regimen c. monitoring d. selection for resection Outcomes

5 Anatomy Kutta H, Steven P, Paulsen F. Anatomical Definition of the Subglottic Region. Cells Tissue Organs. 2006;184:

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9 Airway Dynamics Shape Airflow Pulmonary function testing

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12 Benign Subglottic Stenosis Idiopathic subglottic stenosis Intubation related Other trauma GPA Amyloid Other inflammatory causes Chondritis

13 Idiopathic Subglottic Stenosis Potential causes Diagnostic evaluation Presentation Treatment Outcomes Discussion

14 Idiopathic subglottic stenosis extraesophageal reflux collagen vascular disease hormonal alteration occult trauma bacteria

15 Reflux Extraesophageal reflux Blumin JH, Johnston N. Evidence of Extraesophageal Reflux in Idiopathic Subglottic Stenosis. Laryngoscope 121: , 2011 (59%) Pepsin Samuels TL, Johnston N. Pepsin as a causal agent of inflammation duringnonacidic reflux. Otolaryngol Head Neck Surg 2009;141: Proton Pumps Altman et al. Proton Pump (H + /K + -ATPase) Expression in Human Laryngeal Seromucinous Glands. Otolaryngology Head and Neck Surgery (2005) 133,

16 Pepsin

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21 Collagen Vascular Disease Relapsing polychondritis Sarcoid Limited Polyangitis with granulomatosis (Wegner s) IgG4 Stone JH, Zen Y and Deshpande V. IgG4-Related Disease. N Engl J Med 366;6:2012

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23 Bacteria Staphloccocal superantigens and enterotoxins Bachert C and Zhang N. Chronic rhinosinusitis and asthma: novel understanding of the role of IgE above atopy Journal of Internal Medicine, 2012, 272; Popa ER etal. Staphylococcal toxic-shock-syndrome-toxin-1 as a risk factor for disease relapse in Wegener s granulomatosis. Rheumatology 2007;46:

24 Chronic rhinosinusitis and asthma: novel understanding of the role of IgE above atopy Journal of Internal Medicine Volume 272, Issue 2, pages , 25 JUL 2012 DOI: /j x

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26 Evaluation Hx Exam Labs/tests Acute inflammation Steroid injection, dilation

27 Treatment Options (mature scar) Endoscopic Tissue removal vs incisions Dilation vs No Dilation Endoscopic resection with skin grafting Reacher procedure Open resection Cricoid split with grafting

28 dental protection eye protection Endoscopic intervention direct microlaryngoscopy intermittent apneic ventilation (communication) kenalog injection CO2 laser scar vaporization (visualize the airway) avoid perichondrial insult Mitomycin application No Dilation

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30 Preop

31 Intraop

32 12 weeks post op

33 Single treatment

34 Recurrent Symptoms weeks post op

35 Outpatient procedure No activity or work restrictions Follow up visit in 6-8 weeks to document condition of the operative site then in one year depending on peak flow meter values (earlier if necessary)

36 Medical Regimen and Monitor Topical Steroid Antireflux measures (behavioral and medications) Bactrim Peak flow

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38 What about evaluating for reflux? Is there a correct evaluation? Is the evaluation accurate? Would one avoid antireflux measures if the studies were negative? Would one utilize the data to prompt consideration of a fundoplication?

39 Outcomes

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42 Resection?

43 Resection Technique Indications Outcomes Proximity to cords

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47 Ashiku S, Kuzucu A, Grillo H, et al. Idiopathic laryngotracheal stenosis: effective definitive treatment with larnygotracheal resection. J Thorac Cardiovasc Surg 2002;127: ) The median length of follow-up was 8.0 years average of 7.9 y Excellent results were obtained in 19 (26%) of 72 patients. Good results were obtained in 47 (64%) of 72 patients. Inability to project voice and change in singing voice was the major complaint in these patients. Fair results occurred in 5 (7%) of 72 patients. The most common problems were noisy breathing and shortness of breath with moderate exertion and the occasional need for dilation.

48 Perotin J-M etal. Endoscopic Management of Idiopathic Tracheal Stenosis. Ann Thorac Surg 2011;92: Endoscopic treatment included mechanical dilation only (52%) or associated with laser or electrocoagulation (30%) and stent placement (18%). All procedures were efficient follow-up after endoscopic management was 41 (+-) 34 months. recurrence occurred in 30% at 6 months, 59% at 2 years, and 87% at 5 years, with a delay of 14 (+-) 16 months treatment of recurrence (n = 13) included endoscopic management in 12 cases

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50 Conclusions 1. Begin with endoscopic treatment 2. Advance to open procedures if necessary 3. Individualize treatment

51 Considerations Evidence for reflux may be increased by the increased work of breathing (increased negative intrathoracic pressure due to stenosis) Association with thyroid inflammation Wounded subglottis HBO

52 Video if time Questions

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