Differing Progression to Posterior Glottic Stenosis in Autoimmune and Idiopathic Subglottic Stenosis

Abstract

Objectives/Hypothesis: We sought to characterize rates of progression to posterior glottic stenosis (PGS) from autoimmune or idiopathic subglottic stenosis.Study Design: This was a retrospective review. Methods: Patients from a tertiary-care laryngology practice over a 10-year period with autoimmune or idiopathic subglottic stenosis (SGS) were included. Patients with a history of prolonged intubation or other causes of iatrogenic stenosis were excluded. PGS was confirmed on videostrobolaryngoscopy recordings by a fellowship-trained laryngologist. PGS type (1-4) was also recorded. Demographic information was recorded, and if applicable, autoimmune disease type was specified. Time until PGS was recorded along with the number of interventions. Chi-squared analysis was used to compare PGS in autoimmune and idiopathic SGS.Results: A total of 77 patients were identified with autoimmune (32 patients) or idiopathic (45 patients) subglottic stenosis. Autoimmune pathologies included systemic lupus erythematosus, granulomatosis with polyangiitis (GPA), rheumatoid arthritis, relapsing polychondritis, and sarcoidosis, with GPA the most common (14/32). Patients with autoimmune SGS had a higher rate of PGS (10 of 32) compared to idiopathic subglottic stenosis (1 of 45) for an odds ratio of 20 (95% CI: 2.4-166.4, P = .006). Patients with idiopathic SGS were more likely to be female (all 45 compared to 29/32 autoimmune, P = .07) and older (mean 53 (range 29-75) compared to 46 (20-82), P = .02).Conclusions: In this large patient cohort, autoimmune SGS patients were found to have a higher likelihood of developing PGS compared to their idiopathic counterparts, suggesting that counseling for this progression may be warranted.

Proximal Scar Progression in Idiopathic Subglottic Stenosis After Wedge Excision: Does it Happen?

“…Outside of airway surgery, glottic stenosis does not appear to be common in the natural history of iSGS. Dion et al demonstrated that although 31.3% of a group of patients with an autoimmune etiology underlying their subglottic stenosis demonstrated concurrent posterior glottic stenosis, only one case of concurrent glottic stenosis was noted out of 45 (2.2%) patients with iSGS 9 . Our LWEP cohort, 3 times larger than this study, observed a slightly higher incidence of baseline glottic stenosis at 4.5%.…”

“…Stenosis higher in the larynx may lead one to suspect a greater role for underlying inflammatory processes including granulomatosis with polyangiitis (GPA) and microscopic polyangiitis, which affect younger individuals and may involve the subglottic surface of the vocal folds 19 . It is also possible that the underlying etiology behind the four individuals with glottic involvement of their scar could later be classified as having an ANCA‐negative form of GPA 9 . However, currently none of these four patients nor any of the 209 other patients included in this study have demonstrated any physical exam findings or laboratory tests that would suggest this underlying disease process.…”

“…This complication is feared amongst airway surgeons given the significant difficulty with treating glottic stenosis. The incidence of glottic stenosis in iSGS was recently reported to be around 2%, significantly less common than what is observed in autoimmune‐derived airway stenosis, which suggests that an increase above this in a cohort of iSGS patients could be perceived as of iatrogenic origin 9 …”

Factors Affecting Dilation Interval in Patients With Granulomatosis With Polyangiitis‐Associated Subglottic and Glottic Stenosis

“…One prior study described cricoarytenoid joint fixation and vocal cord immobility suggestive of glottic involvement in 20% of its GPA-associated SGS cohort; another described development of posterior glottic stenosis in 28% of their 14 patients with GPA-associated SGS. 18,48 Our study showed that 33% of patients with GPA-associated SGS had glottic involvement and a shorter dilation interval and were more likely to have the clinical complaint of dysphonia. Surprisingly, VRQOL scores did not differ between groups, which may be due to limited availability of data.…”

Recurrence Following Endoscopic Laser Wedge Excision and Triple Medical Therapy for Idiopathic Subglottic Stenosis

“…Hesitation remains regarding employing the LWE for iSGS, with concern for the potential of thermal injury from the CO 2 laser promoting a proximal increase in scar length and the development of glottic involvement, a pathophysiology observed infrequently within the natural history of iSGS. 19 Future studies should focus on the rate of complications within airway surgery-naı ¨ve patients with iSGS, looking for evidence of postoperative scar migration. While we acknowledge the short follow-up of some of our patients within this analysis, the median for the cohort overall was 5.6 years, approximately 4 times greater than the PCORI analysis (1.2 years).…”