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Supraglottic Stenosis:Etiology and Treatment of a Rare ConditionJournal Reading

Nurul Faizatul Amira Bt Ab Mutalib11-2012-228

Dr.Pembimbing:Dr.Yuswandi Affandi, Sp THT-KLDr. Tantri Kurniawati,Sp.THT-KL

AbstractObjectives: Supraglotic stenosis is an unusual subset of laryngotracheal stenosis that has distinctly different causes, symptoms, and treatment options.

Methods: A retrospective chart review on all adult patients with diagnosis of supraglotic stenosis.Clinical recordsVideolaryngoscopic examinationsOperative and clinic procedure records All patients had a minimum follow-up of 12 months.

Abstract Results: 8 patients with supraglottic stenosis:5 had a history of radiation therapy (62.5%)3 associated with autoimmune disorders Dysphagia (7cases, 87.5%)2 with complete pharyngoesofageal stricture3 required a percutaneous gastrostomy tube All of the patients need more than surgical intervention3 underwent succesful endoscopic treatment (CO2 laser)1 (endoscopic treatment) + 5 additional patients sucessfully managed with pulsed KTP laser without complications. 1 of 2 cases of acute intaoperative supraglottic edema necessitated emergent tracheostomy.

Abstract Conclusions: Supraglottic stenosis is rare condition that is often associated with external-beam radiation or autoimmune The majority had coexisting dysphagia, often associated with pharyngeal or esophageal stricture. Although endoscopic treatment (CO2 laser) is a viable option, pulsed KTP laser appears to be effective and potentially safer alternative.

IntroductionNo specific incidence or prevelance of supraglottic stenosis exists in the medical literature.

The clinical presentation of supraglottic stenosis:Shortness of breath at rest or with exertionInspiratory stridor Voice alterations due to resonance changesDysphagia

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IntroductionIn previous literature, multiple causes and various treatment for laryngeal stenosis have been described.

In this case series, they report the management of 8 cases of supraglottic stenosis performed by the senior author over a 12-year period.

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Methods A restrospective chart review was conducted on 8 adult patients at their institution with diagnosis of supraglottic stenosis (Jan 2000 Marcch 2012).

All patients had a follow-up of at least 12 months from initial treatment.

Methods The patients were treated with 1 or more of the following therapies:CO2 laser532-nm pulsed KTP (potassium titanyl phosphate) laserBalloon dilatationMitomycin C applicationnIntralesional corticosteroid injections

Methods CO2 laser Operating room via endoscopic approachIn the office setting under local anesthesia

KTP laser In the office setting onlyWere performed in contact mode with following settings:30W, 20-ms pulse width, 2pps, and a mean of 301.3 J per treatment

Methods Both CO2 and KTP laser approaches:Creating wedge resections at region of greatest scar volume, with the intervening tissue left largely undisturbed.For larger scar formation, serial excisions were performed in separate areas of stenosis to avoid circumferential trauma that could induce further stenosis.Only membranous stenosis was treated (no cartilage was excised).

KTP laser was performed by placing fiber at the edge of stenosis and ablating it centrifugally (medial to lateral). The excision tende to widen into a wedge shape.

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Methods Topical laryngeal anesthesia was achieved with 4% lidocaine hydrochloride (5-7ml) via a flexible working channel, distal tip laryngoscope, transoral cannula or percutaneous before the procedure.

Both CO2 and KTP laser fibers were delivered via a flexible working channel, distal tip laryngoscope.

All application of mitomycin C (0.4mg/ml) and steroid injections (10mg/ml) were performed in operating room.

Controlled radial expansion balloons were used to dilate the stenotic tissue (in operating room and office setting).

Methods The assessment of treatment success included:Pretreatment and posttreatment endoscopic examinationSubjective symptom reports

The images from clinic-based procedures (preprocedure and postprocedure) were recorded by means of nStream software.

ResultsAll 8 patients with supraglottic stenosisAge: 37 90 yearsFollow up: 12 -140 monthsAll patients had sparing of glottis with fully intact vocal fold mobility.6 of patients demostrated isolated stenosis stenosis.2 had extension of their stenosis superiorly (to the level of oropharynx and nasopharynx)The dimensions of stenosis at supraglottic level: 1x1 mm to 10x6 mm

Results5 of the patientsHave history of external-beam radiation therapy for head and neck squamous cell carcinoma that originated from:nasopharynx, hypopharynx, glottis and unknown.Time from completion of radiation therapy to onset of symptoms: 18 to 120 monts.

The remaining 3 cases were related to autoimmune disorders:SarcoidosisErosive lichen planusCicatricial pemphigoid

ResultsAll of the patients exhibited some degree of airway obstruction that ultimately required intervention. 7 patients had a history of dysphagia3 with mild symptoms were managed successfully with basic compensatory swallowing techniques (chin positioning)The other patient with recurrent esophageal stricture required frequent dilatations

3 patients required a percutaneous gastrostomy tube for all nutritional intake.2 with complete pharyngoesophageal strictures1 experienced severe aspiration secondary to a combination of reduced pharyngeal contraction and retroversion of epiglottis and associated sensory deficits.

ResultsSurgical treatment result in significant improvement of dyspnea but all patients need more than 1 surgical intervention because of symptomatic reccurent airway stenosis.Mean: 4.0 treatmentsWhen excluded patient 6 (with severe tendency to experienced current stenosis : Mean 2.8 treatments.The interval between the treatment: 1.66 to 85 months

Results7 patients underwent clinic-based KTP laser partial resection:6 patients tolerated well (4 treated with CO2 laser in operating room)1 patient unable to tolerate on 2 separate attempts was subsequently treated in the operating room by endoscopic CO2 laser procedure.

1 patient with cicatricial pemphigoid was managed conservatively (without KTP or CO2 laser) and has maintained widely patent supraglottic airway (follow-up: 8 months).Serial corticosteroid injectionsBalloon dilatations

ResultsAdditional observation on 2 cases of acute intraoperative supraglottic edema in the setting of suspension laryngoscopy and jet ventilation who had previously undergone radiation therapy:1 of patients successfully managed conservatively by immediate cessation of surgery after recognition of the edemahigh dose parenteral corticosteroidsracemic epinephrine treatmentsThe other patient required immediate intubation with 4.0 endotracheal tube and tracheostomy because of rapidly progressive supraglottic edema.

DiscussionGiven the rare incidence and the scarce medicine literature concerning the supraglottic stenosis, this study aims to define the causes and management strategies of this rare disease.

External beam radiation was found to be the most common cause. The second most common cause was autoimmune disorders.

DiscussionThe interventions were directed at airway concerns rather than dysphagia. The causes of dysphagia: Location of stricture Decreased sensation Decreased pharyngeal contracture Poor epiglottic retroversion

DiscussionClinic-based laser partial resection under topical anesthesia was well-tolerated and safe method without complications: no significant bleeding no reactive airway edema

Therefore, CO2 laser treatment was transitioned to clinic based KTP laser. The advantages of KTP laser: has aiming beam less expensive fiber more precise ablation

DiscussionCurrent protocol: A clinic-based KTP laser for patients with stable, noncritical supraglottic stenosis. For patients who cannot tolerate or fail to achieve an adequate airway with the KTP laser procedure, perform endoscopic treatment with CO2 laser. Topical mitomycin C is used as part of standard airway stenosis protocol. Balloon dilatation is used occasionally as long as there is no risk of circumferential tearing of the stenotic region.

DiscussionAirway edema may have been secondary to mechanical pressure on the epiglottis caused by suspension laryngoscopy due to lymphatic disruption that is present from previous radiation therapy.

The use of laryngoscope that is placed in vallecula, such as Lindholm laryngoscope may reduce the chance of progressive edema formation.

ConclusionsSupraglottic stenosis is a rare condition that is often associated with external-beam therapy or autoimmune disorders.

All of patients experienced some degree of symptomatic airway obstruction and majority had coexisting dysphagia.

All patients required additional procedures because of reccurence of stenosis.

Pulsed KTP laser is an effective and potentially safer alternative.