Serial intralesional steroid injection for subglottic stenosis

Song, Sungjin A.; Franco, Ramon A.

doi:10.1002/lary.28015

Cited by 12 publications

(18 citation statements)

References 6 publications

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“…The diagram depicted in Figure 4A describes the design of the study. 30 All patients were symptomatic at baseline, with exertional dyspnea due to the subglottic stenosis, which led to forced spirometry values ranging well below normal (mean starting PEF % Z 45% when normal is PEF% > 80%). After an initial endoscopic removal of scar plus steroid injection and two subsequent in-office subglottic steroid injections, the airway diameter of all patients increased, translating into a statistically significant improvement in forced spirometry (baseline PEF% Z 45% to SILSI-2 PEF% Z 91%; P Z 0.001) (Figure 4, B and C, and Table 3).…”

Section: Two Consecutive Rounds Of Intralesional Steroidal Injections Improve the Clinical Outcome Of Patients With Isgsmentioning

confidence: 98%

Down-Regulation of a Profibrotic Transforming Growth Factor-β1/Cellular Communication Network Factor 2/Matrix Metalloprotease 9 Axis by Triamcinolone Improves Idiopathic Subglottic Stenosis

Treviño-Villarreal

Reynolds

Langston

et al. 2021

The American Journal of Pathology

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Idiopathic subglottic stenosis (iSGS) is a progressive fibrotic disease characterized by life-threatening airway narrowing. Although the molecular underpinnings are unknown, previous reports showing that subglottic serial intralesional steroid injections (SILSIs) improve clinical outcomes suggest a steroidsensitive pathway in iSGS. Herein, a prospective study was conducted to determine the changes in profibrotic markers during SILSI to identify steroid-sensitive profibrotic drivers. Seven newly diagnosed patients with iSGS were recruited for SILSI. Subglottic biopsies before and after SILSI treatments were evaluated for histologic and molecular markers by confocal microscopy and RT-qPCR. At baseline, iSGS subglottises contained abundant vimentin-positive/a-smooth muscle actinenegative fibroblasts, intermingled with a matrix of fibronectin and types I and VI collagen. Transforming growth factor (TGF)-b1 was up-regulated primarily in glandular epithelium. Cellular communication network factor 2 (CCN2) was mainly up-regulated in stromal fibroblasts surrounding TGF-b1epositive glandular structures. SILSI improved iSGS by reducing fibroblast infiltration and increasing matrix remodeling. Mechanistically, SILSI counteracted the effects of TGF-b1 by inducing matrix metalloprotease 9 (MMP9) expression while repressing CCN2 expression, without affecting TGFb1 levels. Treatment of primary iSGS-derived fibroblasts with TGF-b1 recapitulated aspects of the disease in vivo, demonstrating that the induction in CCN2 and repression of MMP9 are caused by changes in histone acetylation induced by TGF-b1. Triamcinolone counteracted the coregulation of these genes by impairing SMAD2/3 binding to promoter regions, and not through histone acetylation. In conclusion, this study shows that SILSI counteracts a dysregulated TGF-b1/CCN2/MMP9 axis involved in iSGS development.

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Section: Two Consecutive Rounds Of Intralesional Steroidal Injections Improve the Clinical Outcome Of Patients With Isgsmentioning

confidence: 98%

Down-Regulation of a Profibrotic Transforming Growth Factor-β1/Cellular Communication Network Factor 2/Matrix Metalloprotease 9 Axis by Triamcinolone Improves Idiopathic Subglottic Stenosis

Treviño-Villarreal

Reynolds

Langston

et al. 2021

The American Journal of Pathology

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“…As office‐based treatments for laryngeal disease have become more popular, serial intralesional steroid injection (SILSI) has become an increasingly accepted treatment for idiopathic subglottic stenosis (ISGS) 1,2 . This technique involves injecting corticosteroid solution into the subglottis and trachea of awake, locally anesthetized patients for the purpose of reducing inflammation and modulating scar formation, with the end goal of improving the patient's airway 3 . SILSI has been in use at our institution (Massachusetts Eye and Ear Infirmary) since 2009 and has gained traction among laryngologists in recent years as both a primary and adjunct treatment for airway management in ISGS 4,5 …”

Section: Introductionmentioning

confidence: 99%

“…1,2 This technique involves injecting corticosteroid solution into the subglottis and trachea of awake, locally anesthetized patients for the purpose of reducing inflammation and modulating scar formation, with the end goal of improving the patient's airway. 3 SILSI has been in use at our institution (Massachusetts Eye and Ear Infirmary) since 2009 and has gained traction among laryngologists in recent years as both a primary and adjunct treatment for airway management in ISGS. 4,5 For laryngologists treating benign and malignant conditions, voice outcomes are critical because they can significantly impact quality of life and health utility.…”

Section: Introductionmentioning

confidence: 99%

Voice‐Related Quality of Life in Idiopathic Subglottic Stenosis: Effect of Serial Intralesional Steroid Injections

et al. 2020

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Objectives Serial intralesional steroid injection (SILSI) is an emerging treatment for idiopathic subglottic stenosis (ISGS), providing improvement in both subjective symptoms and objective airflow parameters. Little is known about how this airway remodeling affects the voice. This project analyzes subjective voice changes after SILSI and correlates these with airflow parameters. Methods An ISGS database containing voice‐related quality of life (V‐RQOL) and spirometry (peak expiratory flow percentage [%PEF]) was retrospectively queried. Included were ISGS patients from 2009 to 2019 who had at least one SILSI treatment. Encounters without complete data were excluded. Differences between preprocedure and postprocedure metrics were calculated. Correlations and nonparametric bivariate analysis were performed. Results Six hundred and seventeen steroid injections were performed in 55 patients, with an average of 3.5 years of follow‐up. The average V‐RQOL for all patient encounters, both pre‐ and postprocedure, showed little subjective dysphonia (83.5 of 100, 95% confidence interval [CI] 81.6 to 85.4). Considering SILSI‐only treatments, there were 143 encounters with full data; of these, V‐RQOL improved in 70 (49.0%), did not change in 40 (28.0%), and worsened in 33 (23.0%). Average V‐RQOL improvement for the entire cohort was 1.9 points (95% CI: 0.7 to 3.2), which was small but significant (P = .0003). Across all data, there was a weak but significant correlation between PEF% and V‐RQOL (ρ = 0.22, P = .0043). Conclusion SILSI was associated with improvement in subjective voice ratings in about half of patients, and the improvement correlated with improved airflow measurements. This research adds to the growing body of data regarding SILSI and suggests that further work on functional changes to the larynx with airway remodeling is imperative. Level of Evidence 4 Laryngoscope, 131:366–369, 2021

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“…2,7,8 Limited retrospective case series also suggest benefit from repeated intralesional steroid injections. 9-11 Endoscopic management typically involves endoscopic dilation (ED) or endoscopic resection and medical therapy (ERMT). 7 Although effective in the short term, endoscopic techniques likely do not address the underlying pathophysiology of iSGS and often require repetition.…”

mentioning

confidence: 99%

“…Current treatment for iSGS is surgical and traditionally involves endoscopic intervention, open airway procedures, or tracheostomy, with considerable heterogeneity in management patterns 2,7,8 . Limited retrospective case series also suggest benefit from repeated intralesional steroid injections 9–11 . Endoscopic management typically involves endoscopic dilation (ED) or endoscopic resection and medical therapy (ERMT) 7 .…”

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confidence: 99%

Endoscopic Resection and Mucosal Reconstitution With Epidermal Grafting: A Pilot Study in Idiopathic Subglottic Stenosis

Davis

Lina

Motz

et al. 2021

Otolaryngol.--head neck surg.

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Objective To describe technical aspects and surgical outcomes of endoscopic resection and mucosal reconstitution with epidermal grafting (ie, the Maddern procedure) in the treatment of idiopathic subglottic stenosis. Study Design Medical record abstraction. Setting Johns Hopkins Hospital. Methods Retrospective series of 9 adults with idiopathic subglottic stenosis who underwent the Maddern procedure by a single surgeon over a 5-year period. Prespecified outcomes included (1) perioperative outcomes (Clavien-Dindo grade 4/5 complications, need for staged tracheostomy, hospital length of stay), (2) postoperative outcomes (peak expiratory flow rate [PEFR], need for subsequent airway surgery, tracheostomy at follow-up), and (3) patient-reported quality-of-life outcomes (Clinical COPD Questionnaire, Voice Handicap Index–10, Eating Assessment Tool–10, and 12-Item Short Form Version 2). Wilcoxon matched-pairs signed rank test and Kaplan-Meier analysis were performed. Results There were no Clavien-Dindo grade 4/5 complications; 2 patients required unplanned staged tracheostomy; and the median length of stay was 3 days. Following endoscopic resection and stent removal, a median of 2 laser resurfacing procedures were required. Two patients developed recurrent stenosis requiring cricotracheal resection (CTR). There were significant improvements in PEFR, Clinical COPD Questionnaire, and Voice Handicap Index–10, without significant difference in Eating Assessment Tool–10. The 12-Item Short Form Version 2 approximated the population norm. Kaplan-Meier analysis demonstrated significant improvement in time to surgery after the final laser resurfacing. Conclusion The Maddern procedure has a low complication rate and offers durable physiologic improvement in PEFR, limiting need for additional procedures. Risks included need for CTR salvage, temporary tracheostomy, phlegm accumulation, and laryngospasm. It is a surgical option for patients with short dilation intervals who prefer to avoid the risks of CTR.

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Serial intralesional steroid injection for subglottic stenosis

Cited by 12 publications

References 6 publications

Down-Regulation of a Profibrotic Transforming Growth Factor-β1/Cellular Communication Network Factor 2/Matrix Metalloprotease 9 Axis by Triamcinolone Improves Idiopathic Subglottic Stenosis

Down-Regulation of a Profibrotic Transforming Growth Factor-β1/Cellular Communication Network Factor 2/Matrix Metalloprotease 9 Axis by Triamcinolone Improves Idiopathic Subglottic Stenosis

Voice‐Related Quality of Life in Idiopathic Subglottic Stenosis: Effect of Serial Intralesional Steroid Injections

Endoscopic Resection and Mucosal Reconstitution With Epidermal Grafting: A Pilot Study in Idiopathic Subglottic Stenosis

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