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In Clinic Steroid Injections for Subglottic Stenosis (Office Based)

last modified on: Mon, 01/08/2024 - 09:00

return to: Subglottic stenosis

Introduction

Endoscopic dilation is a mainstay treatment for subglottic and proximal tracheal stenosis with the major limitation of restenosis requiring repeated surgery warranting consideration for other interventions. Intralesional steroid injection (ISI), with triamcinolone 40 mg/mL, using topical anesthesia, spaced 3 to 6 weeks apart, has been shown to prolong the effects of dilation. Bertelsen et al. reported that the interval between OR dilations increased from 10 months to 22 months after ISI was initiated. ISI can be done in office with percutaneous injections under flexible laryngoscopy guidance. 

Study by Woliansky et al (2018) evaluated the impact of serial intralesional (subglottic) steroid (triamciniolone - kenalog 40 - with 40 to 200 mg) on the HPA (hypothalamic-pituitary-adrenal) axis suppression. They identified that systemic absorption of the steroid acutely suppressed the HPA axis with normalization of function by day 7 following treatment. They concluded that although the possibility of acute steroid effects should be discussed with the patient, no cumulative systemic steroid effects would occur with spacing serial injections every 3 to 5 weeks (following the Franco (2018) protocol).

 

Update: note the patient depicted ultimately underwent cricotracheal resection (open resection of stenosis) with subsequent touch-up endoscopic procedures - having identified only temporary benefit from steroid injections.

 

Sample Dictation Template

Anesthesia: Premedication with Bactrim on the day of the procedure to continue for one week. In sitting position, nasal decongestion and anesthesia with 4% lidocaine and phenylephrine mixture after having injected 1 cc of 2% lidocaine with 1:100,000 epinephrine (dental carpule) to the region anterior to the cricothyroid membrane. Trans-cricothyroid puncture with a 23-gauge needle instillation of 2 cc of 1% lidocaine: 100,000 epinephrine with coughing to anesthetize the larynx and trachea.
Description of Procedure: Following identification of the patient and the procedure on the informed consent, as well as the above-mentioned anesthesia, a time out was performed. The patient was then placed in a semi-recombinant position while the transnasal laryngoscopy with the small (red labelled) flexible scope was performed. The laryngoscope passed beyond normal-appearing vocal cords to image the subglottis.  A 25-gauge needle affixed to a 3 cc syringe with a 1:1 dilution of Kenalog 40 with 1% lidocaine with 100,000 epinephrine ("kenalog 20") was then oriented intraluminally to inject in all 4 quadrants of the subglottic narrowing to a total dose of 1 cc. Note that reference to images from most resent surgery under general anesthesia helped to target the injection. The patient was then reevaluated in the sitting position with the flexible transnasal laryngoscope identifying a good airway. She was observed in clinic for an additional one half hour before discharged home with follow-up with a similar procedure targeted in one month.

References

Bertelsen C, Shoffel-Havakuk H, O’Dell K, Johns MM, Reder LS. Serial In-Office Intralesional Steroid Injections in Airway Stenosis. JAMA Otolaryngol Head Neck Surg. 2018;144(3):203–210. doi:10.1001/jamaoto.2017.2800

Franco RA, Husain I, Reder L, Paddle P: Awake serial intralesional steroid injections without surgeyr as a novel targeted treatement for idiopathic subglottic stenosis. Laryngoscope 2018 Mar;128(3):610-617

Hoffman MR, Coughlin AR, Dailey SH. Serial office-based steroid injections for treatment of idiopathic subglottic stenosis. Laryngoscope. 2017 Nov;127(11):2475-2481. doi: 10.1002/lary.26682. Epub 2017 Jun 5.

Gelbard A, Shyr Y, Berry L, Hillel AT, Ekbom DC, Edell ES, Kasperbauer JL, Lott DG, Donovan DT, Garrett CG, Sandhu G, Daniero JJ, Netterville JL, Shcindler JS, Smith ME, Bryson PC, Lorenz RR, Francis DO. BMJ Open 2018 Apr 10;8(4):e022243

Sekioka A, Fukumoto K, Yamoto M, Takahashi T, Nakaya K, Nomura A, Yamada Y, Urushihara N. Serial intralesional triamcinolone acetonide injections for acquired subglottic stenosis in premature infants. Pediatr Surg Int. 2018 Oct;34 (10):1047-1052

Woliansky J, Phyland D, and Paddle P: Systemic Safety of Serial Intralesional Steroid Injection for Subglottic Stenosis. Laryngoscope, 00:1-6, 2018

Schoeff S, Hoffman MR, Zhang Y, Yang Q, Dailey SH. Long-Term Follow-up of 64 Patients With Idiopathic Subglottic Stenosis: Treatment Pathways, Outcomes, and Impact of Serial Intralesional Steroid Injections. Ann Otol Rhinol Laryngol. 2023 Nov;132(11):1341-1348. doi: 10.1177/00034894231156122. Epub 2023 Feb 24. PMID: 36840325.