Initial Experience With Low-Dose Methotrexate as an Adjuvant Treatment for Rapidly Recurrent Nonvasculitic Laryngotracheal Stenosis

Rosow, David E.; Ahmed, Jamal Uddin

doi:10.1001/jamaoto.2016.2895

Cited by 13 publications

(12 citation statements)

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“…Recent studies have prompted the consideration that better treatment modalities exist outside the surgical realm, used in combination or possibly even standalone, to achieve successful management of SGS. The concept of adjuvant therapy has already been well investigated for SGS with anti‐inflammatory/immunomodulating agents such as mitomycin C, inhaled corticosteroids, proton‐pump inhibitors, antibiotics, and methotrexate based on the principle that SGS pathophysiology is heavily driven by inflammation and fibroblast proliferation . In Maldonado et al study, a trend between aggressive medical treatment (anti‐reflux medications, inhaled corticosteroids, and trimethoprim‐sulfamethoxazole) and lowered idiopathic SGS recurrence rate was identified demonstrating a relative risk of 0.52, P = .051 with adjuvant treatments versus no further treatments after endoscopic surgery .…”

Section: Discussionmentioning

confidence: 99%

Office‐based corticosteroid injections as adjuvant therapy for subglottic stenosis

Pan

Rosow

2019

Laryngoscope Investig Oto

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Objective Subglottic stenosis (SGS) is a serious, potentially life‐threatening disorder that is difficult to treat due to significant recurrence rates. While conventional treatment of SGS relies heavily on serial endoscopic dilation procedures, this study aims to characterize the efficacy of incorporating subglottic corticosteroid injections in increasing surgery‐free intervals (SFIs) for a cohort of patients at a university‐based medical system. Study Design Retrospective chart review. Methods All SGS patients who underwent endoscopic dilation and at least one adjuvant office‐based serial intralesional steroid injection (SILSI) were reviewed. Patients were excluded if they had synchronous airway lesions or stenosis outside of the subglottis. Charts were reviewed for demographic and treatment‐specific data. The SFI was calculated for patients both prior to the initiation of SILSI and after. Groups were compared via Mann–Whitney U test, with P < .05 as the threshold for significance. Results Thirteen patients met criteria, with mean age 50.1 ± 14.1 years and 7:6 female to male ratio. Eight of the thirteen (61.5%) had intubation‐related stenosis, while 4/13 were idiopathic and 1/13 was due to Wegener's granulomatosis. Mean follow‐up was 20.4 months. Patients underwent an average of 4.2 ± 2.2 postoperative injections, beginning 45.9 ± 19.0 days after surgery. The mean SFI prior to initiating SILSI was 288.6 ± 362.0 days; while after receiving SILSI, the mean interval was significantly longer (545.5 ± 152.7 days, P = .0041). Conclusions We demonstrate that office‐based corticosteroid injection for SGS was associated with a statistically significant improvement in the SFI and is a promising adjuvant approach. Future prospective studies should evaluate if the efficacy is reproducible on a large scale and if SILSI can and/or should be incorporated into the standard management paradigm for SGS treatment. Level of Evidence 4

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Section: Discussionmentioning

confidence: 99%

Office‐based corticosteroid injections as adjuvant therapy for subglottic stenosis

Pan

Rosow

2019

Laryngoscope Investig Oto

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“…Definitive treatment should be offered while a sufficient length of healthy infraglottic mucosa remains to accommodate the anastomosis fashioned during a cricotracheal resection [23, 24], or full coverage of the proximal extent of the disease by a skin graft during an open laryngotracheal reconstruction [4] or an endoscopic laryngotracheoplasty with biological inhibition [1] procedure. Further investigation is required to determine whether, at the time that proximal stenosis progression is observed initially, but before it has caused vocal fold fixation, the proximal stenosis progression can be halted with pharmacological agents such as methotrexate [15], mitomycin C [11, 26], or intralesional steroids [13, 14, 27], or whether a definitive procedure should be performed expeditiously.…”

Section: Discussionmentioning

confidence: 99%

“…This is accomplished by incising and dilating the stenosis and by pharmacologically modulating the scar response [11] to maximise intervention-free intervals [12]. More recently, serial intralesional injections of corticosteroids [13, 14] and systemic administration of antimetabolites [15] have been used as adjunctive or single-modality airway maintenance treatments.…”

Section: Introductionmentioning

confidence: 99%

Vocal fold fixation due to proximal stenosis progression complicating idiopathic subglottic stenosis

Nouraei

Dorman

Johnston

et al. 2019

Eur Arch Otorhinolaryngol

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Purpose This study examined the incidence and risk factors for vocal fold fixation due to proximal progression of idiopathic subglottic stenosis (ISS) over the course of serial treatments. Methods Records of 22 consecutive patients with ISS treated between 2004 and 2016 were retrospectively reviewed. Patient, stenosis, and treatment details were recorded. Cox regression was used to identify independent predictors of vocal fold fixation. Results All patients were female and mean age at diagnosis was 46 ± 7 years. In five patients, the stenosis was within 15 mm of the glottis at first treatment. Vocal fold fixation due to proximal stenosis progression occurred in seven (32%) patients. It led to permanent hoarseness due to unilateral vocal fold fixation in two patients and caused airway compromise due to bilateral vocal fixation in two other patients. No airway-related deaths occurred and no patient required a tracheostomy. Stenosis incision using coblation or potassium titanyl phosphate laser, and an initial glottis-to-stenosis (GtS) distance < 15 mm significantly increased the risk of proximal stenosis progression on univariable analysis. Conclusion Vocal fold fixation due to proximal stenosis progression is a significant complication of idiopathic subglottic stenosis and causes permanent voice and/or airway sequelae. It should be actively looked for and documented every time a patient is assessed. If a reduction in the GtS distance is observed, definitive surgery should be promptly considered before proximal stenosis progression compromises the efficacy and safety of definitive treatment or, worse, causes vocal fold fixation.Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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“…Further prospective investigation is encouraged. Other potential adjuvant therapies include the use of methotrexate, an immunomodulatory agent, which may increase the mean SFI in patients with recurrent nonvasculitic LTS [101].…”

Section: Adjuvant Therapymentioning

confidence: 99%

An Updated Review of Subglottic Stenosis: Etiology, Evaluation, and Management

2022

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Purpose of ReviewTo assimilate the newly published literature regarding subglottic stenosis (SGS), including basic science and translational research on mechanisms of etiology, clinical diagnostics, and therapeutic treatments. Recent FindingsThe role of inflammation in development of iatrogenic and idiopathic SGS (iSGS) is continuing to be studied. The IL-23/IL-17A inflammatory axis appears to be a potential mechanism for development of iSGS. Additionally, as anticipated in an inflammatory milieu, PD-1/PD-L1 expression is upregulated. If the PD-1/PD-L1 axis is important in SGS pathogenesis, then it may represent a potential target for immunotherapeutic inhibition, given its success in cancer treatment. In terms of surgical management, prospective studies show that endoscopic approaches have more frequent recurrence compared to open techniques. Summary SGS arises from various etiologies, and further understanding of its pathogenesis can aid in the development of novel therapies. It is imperative to obtain a thorough history for each patient presenting with respiratory complaints, as misdiagnosis can delay proper treatment. Endoscopic and open surgical techniques continue to be investigated in a growing number of prospective clinical trials to determine optimal treatment protocols. In-office injections are gaining popularity and show promise in the treatment of SGS.

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Initial Experience With Low-Dose Methotrexate as an Adjuvant Treatment for Rapidly Recurrent Nonvasculitic Laryngotracheal Stenosis

Cited by 13 publications

References 20 publications

Office‐based corticosteroid injections as adjuvant therapy for subglottic stenosis

Office‐based corticosteroid injections as adjuvant therapy for subglottic stenosis

Vocal fold fixation due to proximal stenosis progression complicating idiopathic subglottic stenosis

An Updated Review of Subglottic Stenosis: Etiology, Evaluation, and Management

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