Surgical Treatment of Benign Subglottic Stenosis JLKasperbauer MD Mayo Clinic Rochester, MN USA
Goals Review Subglottic Stenosis Anatomy, Airway Dynamics, Etiology Idiopathic Subglottic Stenosis Definition, History, Differential Diagnosis, Evaluation Treatment Options a. endoscopic b. resection
Our Method a. endoscopic operative approach b. medical regimen c. monitoring d. selection for resection Outcomes
Anatomy Kutta H, Steven P, Paulsen F. Anatomical Definition of the Subglottic Region. Cells Tissue Organs. 2006;184: 204-215.
Airway Dynamics Shape Airflow Pulmonary function testing
Benign Subglottic Stenosis Idiopathic subglottic stenosis Intubation related Other trauma GPA Amyloid Other inflammatory causes Chondritis
Idiopathic Subglottic Stenosis Potential causes Diagnostic evaluation Presentation Treatment Outcomes Discussion
Idiopathic subglottic stenosis extraesophageal reflux collagen vascular disease hormonal alteration occult trauma bacteria
Reflux Extraesophageal reflux Blumin JH, Johnston N. Evidence of Extraesophageal Reflux in Idiopathic Subglottic Stenosis. Laryngoscope 121:1266 1273, 2011 (59%) Pepsin Samuels TL, Johnston N. Pepsin as a causal agent of inflammation duringnonacidic reflux. Otolaryngol Head Neck Surg 2009;141:559 563. Proton Pumps Altman et al. Proton Pump (H + /K + -ATPase) Expression in Human Laryngeal Seromucinous Glands. Otolaryngology Head and Neck Surgery (2005) 133, 718-724
Pepsin
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
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; 133 143 Popa ER etal. Staphylococcal toxic-shock-syndrome-toxin-1 as a risk factor for disease relapse in Wegener s granulomatosis. Rheumatology 2007;46:1029 1033
Chronic rhinosinusitis and asthma: novel understanding of the role of IgE above atopy Journal of Internal Medicine Volume 272, Issue 2, pages 133-143, 25 JUL 2012 DOI: 10.1111/j.1365-2796.2012.02559.x http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2012.02559.x/full#f2
Evaluation Hx Exam Labs/tests Acute inflammation Steroid injection, dilation
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
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
Preop
Intraop
12 weeks post op
Single treatment 2008 2008 2012
Recurrent Symptoms 2014 2014 8 weeks post op
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)
Medical Regimen and Monitor Topical Steroid Antireflux measures (behavioral and medications) Bactrim Peak flow
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?
Outcomes
Resection?
Resection Technique Indications Outcomes Proximity to cords
Ashiku S, Kuzucu A, Grillo H, et al. Idiopathic laryngotracheal stenosis: effective definitive treatment with larnygotracheal resection. J Thorac Cardiovasc Surg 2002;127:99 107.) 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.
Perotin J-M etal. Endoscopic Management of Idiopathic Tracheal Stenosis. Ann Thorac Surg 2011;92:297 302 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
Conclusions 1. Begin with endoscopic treatment 2. Advance to open procedures if necessary 3. Individualize treatment
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
Video if time Questions