HSC Section 6 Nov2016 Green Book

Table 4. Operative Technique at Time of Endoscopic Dilation

Characteristic, No.

GPA

Idiopathic

Combined

P Value

Patients undergoing endoscopic dilation

14 48 15

23 55 35

38

NA NA

Total dilations

103

Operative use of laser Intraoperative injections No injection

50

.01

10 31

5

15 70

.10 .53 .99 .59

Triamcinolone Mitomycin C

39

1 6

1

2

Triamcinolone and mitomycin C

10

16

Abbreviations: GPA, granulomatosis with polyangiitis; NA, not applicable.

Table 5. Therapeutic Airway Procedure Frequency a

Granulomatosis With Polyangiitis, No.

Idiopathic, No.

P Value DBP, Mean

P Value Patients Procedures

P Value DBP, Mean

P Value

Characteristic

Patients Procedures

All patients

15

48

557

24

46

495

NA

GERD history Yes

506 470

4

9

.74 .74

565 555

.96 .96

12 12

32 14

.35

.60

No

11

39

Lifetime tracheotomy history Yes

6 9

33 15

.24 .24

367 975

.11 .11

NA NA

NA NA

NA NA

NA NA

NA NA

No

Sex

Male

6 9

31 17

.24 .24

318 994

.04 .04

NA NA

NA NA

NA NA

NA NA

NA

Female

NA

Abbreviations: DBP, days between procedures; GERD, gastroesophageal reflux disease; NA, not applicable. a Excludes surgical procedures with less than 6 months’ postoperative follow-up.

whereas the median age at which SGS was diagnosed in a cohort of patients with GPA was 26 years. 2 Further- more, patients with GPA and SGS are frequently diag- nosed as having GPA at a very young age; in fact, up to 44% are diagnosed before the age of 20 years. 13 27% of patients with GPA-SGS in our cohort were diagnosed as having GPA when younger than 20 years. GERD has been implicated in the development of SGS and has been identified as a probable precipitant of iSGS. 14-17 However, some question the existence of a di- rect association. 9 GERD has also been explored as a pos- sible cause of GPA-SGS, but evidence of a definitive link has yet to be identified. 18 The most compelling data to date come from a study by Blumin and Johnston 19 dem- onstrating pepsin in the larynx and trachea in 59% of pa- tients with iSGS, but none in matched control patients. Half of our iSGS group either had a history of, or was em- pirically treated for, GERD, which was statistically no dif- ferent from the comparison GPA-SGS group. Further- more, the rate of surgical utilization between those with a diagnosis of GERD and those without was no different in both groups. While our results fail to demonstrate a difference in the rate of GERD and SGS in the iSGS and GPA-SGS groups, understanding the impact of GERD on the development of SGS will be best accomplished through continued prospective studies. Operative management strategies for subglottic ste- nosis are focused on improving the airway, either via en- doscopic dilation of the stenosis, excision of the steno-

Table 6. Endoscopic Dilation Frequency a Based on Myer-Cotton Staging (MCS) at Time of Endoscopic Dilation

Characteristic

GPA Idiopathic

P Value

Patients undergoing endoscopic dilation, No.

14

23

NA

Dilations with known MCS

36

50

NA

Days between procedures based on MCS, mean, No. 1

NA b

829 562 462

358 602 477

2 3 4

.03 .23

NA

NA

NA

sis with laryngotracheal reconstruction, or bypassing the stenosis with tracheostomy. Carbon dioxide laser resec- tion and/or intralesional corticosteroid injection are com- mon adjuvant treatments to endoscopic dilation. Inter- estingly, in our series we found that laser resection was utilized more frequently in patients with iSGS than in those with GPA-SGS. This may in part be explained by practices of the operating surgeon or a reluctance to use the carbon dioxide laser if there is a possibility of active Abbreviations: GPA, granulomatosis with polyangiitis; NA, not applicable. a Excludes surgical procedures with less than 6 months’ postoperative follow-up. b Only 1 dilation in the idiopathic MCS 1 group with more than 6 months’ postoperative follow-up.

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