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

Abstract

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.

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

“…To date, only one investigation has assessed the development of glottic stenosis during the management of iSGS. Nouraei et al identified vocal fold fixation due to proximal migration of subglottic scar in 32% of a cohort of iSGS patients ( n = 22), with nearly a third of these cases resulting in glottic airway compromise and 2 requiring additional surgical management (cricotracheal resection, CTR) 8 . This rate, which is significantly higher than what is reported in our cohort, was attributed to the use of coblation and potassium titanyl phosphate lasers.…”

“…This increased use of the laser which is transmitted between the glottis through a rigid laryngoscope in theory comes with an increased risk of thermal injury to the glottis. Aside from breathing symptoms that come with glottic stenosis, the involvement of the cricoarytenoid joint causing decreased mobility of the vocal folds is a feared condition in airway surgery given the significant complexity in management and the associated impact on voice and swallowing function 8,15 …”

“…This rate, which is significantly higher than what is reported in our cohort, was attributed to the use of coblation and potassium titanyl phosphate lasers. We believe that this use of alternative lasers and a described methodology that includes aspects of both wedge excision and dilation is the reason for the significantly different results 8 …”

“…Despite similarities in technique and non‐inferior recurrence rates compared to endoscopic dilation (ED), the LWE is still employed by only a small minority of laryngologists in treating iSGS compared to ED. This may be secondary to lingering concerns for the potential of thermal injury from extended use of the CO 2 laser in promoting the development of proximal progression of the scar toward the glottis, leading to glottic stenosis 7,8 . This complication is feared amongst airway surgeons given the significant difficulty with treating glottic stenosis.…”

“…This may be secondary to lingering concerns for the potential of thermal injury from extended use of the CO 2 laser in promoting the development of proximal progression of the scar toward the glottis, leading to glottic stenosis. 7,8 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.…”