NEW YORK (Reuters Health) – Serial intralesional steroid injections (ISI) administered in the office are safe and effective in many patients with airway stenosis, according to a retrospective study.
“What I found most interesting was that the patients with traumatic (iatrogenic) stenosis responded so well,” Dr. Lindsay S. Reder from Keck School of Medicine of USC, Los Angeles, California, told Reuters Health by email. “Historically, these patients were either left to have a tracheotomy indefinitely or endure an open tracheal resection. While a proportion of our patients did require these interventions, the fact that many responded well gives us hope that we can try more-conservative treatment as well as counsel patients about the decannulation rates.”
One prior report described the successful use of serial in-office ISI in patients with idiopathic subglottic stenosis (iSGS).
Dr. Reder’s team now report on their experience using serial in-office ISI with triamcinolone, under topical anesthesia, as an adjunctive treatment to endoscopic dilation or as a sole treatment. The cohort comprised 24 patients (18 women) with SGS or proximal tracheal stenosis (PTS) of various causes: 10 with idiopathic SGS/PTS, 8 with traumatic SGS/PTS, and 6 with SGS/PTS related to rheumatologic disease.
The mean length of stenosis was 1.38 cm (range, 0.5-2.75 cm), with 75% of cases limited to the subglottis, according to the January 11 JAMA Otolaryngology-Head and Neck Surgery online report.
Patients underwent a mean of four injections (range, 2-9), and 17 of the 24 patients have not required surgery since the ISI series.
Six of 8 patients who had undergone multiple previous dilations and who had sufficient follow-up had a longer mean surgery-free interval after ISI (22.6 months) than before ISI (10.1 months).
Only two patients were classified as nonresponders given their surgery-free intervals before and after ISI.
None of the three patients who had undergone open airway surgery before ISI required open airway surgery after ISI. Three of 6 patients with traumatic SGS/PTS who presented with a tracheotomy were successfully decannulated in the course of treatment with dilation and ISI.
No adverse events were associated with ISI.
“We think the patients with inflammatory causes of stenosis – for example, those with idiopathic subglottic stenosis and those with stenosis caused by rheumatologic disorders (i.e., granulomatosis with polyangiitis, GPA) – respond the best, especially when it comes to using it as a maintenance treatment,” Dr. Reder said.
“For patients with the inflammatory types of stenosis (idiopathic and rheumatologic), we are starting to treat these patients as if they have a chronic medical problem, instead of a surgical disease,” she said. “Serial steroid injections for these patients can be performed for early recurrence and have a great potential to keep them out of the operating room, which is a very exciting breakthrough.”
“Of course, there are times surgery to dilate the airway will still be necessary,” Dr. Reder said, “but the possibility of minimizing surgical procedures for this set of patients is meaningful and improves their quality of life.”
Dr. Ramon A. Franco from Harvard Medical School and Massachusetts Eye and Ear Infirmary, Boston, who first reported this approach to treating iSGS, told Reuters Health by email, “I started to report my findings sometime in 2012, offering my colleagues a glimpse into the incredible results I was observing by using the steroids as the treatment of the airway scarring instead of as an adjuvant that is ‘sprinkled’ in the wound (injected) at the conclusion of the case (as an afterthought). I met with a tremendous amount of resistance and skepticism from many in the ENT community and it was dismissed by many. This is despite recording improving pulmonary function tests at each encounter and seeing the improvement in airway caliber and a reduction in patient complaints.”
“Ultimately, the reduction in need for surgery is the most important factor, but we need to get studies in the literature that prove the steroid injections alter the disease process sufficiently to obviate the need for surgery,” he said. “I have been trying to get ENTs to think of subglottic stenosis as primarily a medical problem, although we have been thinking of it as a surgical problem for many decades. I do think surgery plays a role, but it should not be thought of as having a primary role in the treatment of subglottic stenosis.”
“Serial intralesional steroid injection (SILSI) is an option that is now available to women to allow them to breathe better, with proven sustained results, that does not require extensive surgery in the form of the voice-mutilating cricotracheal resection,” Dr. Franco concluded.
SOURCE: http://bit.ly/2CX6gkf
JAMA Otolaryngol Head Neck Surg 2018.
Tidak ada komentar:
Posting Komentar