Awake serial intralesional steroid injections without surgery as a novel targeted treatment for idiopathic subglottic stenosis

Abstract

Objectives/hypothesis: The fibrotic/erythematous appearance of the subglottis in idiopathic subglottic stenosis (iSGS) hints that it might respond to repeated intralesional steroid treatment similar to keloids.

Study design: Retrospective cohort study.

Methods: Thirteen iSGS subjects (six treated in-office with serial intralesional steroid injections [SILSI] versus seven treated endoscopically in the operating room [OR] followed by awake SILSI) between October 2011 and April 2017. Forced spirometry was performed before injections and at each follow-up visit (peak expiratory flow [%PEF] and peak inspiratory flow). Steroids were injected via transcricothyroid or transnasal routes. Injections were grouped into rounds of four to six injections separated by 3 to 5 weeks.

Results: Thirteen subjects with a mean follow-up of 3 years (3.3 years for SILSI and 2.7 years for OR). Awake-only SILSI subjects had a mean improvement/round of 23.1% %PEF (range, 65.4%-88.6%), whereas the OR-treated subjects had a mean %PEF improvement/round of 25.1% (range, 57.4%-82.5%). Both groups had improved breathing, and the improvements were statistically equal (P = .569). SILSI subjects underwent 5.3 injections/round in 1.3 rounds, whereas OR subjects had 5.9 injections/round over 2.1 rounds. Statistically significant improvement was seen in %PEF for both groups (SILSI P = .007, OR P = .002). Overall, SILSI achieved sustained %PEF above 80% in 83% (5/6) and OR + SILSI 86% (6/7).

Conclusions: SILSI in the awake outpatient setting can improve the airway caliber in iSGS and is equivalent to endoscopic OR treatment. We believe iSGS can be viewed as a chronic scarring/inflammatory condition that can benefit from steroid scar-modification therapy.

Level of evidence: 4. Laryngoscope, 128:610-617, 2018.

Keywords: Airway stenosis; idiopathic subglottic stenosis; in-office treatment; reconstruction; steroid injection.