4/1/2020 Adult Subglottic and Tracheal Stenosis Karla ODell, MD - PDF document

4/1/2020 Adult Subglottic and Tracheal Stenosis Karla O’Dell, MD Assistant Professor, Laryngology USC Voice Center Caruso Department of Otolaryngology, Head and Neck Co-Director USC Center for Airway Intervention and Reconstruction (AIR Center) 2 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Causes of subglottic or tracheal stenosis 3 4 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Idiopathic Subglottic Stenosis • “Idiopathic” • Disease homogeneity • Female • Middle age • Caucasian • Stenosis subglottic and first ring • Theories on cause –Estrogen, Inflammatory markers IL-17 5 6 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 1

4/1/2020 North American Airway Collaborative 7 8 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE In Office Bronchoscopy Pulmonary Function Tests 10 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Initial Procedure- Endoscopic treatment 11 12 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 2

4/1/2020 USC- Post dilation protocol Serial steroid injections • First described by Ramon Franco in 2015, alternative • Qvar or steroid inhaler 1 month treatment for iSGS • Bactrim 1 month • Series of 3 subglottic Kenalog 40-80mg injected into scar spaced 1 month apart • PFTs pre, post, after serial steroid, q 3 months • Repeat series if begin to have symptoms or progressive change in PFTs 13 14 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 15 16 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Endoscopic Resection Cricotracheal resection Removing all tissue except thin mucosal bridges 17 18 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 3

4/1/2020 19 20 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Maddern procedure 21 22 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 24 23 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 4

4/1/2020 Traumatic/Iatrogenic Cotton-Myer grade of stenosis • Intubation • Cuff pressure  Necrosis  Exposed cartilage  Circumferential scar  Stenosis • Trach tube placement • Size of tube • Perc trach vs. open • High trach 25 26 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 27 28 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Tracheal resection/Cricotracheal resection 30 29 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 5

4/1/2020 31 32 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Tracheal Resection/CTR- USC Complex cases • In the last 5 years • Multi-level stenosis • Low stenosis Etiology # of patients % of total Idiopathic 2 4.65% • Requires team Traumatic approach Intubation 2 5% Tracheostomy 31 72% Autoimmune/Inflammatory 0 0% Cancer 8 19% Total patients 43 33 34 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Complex cases • Multi-level stenosis- Glottic and tracheal • Manage the glottic stenosis first • Low stenosis- Thoracic for mini sternotomy 36 35 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 6

4/1/2020 3 months post op 37 38 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Composite Grafting • Radial forearm free flap with buried auricular cartilage • Rarely used • Option after failed resection 39 40 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Pre op 1 month post op Tracheal regeneration 41 42 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE 7

4/1/2020 43 44 BEYOND EXCEPTIONAL VOICE CARE BEYOND EXCEPTIONAL VOICE CARE Any questions? 45 BEYOND EXCEPTIONAL VOICE CARE 8