2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Ann Thorac Surg 2017;103:246 – 53

SHADMEHR ET AL

SYSTEMIC STEROIDS IN TRACHEAL STENOSIS

Fig 2. Primary and secondary outcomes. White bars indicate corticosteroid group; gray bars indicate placebo group.

systemic corticosteroid therapy might increase the time between RBD that patients either require to become ready for airway resection or require for their respiratory status to become stable. This means that the patients confront less physical, psychological, and economic stress because they may undergo fewer numbers of broncho- scopic procedures. It could also be bene fi cial to health system by increasing the number of beds available for other patients and reduction of the economic burden. It was also shown that it might decrease the number of patients who would ultimately need airway resection, which is another potential bene fi t for this group of patients. These two trends, one toward fewer RBDs and the other toward fewer patients who ultimately need airway resec- tion, are very important for thoracic surgeons, and perhaps a larger sample size would be needed to show a true dif- ference in these two outcomes. In addition, our study demonstrated that patients in group C, who underwent airway surgery, required a shorter length of resection. As it was shown [21] that the longer the resection, the more the tension on the anastomosis, and then the more the risk of complications, it is clear how this outcome could be very advantageous to patients with PITS. Nevertheless, this study had a number of limitations, resulting from extended exclusion criteria, which made it take 3.5 years for us to recruit 120 eligible patients of 522 (roughly 23%) with PITS during that time. We had many patients presenting to us with tracheostomy tubes. Because they did not need to undergo RBD as temporary management, they had to be excluded because of the design of our study. As has also been shown by several studies [7, 8, 18, 22] , we believe that early periodic dilation and granulation tissue removal is effective in the prevention of stenosis; and late periodic dilations for chronic stenosis, particu- larly when the process of fi brosis has matured and the cartilage has been destroyed, are not helpful in further alleviation of obstruction. Therefore, we excluded pa- tients for whom, at the time of fi rst presentation to us, more than 6 months had passed since their intubation.

tracheal stenosis. Croft and colleagues [18] , through an experimental studies on 15 dogs divided into three groups, concluded that the introduction of a steroid/ antibiotic regimen has a bene fi cial effect on developing subglottic stenosis and that the timing of such therapy is of importance. Gosh and coworkers [19] , working on mice, also showed that systemic steroids might prevent formation of granulation tissue and subglottic stenosis. Kryzer and associates [20] showed on a ferret animal model that aerosolized dexamethasone appeared to be bene fi cial in preserving the subglottic airway after injury, possibly secondary to decreasing the edema associated with injury. Hirshoren and Eliashar [5] performed a systematic search of the relevant PubMed and Ovid databases from 1960 to 2007. They found that several wound-healing modulating agents in upper airway stenosis have been tested, but most of them were poorly investigated. They also found con fl icting data regarding their role in pre- venting and treating subglottic stenosis, and fi nally, they support to some extent the textbook suggestions of anti- biotics, steroids, and antire fl ux treatment [5] . Lack of strong scienti fi c evidence in the human setting led us to design a randomized double-blind clinical trial with a large number of patients, to answer some ques- tions regarding the role of corticosteroids in the man- agement of PITS. As our results showed, early low-dose

Table 7. Follow-Up Results One Month After Surgery Follow-Up Results Corticosteroid Placebo

p Value

Respiratory status Normal

23 (82.1%) 5 (17.9%)

32 (80%)

0.701

Exertional dyspnea

7 (17.5%) 1 (2.5%)

Dyspnea at rest

0 (0%)

Voice status Normal

24 (85.7%) 4 (14.3%)

37 (92.5%)

0.435

Husky voice

3 (7.5%)

No voice/cannulated 0 (0%)

0 (0%)

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