Triamcinolone acetonide injection for laryngeal stenosis By G. ROSEN and I. Y. VERED (Afula, Israel)

ONE of the most difficult problems encountered in laryngology is laryngeal stenosis. There is an increasing incidence of acquired laryngeal stenosis caused by external and internal trauma: Automobile accidents, industrial accidents, gunshot wounds, prolonged intubation, feeding tube insertion, caustic burns, and tracheotomies. The glottis is the commonest site of stenotic scar (Skolnic and Tardy, 1970). The trauma causes a derangement of laryngeal structures with mucosal ulceration and, sometimes, injury to perichondrium and cartilage. This involves the formation of granulation tissue that will resurface with new epithelium. Later the granulation tissue will form a cicatrix (Smith et al., 1969). The most disturbing symptoms of this laryngeal lesion are: (1) Breathing difficulty; (2) Vocal impairment; (3) Aspiration. The treatment offered to the patients may be conservative (dilatation) or surgical: 1. Thyrotomy with McNaught Keel placement. 2. Thyrotomy with antogenous graft to denuded areas. 3. Partial laryngectomy and rarely total laryngectomy. Recently several studies have reported the use of repository steroids, injected intra-lesionally in keloid, in esophageal stenosis and in laryngeal stenosis. Maguire (1965) reports a very satisfactory response of large keloids after injection of triamcinolone acetonide. Ashcraft and Holder (1969) and Holder et al. (1969) report good results in the treatment of short esophageal strictures by intralesional triamcinolone acetonide injections. Cobb and Sudderth (1972) describe the use of triamcinolone acetonide and methyl prednisolone acetate injected intralesionally in three cases of acquired laryngeal stenosis. They report success in improving the airway and voice in two cases, and they report initial success in the third case. Waggoner et al. (1973) injected triamcinolone acetonide suspesion, combined with hyaluronidase locally to four children with severe subglottic stenosis. They used gentle dilatations, too. They reported that the treatment greatly reduced the time needed for tracheotomy maintenance. 1043

G. Rosen and I. Y. Vered A comparison was made with cases where the treatment consisted of dilatations only. We report three cases of acquired glottic stenosis treated by percutaneous injections of triamcinolone acetonide using mirror laryngoscopv, with favourable results. Case reports

Case I A 35-year-old woman was admitted after the accidental ingestion of a solution of lye. Because of severe dyspnoea and inability to intubate the patient, an emergency tracheotomy was performed. Repeated laryngoscopies showed marked glottic stenosis with web formation anteriorly. Six weeks after admission a treatment of triamcinolone acetonide injected intralesionally commenced. The patient was given 20 mg. once a week for a period of six weeks. Two months following the conclusion of the treatment, an adequate airway was observed and the tracheotomy cannula was removed. This patient underwent surgery for extensive corrosive esophageal stenosis, using colon replacement. She has been followed-up closely for six years and her laryngeal airway has remained excellent. Case 2 A 69-year-old woman had a history of a craniotomy and tracheotomy for a middle cerebral artery aneurysm. Three months following the tracheotomy decannulation, a second tracheotomy was performed because of severe dyspnoea. Direct laryngoscopy at that time showed a large amount of granulation tissue in the glottic and sub-glottic regions. The granulation tissue was removed endoscopically. The patient was decannulated one month after the second tracheotomy. Two months following the second decannulation the patient became markedly dyspnoeic and an emergency direct larayngoscopv was perfoimed. It revealed reformation of granulation tissue, causing almost complete obstruction of the glottic and subglottic regions. The granulations were removed under microscopic vision. No tracheotomy was done. Twenty mg. of triamcinolone acetonide was injected into the glottic region. A six weeks' course of injections followed. Twenty mg. triamcinolone acetonide was injected once a week intra-glottically, percutaneously. Most of the treatments were done on an ambulatory basis. There has been no recurrence of laryngeal stenosis. A follow-up of three years is completely satisfactory as to the laryngeal airway and phonation. Case 3 A 61-year-old woman suffering from aplastic anaemia of undertermined origin had a recurring anterior commissure polyp removed endoscopically, several times. A moderate anterior glottic stenosis was noted about four months following the last treatment. The patient received a course of intralesional triamcinolone acetonide as described before. A two-year follow-up shows a slight anterior glottic web with adequate airway and fair phonation. 1044

Triamcinolone acetonide injection for laryngeal stenosis Method

The technique of percutaneous laryngeal injection is simple. Local anaesthesia may be used, but not necessarily, since the discomfort is minimal. The discomfort tapers down with each injection. The procedure is performed by two people. The patient is seated with his neck hyperextended. The cricoid is palpated and the crico-thyroid membrane identified. A 25-gauge needle i j in. long is inserted into the membrane by the first examiner, pointing 450 up. A mirror laryngoscopy is done by the second examiner. A small amount of saline is injected through the needle, until a small bulge is seen in the larynx. The position of the needle can then be changed according to the location of the lesion. The triamcinolone acetonide is then injected (Fig. 1).

FIG. 1. Percutaneous intralaryngeal injection, using mirror laryngoscopy.

Comment

The percutaneous trans-cricothyroid needle puncture is used in selective bronchography (Sargent and Turner, 1968). Percutaneous injection of the vocal cord with teflon, using direct laryngoscopy, has been described (Hurst, 1972). We have found no report describing the injection of depository steroids into the larynx, using mirror laryngoscopy. We find the method simple and safe. The patient may have the initial treatment in the hospital and continue the injections on an ambulatory basis.

G. Rosen and I. Y. Vered We think it is worthwhile using triamcinolone acetonide injections for laryngeal stenosis in relatively fresh cases. Summary

Three cases with acquired laryngeal stenosis have been presented. They were treated by percutaneous intralesional injection of triamcinolone acetonide using mirror laryngoscopy. The laryngeal airway and the phonation have been satisfactory for a period of two to six years of close follow-up. REFERENCES ASHCRAFT, K. W., and HOLDER, T. M. (1969) Journal of Thoracic and Cardiovascular Surgery, 58, 685. COBB, W. B., and SUDDERTH, J. F. (1972) Archives of Otolaryngology, 96, 52. HOLDER, T. M., ASHCRAFT, K. W., and LEAPE, L. (1969) Journal

of Pediatric

Surgery, 4, 646. HURST, W. B. (1972) The Journal of Laryngology and Otology, 86, 633. MAGUIRE, H. C. Jnr. (1965) Journal of the American Medical Association, 192, 325. SARGENT, E. N., and TURNER, A. F. (1968) The American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 104. 792. SKOLNIC, E. M., and Tardy, M. E. (1970) Otolaryngologic Clinics of North America, 3, 569. SMITH, R. O., HEMENWAY, W. G., and ENGLISH, G. M. (1969) Laryngoscope, 79,

1227. WAGGONER, L. G., BELENKY, W. M., and CLARK, C. E. (1973) Annals of Otology,

Rhinology and Laryngology, 82, 822. Department of Otolaryngology Central Emek Hospital Afula Israel

1046

Triamcinolone acetonide injection for laryngeal stenosis.

Three cases with acquired laryngeal stenosis have been presented. They were treated by percutaneous intralesional injection of triamcinolone acetonide...
339KB Sizes 0 Downloads 0 Views