2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

SHADMEHR ET AL

Ann Thorac Surg 2017;103:246 – 53

SYSTEMIC STEROIDS IN TRACHEAL STENOSIS

4. Saghebi SR, Zangi M, Tajali T, et al. The role of T-tubes in the management of airway stenosis. Eur J Cardiothorac Surg 2013;43:934 – 9 . 5. Hirshoren N, Eliashar R. Wound-healing modulation in upper airway stenosis — myths and facts. Head Neck 2009;31:111 – 26 . 6. Hillel AT, Namba D, Ding D, et al. An in situ, in vivo murine model for the study of laryngotracheal stenosis. JAMA Oto- laryngol Head Neck Surg 2014;140:961 – 6 . 7. Eliashar R, Eliachar I, Esclamado R, Gramlich T, Strome M. Can topical mitomycine prevent laryngotracheal stenosis? Laryngoscope 1999;109:1594 – 600 . 8. Guven M, Turan F, Eyibilen A, Akbas A, Erkorkmaz U. A comparison of the ef fi cacy of 5. fl uorouracil/triamcinolone, carnitine and dexamethasone therapy on wound healing in tracheal injury: potential for preventing tracheal stenosis? Eur Arch Otorhinolaryngol 2012;269:201 – 6 . 9. Supance JS. Antibiotics and steroids in the treatment of ac- quired subglottic stenosis. A canine model study. Ann Otol Rhinol Laryngol 1983;92:377 – 82 . 10. Doolin EJ, Tsunu K, Strande LF, Santos MC. Pharmacologic inhibition of collagen in an experimental model of subglottic stenosis. Ann Otol Rhinol Laryngol 1998;107:275 – 9 . 11. Kil HK, Alberts MK, Liggitt HD, Bishop MJ. Dexamethasone treatment does not ameliorate subglottic ischemic injury in rabbits. Chest 1997;111:1356 – 60 . 12. Perepelitsyn I, Shapshay SM. Endoscopic treatment of laryngeal and tracheal stenosis — has mitomycin C improved the outcome? Otolaryngol Head Neck Surg 2004;131:16 – 20 . 13. Braidy J, Breton G, Clement L. Effect of corticosteroid on postintubation tracheal stenosis. Thorax 1989;44:753 – 5 . 14. Gharde P, Makhija N, Chauhan S. Post-intubation tracheal stenosis in paediatric patients after cardiac surgery. Ann Card Anaesth 2005;8:148 – 51 . 15. Abo M, Fujimura M, Kibe Y, Kida H, Matsuda T. Beclome- thasone diproprionate inhalation as a treatment for post- intubation tracheal stenosis. Int J Clin Pract 1999;53:217 – 8 . 16. Gnanapragasam A. Intralesional steroids in conservative management of subglottic stenosis of the larynx. Int Surg 1979;64:63 – 7 . 17. Yokoi A, Nakao M, Bitoh Y, Arai H, Oshima Y, Nishijima E. Treatment of postoperative tracheal granulation tissue with inhaled budesonide in congenital tracheal stenosis. J Pediatr Surg 2014;49:293 – 5 . 18. Croft CB, Zub K, Borowiecki B. Therapy of iatrogenic sub- glottic stenosis: a steroid/antibiotic regimen. Laryngoscope 1979;89:482 – 9 . 19. Ghosh A, Philiponis G, Lee JY, et al. Pulse steroid therapy inhibits murine subglottic granulation. Otolaryngol Head Neck Surg 2013;148:284 – 90 . 20. Kryzer TC, Gonzalez C, Burgess LP. Effects of aerosolized dexamethasone on acute subglottic injury. Ann Otol Rhinol Laryngol 1992;101:95 – 9 . 21. Wright CD, Grillo HC, Wain JC, et al. Anastomotic compli- cations after tracheal resection: prognostic factors and man- agement. J Thorac Cardiovasc Surg 2004;128:713 – 39 . 22. Campell BH, Dennison BF, Durkin GE, Strigenz MA, Toohill RJ. Early and late dilatation for acquired subglottic stenosis. Otolaryngol Head Neck Surg 1986;95:566 – 73 .

We also excluded patients with recurrent stenosis after airway resectional surgery, because their cause of stenosis at presentation to us was not only post-intubation. Another limitation was excluding patients younger than 15 years to whom we did not want to give systemic corticosteroids even at a low dosage, because of its po- tential hazard for growth and the complexity of ethical approval. Some elderly patients were also excluded because of associated diseases like diabetes mellitus or glaucoma, which did not allow us to give them cortico- steroids. In addition to all these issues, which led to the exclusion of many patients before intervention, we had a couple of patients in each group who were excluded after recruitment and during the process of our study because they required RBD at short intervals and had to undergo tracheostomy or T-tube insertion as their temporary management. Considering all limitations meant that us- ing systemic corticosteroids could be indicated for about one fourth of the patients. Taking into account that with this low-dose of pred- nisolone, we did not see any important drug side effects, and by discontinuing the drug at least 1 week before airway resection, there was no increased morbidity or mortality among our patients, its use in the management of PITS can be recommended, whenever it is indicated. In conclusion, early low-dose systemic corticosteroid therapy could be helpful as an adjunct in the manage- ment of patients with postintubation tracheal stenosis who at the time of presentation are not in an ideal situ- ation for airway resection. The authors wish to thank Professor Fanak Fahimi, PharmD, for his contribution to preparing the drug and placebo. This study was funded by the National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sci- ences, Tehran, Iran. The research support was allocated for providing the drug, placebo, and administrative costs. References 1. Abbasi Dezfouli A, Shadmehr MB, Javaherzadeh M, et al. Surgical treatment of post-intubation tracheal stenosis. Tanaffos 2010;9:9 – 21 . 2. Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109:486 – 92 . 3. Abbasidezfouli A, Arab A, Shadmehr M, et al. [Results of surgical treatment for postintubation airway stenosis, in 901 patients.]. J Med Council Islamic Repub Iran 2010;28:120 – 9 .

DISCUSSION DR JOSEPH B. SHRAGER (Stanford, CA): So how big is your hospital? I am amazed by the number of tracheal stenoses you have. Are you still using high-pressure cuffs for some reason?

DR SHADMEHR: I can say more than 90% of them.

DR SHRAGER: Okay.

DR SHADMEHR: No. But we are a referral center for the whole country.

DR SHADMEHR: Unfortunately, we have a lot of car accidents in our country, and the vast majority of our patients are young adults who could survive after a car accident, and so they had a long term of prolonged intubation. Irrespective of this great number of car accident victims, we are concerned about this high

DR SHRAGER: The referral center? Every tracheal stenosis in the country comes to you?

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