Idiopathic Subglottic Stenosis Treatment: Steroids, Dilation or Surgery?

[Dr. Ashley Agan]
That's interesting that steroid injections are helpful, but oral steroids aren't helpful at all. Why do you think the concentration that you're able to deliver with an injection is just so much higher or any thoughts on that? Because we love giving steroids at ENT. To hear that steroids don't work is like, what?

[Dr. Stephen Schoeff]
It's a really interesting question. There's definitely a debate within our field. I'd say most laryngologists I know are using these, but there's a few and a few very prominent laryngologists that are pretty skeptical. There's a couple of factors. One of which is what's the underlying problem? What's going on here? Dr. Gelbard at Vanderbilt has led a lot of the high-level basic science research into this. I don't want to ignore his colleagues there, but he's the person who's, I think, spearheading it right now. He's shown that there is this lack of epithelial integrity, some invasion by bacteria. There's a little bit of a chicken or the egg question, what starts the process? We're observing the process after it started. What's going on there? Ultimately, you end up with this inappropriate fibroblast process as well that's laying down scar where you shouldn't be laying down scar and an alteration of the immune response in the sub-epithelial tissue. The steroid injection side, how that addresses it, the theory from what I understand, came from what we see in keloids and hypertrophic scar and approaching those. Dr. Franco and Dr. Dailey have both been big early adopters. Dr. Franco was the first person to describe it. Then Dr. Dailey also has been an early adopter of the steroid injections in the office and seeing really good results with these since about 2014 or so. Dr. Franco recently presented, I believe it was a poster actually, but some basic science showing that the fibroblast activity actually has changed with steroid injection. I don't think we get that from oral steroids or at least we can't give oral steroids long enough to achieve that response. Basically a fibroblast activity is changing from laying down scar to actually removing scar. That's hugely valuable, of course, when we're talking about really just needing a few millimeters of airway and needing some improvement in that scar deposition.

[Dr. Ashley Agan]
For your steroid injections, whether you decide to do initial treatment of the serial injections or at the time of your endoscopic dilation in the OR, what steroid do you use and how much do you end up giving? Do you have a special needle you like?

[Dr. Stephen Schoeff]
Yes. I'm using Kenalog 40. I think that's pretty standard across the field. We like that deposition. Of course, that's what I think a lot of facial plastic surgeons and folks have used in keloid as well. I use that just with a-- There's an Integra laryngeal injector in the OR. Usually I'm removing the tissue and then injecting steroid, and then possibly dilating a little bit after that just to make sure the airway is completely open for somebody coming out of anesthesia. Then in the clinic, I'm using either a 25-gauge needle trans-cricothyroid with a physician assistant driving a camera or I'm driving a working channel scope with a sclerotherapy needle through the channel that is, I believe, a 20, 23-gauge that we're getting into the tissue subepithelially and infiltrating with the Kenalog.

[Dr. Ashley Agan]
You just try to do several little injections around the edges of it?

[Dr. Stephen Schoeff]
Exactly. Yes. Just finding places where there is more scar deposition, where there's more tissue and filling that tissue. I generally aim to do about one milliliter, plus or minus. It just depends. Patients who have minimal stenosis, we're oftentimes doing less than that. Then usually it's done in a series. If somebody's starting out with treatment that way, we're doing it in a series of three or four injections over the course of three or four months. Oftentimes after somebody is taken to the OR, I offer a series of injections afterward as well. There's evidence that helps to improve the interoperative interval. For some patients, it really keeps them out of the OR entirely. We had a good number of patients at University of Wisconsin who stopped going to the OR with this approach. I've had that experience as well, taking over practice from a surgeon who is treating patients with dilation every six to 12 months or so based on their symptoms. A number of them have switched to steroid injections and it's been three plus years that I've been here and they've never had to go back to the OR. Some patients respond to it beautifully. Not everybody does. We still don't quite have a handle on why those patients who don't respond to it really well don't. Certainly there's some variability in that.

[Dr. Ashley Agan]
It's every- once a month for three to four months?

[Dr. Stephen Schoeff]
Correct. Then after that, and this is where I think there's a lot of variation, I think a lot of laryngologists are using that approach if somebody elects endoscopic treatment and doing this postoperatively. I think there is quite a bit of variation around the country in terms of how we approach it after that. Whether somebody- folks are followed or folks are told just to come back if their symptoms start to worsen again. There's, I think, a huge variability in terms of how that practice is approached.

[Dr. Gopi Shah]
Just transitioning to CTR and open airway. Are there certain hard indications for CTR? Is there a certain amount of stenosis or, hey, now we're in the OR every two to three months? When do you start to that, hey, we're here now?

[Dr. Stephen Schoeff]
Yes, that's really driven by the patient scenario. I think some patients are very interested in that upfront. I would say it's a minority, but some are. Then I don't know that there is necessarily a cutoff, but certainly if patients are just needing constant, really frequent interventions, then you're really thinking about some of these more aggressive surgical options, whether that's a CTR or this what you might call an endoscopic CTR, which is the Maddern procedure that's mainly been developed at Cleveland Clinic. We're going in with a micro-debrider actually and removing the scar, and micro-debrider and then putting in a stent with a graft, either split the skin or a buccal mucosa to try and reline that tissue. It's a middle ground between the options, so to speak. They just published a series of almost 30 patients or so that have had pretty good results on average. That's definitely something that's out there as a potential middle ground between cricotracheal resection and the associated risks and potential issues there and the endoscopic options.

[Dr. Gopi Shah]
Do you ever have patients where tracheostomy is the best option? Who are those patients?

[Dr. Stephen Schoeff]
Occasionally there are patients who are just fed up with it, are either considered too high risk. Diabetes is always considered a big risk factor for cricotracheal resection. Not in my current practice, but I have seen patients who either had a mucus plugging event and presented emergently and gotten a tracheostomy or were in a place where there wasn't somebody who could do jet ventilation and things like that. I just found that once they got used to a tracheostomy, they said, oh, this is actually easier than going back to the OR, and things like that, and actually found it to be pretty manageable. I have seen a couple of patients who actually, ultimately prefer, or at least have elected just to use a tracheostomy and bypass the issue.