Case study
Corticosteroid Injection for Treatment of Idiopathic Subglottic Stenosis
Inyección intralesional de corticoide como tratamiento para la estenosis subglótica idiopática
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array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario La Princesa, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital MD Anderson Cancer Center Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Inyección intralesional de corticoide como tratamiento para la estenosis subglótica idiopática" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2552 "Ancho" => 2500 "Tamanyo" => 491809 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A and B) Axial and sagittal images of the pre-treatment CT. C and D) Axial and sagital images of the post-treatment CT.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical case</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 62 year-old patient was referred to the otorhinolaryngology department after presenting with a failed orotrachial intubation in the context of an endometriod adenocarcinoma hysterectomy. The patient mentioned progressive stridor and limitations to their basic activities over the last few years which they had attributed to poorly controlled asthma, in spite of treatment. They had not had any previous intubations, or trauma or any other subglottic stenosis risk factors. Any disease of autoimmune origin was also ruled out.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Fibroscopy showed subglottic concentric stenosis of approximately 70% with mobile larynx. Computerised tomography (CT) confirmed the narrowing of the airway at cricoids level. Intubation for hysterectomy was not possible, and tracheostomy was therefore performed under local anaesthesia within the same time in surgery. During the postoperative period the patient was re-assessed, presenting with paralysis of the right vocal cord with no associated dysphonia. Decannulation after this process was not possible since the patient did not tolerate the plug, presenting with dyspnoea and stridor at the most minimal effort Electromyography of the larynx showed partial axonal damage of moderate intensity in the paralysed cord and the magnetic resonance showed a reduction of the subglottic airway with an increase in soft tissue of probable inflammatory origin and no change to the level of cricoarytenoid articulation to suggest rheumatic disease.</p><p id="par0015" class="elsevierStylePara elsevierViewall">With diagnosis of idiopathic subglottic stenos and due to the fact that the patient refused any blood product transfusions for religious reasons, the surgical option was ruled out. Five intralesional injections of 1 ml of acetonide triamcinolone 40 mg/mL divided between 2 or 3 points of the stenosis every 2 months through the stoma were administered. After these injections a reduction in stenosis calibre was observed, reaching under 50% (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and spontaneous recovery of right vocal cord motility occurred which had been expected in view of the results of the laryngeal electromyography. CT imaging confirmed this reduction (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Thanks to this the patient began to tolerate the occlusion of the tracheotomy both during the night and during physical activities of moderate intensity without dyspnoea or stridor over several months, with the consequent closure of the same.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Idiopathic subglottic stenosis was first described by Brandenburg<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in 1972 as a fibro inflammatory lesion combined with a narrowing of the airway at cricoid level and proximal trachea. The level of maximum stenosis is usually situated in the cricoid or in the first tracheal ring. This is a progressive disease which almost exclusively affects women.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Traditionally, treatment is based on surgery, either through cricotracheal resection which on very many occasions’ must be accompanied by a series of dilations, or the use of endoscopic procedures. However, success rates with these treatments are not high due to the high recurrence of stenosis, and it is therefore highly exceptional that symptoms will cease with a single intervention.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Furthermore, all these procedures require multiple general anaesthesia and are not exempt from treatment-induced vocal co morbidities.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The fact that endoscopic imaging of these lesions is similar to cutaneous keloids, as a combination of inflammation and a healing process, infers that similar management of them could be satisfactory. As a result of this concept, Franco et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> conducted a study in which they assessed the results obtained with intralesional injections of corticoids at stenosis level, with satisfactory results.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The treatment of cutaneous keloids with intralesional corticoid injections has response rates of between 50%–100% and recurrences of between 9%–50%<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>; this would therefore be the expected success rate in the case of subglottic idiopathic stenosis due to the parallelism between them and keloids.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the other study existing in the literature currently referring to corticoid injections in subglottic stenosis,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reference was made to a reduction of around 20% with a series of 6 corticoid injections (betamethasone or triamcinolone). With these injections stenosis was kept below the 50%, level, the level at which significant symptoms are expected to present.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Intralesional corticoid injections for the treatment of idiopathic subglottic stenosis are a promising option for the management of these patients. The main advantages are that they may be administered in the surgery and are well tolerated by the patient. As a result, the multiple interventions under general anaesthesia to which the patient is normally subjected may be avoided. Long-term results are yet to be defined and a more objective determination of the effectiveness of this treatment. If in the long term re-growth of stenosis presents, further maintenance cycles of intralesional injections may be administered as a more viable option, since this is a safe treatment, which is not associated with significant morbidity and which presents with good tolerance.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Financing</span><p id="par0050" class="elsevierStylePara elsevierViewall">No financing was received for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusions" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Financing" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 5 => array:2 [ "identificador" => "xack473204" "titulo" => "Acknowledgements" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-21" "fechaAceptado" => "2019-07-20" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Delgado-Vargas B, Sanz López L, Acle Cervera L, Mata Castro N. Inyección intralesional de corticoide como tratamiento para la estenosis subglótica idiopática. Acta Otorrinolaringol Esp. 2020;71:256–259.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1484 "Ancho" => 1500 "Tamanyo" => 224111 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Fibroscopic imaging of the stenosis before treatment. B) Imaging through the stoma of the pre-treatment stenosis. C) Fibroscopic imaging of the stenosis after treatment. D) Imaging through the stoma of the post-treatment stenosis.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2552 "Ancho" => 2500 "Tamanyo" => 491809 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A and B) Axial and sagittal images of the pre-treatment CT. C and D) Axial and sagital images of the post-treatment CT.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Idiopathic subglottic stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.H. 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